Nokea
Which nursing intervention is most effective in helping a client with aphasia communicate?
- A. Speak loudly and clearly to the client.
- B. Use simple pictures or a communication board.
- C. Ask the client to write responses to questions.
- D. Encourage the client to repeat words after the nurse.
Correct Answer: B
Rationale: A communication board or pictures aids communication for clients with aphasia by providing visual cues to express needs.
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The client is withdrawing from a heroin addiction. Which interventions should the nurse implement? Select all that apply.
- A. Initiate seizure precautions.
- B. Check vital signs every eight (8) hours.
- C. Place the client in a quiet, calm atmosphere.
- D. Have a consent form signed for HIV testing.
- E. Provide the client with sterile needles.
Correct Answer: C
Rationale: Heroin withdrawal causes discomfort but not seizures, so seizure precautions (A) are unnecessary. Vital signs every 8 hours (B) is too infrequent; every 4 hours is standard. A quiet, calm atmosphere (C) reduces stimulation. HIV testing (D) requires consent but isn’t withdrawal-specific, and sterile needles (E) are inappropriate.
When changing the client's position postoperatively, which nursing action is best?
- A. Raise the client with a mechanical lift.
- B. Logroll the client from side to side.
- C. Have the client flex the knees and lift.
- D. Pull the client's arms and then the legs.
Correct Answer: B
Rationale: Logrolling maintains spinal alignment, preventing strain on the surgical site after diskectomy and spinal fusion.
The client diagnosed with Parkinson’s disease is being discharged. Which statement made by the significant other indicates an understanding of the discharge instructions?
- A. All of my spouse’s emotions will slow down now just like his body movements.'
- B. My spouse may experience hallucinations until the medication starts working.'
- C. I will schedule appointments late in the morning after his morning bath.'
- D. It is fine if we don’t follow a strict medication schedule on weekends.'
Correct Answer: C
Rationale: Scheduling appointments late in the morning (C) accommodates Parkinson’s patients’ morning stiffness and medication timing, indicating understanding. Emotional slowing (A) is incorrect, hallucinations (B) are a side effect not limited to initiation, and strict medication schedules (D) are critical.
While awaiting the diagnostic test results for a client with possible meningitis, which transmission-based precautions are the supplement?
- A. Droplet precautions
- B. Airborne precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: A
Rationale: Meningitis, especially bacterial, is often transmitted via respiratory droplets, necessitating droplet precautions.
Which nursing action is best for controlling the symptoms of the client diagnosed with myasthenia gravis?
- A. Ensure that the client has regular bowel and bladder elimination.
- B. Administer each dose of medication at the precise scheduled time.
- C. Encourage the client to exercise twice daily for 30 minutes.
- D. Monitor the client's blood pressure every 4 hours.
Correct Answer: B
Rationale: Precise timing of pyridostigmine administration ensures consistent symptom control in myasthenia gravis by maintaining acetylcholine levels.