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The nursing team includes two RNs, one LPN/LVN, and one nursing assistant.
- A. Which client is appropriate for the nursing assistant to care for?
- B. A client with Alzheimer’s requiring assistance with feeding.
- C. A client with osteoporosis complaining of burning on urination.
- D. A client with scleroderma receiving a tube feeding.
- E. A client with cancer who has Cheyne-Stokes respirations.
Correct Answer: A
Rationale: Nursing assistants can care for clients with standard, unchanging procedures like feeding an Alzheimer’s patient. Clients with urinary symptoms, tube feedings, or unstable respirations require RN or LPN assessment and intervention.
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Which of the following statements describes Piaget's stage of concrete operations?
- A. Reflex activity proceeds to imitative behavior.
- B. There is an increased ability to see another's point of view.
- C. Thought processes become more logical and coherent.
- D. The ability to think abstractly leads to logical conclusions.
Correct Answer: C
Rationale: Concrete operations (ages 7-11) involve logical, coherent thought about concrete events. Perspective-taking develops but is not primary, and abstract thinking is characteristic of later stages.
The nurse is caring for a client with a history of asthma who is receiving montelukast (Singulair) 10 mg PO daily. Which of the following client statements would be of GREATest concern to the nurse?
- A. I take my medication at night.
- B. I have a headache sometimes.
- C. I feel sad and hopeless.
- D. I use my albuterol inhaler when I wheeze.
Correct Answer: C
Rationale: Feeling sad and hopeless suggests depression, a rare but serious side effect of montelukast, requiring immediate evaluation. Options A, B, and D are less concerning: nighttime dosing is standard, headaches are nonspecific, and albuterol use is appropriate.
The nurse is teaching a community group about healthy lifestyles to prevent cancer and heart disease. Which comment by a member of the group indicates a need for more teaching?
- A. Smoking is not good for you.'
- B. Reducing fat intake helps reduce the risk of heart disease.'
- C. Walking every day puts a strain on your heart.'
- D. Eating lots of fruits and vegetables helps keep me healthy.'
Correct Answer: C
Rationale: Daily walking strengthens the heart, reducing cardiovascular risk, not straining it. The other statements align with healthy lifestyle practices.
The nurse is caring for a client who is in the late stage of multiple myeloma. Which of the following should be included in the plan of care?
- A. Monitor for hyperkalemia
- B. Place in protective isolation
- C. Precautions with position changes
- D. Administer diuretics as ordered
Correct Answer: C
Rationale: Precautions with position changes. Multiple myeloma causes osteoporosis, increasing the risk of pathological fractures, necessitating careful positioning.
A young child with a history of grand mal seizures is in public school. He is on phenobarbital and hydantoin (Dilantin) to control the seizures. His teacher tells the nurse that he has not had any seizures but he does keep falling asleep in class. What should the nurse include when discussing his drowsiness with the teacher?
- A. It is common in children who take barbiturates.
- B. It usually occurs after seizures; let him sleep.
- C. It is probably not related to his seizure disorder or treatment.
- D. It is probably a warning sign that he is about to have a seizure.
Correct Answer: A
Rationale: Phenobarbital, a barbiturate, commonly causes drowsiness, explaining the child's sleepiness in class, which should be monitored but is expected.