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When assessing a patient's level of consciousness, the nurse should:
- A. Evaluate the patient's response to verbal and physical stimuli.
- B. Measure the patient's blood pressure.
- C. Inspect the patient's skin color.
- D. Assess the patient's respiratory rate.
Correct Answer: A
Rationale: Evaluating a patient's response to verbal and physical stimuli is essential for assessing their level of consciousness. Blood pressure, skin color, and respiratory rate are important but do not directly measure consciousness.
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For the patient who has expressive aphasia following a cerebrovascular accident, the most therapeutic nursing intervention would be to
- A. keep verbal nurse-patient interchanges to a minimum
- B. talk to the patient as if he understands
- C. avoid using objects or gestures to communicate
- D. keep the sound of a radio or television audible in the background
Correct Answer: B
Rationale: Talking normally helps maintain cognitive engagement.
Mrs. Rollo has been instructed to check her urine with a multiple test stick. For which abnormal finding should she be particularly alert and report to you when the test is positive?
- A. Glucose
- B. pH of 5
- C. Protein
- D. Ketones
Correct Answer: C
Rationale: Proteinuria can indicate kidney damage, a potential side effect of gold therapy.
What nursing interventions are most critical for a client diagnosed with encephalitis?
- A. Evaluating the client's ventilation capacity and lung sounds frequently.
- B. Observing closely for signs of respiratory distress.
- C. Administering an indwelling urethral catheter.
- D. Monitoring vital signs and LOC frequently.
Correct Answer: B
Rationale: Respiratory distress is a potential complication requiring close monitoring.
When Mr. Jones develops an attack of autonomic dysreflexia, it is initially most important to
- A. elevate the head of his bed
- B. monitor his blood pressure closely
- C. assess for bowel and bladder distention
- D. encourage him to ventilate his concerns
Correct Answer: C
Rationale: Assessing for bowel and bladder distention is critical as these can trigger autonomic dysreflexia.
What is an appropriate nursing intervention to promote communication during rehabilitation of the patient with aphasia?
- A. Use gestures
- B. pictures
- C. and music to stimulate patient responses.
- D. Talk about activities of daily living (ADLs) that are familiar to the patient.
Correct Answer: A
Rationale: Non-verbal cues and familiar topics help facilitate communication in patients with aphasia