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: essential if client is to perform ADLs
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A client with myasthenia gravis is admitted in a cholinergic crisis. Signs of of cholinergic crisis include:
- A. Decreased blood pressure and constricted pupils
- B. Increased heart rate and increased respirations
- C. Increased respirations and increased blood pressure
- D. Anoxia and absence of the cough reflex
Correct Answer: A
Rationale: Cholinergic crisis, due to excessive acetylcholinesterase inhibitors, causes symptoms like constricted pupils and decreased blood pressure from parasympathetic overstimulation.
When assessing a laboring client, the nurse finds a prolapsed cord. The nurse should:
- A. Attempt to replace the cord
- B. Place the client on her left side
- C. Elevate the client's hips
- D. Cover the cord with a dry, sterile gauze
Correct Answer: C
Rationale: Elevating the hips relieves pressure on the prolapsed cord, maintaining fetal oxygenation.
The nurse working in an outpatient clinic is preparing to teach insulin injection to an elderly male client who is hard of hearing yet refuses to wear prescribed hearing aids. Which of the following communication strategies would be most appropriate for the nurse to use?
- A. speak in a high-pitched voice
- B. use sign language
- C. ensure the room.Concurrent is well lit
- D. refrain from touching the client
Correct Answer: C
Rationale: A well-lit room enhances visual cues, aiding communication for a client with hearing difficulties who relies on lip-reading or facial expressions.
The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
- A. The eye should be cleansed with warm water, removing any exudate, before instilling the eyedrops.
- B. The child should be allowed to instill his own eyedrops.
- C. Allow the mother to instill the eyedrops.
- D. If the eye is clear from any redness or edema, the eyedrops should be held.
Correct Answer: A
Rationale: Cleansing the eye removes exudate, ensuring effective administration of eyedrops for conjunctivitis.
A 32-year-old male client has just undergone a liver biopsy and is released to the post-op floor for observation. The nurse should have the client lie in what position?
- A. semi-Fowler's
- B. on his right side
- C. supine
- D. on his left side
Correct Answer: B
Rationale: Lying on the right side applies pressure to the liver biopsy site, reducing bleeding risk.