Nokea
The home-care nurse visits an older client diagnosed with Parkinson's disease who requires instillation of multiple eye drops. Which instruction for the administration of eye drops should the nurse plan to provide to this client who demonstrates signs/symptoms of this diagnosis?
- A. Administer the eye drops rapidly.
- B. Have a family member instill the eye drops.
- C. Lie down on a bed or sofa to instill the eye drops.
- D. Keep the eye drops in the refrigerator so that they will thicken.
Correct Answer: C
Rationale: Older adults diagnosed with Parkinson's disease will experience tremors, making it more difficult to instill eye drops. The older client is instructed to lie down on a bed or sofa to instill the eye drops to provide control and allow the drops to be administered more easily. If multiple eye drops are needed, there should be a wait time of 3 to 4 minutes between drops. It is unreasonable to expect a family member to be available consistently to instill the eye drops. Additionally, this discourages client independence. Placing the eye drops in the refrigerator should not be done unless specifically prescribed.
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The nurse is teaching a group of student nurses about principles of teaching. Which statement by a student nurse requires further instruction from the licensed nurse?
- A. A client's living situation can affect his readiness and ability to learn.
- B. The client's age and developmental stage must be considered when teaching clients.
- C. Tactile or kinesthetic learners prefer to learn by watching a video or reading a handout.
- D. I should allow clients to demonstrate their understanding of what they have learned and practice skills.
- E. Some barriers to learning include financial resources, lack of support systems, and a low level of literacy.
Correct Answer: C
Rationale: Tactile/kinesthetic learners prefer hands-on learning, not videos or handouts. Other statements are correct.
The mother of a teenage client diagnosed with an anxiety disorder is concerned about her daughter's progress after discharge. She states that her daughter 'stashes food, eats all the wrong things that make her hyperactive,' and 'hangs out with the wrong crowd.' To assist the mother with preparing for her daughter's discharge, the nurse advises the mother to implement which action in order to promote optimal health?
- A. Restrict the daughter's socializing time with her school friends.
- B. Consider taking time off to help her daughter readjust to the home environment.
- C. Limit the amount of chocolate and caffeine products that are available in the home.
- D. Keep her daughter out of school until she proves that she can adjust to the school environment.
Correct Answer: C
Rationale: Limiting chocolate and caffeine reduces anxiety triggers in clients with anxiety disorders. Restricting socializing, taking time off work, or keeping her out of school are impractical or unhealthy, hindering social and emotional adjustment.
A client is diagnosed with hyperphosphatemia caused by hypoparathyroidism. To prevent worsening of the condition, the nurse should instruct the client to avoid which food selections? Select all that apply.
- A. Fish
- B. Eggs
- C. Coffee
- D. Grapes
- E. Bananas
- F. Whole-grain breads
Correct Answer: A,B,F
Rationale: Food items and liquids that are naturally high in phosphates include fish, eggs, milk products, whole grains, vegetables, and carbonated beverages, and they should be avoided by the client with hyperphosphatemia. Coffee, grapes, and bananas are acceptable for this client to consume because their phosphate levels are not significant.
Using Naegele's Rule, calculate the estimated date of birth for a client who reports the first day of the last menstrual period was August 7.
- A. 7-May
- B. 14-May
- C. 31-Oct
- D. 14-Nov
Correct Answer: B
Rationale: Naegele's Rule: Add 1 year, subtract 3 months, add 7 days. August 7 + 1 year = August 7 next year; minus 3 months = May 7; plus 7 days = May 14.
A client is receiving lipids (fat emulsion) intravenously at home, and the client's spouse manages the infusion. The home care nurse makes a visit and discusses potential side and adverse effects of the therapy with the client and the spouse. After the discussion, the nurse expects the spouse to verbalize that, in case of a suspected adverse effect, which action is the priority?
- A. Stop the infusion.
- B. Contact the nurse.
- C. Take the client's blood pressure.
- D. Contact the local area emergency response team.
Correct Answer: A
Rationale: Signs/symptoms of an adverse effect to lipids (fat emulsion) include chest and back pain, chills, vertigo, cyanosis, diaphoresis, dyspnea, fever, flushing, headache, nausea and vomiting, and thrombophlebitis of the vein. The priority action is to stop the infusion to limit the adverse response. Although contacting the nurse, taking the client's blood pressure, and contacting the local emergency response team are correct interventions, the priority is to stop the infusion.