Nokea
A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?
- A. The client is able to discuss the appropriate technique.
- B. The client is able to demonstrate the appropriate technique.
- C. The client states an understanding of the process.
- D. The client is able to write the steps on a piece of paper.
Correct Answer: B
Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.
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A client has had their diet prescription changed to a mechanical soft diet. Which of the following food items should the nurse remove from the client's breakfast tray?
- A. smoothie
- B. sliced banana
- C. pancakes
- D. sunny side up (fried) eggs
Correct Answer: D
Rationale: The correct answer is 'D: sunny side up (fried) eggs.' Fried eggs should be removed as they are not suitable for a mechanical soft diet due to their texture. The yolk of a fried egg is usually too hard and can be difficult for a client on a mechanical soft diet to chew and swallow. Poached or scrambled eggs are better alternatives for this diet as they are softer and easier to consume. Choices A, B, and C are all suitable for a mechanical soft diet as they are softer in texture and easier to chew and swallow.
What intervention should be taken to minimize the risk for injury in a client with dementia?
- A. Use a bed exit alarm system.
- B. Place the client in restraints for safety.
- C. Ensure the client has frequent visitors to reduce isolation.
- D. Keep the client's room dark and quiet at night.
Correct Answer: A
Rationale: The correct intervention to minimize the risk for injury in a client with dementia is to use a bed exit alarm system. Bed exit alarms are effective tools to alert healthcare providers when a client attempts to get out of bed, helping prevent falls and injuries. Placing the client in restraints (Choice B) is not the preferred method as it can lead to physical and psychological harm, restrict mobility, and increase agitation. While social interaction is important for clients with dementia, ensuring frequent visitors (Choice C) is not directly related to preventing physical injuries. Keeping the client's room dark and quiet at night (Choice D) may be soothing for some clients but does not directly address the risk for injury associated with dementia.
The nurse manager has been using a decentralized block scheduling plan to staff the nursing unit. However, staff have asked for many changes and exceptions to the schedule over the past few months. The manager considers self-scheduling knowing that this method will
- A. Improve the quality of care
- B. Decrease staff turnover
- C. Minimize the amount of overtime payouts
- D. Improve team morale
Correct Answer: D
Rationale: The correct answer is D: 'Improve team morale.' Self-scheduling allows staff more control over their work hours, which can lead to increased job satisfaction, autonomy, and a sense of ownership over their schedules. This, in turn, fosters a positive work environment, enhances collaboration among team members, and boosts morale. Choices A, B, and C are incorrect because while self-scheduling may indirectly contribute to improved quality of care, decreased staff turnover, and minimized overtime payouts, the primary benefit in this context is the positive impact on team morale.
Three days following surgery, a male client observes his colostomy for the first time. He becomes quite upset and tells the LPN that it is much bigger than he expected. What is the best response by the nurse?
- A. Reassure the client that he will become accustomed to the stoma's appearance in time.
- B. Instruct the client that the stoma will become smaller when the initial swelling diminishes.
- C. Offer to contact a member of the local ostomy support group to help him with his concerns.
- D. Encourage the client to handle the stoma equipment to gain confidence with the procedure.
Correct Answer: B
Rationale: The correct response is to instruct the client that the stoma will become smaller when the initial swelling diminishes. This explanation helps reassure the client about the temporary appearance of the stoma. Choice A is incorrect because simply reassuring the client that he will become accustomed to the stoma's appearance does not address the immediate concern about the stoma size. Choice C is incorrect because offering to contact a support group does not directly address the client's current distress about the stoma size. Choice D is incorrect because encouraging the client to handle stoma equipment does not directly address the client's concern about the stoma size and may not be appropriate at this time.
The nurse is discharging an adult woman who was hospitalized for 6 days for treatment of pneumonia. While the nurse is reviewing the prescribed medications, the client appears anxious. What action is most important for the nurse to implement?
- A. Instruct the client to repeat the medication plan
- B. Encourage the client to take a PRN antianxiety drug
- C. Provide written instructions that are easy to follow
- D. Include a family member in the teaching session
Correct Answer: D
Rationale: Including a family member in the teaching session is the most important action for the nurse to implement in this scenario. By involving a family member, the nurse can ensure that there is additional support and reinforcement of the medication plan. This can help the client and family better understand and adhere to the prescribed medications, reducing the client's anxiety. Instructing the client to repeat the medication plan (Choice A) may not address the client's anxiety effectively. Encouraging the client to take a PRN antianxiety drug (Choice B) should not be the first intervention without exploring other supportive measures. Providing written instructions (Choice C) alone may not offer the immediate support and reassurance needed for the anxious client.