Nokea
The nurse is caring for clients in a rehabilitation facility. The nursing team reports that a client recovering from a hip fracture has repeatedly 'transferred herself to the floor.' Which of the following actions, if taken by the nurse, is BEST?
- A. Place the call light within the client's reach.
- B. Remove the footrests from the wheelchair.
- C. Observe the client trying to rise from a sitting to a standing position.
- D. Place a posey vest restraint on the client.
Correct Answer: C
Rationale: Observing the client’s transfer technique identifies the cause of falls, guiding interventions. Options A, B, and D are premature or restrictive.
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A nurse is assessing a patient in the rehab unit at shift change. The patient has suffered a TBI 3 weeks ago. Which of the following is the most distinguishing characteristic of a neurological disturbance?
- A. LOC (level of consciousness)
- B. Short term memory
- C. #NAME?
- D. #NAME?
Correct Answer: A
Rationale: LOC is the most critical indicator of impaired neurological capabilities.
At an inpatient psychiatric unit, a 40-year-old woman insists on staying in her room and repeatedly comments to the nurse: 'Special agents are here. Maybe you are one.'
Which of the following responses, if made by the nurse, is BEST?
- A. You can trust me. There are no agents here.'
- B. You must feel afraid if you believe that, but there are no agents here.'
- C. No one here will hurt you. They are here to help you.'
- D. Agents? Tell me more about what you mean.'
Correct Answer: B
Rationale: Strategy: Remember therapeutic communication. (1) nontherapeutic, fails to respond to feeling tone, trust builds through interactions (2) correct-patient experiencing delusion (persistent false belief), responds to feeling tone, acknowledges that patient believes it to be true, represents reality (3) statement of reassurance, but denies acceptance of patient's feelings (4) should not encourage patient to explain delusions, would serve to reinforce them
The nurse is teaching a client with a new diagnosis of Parkinson’s disease about levodopa-carbidopa (Sinemet). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication on an empty stomach.
- B. I should avoid high-protein meals with this medication.
- C. I should report any muscle twitching to my doctor.
- D. I should expect my urine to turn dark.
Correct Answer: D
Rationale: Dark urine is not an expected side effect of levodopa-carbidopa; it may indicate another issue, such as hematuria, requiring investigation. Options A, B, and C are correct: taking on an empty stomach improves absorption, high-protein meals interfere with efficacy, and muscle twitching may indicate toxicity.
The nurse is caring for a client with a history of type 2 diabetes who is receiving sitagliptin (Januvia) 100 mg PO daily. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Upper abdominal pain.
- C. Occasional thirst.
- D. Mild headache.
Correct Answer: B
Rationale: Upper abdominal pain may indicate pancreatitis, a serious sitagliptin side effect. Options A, C, and D are less urgent.
The client is admitted to the unit with the following lab values. Which of the following lab values should be reported immediately?
- A. BUN $18 \mathrm{mg} / \mathrm{dL}$
- B. $\mathrm{PO}_2 72 \%$
- C. Hemoglobin $10 \mathrm{mg} / \mathrm{dL}$
- D. White blood cell count of 5,500
Correct Answer: B
Rationale: A $\mathrm{PO}_2$ of 72% indicates severe hypoxemia, requiring immediate intervention. BUN, hemoglobin, and WBC values are less urgent.