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Questions 164

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Question 1 of 5

A client with advanced Alzheimer’s dementia is admitted to a skilled nursing facility for delirium. The health care provider prescribes ambulation with partial weight bearing. Which would be the most appropriate method for the nurse to use to transfer this client safely?

Correct Answer: D

Rationale: A 2-person stand and pivot with a gait belt and walker ensures safety for a client with dementia and partial weight bearing, accounting for confusion and weakness. One-person transfer risks falls, and lifts are excessive for ambulation.

Question 2 of 5

The nurse in the pediatric unit is collecting data from several newly admitted clients. Which finding should the nurse follow up for possible abuse and mandatory reporting?

Correct Answer: A

Rationale: A 2-month-old cannot roll, and lethargy after a fall suggests possible non-accidental head trauma, requiring abuse investigation. Bluish buttock marks may be Mongolian spots (benign), and splatter burns are consistent with an accident.

Question 3 of 5

The nurse in the mental health unit observes a client hitting the wall repeatedly with the hands after an upsetting family therapy session. The nurse should recognize that the client is exhibiting which of the following defense mechanisms?

Correct Answer: B

Rationale: Defense mechanisms are unconscious mental processes used to protect individuals from uncomfortable thoughts, internal conflicts, and external stresses. Defense mechanisms may be therapeutic to clients with anxiety. However, with excessive use, defense mechanisms may become notherapeutic because they involve a degree of self-deception and reality distortion that can result in poor interpersonal relationships, irrational behavior, and decreased productivity.

Question 4 of 5

Damage to the VIII cranial nerve results in:

Correct Answer: B

Rationale: The VIII cranial nerve (vestibulocochlear) is responsible for hearing and balance; damage causes sensorineural hearing loss, affecting the inner ear or nerve pathways.

Question 5 of 5

A nurse is caring for a client with an exacerbation of chronic obstructive pulmonary disease (COPD) and a history of type 2 diabetes mellitus requiring insulin. The client has been prescribed prednisone. The nurse anticipates which need?

Correct Answer: C

Rationale: Prednisone increases blood glucose, necessitating a higher insulin dose in diabetes. Hypotension is not a primary concern, prednisone is not typically titrated upward, and intake/output monitoring is less critical.

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