Nokea
A client with dementia.
The nurse knows that which of these plans would be MOST successful in caring for a client with dementia?
- A. Teach new skills for adjusting to the aging process.
- B. Adjust the environment to meet the client's individual needs.
- C. Encourage competitive activities to keep the client physically strong.
- D. Provide unstructured activities with frequent changes to increase stimulation.
Correct Answer: B
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) unable to learn new skills (2) correct-client with dementia does not have cognitive abilities to learn new skills or to adapt, environment must be adapted for client with attention to safety and predictability (3) requires skills the client with dementia does not have (4) requires skills the client with dementia does not have
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A client who had a lumbar laminectomy has just returned to the nursing care unit following an uneventful stay in the postanesthesia care unit. How should the nurse position the client?
- A. Supine
- B. Prone
- C. Side-lying
- D. Semi-reclining
Correct Answer: C
Rationale: Side-lying with a pillow between legs maintains spinal alignment post-lumbar laminectomy, reducing strain. Supine or prone may stress the surgical site, and semi-reclining is less ideal.
The nurse is caring for a client who is postoperative day 1 after a total hip replacement. Which of the following findings would be of GREATest concern to the nurse?
- A. Temperature of 100.8°F (38.2°C).
- B. Pain at the incision site.
- C. Leg swelling on the operative side.
- D. Urine output of 40 mL/hour.
Correct Answer: A
Rationale: A temperature of 100.8°F suggests infection, a serious complication post-hip replacement requiring immediate evaluation. Options B, C, and D are expected or less concerning: incision pain and leg swelling are normal, and urine output 40 mL/hour is adequate.
The nurse is teaching a client with newly diagnosed diabetes mellitus about foot care. Which of the following instructions should the nurse include?
- A. Soak feet in hot water daily.
- B. Apply lotion between the toes.
- C. Trim toenails with rounded edges.
- D. Inspect feet daily for cuts or sores.
Correct Answer: D
Rationale: Daily foot inspection prevents complications like infections in diabetes. Options A, B, and C risk burns, fungal growth, or ingrown nails.
Which of the following laboratory results would suggest to the emergency room nurse that a client admitted after a severe motor vehicle crash is in acidosis?
- A. Hemoglobin 15 gm/dl
- B. Chloride 100 mEq/L
- C. Sodium 130 mEq/L
- D. Carbon dioxide 20 mEq/L
Correct Answer: D
Rationale: Serum carbon dioxide is an indicator of acid-base status. This finding would indicate acidosis.
During seizure activity which observation is the priority to enhance further direction of treatment?
- A. Observe the sequence or types of movement
- B. Note the time from beginning to end
- C. Identify the pattern of breathing
- D. Determine if loss of bowel or bladder control occurs
Correct Answer: A
Rationale: Observe the sequence or types of movement. Noting movement types is critical for diagnosis and guiding treatment.