Nokea
Nurse caring for client who has new prescription. Prior to admin, nurse uses electronic database to gather info about med & effects it might have on this client. Which following component of critical thinking is nurse using when he reviews med info?
- A. knowledge
- B. experience
- C. intuition
- D. competence
Correct Answer: A
Rationale: The correct answer is A: knowledge. By reviewing medication information in an electronic database, the nurse is utilizing knowledge as a component of critical thinking. Knowledge involves the understanding of facts, evidence, and information relevant to the situation at hand, which in this case is understanding the medication and its potential effects on the client. This process allows the nurse to make informed decisions based on evidence and data.
Summary of incorrect choices:
B: Experience alone may not provide the detailed information about the medication's effects on the client.
C: Intuition is based on gut feelings rather than factual information from the database.
D: Competence is the ability to perform a task effectively, but it does not specifically address the gathering of information from a database for decision-making in this scenario.
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Nursing instructor is reviewing steps of nursing process with group of students. Students should identify which of following data as objective? (Select all that apply.)
- A. Respiratory rate of 22/min with even, unlabored respirations
- B. I can only walk 3 blocks before my legs start to hurt'
- C. Pain level 3/10
- D. Skin pink, warm, dry
- E. Urine output 300 mL/8 hr
- F. Dressing clean, dry, intact
Correct Answer: A, D, E, F
Rationale: Objective data refers to measurable and observable information.
A: Respiratory rate and breathing pattern can be directly observed and counted, making it objective data.
D: Skin color, temperature, and moisture can be seen and felt, making it objective data.
E: Urine output is quantifiable and measurable, making it objective data.
F: The cleanliness, dryness, and integrity of a dressing can be visually assessed, making it objective data.
The other choices involve subjective experiences or interpretations (B), self-reported pain level (C), or may require additional assessments beyond direct observation (G).
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. At age 2, children often exhibit behaviors to assert their independence. By saying 'no' and resisting help with dressing, the toddler is showing a desire to do things on her own and asserting her autonomy. This behavior aligns with the typical developmental stage of toddlers seeking independence and autonomy. Choices B, C, and D are incorrect because they do not align with the typical behaviors and developmental milestones of a 2-year-old. Choice B (Developing sense of trust) is more characteristic of infancy, choice C (Manifesting anger management problem) is not appropriate for a toddler's behavior in this context, and choice D (Attempting to finish a project she started) does not reflect the developmental stage of a 2-year-old.
Nurse is completing discharge teaching to client with COPD. Client verbalizes understanding of orthopneic position when he states, 'When I have difficulty breathing at night, I will...'
- A. Lie on my back with head & shoulders elevated on a pillow
- B. Lie flat on my stomach with head to one side
- C. Sit on side of my bed & rest my arms over pillows on top of my raised bedside table
- D. Lie on my side with my weight on my hips & shoulder with my arms flexed in front of me
Correct Answer: C
Rationale: The correct answer is C: Sit on side of my bed & rest my arms over pillows on top of my raised bedside table. Orthopneic position is sitting upright with arms supported, which helps improve lung expansion and ease breathing. Choice A is incorrect as lying on the back can worsen breathing difficulties. Choice B is incorrect as lying flat on the stomach hinders breathing. Choice D is incorrect as lying on the side does not provide the same lung expansion as sitting upright.
Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I'm struggling to accept my parents are aging & need so much help"
- B. It's been so stressful for me to think about having intimate relationships
- C. I know I should volunteer my time for good cause, but maybe I'm just selfish
- D. I love my grandchildren, but my son expects me to relive my parenting days
Correct Answer: B
Rationale: The correct answer is B. The nurse should prioritize assessing and intervening in the middle adult's difficulty with intimate relationships because it can significantly impact their emotional well-being and ability to form healthy connections. Intimate relationships play a crucial role in one's overall quality of life and can affect various aspects of mental health. By addressing this issue first, the nurse can help the individual work through their stress and potentially improve their relationships and overall psychological health.
Choices A, C, and D are not as critical as choice B because they involve different aspects of the individual's life that may not have an immediate impact on their emotional well-being and relationships. While accepting aging parents or volunteering are important, they do not directly address the middle adult's current emotional distress. Similarly, the expectation from the son regarding grandparenting, while challenging, may not be as urgent as addressing the stress related to intimate relationships.
Nurse transferring a client from an acute-care hospital to a rehab facility. Which of the following info about the client should the nurse include in the transfer report? (Select all that apply.)
- A. Alert & oriented
- B. Refuses to eat spinach
- C. Has shellfish allergy
- D. Requests morphine every 4h
- E. Misses the 2 cats he has at home
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Including that the client is alert and oriented is crucial for providing a comprehensive overview of the client's mental status and ability to participate in the rehabilitation program.
C: Informing about the shellfish allergy is essential for ensuring the client's safety and preventing any potential allergic reactions during their stay at the rehab facility.
D: Noting the client's request for morphine every 4 hours is important for ensuring that their pain management needs are properly addressed during their transition to the rehab facility.
B, E: Refusing to eat spinach and missing cats at home are not relevant pieces of information that directly impact the client's care during their transfer to the rehab facility.