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The nurse is caring for a client with a history of dementia.
- A. Which intervention is most effective for communicating with a client with dementia?
- B. Speak loudly to ensure understanding.
- C. Use simple, clear sentences.
- D. Ask open-ended questions.
- E. Provide written instructions.
Correct Answer: B
Rationale: Using simple, clear sentences enhances comprehension in dementia patients with cognitive impairment. Loud speaking is unnecessary, open-ended questions overwhelm, and written instructions are ineffective.
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A newborn has hyperbilirubinemia and is undergoing phototherapy with a fiberoptic blanket. Which safety measure is most important during this process?
- A. Regulate the neonate's temperature using a radiant heater
- B. Withhold feedings while under the phototherapy
- C. Provide water feedings at least every 2 hours
- D. Protect the eyes of neonate from the phototherapy lights
Correct Answer: C
Rationale: Provide water feedings at least every 2 hours. Protecting the eyes of the neonates is very important to prevent damage when under the ultraviolet lights, but since the blanket is used, extra protection of the eyes is unnecessary. It is recommended that the neonate remain under the lights for extended periods. The neonate's skin is exposed to the light and the temperature is monitored, but a heater may not be necessary. There is no reason to withhold feedings. Frequent water or feedings are given to help with the excretion of the bilirubin in the stool.
A teen hospitalized with anorexia nervosa is now permitted to leave her room and eat in the dining room. Which of the following nursing interventions should be included in the client's plan of care?
- A. Weighing the client after she eats
- B. Having a staff member remain with her for 1 hour after she eats
- C. Placing high-protein foods in the center of the client's plate
- D. Providing the client with child-sized utensils
Correct Answer: B
Rationale: Having a staff member stay with the client for 1 hour after eating prevents purging, a common behavior in anorexia nervosa.
The nurse is providing instructions for a client with asthma who is sensitive to house dust-mites. Which information about prevention of asthma episodes would be the most helpful to include during the teaching?
- A. Change the pillow covers every month
- B. Wash bed linens in warm water with a cold rinse
- C. Wash and rinse the bed linens in hot water
- D. Use air filters in the furnace system
Correct Answer: C
Rationale: Wash and rinse the bed linens in hot water. For asthma clients sensitive to house dust-mites, washing bed linens in hot water above 130 degrees Fahrenheit is necessary to kill dust-mites.
The nurse is teaching a client with a new diagnosis of atrial fibrillation about diltiazem (Cardizem). Which of the following instructions should the nurse include?
- A. Take the medication with grapefruit juice.
- B. Report any swelling in the legs.
- C. Stop the medication if heart rate normalizes.
- D. Avoid checking pulse rate.
Correct Answer: B
Rationale: Swelling in the legs may indicate heart failure, requiring reporting. Options A, C, and D are incorrect.
A client returned from surgery for a perforated appendix with localized peritonitis. In view of this diagnosis, how would the nurse position the client?
- A. Prone
- B. Dorsal recumbent
- C. Semi-Fowler
- D. Supine
Correct Answer: C
Rationale: Semi-Fowler. The semi-Fowler position assists drainage and prevents spread of infection throughout the abdominal cavity.