Nokea
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. At age 2, children often exhibit behaviors to assert their independence. By saying 'no' and resisting help with dressing, the toddler is showing a desire to do things on her own and asserting her autonomy. This behavior aligns with the typical developmental stage of toddlers seeking independence and autonomy. Choices B, C, and D are incorrect because they do not align with the typical behaviors and developmental milestones of a 2-year-old. Choice B (Developing sense of trust) is more characteristic of infancy, choice C (Manifesting anger management problem) is not appropriate for a toddler's behavior in this context, and choice D (Attempting to finish a project she started) does not reflect the developmental stage of a 2-year-old.
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Nurse on med-surg unit is informed that mass casualty event occurred & it's necessary to discharge clients to make beds available for injury victims. Which clients can be safely discharged? (Select all that apply.)
- A. Client who's dehydrated & receiving IV fluid/electrolytes
- B. Client with NG tube to treat small bowel obstruction
- C. Client who's scheduled for TURP (prostate resection)
- D. Client who is 24h post-op after mastectomy
- E. Client scheduled for appendectomy
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
1. Client scheduled for TURP (prostate resection): This client can be safely discharged as the procedure is elective and not urgent.
2. Client who is 24h post-op after mastectomy: This client is stable post-operation and can be discharged with appropriate follow-up care.
Summary of other choices:
A: Client who's dehydrated & receiving IV fluid/electrolytes - This client needs continued treatment and monitoring.
B: Client with NG tube to treat small bowel obstruction - This client requires ongoing treatment and observation.
E: Client scheduled for appendectomy - This client needs urgent surgical intervention and cannot be safely discharged.
Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. Affective domain involves attitudes, beliefs, and emotions. In this scenario, the mother's change in willingness to postpone toilet training indicates a shift in her emotions and attitudes towards the topic. The nurse's teaching likely influenced her feelings and perceptions, leading to a change in her decision-making process. The other choices are incorrect because: A) Cognitive domain focuses on knowledge and understanding, which is not directly reflected in the scenario. C) Psychomotor domain involves physical skills, such as toilet training itself, which are not the focus of the learning described. D) Kinesthetic domain relates to movement and physical sensations, which are not the primary factors influencing the mother's change in decision.
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. "I already had my immunizations as a child
- B. so I'm protected in that area."
- C. It's important to schedule routine healthcare visits even if I'm feeling well.
- D. If I'm having any discomfort, I'll just go to an urgent care center.
- E. If I'm feeling stressed, I will remind myself that this is something I should expect.
Correct Answer: B
Rationale: The correct answer is B because the statement demonstrates an understanding of the importance of immunizations in preventing diseases. By acknowledging that immunizations from childhood offer protection, the client shows awareness of the role of vaccines in health promotion. Choice A only mentions past immunizations but does not indicate understanding of their ongoing importance. Choices C and D do not directly address health promotion or illness prevention. Choice E focuses on stress management rather than health maintenance.
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.
Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.)
- A. Assembling puzzles
- B. Pulling wheeled toys
- C. Using musical toys
- D. Using finger paints
- E. Coloring with crayons
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. Preschoolers have developing fine motor skills and benefit from activities that promote hand-eye coordination and creativity. Assembling puzzles (A) helps with problem-solving and fine motor skills. Using musical toys (C) encourages creativity and sensory development. Coloring with crayons (E) promotes fine motor skills and creativity. Pulling wheeled toys (B) may not be appropriate for inpatient setting and finger paints (D) can be messy and require close supervision.