Nokea
The nurse is conducting an aphasia assessment of a client who has suffered a stroke. Which of the following observations should the nurse include in the assessment? Select all that apply.
- A. Spontaneous speech.
- B. Comprehension of the spoken and written word.
- C. Ability to name objects.
- D. Ability to describe objects.
- E. Ability to write.
- F. Ability to recall four named items after five minutes.
Correct Answer: A,B,C,D,E
Rationale: Aphasia assessment post-stroke includes evaluating spontaneous speech (A), comprehension (B), naming objects (C), describing objects (D), and writing (E). Memory recall (F) is not specific to aphasia.
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A student nurse is developing a care plan for a 23-year-old woman with Meniere's disease. Which of the following would NOT be an expected intervention?
- A. administer narcotic pain medication PRN as ordered
- B. refer client to dietician to plan meals with reduced sodium levels
- C. assist client out of bed to shower and to toilet
- D. encourage client to eat several, similarly sized meals throughout the day
Correct Answer: A
Rationale: Meniere’s disease causes vertigo and hearing loss, not typically requiring narcotic pain medication. Low-sodium diets, assistance with mobility, and balanced meals help manage symptoms.
The newly licensed nurse has been asked to perform a procedure that he feels unqualified to perform. The nurse's best response at this time is to:
- A. Attempt to perform the procedure
- B. Refuse to perform the procedure and give a reason for the refusal
- C. Request to observe a similar procedure and then attempt to complete the procedure
- D. Agree to perform the procedure if the client is willing
Correct Answer: B
Rationale: Refusing and explaining the lack of qualification ensures patient safety and adheres to ethical standards.
A client with osteomylitis has an order for a trough level to be done because he is taking Gentamycin. When should the nurse call the lab to obtain the trough level?
- A. Before the first dose
- B. 30 minutes before the fourth dose
- C. 30 minutes after the first dose
- D. 30 minutes before the first dose
Correct Answer: B
Rationale: Trough levels measure the lowest drug concentration and are drawn just before a dose after steady-state, typically around the fourth dose for Gentamicin.
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
- A. Remove the mold and clean every week.
- B. Store the hearing aid in a warm place.
- C. Clean the lint from the hearing aid with a toothpick.
- D. Change the batteries weekly.
Correct Answer: A
Rationale: Regular cleaning of the hearing aid mold prevents wax buildup and ensures proper function.
The nurse is teaching a client with a new diagnosis of epilepsy about self-care. Which of the following instructions should the nurse include?
- A. Avoid swimming or bathing alone.
- B. Take medications only when a seizure occurs.
- C. Drive a car as long as you feel alert.
- D. Consume alcohol in moderation to reduce stress.
Correct Answer: A
Rationale: avoiding swimming or bathing alone reduces the risk of injury during a seizure