Nokea
The nurse is caring for a client with partial hearing loss. Which of the following actions will promote effective communication? Select all that apply.
- A. Dim lights to prevent overstimulation
- B. Directly face the client when speaking
- C. Ensure hearing aids are properly applied
- D. Provide written information to supplement conversation
- E. Raise voice to speak loudly to the client
Correct Answer: B,C,D
Rationale: Facing the client aids lip-reading, properly applied hearing aids optimize hearing, and written information reinforces verbal communication. Dimming lights may hinder lip-reading, and shouting distorts speech.
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The practical nurse and the charge nurse work together to assign a semi-private room to a client with diabetes mellitus admitted for IV antibiotic therapy to treat argumentative cellulitis. Which of the 4 room assignments is the best option for this client?
- A. Room 1: Client 1 day postoperative laparoscopic cholecystectomy who is awaiting discharge
- B. Room 2: Client with dementia and urinary incontinence wearing an external urine collection device
- C. Room 3: Client with history of splenectomy 15 years ago, now admitted for pulmonary embolism
- D. Room 4: Client with lupus nephritis who is prescribed treatment with azathioprine
Correct Answer: A
Rationale: The postoperative client in Room 1 is stable and awaiting discharge, posing the least risk of complications or infection to the client with cellulitis. Other roommates have conditions (dementia, embolism, immunosuppression) that could complicate care or increase infection risk.
The nurse is reviewing the medical record for an adolescent client with major depressive disorder. Which of the following findings would be consistent with the condition? Select all that apply.
- A. often sleeps during class or after-school activities
- B. has received disciplinary action at school due to absenteeism and angry outbursts
- C. has unintentionally lost 8 lb (3.6 kg) over the past 3 weeks
- D. abruptly quit playing sports despite receiving previous athletic awards and trophies
- E. voices concern about the appearance of acne on the face
Correct Answer: A,B,C,D
Rationale: Excessive sleep, irritability (outbursts), weight loss, and loss of interest in activities (quitting sports) are hallmarks of depression. Acne concern is typical adolescent behavior, not specific to depression.
The nurse is caring for a client with deep venous thrombosis of the lower extremity. Which of the following findings would the nurse expect to observe? Select all that apply.
- A. dry, shiny, hairless skin on the affected extremity
- B. warmth and redness of the affected extremity
- C. reports of pain in the affected calf
- D. edema of the affected extremity
- E. cyanosis of the affected toes
Correct Answer: B,C,D
Rationale: DVT causes inflammation, leading to warmth, redness, pain, and edema in the affected extremity. Dry, shiny, hairless skin and cyanosis are more typical of arterial insufficiency, not DVT.
Which findings reflect vital signs that are concerning and require further nursing monitoring and intervention? Select all that apply.
- A. After albuterol administration, 5-year-old client has a pulse of 120/min and reports tremor
- B. After hydromorphone 1 mg IV push, blood pressure decreases from 130/80 mm Hg to 110/70 mm Hg
- C. Blood pressure is 90/60 mm Hg, and the nurse is preparing to administer prescribed nifedipine
- D. Blood pressure was 120/80 mm Hg and pulse was 80/min before blood transfusion, current values are 90/70 mm Hg and 100/min, respectively
- E. Fetal heart rate monitored during labor decreases from 140/min to 100/min following a contraction
Correct Answer: C,D,E
Rationale: Hypotension (90/60 mm Hg) with nifedipine risks severe hypotension. Transfusion-related hypotension and tachycardia suggest a reaction. Fetal heart rate deceleration post-contraction indicates potential distress. Albuterol's tachycardia/tremor and hydromorphone's mild BP drop are expected.
The nurse is planning care for a group of senior citizens. The nurse should plan activities that promote achievement of which developmental task?
- A. Identity
- B. Intimacy
- C. Generativity
- D. Ego integrity
Correct Answer: D
Rationale: Ego integrity, accepting one's life as meaningful, is the developmental task for seniors per Erikson's theory. Identity, intimacy, and generativity apply to younger stages.