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A nurse is assisting with the development of a plan of care for an older adult who is at risk for falls. Which of the following actions should the nurse contribute to the plan? (Select all that apply)
- A. Keep a night light on in the client's room and bathroom.
- B. Keep the bed at a comfortable working height.
- C. Lock the wheels on beds and wheelchairs during transfers.
- D. Place the bedside table within the client's reach.
- E. Administer a sedative at bedtime.
Correct Answer: A,C,D
Rationale: The correct actions to contribute to the fall prevention plan are A, C, and D. A night light can help the client see clearly at night, reducing the risk of tripping. Locking the wheels on beds and wheelchairs ensures stability during transfers. Placing the bedside table within reach promotes independence and prevents falls from reaching for items. Choice B is incorrect as bed height doesn't directly impact fall risk. Choice E, administering a sedative, can increase fall risk due to drowsiness.
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A nurse is collecting data as part of a neurological examination of a client who is receiving treatment for head trauma. Which of the following observations will give the nurse information about the function of the third cranial nerve?
- A. Instruct the client to look up and down without moving his head.
- B. Observe the client's ability to smile and frown.
- C. Evaluate the client's pupillary reaction to light.
- D. Ask the client to shrug his shoulders against passive resistance.
Correct Answer: C
Rationale: The correct answer is C: Evaluate the client's pupillary reaction to light. The third cranial nerve, also known as the oculomotor nerve, controls the pupillary response by constricting the pupil when exposed to light. By observing the client's pupillary reaction to light, the nurse can assess the function of the third cranial nerve. This test specifically targets the parasympathetic fibers of the nerve, which control pupillary constriction.
Choice A (Instruct the client to look up and down without moving his head) would assess the function of the fourth cranial nerve (trochlear nerve).
Choice B (Observe the client's ability to smile and frown) would assess the function of the seventh cranial nerve (facial nerve).
Choice D (Ask the client to shrug his shoulders against passive resistance) would assess the function of the eleventh cranial nerve (accessory nerve).
Therefore, choices A, B, and D are
A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
A nurse in a long-term care facility sees a client who is choking. Which of the following data should the nurse identify as requiring an abdominal thrust?
- A. The client is grasping his abdomen
- B. The client is hyperventilating
- C. The client is coughing
- D. The client cannot speak
Correct Answer: D
Rationale: Inability to speak is a sign of complete airway obstruction requiring abdominal thrusts. Coughing indicates partial obstruction and does not require immediate thrusts.
A nurse is reinforcing teaching with a client who has a new diagnosis of heart failure. Which of the following tools should the nurse use when speaking with the client? (Select all that apply.)
- A. Materials should be culturally diverse.
- B. Information must be accurate and current.
- C. Materials should be written at the eighth-grade level.
- D. Materials should be written in the client's spoken language.
- E. Materials should be distributed to the client in advance.
Correct Answer: A,B,C,D
Rationale: The correct tools for teaching a client with heart failure should include: A) Culturally diverse materials to ensure relevance and understanding across different backgrounds; B) Accurate and current information to provide the client with up-to-date knowledge for managing their condition effectively; C) Materials written at an eighth-grade level to ensure clarity and ease of comprehension; D) Materials in the client's spoken language to facilitate understanding and communication. These tools are essential for effective patient education in heart failure management. Other choices are incorrect as they may not address the client's specific needs or may hinder their understanding of the information.
A nurse is assisting with a presentation at a senior center regarding age-related changes. Which of the following should the nurse include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. With aging, there is a natural decline in muscle mass known as sarcopenia. The nurse should include this because it is a common age-related change that can affect strength and mobility in older adults. Decreased muscle mass can lead to frailty and increased risk of falls. Thickened vertebral disks (B) are not a typical age-related change; instead, they tend to degenerate and become thinner. Decreased chest width (C) is not a significant age-related change and may vary among individuals. Increased force of isometric contractions (D) is not a typical age-related change; in fact, muscle strength tends to decrease with age, leading to reduced force production.