The nurse is caring for an older adult. Which statement made by the client is not typical of normal aging?
- A. I seem to be more sensitive to the taste of salt than I used to be.'
- B. I have trouble reading the newspaper.'
- C. I don't drive at dusk anymore.'
- D. Sometimes I have trouble matching my socks.'
Correct Answer: A
Rationale: Increased sensitivity to salt taste is not typical of aging; taste sensitivity usually decreases. Difficulty reading, avoiding dusk driving, and color matching issues are normal aging changes.
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A client with severe multiple trauma injuries from a motor vehicle accident.
After stabilizing a client with severe multiple trauma injuries from a motor vehicle accident, which of the following actions by the nurse is BEST?
- A. Limit visiting hours to promote optimal rest.
- B. Arrange for clergy to visit with the client and family as requested.
- C. Arrange for a psychologist to visit with the family.
- D. Arrange for the family to meet with a social worker to discuss financial aid.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer. Is it desired? (1) inappropriate (2) correct-would provide the appropriate spiritual support necessary during a crisis (3) inappropriate for the data given in the situation (4) inappropriate for the data given in the situation
A client with lung cancer is advised to increase the protein and kilocalorie content of his diet. Which of the following choices will best meet his need for increased protein and calories?
- A. Toast, jelly, chicken broth
- B. Crackers, butter, fresh vegetables
- C. Crackers, fresh fruit, ginger ale
- D. Crackers, cheese, fruit yogurt
Correct Answer: D
Rationale: Cheese and yogurt provide high protein and calories, ideal for a client with lung cancer needing nutritional support.
The nurse is transcribing the following physician's orders.
Which of the following orders warrants further clarification?
- A. Administer haloperidol (Haldol) 5 mg.
- B. Instruct client to use incentive spirometer q1h while awake.
- C. D5W 1/4 NS + KCl 20 mEq/L at 100 mL/h.
- D. CBC with differential and platelets at 8 AM.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-has no route of administration or schedule (2) clear and complete and needs no further clarification (3) clear and complete and needs no further clarification (4) clear and complete and needs no further clarification
The nurse is working in a surgeon's office and talking with a client who is scheduled for surgery in two weeks. The nurse asks about medications and supplements the client may be taking. What medication(s) the client reports would be of most concern to the nurse? Select all that apply.
- A. Acetaminophen
- B. Ibuprofen
- C. Vitamin C
- D. Vitamin E
- E. Ginseng
- F. Vitamin B complex
Correct Answer: B,D,E
Rationale: Ibuprofen, Vitamin E, and ginseng increase bleeding risk, posing concerns for surgical hemostasis.
A client is admitted with the diagnosis of meningitis. Which finding would the nurse expect when assessing this client?
- A. Hyperextension of the neck with passive shoulder flexion
- B. Flexion of the hip and knees with passive flexion of the neck
- C. Flexion of the legs with rebound tenderness
- D. Hyperflexion of the neck with rebound flexion of the legs
Correct Answer: B
Rationale: Flexion of the hip and knees with passive flexion of the neck. This is a positive Brudzinski's sign, indicative of meningitis.
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