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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.
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When planning care for a client with a stroke, which goal is most appropriate for addressing dysphagia?
- A. The client will swallow soft foods without choking.
- B. The client will eat three full meals daily.
- C. The client will gain 2 pounds in one week.
- D. The client will verbalize hunger before meals.
Correct Answer: A
Rationale: Swallowing soft foods without choking is a realistic and safe goal for managing dysphagia in stroke clients.
On the basis of the factors that cause the client to experience paroxysmal pain, which intervention is most appropriate to include in this client's care plan?
- A. Direct a fan toward the client's face.
- B. Avoid care that involves touching the client's face.
- C. Apply ice packs to the client's face.
- D. Apply warm facial compresses for pain.
Correct Answer: B
Rationale: Avoiding facial touch minimizes triggering paroxysmal pain in trigeminal neuralgia, which is sensitive to tactile stimuli.
Which nursing actions are essential when finding a client experiencing a tonic-clonic seizure? Select all that apply.
- A. Calling out the client's name
- B. Padding the client's body during the seizure activity
- C. Placing an emesis basin close to the client's mouth
- D. Rolling the client's body to the side
- E. Removing environmental hazards to protect the client
- F. Calling the respiratory therapy department
Correct Answer: D,E
Rationale: Rolling the client to the side prevents aspiration, and removing environmental hazards minimizes injury risk during a tonic-clonic seizure.
Which method is most appropriate to provide adequate nutrition for the client at this time?
- A. Crystalloid I.V. fluid
- B. Nasogastric tube feedings
- C. Total parenteral nutrition
- D. Gastrostomy tube feedings
Correct Answer: B
Rationale: Nasogastric tube feedings are appropriate for providing nutrition in clients with Guillain-Barré syndrome who have difficulty swallowing, as they are less invasive than total parenteral nutrition or gastrostomy tubes.
The client diagnosed with amyotrophic lateral sclerosis (Lou Gehrig's disease) is prescribed medications that require intravenous access. The HCP has ordered a primary intravenous line at a keep-vein-open (KVO) rate at 25 mL/hr. The drop factor is 10 gtts/mL. At what rate should the nurse set the IV tubing?
Correct Answer: 4 gtts/min
Rationale: Calculate: (25 mL/hr ÷ 60 min) × 10 gtts/mL = 4.17 gtts/min, rounded to 4 gtts/min.