Nokea
When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place?
- A. Client able to discuss appropriate technique
- B. Client able to demonstrate appropriate technique
- C. Client states he understands
- D. Client is able to write steps on piece of paper
Correct Answer: B
Rationale: The correct answer is B because demonstrating the appropriate technique shows psychomotor learning has taken place. This means the client has acquired the physical skills needed to draw up and mix insulin injections. Discussing technique (A) only shows verbal understanding, not necessarily physical ability. Stating understanding (C) shows cognitive learning, not physical skill. Writing steps on paper (D) demonstrates knowledge but not practical application.
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Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Crib gyms can pose a suffocation risk for infants, so removing it shows understanding of safety.
2. Soft mattresses increase the risk of Sudden Infant Death Syndrome.
3. Fluffy pillows pose suffocation hazard; infants should sleep on a firm, flat surface.
4. Child-safety gates should not fold like accordions as they can trap fingers.
Summary:
B and C pose suffocation risks. D is incorrect as accordion-style gates can be hazardous. A demonstrates understanding of infant safety by removing the crib gym.
A nurse on a med-surg unit has received change-of-shift report & will care for 4 clients. Which of the following client's needs may the nurse assign to an AP?
- A. Feeding client admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching with client learning to walk using a quad cane
- C. Reapplying a condom catheter for a client with urinary incontinence
- D. Applying sterile dressing to a pressure ulcer
Correct Answer: C
Rationale: The correct answer is C: Reapplying a condom catheter for a client with urinary incontinence. This task involves non-invasive, routine care that can be safely delegated to an assistive personnel (AP). The nurse should ensure that the AP is trained and competent in performing this procedure.
Choice A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse due to the risk of complications.
Choice B: Reinforcing teaching with a client using a quad cane involves critical thinking, assessment of the client's understanding, and ensuring safety, which should be done by a licensed nurse.
Choice D: Applying a sterile dressing to a pressure ulcer requires sterile technique, assessment of wound status, and potential need for wound care interventions, which should be performed by a licensed nurse.
Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I'm struggling to accept my parents are aging & need so much help
- B. It's been so stressful for me to think about having intimate relationships
- C. I know I should volunteer my time for good cause, but maybe I'm just selfish
- D. I love my grandchildren, but my son expects me to relive my parenting days
Correct Answer: B
Rationale: The correct answer is B: It's been so stressful for me to think about having intimate relationships. This issue should be prioritized for more assessment and intervention because difficulties with intimate relationships can significantly impact one's mental and emotional well-being. It may indicate underlying issues such as fear of intimacy, past trauma, or self-esteem issues. Addressing these issues can help improve overall quality of life.
Choice A is not the priority as accepting aging parents is a common life transition and may not have an immediate negative impact on mental health. Choice C, feeling selfish for not volunteering, is important but may not be as urgent as addressing intimate relationship stress. Choice D, feeling pressured by son about grandparenting, is important but may not directly affect the individual's mental well-being.
Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information to identify the location or nature of the threat. By actively listening, the security officer can gather valuable details without alerting the caller. Choice A is incorrect because abruptly ending the call may prevent gathering important information. Choice B is incorrect as overhead paging may cause panic. Choice C is incorrect as asking questions can elicit useful details.
The nurse is caring for a patient in restraints. Which essential information will the nurse document in the patient's medical record to provide safe care? Select all that apply
- A. One family member has gone to lunch.
- B. Patient is placed in bilateral wrist restraints at 0815.
- C. Bilateral radial pulses present, 2+, hands warm to touch
- D. Straps with quick-release buckle attached to bed side rails
- E. Attempts to distract the patient with television are unsuccessful.
- F. Released from restraints, active range-of-motion exercises completed.
Correct Answer: B, C, E, F
Rationale: The correct answers are B, C, E, and F.
B: Documenting the time and type of restraints applied is essential for monitoring and ensuring proper care.
C: Assessing and documenting the patient's radial pulses and skin temperature in restraints is crucial to monitor circulation and skin integrity.
E: Documenting unsuccessful attempts to distract the patient with television helps identify alternative strategies for patient management.
F: Documenting the release from restraints and completion of range-of-motion exercises ensures proper follow-up care and monitoring.
Incorrect choices:
A: Not relevant to the patient's care in restraints.
D: Describes the equipment used but does not provide information on the patient's condition or care.