Which communication technique will help a nurse communicate with clients who do not speak English?
- A. Repeat the question without changing words.
- B. Look at the translator when asking questions.
- C. Speak slowly,using simple words and short sentences.
- D. Refer to an English or foreign language dictionary for bilingual words.
Correct Answer: C
Rationale: Speaking slowly and using simple language improves comprehension for non-native speakers.
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A nurse caring for a patient in the intensive care unit (ICU) implements strategies to create an environment conducive to sleep. Which strategy would be most effective?
- A. Turning off the lights in the room during the night
- B. Having the television on at all times for background noise
- C. Silencing the alarms on the bedside monitor and infusion pumps
- D. Administering ordered analgesics around the clock, even if the patient denies pain
Correct Answer: A
Rationale: The correct answer is A. Turning off the lights minimizes disruption to the patient's circadian rhythm. Background noise (B) and silencing alarms (C) may not always be feasible, and unnecessary analgesics (D) could interfere with sleep.
Jane, an obese hypertensive homemaker, complains of continual hunger and lack of energy. What nursing measure would be most helpful?
- A. Giving her a list of low-calorie foods
- B. Discussing the importance of eating breakfast
- C. Recommending a strict vegetarian diet
- D. Suggesting vitamin supplements
Correct Answer: B
Rationale: Eating breakfast helps regulate metabolism and energy levels throughout the day, reducing hunger and fatigue.
For the nursing diagnoses and written patient outcomes listed below, use the Nursing Interventions Classification (NIC) to identify a specific nursing intervention to help the patient reach the outcome.
- A. Risk for impaired skin integrity related to immobility
- B. Constipation related to inadequate fluid and fiber intake
- C. None
- D. All
Correct Answer: A
Rationale: For preventing pressure ulcers, interventions like turning and positioning are critical. For constipation, increasing fluid and fiber intake is key.
During the rehabilitation of a patient with limited mobility, how can decubitus ulcers be prevented?
- A. Turning the patient every 4 hours
- B. Using a heat lamp on reddened areas
- C. Applying vitamin C to bony prominences
- D. Keeping the skin clean, dry, and well lubricated
Correct Answer: D
Rationale: Maintaining skin integrity through cleanliness and moisture management prevents pressure ulcers.
A client continually repeats phrases that others have just said. The nurse recognizes this behavior as:
- A. Autistic.
- B. Ecopraxic.
- C. Echolalic.
- D. Catatonic.
Correct Answer: C
Rationale: Echolalia is the repetition of words or phrases heard from others.
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