Nokea
Based on principles of teaching and learning, what is the best initial approach to pre-op teaching for a client scheduled for coronary artery bypass?
- A. Touring the coronary intensive unit
- B. Mailing a video tape to the home
- C. Assessing the client's learning style
- D. Administering a written pre-test
Correct Answer: C
Rationale: Assessing the client's learning style. Tailoring teaching to the client's learning preferences enhances understanding.
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A client describing seeing snakes on the walls of his room in a psychiatric facility.
Based on this information, the nurse should identify a nursing diagnosis of
- A. sensory-perceptual alterations: visual.
- B. altered thought processes.
- C. ineffective individual coping.
- D. impaired social interaction.
Correct Answer: A
Rationale: Strategy: Think about each answer choice. (1) correct-reflects a pattern of impaired perception, which is supported by the data that client is having a hallucination, defined as a sensory perception for which no external stimuli exist (2) not relevant to the data (3) not relevant to the data (4) not relevant to the data
The nursing care plan for a toddler diagnosed with Kawasaki disease (mucocutaneous lymph node syndrome) should be based on the high risk for development of which problem?
- A. Chronic vessel plaque formation
- B. Pulmonary embolism
- C. Occlusions at the vessel bifurcations
- D. Coronary artery aneurysms
Correct Answer: D
Rationale: Coronary artery aneurysms. Kawasaki disease can lead to inflammation and aneurysms in coronary arteries.
The nurse is caring for a client with a history of HIV/AIDS.
- A. Which laboratory finding is most concerning for a client with HIV/AIDS?
- B. CD4 count of 150 cells/mm³.
- C. Viral load of 10,000 copies/mL.
- D. White blood cell count of 5,000/mm³.
- E. Hemoglobin of 12.0 g/dL.
Correct Answer: A
Rationale: A CD4 count of 150 cells/mm³ indicates severe immunosuppression in HIV/AIDS, increasing infection risk and requiring immediate intervention. High viral load is concerning but less urgent, and normal WBC and hemoglobin are unremarkable.
A 10-year-old child is admitted to the hospital with injuries. Which finding most suggests that additional assessment for child abuse is indicated?
- A. The child asks to have friends visit.
- B. The child asks to have a teacher bring in homework.
- C. The child's parents state that they need to spend some time with the child's siblings.
- D. The child's parents will not leave the child alone while in the hospital.
Correct Answer: D
Rationale: Constant parental presence may indicate control or fear of the child disclosing abuse, warranting further abuse assessment.
An alert adult who has terminal cancer says to the home care nurse, 'When the time comes for me to go, I don't want to be in pain and I don't want you to try to resuscitate me. Please promise me you won't.' How should the nurse respond?
- A. Of course, I will do as you wish.
- B. I am obligated to try and preserve life.
- C. Do you have advance directives? These need to be in your record.
- D. Be sure to tell each nurse your desires.
Correct Answer: C
Rationale: Asking about advance directives ensures the client's wishes are documented and legally binding, facilitating appropriate end-of-life care.