Nokea
Which of the following is not a realistic outcome to establish with a client who has multiple sclerosis (MS)? The client will:
- A. Develop joint mobility.
- B. Develop muscle strength.
- C. Develop cognition.
- D. Develop mood elevation.
Correct Answer: C
Rationale: Developing cognition is not realistic, as MS can cause cognitive decline that is not typically reversible. Improving mobility, strength, and mood are achievable with therapy and support.
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Which of the following is the best way for the nurse to begin the preoperative interview?
- A. Walk in the client's room and ask, 'Are you Mrs. Smith?'
- B. Walk in the client's room, sit down, and take the client's blood pressure.
- C. Walk in the client's room, sit down, maintain eye contact, and introduce yourself.
- D. Walk in the client's room, and ask the client her name.
Correct Answer: C
Rationale: Introducing oneself while maintaining eye contact and sitting down establishes rapport and trust, creating a therapeutic environment for the interview. This approach prioritizes patient comfort and communication.
A nurse is caring for a client who is prescribed a medication with a narrow therapeutic index (NTI). Which action should the nurse take when administering this medication?
- A. Administer the medication as prescribed, ensuring strict adherence to the dosing schedule.
- B. Administer the medication concurrently with herbal supplements to augment its efficacy.
- C. Combine the medication with other medications to enhance its therapeutic effects.
- D. Administer the medication at a higher dose than prescribed to achieve faster results.
Correct Answer: A
Rationale: NTI medications require strict adherence to dosing to maintain therapeutic levels and avoid toxicity.
Which of the following goals is a priority for a client who has undergone surgery for retinal detachment?
- A. Control pain.
- B. Prevent an increase in intraocular pressure.
- C. Follow a low-sodium diet.
- D. Maintain a darkened environment.
Correct Answer: B
Rationale: Preventing an increase in intraocular pressure is the priority to protect the surgical repair and prevent complications like re-detachment or hemorrhage.
A client with bladder cancer reports fatigue and weight loss. The nurse should assess for:
- A. Metastasis.
- B. Dehydration.
- C. Infection.
- D. Anemia.
Correct Answer: A
Rationale: Fatigue and weight loss in bladder cancer may indicate metastasis, as the disease progresses.
The nurse has attended a staff development conference regarding patient-controlled analgesia. Which of the following statements by the nurse indicates effective understanding?
- A. A client may be prescribed a loading dose before they are able to activate their own prescribed dosage.
- B. PCAs are not recommended for individuals with acute pain.
- C. PCAs decrease the need for a client to have pain assessments.
- D. When a client receives a PCA via a continuous basal rate, it decreases their risk for adverse effects.
Correct Answer: A
Rationale: A loading dose is often used in PCA to achieve initial pain control before the patient begins self-administering doses. PCAs are suitable for acute pain, do not eliminate the need for pain assessments, and continuous basal rates may increase adverse effect risks.