Nokea
The nurse is caring for an assigned team of clients. Which client is the priority for the nurse at this time?
- A. Client admitted with Guillain-Barré syndrome yesterday is paralyzed to the knees
- B. Client admitted with multiple sclerosis exacerbation has scanning speech
- C. Client with epilepsy puts on call light and reports having an aura
- D. Client with fibromyalgia reports pain in the neck and shoulders
Correct Answer: C
Rationale: An aura (C) indicates an impending seizure, requiring immediate intervention to ensure safety. Guillain-Barré (A), multiple sclerosis (B), and fibromyalgia (D) are less acute at this moment.
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The client with COPD may lose weight despite having adequate caloric intake. When counseling the client in ways to maintain an optimal weight, the nurse should tell the client to:
- A. Continue the same caloric intake and decrease his activity level
- B. Increase his activity level to stimulate his appetite
- C. Increase the amount of complex carbohydrates and decrease the amount of fat intake
- D. Decrease the amount of complex carbohydrates while increasing calories, protein, fat, vitamins, and minerals
Correct Answer: D
Rationale: Clients with COPD often have increased metabolic demands and may lose weight. To maintain optimal weight, they should increase overall caloric intake, including protein, fat, vitamins, and minerals, while possibly decreasing complex carbohydrates to balance the diet. Answer A is incorrect as decreasing activity is not beneficial. Answer B may not be feasible due to respiratory limitations. Answer C does not address the need for increased calories and nutrients.
The nurse reviews the ECG of a client. Which prescribed medication should the nurse suspect as the cause of the ECG findings?
- A. Captopril
- B. Carvedilol
- C. Glipizide
- D. Levothyroxine
Correct Answer: D
Rationale: Levothyroxine (D) can cause arrhythmias, which may be reflected in ECG changes. Captopril (A), Carvedilol (B), and Glipizide (C) are less likely to cause significant ECG alterations.
The nurse is instructing the client with a fractured femur in crutch walking. When instructing the client in the best method of manipulating stairs, the nurse should tell the client to:
- A. Start up the stairs with the crutches first.
- B. Start up the stairs with the unaffected leg first.
- C. Use the affected leg to move up the stairs first.
- D. Use the unaffected leg to move down the stairs.
Correct Answer: B
Rationale: For ascending stairs, lead with the unaffected leg to bear weight, followed by crutches and affected leg. This ensures stability and safety.
The nurse is caring for an ambulatory client who has a new order for continuous cardiac monitoring via a portable unit. It would require follow-up if the nurse
- A. verifies that gel is present on each electrode and is not dried out
- B. cleanses and dries the skin before placing the electrodes on the client
- C. clips excessive hair off the client before applying the electrodes
- D. places one electrode each on the client's upper and lower extremities
Correct Answer: D
Rationale: Placing electrodes on extremities (D) is incorrect for cardiac monitoring, which requires chest placement. Verifying gel (A), cleansing skin (B), and clipping hair (C) are appropriate.
A client with obesity reports several failed attempts at weight loss. Which client statement best indicates that the client is ready and motivated for successful weight loss?
- A. I have signed up to be a dog walker when I normally would watch television.'
- B. I understand that losing weight would improve my health and well-being.'
- C. I want to lose 8 pounds (3.6 kg) so that my formal gown will fit in 4 weeks.'
- D. My spouse and children are always encouraging me to eat healthier.'
Correct Answer: A
Rationale: Signing up as a dog walker (A) shows a concrete behavioral change, indicating readiness. Understanding benefits (B), short-term goals (C), or external encouragement (D) are less indicative of sustained motivation.