Nokea
The nurse is discussing dementia with the families of older adults. All of the following behaviors are reported. Which behavior is most suggestive of dementia?
- A. The woman can't remember the birth year of each of her six children.
- B. A woman walked to the store and got lost on the way home.
- C. A woman forgot where she put her purse.
- D. A man is wearing one green sock and one red sock and doesn't see the difference.
Correct Answer: B
Rationale: Getting lost in a familiar area indicates significant spatial disorientation, a hallmark of dementia. Forgetting details, misplacing items, or color oversight are less specific.
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The clinic nurse cares for a 4-year-old who has been diagnosed with a pinworm infection. Which client symptom supports this diagnosis?
- A. Anal itching that is worse at night
- B. Intestinal bleeding with anemia
- C. Poor appetite with weight loss
- D. Red, scaly, blistered rings on skin
Correct Answer: A
Rationale: Pinworms cause anal itching, worse at night (A), due to female worms laying eggs. Bleeding (B), appetite loss (C), and skin lesions (D) are not typical, suggesting other conditions like hookworms or dermatitis.
A young adult is admitted to the psychiatric unit because she has become very withdrawn and has stopped attending college classes. She sits for hours rocking back and forth and appears to be talking to someone at intervals. She does not eat or bathe or relate to others. How should the nurse approach this client upon admission?
- A. Explain the unit routines to her in detail
- B. Ask her if she has any question about the unit or what she is supposed to do
- C. Briefly explain the most essential information and then sit with her
- D. Take her by the hand and orient her to the unit
Correct Answer: C
Rationale: A withdrawn client may be overwhelmed by detailed explanations. Brief information and quiet presence build trust and reduce anxiety.
The nurse reinforces teaching about self-management strategies for a client with urge incontinence. Which of the following statements indicate that teaching has been effective? Select all that apply.
- A. I am going to join a walking program to lose excess weight.
- B. I may have dry mouth as a side effect from the oxybutynin.
- C. I really need caffeine to get myself going in the morning.
- D. I should perform Kegel exercises several times daily.
- E. I will void every 2 hours until I am having fewer accidents.
Correct Answer: A,B,D,E
Rationale: Weight loss (A) reduces bladder pressure, oxybutynin’s dry mouth side effect (B) is correct, Kegel exercises (D) strengthen pelvic floor muscles, and scheduled voiding (E) prevents urgency. Caffeine (C) irritates the bladder, worsening incontinence, indicating ineffective teaching.
To maintain Bryant's traction, the nurse must make certain that the child's:
- A. Hips are resting on the bed with the legs suspended at a right angle to the bed
- B. Hips are slightly elevated above the bed with the legs suspended at a right angle to the bed
- C. Hips are elevated above the level of the body on a pillow with the legs suspended parallel to the bed
- D. Hips and legs are flat on the bed with the traction positioned at the foot of the bed
Correct Answer: B
Rationale: Bryant's traction requires hips slightly elevated and legs at a right angle to the bed to align the femur properly and reduce pressure on the pelvis.
The nurse is caring for a client who received albuterol 30 minutes ago for an acute exacerbation of asthma. It would indicate that the medication has been effective if the client experiences a decreased
- A. Use of accessory muscles
- B. Blood pressure
- C. Level of anxiety
- D. Heart rate
Correct Answer: A
Rationale: Albuterol, a bronchodilator, relieves bronchospasm in asthma, reducing airway resistance. Decreased use of accessory muscles (A) indicates improved breathing and oxygenation, a direct sign of albuterol's effectiveness. Changes in blood pressure (B), anxiety (C), or heart rate (D) are not primary indicators of albuterol's effect, as they may be influenced by other factors like the stress of the attack or concurrent medications.