Nokea
What intervention should be taken to minimize the risk for injury in a client with dementia?
- A. Use a bed exit alarm system.
- B. Place the client in restraints for safety.
- C. Ensure the client has frequent visitors to reduce isolation.
- D. Keep the client's room dark and quiet at night.
Correct Answer: A
Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.
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When providing oral care for an unconscious client, which of the following actions should the nurse take?
- A. Place the client in a lateral position with the head turned to the side before beginning the procedure.
- B. Insert a suction catheter before brushing the teeth.
- C. Use a soft-bristled toothbrush only with water.
- D. Brush the client's teeth while they are in a supine position.
Correct Answer: A
Rationale: When providing oral care for an unconscious client, it is essential to place them in a lateral position with the head turned to the side before beginning the procedure. This positioning helps prevent aspiration by allowing fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Inserting a suction catheter before brushing the teeth (Choice B) is not recommended as it can cause discomfort and increase the risk of oral tissue injury. Using a soft-bristled toothbrush only with water (Choice C) is not sufficient for effective oral care as toothpaste helps in removing plaque and bacteria. Brushing the client's teeth while they are in a supine position (Choice D) is not safe as it increases the risk of aspiration since fluids can easily enter the airway in this position.
The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the healthcare team use for logrolling?
- A. Involve at least three to four people.
- B. Instruct the patient not to reach for the opposite side rail when turning.
- C. Move the bottom part of the patient's torso first and then the top part.
- D. Use pillows for support before turning.
Correct Answer: A
Rationale: The correct technique for logrolling involves at least three to four people to ensure the safety and proper alignment of the patient's spine. Logrolling requires coordinated effort from multiple individuals to prevent twisting or bending of the spine, hence option A is correct. Option B is incorrect as patients with spinal cord injuries should not be instructed to reach for the opposite side rail due to the risk of causing harm. Option C is incorrect as moving the bottom part of the patient's torso first could lead to spinal misalignment. Option D is incorrect as pillows should be used for support and comfort after the patient has been successfully turned, not before.
A client is scheduled to have his alanine aminotransferase (ALT) level checked. The client asks the nurse to explain the laboratory test. Which of the following is an appropriate response by the nurse?
- A. "This test will indicate if you are at risk for developing blood clots."
- B. "This test will determine if your heart is performing properly."
- C. "This test will provide information about the function of your liver."
- D. "This test is used to check how your kidneys are working."
Correct Answer: C
Rationale: The correct answer is C: "This test will provide information about the function of your liver." Alanine aminotransferase (ALT) is an enzyme mainly found in the liver. An elevated ALT level may indicate liver damage or disease. Choices A, B, and D are incorrect because ALT is specifically related to liver function and not indicative of blood clot risk, heart performance, or kidney function.
A postoperative client will need to perform daily dressing changes after discharge. Which outcome statement best demonstrates the client's readiness to manage his wound care after discharge?
- A. Asks relevant questions regarding the dressing change.
- B. States he will be able to complete the wound care regimen.
- C. Demonstrates the wound care procedure correctly.
- D. Has all the necessary supplies for wound care.
Correct Answer: C
Rationale: The correct answer is C. Demonstrating the wound care procedure correctly indicates the client's readiness to independently manage wound care. This action shows practical understanding and application of the necessary skills. Choice A, asking relevant questions, is important but does not directly demonstrate the ability to perform the procedure. Choice B, stating the ability to complete the regimen, is a good intention but does not confirm practical competence. Choice D, having necessary supplies, is essential but does not ensure the client's ability to execute proper wound care.
A patient has damage to the cerebellum. Which disorder is most important for the nurse to assess?
- A. Impaired balance
- B. Hemiplegia
- C. Muscle sprain
- D. Lower extremity paralysis
Correct Answer: A
Rationale: When the cerebellum is damaged, it leads to impaired balance. The cerebellum plays a crucial role in coordinating movements and maintaining balance. Therefore, assessing the patient's balance is essential in determining the extent of cerebellar damage. Options B, C, and D are incorrect because hemiplegia refers to paralysis of one side of the body, muscle sprain is a soft tissue injury, and lower extremity paralysis involves loss of function in the lower limbs. These conditions are not directly associated with damage to the cerebellum.