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1. A home health nurse is preparing for an initial visit with an older adult client who lives alone. Which of the following actions should the nurse take first?
- A. Educate the client about their current medical diagnosis.
- B. Refer the client to a meal delivery program.
- C. Identify environmental hazards in the home.
- D. Arrange transportation for the client to follow-up appointments.
Correct answer: C
Rationale: Identifying environmental hazards in the client's home is the priority during the initial visit with an older adult living alone. This action is crucial to prevent accidents, falls, and ensure the client's safety. While educating the client about their medical diagnosis, referring them to a meal delivery program, and arranging transportation for follow-up appointments are essential, addressing environmental hazards takes precedence as it directly impacts the client's immediate safety and well-being.
2. What should a healthcare professional do when a client with anorexia nervosa insists on working out constantly?
- A. Allow the client to workout and continue their regimen
- B. Restrict the client's workout regimen to one hour a day
- C. Discuss the risks of over-exercising with the client
- D. Speak to the client privately to uncover the source of the obsession
Correct answer: D
Rationale: When dealing with a client with anorexia nervosa who insists on working out constantly, it is crucial to address the situation sensitively. Speaking to the client privately to uncover the source of the obsession is the most appropriate action. This approach allows the healthcare professional to understand the underlying reasons for the behavior and work towards a solution together. Choices A and B could potentially exacerbate the client's condition by either enabling the behavior or imposing restrictions without addressing the root cause. While choice C is important, simply discussing the risks may not address the client's compulsion to exercise excessively.
3. What are the key components of a neurological assessment?
- A. Assess level of consciousness and motor function
- B. Check for headache and nausea
- C. Monitor reflexes and pupil size
- D. Assess for tremors and confusion
Correct answer: A
Rationale: The correct answer is A. A neurological assessment includes evaluating the level of consciousness and motor function as they are key components in assessing neurological function. Choices B, C, and D are incorrect as headache, nausea, reflexes, pupil size, tremors, and confusion may be part of a neurological assessment but are not the key components that are fundamental for a comprehensive assessment.
4. A nurse is teaching a client who has ulcerative colitis about dietary recommendations. Which of the following instructions should the nurse include?
- A. Avoid high-fiber foods
- B. Increase intake of spicy foods
- C. Consume foods high in fiber
- D. Eat large, infrequent meals
Correct answer: C
Rationale: The correct answer is C: 'Consume foods high in fiber.' Consuming high-fiber foods helps manage symptoms of ulcerative colitis by promoting regular bowel movements. Choices A, B, and D are incorrect. Avoiding high-fiber foods can worsen symptoms as fiber is beneficial for digestive health. Increasing the intake of spicy foods can exacerbate inflammation in the digestive tract, leading to more discomfort. Eating large, infrequent meals can put more strain on the digestive system, which is not ideal for managing ulcerative colitis.
5. A nurse is caring for a client who is postoperative following a thyroidectomy and reports tingling and numbness in the hands. The nurse should expect to administer which of the following medications?
- A. Sodium bicarbonate.
- B. Calcium gluconate.
- C. Potassium chloride.
- D. Magnesium sulfate.
Correct answer: B
Rationale: Tingling and numbness in the hands can indicate hypocalcemia, a common complication following a thyroidectomy. Hypocalcemia requires immediate intervention to prevent severe complications like tetany and seizures. Calcium gluconate is the drug of choice for rapidly raising serum calcium levels in hypocalcemic patients. Sodium bicarbonate is not indicated for treating hypocalcemia or related symptoms. Potassium chloride is used to correct potassium imbalances, not calcium. Magnesium sulfate is not the appropriate treatment for hypocalcemia; it is commonly used for conditions like preeclampsia or eclampsia.
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