Nokea
Which home care suggestion is best for promoting the mobility of the client with a spinal cord injury?
- A. Rent or buy a conventional hospital bed.
- B. Build a wheelchair ramp to the door.
- C. Apply for a handicapped parking sticker.
- D. Provide a raised toilet seat with grab bars.
Correct Answer: B
Rationale: A wheelchair ramp enhances home accessibility, significantly improving mobility for a client with a spinal cord injury.
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Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel?
- A. Teach Credé’s maneuver to the client needing to void.
- B. Administer the tube feeding to the client who is quadriplegic.
- C. Assist with bowel training by placing the client on the bedside commode.
- D. Observe the client demonstrating self-catheterization technique.
Correct Answer: C
Rationale: Assisting with bowel training by placing the client on a commode (C) is within the UAP’s scope, involving physical assistance. Teaching (A), administering tube feedings (B), and observing techniques (D) require nursing judgment and are not delegable.
The client is diagnosed with a metastatic brain tumor, and radiation therapy is scheduled. The client asks the nurse, 'Why not try chemotherapy first? It has helped my other tumors.' The nurse’s response is based on which scientific rationale?
- A. Chemotherapy is only used as a last resort in caring for clients with brain tumors.
- B. The blood-brain barrier prevents medications from reaching the brain.
- C. Radiation therapy will have fewer side effects than chemotherapy.
- D. Metastatic tumors become resistant to chemotherapy and it becomes useless.
Correct Answer: B
Rationale: The blood-brain barrier (B) limits chemotherapy penetration into the brain, making radiation more effective for brain metastases. Chemotherapy is used in some cases (A), radiation side effects vary (C), and resistance (D) is not universally true.
When the client is observed wandering about the facility, the nurse modifies the client's care plan to provide for safety. Which nursing intervention is most appropriate at this time?
- A. Keep the client confined to the room.
- B. Attach an identity tag to the client's clothes.
- C. Lock all the outside doors in the facility.
- D. Make sure the client knows the location of the facility.
Correct Answer: B
Rationale: An identity tag helps ensure the client can be identified and returned safely if they wander, promoting safety without restricting freedom.
Which discharge instruction is most appropriate following the positron emission tomography scan?
- A. Take a mild sedative tonight.
- B. Increase your fluid intake.
- C. Avoid excessive sitting.
- D. Report signs of a fever.
Correct Answer: B
Rationale: Increasing fluid intake helps flush the radioactive tracer used in the PET scan from the body.
The nurse is performing a Glasgow Coma Scale (GCS) assessment on a client with a problem with intracranial regulation. The client’s GCS one (1) hour ago was scored at 10. Which datum indicates the client is improving?
- A. The current GSC rating is 3.
- B. The current GSC rating is 9.
- C. The current GSC rating is 10.
- D. The current GSC rating is 12.
Correct Answer: D
Rationale: A GCS of 12 (D) is higher than 10, indicating improved neurological status. Scores of 3 (A) or 9 (B) indicate worsening, and 10 (C) shows no change.