Nokea
The nurse in the outpatient clinic teaches a young adult with a sprained right ankle to walk with a cane. While teaching the client to use the cane, how should the nurse be positioned?
- A. Standing on the client's left side and slightly behind the client.
- B. Standing on the client's right with one hand on the client's waist.
- C. Standing directly in front of the woman with both hands on the client's arms.
- D. Standing in front of the client on the right side.
Correct Answer: A
Rationale: stand slightly behind patient on strong side
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An elderly man diagnosed with chronic schizophrenia is being followed in a partial hospitalization program. The client has been on long-term antipsychotic medication and has recently developed symptoms of tardive dyskinesia.
The nurse's documentation on this client should include
- A. assessment of ADL (self-care) ability.
- B. Mini-Mental Status Examination (MMSE).
- C. Abnormal Involuntary Movement Scale (AIMS).
- D. Modified Overt Aggression Scale (MOAS).
Correct Answer: C
Rationale: Strategy: Think about each answer choice. (1) assessment of client's abilities to complete his activities of daily living (ADLs) needs to be completed and revised with a client who is aging and chronically mentally ill (2) measures cognitive function (3) correct-is most widely accepted examination to Test for the presence of tardive dyskinesia (4) assessment tool for determining severity of aggression; usually utilized to determine nature, severity, and prevalence of aggression in an inpatient population
The nurse is teaching a client with chronic kidney disease about sevelamer (Renagel). Which of the following instructions should the nurse include?
- A. Take the medication with meals.
- B. Stop the medication if phosphate levels are normal.
- C. Avoid reporting constipation.
- D. Take the medication with calcium supplements.
Correct Answer: A
Rationale: Sevelamer binds phosphate during meals, reducing absorption. Options B, C, and D are incorrect.
A client is transferred to the neurology unit after developing right-sided paralysis and aphasia. Which of the following should be included in the patient's plan of care?
- A. Encourage client to shake head in response to questions.
- B. Speak in a loud voice during interactions.
- C. Speak using phrases and short sentences.
- D. Encourage the use of radio to stimulate the client.
Correct Answer: C
Rationale: will decrease tension and anxiety; client may understand some of the incoming communication if it is kept simple; speech may be relearned with appropriate support and interventions
Which of the following guidelines is appropriate for the nurse to give a mother concerning the developmental stage of her seven-year-old daughter?
- A. The child's periods of shyness are to be expected.
- B. Nightmares are not characteristic of this age and should be investigated.
- C. The child should be encouraged to care for her younger sister.
- D. Punishment may be necessary for acts of independence.
Correct Answer: A
Rationale: normal for developmental stage, beginning to show independence from parents
The physician orders meperidine (Demerol) 50 mg IM every 3-4 h PRN for pain for a client. The client asks the nurse for the medication at bedtime. Prior to administering the pain medication, the nurse should
- A. take measures to determine if the pain is psychological.
- B. check to see if the man has a history of addiction.
- C. try several other comfort and pain relief measures.
- D. learn the location, character, and intensity of the pain.
Correct Answer: D
Rationale: assessment first step in nursing process