Nokea
You see a patient lying on the floor of the bathroom. You are NOT assigned to this patient. What is the first thing that you should do?
- A. Get the nurse who is caring for the patient.
- B. Tell the nurse that the patient has had another seizure.
- C. Observe the patient for any injuries and call out for help.
- D. Nothing. This patient is not one of your assignments.
Correct Answer: C
Rationale: The correct course of action in this situation is to observe the patient for any injuries and call out for help. It is crucial to act immediately in an emergency, regardless of whether the patient is under your care. Checking for injuries and seeking assistance can help ensure the patient receives prompt and appropriate care. Choosing to inform the nurse of a seizure without evidence or taking no action because the patient is not your assignment are not optimal responses. In a healthcare setting, patient safety and well-being should always be the top priority.
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A client is about to have a TENS unit attached for pain relief. Which of the following actions is most appropriate in this situation?
- A. Inform the client that he may experience tingling sensations.
- B. Connect the TENS unit before the client goes to bed for the night.
- C. Inform the client that the TENS unit may have pain-reducing effects for 10 to 15 days.
- D. After treatment, inform the client that he may not use a TENS unit again for at least 2 weeks.
Correct Answer: A
Rationale: When attaching a TENS unit for pain relief, it is essential to inform the client that he may experience tingling sensations. This is a common sensation experienced when using a TENS unit, but it should not cause muscle twitching. The therapeutic effects of a TENS unit usually last between 3 to 5 days. Choice B is incorrect because there is no specific recommendation to connect the TENS unit before bedtime. Choice C is incorrect as stating that the TENS unit may have pain-reducing effects for 10 to 15 days is inaccurate, as the effects typically last 3 to 5 days. Choice D is incorrect because there is no guideline suggesting that the client cannot use a TENS unit again for at least 2 weeks after treatment.
While caring for Mr. Charles Y., you see a notation on the nursing care plan that states, 'remind the patient to use the incentive spirometer tid.' This patient will be reminded at which of the following times?
- A. 10:00 AM
- B. 10 am and 2 pm
- C. 10 am, 2 pm, and 6 pm
- D. 10 am, 2 pm, 6 pm, and 10 pm
Correct Answer: C
Rationale: The abbreviation 'tid' stands for 'ter in die,' which means three times a day. In this case, the patient should be reminded to use the incentive spirometer at 10 am, 2 pm, and 6 pm. Option A, '10 am,' is too infrequent for tid dosing. Option B, '10 am and 2 pm,' is missing the third reminder at 6 pm. Option D, '10 am, 2 pm, 6 pm, and 10 pm,' includes an additional time that is not part of the standard tid dosing schedule.
You are ready to give your resident a complete bed bath. The temperature of this bath water should be which of the following?
- A. Cooler than a tub bath.
- B. Hotter than a tub bath.
- C. About 106 degrees.
- D. Over 120 degrees.
Correct Answer: C
Rationale: The correct temperature for a bed bath water should be about 106 degrees. This temperature is considered safe and comfortable for residents. Using a bath thermometer is essential to ensure the water is not too hot, as hot water can cause burns. On the other hand, water that is too cool can lead to discomfort, shivering, and chilling. Options A, B, and D are incorrect because cooler water may cause discomfort and shivering, hotter water can lead to burns, and water over 120 degrees is considered too hot and risky for a resident's skin.
A client is being instructed on how to use crutches. Which of the following information should be included in the teaching?
- A. Place the majority of body weight on the axilla.
- B. Dry crutch tips with a paper towel if they become wet.
- C. Use the crutches for support to lift both feet simultaneously when ascending stairs.
- D. Both B and C.
Correct Answer: B
Rationale: When instructing a client on how to use crutches for ambulation, it is important to emphasize keeping the crutch tips dry to prevent slipping while bearing weight on them. Moisture on the crutch tips can lead to accidents. Therefore, the correct answer is to dry the crutch tips with a paper towel if they become wet. Choice A, placing the majority of body weight on the axilla, is incorrect as the weight should be borne through the hands, not the axilla, to avoid nerve damage. Choice C, using the crutches to lift both feet simultaneously when ascending stairs, is incorrect as the client should ascend stairs by placing weight on the unaffected leg first, followed by the crutches and then the affected leg. This method provides stability and safety during stair climbing.
Which of the following statements best describes footdrop?
- A. The foot is permanently fixed in the dorsiflexion position
- B. The foot is permanently fixed in the plantar flexion position
- C. The toes of the foot are permanently fanned
- D. The heel of the foot is permanently rotated outward
Correct Answer: B
Rationale: Footdrop results in the foot becoming permanently fixed in a plantar flexion position, not dorsiflexion. This position points the toes downward. The client may be unable to put weight on the foot, making ambulation difficult. Footdrop can be caused by immobility or chronic illnesses that cause muscle changes, such as multiple sclerosis or Parkinson's disease. Choice A is incorrect because footdrop leads to plantar flexion, not dorsiflexion. Choice C is incorrect as it describes a different condition known as 'toe fanning.' Choice D is incorrect as it describes an external rotation of the heel, which is not a characteristic of footdrop.