Nokea
The nurse is reviewing teaching about newly prescribed clonazepam with a client who is receiving palliative care for cancer. Which client statement shows a correct understanding of the nurse's teaching?
- A. I am glad that I can continue to take my kava supplement each morning.
- B. If I can't sleep, I will take some melatonin with my evening dose of clonazepam.
- C. If I feel restless, I can put some drops of lavender essential oil in a diffuser to calm myself.
- D. When my anxiety is getting really intense, I will drink some valerian tea to help me relax.
Correct Answer: C
Rationale: Lavender essential oil in a diffuser is a safe, non-pharmacological method to reduce restlessness, compatible with clonazepam without risk of interaction.
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The nurse is documenting the assessment of a client's peripheral pulses. The nurse palpates the top portion of the client's feet and notes that the right pulse is full and strong, and the left pulse is diminished but still palpable. Which of the following would be correct documentation to include in the client's medical record?
- A. Bilateral dorsalis pedis pulses palpable. Right pulse 3+, left pulse 1+.
- B. Bilateral dorsalis pedis pulses palpable. Right pulse 4+, left pulse 2+.
- C. Bilateral popliteal pulses palpable. Right foot > left foot.
- D. Bilateral posterior tibial pulses palpable. Right pulse 3+, left pulse 1+.
Correct Answer: A
Rationale: The dorsalis pedis pulse is palpated on the top of the foot. A 3+ pulse is full and strong, and 1+ is diminished but palpable, accurately reflecting the findings.
The nurse practicing in a maternity setting recognizes that the post mature fetus is at risk due to
- A. Excessive fetal weight
- B. Low blood sugar levels
- C. Depletion of subcutaneous fat
- D. Progressive placental insufficiency
Correct Answer: D
Rationale: The placenta functions less efficiently as pregnancy continues beyond 42 weeks. Immediate and long term effects may be related to hypoxia.
The nurse in a long-term care facility observes a nursing assistant caring for a resident who has a hearing aid and dentures. Which action by the nursing assistant should be corrected?
- A. The nursing assistant places a washcloth in the sink before brushing the client's dentures.
- B. The nursing assistant uses toothpaste to clean the dentures.
- C. The nursing assistant uses alcohol to wipe off the exterior of the hearing aid.
- D. The nursing assistant wipes the exterior of the hearing aid with a damp cloth.
Correct Answer: C
Rationale: The exterior of a hearing aid should be wiped regularly with a damp cloth. Alcohol should not be used as it can damage the device. The nursing assistant should place a washcloth in the sink before brushing dentures to protect them if dropped. Toothpaste is appropriate to clean dentures.
The nurse is teaching a client who has a hip prosthesis following total hip replacement. Which of the following should be included in the instructions for home care?
- A. Avoid climbing stairs for 3 months
- B. Ambulate using crutches only
- C. Sleep in a supine position only
- D. Do not cross your legs
Correct Answer: D
Rationale: Do not cross your legs. Crossing legs can exceed the 90-degree hip flexion limit, risking dislocation.
The nurse has been interacting for several weeks with a client on the psychiatric unit. The nurse is to be transferred to another unit. Which comment by the client indicates separation anxiety?
- A. We had a good time at the party last night. You should have been here.'
- B. Some of us are going to the museum next week. Too bad you can't go.'
- C. I was thinking about my friend last night; the one who died in the car crash.'
- D. I was telling my wife what a good nurse you are.'
Correct Answer: B
Rationale: Expressing regret about the nurse missing a future event suggests attachment and anxiety about the nurse's departure, indicating separation anxiety. Other comments lack this emotional connection.