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Questions 164

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Question 1 of 5

During a home visit, the community health nurse observes bruises in various stages of healing on the extremities and torso of an elderly client. The client explains that the bruises are from bumping into furniture and the well in the wheelchair. What is the priority nursing action?

Correct Answer: C

Rationale: Multiple bruises in various stages raise suspicion for elder abuse, requiring reporting to the HCP for investigation. Further questioning may cause distress, and hygiene/nutrition assessments are secondary. Discussing with family risks alerting potential abusers.

Question 2 of 5

The nurse has reinforced teaching with a client who has anxiety and a new prescription for alprazolam. Which of the following statements by the client would indicate a correct understanding of the teaching?

Correct Answer: D

Rationale: Alprazolam is a benzodiazepine, and its use during pregnancy can pose risks to the fetus. Discontinuing and notifying the provider is critical. Muscle relaxants may enhance sedation, skipping doses disrupts therapeutic levels, and dietary restrictions like avoiding tyramine are not required for alprazolam.

Question 3 of 5

The nurse is caring for a bedridden client experiencing fecal incontinence. Which nursing intervention is the highest priority for this client?

Correct Answer: C

Rationale: Perianal skin care with barrier cream prevents skin breakdown, a common complication of fecal incontinence. Wound care consultation follows if breakdown occurs. Rectal tubes risk complications, and briefs may trap moisture, worsening irritation.

Question 4 of 5

A nursing assistant comes to the LPN/LVN and complains that she has more residents to care for than another nursing assistant (NA). She has one more resident assigned to her than the other NA. However, the other NA has more total care residents than the complaining NA. How should the LPN/LVN handle this situation?

Correct Answer: C

Rationale: Discussing needs and organizing care addresses the NA's concerns constructively, promoting teamwork and efficiency without dismissing or deferring.

Question 5 of 5

A nurse is teaching a class for new parents at a local community center. The nurse would stress that what is most hazardous for an 8 month-old child?

Correct Answer: D

Rationale: Eating peanuts. Asphyxiation due to foreign materials in the respiratory tract is the leading cause of death in children younger than 6 years of age.

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