Nokea
A 14-year-old client is scheduled for a below-knee (BK) amputation following a motorcycle accident. The nurse knows preoperative teaching for this client should include
- A. explaining that the client will be walking with a prosthesis soon after surgery.
- B. encouraging the client to share his feelings and fears about the surgery.
- C. taking the informed consent form to the client and asking him to sign it.
- D. evaluating how the client plans to maintain his schoolwork during hospitalization.
Correct Answer: B
Rationale: discussing his feelings and fears is important in dealing with his anxiety due to a change in body image and functioning
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The nurse is teaching a client with a new diagnosis of type 2 diabetes about insulin detemir (Levemir). Which of the following statements by the client indicates a need for further teaching?
- A. I should take this insulin at bedtime.
- B. I should rotate injection sites.
- C. I should refrigerate unopened vials.
- D. I should take this insulin when my blood sugar is high.
Correct Answer: D
Rationale: Taking insulin detemir when blood sugar is high is incorrect, as it is a long-acting basal insulin for steady control, not for acute hyperglycemia. Options A, B, and C are correct: bedtime dosing is standard, rotation prevents lipodystrophy, and refrigeration preserves insulin.
A 10-year-old for a cardiac catheterization.
Which of the following plans would be MOST appropriate for the nurse to use to prepare a 10-year-old for a cardiac catheterization?
- A. Show a videotape specifically prepared for children about cardiac catheterization.
- B. Provide the child with a pamphlet about the procedure and encourage him to read it.
- C. Draw a picture of a heart and explain where the tube will go and what the doctor will see.
- D. Present a puppet show explaining the anatomy and physiology of the heart.
Correct Answer: C
Rationale: Strategy: Think about the developmental stage of a 10-year-old. (1) video will provide correct information but is not best preparation for a school-age child (2) pamphlet will contain correct information but is not best preparation for a school-age child (3) correct-this plan will best prepare the child for the procedure (4) would be more appropriate for a younger child
An 85-year-old woman recovering from a fractured pelvis in a long-term care facility. The woman's activity order reads: ambulate with walker bid.
After the nurse implements the order, which of the following charting entries is BEST?
- A. Patient ambulated well with walker. States has no c/o stiffness or pain. Did not appear fatigued.'
- B. Ambulated without difficulty for 20 minutes. Vital signs remained stable. Color good.'
- C. Walked full length of hall with walker. No difficulty with balance. Using walker correctly.'
- D. Patient ambulated 60 feet independently with walker. Gait steady. Respirations 14 and unlabored.'
Correct Answer: D
Rationale: Strategy: All answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) gives subjective information (2) gives judgments without objective information (3) information is not complete, contains some judgments without objective information (4) correct-gives objective information
A client with a family history of Huntington's disease asks the nurse for information on how the disease is transmitted. Which of the following statements indicates that she understands the nurse's teaching?
- A. The chances of my passing the disease to my child are 1 in 2
- B. I have no chance of passing the disease to a male child, but a female child would carry the disease
- C. I have no chance of passing the disease to a female child, but a male child will have the disease
- D. The chances of my passing the disease to my child are 1 in 4
Correct Answer: A
Rationale: Huntington's disease is autosomal dominant, meaning there is a 50% (1 in 2) chance of passing the gene to each child, regardless of sex.
After admission for elective surgery, an adult says to the nurse, 'They asked me if I had advance directives. I don't even know what that is.' What is the best response by the nurse?
- A. Advance directives are usually written by persons who have a terminal illness. They are not indicated for elective surgery.
- B. An advance directive is a document that tells the medical and nursing staff what your wishes are regarding certain health care items should you not be able to make decisions for yourself.
- C. An advance directive includes information about you and your specific medical history that could be important to care givers if you are not alert.
- D. Advance directives direct your family about your plans for distributing your belongings when you are no longer here.
Correct Answer: B
Rationale: Advance directives specify healthcare preferences for incapacitation, relevant for any adult, clearly explaining their purpose.