Nokea
In which stage do you determine if the patient has achieved the expected outcomes?
- A. Implementation
- B. Evaluation
- C. Assessment
- D. Diagnosis
Correct Answer: B
Rationale: Evaluation is the correct stage in the nursing process to determine if the patient has achieved the expected outcomes. During the evaluation stage, the healthcare provider assesses the effectiveness of the care plan and decides on any necessary adjustments to reach the desired goals.
Choice A, Implementation, is incorrect because this stage involves putting the care plan into action. Choice C, Assessment, is incorrect as it is the stage where data about the patient's health status is gathered. Choice D, Diagnosis, is also incorrect as it is the stage where the healthcare provider identifies the patient's health problems based on the assessment data.
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A mother visited your facility with the complaint of her child passing watery stools for two days. This is the first time the child is having such an experience. How will you describe such a visit?
- A. Initial
- B. Follow-up
- C. Routine visit
- D. None of the above
Correct Answer: A
Rationale: The correct answer is 'Initial.' This visit is described as initial because it is the first time the child is experiencing these symptoms. It signifies the first encounter with healthcare professionals for this specific issue, distinguishing it from subsequent visits which would be follow-up appointments to monitor progress or routine visits for preventive care. Choice B, 'Follow-up,' is incorrect as it implies subsequent visits after the initial encounter. Choice C, 'Routine visit,' is also incorrect as it implies a scheduled visit for preventive care rather than a visit prompted by a new or acute issue. Choice D, 'None of the above,' is incorrect as one of the options accurately describes the situation, which is 'Initial.'
A 6-year-old male is hospitalized in stable condition with multiple fractures following a car accident. The child's parents tell the nurse that their 7-year-old daughter is very upset about the accident and is concerned that her brother will die. Which suggestion by the nurse is most appropriate?
- A. Encourage the parents to phone the sister frequently with updates on her brother's condition.
- B. Suggest that the sister come to the hospital for a visit.
- C. Suggest that one parent leave the hospital to spend extra time with their daughter at home.
- D. Remind the parents that it is normal for children to be upset when their sibling is hospitalized.
Correct Answer: B
Rationale: In situations where a sibling is upset about a family member being hospitalized, suggesting that the sister come to the hospital for a visit can help alleviate her concerns. This allows the sister to see her brother, ask questions, and receive reassurance from seeing him in stable condition. Direct contact and interaction can often provide more comfort and understanding than phone calls or staying at home. Encouraging phone calls (Choice A) might not provide the same level of comfort as a physical visit. While spending extra time with the daughter at home (Choice C) is important, in this scenario, facilitating a visit to the hospital can address the daughter's immediate concerns better. Reminding the parents that it is normal for children to be upset (Choice D) is not as proactive as arranging for the sister to visit her brother.
Kobby, who is diagnosed with diabetes mellitus type 1, displays symptoms of hypoglycemia; which of the following actions should the nurse instruct the parents to take?
- A. Give the child honey (simple sugar)
- B. Give the child milk (complex sugar)
- C. Contact the healthcare provider before doing anything
- D. Give the child nothing by mouth
Correct Answer: A
Rationale: During hypoglycemia, it is crucial to quickly raise blood glucose levels. Giving a simple sugar like honey is recommended as it can rapidly increase blood sugar levels and alleviate the symptoms of hypoglycemia in individuals with diabetes mellitus type 1. Milk, being a complex sugar, will not act as quickly as honey in raising blood sugar levels. Contacting the healthcare provider may lead to a delay in treatment, as immediate action is necessary during hypoglycemia. Withholding food or drink (choice D) is not appropriate when dealing with hypoglycemia as it can worsen the condition.
How can the nurse best assess that the parents demonstrate understanding of the dressing change procedure prior to discharge for their child with burns?
- A. The parents explaining the importance of using sterile technique to the nurse.
- B. The nurse observing the parents changing the dressing using appropriate technique.
- C. The parents observing the nurse changing the dressing and confirming their understanding of the procedure.
- D. The nurse allowing the parents to explain the dressing change procedure and perform it in private to boost their confidence.
Correct Answer: B
Rationale: The most effective way for the nurse to assess the parents' understanding of the dressing change procedure is by observing them as they change the dressing using the correct technique. This direct observation ensures that the parents are able to perform the task correctly and confidently before discharge. Merely verbalizing or explaining the procedure may not accurately reflect the parents' competency in performing the actual task. Choice A involves the parents explaining to the nurse, which does not directly assess their practical skills. Choice C suggests the parents observing the nurse, which does not evaluate the parents' ability to perform the task independently. Choice D focuses on boosting the parents' confidence but does not directly assess their understanding and competency in performing the dressing change.
What should the nurse include in the insulin administration instruction for the parents of a child being discharged on insulin?
- A. Insert the needle and aspirate before injecting
- B. Inject insulin into the extremity to be exercised to improve absorption
- C. The muscles in the abdomen and thigh are the easiest for self-administration
- D. Clean the injection site with soap and water and avoid alcohol
Correct Answer: C
Rationale: The correct answer is C because the muscles in the abdomen and thigh are the most suitable areas for self-administration of insulin due to consistent absorption. Choices A and B are incorrect as aspirating before injecting insulin is unnecessary, and injecting into an extremity to be exercised does not enhance absorption. Choice D is incorrect as alcohol should be used to clean the injection site instead of soap and water, which can cause skin irritation.