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Which of these clients is at greatest risk for falls?
- A. A 77 year old female client in a client room that has low glare floors.
- B. An 87 year old female client in a client room that has low glare floors.
- C. A 27 year old sedated male client.
- D. A 37 year old male client with impaired renal perfusion.
Correct Answer: B
Rationale: An 87-year-old female is at the greatest risk for falls due to age-related factors like decreased mobility, balance issues, and potential comorbidities, compared to younger or less impaired clients.
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The nurse teaches a client scheduled for an I.V. pyelogram what to expect when the dye is injected. The nurse knows that the client has correctly understood what was taught when he states that he may experience which of the following sensations when the dye is injected?
- A. A metallic taste.
- B. Flushing of the face.
- C. Cold chills.
- D. Chest pain.
Correct Answer: B
Rationale: Flushing is a common sensation during I.V. pyelogram dye injection due to vasodilation caused by the contrast medium.
You are working in a community pediatric health clinic. Which developmental task should you apply into your practice?
- A. You should apply the principles of initiative when caring for preschool children.
- B. You should apply the principles of sensorimotor thought when caring for preschool children.
- C. You should apply the principles of intimacy when caring for the adolescent.
- D. You should apply the principles of concrete operations when caring for the adolescent.
Correct Answer: A
Rationale: According to Erikson's developmental stages, preschool children (ages 3-5) are in the stage of Initiative vs. Guilt, where they develop a sense of purpose through exploration and play. This is the appropriate developmental task to apply in a pediatric clinic for this age group.
The nurse is caring for a client with a history of chronic obstructive pulmonary disease who is prescribed fluticasone (Flovent). The nurse should instruct the client to:
- A. Use the inhaler as needed for shortness of breath.
- B. Rinse the mouth after using the inhaler.
- C. Shake the inhaler before use.
- D. Take two puffs twice daily.
Correct Answer: B
Rationale: Rinsing the mouth after using fluticasone prevents oral candidiasis, a common side effect of inhaled corticosteroids.
During a home visit to a primiparous client 1 week postpartum who is bottle-feeding her neonate, the clientiant tells the nurse that her mother has suggested that she feed the neonate cereal so he will sleep through the night. Which of the following would be the nurse's best response?
- A. It is permissible to give the baby cereal if it is thinned with formula.'
- B. The time for starting cereal varies, so check with your pediatrician.'
- C. Formula is the food best digested by the baby until about 4 to 6 months of age.'
- D. If cereal is given too early in life, the undigested food can lead to a need for surgery.'
Correct Answer: C
Rationale: Formula is best for infants until 4-6 months, as early introduction of solids like cereal can cause digestive issues.
During the admission interview, an adult client reveals that, as a child, she was sexually abused by her uncle and a male cousin. She reports that she cuts the skin of her arms, legs, and abdomen. In addition to having the client sign a no-harm contract, which nursing intervention is most important?
- A. Assist the client with finding safe ways to express her anger.
- B. Talk with the client about confronting her uncle and cousin directly.
- C. Defer talking about the abuse to prevent further self-mutilation.
- D. Discuss the possibility of the client suing her relatives for their abuse.
Correct Answer: A
Rationale: Helping the client find safe ways to express anger addresses the self-harm behavior therapeutically, promoting coping skills and safety.