Nokea
Developing a plan to achieve patient outcomes is included in which step of the CJMM?
- A. prioritizing hypotheses
- B. generating solutions
- C. taking action
- D. evaluating outcomes
Correct Answer: B
Rationale: The correct answer is B: generating solutions. In the CJMM (Clinical Judgment Model in Nursing), developing a plan to achieve patient outcomes falls under the step of generating solutions. This step involves identifying and implementing interventions to address the patient's needs and achieve the desired outcomes. Prioritizing hypotheses (A) is about identifying potential issues, not developing a plan. Taking action (C) is about implementing the plan, not developing it. Evaluating outcomes (D) is the final step where the effectiveness of the plan is assessed, not where the plan is developed. Therefore, B is the correct choice as it specifically focuses on the process of creating a plan to achieve patient outcomes within the CJMM.
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16wks gestation reports for a triple screen test. What statements determines understanding?
- A. "This test can be used as a screening for spina bifida."
- B. "This test is a screen test, and I will need other testing if I have abn results."
- C. "this test can indicate if I may be at an increased risk for having a child with down syndrome."
- D. A triple screen test is a screening tool. Maternal blood is drawn and alpha-fetoprotein, hcg, and estriol values are assessed to determine if the mother is at an increased risk for neural tube defects or chromosomal trisomy's. Spina bifida and downs syndrome are the two most common risks.
Correct Answer: D
Rationale: Step-by-step rationale for why answer D is correct:
1. A triple screen test includes assessing alpha-fetoprotein, hCG, and estriol levels.
2. These values help determine the risk for neural tube defects and chromosomal trisomies.
3. The test does not directly diagnose spina bifida but assesses neural tube defects.
4. Down syndrome risk is also evaluated, not diagnosed directly.
5. Answer D provides a comprehensive explanation of the test components and its purpose, aligning with the test's actual function.
Summary of why other choices are incorrect:
A. Incorrect because the test screens for neural tube defects and chromosomal trisomies, not just spina bifida.
B. Incorrect because the test is a screening tool for specific conditions, not a definitive diagnostic test.
C. Incorrect because the test assesses multiple conditions, not just Down syndrome specifically.
A client at 30 weeks' gestation is receiving magnesium sulfate for preterm labor. What assessment finding indicates magnesium toxicity?
- A. Deep tendon reflexes +3.
- B. Respiratory rate of 10 breaths per minute.
- C. Urine output of 40 mL/hour.
- D. Blood pressure of 120/80 mmHg.
Correct Answer: B
Rationale: The correct answer is B: Respiratory rate of 10 breaths per minute. Magnesium sulfate toxicity can lead to respiratory depression, resulting in a decreased respiratory rate. This is a critical sign of magnesium toxicity and should be addressed promptly.
Explanation for other choices:
A: Deep tendon reflexes +3 are actually a common finding in clients receiving magnesium sulfate due to its muscle relaxant effects.
C: Urine output of 40 mL/hour is within the normal range and does not indicate magnesium toxicity.
D: Blood pressure of 120/80 mmHg is also within the normal range and is not a sign of magnesium toxicity.
What statement by a health-care provider is an example of shared decision making between a health-care provider and a patient?
- A. I'm going to start this medication because it is best for your baby.
- B. Can you agree with me because I am your health-care provider?â€
- C. I understand how the hospital works, and it will be easier for you to just do what is easy for the nurses.â€
- D. Do you feel ready to make a decision after we talked about this medication?â€
Correct Answer: D
Rationale: The correct answer is D because it involves the patient in the decision-making process by asking for their readiness to make a decision after discussing the medication. This approach respects the patient's autonomy and encourages them to actively participate in their healthcare choices.
A is incorrect as it does not involve the patient in the decision-making process but rather imposes the provider's choice. B is incorrect as it uses authority to influence the patient's decision, which is not in line with shared decision making. C is incorrect as it focuses on convenience rather than involving the patient in the decision-making process.
The client delivered a 4200 g fetus. The physician performed a
midline episiotomy which extended into a 3rd degree laceration. The
client asks the nurse where she tore. Which response is best?
- A. Through your rectal sphincter
- B. Through your vaginal mucosa
- C. Through your cervix
- D. Through your bladder
Correct Answer: A
Rationale: The correct answer is A: Through your rectal sphincter. A 3rd degree laceration involves the perineal body and extends through the anal sphincter muscles. This type of laceration can occur with a midline episiotomy during childbirth. The rectal sphincter is a part of the anal canal and can be torn in severe cases. Choices B, C, and D are incorrect because a 3rd degree laceration does not involve the vaginal mucosa, cervix, or bladder. The tear is specifically related to the rectal area due to the extension of the episiotomy.
A preterm neonate develops physiologic jaundice and phototherapy is ordered. The nurse understands that this therapy:
- A. Activates the liver to dispose the bilirubin
- B. Breaks down the unconjugated bilirubin in the skin to conjugated form permitting excretion
- C. Activates Vit. K to facilitate excretion of the bilirubin
- D. Dissolves the bilirubin and allows it to be excreted from the skin
Correct Answer: B
Rationale: The correct answer is B because phototherapy works by breaking down unconjugated bilirubin in the skin to a water-soluble form, allowing it to be excreted from the body. This process does not activate the liver (choice A), nor does it activate Vitamin K (choice C) or dissolve the bilirubin for excretion from the skin (choice D). Phototherapy specifically targets the unconjugated bilirubin in the skin, converting it to a form that can be eliminated through the urine and stool.