Nokea
Nurse preparing instructional session about managing stress incontinence for older adult. Which actions should nurse take first when meeting with client?
- A. Encourage client to participate actively in learning
- B. Select instructional materials appropriate for older adult
- C. Identify goals nurse & client can agree are reasonable
- D. Determine what client knows about stress incontinence
Correct Answer: D
Rationale: The correct answer is D: Determine what client knows about stress incontinence. This is the first step because it helps the nurse assess the client's baseline knowledge, tailor the information to their level of understanding, and avoid providing redundant information. Understanding the client's knowledge also helps to establish a starting point for education and to address any misconceptions. This approach promotes client-centered care and enhances the effectiveness of the educational session.
Choice A (Encourage client to participate actively in learning) is important but should come after assessing the client's knowledge. Choice B (Select instructional materials appropriate for older adult) is essential but should be based on the client's knowledge level. Choice C (Identify goals nurse & client can agree are reasonable) is important but should come after assessing the client's knowledge to set appropriate goals.
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Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client? (Select all that apply.)
- 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: The correct choices are B and E. Providing a TV & DVDs and allowing the adolescent to perform his own morning care are appropriate interventions for the client's care. Offering entertainment can help with psychological well-being. Allowing independence in self-care promotes autonomy and self-esteem. Choice A may not be appropriate for an adolescent seeking independence. Choice C may restrict emotional support from close friends. Choice D is important but not the most crucial in this scenario.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. This is because at the age of 2, children often exhibit behaviors such as saying 'no' and resisting help as they start to assert their independence and autonomy. This behavior is a normal part of their development as they strive to explore their own abilities and assert control over their environment. Choices B, C, and D are incorrect because at this age, the child is not yet focused on developing a sense of trust, managing anger, or finishing projects. It is important to recognize and support the child's need for independence while providing guidance and setting appropriate boundaries.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.)
- A. Do you eat alone or with someone?
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A,C,D,E
Rationale: The correct answers are A, C, D, and E.
A: Asking if the person eats alone or with someone helps to assess social factors influencing eating habits, such as loneliness or lack of social interaction affecting appetite.
C: Inquiring about new medications can reveal potential side effects like appetite changes, nausea, or malabsorption leading to weight loss.
D: Knowing the foods consumed in the past 24 hours helps identify dietary patterns that may contribute to weight loss, such as poor nutrition or reduced intake.
E: Asking about a fixed income can uncover financial constraints affecting food choices and access to nutritious meals, potentially leading to weight loss.
Summary:
B: Watching TV while eating is not directly related to weight loss causes.
F and G: Not provided in the question, so no basis to consider them as relevant questions for investigating weight loss.