Nokea
When the nurse observes that the client has difficulty swallowing the capsule of medication, which action is best to take?
- A. Soak the capsule in water until soft.
- B. Tell the client to chew the capsule.
- C. Moisten the capsule in the client's mouth.
- D. Offer water before giving the capsule.
Correct Answer: D
Rationale: Offering water before giving the capsule aids swallowing without altering the medication's integrity.
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Which assessment data indicate that the client with a traumatic brain injury (TBI) exhibiting decorticate posturing on admission is responding effectively to treatment?
- A. The client has flaccid paralysis.
- B. The client has purposeful movement.
- C. The client has decerebrate posturing with painful stimuli.
- D. The client does not move the extremities.
Correct Answer: B
Rationale: Purposeful movement (B) indicates improved brain function compared to decorticate posturing. Flaccid paralysis (A) or decerebrate posturing (C) suggest worsening, and no movement (D) is not an improvement.
The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?
- A. Do you have trouble hearing?'
- B. Are you allergic to any type of dairy products?'
- C. Have you eaten anything in the last eight (8) hours?'
- D. Are you uncomfortable in closed spaces?'
Correct Answer: D
Rationale: MRI scans require lying still in a confined space, so assessing for claustrophobia (D) is critical to ensure patient safety and comfort. Hearing issues (A), dairy allergies (B), and recent eating (C) are not relevant to MRI preparation.
The unlicensed assistive personnel (UAP) is attempting to put an oral airway in the mouth of a client having a tonic-clonic seizure. Which action should the primary nurse take?
- A. Help the UAP to insert the oral airway in the mouth.
- B. Tell the UAP to stop trying to insert anything in the mouth.
- C. Take no action because the UAP is handling the situation.
- D. Notify the charge nurse of the situation immediately.
Correct Answer: B
Rationale: Inserting objects during a seizure (B) risks injury to the mouth or airway and is contraindicated. The nurse must intervene immediately. Helping the UAP (A) is unsafe, taking no action (C) neglects responsibility, and notifying the charge nurse (D) delays correction.
Based on the nurse's knowledge, which characteristic is found in Alzheimer's disease that distinguishes it from other dementias?
- A. Destruction of brain cells from hypoxia
- B. Destruction of brain cells from a stroke
- C. Neurofibrillary tangles and plaques in the brain
- D. A superficial infection in the meninges of the brain
Correct Answer: C
Rationale: Neurofibrillary tangles and amyloid plaques are hallmark pathological features of Alzheimer's disease.
The public health nurse is giving a lecture on potential outbreaks of infectious meningitis. Which population is most at risk for an outbreak?
- A. Clients recently discharged from the hospital.
- B. Residents of a college dormitory.
- C. Individuals who visit a third world country.
- D. Employees in a high-rise office building.
Correct Answer: B
Rationale: College dormitory residents (B) are at high risk for meningococcal meningitis due to close living conditions and shared spaces. Hospital discharges (A), travel (C), or office workers (D) are less specific risks.