Nokea
A disoriented male client reveals that the client has a self-care deficit (feeding).
Which of the following would indicate to the nurse that the client has made a positive response to the plan of care?
- A. Client explains the relationship between weight loss and change in mental status.
- B. Client identifies the basic four food groups.
- C. Client states he needs to drink more water.
- D. Client feeds self when the nurse stays with him and cues him.
Correct Answer: D
Rationale: Strategy: Determine the outcome of each answer choice. (1) would not be realistic in a client who is disoriented (2) would not be realistic in a client who is disoriented (3) would not be realistic in a client who is disoriented (4) correct-disoriented client who is not able to be an independent self-care agent will need cuing from the nurse to accomplish self-feeding
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A fifty-five year-old man suffered a left frontal lobe CVA. The patient's family is not present in the room. Which of the following should the nurse watch most closely for?
- A. Changes in emotion and behavior
- B. Monitor loss of hearing
- C. Observe appetite and vision deficits
- D. Changes in facial muscle control
Correct Answer: A
Rationale: The frontal lobe is responsible for behavior and emotions.
Which task for a client with anemia and confusion could the nurse delegate to the unlicensed assistive personnel (UAP)?
- A. Assess and document skin turgor and color changes
- B. Test stool for occult blood and urine for glucose and report results
- C. Suggest foods high in iron and those easily consumed
- D. Report mental status changes and the degree of mental clarity
Correct Answer: B
Rationale: Test stool for occult blood and urine for glucose and report results. The UAP can do standard, unchanging procedures that require no decision making.
The nurse is caring for a client with a history of depression who is receiving venlafaxine (Effexor) 75 mg PO bid. Which of the following symptoms should the nurse report immediately?
- A. Mild fatigue.
- B. Dry mouth.
- C. Suicidal thoughts.
- D. Insomnia.
Correct Answer: C
Rationale: Suicidal thoughts are a medical emergency with venlafaxine. Options A, B, and D are common side effects.
A 12-year-old girl whose tracheostomy tube inserted 2 days ago has been accidentally dislodged.
The nurse should
- A. immediately replace the tracheostomy tube.
- B. suction the patient's airway using sterile technique.
- C. provide oxygen at 8 liters per minute per mask over the stoma.
- D. check for bilateral breath sounds immediately.
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require validation? No. Determine the outcome of the implementations. Remember ABCs. (1) correct-implementation, will secure the airway (2) implementation, will not provide for open airway (3) implementation, will not help with open airway (4) assessment, should be done after tracheostomy tube is replaced
The school nurse conducts a class on childcare at the local high school. During the class, one of the participants asks the nurse what age is best to start toilet training a child. Which of the following is the BEST response by the nurse?
- A. 11 months of age.
- B. 14 months of age.
- C. 17 months of age.
- D. 20 months of age.
Correct Answer: D
Rationale: by 24 months may be able to achieve daytime bladder control