Nursing Elites

1. What intervention should be taken to minimize the risk for injury in a client with dementia?

• A. Use a bed exit alarm system.
• B. Place the client in restraints for safety.
• C. Ensure the client has frequent visitors to reduce isolation.
• D. Keep the client's room dark and quiet at night.

Correct answer: A

Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.

2. Following major abdominal surgery, a client postoperative refuses to use the incentive spirometer. What is the nurse's priority?

• A. Determine the reason why the client is refusing to use the incentive spirometer.
• B. Insist that the client use the incentive spirometer.
• C. Administer pain medication to help the client use the spirometer.
• D. Document the refusal in the client’s medical record.

Correct answer: A

Rationale: The nurse's priority in this situation is to determine the reason why the client is refusing to use the incentive spirometer. By understanding the client's concerns or barriers, the nurse can address them effectively and encourage the client to use the spirometer for optimal postoperative recovery. Insisting that the client use the spirometer without understanding the underlying reason may lead to further resistance. Administering pain medication as a solution does not address the root cause of refusal and may not be necessary if pain is not the primary reason for refusal. Documenting the refusal is important but should come after understanding the client's perspective to provide appropriate care and follow-up.

3. A 15-year-old client has been placed in a Milwaukee Brace. Which statement from the adolescent indicates the need for additional teaching?

• A. I will only have to wear this for 6 months.
• B. I should inspect my skin daily.
• C. The brace will be worn day and night.
• D. I can take it off when I shower.

Correct answer: A

Rationale: The correct answer is A. The statement 'I will only have to wear this for 6 months' indicates a need for additional teaching because the Milwaukee Brace is typically worn for 12-18 months, not just 6 months. Choice B is correct as inspecting the skin daily is important to prevent skin breakdown. Choice C is correct as the brace is usually worn day and night for effectiveness. Choice D is correct as the brace can be removed when showering to maintain hygiene.

4. A client on a telemetry unit is being cared for by a nurse after a myocardial infarction. The client expresses, 'All this equipment is making me nervous.' Which of the following responses should the nurse make?

• A. 'All of this equipment can be frightening.'
• B. 'The equipment is necessary to monitor your condition.'
• C. 'You should try to ignore the equipment.'
• D. 'Try to relax; the equipment is not harmful.'

Correct answer: A

Rationale: Choice A is the most appropriate response as it acknowledges the client's feelings, showing empathy and understanding. It validates the client's experience, which can help reduce anxiety and build rapport. Choice B provides information but may not address the client's emotional needs. Choice C dismisses the client's concerns and does not offer support. Choice D minimizes the client's feelings and may not effectively address their anxiety.

5. A client with Parkinson's disease is being discharged. Which statement by the client indicates a need for further teaching?

• A. I will take my medication at the same time every day.
• B. I will increase my fiber intake to prevent constipation.
• C. I will perform range of motion exercises to maintain mobility.
• D. I will stop taking my medication if I feel better.

Correct answer: D

Rationale: The correct answer is D. Patients with Parkinson's disease should not stop taking their medication if they feel better, as doing so can worsen symptoms. It is crucial for patients to continue their prescribed medication regimen as directed by their healthcare provider. Choices A, B, and C are all appropriate actions that promote the well-being of a client with Parkinson's disease. Choice A emphasizes medication adherence, which is vital for symptom management. Choice B addresses a common issue in Parkinson's patients and shows an understanding of the importance of dietary management. Choice C highlights the significance of physical activity in maintaining mobility, which is essential for overall quality of life in Parkinson's disease.

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