Nokea
The nurse observes that a client's upper arm tremors disappear as he unbuttons his shirt. Which statement best guides the nurse's analysis of this observation about the client's tremors?
- A. The tremors are probably psychological and can be controlled at will.
- B. The tremors sometimes disappear with purposeful and voluntary movements.
- C. The tremors disappear when the client's attention is diverted by some activity.
- D. There is no explanation for the observation; it is probably a chance occurrence.
Correct Answer: B
Rationale: In Parkinson's disease, resting tremors often decrease or disappear during purposeful movements, such as unbuttoning a shirt. This is a characteristic feature, not psychological, distraction-related, or random.
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Which of the following exercises should the nurse advise the client to avoid after a lumbar laminectomy?
- A. Knee-to-chest lifts.
- B. Hip tilts.
- C. Sit-ups.
- D. Pelvic tilts.
Correct Answer: C
Rationale: Sit-ups strain the surgical site and should be avoided to prevent injury post-laminectomy.
The nurse is planning a staff development conference about medication reconciliation. Which of the following information should the nurse include?
- A. Obtain a list of the medications instead of reviewing the list with the client
- B. Medication reconciliation should occur just at discharge to prevent omissions.
- C. Prescribed medications should be obtained and omit herbs and supplements.
- D. This process should occur at admission, client transfer, and discharge.
Correct Answer: C
Rationale: Medication reconciliation at admission, transfer, and discharge ensures accuracy and continuity of care.
After surgery for gastric cancer, a client is scheduled to undergo radiation therapy. It will be most important for the nurse to include information about which of the following in the client's teaching plan?
- A. Nutritional intake.
- B. Management of alopecia.
- C. Exercise and activity levels.
- D. Access to community resources.
Correct Answer: A
Rationale: Radiation therapy can affect appetite and digestion, making nutritional intake a priority in the teaching plan to maintain the client's strength and recovery. The other options are less critical.
Which of the following indicates that the client with diabetes insipidus understands how to manage care?
- A. The client will maintain normal fluid and electrolyte balance.
- B. The client will select American Diabetes Association diet correctly.
- C. The client will state dietary restrictions.
- D. The client will exhibit serum glucose level within normal range.
Correct Answer: A
Rationale: Effective management of diabetes insipidus involves maintaining fluid and electrolyte balance through medication and adequate hydration.
A 32-year-old female meets with the nurse on her first office visit since undergoing a left mastectomy. When asked how she is doing, the woman says her appetite is still not good, she is not getting much sleep because she doesn't go to bed until her husband is asleep, and she is really anxious to get back to work. Which of the following nursing interventions should the nurse explore to support the client's current needs?
- A. Call the physician to discuss allowing the client to return to work earlier.
- B. Suggest that the client learn relaxation techniques for help with her insomnia.
- C. Perform a nutritional assessment to assess for anorexia.
- D. Ask open-ended questions about sexuality issues related to her mastectomy.
Correct Answer: B
Rationale: Insomnia is a primary concern, and relaxation techniques can help improve sleep, addressing the client's emotional and physical recovery needs post-mastectomy.