Nokea
Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.)
- A. Open doors to client rooms
- B. Place blankets over clients who are confined to beds
- C. Move beds away from windows
- D. Draw shades & close drapes
- E. Relocate ambulatory clients in hallways back to rooms
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. B: Placing blankets over confined clients helps protect them from debris. C: Moving beds away from windows reduces the risk of injury from shattered glass. D: Drawing shades and closing drapes can prevent glass from shattering and flying into the room. A: Opening doors to client rooms can increase the risk of debris entering and injuring clients. E: Relocating ambulatory clients back to rooms can expose them to more danger in case of a tornado.
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Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.)
- A. Building simple models
- B. Working with clay
- C. Filling & emptying containers
- D. Playing with blocks
- E. Looking at books
Correct Answer: C,D,E
Rationale: The correct activities for a toddler include filling & emptying containers (C) to promote sensory exploration, playing with blocks (D) for fine motor skills and spatial awareness, and looking at books (E) to encourage language development and cognitive skills. Building simple models (A) may be too complex for toddlers. Working with clay (B) can pose a choking hazard. The other options are not developmentally appropriate for toddlers.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. "I have my own apt now
- B. but it's not easy living away from my parents."
- C. It's been so stressful for me to even think about having my own family.
- D. I don't even know who I am yet, & now I'm supposed to know what to do.
- E. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.
Correct Answer: C
Rationale: The correct answer is C: "It's been so stressful for me to even think about having my own family." This is the priority issue as it indicates the young adult is struggling with the idea of starting a family, which can have long-term implications. This concern may affect their mental health, relationships, and decision-making. Option A is about independence, B about transitioning from parents, D about self-identity, and E about impending fatherhood. While important, these issues are not as urgent as the stress related to starting a family.
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.
By 2nd post-op day, a client has not achieved satisfactory pain relief. Based on this evaluation, what should nurse do next according to nursing process?
- A. Reassess client to determine reasons for unsatisfactory pain relief
- B. See whether pain lessens during next 24h
- C. Change plan to ensure client achieves adequate pain relief
- D. Teach client about plan of care for managing his pain
Correct Answer: A
Rationale: The correct answer is A. In the nursing process, the first step in addressing a client's unsatisfactory pain relief is to reassess the client to determine the reasons for it. This involves evaluating the pain intensity, location, characteristics, aggravating factors, and the client's response to current pain management interventions. By reassessing, the nurse can identify any underlying causes contributing to the lack of pain relief and adjust the plan of care accordingly.
Choice B is incorrect because waiting another 24 hours without further assessment delays appropriate intervention. Choice C is incorrect as changing the plan without reassessment may not address the root cause of the issue. Choice D is incorrect as teaching the client about the plan of care should come after reassessment to ensure it is tailored to the client's specific needs.
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.