Nokea
The LPN/LVN is providing home care to an elderly widow who has senile dementia. The woman tells the nurse that her daughter hits her and tells her to shut up. The nurse notes one ecchymotic area on the client's right forearm. The daughter seems attentive to the woman when the nurse is present. What action should the nurse take?
- A. Immediately call the police
- B. Ask the daughter why she abuses her mother
- C. Ask the physician to order long bone x-rays
- D. Report the woman's remarks and the nurse's findings to the nursing supervisor
Correct Answer: D
Rationale: Reporting suspected abuse to the supervisor initiates investigation and protection, the appropriate action for potential elder abuse.
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The nurse is caring for a client who has bacterial meningitis. Which of the following actions should the nurse take? Select all that apply.
- A. Minimize environmental stimuli.
- B. Implement seizure precautions.
- C. Maintain the head of bed at 30 degrees.
- D. Keep a surgical mask on the client at all times.
- E. Place the client in a room with monitored negative air pressure.
Correct Answer: A, B, C
Rationale: Minimizing stimuli (A), seizure precautions (B), and elevating the head (C) reduce complications in meningitis. Masks (D) are unnecessary, and negative pressure rooms (E) are for airborne diseases.
The nurse is collecting data from a 10-year-old client during a routine physical examination. Which of the following actions should the nurse take? Select all that apply.
- A. Use correct anatomical terminology while reinforcing teaching about self-care.
- B. Conduct a head-to-toe examination in the same sequence as an adult examination.
- C. Explain the purpose of the examination equipment and any procedures to the client.
- D. Offer the client a gown and allow the client to keep the underwear on during the examination.
- E. Ask the accompanying parent to rate and describe any pain the client may be experiencing.
Correct Answer: A, C, D
Rationale: Using anatomical terminology (A) promotes understanding. Explaining equipment and procedures (C) reduces anxiety. Offering a gown and allowing underwear (D) respects privacy. Adult examination sequences (B) may not suit pediatric needs, and parents rating pain (E) may not accurately reflect the child's experience.
The nurse is evaluating a parent's understanding of home care management for a 2-week-old client after initial cast placement for treatment of congenital clubfoot. Which of the following statements by the parent indicate a correct understanding? Select all that apply.
- A. Cradling my baby in my arms may cause stress and damage to the cast.'
- B. I will check my baby's toes several times a day to ensure that they are pink and warm.'
- C. My baby should alternate between sleeping on the stomach and back'
- D. My baby will need to have a new cast applied weekly for 5-8 weeks.'
- E. When I bathe or diaper my baby, I will be sure to keep the cast dry.'
Correct Answer: B, D, E
Rationale: Checking toes (B), weekly casts (D), and keeping the cast dry (E) are correct. Cradling (A) is safe, and alternating sleep positions (C) is not cast-related.
The nurse is instructing the client with a fractured femur in crutch walking. When instructing the client in the best method of manipulating stairs, the nurse should tell the client to:
- A. Start up the stairs with the crutches first.
- B. Start up the stairs with the unaffected leg first.
- C. Use the affected leg to move up the stairs first.
- D. Use the unaffected leg to move down the stairs.
Correct Answer: B
Rationale: For ascending stairs, lead with the unaffected leg to bear weight, followed by crutches and affected leg. This ensures stability and safety.
The nurse is caring for a client who had an endoscopic procedure yesterday to stop upper gastrointestinal bleeding and who started a clear liquid diet today. Which of the following foods would be appropriate to offer to this client? Select all that apply.
- A. Apple juice
- B. Chicken broth
- C. Cranberry juice
- D. Cream of chicken soup
- E. Unsweetened tea
- F. Vanilla ice cream
Correct Answer: A, B, C, E
Rationale: Clear liquids include apple juice (A), chicken broth (B), cranberry juice (C), and unsweetened tea (E). Cream of chicken soup (D) and ice cream (F) are not clear liquids.