Nokea
Which of the following activities documented by the recreational therapist following a community reorientation outing for a paraplegic client would indicate to the nurse a readiness for discharge?
- A. The client states that he/she enjoyed being outside the hospital environment.
- B. The client was able to participate in a structured team sport by keeping score.
- C. The client was independently able to order his meal and feed himself.
- D. The client was independent in transfers and wheelchair mobility.
Correct Answer: D
Rationale: correct, physical, these skills are requisite for discharge
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The nursing care plan for a five-year-old with a closed head injury should contain which of the following?
- A. Encourage child to sleep and decrease stimuli in the room.
- B. Assess orientation to person, place, and time every hour.
- C. Notify the physician regarding a negative Babinski reflex.
- D. Increase fluid intake to maintain adequate urinary output.
Correct Answer: B
Rationale: early signs of increased intracranial pressure are alterations in orientation
The physician prescribes cimetidine (Tagamet) 300 mg PO qid for a 75-year-old man. The nurse instructs the client about the medication. Which of the following statements, if made by the client, would indicate that further teaching is needed?
- A. I'll take this pill with meals and before bed.
- B. I may experience mild diarrhea for a while.
- C. My stools may change color while I'm on this medication.
- D. I should call my doctor if I get an acne-like rash.
Correct Answer: C
Rationale: no change in stool color
The nurse is assessing a client with suspected appendicitis. Which of the following findings would the nurse expect to observe?
- A. Pain relieved by pressure at McBurney's point.
- B. Rebound tenderness at McBurney's point.
- C. Pain in the left lower quadrant.
- D. Decreased bowel sounds in all quadrants.
Correct Answer: B
Rationale: rebound tenderness at McBurney's point is a classic sign of appendicitis
A five-year-old is scheduled for a lumbar puncture (LP). Which of the following nursing actions would BEST prepare the child for the procedure?
- A. Explain the procedure in detail.
- B. Show a video of the procedure.
- C. Do a mock run-through of the procedure.
- D. Answer all questions simply and honestly.
Correct Answer: C
Rationale: excellent method to use with a child because it incorporates actually 'feeling' many aspects of the procedure as they are explained
The nurse is teaching a client with type 1 diabetes about insulin administration. Which of the following statements by the client indicates a need for further teaching?
- A. I should rotate injection sites to prevent tissue damage.
- B. I should store my insulin in the refrigerator.
- C. I should check my blood sugar before giving insulin.
- D. I should inject insulin into my thigh if I’m going to exercise.
Correct Answer: D
Rationale: Injecting insulin into the thigh before exercise can increase absorption due to muscle activity, risking hypoglycemia. The abdomen is preferred for consistent absorption. Options A, B, and C are correct: rotation prevents lipodystrophy, refrigeration preserves insulin, and checking blood sugar ensures proper dosing.