Nokea
Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline?
- A. Establish consistent boundaries
- B. Place him in room with door closed
- C. Have him learn by trial & error
- D. Use favorite snacks as rewards
Correct Answer: A
Rationale: The correct answer is A: Establish consistent boundaries. This is important in toddler discipline as it provides structure and teaches the child what behaviors are acceptable. Consistency helps in setting clear expectations and enforcing consequences. Option B is incorrect as isolation can lead to feelings of abandonment. Option C is incorrect as trial and error may not provide clear guidance for the child. Option D is incorrect as using food rewards may lead to unhealthy eating habits.
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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.
Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information such as location, type of environment, and potential threats. By gathering this information discreetly, security personnel can better assess the situation and coordinate an appropriate response.
Choice A is incorrect because abruptly ending the call can hinder the ability to gather vital details. Choice B is incorrect as using overhead paging may cause panic and compromise safety. Choice C is incorrect because not asking questions can lead to missing important information.
Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities?
- A. "develop acceptance of diminished strength & increased dependence on others"
- B. feel frustrated that time is too short for trying to start another life
- C. welcome opportunities to be creative & productive
- D. commit to finding friendship & companionship
- E. become involved in community issues & activities
Correct Answer: C, E
Rationale: The correct answers are C and E. Middle adults are typically in the generativity vs. stagnation stage, where they seek to contribute to society and make a positive impact. Choice C, welcoming opportunities to be creative and productive, aligns with generativity. Additionally, becoming involved in community issues and activities (choice E) reflects their desire to engage with society. Choices A and B are incorrect as middle adults do not typically accept diminished strength and do not feel frustrated about time constraints for starting a new life. Choice D is incorrect as seeking friendship and companionship is more characteristic of young adulthood.
Nurse performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.
Nurse transferring a client from an acute-care hospital to a rehab facility. Which of the following info about the client should the nurse include in the transfer report? (Select all that apply.)
- A. Alert & oriented
- B. Refuses to eat spinach
- C. Has shellfish allergy
- D. Requests morphine every 4h
- E. Misses the 2 cats he has at home
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Including that the client is alert and oriented is crucial for providing a comprehensive overview of the client's mental status and ability to participate in the rehabilitation program.
C: Informing about the shellfish allergy is essential for ensuring the client's safety and preventing any potential allergic reactions during their stay at the rehab facility.
D: Noting the client's request for morphine every 4 hours is important for ensuring that their pain management needs are properly addressed during their transition to the rehab facility.
B, E: Refusing to eat spinach and missing cats at home are not relevant pieces of information that directly impact the client's care during their transfer to the rehab facility.