Nokea
The nurse makes a home visit to a client with Alzheimer disease. While reviewing the client's home care needs, the client's spouse states, 'It's hard to see my spouse worsen each day. I'm not sure I can keep doing this alone anymore.' Which response by the nurse is best?
- A. Perhaps finding a caregiver to care for your spouse at night might be helpful.
- B. Tell me about the care you provide in a typical day and its challenges.
- C. Try not to worry. It's normal to feel overwhelmed when you are stressed.
- D. You seem worried that you won't be able to provide the care that your spouse needs.
Correct Answer: B
Rationale: Exploring the spouse's daily challenges encourages open communication and helps identify specific support needs.
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The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
- A. Avoid excess caffeine
- B. Immerse hands in cold water
- C. Practice yoga or tai chi
- D. Refrain from using tobacco products
- E. Wear gloves when handling cold objects
Correct Answer: A,C,D,E
Rationale: Caffeine, tobacco, and cold exposure can trigger Raynaud episodes. Yoga/tai chi and gloves help prevent attacks. Cold water immersion exacerbates symptoms.
The nurse learns that an Orthodox Jewish client has not started taking recently prescribed diltiazem extended-release capsules. The client states 'I cannot take the medication in this form.' What is the nurse's first action?
- A. Ask the health care provider to prescribe a different calcium channel blocker
- B. Consult with the pharmacist to see if an alternate form of the drug is available
- C. Open the capsule and sprinkle the medication in a cup of applesauce
- D. Warn the client about the dangers of uncontrolled hypertension
Correct Answer: B
Rationale: The client may object to gelatin in capsules due to dietary restrictions. Consulting the pharmacist for an alternative form respects the client's beliefs.
A 54-year-old male is admitted to the cardiac unit with chest pain radiating to the jaw and left arm. Which enzyme would be most specific in the diagnosis of a myocardial infarction?
- A. Aspartate aminotransferase
- B. Lactic acid dehydrogenase
- C. Hydroxybutyric dehydrogenase
- D. Creatine phosphokinase
Correct Answer: D
Rationale: CK-MB (creatine phosphokinase muscle bond isoenzyme) is the most specific for a myocardial infarction. Troponin is also extremely reliable. Answers A, B, and C are nonspecific to myocardial infarctions, so they are incorrect.
A client with a recent spinal cord injury is experiencing dysreflexia and is noted to have a BP of $240 / 110$. The nurse's initial response should be to:
- A. Check the client's pulse and respiratory rate.
- B. Elevate the client's head to a $45^{\circ}$ angle.
- C. Place the client flat and supine.
- D. Administer antihypertensive and recheck BP in 15 minutes.
Correct Answer: B
Rationale: Elevating the head to a 45° angle helps reduce blood pressure in autonomic dysreflexia by promoting venous return and reducing intracranial pressure.
The nurse is talking with a female client about collecting a clean-catch urine specimen. Which of the following information should the nurse include? Select all that apply.
- A. Avoid touching the inside of the specimen container.
- B. Position the specimen container before initiating your stream of urine.
- C. Cleanse your vulva from front to back with single-use antiseptic towelettes.
- D. Spread your labia using your nondominant hand before cleansing your perineum and urinating.
- E. Remove the lid from the specimen container and place it on the counter with the sterile side facing down.
Correct Answer: A,C,D
Rationale: Avoiding contamination, proper cleansing, and spreading the labia are critical for a clean-catch specimen. The lid should be placed sterile side up, and the container should be positioned midstream.