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The nurse assists a client with Parkinson's disease (PD) to ambulate in the hallway. The client appears to "freeze" and then carefully lifts one leg and steps forward. The client tells the nurse of pretending to step over a crack on the floor. How should the nurse respond
Assist the client to a carpeted area where he can walk more easily.
Confirm that this is an effective technique to help with ambulation.
Plan to assess the client's cognition after returning to his room.
Re-orient the client to his present location and circumstances.
Correct Answer B: Confirm that this is an effective technique to help with ambulation.
Why this is the correct answer:
The client with Parkinson’s disease is using a known and effective compensatory strategy to overcome freezing of gait, which is a common motor symptom. Techniques such as pretending to step over a line or crack, using visual cues, or counting can help initiate movement and prevent falls. This method is cognitively purposeful and appropriate, demonstrating that the client is aware of their limitations and has adopted a strategy to remain mobile. The nurse should validate and encourage this approach as it promotes safety and autonomy.
Why the other options are incorrect:
A. Assist the client to a carpeted area where he can walk more easily.
Carpeted surfaces may increase the risk of tripping and falling for clients with Parkinson’s due to uneven footing or increased resistance. There is no evidence that a carpeted area helps with freezing of gait; it could, in fact, make walking more difficult.
C. Plan to assess the client's cognition after returning to his room.
This response implies that the client’s behavior is inappropriate or cognitively impaired, which it is not. The client is demonstrating a deliberate and effective strategy, not confusion or disorientation. Planning a cognitive assessment would not be warranted based on this specific behavior.
D. Re-orient the client to his present location and circumstances.
Re-orienting is unnecessary and inappropriate here because the client is not disoriented. The action of pretending to step over a crack is intentional, not a sign of confusion. This response could discourage the use of a helpful coping strategy.
While planning care for a client experiencing pain, which outcome statement should the nurse include in the plan of care
Request no PRN pain medication after experiencing a precipitating cause.
Report a 5 point decrease on a 0 to 10 pain scale one hour after analgesia.
Learn four pain management techniques
Be pain free and sleep through the night.
Correct Answer B: Report a 5 point decrease on a 0 to 10 pain scale one hour after analgesia.
Explanation of the correct answer:
Outcome statements should be measurable, specific, and achievable within a defined timeframe. The statement "Report a 5 point decrease on a 0 to 10 pain scale one hour after analgesia" is appropriate because it provides a specific and measurable goal (a 5-point decrease on the pain scale) and a clear timeframe (one hour after receiving analgesia). This allows the nurse to evaluate the effectiveness of the pain management intervention and adjust care as necessary.
Why the other options are incorrect:
A. Request no PRN pain medication after experiencing a precipitating cause:
This is not a realistic or measurable outcome. While it is important to reduce pain, expecting the client to request no pain medication after a specific cause may not be achievable for all individuals or situations. Pain management often requires flexibility, and it is important to recognize that some clients may need pain medication even after a precipitating cause is identified.
C. Learn four pain management techniques:
This is a process-oriented goal, but it does not focus on the outcome of pain relief. While learning pain management techniques is important for self-care, the goal of pain management is to reduce or alleviate the pain itself. A more specific and measurable goal related to pain relief would be more appropriate for the plan of care.
D. Be pain free and sleep through the night:
While the goal of pain management is to reduce or eliminate pain, expecting the client to be completely pain-free and sleep through the night may not always be realistic or achievable. Pain management goals should be more focused on measurable improvement and functional outcomes, recognizing that complete pain relief may not always be possible.
An older adult with chronic obstructive pulmonary disease (COPD) was recently admitted to the hospital with heart failure (HF) Which actions should the nurse take in providing care
Monitor electrolyte values
Encourage increased fluid intake.
Maintain pulse oximeter.
Provide assistance with mobility.
Offer low residue snacks.
Correct Answers:
A. Monitor electrolyte values.
C. Maintain pulse oximeter.
D. Provide assistance with mobility.
Correct Answers: A, C, D
Explanation of the correct answers:
A. Monitor electrolyte values:
Electrolyte imbalances are common in both COPD and heart failure. Heart failure can lead to fluid retention, which can affect electrolyte balance, particularly sodium and potassium levels. COPD may also lead to respiratory acidosis, which can impact potassium levels. Monitoring electrolytes ensures that the nurse can detect and manage any imbalances early, as they can affect cardiac function and respiratory status.
