Nokea
To minimize confusion in the elderly hospitalized client, the nurse should:
- A. Provide sensory stimulation by varying the daily routine
- B. Keep the room brightly lit and the television on to provide orientation to time
- C. Encourage visitors to limit visitation to phone calls to avoid overstimulation
- D. Provide explanations in a calm, caring manner to minimize anxiety
Correct Answer: D
Rationale: Calm, clear explanations reduce anxiety and confusion in elderly clients, promoting orientation and comfort in the hospital setting.
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The nurse enters the client's room and smells cigarette smoke. When confronted, the client says, 'I only smoked one cigarette because I was having a bad craving.' Which action by the nurse is most appropriate?
- A. escort the client outside to smoke
- B. call the health care provider to obtain an order for a nicotine patch
- C. remind the client that oxygen is in use and smoking is banned in the facility
- D. tell the client that if he continues to smoke in the room, he will be discharged from the hospital
Correct Answer: C
Rationale: Reminding the client of the danger of smoking near oxygen and hospital policy addresses safety and compliance immediately.
The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirm a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:
- A. Prostigmine (neostigmine)
- B. Atropine (atropine sulfate)
- C. Didronel (etidronate)
- D. Tensilon (edrophonium)
Correct Answer: A
Rationale: Neostigmine (Prostigmine) is a cholinesterase inhibitor used to improve muscle strength in myasthenia gravis.
The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
- A. Intravenous access supplies
- B. Emergency intubation equipment
- C. Intravenous fluid-administration pump
- D. Supplemental oxygen
Correct Answer: B
Rationale: Emergency intubation equipment is essential for LTB due to the risk of airway obstruction requiring immediate intervention.
A client is admitted to the labor and delivery unit in active labor. During examination, the nurse notes a papular lesion on the perineum. Which initial action is most appropriate?
- A. Document the finding
- B. Report the finding to the doctor
- C. Prepare the client for a C-section
- D. Continue primary care as prescribed
Correct Answer: B
Rationale: A papular lesion on the perineum during labor could indicate an infectious process (e.g., herpes), so reporting it to the doctor is the most appropriate initial action.
A client with metastatic cancer of the lung has just been told the prognosis by the oncologist. The nurse hears the client state, 'I don't believe the doctor; I think he has me confused with another patient.' This is an example of which of Kubler-Ross' stages of dying?
- A. Denial
- B. Anger
- C. Depression
- D. Bargaining
Correct Answer: A
Rationale: The client's statement reflects denial, a stage where patients refuse to accept a terminal diagnosis, per Kubler-Ross' model.