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1. A nurse is collecting data from an older adult client during a routine physical examination. Which of the following client statements should the nurse identify as a possible indication of maltreatment?
- A. My son took my wallet to keep track of my spending
- B. My son always cooks my meals for me
- C. My son doesn't want me to drive alone
- D. I exercise every day with my son
Correct answer: A
Rationale: The correct answer is A. Taking away a wallet to control spending is a form of financial maltreatment, which is a common form of abuse among older adults. Choices B, C, and D do not indicate maltreatment; rather, they show examples of care and concern from the son. Cooking meals, preventing the older adult from driving alone, and engaging in daily exercise are positive behaviors.
2. Which of the following interventions should the nurse implement for a client with hyperkalemia?
- A. Administer calcium gluconate
- B. Increase fluid intake to promote potassium excretion
- C. Administer a diuretic
- D. Administer sodium bicarbonate
Correct answer: A
Rationale: The correct intervention for a client with hyperkalemia is to administer calcium gluconate. Calcium gluconate helps counteract the effects of hyperkalemia by stabilizing the cardiac cell membrane. Increasing fluid intake (Choice B) may not effectively lower potassium levels. Administering a diuretic (Choice C) or sodium bicarbonate (Choice D) is not the primary treatment for hyperkalemia and may not address the immediate need to lower potassium levels.
3. A nurse is planning an educational program for high school students about cigarette smoking. Which of the following potential consequences of smoking is most likely to discourage adolescents from using tobacco?
- A. Use of tobacco might lead to alcohol and drug abuse.
- B. Smoking in adolescence increases the risk of developing lung cancer later in life.
- C. Use of tobacco decreases the level of athletic ability.
- D. Smoking in adolescence increases the risk of lifelong addiction.
Correct answer: C
Rationale: The most likely consequence to discourage adolescents from smoking is the immediate effect of decreased athletic ability. This consequence is more tangible and relevant to high school students compared to long-term health risks like lung cancer or addiction. While choices A, B, and D are all negative outcomes of smoking, choice C is more likely to have a direct impact on adolescents due to its immediate and visible effects on their physical performance.
4. What is the healthcare provider's role in providing patient education about hypertension management?
- A. Encourage lifestyle modifications and medication adherence
- B. Advise patients to avoid physical activity
- C. Recommend a low-sodium diet
- D. Increase potassium in the diet
Correct answer: A
Rationale: The correct answer is A: Encourage lifestyle modifications and medication adherence. Patient education in hypertension management should focus on encouraging lifestyle changes like a healthy diet, exercise, stress management, and adherence to prescribed medications. Choices B, C, and D are incorrect because advising patients to avoid physical activity, recommending a low-sodium diet, and increasing potassium intake, although related to hypertension management, do not encompass the comprehensive approach needed for effective patient education on this topic.
5. A client who is 1 day postoperative following a total hip arthroplasty should be instructed to do which of the following?
- A. Avoid using a walker while walking.
- B. Keep the hip flexed at 90° while sitting.
- C. Place a pillow between your legs when turning.
- D. Cross your legs at the ankles when sitting.
Correct answer: C
Rationale: Placing a pillow between the legs is essential post-total hip arthroplasty to prevent adduction of the hip joint, reducing the risk of dislocation. Choices A, B, and D are incorrect. Using a walker while walking is encouraged for support and stability. Keeping the hip flexed at 90° while sitting can increase the risk of hip dislocation. Crossing legs at the ankles when sitting may also lead to hip dislocation.
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