Nokea
Which measures will help prevent falls in the elderly clients of a long-term care facility? Select all that apply.
- A. Exercise programs
- B. Good room lighting
- C. Handrails in stairwell
- D. Smooth-soled shoes
- E. Staff hourly rounds
Correct Answer: A,B,C,E
Rationale: Exercise, lighting, handrails, and rounds reduce fall risk. Smooth-soled shoes increase slipping risk.
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The nurse is observing a certified nursing assistant move a client. Which action, if observed, indicates that the nursing assistant needs more instruction?
- A. The assistant stands with feet spread apart.
- B. The assistant bends from the waist.
- C. The assistant turns her whole body.
- D. The assistant keeps her back straight.
Correct Answer: B
Rationale: Bending from the waist strains the back, indicating improper technique. Wide stance, whole-body turning, and straight back are correct for safe client movement.
The client is unable to adequately bathe himself because he has dressings on his hands that cannot get wet. What is the most appropriate nursing diagnosis for this assessment finding?
- A. Risk for infection
- B. Deficient knowledge
- C. Acute pain related to specific illness or disease process
- D. Self-care deficit (bathing)
Correct Answer: D
Rationale: Inability to bathe due to hand dressings indicates a self-care deficit in bathing, the most specific nursing diagnosis.
The nurse at an orthopedic joint clinic is assisting with the preparation of pre-operative teaching for clients scheduled for total hip replacement surgery. Which would be included in the teaching plan?
- A. Avoid sitting in a recliner
- B. Make sure that commode seats are at low levels
- C. Avoid crossing the legs when sitting
- D. Physical therapy will assist with adduction leg exercises
Correct Answer: C
Rationale: The client with joint hip replacement should avoid adduction of the legs and flexion of the hips greater than 90 degrees to ensure continued placement of the prosthetic joint. It is recommended for these clients to use recliners for seating instead of straight chairs, therefore A is incorrect. Commode seats will have to be raised and abduction of the legs is required, making B and D incorrect choices.
The nurse is collecting data from a client during a routine physical examination. Which of the following findings would be most important to report to the health care provider?
- A. BMI of 30 kg/m²
- B. Brownish skin thickening on the neck
- C. Cholesterol level
- D. Round 3x3 mm pale pink mole
Correct Answer: B
Rationale: Brownish skin thickening on the neck may indicate acanthosis nigricans, associated with insulin resistance or diabetes, requiring prompt reporting.
The nurse is reinforcing teaching to a client diagnosed with Raynaud phenomenon about ways to prevent recurrent episodes. Which instructions should the nurse include? Select all that apply.
- A. Avoid excess caffeine
- B. Immerse hands in cold water
- C. Practice yoga or tai chi
- D. Refrain from using tobacco products
- E. Wear gloves when handling cold objects
Correct Answer: A,C,D,E
Rationale: Caffeine, tobacco, and cold exposure can trigger Raynaud episodes. Yoga/tai chi and gloves help prevent attacks. Cold water immersion exacerbates symptoms.