Nokea
The nurse is evaluating the progress of a client who has had a cerebrovascular accident and realizes there has been limited progress. What should the nurse do?
- A. Transfer the client to another caregiver
- B. Reassess the goals with the client
- C. Request a longer hospital stay
- D. Role play the current plan with the client
Correct Answer: B
Rationale: Reassessing goals adjusts the care plan to the client's current abilities, optimizing recovery post-CVA.
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Which action by the client indicates an acceptance of his recent amputation?
- A. He verbalizes acceptance.
- B. He looks at the operative site.
- C. He asks for information regarding prosthesis.
- D. He remains silent during dressing changes.
Correct Answer: C
Rationale: Asking about a prosthesis indicates the client is planning for future mobility and adapting to the amputation, a strong sign of acceptance. Verbalizing acceptance is less specific, looking at the site may indicate curiosity or distress, and silence suggests denial or withdrawal.
The nurse is caring for a 14 month-old just diagnosed with cystic fibrosis. The parents state this is the first child in either family with this disease, and ask about the risk to future children. What is the best response by the nurse?
- A. 1 in 4 chance for each child to carry that trait
- B. 1 in 4 risk for each child to have the disease
- C. 1 in 2 chance of avoiding the trait and disease
- D. 1 in 2 chance that each child will have the disease
Correct Answer: B
Rationale: 1 in 4 risk for each child to have the disease. Cystic fibrosis is autosomal recessive, with a 25% chance of the disease per pregnancy if both parents are carriers.
The nurse is observing a certified nursing assistant (CNA) caring for a client who has AIDS. Which action, if observed, is not correct?
- A. The CNA wears gloves when cleaning the client after an episode of fecal incontinence.
- B. The CNA uses chlorine bleach to wipe up blood after the client cut himself shaving.
- C. The CNA is observed giving the client a back rub without gloves on.
- D. The CNA wears a mask whenever entering the client's room.
Correct Answer: C
Rationale: Standard precautions require gloves during contact with non-intact skin or bodily fluids, including during a back rub for an AIDS client, to prevent transmission. Gloves for incontinence, bleach for blood, and masks (if indicated) are appropriate.
The nurse is teaching a client with a new diagnosis of type 2 diabetes about metformin (Glucophage). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this medication with meals.
- B. I should report nausea to my doctor.
- C. I should avoid drinking alcohol.
- D. I should stop this medication if my blood sugar is normal.
Correct Answer: D
Rationale: Stopping metformin when blood sugar is normal is incorrect, as type 2 diabetes requires ongoing treatment to maintain control. Options A, B, and C are correct: taking with meals reduces GI upset, nausea is a side effect, and alcohol increases lactic acidosis risk.
The nurse discusses symptoms of the onset of labor with a 26-year-old primipara. Which of the following statements, if made by the client to the nurse, indicates a need for further teaching?
- A. I will note an increase in fetal movement.
- B. I may feel a gush of fluid run down my legs.
- C. I may see some blood in my vaginal discharge.
- D. I may experience a low backache.
Correct Answer: A
Rationale: Fetal movement decreases at labor onset due to limited space; expecting an increase indicates misunderstanding. Options B, C, and D are correct labor signs.