C. Maintain pulse oximeter:
Patients with COPD are at risk for hypoxemia, especially when hospitalized due to comorbid conditions such as heart failure. A pulse oximeter allows continuous monitoring of oxygen saturation levels, which is critical in managing both conditions. It will help the nurse assess the need for oxygen therapy and prevent complications related to low oxygen levels.
D. Provide assistance with mobility:
Heart failure and COPD can both cause fatigue and limit mobility due to shortness of breath, weakness, and fluid retention. Providing assistance with mobility helps the client perform daily activities safely and reduces the risk of falls or other injuries. It also prevents the client from overexerting themselves, which can exacerbate both conditions.
Why the other options are incorrect:
B. Encourage increased fluid intake:
In heart failure, fluid retention is a concern because the heart is unable to pump efficiently, leading to fluid buildup in the body. Encouraging increased fluid intake can exacerbate fluid overload and worsen symptoms of heart failure, such as edema and shortness of breath. Therefore, fluid intake should be carefully monitored and restricted as prescribed.
E. Offer low residue snacks:
Low residue diets are typically recommended for clients with gastrointestinal issues, such as inflammatory bowel disease or after certain surgeries, to reduce bowel movement frequency. However, this is not relevant for a client with COPD and heart failure unless there is a specific gastrointestinal concern. The focus for these clients should be on managing fluid and electrolyte balance, maintaining oxygenation, and supporting mobility.
When inspecting the spine of a 10-year-old, the nurse notes a concave curvature at the back of the neck. How should this finding be classified
Minor deviation.
Abnormal.
Normal.
Check serum human chorionic gonadotropin.
Correct Answer: C. Normal.
Why this is the correct answer:
A concave curvature at the back of the neck is the natural cervical lordosis seen in children and adults. It represents the normal alignment of the cervical spine, which helps balance the head and distribute weight. By age 10, cervical lordosis is well established as part of spinal development. Therefore, this finding should be documented as a normal curvature and not mistaken for abnormality.
Why the other options are incorrect:
A. Minor deviation.
Labeling this curvature as a minor deviation would be inaccurate since it is not a deviation but a normal spinal alignment. Deviations suggest abnormality, which is not the case here.
B. Abnormal.
A concave cervical curve is not abnormal in a 10-year-old. An abnormal finding would be kyphosis or scoliosis, not the expected cervical lordosis.
D. Indicative of skeletal immaturity.
Skeletal immaturity refers to incomplete bone growth or epiphyseal plate status, not the presence of cervical lordosis. The curvature is part of normal spinal anatomy, not a marker of immaturity.
An adult client who is experiencing an exacerbation of Crohn's disease is admitted to the medical unit from the emergency department (ED). When preparing for the client's arrival to the unit, the nurse requests a lunch tray for the client. Which menu should the nurse choose
Chef salad with turkey, cheese, tomatoes, and ranch dressing.
Oral nutritional supplement, herbal tea, and gelatin.
Chicken noodle soup and a toasted ham and cheese sandwich.
Hamburger patty, mashed potatoes, green beans, and corn.
Correct Answer B: Oral nutritional supplement, herbal tea, and gelatin.
Why this is the correct answer:
During an exacerbation of Crohn’s disease, the gastrointestinal (GI) tract is inflamed, and the priority is to minimize further irritation. The client should be placed on a low-residue, low-fiber, easily digestible diet or, in many cases, a clear liquid or full liquid diet depending on severity. Oral nutritional supplements, gelatin, and herbal tea provide calories and hydration without burdening the digestive tract, allowing the bowel to rest. This option avoids fiber, fats, and roughage that could aggravate inflammation and exacerbate symptoms such as diarrhea, abdominal pain, and cramping.
Why the other options are incorrect:
A. Chef salad with turkey, cheese, tomatoes, and ranch dressing.
This meal contains raw vegetables (lettuce, tomatoes) which are high in fiber and can irritate the inflamed bowel. Cheese and ranch dressing are also high in fat, which may be difficult to digest during a flare. Salads are generally contraindicated during active inflammation in Crohn’s disease.
C. Chicken noodle soup and a toasted ham and cheese sandwich.
Though this meal may seem mild, bread and processed meats like ham and cheese are not ideal during a Crohn's exacerbation. They can be high in sodium, fat, and difficult to digest. The soup may contain vegetables and seasonings that can further irritate the GI tract. It is not suitable during an acute flare when bowel rest is the priority.
