Community nursing NCLEX set 2

The nurse is trying to determine the ability of the client with myocardial infarction (MI) to manage independently at home after discharge. Which statement by the client is the strongest indicator of the potential for difficulty after discharge?

"I don't have anyone to help me with doing heavy housework at home."

The nurse is caring for a client with an exacerbation of multiple sclerosis. Which medication(s) will the nurse expect to be prescribed to hasten recovery from the exacerbation?

Methylprednisolone and cyclophosphamide intravenously

The nurse is reviewing the record for a client seen in the health care clinic and notes that the health care provider has documented a diagnosis of amyotrophic lateral sclerosis (ALS). Which initial clinical manifestation of this disorder should the nurse expect to see documented in the record?

Mild clumsiness

The home care nurse is visiting a male client who is recovering at home after suffering a brain attack (stroke) 2 weeks ago. The client's wife states that the client has difficulty feeding himself and difficulty with swallowing food and fluids. Which would be the initial nursing action?

Observe the client feeding himself.

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain?

Parietal

A client has a difficulty with the ability to flex the hips. The nurse determines that the client is adapting successfully to this problem if the client demonstrates proper use of which item?

Raised toilet seat

The nurse is admitting a homeless man who was brought to the emergency department by paramedics. He was found unresponsive next to the back door of a restaurant, was unkempt in appearance, and had various scratches on his body. The nurse develops a plan of care for the client. Which priority client problems apply? Select all that apply.

Risk for unsafe conditions because of homelessness Anxiety when consciousness is regained because of the unfamiliar surroundings Risk for infection because of his unkempt condition, various scratches, and homelessness

A home care nurse is assessing a client's activities of daily living (ADLs) after a stroke. What should the nurse include in the client's focused assessment?

Self-care needs such as toileting, feeding, and ambulating

Which would be the highest expected growth and development occurrences at 9 months of age for an infant who has had appropriate growth assessed at each well-child visit? Select all that apply.

Should be able to say "mama" and "dada'' Will pull up and stand for several seconds holding on to furniture Will be able to pick up small pieces of food when placed in a high chair

The nurse is caring for a client with Parkinson's disease. Which finding about gait should the nurse expect to note in the client?

Shuffling and propulsive

A client with acquired immunodeficiency syndrome (AIDS) is experiencing fatigue. The nurse should plan to teach the client which strategy to conserve energy after discharge from the hospital?

Sit for as many activities as possible.

The nurse is caring for a client with a swollen left ankle who has difficulty bearing weight on this leg and states that he twisted his ankle. Based on these findings, which condition does the nurse determine the client has most likely experienced?

Sprain

A client who had a stroke (brain attack) has right-sided hemianopsia. What should the nurse plan to do to help the client adapt to this problem?

Teach the client to scan the environment.

The nurse notes that an older client with dementia is unable to care for herself. Which is an appropriate goal for this client?

The client will function at the highest level of independence possible.

The nurse is assessing the client's gait and notes it is unsteady and staggering. Which description should the nurse use when documenting the assessment finding?

Ataxic

The nurse is reviewing the record of a client with a suspected diagnosis of Huntington's disease. The nurse should expect to note documentation of which early symptom of this disease?

Balance and coordination problems

Which would be the highest expected growth and development occurrence at 12 months of age for an infant who has had appropriate growth assessed at each well-child visit?

Walks holding on to someone's hand

The nurse has instructed a client with myasthenia gravis about strategies for self-management at home. The nurse determines a need for further teaching if the client makes which statement?

"Going to the beach will be a nice, relaxing form of activity."

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instruction if the client makes which statement?

"I need to restrict my activity while this catheter is in place."

The home care nurse has taught a client with a problem of inadequate cardiac output about helpful lifestyle adaptations to promote health. Which statement by the client best demonstrates an understanding of the information provided?

"I will eat enough daily fiber to prevent straining at stool."

The nurse is teaching the client with angina pectoris about disease management and lifestyle changes that are necessary to control disease progression. Which statement by the client indicates a need for further teaching?

"It is best to exercise once a week for 1 hour."

The home health care nurse is providing instructions to a client after a vulvectomy. Which instruction should the nurse provide to the client?

"Resume activities slowly, keeping in mind that walking is a beneficial activity."

The nurse provides a list of instructions to a client being discharged to home with a peripherally inserted central catheter (PICC). The nurse determines that the client needs further instructions if the client made which statement?

''I need to restrict my activity while this catheter is in place."

A client with myasthenia gravis has difficulty chewing and has received a prescription for pyridostigmine. The nurse should check to see that the client takes the medication at what time?

30 minutes before meals

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?

A hearing aid

The nurse is talking to a client who had a below-the-knee amputation 2 days earlier. The client states, "I hate looking at this; I feel that I'm not even myself anymore." What client problem should the nurse incorporate in the plan of care based on the statement by this client?

