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The nurse can best ensure the safety of a client suffering from dementia who wanders from the room by which action?
- A. Repeatedly remind the client of the time and location
- B. Explain the risks of walking with no purpose
- C. Use protective devices to keep the client in the bed or chair in the room
- D. Attach a wander-guard sensor band to the client's wrist
Correct Answer: D
Rationale: This type of identification band easily tracks the client's movements and ensures safety while the client wanders on the unit. Restriction of activity is inappropriate for any client unless they are potentially harmful to themselves or others.
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While performing an initial assessment on a newborn following a breech delivery, the nurse suspects hip dislocation. Which of the following is most suggestive of the abnormality?
- A. Flexion of lower extremities
- B. Negative Ortolani response
- C. Lengthened leg of affected side
- D. Irregular hip symmetry
Correct Answer: D
Rationale: Irregular hip symmetry. Early assessment of irregular hip symmetry alerts the nurse and the provider to a correctable congenital hip dislocation.
An ambulatory client reports edema during the day in his feet and ankles that disappears while sleeping at night. What is the most appropriate follow-up question for the nurse to ask?
- A. Have you had a recent heart attack?
- B. Do you become short of breath during your normal daily activities?
- C. How many pillows do you use at night to sleep comfortably?
- D. Do you smoke?
Correct Answer: B
Rationale: Do you become short of breath during your normal daily activities? This assesses for activity intolerance, a symptom of right-sided heart failure causing edema.
The home health nurse is reinforcing teaching for a client with atrial fibrillation who is prescribed digoxin 0.25 mg orally on even-numbered days. Which client statement will require further teaching about digoxin?
- A. I will call the health care provider if I don't feel like eating.
- B. I will call the health care provider if I feel dizzy and lightheaded.
- C. I will call the health care provider if I have trouble reading.
- D. I will take my blood pressure before taking my medicine.
Correct Answer: D
Rationale: Taking blood pressure (D) is unrelated to digoxin monitoring. Anorexia (A Anorexia (A), dizziness (B), and visual changes (C) are signs of digoxin toxicity, requiring provider notification.
A client with moderate Alzheimer disease is started on memantine. What should the nurse monitor to evaluate the effectiveness of this medication?
- A. Improved ability to perform activities of daily living
- B. Indications that disease progression has stopped
- C. Rapid improvement in cognitive functioning
- D. Reversal of Alzheimer disease
Correct Answer: A
Rationale: Memantine may slow decline and improve daily functioning (A). It does not stop progression (B), provide rapid improvement (C), or reverse Alzheimer's (D).
The school nurse observes a 7-year-old client with attention deficit hyperactivity disorder begin to throw books and attempt to hit the classmates. Which of the following actions would be a priority for the nurse to take?
- A. Ask the client to blow up a balloon.
- B. Administer a PRN dose of methylphenidate
- C. Place the client in a quiet room with supervision.
- D. Reinforce the consequences of disruptive behaviors.
Correct Answer: C
Rationale: Removing the client to a quiet room (C) ensures safety and de-escalates the situation. Balloon blowing (A) is inappropriate, PRN methylphenidate (B) is not typically ordered, and consequences (D) are secondary.