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Questions 164

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Question 1 of 5

A nurse has received report from the off-going shift that a client is confused and has been identified as a high risk for falls. The nurse shares this information with the unlicensed assistive personnel (UAP). Which finding by the nurse requires intervention?

Correct Answer: C

Rationale: Raising all four side rails is a restraint and can increase fall risk if the client attempts to climb over them. It also violates standards of care unless specifically prescribed.

Question 2 of 5

A victim of domestic violence tells the batterer she needs a little time away. How would the nurse expect that the batterer might respond?

Correct Answer: B

Rationale: With fear of rejection causing increased rage toward the victim. Fear of abandonment often escalates abusive behavior.

Question 3 of 5

A 35 year-old client with sickle cell crisis is talking on the telephone but stops as the nurse enters the room to request something for pain. The nurse should

Correct Answer: C

Rationale: Administer the prescribed analgesia. Pain relief is a priority in sickle cell crisis, and prescribed analgesics are appropriate.

Question 4 of 5

The nurse is reinforcing teaching to a client with advanced chronic obstructive pulmonary disease who was prescribed oral theophylline. Which client statement indicates that additional teaching is required?

Correct Answer: D

Rationale: Cimetidine inhibits theophylline metabolism, increasing toxicity risk. Omeprazole is safer, and this statement indicates a need for further teaching.

Question 5 of 5

During the initial home visit, a nurse is discussing the care of a client newly diagnosed with Alzheimer's disease with family members. Which of these interventions would be most helpful at this time?

Correct Answer: D

Rationale: Alzheimer's disease, a progressive chronic illness, greatly challenges caregivers. The nurse can be of greatest assistance in helping the family to use communication strategies to enhance their ability to relate to the client.

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