Nokea
The nurse is caring for a male client with decreased circulation in the lower extremities. The client washes his feet in the shower but is unable to bend safely to dry the feet.While drying the client's feet, the nurse should emphasize the need to thoroughly dry which area of the feet?
- A. On the dorsal surfaces.
- B. Between the toes.
- C. Over the heels.
- D. Around the ankles.
Correct Answer: B
Rationale: While drying the client's feet, the nurse should emphasize the need to thoroughly dry between the toes. Moisture between the toes can create a breeding ground for bacteria and fungi, which can lead to infections such as athlete's foot.
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Which of the following responses would be the most therapeutic when communicating with a client who has recently had a visit from their significant other and is displaying changes in behavior?
- A. Tell me about the visit with your significant other. I can see that you are feeling lonely.
- B. I noticed that you were more insulting to the evening group after your significant other left. Why is that?
- C. Why don't you try to make some friends here so you won't feel so lonely?
- D. It sounds like your visit with your significant other was important to you. How did it go?
- E. None
- F. None
Correct Answer: D
Rationale: This response is most therapeutic because it offers the client an opportunity to talk and express their feelings while also focusing on the positive aspects of their visit.
The nurse is teaching a client how to do active range of motion (ROM) exercises.To exercise the hinge joints, which action should the nurse instruct the client to perform?
- A. Tap the feet forwards and backwards.
- B. Bend the arm by flexing the ulna to the humerus.
- C. Turn the head to the right and left.
- D. Extend the arm at the side and rotate in circles.
Correct Answer: B
Rationale: To exercise the hinge joints, the nurse should instruct the client to bend the arm by flexing the ulna to the humerus. Hinge joints allow for movement in one direction, like a door hinge. The elbow joint is an example of a hinge joint.
A client presents to the doctor's office with a report of fatigue and difficulty sleeping.Which information should the nurse recognize as a potential contributing factor?
- A. Reads a book entitled 'How to Sleep Better'.
- B. Exercises in the morning and afternoon.
- C. Consumes antibiotics twice a day.
- D. Sleeps between 10 PM and 9 AM each night.
Correct Answer: C
Rationale: Antibiotics can have side effects that may contribute to fatigue and difficulty sleeping.
A healthcare organization requires nurses to chart by exception. Which assessment should the nurse document?
- A. Basilar lung sounds that are diminished in the left lung.
- B. Contraction of the left pupil when light shines in the right eye.
- C. Capillary refill of 2 seconds in the lower right foot.
- D. Active bowel sounds in the lower right quadrant.
Correct Answer: A
Rationale: Charting by exception means that the nurse only documents findings that deviate from the established norm or expected outcome. In this case, the nurse should document the assessment that is not within normal limits, which is 'Basilar lung sounds that are diminished in the left lung.'
How should the nurse document the finding of pain, numbness, and tingling sensations in the lower legs?
- A. Acute pain.
- B. Neuropathic pain.
- C. Visceral pain.
- D. Nociceptive pain.
Correct Answer: B
Rationale: The symptoms of pain, numbness, and tingling sensations in the lower legs are consistent with neuropathic pain. Neuropathic pain is a complex type of pain initiated or caused by a primary lesion or dysfunction in the nervous system.