Nokea
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.
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The nurse is caring for a client with cirrhosis who has ascites, peripheral edema, shortness of breath, fatigue, and generalized discomfort. Which of the following actions should the nurse take? Select all that apply.
- A. Assist the client to ambulate in the hallway every shift
- B. Encourage the client to increase sodium intake
- C. Maintain the client in semi-Fowler position
- D. Provide an alternating air pressure mattress for the client
- E. Use music to provide a distraction for the client
Correct Answer: C,D,E
Rationale: Semi-Fowler position helps alleviate shortness of breath by reducing pressure on the diaphragm. An alternating air pressure mattress reduces the risk of pressure injuries due to immobility. Music can help reduce discomfort and anxiety, providing a non-pharmacological distraction.
The nurse hears another staff member talking in a crowded elevator about a client on the unit. The client is identified by name and details of illness. What action should the practical nurse take at this time?
- A. Report the behavior to the head nurse
- B. Report the behavior if it happens again
- C. Interrupt the conversation in the elevator
- D. Speak to the staff member when he/she gets off the elevator
Correct Answer: D
Rationale: Speaking to the staff member privately after the elevator ride addresses the HIPAA violation discreetly, promoting education and correction without immediate escalation.
A neonate born 12 hours ago to a methadone maintained woman is exhibiting a hyperactive MORO reflex and slight tremors. The newborn passed one loose, watery stool. Which of these is a nursing priority?
- A. Hold the infant at frequent intervals.
- B. Assess for neonatal withdrawal syndrome
- C. Offer fluids to prevent dehydration
- D. Administer paregoric to stop diarrhea
Correct Answer: B
Rationale: Assess for neonatal withdrawal syndrome. These symptoms indicate possible opioid withdrawal, requiring immediate assessment.
The nurse is reinforcing teaching for a client who has a new prescription for levothyroxine. Which of the following information should the nurse reinforce?
- A. Discontinue the medication if you become pregnant.
- B. Take the medication at bedtime to decrease drowsiness.
- C. Notify your health care provider if you experience palpitations.
- D. Take the medication with a snack if you experience an upset stomach.
Correct Answer: C
Rationale: Palpitations may indicate levothyroxine overdose or hyperthyroidism, requiring prompt reporting to adjust the dose or evaluate thyroid function.
During the initial interview, the client reports that she has a lesion on the perineum. Further investigation reveals a small blister on the vulva that is painful to touch. The nurse is aware that the most likely source of the lesion is:
- A. Syphilis
- B. Herpes
- C. Gonorrhea
- D. Condylomata
Correct Answer: B
Rationale: A lesion that is painful is most likely a herpetic lesion. A chancre lesion associated with syphilis is not painful, so answer A is incorrect. Gonorrhea does not present as a lesion but is exhibited by a yellow discharge, so answer C is incorrect. Condylomata lesions are painless warts, so answer D is incorrect.