Nokea
Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning?
- A. Encourage client to ask questions
- B. Ask client to explain how to select or prepare meals
- C. Encourage client to fill out eval form
- D. Ask client if she has resources for further instruction on topic
Correct Answer: B
Rationale: The correct answer is B: Ask client to explain how to select or prepare meals. This action allows the nurse to assess the client's understanding by evaluating if the client can articulate the key concepts of a heart-healthy diet, demonstrating comprehension. It goes beyond a simple affirmation of understanding and requires the client to apply the knowledge. Encouraging questions (choice A) is important but may not provide a direct assessment of the client's grasp of the material. Choices C and D do not directly assess the client's understanding of the heart-healthy diet teachings.
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Adult client who is competent tells the nurse that he is thinking about leaving the hospital against medical advice. Nurse believes that this is not in client's best interest, so she administers a PRN sedative medication that the client has not requested along with his usual medication. Which of the following types of tort has the nurse committed?
- A. Assault
- B. False imprisonment
- C. Negligence
- D. Breach of confidentiality
Correct Answer: B
Rationale: The correct answer is B: False imprisonment. False imprisonment occurs when a person is confined or restrained against their will. In this scenario, the nurse's act of administering a sedative medication without the client's consent constitutes a form of restraint, therefore, it falls under false imprisonment. The nurse's action restricts the client's freedom to leave the hospital, even though the client is competent and has expressed the intention to leave. The other options are not applicable in this situation: A - Assault involves the threat of harm, C - Negligence involves a breach of duty of care, and D - Breach of confidentiality involves disclosing private information without consent.
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.
Nurse reviewing car seat safety with parents of 1 mo infant. When reviewing this, which instructions should nurse include?
- A. Use car seat that has 3-point harness
- B. Position car seat so that infant is rear-facing
- C. Secure car seat in front passenger seat of car
- D. Put soft padding in car seat behind infant's back & neck
Correct Answer: B
Rationale: The correct answer is B: Position car seat so that infant is rear-facing. This is crucial for newborn safety as it reduces the risk of injury in the event of a crash. Rear-facing car seats provide optimal support for the infant's head, neck, and spine. Choice A is incorrect because a 5-point harness is recommended for infants for better protection. Choice C is incorrect as the back seat is the safest location for a car seat. Choice D is incorrect because soft padding can compress in a crash, leading to injury.
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 delegating ambulation of client who had knee arthroplasty 5 days ago to an AP. Which of following info should nurse share with the AP? (Select all that apply.)
- A. The roommate is up independently
- B. Client ambulates with his slippers on over his antiembolic stockings
- C. Client uses front-wheeled walker when ambulating
- D. Client had pain med 30 min ago
- E. Client is allergic to codeine
- F. Client ate 50% of his breakfast this morning
Correct Answer: B, C, D
Rationale: The correct answers are B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure safety. The nurse should inform that the client uses a front-wheeled walker (C) to maintain stability during ambulation post-knee arthroplasty. Lastly, sharing that the client had pain medication 30 minutes ago (D) is crucial for the AP to monitor for potential side effects and adjust care accordingly.
Incorrect choices:
A: The roommate being up independently is irrelevant to the client's ambulation post-knee arthroplasty.
E: The client's allergy to codeine is important medical information but not essential for the AP to know when delegating ambulation.
F: The client's breakfast intake is not directly related to safe ambulation post-knee arthroplasty.