Nokea
The nurse is caring for a client with organic brain syndrome in a long-term care facility.
Which of the following actions by the nurse is BEST?
- A. Encourage the client to verbalize his feelings regarding the relationship with his family that initiated his nursing home placement.
- B. Help the client to express his favorite pastimes and the type of activities that he enjoys.
- C. Orient the client to the present time and assist him to be alert and oriented when his family comes to visit.
- D. Direct conversation toward assisting the client to reminisce and talk about important past events in his life.
Correct Answer: D
Rationale: Strategy: The topic of the question is unstated. Read the answer choices for clues. (1) may not remember who or where he is (2) not as important as answer choice #4 (3) even with orientation, the client soon forgets (4) correct-geriatric client should be encouraged to talk about his life and important things in the past because he has recent memory loss
You may also like to solve these questions
An involuntary psychiatric patient asks the nurse to mail his letter to the President. He states that the letter will make the President regret his actions to prevent homosexuals from serving in the military. Which of the following responses by the nurse is BEST?
- A. Accept the letter and place it in the patient's medical record.
- B. Read the patient's letter and decide if it is appropriate to mail.
- C. Call the patient's psychiatrist and inform him of the letter.
- D. Discourage the patient from sending the letter, but mail it if patient insists.
Correct Answer: D
Rationale: Mailing the letter respects the patient’s communication rights while addressing potential concerns. Options A, B, and C violate autonomy or privacy.
An elderly client is returned to her room after an open reduction and internal fixation of the left femoral head after a fracture.
- A. What is the most important nursing care plan inclusion for an elderly client post-femoral fracture repair?
- B. Eat a high-protein, low-residue diet.
- C. Lie on her unoperated side.
- D. Exercise her arms and legs.
- E. Cough and deep breathe.
Correct Answer: D
Rationale: Coughing and deep breathing prevent respiratory complications like pneumonia, a significant risk due to immobility post-surgery. A high-residue diet prevents constipation, positioning varies, and exercises are secondary to respiratory care.
An infant is suspected of having coarctation of the aorta. Which assessment finding is most related to coarctation of the aorta?
- A. Respirations are 70 per minute.
- B. Blood pressure is higher in the upper extremities than in the lower extremities.
- C. There is a heart murmur.
- D. Heart rate is 150 beats per minute.
Correct Answer: B
Rationale: Coarctation of the aorta causes aortic narrowing, leading to higher blood pressure in the upper extremities compared to the lower, a hallmark sign.
A nurse is to administer meperidine hydrochloride (Demerol) 100 mg, atropine sulfate (Atropesol) 0.4 mg, and promethazine hydrochloride (Phenergan) 50 mg IM to a pre-operative client. Which action should the nurse take first?
- A. Raise the side rails on the bed
- B. Place the call bell within reach
- C. Instruct the client to remain in bed
- D. Have the client empty bladder
Correct Answer: D
Rationale: Have the client empty bladder. The first step in the process is to have the client void prior to administering the pre-operative medication. The other actions follow this initial step in this sequence: D, C, B, A. Note: It is much easier to administer IM meds with the side rails down, and then raising them when the nurse is done. Other activities can then be carried out more safely.
A client is going to be taking imipramine (Tofranil) at home following discharge.
The nurse should instruct the client to report which of the following immediately to the nurse?
- A. Sore throat, fever, increased fatigue, vomiting, diarrhea.
- B. Dry mouth, nasal stuffiness, weight gain.
- C. Rapid heartbeat, frequent headaches, yellowing of eyes or skin.
- D. Weakness, staggering gait, tremor, feeling of drunkenness.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-possible side effects of Tofranil, a tricyclic antidepressant medication, which can be resolved by altering the dosage or changing the medication (2) describes side effects of antidepressants, which client can learn to manage at home without changing the medication (3) describes side effects of a different category of medications (4) describes side effects of a different category of medications