Nokea
When admitting a client at risk for falls in a long-term care facility, what should the nurse do first?
- A. Complete a fall-risk assessment
- B. Place a fall-risk identification bracelet on the client
- C. Provide the client with nonskid footwear
- D. Set the bed to the lowest position
Correct Answer: A
Rationale: The initial step in caring for a client at risk for falls is to conduct a fall-risk assessment. This assessment helps the nurse gather crucial data to identify specific risks and individualized needs, guiding subsequent interventions and preventive measures. By completing a thorough assessment, the nurse can develop a targeted plan of care to mitigate fall risk and ensure the client's safety. Placing a fall-risk identification bracelet, providing nonskid footwear, or setting the bed to the lowest position may be important interventions, but these actions should be based on the findings of the fall-risk assessment, making choice A the priority.
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A client with peptic ulcer disease is being taught about dietary management. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should avoid drinking milk.
- B. I should avoid drinking coffee.
- C. I should avoid eating high-fiber foods.
- D. I should avoid eating low-fat foods.
Correct Answer: B
Rationale: The correct answer is B. Avoiding coffee is important in managing peptic ulcer disease as it helps reduce acid production and alleviate symptoms. Coffee is known to stimulate acid secretion in the stomach, which can exacerbate ulcer symptoms. Therefore, instructing the client to avoid drinking coffee is essential in the dietary management of peptic ulcer disease. Choices A, C, and D are incorrect. Drinking milk is generally allowed and can even provide a protective effect against ulcers. High-fiber foods are beneficial for digestion and do not need to be avoided unless they cause discomfort. Low-fat foods are also typically recommended for individuals with peptic ulcer disease as they are easier on the digestive system.
Which of the following statement is TRUE about patient's bill of rights?
- A. The client can leave anytime he wants even against medical advice
- B. The client has no right to refuse treatment
- C. The hospital can deny treatment in emergency cases
- D. The client has the right to considerate care only from nurses
Correct Answer: A
Rationale: The client can leave anytime, even against medical advice (A), per autonomy in the bill of rights AMA discharge is legal. No right to refuse (B) is false, hospitals can't deny emergencies (C) per EMTALA, considerate care isn't nurse-only (D). A upholds patient choice, making it true.
Client perceptions about their health problems are:
- A. Objective data
- B. Observational recordings
- C. Aucilliary reports from the data collector
- D. Subjective data
Correct Answer: D
Rationale: Subjective data are clients' perceptions e.g., 'I feel dizzy' reported directly, capturing experiences unmeasurable by others. This contrasts with objective data (e.g., pulse), observable by nurses. Observational recordings are objective, like noting pallor, not perceptions. Ancillary reports (e.g., lab results) are objective, external data, not client-voiced. Subjective data's focus on personal input e.g., pain severity enriches assessment, guiding nurses to explore symptoms' impact (e.g., anxiety's role), making it vital for holistic care and the correct classification here.
The nurse is assessing a post operative client who underwent a colostomy, which of the following findings will warrant further nursing interventions?
- A. The stoma appears pale and dry
- B. The stoma appears red
- C. The stoma drains a bloody drainage then progressed to greenish discharge
- D. The stoma drains a greenish discharge
Correct Answer: A
Rationale: A pale, dry stoma e.g., ischemia needs intervention (e.g., notify MD), unlike red (healthy), bloody-to-green (normal), or green (expected). Nurses assess e.g., color for complications, per ostomy care.
A patient about to undergo abdominal inspection is best placed in which of the following positions?
- A. Prone
- B. Trendelenburg
- C. Supine
- D. Side-lying
Correct Answer: C
Rationale: Supine allows full abdominal exposure for inspection.