Nokea
The nurse is caring for a 78-year-old woman in a long-term care facility. The client is sitting in a geriatric chair with the attached tray in place. The client is agitated and appears to be sliding down in the chair. What is the best action for the nurse to take?
- A. Ask the supervisor for advice
- B. Put a jacket restraint on the client
- C. Tie a sheet around the client's waist
- D. Use foam wedges beside the client
Correct Answer: D
Rationale: Foam wedges stabilize the client safely and comfortably, preventing sliding without restrictive measures. Restraints (jacket or sheet) increase agitation and risk, and consulting the supervisor delays action.
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An adult has the following blood gasses: pH=7.52, pCO2=50, HCO3=35, and pO2=90. What is most likely to be in the client's history of presenting signs and symptoms?
- A. Persistent diarrhea
- B. Frequent vomiting
- C. Anxiety attack
- D. Emphysema
Correct Answer: B
Rationale: High pH and HCO3 indicate metabolic alkalosis, commonly caused by frequent vomiting, losing gastric acid.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should rotate injection sites.
- C. I should refrigerate unopened vials.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.
Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. There is an increased ability to see another's point of view.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusions.
Correct Answer: C
Rationale: Concrete operations (ages 7-11) involve logical, coherent thought about concrete events. Perspective-taking develops but is not primary, and abstract thinking is characteristic of later stages.
The nurse is caring for a client who is postoperative day 1 after a pancreaticoduodenectomy (Whipple procedure). Which of the following findings should the nurse report immediately?
- A. Pain at the incision site.
- B. Temperature of 100.8°F (38.2°C).
- C. Nasogastric tube output of 200 mL.
- D. Urine output of 40 mL/hour.
Correct Answer: B
Rationale: A temperature of 100.8°F suggests infection, a serious post-Whipple complication. Options A, C, and D are normal.
Which assessment finding is most indicative of increased ICP in a client admitted with a basilar skull fracture?
- A. Nausea and vomiting
- B. Headache
- C. Dizziness
- D. Papilledema
Correct Answer: D
Rationale: Papilledema, or swelling of the optic disc, is a specific sign of increased intracranial pressure due to pressure on the optic nerve. Nausea, vomiting, headache, and dizziness are less specific symptoms, so answers A, B, and C are incorrect.