Nokea
A nurse is contributing to the plan of care for a client who practices the Muslim faith. Which of the following actions should the nurse include in the plan?
- A. Serve foods that have a hot/cold balance.
- B. Serve milk products prior to meals
- C. Request a meal tray without pork.
- D. Remove tea and coffee from meal trays.
Correct Answer: C
Rationale: Muslim dietary laws prohibit pork, so meals should be planned accordingly.
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A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?
- A. Ask the client to perform a return demonstration of insulin injection.
- B. Review the action of insulin therapy.
- C. Explore the client's feelings about dietary modifications.
- D. Have a family member practice blood glucose monitoring using a glucometer.
Correct Answer: C
Rationale: The correct answer is C because exploring the client's feelings about dietary modifications focuses on the affective domain of learning, which involves emotions, attitudes, and values. By understanding the client's feelings, the nurse can address any concerns, fears, or resistance the client may have towards changing their diet. This approach helps to create a supportive and empathetic environment for the client to embrace necessary dietary changes.
Regarding the incorrect choices:
A: Asking the client to perform a return demonstration of insulin injection focuses on psychomotor skills, not affective learning.
B: Reviewing the action of insulin therapy focuses on cognitive learning, not affective learning.
D: Having a family member practice blood glucose monitoring is not directly related to addressing the client's emotional response to dietary modifications.
A nurse observes an adolescent client who has paraplegia sitting in a wheelchair crying. The client says, “Go away! No one can help me.†Which of the following responses should the nurse make?
- A. Everything will be ok.
- B. I will come back later and we can talk.
- C. Why are you crying?
- D. Do you think crying will help?
Correct Answer: B
Rationale: The correct answer is B: "I will come back later and we can talk." This response shows empathy, respect for the client's autonomy, and a willingness to provide support without being intrusive. By offering to come back later, the nurse acknowledges the client's feelings and demonstrates a willingness to engage in a supportive conversation when the client is ready.
Choice A is incorrect because it dismisses the client's feelings without offering meaningful support. Choice C may come off as confrontational and put the client on the defensive. Choice D is dismissive and lacks empathy, potentially making the client feel unsupported. Overall, choice B is the best response as it respects the client's feelings and allows for a supportive conversation at a later time.
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Bell's palsy is characterized by muscle distortion due to facial nerve paralysis, leading to asymmetry in facial expressions (A). Pain behind the ear may occur due to inflammation or compression of the facial nerve (B). Impaired taste can result from altered function of the chorda tympani nerve, affecting taste sensation on the anterior two-thirds of the tongue (E). Choices C, D, F, G are incorrect as hearing loss is not a typical feature of Bell's palsy (C), facial twitching is more characteristic of conditions like hemifacial spasm (D), and there are no specific findings associated with F and G in Bell's palsy.
A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
- A. Pain
- B. Hearing loss
- C. The client's culture
- D. Motor impairment
Correct Answer: A
Rationale: The correct answer is A. Pain can significantly impact a client's ability to concentrate and retain information during a teaching session. Pain can cause distress, affecting the client's focus and ability to engage in the learning process. Therefore, addressing pain as a priority before proceeding with discharge teaching is essential.
Hearing loss (B) can be accommodated with visual aids or written materials. Cultural considerations (C) can be integrated into the teaching plan. Motor impairment (D) can also be managed by providing alternative methods for learning. Other choices are not as critical as pain in hindering the learning process.
A nurse is measuring the vital signs of a client he suspects has hypovolemic shock. Which of the following findings should the nurse expect?
- A. High BP and low pulse rate
- B. Low BP and low pulse rate
- C. High BP and high pulse rate
- D. Low BP and high pulse rate
Correct Answer: D
Rationale: Hypovolemic shock leads to decreased blood pressure due to fluid loss and compensatory tachycardia.