Nokea
A nurse is caring for a client who has type I diabetes mellitus and is not adhering to guidelines for therapy. Which of the following factors should the nurse consider as contributing to the nonadherence?
- A. Gender
- B. Culture
- C. Allergies
- D. Dexterity
- E. Motivation
Correct Answer: B,D,E
Rationale: Cultural beliefs, dexterity limitations, and motivation significantly impact adherence to diabetes management.
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A nurse is collecting data about a client's skin turgor. Which of the following actions should the nurse take?
- A. Lightly palpate the skin using the fingertips.
- B. Press the skin over the client's ankle bone.
- C. Observe for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen.
- D. Grasp a fold of skin on the client's forearm or near the sternum.
Correct Answer: D
Rationale: Correct Answer: D
Rationale: Grasping a fold of skin on the client's forearm or near the sternum is the appropriate method to assess skin turgor. Skin turgor is the skin's ability to return to normal after being pinched. By grasping the skin and observing how quickly it returns to its original state, the nurse can assess the client's hydration status accurately. This method is commonly used and recommended for assessing skin turgor.
Incorrect Choices:
A: Lightly palpating the skin using the fingertips does not provide an accurate assessment of skin turgor.
B: Pressing the skin over the client's ankle bone is not the standard method for assessing skin turgor.
C: Observing for nonblanching, pinpoint-size, red or purple spots on the skin of the abdomen is unrelated to assessing skin turgor and indicates a different condition.
Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
- A. Increased urine output
- B. Adventitious breath sounds
- C. Decreased level of consciousness
- D. Dry crust on the incision line
- E. Oral temperature of 38.3°C (101°F)
Correct Answer: B,C,E
Rationale: Adventitious breath sounds suggest pneumonia, decreased consciousness may indicate sepsis, and fever is a systemic infection response. Increased urine output is not a sign, and dry crust is part of normal healing.
A nurse is reinforcing teaching with the spouse of a client about how to take a blood pressure. Which of the following actions by the spouse indicates a need for further instruction?
- A. Wrap the blood pressure cuff snugly around the arm.
- B. Place the client's arm above the level of the heart.
- C. Check the instrument gauge to ensure the reading starts at zero.
- D. Center the cuff bladder over the brachial artery.
Correct Answer: B
Rationale: The correct answer is B because placing the client's arm above the level of the heart can result in an inaccurate blood pressure reading. Ideally, the arm should be at heart level to obtain an accurate measurement. A: Wrapping the cuff snugly ensures an accurate reading. C: Checking the gauge for zero ensures proper calibration. D: Centering the cuff bladder over the brachial artery is correct for accurate measurement. Overall, maintaining the arm at heart level is crucial to obtaining an accurate blood pressure reading.
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C: Listen attentively when the client talks about the past. Active listening is crucial in helping the client cope with feelings of grief. By providing a supportive environment and allowing the client to express his emotions, the nurse can validate his feelings and provide emotional support. This helps the client feel understood and accepted, facilitating the grieving process.
Choice A is incorrect because simply stating that it is a common problem does not address the individual client's feelings. Choice B is incorrect as it dismisses the client's emotions and distracts rather than addressing the root of the issue. Choice D is inappropriate as it is not empathetic and may invalidate the client's experience by comparing it to others.
A nurse is caring for a client who has an electrical burn. With the client's permission, the nurse is answering questions from the family about his status. Which of the following responses should the nurse make?
- A. He is doing well, although he might be in the hospital for some time.
- B. He has an electrical burn. He is stable, and we will update you with any changes.
- C. He has an electrical burn, which caused coagulation of some tissues.
- D. He does not appear to have much damage and should be fine soon.
Correct Answer: B
Rationale: Providing factual and clear information about the client's condition maintains trust and transparency with the family.