Nokea
The nurse is caring for a client with Parkinson's disease. The client spends over 1 hour to dress for scheduled therapies. What is the most appropriate action for the nurse to take in this situation?
- A. Ask family members to dress the client
- B. Encourage the client to dress more quickly
- C. Allow the client the time needed to dress
- D. Demonstrate methods on how to dress more quickly
Correct Answer: C
Rationale: Allow the client the time needed to dress. Clients with Parkinson's disease often wish to take care of themselves but become very upset when hurried and then are unable to manage at all.
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The nurse is reinforcing instructions to a client receiving oxybutynin for overactive bladder. Which client statement indicates that further teaching is required?
- A. I am looking forward to our summer vacation at the beach
- B. I plan to eat more fruits and vegetables to prevent constipation
- C. I should not drive until I know how this drug affects me
- D. I will drink at least 6-8 glasses of water daily
Correct Answer: A
Rationale: Planning a beach vacation suggests unawareness of oxybutynin’s heat intolerance side effect, increasing dehydration risk. Preventing constipation, avoiding driving, and adequate hydration are correct.
A nurse is asked to float to the telemetry unit because the unit is short-staffed. The nurse is not familiar with this client population and is concerned about providing safe client care. What is the best action by the nurse?
- A. Accept the assignment and ask about what skills need to be performed
- B. Ask the nurse supervisor if a more experienced nurse can go instead
- C. Read the policy and procedure book for the unit before providing care
- D. Refuse to float to the unit because of concerns about client safety
Correct Answer: A
Rationale: Accepting the assignment and clarifying required skills ensures safe care with support, addressing concerns proactively. Refusing or deferring may disrupt staffing, and reading policies delays care.
The nurse is caring for a client hospitalized with bipolar disorder, manic phase who is taking Eskalith (lithium carbonate). Which of the following snacks would be best for the client?
- A. Potato chips
- B. Diet cola
- C. An apple
- D. A milkshake
Correct Answer: C
Rationale: Lithium carbonate can cause sodium depletion, and high-sodium snacks like potato chips should be avoided to prevent toxicity. Diet cola lacks nutritional value and may contain caffeine, which can exacerbate mania. An apple is a healthy, low-sodium snack that supports hydration and nutrition. A milkshake may be high in sugar or fat, which is less ideal.
An adult diagnosed with celiac disease 3 weeks ago was placed on a gluten-free diet. The client returns for ambulatory care follow-up, reports continuation of symptoms, and does not seem to be responding to therapy. Which is the best response by the nurse?
- A. It should take about 6-8 weeks before your symptoms improve
- B. Tell me what you had to eat yesterday
- C. We will refer you to the dietitian
- D. You must not be following your diet
Correct Answer: B
Rationale: Asking about recent food intake helps identify unintentional gluten exposure, common in new celiac diagnoses. Assuming 6-8 weeks, immediate referral, or blaming non-compliance may overlook dietary errors or other causes.
The nurse is caring for a child admitted with measles. Which of the following interventions should the nurse anticipate for this client? Select all that apply.
- A. Advising measles vaccination for susceptible family members
- B. Applying calamine lotion to reduce itching
- C. Placing a tracheostomy tray at the bedside
- D. Placing the client in a negative pressure isolation room
- E. Using an N95 respirator mask during client contact
Correct Answer: A,D
Rationale: Measles is highly contagious, requiring negative pressure isolation to prevent airborne spread and vaccination for susceptible contacts to prevent outbreaks. Calamine is for skin conditions like chickenpox, tracheostomy is not indicated, and N95 masks are for tuberculosis, not measles (droplet precautions).