Extract:

Question 1 of 5

The nurse notes old and new ecchymotic areas on an older adult client's arms and buttocks upon admission. The client tells the nurse in confidence that her family members frequently hit her. Which statement should the nurse use in response?

A. I have a legal obligation to report this type of abuse.'B. Let's get these treated, and I will maintain confidence.'C. Let's talk about ways to prevent someone from hitting you'D. If this happens again, you must call the emergency department.'

Correct Answer: A

Rationale: Mandatory reporting laws require nurses to report suspected abuse to protect vulnerable clients, prioritizing safety over confidentiality.

Question 2 of 5

A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client tells the nurse, 'I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem to bring anything up.' Which of the following actions should the nurse take to help this client with tenacious bronchial secretions?

A. Administering oxygen via nasal cannula at 2 U/minB. Helping the client select a low-salt dietC. Maintaining a semi-Fowler's position as often as possibleD. Encouraging the client to drink 2 to 3 L of water daily

Correct Answer: D

Rationale: Adequate hydration thins mucus, facilitating clearance of tenacious bronchial secretions in COPD patients.

Question 3 of 5

A nurse is caring for a client who was recently diagnosed with ALS (Amyotrophic lateral sclerosis). Which of the following signs and symptoms is MOST important for the nurse to assess for?

A. Inability to voidB. Unable to eat without thickening mealsC. Loss of function in the lower extremityD. Difficulty breathing

Correct Answer: D

Rationale: As ALS progresses, respiratory muscles weaken, leading to respiratory failure, a life-threatening condition requiring interventions like mechanical ventilation. This makes assessing for difficulty breathing the most critical.

Question 4 of 5

The nurse is educating a patient who is newly diagnosed with amyotrophic lateral sclerosis (ALS). Which statement would be the most appropriate for the nurse to include in education?

A. ALS is caused by excess chemicals in the brain. The symptoms can be controlled with medication.'B. The disease is progressive and will eventually lead to paralysis while maintaining cognitive function.'C. Before you lose cognitive function, you should consider creating an advanced directive.'D. Despite severe symptoms right now, most patients recover with treatment.'

Correct Answer: B

Rationale: ALS is progressive, leading to paralysis while typically preserving cognitive function, making this the most accurate educational statement.

Question 5 of 5

A nurse is monitoring a client with COPD that suddenly becomes restless and anxious. Which of the following steps should the nurse take next?

A. Assess the client's potassium level.B. Check the client's temperature.C. Increase the client's oxygen flow rate to 15 L/min.D. Encourage the client to perform pursed-lip breathing.

Correct Answer: D

Rationale: Pursed-lip breathing helps increase oxygenation and decrease the work of breathing in COPD patients, addressing restlessness and anxiety caused by hypoxia or hypercapnia.