Nokea
The nurse and a nursing assistant are preparing to move an elderly immobile client up in the bed using a sheet. The staff should be standing on opposite sides of the bed even with the client's:
- A. Hips
- B. Knees
- C. Shoulders
- D. Chest
Correct Answer: C
Rationale: Positioning at the shoulders aligns staff with the client's upper body, ensuring safe and effective movement.
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A client recovering from acute pancreatitis is started on solid food. Which of the following foods should be avoided?
- A. Vanilla custard
- B. Sponge cake
- C. Sliced peaches
- D. Cereal
Correct Answer: A
Rationale: Vanilla custard is high in fat, which can stimulate pancreatic enzyme release and worsen pancreatitis. Sponge cake, peaches, and cereal are lower in fat and safer.
A client is admitted with a tentative diagnosis of bladder cancer. Which finding most likely contributed to the development of bladder cancer?
- A. Two PPD cigarette use for 25 years
- B. Frequent urinary tract infections
- C. Employment in the textile industry
- D. A history of renal calculi
Correct Answer: A
Rationale: Cigarette smoking is a significant risk factor for bladder cancer due to the exposure to carcinogenic chemicals excreted in urine. Answer A (two packs per day for 25 years) is the most likely contributor. Answers B, C, and D are less directly associated with bladder cancer development.
The nurse is planning care for a client with a diagnosis of paranoid schizophrenia. The nurse knows that questioning the client about his false ideas will
- A. cause him to defend the idea.
- B. help him clarify his thoughts.
- C. facilitate better communication.
- D. lead to a breakdown of the defense.
Correct Answer: A
Rationale: contraindicated; encourages patient to engage in further distortion of reality
A client with newly diagnosed diabetes mellitus.
Which of the following statements, if made by the client to the nurse, would indicate that further teaching is necessary?
- A. I should cut my toenails straight across.
- B. I should not go barefoot.
- C. I should inspect my feet once a week.
- D. I should bathe my feet daily in warm water.
Correct Answer: C
Rationale: Strategy: 'Further teaching' indicates an incorrect response. (1) prevents ingrown nails (2) prevents possible injury to feet (3) correct-should inspect feet daily for blisters, sores, ingrown nails, and cuts (4) proper care
The nurse is caring for a client with a history of systemic lupus erythematosus.
- A. Which symptom is expected in a client with systemic lupus erythematosus?
- B. Chest pain and shortness of breath.
- C. Fever and joint pain.
- D. Weight gain and edema.
- E. Persistent headaches.
Correct Answer: B
Rationale: Fever and joint pain are common in systemic lupus erythematosus due to autoimmune inflammation. Chest pain may occur with pericarditis, but weight gain and headaches are less specific.