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When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place?
- A. Client able to discuss appropriate technique
- B. Client able to demonstrate appropriate technique
- C. Client states he understands
- D. Client is able to write steps on piece of paper
Correct Answer: B
Rationale: The correct answer is B because demonstrating the appropriate technique shows psychomotor learning has taken place. This means the client can physically perform the actions involved in drawing up and mixing insulin injections. Merely discussing the technique (choice A) or stating understanding (choice C) doesn't necessarily mean the client can apply the knowledge in practice. Writing steps on paper (choice D) assesses cognitive understanding, not physical skill. In summary, the ability to physically demonstrate the technique is a direct indicator of psychomotor learning, making choice B the best option.
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Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when new nurse states client who has heat stroke will have which of following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. In heat stroke, the body's temperature regulation fails, leading to vasodilation and dehydration. This results in decreased blood pressure (hypotension) as the body struggles to cool down. Choices B (Bradycardia), C (Clammy skin), and D (Bradypnea) are not typical signs of heat stroke. Bradycardia is a slower heart rate, which is usually not seen in heat stroke as the body tries to cool itself. Clammy skin may be present in heat exhaustion but not necessarily in heat stroke. Bradypnea, or slow breathing, is not a common symptom of heat stroke, which is more associated with rapid breathing due to the body's attempt to cool down.
Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client?
- A. "suggest his parents room in with him"
- B. provide a TV & DVDs for him to watch
- C. limit visitors to immediate family
- D. devise a regular schedule for inpatient routines
- E. allow him to perform his own morning care
Correct Answer: B, E
Rationale: Correct Answer: B, E
Rationale:
B: Providing entertainment like TV and DVDs can help distract the adolescent from pain and boredom during recovery.
E: Allowing the adolescent to perform his own morning care promotes independence and self-esteem, aiding in his emotional well-being.
Summary:
A: Suggesting parents room in may not always be feasible or preferred by the adolescent.
C: Limiting visitors to immediate family can be isolating and may not address the adolescent's social needs.
D: While having a regular schedule is important, it may not address the adolescent's individual preferences and needs.
Nurse at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children?
- A. "childhood obesity"
- B. substance use disorders
- C. scoliosis screening
- D. front-seat seatbelt use
- E. stranger awareness
Correct Answer: A, B, C, E
Rationale: The correct topics for parents of school-age children are A, B, C, and E. A- Childhood obesity is relevant for promoting healthy habits. B- Substance use disorders prevention can educate parents on risks. C- Scoliosis screening is important for early detection. E- Stranger awareness is crucial for child safety. Choices D and any other options not selected are inappropriate as they do not directly relate to health promotion and primary prevention for school-age children.
Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion?
- A. "HPV"
- B. measles, mumps, rubella
- C. varicella
- D. Haemophilus influenzae type b
- E. polio
Correct Answer: A, B, C
Rationale: The correct answer is A, B, C. The nurse should include these in the discussion because they are important immunizations recommended for young adults by the CDC. HPV vaccine helps prevent certain cancers; measles, mumps, rubella protects against these highly contagious diseases; varicella prevents chickenpox. The other choices, Haemophilus influenzae type b and polio, are not routinely recommended for young adults. Haemophilus influenzae type b is typically given in infancy, and polio is rare in the US due to successful vaccination programs.
Nurse caring for 19 yo client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?
- A. Measure the vital signs
- B. Encourage HIV screening
- C. Determine client's risk factors
- D. Instruct client to use condoms
Correct Answer: C
Rationale: The correct answer is C: Determine client's risk factors. This intervention is essential to assess the client's current health status, identify potential health risks, and develop a personalized health promotion plan. By understanding the client's risk factors, the nurse can provide targeted education and interventions to prevent diseases and promote overall well-being.
A: Measuring vital signs is important but does not directly address health promotion and disease prevention specific to the client's sexual activity.
B: Encouraging HIV screening is important, but it focuses on a specific disease rather than a comprehensive assessment of risk factors.
D: Instructing the client to use condoms is important for safe sex practices but does not address broader health promotion and disease prevention strategies effectively.