NCLEX EXAM PREVIEW IS NOW
REDALY AVAILABLE WITH
BRANDNEW TEST APPROVED
BY ACE MARKET FOR BETTER
GRADES!!
The nurse is planning care for a client with moderate Alzheimer's disease (AD).
Which of the following interventions should the nurse include in the client's plan of care?
1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated behaviors occur.
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
4. Provide the client with information about activity choices in the morning so the client can
make plans for the day.
1. Encourage the client to reminisce about happy memories.
Its possible for AD patients to retain long-term memories
Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and
planning daily activities. Asking them to plan can frustrate them and cause distress.
STRUCTURED pleasant activities that consider the persons likes and interests are the best.
The nurse is teaching a client how to ambulate using crutches. Which of the following
information should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
, 3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended."
1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding of the
teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
4. "I should expect the blurred vision to resolve after I have received medications for several
weeks."
4. "I should expect the blurred vision to resolve after I have received medications for several
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases
it resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it
quicker
Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities and allow
time for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with
it but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked
up and extra heat can stress your body into overdrive
Q: The charge nurse has received a change-of-shift report on the following clients in labor. The
charge nurse should ask a staff member to first see the client in the:
A: First stage of labor whose contractions are occurring every 30 seconds.
REDALY AVAILABLE WITH
BRANDNEW TEST APPROVED
BY ACE MARKET FOR BETTER
GRADES!!
The nurse is planning care for a client with moderate Alzheimer's disease (AD).
Which of the following interventions should the nurse include in the client's plan of care?
1. Encourage the client to reminisce about happy memories.
2. Confront the client when inappropriate or agitated behaviors occur.
3. Administer to the client the cholinesterase inhibitor to reverse the course of AD.
4. Provide the client with information about activity choices in the morning so the client can
make plans for the day.
1. Encourage the client to reminisce about happy memories.
Its possible for AD patients to retain long-term memories
Rationale:
2. Acknowledge feelings --> Redirect is protocol for Dementia. Don't confront; they can't learn
3. AD is irreversible
4. In moderate AD, dementia has already progressed to where pt needs help with ADLs and
planning daily activities. Asking them to plan can frustrate them and cause distress.
STRUCTURED pleasant activities that consider the persons likes and interests are the best.
The nurse is teaching a client how to ambulate using crutches. Which of the following
information should the nurse include?
1. "Use your hands and arms to support your body weight."
2. "Wear slippers when ambulating with the crutches in your home."
, 3. "Maintain the crutches 12 in (30 cm) in front of your feet while standing."
4. "Adjust the hand grips of the crutches so that your elbows are fully extended."
1. "Use your hands and arms to support your body weight."
True! But watch out if it isn't 2-3 finger-widths, crutch paralysis can occur. s/s: paresis and
paresthesias in wrists and hands
Rationales:
2. Fall risk!
3. Should be 6 in. in front and 6 in. lateral
4. Elbows should be bent at 30 degree angle
The nurse has taught a client with multiple sclerosis (MS).
Which of the following statements by the client would indicate a correct understanding of the
teaching?
1. "I will complete all of my household chores in the morning when I am well rested."
2. "I have learned how to massage my bladder to help empty my bladder completely."
3. "I will take a hot bath in the evening to help me relax if I have had a stressful day at work."
4. "I should expect the blurred vision to resolve after I have received medications for several
weeks."
4. "I should expect the blurred vision to resolve after I have received medications for several
weeks."
MS causes nerve damage and can result in optic neuritis (vision loss, burry vision). In most cases
it resolves itself in 4-12 weeks, but medication (steroids) can speed up the process and resolve it
quicker
Rationale:
1. MS patients should not exert themselves too much at one time. Space out activities and allow
time for rest.
2. Urinary retention is primarily treated by medication (bethanochol), and exercises can aid with
it but are not the primary treatment
3. Hot temperatures are bad for MS and can worsen symptoms. Your nerves are already fcked
up and extra heat can stress your body into overdrive
Q: The charge nurse has received a change-of-shift report on the following clients in labor. The
charge nurse should ask a staff member to first see the client in the:
A: First stage of labor whose contractions are occurring every 30 seconds.
