Nokea
Which intervention supports a client with expressive aphasia?
- A. Speak loudly.
- B. Use written instructions.
- C. Provide a communication board.
- D. Ask complex questions.
Correct Answer: C
Rationale: A communication board supports communication for clients with expressive aphasia.
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A nurse is assessing a group of clients. Which clients are at risk for vasospastic disorder (Raynaud's phenomenon)?
- A. Young women
- B. Old women
- C. Old men
- D. Young men
Correct Answer: A
Rationale: Young women are at highest risk for Raynaud's phenomenon, particularly primary Raynaud's, due to hormonal influences and higher prevalence of autoimmune conditions. While men and older individuals can develop it, young women are most commonly affected.
A client with cirrhosis is receiving Lactulose (Cephulac). During the assessment the nurse notes increased confusion and asterixis. The nurse should:
- A. Assess for GI bleeding.
- B. Hold the Lactulose (Cephulac).
- C. Increase protein in the diet.
- D. Monitor serum bilirubin levels.
Correct Answer: A
Rationale: Confusion and asterixis indicate hepatic encephalopathy, often precipitated by GI bleeding (A), which increases ammonia levels. Holding lactulose (B) is incorrect as it reduces ammonia. Increasing protein (C) worsens encephalopathy. Bilirubin (D) is unrelated to acute symptoms.
The nurse is providing discharge teaching for a client post-inguinal herniorrhaphy. Which statement by the client indicates a need for further teaching?
- A. I'll avoid heavy lifting for about 6 weeks.
- B. I can take a shower tomorrow.
- C. I'll call the doctor if I have a fever.
- D. I can resume sexual activity next week.
Correct Answer: D
Rationale: Resuming sexual activity within a week post-inguinal herniorrhaphy may strain the surgical site, indicating a need for further teaching to delay such activities for 4–6 weeks. The other statements align with appropriate postoperative care. CN: Health promotion and maintenance; CL: Evaluate
The nurse is caring for an older adult in the emergency department with moderate hypothermia. Which of the following actions should the nurse take? Select all that apply.
- A. Apply external heat with a heating blanket to the client's trunk.
- B. Actively rewarm the extremities first, followed by the client's trunk.
- C. Use extracorporeal rewarming methods such as cardiopulmonary bypass or hemodialysis.
- D. Monitor for fluid, electrolyte, and metabolic abnormalities.
- E. Administer ordered medications at spaced longer intervals.
- F. Administer room temperature intravenous (IV) fluids for core rewarming.
Correct Answer: A,D,F
Rationale: Applying heat to the trunk (A), monitoring electrolytes (D), and using room-temperature IV fluids (F) are appropriate for moderate hypothermia. Rewarming extremities first (B) risks core afterdrop, extracorporeal methods (C) are for severe cases, and altering medication intervals (E) lacks evidence.
After instructing a client with diverticulosis about appropriate self-care activities, which of the following client comments indicate effective teaching? Select all that apply.
- A. With careful attention to my diet, my diverticulosis can be cured.
- B. Using a cathartic laxative weekly is okay to control bowel movements.
- C. I should follow a diet that's high in fiber.
- D. It is important for me to drink at least 2,000 mL of fluid every day.
- E. I should exercise regularly.
Correct Answer: C,D,E
Rationale: Effective teaching is indicated by the client understanding the need for a high-fiber diet (C), adequate fluid intake (D), and regular exercise (E) to manage diverticulosis. Diverticulosis cannot be cured (A), and cathartic laxatives (B) are not recommended as they can irritate the bowel. CN: Health promotion and maintenance; CL: Evaluate