Nokea
The nurse is conducting a home visit to assess an elderly client with advanced heart failure who lives alone. When the nurse asks about sodium intake, the client becomes angry and says, 'I'm so tired of people telling me what to do! I'm going to eat what I want, so leave me alone!' Which of the following is the most appropriate response by the nurse?
- A. I can tell that you want me to go, so I will call in a few days to see how you are doing.
- B. I know you are frustrated with losing control of your life.
- C. It sounds like you are angry. Tell me what's bothering you.
- D. Okay. I'll just check your blood pressure and then go.
Correct Answer: C
Rationale: Acknowledging the client's anger and inviting them to express their feelings promotes therapeutic communication, helping to de-escalate the situation and address underlying concerns.
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A triage nurse has these 4 clients arrive in the emergency department within a 15 minute period. Which client should the triage nurse send back to be seen first?
- A. A 2 month old infant with a history of rolling off the bed and has bulging fontanels with crying
- B. A teenager who got a singed beard while camping
- C. An elderly client with complaints of frequent liquid brown colored stools
- D. A middle aged client with intermittent pain behind the right scapula
Correct Answer: B
Rationale: A teenager who got a singed beard while camping. This client is in the greatest danger with a potential of respiratory distress, Any client with singed facial hair has been exposed to heat or fire in close range that could have caused damage to the interior of the lung. Note that the interior lining of the lung has no nerve fibers so the client will not be aware of swelling.
The nurse is planning care for a client who has a hearing impairment. Which action will likely help the most with communication?
- A. Repeat everything twice.
- B. Speak loudly.
- C. Speak slowly and clearly.
- D. Use gestures.
Correct Answer: C
Rationale: Speaking slowly and clearly enhances comprehension for hearing-impaired clients. Repeating, shouting, or gestures may confuse or overwhelm.
A client has just been diagnosed with diabetes and is admitted for insulin regulation. The client asks the nurse, 'Why do I need to be stuck so many times per day?' Which of the following statements best explains the rationale for checking the client's blood glucose level frequently?
- A. Blood glucose levels need to be checked every hour to ensure constant insulin needs.'
- B. Any fluctuation in blood glucose levels must be avoided.'
- C. Blood glucose levels are checked to be able to adjust the dosage of your insulin.'
- D. Elevations in glucose can result in alkalosis.'
Correct Answer: C
Rationale: Frequent blood glucose checks allow for insulin dose adjustments to maintain glycemic control. Hourly checks are excessive, fluctuations are managed not avoided, and alkalosis is unrelated to glucose elevations.
The nurse in a long-term care facility is talking with a client with multiple sclerosis who states, 'I want to live in my own home again.' Which of the following responses would be most appropriate for the nurse to make?
- A. Do you have family or friends who could live with you?
- B. I will refer you to a local home-health agency.
- C. How will you manage your care at home?
- D. Tell me more about your concerns.
Correct Answer: D
Rationale: Encouraging the client to express their concerns promotes client-centered care and helps the nurse understand the client's motivations and needs for returning home.
The nurse is collecting data from a 30-month-old client. Which of the following findings would require follow-up?
- A. head circumference has increased by 1 inch (2.5 cm) in the past year
- B. current weight is six times greater than birth weight
- C. nighttime bladder control has not been achieved
- D. anterior and posterior fontanels are both fused
Correct Answer: C
Rationale: Lack of nighttime bladder control at 30 months may indicate developmental delay or medical issues, requiring follow-up to assess for underlying causes.