Nokea
When an autistic client begins to eat with her hands, the nurse can best handle the problem by
- A. Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.'
- B. Commenting, 'I believe you know better than to eat with your hand.'
- C. Jokingly stating, 'Well I guess fingers sometimes work better than spoons.'
- D. Removing the food and stating, 'You can't have anymore food until you use the spoon.'
Correct Answer: A
Rationale: Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.' This provides clear instruction and encourages adaptive behavior.
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The nurse observes a staff member not following the plan of care for a client with an antisocial personality disorder. The nurse should:
- A. confront the staff member immediately and say, 'You know that is not the treatment plan.'
- B. write an incident report to create a paper trail of the staff member's failure to follow the planned program.
- C. ask the staff member to talk in private, and reinforce how antisocial clients try to divide staff.
- D. bring up the incident during the weekly conference so that this staff member is not assigned to work with antisocial persons again.
Correct Answer: C
Rationale: It is essential that the treatment program be followed exactly for clients with antisocial personality disorder because they are very manipulative and attempt to divide staff. However, confronting the staff member in front of the client enhances the division of staff.
The nurse is caring for a client who had a stroke and is experiencing dysphagia. Which of the following nursing actions is the PRIORITY?
- A. Position the client upright during meals.
- B. Offer the client thin liquids to drink.
- C. Provide the client with a soft diet.
- D. Encourage the client to eat quickly.
Correct Answer: A
Rationale: Positioning the client upright during meals reduces the risk of aspiration, a life-threatening complication in dysphagia. Options B, C, and D are inappropriate: thin liquids increase aspiration risk, soft diets are secondary, and eating quickly exacerbates the problem.
Which of the following should the nurse implement to prepare a client for a kidney, ureter, bladder (KUB) radiograph test?
- A. Client must be NPO before the examination
- B. Enema to be administered prior to the examination
- C. Medicate client with Lasix 20 mg IV 30 minutes prior to the examination
- D. No special orders are necessary for this examination
Correct Answer: D
Rationale: No special orders are necessary for this examination. No special preparation is necessary for this examination.
Which of the following assessment findings should the nurse recognize as pertinent to a diagnosis of Cushing's syndrome?
- A. Low blood pressure and weight loss.
- B. Thin extremities with easy bruising.
- C. Decreased urinary output and decreased serum potassium.
- D. Tachycardia with complaints of night sweats.
Correct Answer: B
Rationale: clients with Cushing's syndrome tend to lose weight in their legs and have petechiae and bruising
Which of the following is a correctly stated nursing diagnosis for a client with abruptio placentae?
- A. Infection related to obstetrical trauma.
- B. Potential for fetal injury related to abruptio placentae.
- C. Potential alteration in tissue perfusion related to depletion of fibrinogen.
- D. Fluid volume deficit related to bleeding.
Correct Answer: D
Rationale: Abruptio placentae causes hemorrhage, leading to fluid volume deficit, a major nursing concern. The other options are incorrectly stated or irrelevant: infection is not typical, ‘potential’ diagnoses are not standard, and fibrinogen depletion is not the primary issue.