Nokea
When assisting an older male client recovering from a stroke to ambulate with a cane, where should the nurse place the cane in relation to the client's body?
- A. In front of the body to lean on while stepping forward
- B. On the opposite side of the affected extremity
- C. Approximately one foot away from the body to stabilize balance
- D. On the same side as the affected extremity
Correct Answer: B
Rationale: The correct answer is B: 'On the opposite side of the affected extremity.' Placing the cane on the opposite side of the affected extremity provides maximum support and stability during ambulation for a client recovering from a stroke. This positioning helps to offload weight from the affected side and improves balance. Choice A is incorrect because placing the cane in front of the body can lead to incorrect weight distribution and instability. Choice C is incorrect as placing the cane one foot away from the body may not provide adequate support and can compromise balance. Choice D is incorrect as placing the cane on the same side as the affected extremity does not offer the necessary balance and support needed for safe ambulation.
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After spinal fusion surgery, a client reports numbness and tingling in the legs. What should the nurse do first?
- A. Assess the client's neurovascular status in the lower extremities.
- B. Reposition the client to relieve pressure on the spine.
- C. Administer prescribed pain medication.
- D. Notify the healthcare provider immediately.
Correct Answer: A
Rationale: After spinal fusion surgery, numbness and tingling in the legs may indicate nerve compression or damage. The priority action for the nurse is to assess the client's neurovascular status in the lower extremities. This assessment will help determine the cause and severity of the symptoms, guiding further interventions. Repositioning the client may be necessary for comfort, but assessing neurovascular status is the initial step. Administering pain medication should only follow the assessment to address any discomfort. Notifying the healthcare provider immediately is not the first action unless there are emergent signs requiring urgent intervention.
The UAP is caring for a male resident of a long-term care facility who has an external urinary catheter. Which finding should the PN instruct the UAP to report immediately?
- A. Swollen and discolored penile shaft
- B. Prepuce extends over the head of the penis
- C. Leaking urine around the top of the catheter
- D. Moist and excoriated perineal skin folds
Correct Answer: A
Rationale: The correct answer is A: Swollen and discolored penile shaft. Swelling and discoloration of the penile shaft may indicate an infection or other complications requiring immediate attention. Prompt reporting allows for timely intervention to prevent further harm to the client. Choice B is incorrect because the prepuce extending over the head of the penis is not an urgent issue. Choice C, leaking urine around the catheter, may require intervention but is not as urgent as the swelling and discoloration described in choice A. Choice D, moist and excoriated perineal skin folds, also needs attention but is not as concerning as the potential complications indicated by the findings in choice A.
The nurse is assigned to administer medications in a long-term care facility. A disoriented resident has no identification band or picture. What is the best nursing action for the nurse to take prior to administering the medications to this resident?
- A. Ask a regular staff member to confirm the resident's identity
- B. Hold the medication until a family member can confirm identity
- C. Re-orient the resident to name, place, and situation
- D. Confirm the room and bed numbers with those on the medication record
Correct Answer: A
Rationale: In a long-term care facility, when a disoriented resident lacks identification, it is crucial to confirm the resident's identity before administering medication to prevent errors. Asking a regular staff member who is familiar with the resident to confirm their identity is the best course of action. This ensures accuracy and safety in medication administration. Holding the medication until a family member can confirm the identity could delay necessary treatment. Re-orienting the resident is important for their well-being but does not address the immediate medication safety concern. Confirming room and bed numbers, though important for administration logistics, does not verify the resident's identity.
What is the primary role of the sinoatrial (SA) node in the heart?
- A. Pacemaker of the heart
- B. Blood pressure regulation
- C. Electrical conduction delay
- D. Stimulating muscle contraction
Correct Answer: A
Rationale: The correct answer is A: Pacemaker of the heart. The SA node, known as the natural pacemaker, initiates the electrical impulses that set the rhythm for the heartbeat. It is responsible for coordinating the heart's contractions by generating electrical signals at regular intervals. Choice B is incorrect as the SA node's primary function is not related to blood pressure regulation. Choice C is incorrect as the SA node does not cause electrical conduction delay but rather initiates and conducts the electrical impulses. Choice D is incorrect as the SA node does not directly stimulate muscle contraction but rather initiates the electrical events that lead to muscle contraction.
The PN is assisting the recreational director of a long-term care facility to plan outdoor activities for wheelchair-bound older residents who are mentally alert. Which activity meets the physical and social needs of these residents?
- A. An open-air concert
- B. A tea party in the courtyard
- C. A team ring-toss competition
- D. A picnic in the park
Correct Answer: B
Rationale: A tea party in the courtyard is the most suitable activity as it allows for social interaction in a comfortable and accessible environment. Wheelchair-bound residents can easily participate, fostering both physical and social engagement. An open-air concert may pose challenges regarding accessibility and comfort for wheelchair-bound individuals. A team ring-toss competition involves physical activity that may not be inclusive for all residents, especially those in wheelchairs. A picnic in the park may also present challenges related to accessibility and comfort for wheelchair-bound individuals.