Nokea
A client is seen in the clinic for complaints of back pain.
Which of the following actions, if performed by the client, would indicate that teaching has been effective?
- A. The client bends over to put on and tie her tennis shoes.
- B. The client stands on her toes to place a box on the top shelf of a closet.
- C. The client sits in a recliner with her feet elevated to watch TV.
- D. The client stands with her feet close together and shifts her weight between her feet.
Correct Answer: C
Rationale: Strategy: 'Teaching has been effective' indicates a true statement. (1) causes stress on lumbar region of back (2) causes stress on lower spine (3) correct-provides lumbar flexion, decreasing pressure on lower spine (4) should have feet apart for wide base of support
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The nurse is the leader of a group of mentally retarded adults. The nurse instructs the group members to ignore another client whenever he interrupts others who are speaking. To evaluate the progress of this intervention, the nurse should
- A. measure improvement by counting the number of times the client succeeds.
- B. measure improvement by counting the number of interruptions.
- C. assess the ability of the group to control the client’s interruptions.
- D. count the number of tokens and earned privileges given for interruptions.
Correct Answer: A
Rationale: Counting successful non-interruptions measures the client’s behavioral improvement, the goal of the intervention. Options B, C, and D are less effective: counting interruptions tracks failures, group control is secondary, and tokens are not given for interruptions.
The nurse knows that the client with peripheral vascular disease understands her instructions in ways to improve circulation if the client states
- A. I will massage my legs three times a day.
- B. I will elevate the foot of my bed on blocks.
- C. I will take a brisk walk for 20 minutes each day.
- D. I will prop my feet up when I sit to watch TV.
Correct Answer: C
Rationale: Answer C is the 'odd answer' and correct. Walking improves circulation by developing muscles that support blood vessels. Massaging may dislodge clots, elevating the bed is not specific to circulation, and propping feet reduces venous pooling but is less effective than walking.
The nurse is supervising the staff providing care for an 18-month-old hospitalized with hepatitis A.
- A. Which observation indicates appropriate care for an 18-month-old with hepatitis A?
- B. The child is placed in a private room.
- C. The staff removes a toy from the child’s bed and takes it to the nurse’s station.
- D. The staff offers the child french fries and a vanilla milkshake for a midafternoon snack.
- E. The staff uses standard precautions.
Correct Answer: A
Rationale: Hepatitis A requires contact precautions for diapered or incontinent patients, including a private room to prevent transmission. Removing toys risks spreading contamination, high-fat snacks are inappropriate, and standard precautions alone are insufficient.
A mother calls the clinic, concerned that her 5 week-old infant is 'sleeping more than her brother did.' What is the best initial response?
- A. Do you remember his sleep patterns?'
- B. How old is your other child?'
- C. Why do you think this a concern?'
- D. Does the baby sleep after feeding?'
Correct Answer: C
Rationale: Open ended questions encourage further discussion and conversation, thereby eliciting further information.
The nurse is caring for a client with a history of atrial fibrillation.
- A. Which medication should the nurse expect to administer to a client with atrial fibrillation to prevent thromboembolism?
- B. Aspirin.
- C. Heparin.
- D. Warfarin (Coumadin).
- E. Clopidogrel (Plavix).
Correct Answer: C
Rationale: Warfarin is the standard anticoagulant for preventing thromboembolism in atrial fibrillation, reducing stroke risk. Aspirin and clopidogrel are antiplatelets, and heparin is used short-term or in acute settings.