Nokea
An elderly client is oriented during the day but becomes disoriented during the evening.
Which of the following nursing actions is MOST appropriate?
- A. Place a clock where the client can see it.
- B. Restrain all four extremities.
- C. Keep a light on in the client's room.
- D. Place the side rails in an upright position.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) will provide visual cues, safety is more important (2) inappropriate (3) may be appropriate, but is not priority over answer choice #4 (4) correct-side rails should always be in an upright position for a disoriented client
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A 20-year-old client has a cast applied for a fracture of the right femur. Three hours later, the client complains that it is hot and painful under his cast.
Which of the following is the MOST appropriate action for the nurse to take?
- A. Assess the cast for wet spots and increase air circulation in the room.
- B. Check the circulation in his casted extremity and change the client's position.
- C. Take the client's temperature and observe him for other signs of infection.
- D. Medicate the client for pain and notify the physician of his complaint.
Correct Answer: B
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) heat is sign of pressure (2) correct-heat is sign of pressure, pressure limits circulation (3) too early to see signs of infection (4) all complaints must be investigated, medication would mask signs of pressure, assessment first step
The nurse is caring for a client who is postoperative day 1 after a lumbar laminectomy. Which of the following actions is the PRIORITY?
- A. Encourage the client to log-roll when turning.
- B. Administer pain medication as needed.
- C. Monitor the surgical drain for output.
- D. Check the incision for redness.
Correct Answer: A
Rationale: Encouraging log-rolling is the priority to prevent spinal strain and maintain alignment post-lumbar laminectomy. Options B, C, and D are important but secondary: pain management, drain monitoring, and incision checks follow proper positioning.
An adult who has multiple sclerosis is receiving cyclophosphamide (Cytoxan). The client asks the nurse why she is receiving the same drug her mother had when she had Hodgkin's disease. The nurse should include which information when responding?
- A. Multiple sclerosis is a type of cancer, so the same drugs are effective for both conditions.
- B. A side effect of cyclophosphamide (Cytoxan), a cancer drug, is immunosuppression. In multiple sclerosis, the immune system is attacking the client's nerves.
- C. Hodgkin's disease causes nervous system symptoms similar to those seen in multiple sclerosis.
- D. Multiple sclerosis and Hodgkin's disease are caused by the same organism, so the same drug is appropriate.
Correct Answer: B
Rationale: Cyclophosphamide's immunosuppressive effect reduces immune activity in MS, where the immune system attacks nerves, unlike cancer treatment, symptom similarity, or shared etiology.
The nurse is supervising care given to a group of patients on the unit. The nurse observes a staff member entering a patient's room wearing gown and gloves. The nurse knows that the staff member is caring for which of the following patients?
- A. An 18-month-old with respiratory syncytial virus.
- B. A 4-year-old with Kawasaki disease.
- C. A 10-year-old with Lyme's disease.
- D. A 16-year-old with infectious mononucleosis.
Correct Answer: A
Rationale: acute viral infection; requires contact precautions; assign to private room or with other RSV-infected children
Which client should receive a private room?
- A. A client with diabetes
- B. A client with Cushing's disease
- C. A client with Graves' disease
- D. A client with gastric ulcers
Correct Answer: D
Rationale: A client with gastric ulcers may have Helicobacter pylori infection, which can be contagious and requires isolation precautions. Clients with diabetes, Cushing's disease, or Graves' disease do not typically require private rooms unless they have a contagious condition.