Nokea
The UAP reports to the PN that a client refused to bathe for the third consecutive day. Which action is best for the PN to take?
- A. Explain the importance of good hygiene to the client
- B. Ask family members to encourage the client to bathe
- C. Reschedule the bath for the following day
- D. Ask the client why the bath was refused
Correct Answer: D
Rationale: The best action for the PN to take when a client refuses to bathe is to ask the client why the bath was refused. Understanding the client's reasons for refusing a bath is crucial as it helps to address any underlying issues, such as fear, discomfort, or physical limitations. By communicating directly with the client, the PN can provide appropriate care tailored to the client's needs. Choices A, B, and C do not directly address the root cause of the refusal and may not effectively resolve the issue.
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Inspiratory and expiratory stridor may be heard in a client who:
- A. Is experiencing an exacerbation of goiter
- B. Is experiencing an acute asthmatic attack
- C. Has aspirated a piece of meat
- D. Has severe laryngotracheitis
Correct Answer: D
Rationale: Inspiratory and expiratory stridor are high-pitched, wheezing sounds caused by disrupted airflow due to airway obstruction. Severe laryngotracheitis, involving inflammation and swelling of the larynx and trachea, leads to airway obstruction and can produce both inspiratory and expiratory stridor. Exacerbation of goiter, an acute asthmatic attack, and aspiration of a piece of meat are not typically associated with both inspiratory and expiratory stridor. Therefore, choices A, B, and C are incorrect.
Which cranial nerve is responsible for the sense of smell?
- A. Olfactory nerve
- B. Optic nerve
- C. Trigeminal nerve
- D. Vagus nerve
Correct Answer: A
Rationale: The olfactory nerve (Cranial Nerve I) is indeed responsible for the sense of smell. It is located in the nasal cavity and transmits olfactory information to the brain. The optic nerve (Choice B) is responsible for vision, the trigeminal nerve (Choice C) is responsible for sensation in the face, and the vagus nerve (Choice D) is responsible for various functions such as heart rate, digestion, and speech. Therefore, the correct answer is the olfactory nerve (Choice A).
During the last 30 days, an elderly client has exhibited a progressively decreasing appetite, is spending increasing amounts of daytime hours in bed, and refuses to participate in planned daytime activities. Which action should the practical nurse take?
- A. Record the findings and report the symptoms to the charge nurse
- B. Ask the family members to visit more often to stimulate the patient
- C. Motivate the client by offering favorite foods as a prize
- D. Withhold any medications that may cause side effects
Correct Answer: A
Rationale: The practical nurse should record the findings and report the symptoms to the charge nurse. These behaviors may indicate a serious underlying condition such as depression or physical illness. By reporting to the charge nurse, the client can receive appropriate assessment and intervention promptly. Choice B is incorrect as family visits may not address the root cause of the symptoms. Choice C is incorrect as it oversimplifies the situation and may not be effective in addressing the underlying issue. Choice D is incorrect because withholding medications without proper assessment and guidance can be harmful to the client's health.
The nurse enters a male client's room to administer routine morning medications, and the client is on the phone. Which action is best for the nurse to take?
- A. Ask another nurse to return with the medication when the client has hung up the phone
- B. Wait for the client to excuse himself from the telephone conversation, and observe the client taking the medication
- C. Return the medication to the client's drawer on the cart and document that the client refused the dose
- D. Leave the medication with the client and let him take it when he finishes the conversation
Correct Answer: B
Rationale: The best action for the nurse to take in this situation is to wait for the client to excuse himself from the telephone conversation and then observe the client taking the medication. This approach ensures that the client takes the medication as prescribed, promoting compliance and safety. Choice A is not ideal as it involves unnecessary delegation and may lead to confusion. Choice C is incorrect because assuming refusal without direct communication can compromise patient care. Choice D is not recommended as leaving the medication with the client unsupervised may result in non-compliance or potential errors.
A client who is at full-term gestation is in active labor and complains of a cramp in her leg. Which intervention should the nurse implement?
- A. Massage the calf and foot
- B. Elevate the leg above the heart
- C. Check the pedal pulse in the affected leg
- D. Extend the leg and flex the foot
Correct Answer: D
Rationale: The correct intervention for a client in active labor complaining of a leg cramp is to extend the leg and flex the foot. This action helps stretch the muscles that are cramping, providing relief. Massaging the calf and foot (Choice A) may not be as effective for relieving the cramp. Elevating the leg above the heart (Choice B) is not indicated for a leg cramp. Checking the pedal pulse in the affected leg (Choice C) is unrelated to addressing the leg cramp.