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Which of these measures is most important for a nurse to include in the plan of care for a client
who has Parkinson's disease?
Providing a cool environment for the client.
Encouraging the client to breathe deeply and cough.
Limiting physical activity for the client.
Increasing the amount of fiber in the client's diet. –
Correct Answer :It is important to increase the amount of fiber in the diet of a client with
Parkinson's disease to prevent constipation. The environment of a client with Parkinson's
disease should be warm. It is not necessary to encourage a client with Parkinson's disease to
cough and deep breathe, but should be encouraged to perform physical activity.
A client who is on bed rest with an indwelling urinary catheter has had no urinary drainage for
the past four hours. Which of these actions should a nurse take first?
Force fluids.
Elevate the client's legs.
Palpate the client's suprapubic area.
Ensure the drainage bag is below the level of the bed. –
,Correct Answer :Urine from a Foley catheter drains by gravity, and thus the drainage bag needs
to be below the level of the bed. Forcing fluids, elevating the client's legs, and palpating the
client's suprapubic area are not the first actions a nurse should take for this client.
Which of these problems should a nurse monitor for in a client who is diagnosed with
Parkinson's disease and has difficulty swallowing?
Gastritis.
Gingivitis.
Aspiration.
Sore throat. –
Correct Answer :A client with Parkinson's disease who has difficulty swallowing is at increased
risk of aspiration. Gastritis, gingivitis, and sore throat are not caused by a client having difficulty
swallowing
When planning care for elderly clients in long-term care facilities a nurse should give highest
priority for which of these measures?
Ensuring that they consume at least one liter of fluids daily.
Maintaining a safe environment.
Securing assistance from family members.
Identifying sensory problems and making appropriate referral. –
Correct Answer :Maintaining a safe environment is always a priority for elderly clients. Although
all the options are important they are not the highest priority.
A nurse is to administer an oral medication to a client who just vomited. Which of these actions
should the nurse take?
Withhold the medication and inform the health care provider.
,Give the client a carbonated beverage 30 minutes prior to administering the medication.
Crush the medication and administer in applesauce.
Ask the pharmacy for the medication to be administered by another route. –
Correct Answer :If a client has just vomited, a nurse should withhold the medication and inform
the HCP. Giving the client a carbonated beverage 30 minutes prior to the administration of the
medication may cause increased vomiting. Crushing the medication is not appropriate as the
client could still vomit up the applesauce. The physician must order a change in the route of the
medication.
A 76-year-old male client who is newly diagnosed with prostate cancer is weighing his options to
undergo chemotherapy or radiation as his treatment. Which ethical principle is the client
utilizing in making his decision?
Confidentiality.
Justice.
Autonomy.
Beneficence. –
Correct Answer :A patient who is making a decision about a treatment regimen is exercising the
ethical principle of autonomy. Autonomy is the personal freedom, self-determination, and right
to make one's own decisions. Beneficence or nonmaleficence are actions that promote good
and attempts to do things that benefit others and do no harm. Confidentiality is the social
contract guaranteeing one's privacy. Justice is treating people fairly and equally as to benefits,
resources, and burdens.
A nurse caring for a postoperative client should keep the knee gatch of the bed low while the
client is in supine position to avoid which of these conditions from developing?
Respiratory restrictions.
, Pressure on the popliteal space.
Abduction of the hip.
Foot drop. –
Correct Answer :The popliteal space is the underside of the knee. Raising the knee gatch would
place pressure on the popliteal space.
A nurse notes a temperature of 100F (32.2C), dry oral mucous membranes, and urine specific
gravity of 1.035 in an 84-year-old client admitted to the hospital. Which of these nursing
diagnoses should be the priority?
Fluid volume deficit.
Impaired skin integrity.
Urinary retention.
Ineffective thermoregulation. –
Correct Answer :These are symptoms of dehydration. Therefore the nurse should address the
diagnosis of fluid volume deficit. Normal single urine specific gravity ranges from 1.002 to 1.030.
A 24-hour specimen of normal urine should be between 1.015 and 1.025. Once the patient is
hydrated, the patient's symptoms of urinary retention, ineffective thermoregulation and
impaired skin integrity should not persist.
A nurse should make an incident report for which of these events?
A client tells the nurse that he would not want to live if he were to become unconscious and
have to depend on a respirator.
A nurse contaminates and discards two catheters when catheterizing a client.
A nurse who has never had back pain before feels a twinge of back pain when moving a client
up in bed.