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Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Removing the crib gym is crucial as it can pose a choking hazard. Infants should sleep on a firm mattress to reduce the risk of suffocation, making option B incorrect. Option C is unsafe as soft pillows increase the risk of suffocation. Option D, while mentioning a safety gate, doesn't directly address infant safety.
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Nursing instructor reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in client record? (Select all that apply.)
- A. Cover errors with correction fluid, & write in correct info
- B. Put date & time on all entries
- C. Document objective data, leaving out opinions
- D. Use as many abbreviations as possible
- E. Wait until the end of shift to document
Correct Answer: B, C
Rationale: Correct Answer: B, C
Rationale:
B: Putting date & time on all entries is crucial for legal purposes to establish timeline of events.
C: Documenting objective data without opinions ensures accuracy and prevents subjective bias.
Summary:
A: Covering errors with correction fluid is not recommended as it can be seen as tampering with records.
D: Using excessive abbreviations can lead to misinterpretation and errors in documentation.
E: Waiting until the end of the shift to document can result in missing crucial information or delayed updates.
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.
Nurse in clinic caring for 21 yo client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The nurse should expect the provider to perform a testicular exam because the client is a 21-year-old male. Testicular cancer is most common in young men, with the highest incidence between ages 15-35. Since the client has not had a doctor visit since high school, it is important to screen for testicular cancer as part of routine health maintenance. This exam can help detect any abnormalities early on, leading to better outcomes. Blood glucose (choice B) screening is more relevant for diabetes, which typically affects older individuals. Fecal occult blood (choice C) screening is used for detecting colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (choice D) screening is for prostate cancer, which is more common in older men.
Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. confidence
- B. perseverance
- C. integrity
- D. discipline
Correct Answer: D
Rationale: The correct answer is D: discipline. The nurse demonstrated discipline by following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.
Nurse evaluating how well client learned the info presented in teaching about heart-healthy diet. Client states she understands what to do now. Which actions by nurse should assist evaluation of client's learning?
- A. Encourage client to ask questions
- B. Ask client to explain how to select or prepare meals
- C. Encourage client to fill out eval form
- D. Ask client if she has resources for further instruction on topic
Correct Answer: B
Rationale: The correct answer is B: Ask client to explain how to select or prepare meals. This action allows the nurse to assess the client's understanding by evaluating if the client can articulate the key concepts of a heart-healthy diet, demonstrating comprehension. It goes beyond a simple affirmation of understanding and requires the client to apply the knowledge. Encouraging questions (choice A) is important but may not provide a direct assessment of the client's grasp of the material. Choices C and D do not directly assess the client's understanding of the heart-healthy diet teachings.