Nokea
The nurse is caring for a manic client in the seclusion room, and it is time for lunch.
- A. What is the most appropriate action for the nurse to take for a manic client in the seclusion room at lunchtime?
- B. Take the client to the dining room with 1:1 supervision.
- C. Inform the client he may go to the dining room when he controls his behavior.
- D. Hold the meal until the client is able to come out of seclusion.
- E. Serve the meal to the client in the seclusion room.
Correct Answer: D
Rationale: For safety, a manic client in seclusion should remain in the seclusion room and have meals served there to maintain a controlled environment. Taking the client to the dining room risks escalation, delaying the meal is unnecessary, and linking meals to behavior control is inappropriate.
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During the physical assessment, the nurse determines the need to perform the bulge Test .
Which of the following statements, if made by the nurse, is BEST?
- A. Please lie down and extend your legs.
- B. Please bend over and touch your toes.
- C. Please hold both hands behind your back.
- D. Please bend your elbow.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-bulge Test confirms presence of fluid in the knee; client's leg should be extended and supported on the bed (2) observing curve of spine; scoliosis will cause lateral curve in the spine (3) unrelated to knee examination (4) Test s articulation of elbow
The nurse is caring for a client who is receiving total parenteral nutrition (TPN). Which of the following laboratory results should the nurse monitor closely?
- A. Serum potassium and glucose.
- B. Serum cholesterol and triglycerides.
- C. Serum calcium and magnesium.
- D. Serum sodium and chloride.
Correct Answer: A
Rationale: TPN can cause hyperglycemia and hypokalemia; monitoring potassium and glucose is critical. Options B, C, and D are less immediately relevant.
The nurse is caring for an older adult in his home. Which of the following factors increase the client's risk for falls? Select all that apply.
- A. The client is 78 years old.
- B. The home is a one-story home.
- C. There are several scatter rugs on the hardwood floors.
- D. The client's wife does all of the housework.
- E. There are handrails in the bathroom.
- F. There are several plants in the living room.
Correct Answer: A,C,F
Rationale: Age over 65, scatter rugs, and obstacles like plants increase fall risk. A one-story home, handrails, and the wife's housework reduce risk.
The nurse is preparing to care for a client who has returned to the surgical nursing unit following a radical neck dissection.
- A. What is the most appropriate nursing action for a client post-radical neck dissection with a tracheostomy?
- B. Suction the tracheostomy every four hours.
- C. Provide tracheostomy care every 12 hours.
- D. Assess the tracheostomy for patency every shift.
- E. Monitor the tracheostomy site for bleeding or swelling.
Correct Answer: D
Rationale: Following a radical neck dissection, monitoring the tracheostomy site for bleeding or swelling is critical due to the risk of hematoma or airway obstruction, which can be life-threatening. Suctioning and care are important but follow a schedule or as needed, and patency assessment is less urgent than monitoring for surgical complications.
The nurse is caring for a client who has right-sided weakness and has been told to use a cane for walking. Which action by the client indicates that he can use a cane correctly?
- A. He holds the cane in his right hand and moves the cane with the right leg when walking.
- B. He moves the cane from hand to hand when walking.
- C. He carries the cane in his left hand and moves it at the same time he moves his right foot.
- D. He puts the cane forward and then moves the left foot forward followed by the right foot.
Correct Answer: C
Rationale: Holding the cane in the left (unaffected) hand and moving it with the right (weak) leg provides support, indicating correct use.