Nokea
Which assessment finding is most atypical of a 65-year-old client?
- A. Making errors in copying a line drawing
- B. Forgetting the names of longstanding neighbors
- C. Reading information slowly
- D. Naming only two of the last three presidents
Correct Answer: A
Rationale: Errors in copying a drawing suggest visuospatial deficits, less common in typical aging and more indicative of neurological issues.
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The older disheveled client is admitted to the ED with hypertension severe dehydration and malnourishment. During the admission interview the daughter notes that she and her husband who is temporarily out of work have been living with the client. Which nursing action is most important?
- A. Report the suspected elder abuse to Adult Health Protective Services.
- B. Ask additional questions of the client in private without the family present.
- C. Ask the daughter whether her father has been eating and taking his medication.
- D. Call the resource hotline to ask whether abuse and neglect should be considered.
Correct Answer: B
Rationale: Private questioning (B) elicits abuse/neglect details. Reporting (A) needs more evidence asking the daughter (C) is less direct and calling a hotline (D) is secondary.
When the nurse responds to a call from a 22-year-old rape victim, which instruction is most important before referring the client to the emergency department of the local hospital?
- A. Do not bathe or shower.
- B. Make a sketch of the rapist.
- C. Write down what happened.
- D. Call a 911 operator.
Correct Answer: A
Rationale: Advising the victim not to bathe preserves forensic evidence, which is critical for potential criminal investigation and prosecution.
The indigent client with both emotional and physical diagnoses has just attended a discharge planning session with the nurse. Which client behavior shows the greatest commitment to the client’s self-management?
- A. Correctly stating the medications prescribed and the administration schedule
- B. Asking to stay with a relative until an affordable place to live can be found
- C. Researching the names of and calling contact people at local support centers
- D. Promising the nurse to keep the scheduled follow-up appointments at the clinic
Correct Answer: C
Rationale: Calling support centers (C) shows proactive engagement. Stating medications (A) seeking housing (B) and promising appointments (D) are less indicative of commitment.
The nurse is aware that such attitudes and statements can have damaging consequences for a mentally ill client. What is the most significant consequence of the remark in this situation?
- A. It violates the client's right to treatment.
- B. It disregards the client's individuality.
- C. It interferes with continuity of client care.
- D. It disrupts good staff relationships.
Correct Answer: B
Rationale: Labeling the client as a hypochondriac dismisses their unique experiences, undermining person-centered care and trust.
Which response by the nurse is most accurate?
- A. It will show up in urine tests 3 to 4 days after use.
- B. Traces may be picked up by sensitive blood tests 8 to 10 weeks later.
- C. Hair analysis can detect marijuana use more than a year before the urine test.
- D. Marijuana leaves the body within 2 hours of smoking it.
Correct Answer: B
Rationale: Marijuana metabolites can be detected in blood tests for weeks, with sensitive tests picking up traces 8 to 10 weeks after use, depending on frequency and amount used.