Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A nurse is caring for a client who has hemiparesis following a right-sided stroke. Which of the following actions should the nurse take?
A. Place objects within reach on the client's right side.
Placing objects within the client's reach on the right side helps to compensate for the hemiparesis and facilitates the client's ability to independently access items.
B. Encourage the client to repeat phonetic sounds.
Encouraging the client to repeat phonetic sounds might be more appropriate for speech therapy and may not directly address hemiparesis.
C. Pause to allow the client time to respond to questions.
Pausing to allow the client time to respond to questions is a communication technique but does not address the physical effects of hemiparesis.
D. Frequently orient the client to time, place, and surroundings.
Frequently orienting the client to time, place, and surroundings is important for cognitive support but does not specifically address hemiparesis.
This question is an excerpt from Nurse Dive's nursing test bank - RN ati Concept-based assessment level proctored exam. Take the full exam now
Full Explanation
Choice A rationale:
Placing objects within the client's reach on the right side helps to compensate for the hemiparesis and facilitates the client's ability to independently access items.
Choice B rationale:
Encouraging the client to repeat phonetic sounds might be more appropriate for speech therapy and may not directly address hemiparesis.
Choice C rationale:
Pausing to allow the client time to respond to questions is a communication technique but does not address the physical effects of hemiparesis.
Choice D rationale:
Frequently orienting the client to time, place, and surroundings is important for cognitive support but does not specifically address hemiparesis.
Similar Questions
A nurse is teaching a client about the use of an epinephrine auto-injector for anaphylaxis.
Which of the following information should the nurse include?
A. Store the injector in the refrigerator.
Epinephrine auto-injectors should be stored at room temperature and protected from light. Refrigeration is not recommended.
B. Expect the solution to appear brown.
The solution in an epinephrine auto-injector should be clear. If it appears discolored or contains particles, it may be expired or compromised.
C. Shake the device for 30 seconds to disperse sediment before injection.
Epinephrine auto-injectors should not be shaken before use, as shaking could cause the solution to foam and result in inaccurate dosing.
D. Hold the injector in place for 10 seconds after injection.
Holding the epinephrine auto-injector in place for 10 seconds allows the medication to be fully delivered into the muscle, enhancing its effectiveness.
Full Explanation
Choice A rationale:
Epinephrine auto-injectors should be stored at room temperature and protected from light. Refrigeration is not recommended.
Choice B rationale:
The solution in an epinephrine auto-injector should be clear. If it appears discolored or contains particles, it may be expired or compromised.
Choice C rationale:
Epinephrine auto-injectors should not be shaken before use, as shaking could cause the solution to foam and result in inaccurate dosing.
Choice D rationale:
Holding the epinephrine auto-injector in place for 10 seconds allows the medication to be fully delivered into the muscle, enhancing its effectiveness.
A nurse is teaching a client about managing diverticulosis. Which of the following statements should the nurse make?
A. "Limit fiber intake to 20 grams each day."
Increasing fiber intake is a key recommendation for managing diverticulosis.
B. "Decrease cellulose-containing foods in the diet."
Cellulose-containing foods, such as whole grains and vegetables, are important sources of dietary fiber and are encouraged for managing diverticulosis.
C. "Take stimulating laxatives as needed."
Stimulating laxatives are not recommended for managing diverticulosis and could potentially exacerbate symptoms.
D. "Limit daily fat intake to 30% or less."
Limiting fat intake to 30% or less is a dietary recommendation for managing diverticulosis. A high-fiber diet is also important to prevent diverticular inflammation.
Full Explanation
Choice A rationale:
Increasing fiber intake is a key recommendation for managing diverticulosis.
Choice B rationale:
Cellulose-containing foods, such as whole grains and vegetables, are important sources of dietary fiber and are encouraged for managing diverticulosis.
Choice C rationale:
Stimulating laxatives are not recommended for managing diverticulosis and could potentially exacerbate symptoms.
Choice D rationale:
Limiting fat intake to 30% or less is a dietary recommendation for managing diverticulosis. A high-fiber diet is also important to prevent diverticular inflammation.
A nurse is assessing a newborn who is 4 hr old. Which of the following findings should the nurse expect?
A. Bulging fontanels
Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.
B. Blue hands and feet
Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.
C. Generalized petechiae
Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.
D. Flaring of the nares
Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.
Full Explanation
Choice A rationale:
Bulging fontanels are a sign of increased intracranial pressure, which is an abnormal finding in newborns. The nurse should assess for other signs of neurological impairment, such as lethargy, irritability, or seizures.
Choice B rationale:
Blue hands and feet, also known as acrocyanosis, are a normal finding in newborns who are 4 hr old. This is due to immature peripheral circulation and should resolve within 24 to 48 hr.
Choice C rationale:
Generalized petechiae are a sign of bleeding disorders, infection, or trauma, which are abnormal findings in newborns. The nurse should assess for other signs of bleeding, such as bruising, hematuria, or melena.
Choice D rationale:
Flaring of the nares is a sign of respiratory distress, which is an abnormal finding in newborns. The nurse should assess for other signs of respiratory distress, such as grunting, retractions, or cyanosis.