Nokea
The nurse is preparing to assist a client to ambulate to the bathroom. The client rises from the chair at the bedside and immediately reports feeling dizzy. It would be a priority for the nurse to
- A. Check the client's orthostatic blood pressure
- B. encourage the client to remain on bed rest
- C. apply a gait belt around the client's waist
- D. assist the client back to a sitting position
Correct Answer: D
Rationale: Dizziness upon standing suggests orthostatic hypotension or other instability. Assisting the client back to a sitting position prevents falls and ensures immediate safety.
You may also like to solve these questions
A client is prescribed long-term pharmacologic therapy with hydroxychloroquine to treat systemic lupus erythematosus. The nurse should reinforce teaching about which intervention related to the drug's adverse effects?
- A. Have an ophthalmologic examination every 6 months
- B. Take the medication on an empty stomach
- C. Take vitamin D and calcium supplements
- D. Wear a MedicAlert bracelet
Correct Answer: A
Rationale: Hydroxychloroquine can cause retinal toxicity. Regular ophthalmologic exams every 6 months are essential to monitor for early signs of retinal damage.
In reviewing the assessment data of a client suspected of having diabetes insipidus, the nurse expects which of the following after a water deprivation test?
- A. Increased edema and weight gain
- B. Unchanged urine specific gravity
- C. Rapid protein secretion
- D. Decreased blood potassium
Correct Answer: B
Rationale: Unchanged urine specific gravity. When fluids are restricted, the client continues to excrete large amounts of dilute urine. This finding supports the diagnosis. Normally, urine is more concentrated with reduced fluid intake.
The nurse is caring for a preschool-age child whose grandparent died 3 days ago. Which intervention is inappropriate?
- A. Assign the same nurses and caregivers to the child each day
- B. Avoid mentioning the loved one's death in the child's presence
- C. Explain the importance of being with the child to the parents
- D. Schedule time each day for age-appropriate play
Correct Answer: B
Rationale: Avoiding discussion of the grandparent's death may confuse the child or hinder grieving. Open, age-appropriate communication supports emotional processing.
The nurse enters a client's room and finds that the client and spouse are crying. The spouse states that the health care provider just diagnosed the client with Alzheimer disease. What is the best response by the nurse?
- A. Do you have any questions about the diagnosis?
- B. There are medications available to treat Alzheimer disease.
- C. This new diagnosis must be frightening for you.
- D. We can help you make decisions about your care.
Correct Answer: C
Rationale: Acknowledging the emotional impact of the diagnosis validates the client's and spouse's feelings, fostering therapeutic communication and trust.
Which of the following manifestations observed by the school nurse confirms the presence of pediculosis capitis in students?
- A. Scratching the head more than usual
- B. Flakes evident on a student's shoulders
- C. Oval pattern occipital hair loss
- D. Whitish oval specks sticking to the hair
Correct Answer: D
Rationale: Diagnosis of pediculosis capitis is made by observation of the white eggs (nits) firmly attached to the hair shafts. Treatment can include application of a medicated shampoo with lindane for children over 2 years of age, and meticulous combing and removal of all nits.