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 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 licensed practical nurse is monitoring a client receiving an IV of Nipride in D5W. The IV bag has a foil covering, and the nurse notes that the IV fluid has a light brownish tint. The nurse should:
- A. Discard the solution.
- B. Obtain a bag of normal saline.
- C. Cover both the solution bag and the IV tubing with foil.
- D. Do nothing because the solution is expected to be light brown in color.
Correct Answer: D
Rationale: Nipride (nitroprusside) is light-sensitive and turns light brown, which is normal if protected by foil. No action is needed.
Because a client has Addison's disease, the nurse would expect to see which of the following in the nursing assessment?
- A. A supraclavicular fat pad
- B. A puffy face
- C. Low blood pressure
- D. Ecchymotic areas
Correct Answer: C
Rationale: Addison's disease causes cortisol and aldosterone deficiency, leading to hypotension. Fat pads and puffy face are Cushing's symptoms, and ecchymosis is less specific.
The licensed practical nurse (LPN) assigns the ambulation of a client to unlicensed assistive personnel (UAP). The LPN observes UAP placing the clients Foley bag on the IV pole at the level of the client's chest during client ambulation down the length of the hallway. What action should the LPN take initially?
- A. Immediately lower the bag and speak privately to unlicensed assistive personnel (UAP)
- B. Let UAP complete assigned tasks and speak to them at the end of the shift
- C. Praise UAP for encouraging the client to walk the entire hallway
- D. Speak with the nurse manager about the need for UAP inservice education
Correct Answer: A
Rationale: The Foley bag must be kept below bladder level to prevent urine backflow and infection risk. Immediate correction and private education ensure safety and learning without delay.
A client with glaucoma has been prescribed Timoptic (timolol) eye drops. Timoptic should be used with caution in the client with a history of:
- A. Diabetes
- B. Gastric ulcers
- C. Emphysema
- D. Pancreatitis
Correct Answer: C
Rationale: Timolol, a beta-blocker, can exacerbate emphysema by causing bronchoconstriction. Diabetes , ulcers , and pancreatitis are not contraindications.