Nokea
The nurse in the outpatient care facility is caring for a client who is blind. Which of the following actions should the nurse take?
- A. Offer the client's service dog food and water.
- B. Teach the client how to ambulate with a stability cane.
- C. Touch the client's shoulder before speaking to the client.
- D. Walk slightly ahead of the client with the client holding the nurse's elbow
Correct Answer: D
Rationale: Walking slightly ahead with the client holding the nurse's elbow is the standard technique for guiding a blind person safely. Offering food to a service dog is inappropriate, teaching cane use assumes need, and touching without warning may startle.
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The nurse is assessing a newborn delivered at home by a client addicted to heroin. Which of the following would the nurse expect to observe?
- A. Hypertonic neuro reflex
- B. Immediate CNS depression
- C. Lethargy and sleepiness
- D. Jitteriness at 24-48 hours
Correct Answer: D
Rationale: Jitteriness at 24-48 hours. Withdrawal signs may not be evident for 1-2 days after birth. Irritability and poor feeding also are evident.
The nursing care plan for a client with decreased adrenal function should include
- A. Encouraging activity
- B. Placing client in reverse isolation
- C. Limiting visitors
- D. Measures to prevent constipation
Correct Answer: C
Rationale: Limiting visitors. Limiting visitors reduces physical and emotional exertion, preventing an Addisonian crisis.
The nurse is discussing child safety with the parents of a 12-month-old child who is just beginning to walk. Which statement by the parents indicates a need for further instruction?
- A. Our swimming pool is fenced in with a lock on the gate.'
- B. We have installed childproof gates at the top and bottom of our stairs.'
- C. We need to lower the mattress in our child's crib.'
- D. When we are unable to supervise, we can put our child in a mobile walker.'
Correct Answer: D
Rationale: Using a mobile walker is unsafe for a walking 12-month-old due to fall and injury risks, requiring further teaching. Fenced pools , stair gates , and lowered crib mattresses are appropriate safety measures.
A 67 year-old client with non-insulin dependent diabetes should be instructed to contact the out-patient clinic immediately if the following findings are present
- A. Temperature of 99.5 degrees Fahrenheit with painful urination
- B. An open, reddened wound on the heel
- C. Insomnia and daytime fatigue
- D. Nausea with 2 episodes of vomiting
Correct Answer: B
Rationale: An open, reddened wound on the heel. When signs of trauma and/or infection occur in their feet, elderly clients who have diabetes and/or vascular disease should seek health care quickly and continue treatment until the problem is resolved. Without treatment, serious infection, gangrene, limb loss, and death may result.
A client asks the nurse to explain the basic ideas of homeopathic medicine. The response that best explains this approach is that such remedies
- A. destroy organisms causing disease
- B. maintain fluid balance
- C. boost the immune system
- D. increase bodily energy
Correct Answer: C
Rationale: boost the immune system. The practitioner treats with minute doses of plant, mineral or animal substances which provide a gentle stimulus to the body's own defenses.