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The nurse is caring for a client with cirrhosis of the liver with ascites. When instructing nursing assistants in the care of the client, the nurse should emphasize that:
- A. The client should remain on bed rest in a semi-Fowler's position.
- B. The client should alternate ambulation with bed rest with legs elevated.
- C. The client may ambulate and sit in chair as tolerated.
- D. The client may ambulate as tolerated and remain in semi-Fowlers positioning bed.
Correct Answer: D
Rationale: Semi-Fowler's position aids in breathing and reduces pressure on the abdomen.
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When assessing the health beliefs and practices of an older Hispanic adult, the nurse observes that the client uses a traditional folk healer to manage health problems. How would you respond?
- A. Respectfully acknowledge the practice and integrate it where possible.
- B. Discredit the folk healer's methods.
- C. Insist on conventional medical treatment only.
- D. Ignore the client's preference.
Correct Answer: A
Rationale: Respecting and integrating traditional practices fosters trust and collaboration in care delivery.
Describe the differences in action of SSRIs, SNRIs, and atypical antidepressants.
- A. High blood pressure
- B. Increased heart rate
- C. Decreased oxygen supply
- D. Muscle relaxation
Correct Answer: D
Rationale: The correct answer is D because it is the most appropriate response based on physiological and medical principles.
What is the primary role of lubricating eye drops?
- A. Moisten the eyes
- B. Treat infections
- C. Correct refractive errors
- D. None of the above
Correct Answer: A
Rationale: Lubricating drops relieve dryness and discomfort by moisturizing the ocular surface.
Which nursing actions would demonstrate the nurse’s understanding of the concept of providing safe care without using restraints (select all that apply)?
- A. Placing patients with fall risk in low beds.
- B. Making hourly rounds on patients to assess for pain and toileting needs.
- C. Applying a jacket vest loosely so the patient can turn but cannot climb out of bed.
- D. Placing a disruptive patient near the nurses’ station in a chair with a seat belt.
Correct Answer: B
Rationale: Low beds, frequent checks, and strategic placement reduce risks without resorting to physical restraints.
A patient who completed detoxing from heroin tells you that his or her family members who are not substance abusers do not understand how it feels to go through withdrawal. He or she asks you for advice. Which of the following is the best response?
- A. Tell your family members to attend Alcoholics Anonymous.
- B. Ask your family members if they ever had the flu. Tell them that withdrawal is like having the worst flu they ever had.
- C. Tell your family member that going through withdrawal is like going on a diet.
- D. Tell your family member to try heroin once.
Correct Answer: B
Rationale: Comparing withdrawal to a severe flu helps family members understand the physical symptoms without trivializing the experience.