Nokea
The significant other of a client diagnosed with a brain tumor asks the nurse for help identifying resources. Which would be the most appropriate referral for the nurse to make?
- A. Social worker.
- B. Chaplain.
- C. Health-care provider.
- D. Occupational therapist.
Correct Answer: A
Rationale: A social worker (A) can connect the family with community resources, financial aid, and support services. Chaplains (B) address spiritual needs, providers (C) focus on medical care, and occupational therapists (D) address functional deficits.
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The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next?
- A. Carefully remove the driver from the car.
- B. Assess the client's pupils for reaction.
- C. Assess the client's airway.
- D. Attempt to wake the client up by shaking him.
Correct Answer: C
Rationale: After cervical spine stabilization, ensuring a patent airway (C) is the next priority to support oxygenation. Removing the driver (A) risks further injury, pupil assessment (B) is secondary, and shaking (D) could worsen spinal injury.
The client is in the terminal stage of ALS. Which intervention should the nurse implement?
- A. Perform passive ROM every two (2) hours.
- B. Maintain a negative nitrogen balance.
- C. Encourage a low-protein, soft-mechanical diet.
- D. Turn the client and have him cough and deep breathe every shift.
Correct Answer: A
Rationale: In terminal ALS, passive ROM every 2 hours (A) prevents contractures and maintains comfort. Negative nitrogen balance (B) is undesirable, low-protein diets (C) are not indicated, and coughing/deep breathing (D) may be infeasible.
Which activity should the nurse encourage for a client with early Parkinson's disease to improve mobility?
- A. High-intensity aerobic exercise
- B. Daily stretching and balance exercises
- C. Weightlifting three times weekly
- D. Complete bed rest during tremors
Correct Answer: B
Rationale: Stretching and balance exercises improve mobility and reduce fall risk in early Parkinson's disease.
The wife of the client diagnosed with chronic alcoholism tells the nurse, 'I have to call his work just about every Monday to let them know he is ill or he will lose his job.' Which would be the nurse’s best response?
- A. I am sure that this must be hard for you. Tell me about your concerns.'
- B. You are afraid he will lose his source of income.'
- C. Why would you call in for your husband? Can’t he do this?'
- D. Are you aware that when you do this you are enabling him?'
Correct Answer: A
Rationale: Reflecting and inviting discussion (A) validates the wife’s feelings and encourages therapeutic communication. Assuming fear (B) is less open-ended, questioning her actions (C) may seem judgmental, and labeling enabling (D) could alienate her.
Which response by the nurse would be best to prevent distress when the client repeatedly asks, 'Where is my mother?'
- A. Explain to the client, 'Your mother died several years ago.'
- B. Tell the client, 'Your mother will visit later.'
- C. State, 'You miss your mother. What was she like?'
- D. Ask the client, 'When did you last see your mother?'
Correct Answer: C
Rationale: Redirecting the conversation to memories of the mother validates the client's feelings without causing distress from confronting reality.