Nokea
The geriatric residents of a long-term care facility are engaged in a reminiscing group. The nurse knows that the primary goal of this type of group activity is to
- A. provide psychosocial educational opportunities for stress and coping.
- B. provide an avenue for physical exercise.
- C. provide an environment for social interaction and companionship.
- D. reorient and provide a reality Test for confused clients.
Correct Answer: C
Rationale: primary goal of a reminiscing group for geriatric clients is to review and share their life experiences with the group members
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A 34-year-old multipara comes to the prenatal clinic during her fifth month of pregnancy. The client complains to the nurse that her breasts are sensitive and sore.
Which of the following suggestions by the nurse is BEST?
- A. Apply warm compresses to your breasts and take two aspirin as needed.
- B. Massage your breasts with lotion and wear loose-fitting clothing.
- C. Apply cold compresses to your breasts and wear a well-fitting, supportive bra.
- D. Take a diuretic once a day and avoid touching your breasts.
Correct Answer: C
Rationale: Strategy: 'BEST' indicates priority question. All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) would increase circulation and increase discomfort, should avoid taking medications (2) not effective in decreasing discomfort (3) correct-during pregnancy there is an increase in lactiferous ducts and lobule-alveolar tissue (4) medications are to be avoided during pregnancy
A male client is admitted with urinary tract problems. A prostate-specific antigen (PSA) and acid phosphatase Test are to be done.
The nurse knows that
- A. these Test s are valuable screening Test s for prostatic cancer.
- B. the level of PSA is decreased in clients with renal stones.
- C. the level reflects the level of renal involvement in acid-base problems.
- D. the level of PSA is elevated in clients in early stage renal failure.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-PSA Test has replaced acid phosphatase Test in screening for prostatic cancer; Test must be drawn before digital rectal exam, as manipulation of the prostate will abnormally increase PSA value (2) inaccurate information about a PSA (3) inaccurate information about a PSA (4) inaccurate information about a PSA
An 11-month-old baby is having trouble gaining weight after discharge from the hospital. Which of the following actions by the nurse is BEST?
- A. Observe the child at mealtime.
- B. Inquire about the child's eating patterns.
- C. Weigh the baby each month.
- D. Attempt to feed the baby for the mother.
Correct Answer: A
Rationale: Observing mealtime assesses feeding behaviors and parental interactions, identifying causes of poor weight gain. Options B, C, and D are less direct or premature.
A 72 year-old client is scheduled to have a cardioversion. A nurse reviews the client's medication administration record. The nurse should notify the health care provider if the client received which medication during the preceding 24 hours?
- A. Digoxin (Lanoxin)
- B. Diltiazem (Cardizem)
- C. Nitroglycerine ointment
- D. Metoprolol (Toprol XL)
Correct Answer: A
Rationale: Digoxin (Lanoxin). Digoxin increases ventricular irritability and increases the risk of ventricular fibrillation following cardioversion. The other medications do not increase ventricular irritability.
A toddler with Tetralogy of Fallot is hospitalized with a diagnosis of pneumonia. During the nursing assessment, the child develops a hypoxic episode. The nurse should:
- A. Provide the child his favorite toy.
- B. Place the child in a supine position.
- C. Pick the child up and comfort him.
- D. Place the child in knee chest position.
Correct Answer: D
Rationale: The knee-chest position increases systemic vascular resistance, reducing right-to-left shunting in Tetralogy of Fallot during hypoxia. Toys or comforting do not address hypoxia. Supine position may worsen shunting.