Nokea
The nurse is providing home care. Which assessment finding would suggest to the nurse that the elderly client should be evaluated for abuse?
- A. The client says, 'My daughter takes some of my Social Security money. She says it's to pay for my food and medicine.'
- B. The client has several bruises on her arms and legs.
- C. The client says her family is mean because they hire someone to stay with her when they go out.
- D. The client has several bruises and circular marks that look like cigarette burns on her back.
Correct Answer: D
Rationale: Bruises and circular marks resembling cigarette burns strongly suggest physical abuse, requiring immediate evaluation. Unexplained bruises are concerning but less specific, and the other options may reflect misunderstanding or caregiving arrangements.
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A low-income client needing to satisfy essential protein needs.
Which of the following foods would the nurse encourage a low-income client to eat to satisfy essential protein needs?
- A. Legumes.
- B. Red meat.
- C. Seafood.
- D. Cheese.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-legumes are an economical source rich in protein (2) high in protein, but more expensive to purchase (3) high in protein, but more expensive to purchase (4) high in protein, but more expensive to purchase
At a health-screening clinic, an adult male client's total plasma cholesterol level is 200 mg/dL. The nurse should
- A. advise the client to decrease intake of fatty foods.
- B. schedule the client for a follow-up clinic visit in one month.
- C. inform the client that the cholesterol level is within normal limits.
- D. report the finding to the physician immediately.
Correct Answer: A
Rationale: A cholesterol level of 200 mg/dL is borderline high; reducing fatty foods is appropriate. Options B, C, and D are less immediate or incorrect.
A 33-year-old woman comes to the local outpatient clinic for complaints of dizziness and palpitations. Her physical exam and laboratory results are normal. She reports that the company she owns is on the verge of bankruptcy.
Which of the following responses, if made to the client by the nurse, would be BEST?
- A. When did you first notice these symptoms?'
- B. Have you shared this information with anyone?'
- C. Are you concerned about your financial difficulties?'
- D. Would you like to discuss your situation with me?'
Correct Answer: A
Rationale: Strategy: 'BEST' indicates there may be more than one correct response. Remember therapeutic communication. (1) correct-open-ended question, encourages client to discuss when problems occurred (2) yes/no question, nontherapeutic, doesn't encourage discussion of symptoms (3) yes/no question, nontherapeutic, too confrontational, does not encourage discussion (4) yes/no question, nontherapeutic
Which of the following nursing interventions is MOST important when caring for a client who has just been placed in physical restraints?
- A. Prepare PRN dose of psychotropic medication.
- B. Check that the restraints have been applied correctly.
- C. Review hospital policy regarding duration of restraints.
- D. Monitor the client's needs for hydration and nutrition while restrained.
Correct Answer: B
Rationale: assessment; while a client is restrained, physiological integrity is important; monitoring positioning, tightness, and peripheral circulation is essential; nurse documents the client's response and clinical status after being restrained
The nurse is teaching a client with a new diagnosis of hyperthyroidism about methimazole (Tapazole). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a sore throat to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating iodized salt.
- D. I should stop this medication if I feel better.
Correct Answer: D
Rationale: Stopping methimazole when feeling better is incorrect, as hyperthyroidism requires prolonged treatment to achieve euthyroid status. Options A, B, and C are correct: sore throat may indicate agranulocytosis, food reduces GI upset, and avoiding iodized salt prevents thyroid stimulation.