Nokea
Which outcome is realistic for a client with a chronic neurological condition?
- A. Complete symptom reversal.
- B. Maintain functional ability.
- C. Eliminate all medications.
- D. Prevent all complications.
Correct Answer: B
Rationale: Maintaining functional ability is a realistic goal for managing chronic neurological conditions.
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The nurse formulates a nursing diagnosis of Spiritual distress related to advanced cancer disease. An appropriate goal for the client would be to:
- A. Start attending church or chapel services once a week.
- B. Call a chaplain and set up an appointment for spiritual guidance.
- C. Reflect on past accomplishments.
- D. Participate in spiritual activities of the client's choice.
Correct Answer: D
Rationale: Participating in spiritual activities of the client's choice respects their individual beliefs and supports resolution of spiritual distress.
A client with allergic rhinitis asks the nurse what he should do to decrease his symptoms. Which of the following instructions would be appropriate for the nurse to give the client?
- A. Use your nasal decongestant spray regularly to help clear your nasal passages.
- B. Ask the doctor for antibiotics. Antibiotics will help decrease the secretion.
- C. It is important to increase your activity. A daily brisk walk will help promote drainage.
- D. Keep a diary of when your symptoms occur. This is a very small amount of the drug. You identify what precipitates your attacks.
Correct Answer: D
Rationale: Keeping a symptom diary helps identify triggers for allergic rhinitis, enabling avoidance or management strategies. Overuse of decongestant sprays can cause rebound congestion. Antibiotics are ineffective for allergic rhinitis, which is not bacterial. Increased activity like walking does not directly alleviate allergic rhinitis symptoms.
A client with tuberculosis is taking Isoniazid (INH). To help prevent development of peripheral neuropathies, the nurse should instruct the client to:
- A. Adhere to a low-cholesterol diet.
- B. Supplement the diet with pyridoxine (vitamin B6).
- C. Get extra rest.
- D. Avoid excessive sun exposure.
Correct Answer: B
Rationale: Isoniazid can deplete vitamin B6, causing peripheral neuropathy; supplementation with pyridoxine prevents this. Diet, rest, and sun exposure are unrelated to this adverse effect.
The nurse has calculated a low PaO2/FIO2 (P/F) ratio <150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions?
- A. Supine.
- B. Semi-Fowler's.
- C. Lateral side.
- D. Prone.
Correct Answer: D
Rationale: Prone positioning in ARDS with a low P/F ratio (<150) improves oxygenation, ventilation distribution, and secretion drainage by recruiting dependent lung regions. Other positions are less effective.
A client has returned from surgery during which her jaws were wired as treatment for a fractured mandible. The client is in stable condition. The nurse is instructing the unlicensed nursing personnel (UAP) on how to properly position the client. Which instructions about positioning would be appropriate for the nurse to give the UAP?
- A. Keep the client in a side-lying position with the head slightly elevated.
- B. Do not reposition the client without the assistance of a registered nurse.
- C. The client can assume any position that is comfortable.
- D. Keep the client's head elevated on two pillows at all times.
Correct Answer: A
Rationale: A side-lying position with the head slightly elevated helps prevent aspiration and maintains airway patency in a client with wired jaws. The other options are either overly restrictive, unsafe, or not optimal for airway management.