Nokea
The nurse is caring for a client who is recovering from a cerebrovascular accident and is partially paralyzed on the right side. How should the nurse position the chair when getting the client out of bed?
- A. On the right side of the bed facing the foot of the bed
- B. On the right side of the bed facing the head of the bed
- C. On the left side of the bed facing the foot of the bed
- D. On the left side of the bed facing the head of the bed
Correct Answer: C
Rationale: Placing the chair on the left (unaffected) side facing the foot allows the client to pivot using their stronger side, facilitating safe transfer. Right-side placement or incorrect orientation hinders mobility.
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While admitting a client to an acute-care psychiatric unit, the nurse asks about substance abuse based on knowledge that:
- A. psychiatric illness is more prevalent in addicted populations.
- B. people with psychiatric disorders are more prone to substance abuse.
- C. substance disorders are easily detected and diagnosed in acute-care psychiatric settings.
- D. undetected substance problems have no real effect on treatment of psychiatric disorders.
Correct Answer: B
Rationale: The failure to address substance abuse among clients with psychiatric disorders interferes with treatment effectiveness and contributes to relapse. Misdiagnosis of a psychiatric disorder, suboptimal pharmacological treatment, neglect of appropriate interventions, or an inappropriate referral might also occur.
A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client and nurse while guiding the client to a horizontal position on the floor?
- A. Step behind client with arms around waist, squat using the quadriceps, and lower client to the floor
- B. Step in front of client, brace knees and feet against the client's, and assist to the floor gently
- C. Step slightly behind client with feet apart, extend one leg, and let client slide against it to the floor
- D. Step 12 inches behind the client, support under axillae, tighten back, and lower client to the floor
Correct Answer: C
Rationale: This technique (C) ensures the nurse maintains balance with feet apart and uses their leg to guide the client safely to the floor, minimizing injury risk to both. Option A risks the nurse losing balance, B places the nurse in an unsafe position, and D involves improper body mechanics.
Thirty-six hours after major surgery, a client has a temperature of 100°F. What is the most likely cause of the temperature elevation?
- A. Dehydration
- B. Atelectasis
- C. Wound infection
- D. Bladder infection
Correct Answer: B
Rationale: Atelectasis, due to reduced lung expansion post-surgery, is a common cause of low-grade fever within 24–48 hours. Dehydration, wound infection (typically later), or bladder infection are less likely without specific symptoms.
A home health nurse is visiting a client with chronic heart failure. The nurse observes that the client is having trouble answering questions due to breathlessness and cough. Which action should the nurse take first?
- A. Auscultate breath sounds
- B. Check for peripheral edema
- C. Measure the client's vital signs
- D. Review the client's weight log over the past several days
Correct Answer: A
Rationale: Auscultating breath sounds (A) assesses the cause of breathlessness (e.g., pulmonary edema) in heart failure, guiding immediate interventions. Edema (B), vitals (C), and weight (D) are secondary.
A woman who had a tuberculosis test three days ago reports to the nurse to have the test read. Which finding, if present, indicates a positive result and a need for referral and follow-up?
- A. A red area 12 mm in diameter
- B. A raised area 10 mm in diameter
- C. Itching at the injection site
- D. A rash on the arm near the test site
Correct Answer: B
Rationale: A raised (indurated) area >10 mm indicates a positive TB skin test, requiring follow-up for potential latent or active TB.