Nokea
Which of the following provides the best evidence that the nursing interventions to deal with a client’s self-care deficit in relation to feeding have been effective?
- A. The client eats at least one-half of all meals and drinks a minimum of 2,000 mL/day.
- B. The client’s dentures have been replaced, and he is able to chew.
- C. The client will eat without verbalizing suspicions when a particular nurse sits with him.
- D. The client appears to have increased energy to complete grooming activities.
Correct Answer: A
Rationale: Eating half of meals and drinking 2,000 mL/day is a concrete measure of adequate nutrition, indicating effective interventions. Options B, C, and D are less direct: dentures aid chewing but don’t ensure intake, suspicions suggest unresolved issues, and grooming energy is unrelated.
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Which of the following interventions is appropriate when caring for a client who has lost function of cranial nerve $\mathrm{V}$ on the left side?
- A. Helping the client select foods that are easy to swallow
- B. Speaking to the client on his right side
- C. Applying an eye patch to the left eye
- D. Speaking to the client on his left side
Correct Answer: C
Rationale: Cranial nerve V (trigeminal) loss may impair corneal sensation, increasing risk of eye injury; an eye patch protects the left eye. Swallowing and hearing are unrelated.
The nurse enters an adult's room to premedicate for surgery. The client says, 'You know, nurse, that form I signed said something about a nephrectomy. What does that mean?' How should the nurse respond initially?
- A. What did your surgeon explain to you about your operation?'
- B. Don't worry about the technical terms. We'll take good care of you.'
- C. I think you're just nervous about the surgery. This injection will make you feel calmer.'
- D. It is a kidney operation.'
Correct Answer: A
Rationale: Asking what the surgeon explained clarifies the client's understanding, ensuring informed consent and addressing concerns.
The nurse is teaching a client with a new diagnosis of hyperthyroidism about propylthiouracil (PTU). Which of the following statements by the client indicates a need for further teaching?
- A. I should report a fever to my doctor.
- B. I should take this medication with food.
- C. I should avoid eating shellfish.
- D. I should stop this medication if my thyroid levels are normal.
Correct Answer: D
Rationale: Stopping propylthiouracil when thyroid levels are normal is incorrect, as hyperthyroidism requires prolonged treatment to maintain euthyroid status. Options A, B, and C are correct: fever may indicate agranulocytosis, food reduces GI upset, and shellfish (iodine-rich) should be avoided.
When a client is having a general tonic clonic seizure, the nurse should
- A. Hold the client's arms at their side
- B. Place the client on their side
- C. Insert a padded tongue blade in client's mouth
- D. Elevate the head of the bed
Correct Answer: B
Rationale: Place the client on their side. This position maintains a patent airway and prevents aspiration.
The home care nurse has been managing a client for 6 weeks. What is the best method to determine the quality of care provided by a home health care aide assigned to assist with the care of this client?
- A. Ask the client and family if they are satisfied with the care given
- B. Determine the home health aide is care to a consistent with the plan of care
- C. Investigate if the home health aide is prompt and stays an appropriate length of time for care
- D. Check the documentation of the aide for appropriateness and comprehensiveness
Correct Answer: B
Rationale: Although the nurse must complete all of the above responsibilities, evaluation of an adherence to the plan of care is the first priority. The plan of care is based on the reason for referral, provider's orders, the initial nursing assessment, the client's responses to the planned interventions, and the client's and family's feedback or inquiries.