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Which goal is the most realistic and appropriate for a client diagnosed with Parkinson's disease?
- A. To cure the disease.
- B. To stop progression of the disease.
- C. To begin preparations for terminal care.
- D. To maintain optimal body function.
Correct Answer: D
Rationale: Maintaining optimal body function is realistic, focusing on symptom management and quality of life. Parkinson's is incurable, progression cannot be stopped, and terminal care is premature for most clients.
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Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress?
- A. Administering oxygen every 2 hours.
- B. Turning the client every 4 hours.
- C. Administering sedatives to promote rest.
- D. Suctioning if cough is ineffective.
Correct Answer: D
Rationale: Suctioning clears secretions when coughing is ineffective in ARDS, maintaining airway patency. Oxygen delivery, turning, and sedatives are supportive but less direct for airway clearance.
A client post-extracorporeal shock wave lithotripsy should report:
- A. Mild hematuria.
- B. Severe flank pain.
- C. Clear urine.
- D. Bruising.
Correct Answer: B
Rationale: Severe flank pain may indicate a complication like hematoma or obstruction.
The nurse should plan to begin rehabilitation efforts for the burn client:
- A. Immediately after the burn has occurred.
- B. After the client's circulatory status has been stabilized.
- C. After the client's pain has been eliminated.
- D. After the client's pain has been eliminated.
Correct Answer: B
Rationale: Rehabilitation begins after stabilizing the client's circulatory status (emergent phase), as this ensures survival and allows focus on recovery. Immediate rehab is unsafe, and complete pain elimination is unrealistic.
Twenty-four hours after a bone marrow aspiration, the nurse evaluates which of the following as an appropriate client outcome?
- A. The client maintains bed rest.
- B. There is redness and swelling at the aspiration site.
- C. The client requests morphine sulfate for pain.
- D. There is no bleeding at the aspiration site.
Correct Answer: D
Rationale: A successful outcome 24 hours after bone marrow aspiration is no bleeding at the site, indicating proper healing and no complications. Bed rest is not required, redness/swelling suggests infection, and morphine requests indicate uncontrolled pain, which is not expected.
Which of the following skin preparations would be best to apply around the client's colostomy?
- A. Karaya.
- B. Petroleum jelly.
- C. Antiseptic cream.
- D. None of the above
Correct Answer: A
Rationale: Karaya is a natural skin barrier that protects the skin around the stoma from irritation and is commonly used in ostomy care. Petroleum jelly is not suitable as it can interfere with adhesion of the ostomy appliance, and antiseptic cream is not typically used for routine skin protection around a stoma. CN: Physiological adaptation; CL: Apply