D. Hamburger patty, mashed potatoes, green beans, and corn.
This meal includes corn and green beans, which are high-fiber vegetables that are difficult to digest during a flare. The hamburger patty can be high in fat and may worsen GI symptoms. Corn in particular is poorly digested and can irritate the mucosa, making it inappropriate during exacerbation.
The nurse is caring for a client that had a thyroidectomy 24 hours ago. The client reports experiencing numbness and tingling of the face. Which intervention should the nurse implement
Inspect the neck for increase in swelling.
Open and prepare the tracheostomy kit.
Assess lung sounds for laryngeal stridor.
Monitor for presence of Chvostek's sign.
Correct Answer D: Monitor for presence of Chvostek's sign.
Why this is the correct answer:
Numbness and tingling of the face after a thyroidectomy may be indicative of hypocalcemia (low calcium levels), which can occur if the parathyroid glands are inadvertently damaged or removed during surgery. One of the classic signs of hypocalcemia is Chvostek's sign, which is characterized by twitching or spasm of the facial muscles when the facial nerve is tapped near the ear. It is important for the nurse to assess for Chvostek's sign to help detect potential hypocalcemia, which requires prompt treatment with calcium replacement.
Why the other options are incorrect:
A. Inspect the neck for increase in swelling.
While swelling in the neck may indicate potential complications like hemorrhage or infection, the numbness and tingling of the face are more likely to be related to hypocalcemia than to an increase in swelling. Swelling would be assessed for other reasons, but it does not explain the specific symptoms the client is experiencing (numbness and tingling).
B. Open and prepare the tracheostomy kit.
A tracheostomy kit is not indicated unless the client experiences significant respiratory distress or airway obstruction, such as laryngeal edema or stridor, which is not suggested by the client’s symptoms of numbness and tingling. The focus should be on assessing for hypocalcemia and its associated symptoms rather than preparing for a tracheostomy at this stage.
C. Assess lung sounds for laryngeal stridor.
While laryngeal stridor can occur after a thyroidectomy due to airway obstruction or laryngeal edema, the client's symptoms of numbness and tingling are more suggestive of hypocalcemia, not respiratory distress. Stridor would typically be associated with breathing difficulties, so the nurse should first assess for hypocalcemia as the likely cause of the reported symptoms.
The nurse is caring for a term infant immediately following delivery. Which action should the nurse implement to reduce the risk of cold stress
Bathe the newborn in warm water and swaddle in 2 blankets.
Place the newborn on the radiant warmer.
Dry off the newborn and place skin-to-skin.
Maintain a room temperature above 70° F (21.1° C).
Correct Answer: C. Dry off the newborn and place skin-to-skin.
Why this is the correct answer:
C. Dry off the newborn and place skin-to-skin.
Immediately after birth, newborns are wet with amniotic fluid and lose heat rapidly through evaporation. The best evidence-based intervention to reduce cold stress is to thoroughly dry the infant and initiate skin-to-skin contact with the mother, covering both with a warm blanket. This promotes thermoregulation, stabilizes vital signs, and encourages bonding and breastfeeding.
Why the other options are incorrect:
A. Bathe the newborn in warm water and swaddle in 2 blankets.
Bathing immediately after birth increases heat loss through evaporation and convection, placing the newborn at risk for hypothermia. Bathing is delayed until the infant is stable and warm.
B. Place the newborn on the radiant warmer.
A radiant warmer is used if the infant cannot maintain temperature or skin-to-skin is not possible. While effective, skin-to-skin with drying is the preferred first action unless contraindicated.
D. Maintain a room temperature above 70° F (21.1° C).
Room temperature alone does not adequately prevent heat loss in a wet newborn. Direct measures such as drying and skin-to-skin are more effective.
A postoperative client reports incisional pain. The client has two prescriptions for PRN analgesia that accompanied the client from the postanesthesia unit. Before selecting which medication to administer, which action should the nurse implement
Compare the client's pain scale rating with the prescribed dosing.
Document the client's report of pain in the electronic medical record.
Determine which prescription will have the quickest onset of action.
Ask the client to choose which medication is needed for the pain.
Correct Answer A: Compare the client's pain scale rating with the prescribed dosing.
