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As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client with dementia. Which component is the priority to determine from their family?
- A. BMI
- B. Usual times for meals/snacks
- C. Favorite foods
- D. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Any difficulty swallowing. This is the priority component to determine because clients with dementia are at higher risk for dysphagia, which can lead to aspiration pneumonia and malnutrition. Identifying swallowing difficulties early can help prevent complications.
A: BMI is important but not the priority in this case.
B: Usual times for meals/snacks may be important but not as critical as identifying swallowing issues.
C: Favorite foods can provide insight into preferences but do not address immediate health risks.
In summary, identifying any difficulty swallowing is crucial for the safety and well-being of the client with dementia.
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Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. Because doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: Correct Answer: A,B,C,E
A: Helping the client see the benefits of their actions promotes motivation and adherence to health promotion strategies.
B: Identifying the client's support systems ensures they have a network to help maintain healthy behaviors and cope with stress.
C: Suggesting and recommending community resources expands the client's access to services that support cardiovascular health.
E: Teaching stress management strategies helps the client reduce risk factors associated with cardiovascular disease.
Incorrect Answer: D
Setting goals for the client without involving them in the process may not be effective in promoting long-term behavior change.
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 can physically perform the actions involved in drawing up and mixing insulin injections. Merely discussing the technique (choice A) or stating understanding (choice C) doesn't necessarily mean the client can apply the knowledge in practice. Writing steps on paper (choice D) assesses cognitive understanding, not physical skill. In summary, the ability to physically demonstrate the technique is a direct indicator of psychomotor learning, making choice B the best option.
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 caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable and less fearful in the healthcare setting.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction, helping to alleviate fear and anxiety during procedures.
E: Engaging the child in pretend play with a toy medical kit allows for familiarization with medical tools in a non-threatening way, helping to reduce fear and anxiety related to medical procedures.
Summary:
B: Clustering invasive procedures may minimize the number of times the child needs to undergo such procedures but does not directly address the fear.
C: Assigning caregivers familiar to the child is important for comfort but may not directly address the fear of painful procedures.