Nokea
The nurse assigns a UAP to assist with the personal care of a client experiencing an acute exacerbation of multiple sclerosis. Which instruction should the nurse provide the UAP?
- A. Assist the client with a hot bath
- B. Encourage self-care but allow rest periods
- C. Face the client directly when speaking
- D. Keep the head of the bed elevated at all times
Correct Answer: B
Rationale: The correct instruction for the UAP to provide when assisting a client experiencing an acute exacerbation of multiple sclerosis is to encourage self-care but allow rest periods. Clients with multiple sclerosis often experience fatigue, so promoting self-care activities while ensuring they have adequate rest periods is crucial for symptom management and maintaining independence. Choice A is incorrect as hot baths can potentially exacerbate symptoms in clients with multiple sclerosis. Choice C is unrelated to the client's care needs during an acute exacerbation of multiple sclerosis. Choice D is not a priority instruction in this situation and may not directly impact the client's immediate care needs.
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A client with uterine cancer asks the nurse, 'Which is the most common type of cancer in women?' The nurse replies that it is breast cancer. Which type of cancer causes the most deaths in women?
- A. Breast cancer
- B. Lung cancer
- C. Brain cancer
- D. Colon and rectal cancer
Correct Answer: B
Rationale: Lung cancer is the leading cause of cancer-related deaths in women, surpassing even breast cancer. While breast cancer is more common, it is often detected early enough for effective treatment. Lung cancer, on the other hand, tends to be diagnosed at later stages, leading to higher mortality rates. Brain cancer and colon and rectal cancer are not the leading causes of cancer-related deaths in women, making them incorrect choices.
The PN is caring for a client who had an acute brain attack with resulting expressive aphasia and urinary incontinence. To ensure care for the client, which task should the PN delegate to the UAP?
- A. Explain how to use a communication board
- B. Document progress in the use of the communication board
- C. Encourage voiding by assisting the client to the bedside commode
- D. Establish a bladder training schedule and methods
Correct Answer: C
Rationale: Assisting the client to the bedside commode is an appropriate task for the UAP as it involves basic patient care and mobility assistance, which are within the UAP's scope of practice. Options A and B involve communication techniques and documentation, which are more appropriate for licensed nursing staff. Option D involves establishing a bladder training schedule, which requires assessment and planning skills beyond the UAP's role.
A homeless male client with a history of alcohol abuse had a CVA 10 years ago that resulted in left hemiparesis. Today he is brought to the clinic reporting pain in his left leg. He is afebrile, has 4+ pitting edema in the lower left leg, and has minimal swelling of the right leg. Which action should the PN implement first?
- A. Obtain a blood alcohol test
- B. Inspect legs for infection or trauma
- C. Complete a mental status exam
- D. Inquire about dietary salt intake
Correct Answer: B
Rationale: Inspecting the legs for infection or trauma is the priority to assess the cause of the pain and edema, which could indicate deep vein thrombosis or cellulitis. Checking for signs of infection or trauma is crucial in this scenario to rule out potentially serious conditions. Obtaining a blood alcohol test, completing a mental status exam, or inquiring about dietary salt intake can be considered after addressing the immediate concern of identifying any infection or trauma in the leg.
A nurse who receives a patient in the operative suite prior to the actual surgery is in charge of the patient's care. Which of the following is NOT a task related to the nurse's intraoperative care?
- A. Go over the surgical procedure with the patient before he or she is anesthetized
- B. Strictly adhere to asepsis during all intraoperative procedures
- C. Provide emotional support to the patient and their family
- D. Monitor the patient's physical status
Correct Answer: A
Rationale: The correct answer is A. Going over the surgical procedure with the patient is typically done preoperatively, not intraoperatively. Intraoperative tasks of a nurse involve strictly adhering to asepsis during procedures, monitoring the patient's physical status, and providing emotional support to the patient and their family during the surgery. Choices B, C, and D are all tasks that are directly related to the nurse's responsibilities during the intraoperative phase of care.
During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse take?
- A. Record the findings and report the symptoms to the charge nurse
- B. Ask the family members to visit more often to stimulate the patient
- C. Motivate the client by offering favorite foods as a prize
- D. Withhold any medications that may cause side effects
Correct Answer: A
Rationale: The practical nurse should record the findings and report the symptoms to the charge nurse. These behaviors may indicate a serious underlying condition such as depression or physical illness. By reporting to the charge nurse, the client can receive appropriate assessment and intervention promptly. Choice B is incorrect as family visits may not address the root cause of the symptoms. Choice C is incorrect as it oversimplifies the situation and may not be effective in addressing the underlying issue. Choice D is incorrect because withholding medications without proper assessment and guidance can be harmful to the client's health.