Nokea
Which of the following observations best indicates to the nurse that a paraplegic client can adequately carry out activities of daily living at home after discharge?
- A. The client can shave himself and brush his teeth.
- B. The client can transfer himself into and out of his wheelchair.
- C. The client can maneuver his wheelchair without difficulty.
- D. The client can prepare his own well-balanced meals.
Correct Answer: B
Rationale: Transferring into and out of a wheelchair is essential for a paraplegic to perform ADLs independently, enabling mobility and access to other tasks. Shaving, maneuvering the wheelchair, and cooking are important but less critical if transfer ability is impaired.
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A man is seen in the outpatient clinic for treatment of hypertension. The client expresses concern to the nurse that his wife has been unemployed for more than six months. He is afraid that soon they will be unable to pay their rent.
Which of these responses by the nurse would be BEST?
- A. These things always have a way of working themselves out.'
- B. It's important for your health that you not worry too much.'
- C. You're worried that you won't be able to pay the rent?'
- D. A social worker might be able to help you with this problem.'
Correct Answer: C
Rationale: Strategy: 'BEST' indicates there may be more than one response you will like. Remember therapeutic communication. (1) minimizes client's concerns (2) minimizes client's concerns and places pressure on client to avoid feelings (3) correct-reflective response, would encourage discussion of feelings and concerns (4) passing the buck, nontherapeutic
When an autistic client begins to eat with her hands, the nurse can best handle the problem by
- A. Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.'
- B. Commenting, 'I believe you know better than to eat with your hand.'
- C. Jokingly stating, 'Well I guess fingers sometimes work better than spoons.'
- D. Removing the food and stating, 'You can't have anymore food until you use the spoon.'
Correct Answer: A
Rationale: Placing the spoon in the client's hand and stating, 'Use the spoon to eat your food.' This provides clear instruction and encourages adaptive behavior.
A nurse performing actions that would be considered negligence.
Which of the following actions, if performed by the nurse, would be considered negligence?
- A. The nurse performs range-of-motion (ROM) exercises for a client with second- and third-degree burns of the chest.
- B. The nurse sits with a client who suffers from depression while he eats his lunch.
- C. The nurse caring for a client with myasthenia gravis administers the 7 AM dose of neostigmine bromide (Prostigmin) PO at 7:45 AM.
- D. The nurse instructs a 15-year-old girl who is sexually active about different types of contraceptives without consulting her parents.
Correct Answer: C
Rationale: Strategy: 'Negligence' indicates an incorrect action. (1) minimizes muscle atrophy (2) promotes eating, offer more frequent feedings of favorite foods (3) correct-delay in medication may cause difficulty in swallowing, might have difficulty taking medication (4) minor can request birth control without the parent's consent
When caring for a client with myasthenia gravis, an important nursing consideration would be to
- A. prevent accidents from falls as a result of vertigo.
- B. maintain fluid and electrolyte balance.
- C. control situations that could increase intracranial pressure and cerebral edema.
- D. assess muscle groups toward the end of the day.
Correct Answer: D
Rationale: client has increased muscle fatigue, needs more assistance toward end of day
Which action is most likely to ensure the safety of the nurse while making a home visit?
- A. Observe no evidence of weapons in the home during the visit
- B. Prior to the visit, review the client's record for any previous entries about violence
- C. Remain alert at all times and leave if cues suggest the home is not safe
- D. Carry a cell phone, pager and/or hand held alarm for emergencies
Correct Answer: C
Rationale: Remain alert at all times and leave if cues suggest the home is not safe. No person or equipment can guarantee nurses' safety, although the risk of violence can be minimized. Before making initial visits, review referral information carefully and have a plan to communicate with agency staff. Schedule appointments with clients. When driving into an area for the first time, note potential hazards. Observe surroundings when parking, walking to the client's door, making the visit, walking back to the car, and driving away. LISTEN to clients. If they tell you to leave, do so.