Nokea
The nurse observes a client using a walker. Which observation indicates that the client needs more instruction?
- A. The client uses the walker to pull herself out of a chair.
- B. The client moves the walker forward and then takes a step.
- C. The client complains that the walker is not waist high.
- D. The client sometimes does not use the walker.
Correct Answer: A
Rationale: Using the walker to pull up risks tipping, indicating improper use and a need for further instruction on safe walker technique.
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A 3 year-old child has tympanostomy tubes in place. The child's parent asks the nurse if he can swim in the family pool. The best response from the nurse is
- A. Your child should not swim at all while the tubes are in place.'
- B. Your child may swim in your own pool but not in a lake or ocean.'
- C. Your child may swim if he wears ear plugs.'
- D. Your child may swim anywhere.'
Correct Answer: C
Rationale: Water should not enter the ears. Children should use ear plugs when bathing or swimming and should not put their heads under the water.
A client with allergic rhinitis has an order for a long-acting nasal spray that contains oxymetazoline. The client should be instructed to use the spray as directed to prevent:
- A. Bleeding tendencies
- B. Increased nasal congestion
- C. Nasal polyps
- D. Tinnitus
Correct Answer: B
Rationale: Overuse of oxymetazoline can cause rebound nasal congestion (rhinitis medicamentosa). It does not typically cause bleeding, nasal polyps, or tinnitus.
A client admitted with glaucoma is being treated with miotic (pilocarpine) eye drops. Following administration of the medication, the nurse will note:
- A. Dilation of the pupils
- B. Diminished redness of the sclera
- C. Decreased edema of the cornea
- D. Constriction of the pupils
Correct Answer: D
Rationale: Miotics, such as pilocarpine, are administered to the client with glaucoma to cause pupillary constriction, thereby lowering intraocular pressure. Answer A is incorrect because miotics constrict the pupil. Answer B is incorrect because miotics do not diminish redness. Answer C is incorrect because miotics do not decrease edema of the cornea.
The nurse is caring for a client with schizophrenia who is experiencing visual hallucinations. The client states, 'There is a bad person standing in my room.' Which of the following responses would be most appropriate for the nurse to make?
- A. Your illness is making you experience visual hallucinations.'
- B. I know you are frightened, but I do not see anyone in your room.'
- C. Do not worry. I will give you medication that will make the bad person go away.'
- D. We will go into the dayroom and play a game. I know you like to play board games.'
Correct Answer: B
Rationale: When addressing hallucinations, the nurse should acknowledge the client’s fear while gently reinforcing reality. Response B validates the client’s emotions and clarifies that the nurse does not see the hallucination, maintaining trust without reinforcing the delusion. Labeling the hallucination as part of the illness (A) may confuse or alienate the client. Promising medication will resolve it (C) oversimplifies treatment, and distracting with games (D) dismisses the client’s distress.
The nurse is caring for a client who has a single-chamber atrial pacemaker. Which of the following findings would the nurse expect to observe on the client’s electrocardiogram strip?
- A. Pacemaker spike on the T wave
- B. Pacemaker spike before the P wave
- C. Occasional wide and distorted QRS complex
- D. Prolonged PR interval with normal QRS complex
Correct Answer: B
Rationale: A single-chamber atrial pacemaker paces the atrium, producing a spike before the P wave (B), followed by normal conduction. Spikes on T waves (A) are abnormal, wide QRS (C) suggests ventricular issues, and prolonged PR (D) is unrelated to pacing.