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The nurse is caring for a client who has recently had a cerebrovascular accident (CVA). When positioning the client and supporting her extremities, the nurse must remember that when voluntary control of muscles is lost:
- A. the feet will maintain a position of eversion.
- B. the upper extremities will rotate externally.
- C. the hip joint will rotate internally.
- D. flexor muscles will become stronger than extensors.
Correct Answer: D
Rationale: After a CVA, flexor muscles become stronger than extensors, leading to flexion contractures, requiring careful positioning to prevent deformities.
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The client with diminished sight has problems with the glare from light. Which recommendation should the nurse make?
- A. Install fluorescent lighting throughout the home.
- B. Wear sunglasses and hats with brims when outdoors.
- C. Avoid going outdoors on days that are sunny.
- D. Use direct sunlight from windows rather than lights.
Correct Answer: B
Rationale: Wearing sunglasses and hats with brims while outdoors blocks direct light, reducing glare. Fluorescent lighting and direct sunlight increase glare, and avoiding sunny days is unnecessary.
Which statement by the daughter of an 80-year-old female client who lives alone warrants immediate intervention by the nurse?
- A. I put a night-light in my mother’s bedroom.
- B. I got carbon monoxide detectors for my mother’s house.
- C. I changed my mother’s furniture around.
- D. I got my mother large-print books.
Correct Answer: C
Rationale: Changing furniture increases fall risk in an elderly client with potential sensory deficits, requiring intervention. Night-lights, CO detectors, and large-print books enhance safety.
The client is a 60-year-old man who had a stapedectomy. He is to ambulate for the first time. Which nursing action should be taken?
- A. Encourage him to walk as far as he comfortably can
- B. Suggest that he practice bending and stretching exercises
- C. Walk with him, holding his arm
- D. Tell him to take deep breaths while he is ambulating
Correct Answer: C
Rationale: Walking with the client and holding his arm ensures safety and prevents falls post-stapedectomy.
Which referral is most important for the nurse to implement for the client with permanent hearing loss?
- A. Aural rehabilitation.
- B. Speech therapist.
- C. Social worker.
- D. Vocational rehabilitation.
Correct Answer: A
Rationale: Aural rehabilitation addresses communication strategies and hearing aids, critical for permanent hearing loss. Speech therapy, social work, and vocational rehab are secondary.
The nurse speaks with the client who recently learned that cataracts are developing in both of the client's eyes. Which statement made by the client should the nurse correct?
- A. It is important that I schedule my surgery as soon as possible.
- B. Usually surgery is performed on each eye at different times.
- C. My own lens will be removed when I have cataract surgery.
- D. An intraocular lens may be inserted with the surgical procedure.
Correct Answer: A
Rationale: Although there is reduced vision with beginning cataract development, a person can wait until vision worsens before having surgery. When vision is reduced to the extent that ADLs are affected, surgery should be performed as soon as possible. If both eyes have cataracts, usually the eyes are treated in separate procedures. Surgery for a cataract involves removal of the client's lens, and in most situations, the lens is replaced with an intraocular lens.