Nokea
The nurse is assessing elderly clients at a community center. Which of the following findings would be the most cause for concern?
- A. Complaint of dry mouth
- B. Loss of 1 inch of height in the last year
- C. Stiffened joints
- D. Rales bilaterally on chest auscultation
Correct Answer: D
Rationale: Rales bilaterally on chest auscultation suggest fluid in the lungs, which could indicate serious conditions like heart failure or pneumonia, requiring immediate attention. Dry mouth, height loss, and stiffened joints are common in aging but less urgent.
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The nurse is caring for a client admitted to ICU following a heart attack. The nurse notes on the chart that the client has named his spouse to make decisions regarding his care if he is unable to speak for himself. What is the name of the document the client has signed? Fill in the blank.
- A. Living Will
- B. Do Not Resuscitate Order
- C. Durable Power of Attorney for Healthcare
- D. Advance Directive
Correct Answer: C
Rationale: The document is a **Durable Power of Attorney for Healthcare** or **Healthcare Proxy**, designating the spouse as the decision-maker.
A Turkish-speaking client is scheduled for a colonoscopy, and the nurse must provide printed directions to the client, but directions are not available in Turkish. Which of the following is most appropriate?
- A. The nurse contacts a medical translator to translate.
- B. The client's 10-year-old daughter translates the directions.
- C. The nurse draws pictures and pantomimes directions.
- D. Client's daughter is advised to tell her parent to seek a translator.
Correct Answer: A
Rationale: Contacting a medical translator (A) ensures accurate communication for critical medical instructions. Using a child (B) is unreliable, pictures/pantomime (C) may be unclear, and advising the daughter to find a translator (D) shifts responsibility inappropriately.
The nurse is calculating the Apgar score for a newborn. Findings are as follows: Heart rate: 110, Respiratory effort: good cry, Muscle tone: some flexion of extremities, Reflex irritability: grimace, Color: completely pink. What is the Apgar score for this neonate?
- A. 7
- B. 8
- C. 9
- D. 10
Correct Answer: C
Rationale: Heart rate 110 (2), good cry (2), some flexion (1), grimace (1), pink (2) = 9.
The nurse has just received the change of shift report. Which client should the nurse assess first?
- A. A client with a supratentorial tumor awaiting surgery
- B. A client admitted with a suspected subdural hematoma
- C. A client recently diagnosed with akinetic seizures
- D. A client transferring to the neuro rehabilitation unit
Correct Answer: B
Rationale: A suspected subdural hematoma is a medical emergency due to potential brain compression, requiring immediate assessment to prevent deterioration.
A client with Alzheimer's disease is awaiting placement in a skilled nursing facility. Which long-term plans would be most therapeutic for the client?
- A. Placing mirrors in several locations in the home
- B. Placing a picture of herself in her bedroom
- C. Placing simple signs to indicate the location of the bedroom, bathroom, and so on
- D. Alternating healthcare workers to prevent boredom
Correct Answer: C
Rationale: Simple signs help orient clients with Alzheimer's, reducing confusion and promoting independence in a new environment.