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Questions 164

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Question 1 of 5

The nurse assesses a client for physiological risk factors for falls. The nurse should conclude that the client is not at risk if which of the following is discovered?

Correct Answer: D

Rationale: Intact recent and remote memory indicates that a client is not at risk for falls. Risk for falls can occur in elder clients, and the nurse should assess each client for the possibility of falls and take appropriate actions.

Question 2 of 5

The nurse is reinforcing skin care guidelines for a client who is receiving external radiation therapy. Which of the following statements by the client would indicate a correct understanding of the teaching?

Correct Answer: C,D,E

Rationale: Sun protection (
C), gentle washing (
D), and loose clothing (E) are correct for radiation therapy skin care. Ice packs (
A) can damage skin, and baby oil (
B) may irritate or trap radiation.

Question 3 of 5

The nurse is collecting data from a client with suspected panic disorder. Which of the following findings would be consistent with the condition?

Correct Answer: A,B,D,E

Rationale: Panic disorder is characterized by sudden, intense fear accompanied by physical symptoms such as sweating (
A), dizziness (
B), heart palpitations (
D), and shortness of breath (E). Compulsions (
C) are associated with obsessive-compulsive disorder, not panic disorder.

Question 4 of 5

The nurse has delegated the task of taking the temperature of a client with a new tympanic thermometer to a certified nursing assistant. The nursing assistant says, 'This looks easy. I am good at figuring things out.' What is the nurse's responsibility?

Correct Answer: D

Rationale: Demonstrating and observing ensures the CNA uses the tympanic thermometer correctly, maintaining accuracy and safety.

Question 5 of 5

The charge nurse in a long-term care facility is making assignments. When assigning personnel to care for residents, which principle is important?

Correct Answer: B

Rationale: Consistency with caregivers reduces anxiety and improves trust for confused clients, enhancing care quality. Daily rotation, gender restrictions, or caregiver choice are less effective.

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