Altered body image

A client has been experiencing difficulty with completion of daily activities because of underlying cardiovascular disease, as evidenced by exertional fatigue and increased blood pressure. Which observation by the nurse best indicates client progress in meeting goals for this problem?

Ambulates 10 feet (3 meters) farther each day

The nurse is caring for a client who is in the chronic phase of stroke (brain attack) and has a right-sided hemiparesis. The nurse identifies that the client is unable to feed self. Which is the appropriate nursing intervention?

Assist the client to eat with the left hand to build strength.

A client with myocardial infarction (MI) has been transferred from the coronary care unit (CCU) to the general medical unit. What activity level should the nurse encourage for the client immediately after transfer?

Bathroom privileges and self-care activities

A client is admitted to the nursing unit after undergoing radical prostatectomy for cancer. The nurse anticipates that which problem would be of most concern to the client in the immediate postoperative period?

Concern about the outcome of surgery

A client who suffered a stroke is prepared for discharge from the hospital. The health care provider has prescribed range-of-motion (ROM) exercises for the client's right side. What action should the nurse include in the client's plan of care?

Consider the use of active, passive, or active-assisted exercises in the home.

The nurse is assessing the adaptation of a client to changes in functional status after a stroke (brain attack). Which observation indicates to the nurse that the client is adapting most successfully?

Consistently uses adaptive equipment in dressing self

The nurse in a long-term care facility is reviewing the health care provider's (HCP's) prescriptions on an assigned client. The nurse notes that the HCP prescribed ropinirole hydrochloride. The nurse determines that this medication has been prescribed to treat which condition in the client?

Parkinsonian syndrome

A client with multiple sclerosis is receiving baclofen. The nurse assessing the client monitors for which finding as an indication of a primary therapeutic response to the medication?

Decreased muscle spasms

A client with a neurological impairment experiences urinary incontinence. Which nursing action would be most helpful in assisting the client to adapt to this alteration?

Establishing a toileting schedule

The nurse is creating a plan of care for a client with a diagnosis of stroke (brain attack) with anosognosia. To meet the needs of the client with this deficit, the nurse should include activities that will achieve which outcome?

Increase the client's awareness of the affected side.

A client with multiple sclerosis is experiencing muscle weakness, spasticity, and an ataxic gait. On the basis of this information, the nurse should include which client problem in the plan of care?

Interruption in physical mobility

The nurse is performing a physical assessment of a client's musculoskeletal system and notes that the client is right-handed. The nurse would document which assessment findings as normal? Select all that apply.

Muscle strength graded 5/5 Symmetrical movements bilaterally Increased muscle size on the dominant arm A 1-cm hypertrophy of the right upper arm

The nurse is caring for a client diagnosed with Alzheimer's disease. The nurse should anticipate that the client has changes in which component of the nervous system?

Neuronal dendrites

A client has sustained damage to Wernicke's area from a stroke (brain attack). On assessment of the client, which sign or symptom would be noted?

Problem with understanding language

The nurse is assessing a client's muscle strength. The nurse asks the client to hold the arms up and supinated, as if holding a tray, and then asks the client to close the eyes. The client's left hand turns and moves downward slightly. The nurse interprets this to mean that the client has which condition?

Pronator drift

The nursing student develops a plan of care for a client with paraplegia who is at risk for injury related to spasticity of the leg muscles. On reviewing the plan, the coassigned licensed nurse identifies which action as an incorrect intervention?

Using padded restraints to immobilize the limb

The nurse at a well-baby clinic is assessing the motor development of a 24-month-old child. On the basis of the age of the child, the nurse expects to note what as the highest-level developmental milestone?

The child opens a door by turning the doorknob.

The nurse has developed a plan of care for a client in traction and documents a problem of inability to perform self-care independently. The nurse evaluates the plan of care and determines that which observation indicates a successful outcome?

The client assists in self-care as much as possible.

The nurse is assigned to care for a client with complete right-sided hemiparesis from a stroke (brain attack). Which characteristics are associated with this condition? Select all that apply.

The client is aphasic. The client has weakness on the right side of the body. The client has weakness on the right side of the face and tongue.

A client diagnosed with tuberculosis (TB) is distressed over fatigue and the loss of physical stamina. What should the nurse tell the client?

This is expected, and the client should gradually increase activity as tolerated.

The nurse has reviewed activity restrictions with a client who is being discharged after insertion of a femoral head prosthetic system. What statement by the client will help the nurse determine that the client understands the material presented?

Use a raised toilet seat.

The nurse is developing a plan of care for a client recovering from pulmonary edema. The nurse establishes a goal to have the client participate in activities that reduce cardiac workload. The nurse should identify which client action as contributing to this goal?

Using a bedside commode

A client has a cerebellar lesion. The nurse should plan to obtain which item for use by the client?

Walker

The nurse is providing medication instructions to a client with multiple sclerosis receiving baclofen. Which information should the nurse include in the instructions?

Watch for urinary retention as a side effect.