Why this is the correct answer:
Before administering any medication, it is important for the nurse to assess the intensity of the client's pain using a pain scale (e.g., 0-10) to determine the appropriate dose and medication needed. This ensures that the medication choice is tailored to the client's level of pain and that the nurse does not under- or over-medicate. The nurse can then select the medication that is most appropriate for the pain severity based on the prescribed dosing schedule. This assessment also helps to avoid medication errors and overmedication, which could be harmful.
Why the other options are incorrect:
B. Document the client's report of pain in the electronic medical record.
While documentation is essential for continuity of care and legal purposes, it is not the first step before selecting a medication. The nurse must first assess the pain level to guide appropriate medication selection, not simply document the report.
C. Determine which prescription will have the quickest onset of action.
While the onset of action is important in selecting an analgesic, it is more crucial to first evaluate the severity of pain to determine whether the client requires immediate relief (for example, if the pain is severe) or whether other factors, such as the type of pain and its source, should be considered. Pain assessment should guide the decision-making process.
D. Ask the client to choose which medication is needed for the pain.
Although client input can be helpful, it is not the nurse's role to allow the client to choose which medication is administered. The nurse must assess the client's pain and decide which medication is appropriate based on the severity of the pain, prescribed orders, and safety guidelines.
The nurse is caring for a child with hypoparathyroidism who demonstrates a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review
Potassium.
Sodium.
Calcium.
Chloride.
Correct Answer C. Calcium.
Why this is the correct answer:
C. Calcium.
A carpal spasm in response to inflating a blood pressure cuff on the arm is Trousseau’s sign, which indicates hypocalcemia. In hypoparathyroidism, parathyroid hormone (PTH) deficiency leads to low serum calcium levels. Hypocalcemia causes neuromuscular excitability, leading to tetany, tingling, and carpopedal spasms. Therefore, the most relevant lab value for the nurse to review is calcium.
Why the other options are incorrect:
A. Potassium.
Potassium imbalances affect cardiac and muscular function but do not cause the specific neuromuscular signs of hypocalcemia, such as Trousseau’s sign.
B. Sodium.
Sodium is essential for fluid and neurological balance but is not linked to carpal spasm or hypoparathyroidism.
D. Chloride.
Chloride helps maintain acid-base and electrolyte balance but has no direct relationship to tetany or carpal spasms caused by hypocalcemia.
Which intervention should the nurse implement to help prevent osteoporosis in a client who has had bariatric surgery
Identify foods high in vitamin D.
Encourage increased intake of milk.
Discuss importance for vitamin A.
Administer supplemental iron.
Correct Answer A: Identify foods high in vitamin D.
Why this is the correct answer:
Bariatric surgery can lead to nutrient deficiencies, including a reduction in calcium and vitamin D absorption, both of which are critical for bone health. Vitamin D plays an essential role in the absorption of calcium, which is crucial for maintaining bone density and preventing osteoporosis. The nurse should educate the client about foods that are rich in vitamin D (such as fortified dairy products, fatty fish, and egg yolks) and emphasize the importance of getting enough vitamin D to support bone health following bariatric surgery.
Why the other options are incorrect:
B. Encourage increased intake of milk.
While milk is a good source of calcium, it may not be enough to fully prevent osteoporosis after bariatric surgery. Additionally, some clients may have lactose intolerance or may have trouble consuming enough milk due to gastric capacity restrictions after surgery. The emphasis should be on vitamin D as well as calcium intake, not just milk alone.
C. Discuss importance for vitamin A.
Vitamin A is important for overall health, but it is not directly involved in the prevention of osteoporosis. The focus should be on vitamins D and calcium, which are more relevant for bone health. Excessive intake of vitamin A can also be toxic and should not be the primary focus for osteoporosis prevention.
D. Administer supplemental iron.
Iron is important for preventing iron deficiency anemia, but it is not directly related to the prevention of osteoporosis. After bariatric surgery, iron deficiency can occur due to decreased stomach acid production and reduced absorption, but iron supplementation would not address the primary concern for bone health.
Summary:
The most effective way to help prevent osteoporosis in a client post-bariatric surgery is to focus on the absorption of calcium and vitamin D. Therefore, the correct intervention is A. Identify foods high in vitamin D. The other options either do not directly address osteoporosis prevention or are not as critical in this context.
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