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A Client is about to undergo an elective surgical procedure. Which of the following actions are appropriate for the nurse providing pre-op care regarding informed consent? (Select all that apply.)
- A. Make sure the surgeon obtained the client's consent
- B. Witness client's signature on consent form
- C. Explain the risks/benefits of procedure
- D. Describe consequences of choosing not to have surgery
- E. Tell client about alternatives to having surgery
Correct Answer: A, B
Rationale: Correct Answer: A, B
Rationale:
A: Making sure the surgeon obtained the client's consent is crucial to ensure that the client has been properly informed about the procedure and has willingly agreed to it.
B: Witnessing the client's signature on the consent form is important to confirm that the client understood the information provided and voluntarily agreed to the procedure.
Summary:
C: Explaining the risks/benefits of the procedure is important, but this is typically the responsibility of the healthcare provider, not the nurse providing pre-op care.
D: Describing consequences of choosing not to have surgery is important, but it is the healthcare provider's role, not the nurse's, to discuss this with the client.
E: Informing the client about alternatives to surgery is important, but the primary responsibility lies with the healthcare provider, not the nurse providing pre-op care.
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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 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 because determining what the client already knows about stress incontinence is essential for tailoring the instructional session effectively. By assessing the client's existing knowledge, the nurse can avoid repeating information that the client already understands and focus on areas where the client needs more education. This approach ensures that the session is individualized and meets the client's specific needs. Encouraging active participation (choice A) and setting goals (choice C) can come after assessing the client's knowledge. Selecting appropriate materials (choice B) is important but should be based on the client's knowledge level.
Nurse collecting history & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions?
- A. "metabolism"
- B. ability to hear low-pitched sounds
- C. gastric secretion
- D. far vision
- E. glomerular filtration
Correct Answer: A, C, E
Rationale: The correct answer is A, C, and E. Middle adulthood is typically associated with a decline in certain physiological functions. Metabolism tends to slow down, leading to weight gain. Gastric secretion decreases, affecting digestion. Glomerular filtration rate decreases, impacting kidney function. Choices B, D, and F are not typically affected by aging in middle adulthood. Ability to hear low-pitched sounds and far vision usually remain stable during this stage.
Nurse providing discharge instructions to client with prescription for oxygen use in home. Which should nurse teach about using oxygen safely in his home? (Select all that apply.)
- A. Family members who smoke must be at least 10 ft from client when his oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish contains flammable substances, which can pose a fire hazard near oxygen. Teaching the client to avoid using nail polish near oxygen is essential for safety.
C: Placing a 'No Smoking' sign on the front door serves as a clear reminder to visitors and family members about the importance of not smoking near the client using oxygen.
E: Having a fire extinguisher readily available in the home is crucial in case of a fire emergency, especially when oxygen is being used, as oxygen can accelerate combustion.
Incorrect Choices:
A: While it is important for family members who smoke to stay away from the client when oxygen is on, the 10 ft rule is arbitrary and not evidence-based.
D: There is no significant safety benefit in replacing cotton bedding/clothing with items made from wool regarding oxygen use in the home.
Summary: Teaching about avoiding flammable substances like nail polish, displaying a 'No Smoking' sign,
Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.)
- A. Building models
- B. Playing video games
- C. Reading books
- D. Using toy carpentry tools
- E. Shaping modeling clay
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. Building models (A) can enhance creativity and fine motor skills. Playing video games (B) can provide entertainment and cognitive stimulation. Reading books (C) promotes literacy and imagination. Using toy carpentry tools (D) may pose safety risks. Shaping modeling clay (E) is more suitable for younger children. No other choices are as developmentally appropriate and beneficial for school-age children as building models, playing video games, and reading books.