Nokea
A nurse is preparing to assess a patient for orthostatic hypotension. Which piece of equipment will the nurse obtain to assess for this condition?
- A. Thermometer
- B. Elastic stockings
- C. Blood pressure cuff
- D. Sequential compression devices
Correct Answer: C
Rationale: The correct answer is C: Blood pressure cuff. To assess for orthostatic hypotension, the nurse needs to measure the patient's blood pressure in different positions - lying down, sitting, and standing. This is done using a blood pressure cuff to monitor any significant drop in blood pressure upon changing positions. A thermometer (choice A) is used to measure temperature and is not relevant to assessing orthostatic hypotension. Elastic stockings (choice B) are used for compression therapy in conditions like venous insufficiency and do not help in assessing orthostatic hypotension. Sequential compression devices (choice D) are used for preventing deep vein thrombosis and improving circulation, not for assessing orthostatic hypotension.
You may also like to solve these questions
Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.)
- A. Building simple models
- B. Working with clay
- C. Filling & emptying containers
- D. Playing with blocks
- E. Looking at books
Correct Answer: C,D,E
Rationale: The correct activities for toddlers should focus on their developmental needs. Filling & emptying containers (C) helps with sensory exploration and fine motor skills. Playing with blocks (D) enhances problem-solving and hand-eye coordination. Looking at books (E) promotes language development and cognitive skills. Building simple models (A) and working with clay (B) may not be suitable for toddlers due to potential choking hazards and fine motor skill requirements.
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.
Nurse educator conducting parenting class for new parents. Which statement made by participant indicates need for further teaching?
- A. I will begin swimming lessons as soon as my baby can close her mouth under water
- B. Once my baby can sit up, he should be safe in the bathtub
- C. I will test the temperature of water before placing baby in bath
- D. Once my infant starts to push up, I will remove mobile from over the bed
Correct Answer: B
Rationale: The correct answer is B. It indicates a need for further teaching because simply being able to sit up does not ensure safety in the bathtub. Babies can easily slip or slide, leading to potential accidents. Testing water temperature (Choice C) and removing hazards (Choice D) show proper safety awareness. Beginning swimming lessons (Choice A) is not recommended for infants. Other choices are not provided, but they would likely focus on safety measures and parenting practices.
Nurse is reviewing nutrition guidelines with parents of 2 yo. Which parent statement should indicate to nurse that they understand feeding guidelines for this age group?
- A. I should keep feeding my son whole milk until he's 3 yo
- B. It's okay for me to give him a cup of apple juice with each meal
- C. I'll give my son about 2 tablespoons of each food at mealtimes
- D. My son loves popcorn, & I know it's better for him than sweets
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Giving a 2-year-old about 2 tablespoons of each food at mealtimes aligns with appropriate portion sizes for toddlers. This indicates an understanding of feeding guidelines for this age group, promoting balanced nutrition and preventing overfeeding.
Incorrect Answers:
A: Keeping a child on whole milk until 3 yo is not recommended due to the risk of excess fat intake.
B: Offering a cup of apple juice with each meal can lead to excessive sugar intake and may displace more nutritious foods.
D: Popcorn, while a better choice than sweets, may still pose a choking hazard for young children and may not provide balanced nutrition.
Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.