Nokea
While observing a client using crutches for a leg injury, which action would indicate a need for more education by the LPN?
- A. The client places the top padding 1-2 inches below the axilla with a firm grip on the handles.
- B. The client rests the axilla on the top padding and loosely grips the handles with hands.
- C. The client has a slight bend in the elbow when using the handles.
- D. When going down the stairs, the client leads with the injured leg.
Correct Answer: B
Rationale: The correct answer is B. Resting the axilla on the top padding can cause nerve damage; instead, the client should place the top padding 1-2 inches below the axilla with a firm grip on the handles for proper support and stability while using crutches. Having a slight bend in the elbow when using the handles (choice C) is a correct technique to ensure proper weight distribution. Leading with the uninjured leg when going down the stairs (choice D) is the correct way to maintain balance and prevent further injury to the injured leg. Therefore, choice B indicates a need for more education to prevent potential nerve damage and ensure safe crutch use.
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Which of the following might be an appropriate nursing diagnosis for an epileptic client?
- A. Dysreflexia
- B. Risk for Injury
- C. Urinary Retention
- D. Unbalanced Nutrition
Correct Answer: B
Rationale: The correct answer is 'Risk for Injury.' Epileptic clients are at risk for injury due to complications of seizure activity, such as falls that could lead to head trauma. 'Dysreflexia' is not typically associated with epilepsy but rather with spinal cord injury. 'Urinary Retention' is not a common nursing diagnosis for epileptic clients unless specifically indicated. 'Unbalanced Nutrition' may not be a priority nursing diagnosis compared to the immediate risk of injury in epileptic clients.
While repositioning a comatose client, the nurse senses a tingling sensation as she lowers the bed. What action should she take?
- A. Unplug the bed's power source.
- B. Remove the client from the bed immediately.
- C. Notify the biomedical department at once.
- D. Turn off the oxygen.
Correct Answer: A
Rationale: The correct action for the nurse to take when sensing a tingling sensation while lowering the bed with a comatose client is to unplug the bed's power source. This should be the initial step as there may be a fault in the bed's grounding. Removing the client from the bed immediately is not safe until the electrical issue is resolved. Notifying the biomedical department is important but should come after ensuring the immediate safety of the client. Turning off the oxygen is not necessary unless there is a specific issue related to oxygen delivery, which is not indicated in this scenario.
Which of these would be an appropriate meal for a client with Celiac disease?
- A. egg noodles with cream sauce and broccoli, oat cookie, almond milk
- B. turkey sandwich with rye bread, carrots
- C. chicken and rice, apple, and tapioca pudding
- D. granola and dried apricots with cow's milk
Correct Answer: C
Rationale: For individuals with Celiac disease, it's crucial to avoid gluten-containing foods. Choice C, which includes chicken, rice, apple, and tapioca pudding, is the most suitable option as all these foods are naturally gluten-free. Rice, fruits, vegetables, meat, dairy, and tapioca are all safe gluten-free options. Oats can be gluten-free if specially labeled, but many are processed on shared equipment with wheat. Granola often contains oats that may have been exposed to gluten. Dried and prepackaged fruits may contain gluten additives. Rye is a wheat derivative, and cream sauces usually contain flour as a base, making choices A and B inappropriate for individuals with Celiac disease.
Which of these statements from the caregiver of a palliative care client indicates a proper understanding?
- A. This treatment plan usually indicates a prognosis of less than 6 months.
- B. We will need to stay in the hospital to receive this level of care.
- C. The main therapeutic goals are comfort and better quality of life.
- D. The medications to treat the underlying disease will be continued.
Correct Answer: C
Rationale: The correct answer is 'The main therapeutic goals are comfort and better quality of life.' This statement reflects a proper understanding of palliative care, which focuses on improving the patient's quality of life and providing comfort. It does not necessarily mean a prognosis of less than 6 months or require hospitalization. Choice A is incorrect because palliative care can be provided regardless of the prognosis. Choice B is wrong as palliative care can be administered in various settings, not just hospitals. Choice D is inaccurate as palliative care aims to improve symptoms and quality of life, so medications may be adjusted but not necessarily stopped.
Which sign might a healthcare professional observe in a client with a high ammonia level?
- A. coma
- B. edema
- C. hypoxia
- D. polyuria
Correct Answer: A
Rationale: A high ammonia level can lead to hepatic encephalopathy, which includes symptoms like confusion, disorientation, and can progress to coma. Coma is a severe condition of unconsciousness. Edema is swelling caused by excess fluid trapped in body tissues, not typically associated with high ammonia levels. Hypoxia is a condition of inadequate oxygen supply to tissues and organs, not directly related to high ammonia levels. Polyuria is excessive urination, which is not a typical sign of high ammonia levels.