Nokea
While planning care for an elderly client with dementia, which of the following should be a priority for the nurse?
- A. Encourage dependency with activities of daily living.
- B. Provide flexibility in schedules due to his confusion.
- C. Limit reminiscing due to poor memory.
- D. Speak slowly in a face-to-face position.
Correct Answer: D
Rationale: is most effective when communicating with an elderly client
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The nurse is obtaining a history on a client just admitted to the unit. The client informs the nurse that any information shared with the nurse during the interview is to remain confidential.
Which of the following responses by the nurse is BEST?
- A. I'll share any information you give me with staff members only with your approval.'
- B. If the information you share is important to your care, I'll need to share it with the staff.'
- C. We can keep the information just between the two of us.'
- D. I have an obligation to maintain nurse/patient confidentiality about anything you tell me.'
Correct Answer: B
Rationale: Strategy: Think about the outcome of each answer choice. (1) the nurse has the obligation to share client information with personnel directly involved with the client's care (2) correct-the nurse is obligated to share client information with personnel directly involved with the client's care (3) the nurse must never agree to keep information confidential without knowing the content of the information (4) the nurse not obligated to report information that is not relevant to the client's care or wellbeing
The nurse is caring for a client in her third trimester of pregnancy. The nurse is MOST concerned by which of the following assessments?
- A. The client complains of epigastric pain.
- B. The client complains of shortness of breath.
- C. The client states she has increased rectal pressure.
- D. The client has gained of 33 pounds during her pregnancy.
Correct Answer: A
Rationale: is usually indicative of an impending convulsion
The nurse is preparing a patient for an 8:00 AM outpatient electroconvulsive (ECT) treatment. Which of the following questions is the MOST important for the nurse to ask?
- A. Did you have anything to eat or drink before you came in today?
- B. Have you had any headaches since your last treatment?
- C. Who came with you to the hospital today?
- D. Have you had much memory loss since you began your treatments?
Correct Answer: A
Rationale: client given general anesthesia for ECT; NPO after midnight
The nurse is caring for a client receiving mechanical ventilation. The high-pressure alarm sounds. Which of the following actions should the nurse take FIRST?
- A. Check the tubing for kinks or obstructions.
- B. Suction the client's airway.
- C. Increase the oxygen concentration.
- D. Notify the respiratory therapist.
Correct Answer: A
Rationale: high-pressure alarms are often caused by obstructions such as kinks in the tubing or mucus in the airway
The nurse is caring for a client who is postoperative day 1 following a total knee replacement. Which of the following findings should the nurse report to the physician immediately?
- A. Pain at the surgical site rated 6/10.
- B. Swelling and warmth at the incision site.
- C. Urine output of 150 mL over 8 hours.
- D. Serosanguineous drainage on the dressing.
Correct Answer: B
Rationale: swelling and warmth may indicate infection or a deep vein thrombosis, which requires immediate attention