Nokea
Nurse is giving presentation about accident prevention to group of parents & toddlers. Which strategies should nurse include? (Select all that apply.)
- A. Keep toxic agents in locked cabinets
- B. Keep toilet seats up
- C. Turn pot handles toward back of stove
- D. Place safety gates across stairways
- E. Make sure balloons are fully inflated
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D. A: Keeping toxic agents in locked cabinets prevents toddlers from accessing harmful substances. C: Turning pot handles toward the back of the stove reduces the risk of toddlers pulling them down. D: Placing safety gates across stairways prevents toddlers from falling down stairs. These strategies are crucial for accident prevention.
Incorrect choices: B: Keeping toilet seats up can lead to toddlers falling into the toilet. E: Making sure balloons are fully inflated increases the risk of choking hazards.
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Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. Orthopneic position is sitting upright with arms supported, which helps improve lung expansion and ease breathing. Choice A is incorrect as lying on the back can worsen breathing difficulties. Choice B is incorrect as lying flat on the stomach hinders breathing. Choice D is incorrect as lying on the side does not provide the same lung expansion as sitting upright.
A home health nurse is discussing dangers of carbon monoxide poisoning with client. Which of following info should nurse include in her counseling?
- A. Carbon monoxide has distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with Hgb in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with Hgb in the body. Carbon monoxide is a colorless and odorless gas, so it does not have a distinct odor (choice A). Water heaters should be inspected annually, not every 5 years (choice B). Carbon monoxide poisoning affects the blood's ability to carry oxygen, not the lungs directly (choice C). By binding with hemoglobin, carbon monoxide reduces the blood's oxygen-carrying capacity, leading to tissue hypoxia and potentially fatal consequences. Therefore, it is crucial for the nurse to emphasize this information during counseling to help the client understand the serious implications of carbon monoxide exposure.
By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process?
- A. Reassess client to determine reasons for unsatisfactory pain relief
- B. See whether pain lessens during next 24h
- C. Change plan to ensure client achieves adequate pain relief
- D. Teach client about plan of care for managing his pain
Correct Answer: A
Rationale: The correct answer is A. In the nursing process, the first step in addressing a client's unsatisfactory pain relief is to reassess the client to determine the reasons for it. This involves evaluating the pain intensity, location, characteristics, aggravating factors, and the client's response to current pain management interventions. By reassessing, the nurse can identify any underlying causes contributing to the lack of pain relief and adjust the plan of care accordingly.
Choice B is incorrect because waiting another 24 hours without further assessment delays appropriate intervention. Choice C is incorrect as changing the plan without reassessment may not address the root cause of the issue. Choice D is incorrect as teaching the client about the plan of care should come after reassessment to ensure it is tailored to the client's specific needs.
Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include?
- A. "scoliosis is more common in girls than in boys"
- B. loss of height is often first sign of scoliosis
- C. scoliosis screening is essential during adolescent growth spurt
- D. slouching is common cause of scoliosis, esp. in adolescents
- E. scoliosis is forward curvature of spine
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: "Scoliosis is more common in girls than in boys" - Correct. Scoliosis is indeed more prevalent in girls, especially during adolescence.
C: "Scoliosis screening is essential during adolescent growth spurt" - Correct. Screening during growth spurts is crucial for early detection and intervention.
Summary:
B: Loss of height as the first sign of scoliosis is incorrect, as it is not a common symptom.
D: Slouching is not a cause of scoliosis; it is a misconception.
E: Scoliosis is a sideways curvature of the spine, not a forward curvature.
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.