Nokea
The nurse is caring for a client on complete bed rest. Which action by the nurse is most important in preventing the formation of deep vein thrombosis?
- A. Elevate the foot of the bed
- B. Apply knee high support stockings
- C. Encourage passive exercises
- D. Prevent pressure at back of knees
Correct Answer: D
Rationale: Preventing popliteal pressure will prevent venous stasis and possibly deep vein thrombosis.
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The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
The nurse is caring for a client with a history of anxiety disorder.
- A. Which intervention is most effective for managing acute anxiety in a client?
- B. Administer a benzodiazepine as ordered.
- C. Encourage deep breathing exercises.
- D. Restrict the client to their room.
- E. Provide a high-stimulus environment.
Correct Answer: B
Rationale: Deep breathing exercises calm the autonomic nervous system, reducing acute anxiety effectively and non-invasively. Benzodiazepines are used cautiously, isolation increases anxiety, and high-stimulus environments worsen it.
Following hip replacement surgery, an elderly client is ordered to begin ambulation with a walker.
Which of the following statements by the nurse is BEST?
- A. Sit in a low chair for ease in getting up to use the walker.
- B. Make sure rubber caps are in place on all four legs of the walker.
- C. You will begin weight-bearing on the affected hip soon.
- D. Practice tying your own shoes before you begin ambulating.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (2) correct-intact rubber caps should be present on walker legs to prevent accidents (3) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks (4) full weight bearing or flexion of the hip greater than 90° should be avoided for four to six weeks
The nurse is discussing negativity with the parents of a 30 month-old child. How should the nurse tell the parents to best respond to this behavior?
- A. Reprimand the child and give a 15 minute 'time out'
- B. Maintain a permissive attitude for this behavior
- C. Use patience and a sense of humor to deal with this behavior
- D. Assert authority over the child through limit setting
Correct Answer: C
Rationale: Use patience and a sense of humor to deal with this behavior. This approach supports the toddler’s developing autonomy.
A client with clotting disorder has an order to continue Lovenox (Enoxaparin) injections after discharge. In assessing the client's readiness for teaching, the most important factor for the nurse to assess is the client's:
- A. Prior knowledge of anticoagulants and their role in controlling his disease
- B. Willingness to learn about injection techniques and site selection
- C. Adaptation to the need for daily injections to control his symptoms
- D. Overall intelligence and developmental level
Correct Answer: B
Rationale: Willingness to learn is critical for effective teaching about self-administering injections. Knowledge, adaptation, and intelligence are secondary.