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Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when a new nurse states that a client who has heat stroke will have which of the following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. Heat stroke leads to severe dehydration and vasodilation, causing a drop in blood pressure (hypotension). Bradycardia (B), clammy skin (C), and bradypnea (D) are not characteristic of heat stroke. Bradycardia is a slow heart rate, while heat stroke typically causes tachycardia. Clammy skin is more indicative of shock or hypoglycemia, not heat stroke. Bradypnea is slow breathing, but heat stroke usually leads to rapid, shallow breathing. Therefore, hypotension is the most appropriate choice as it aligns with the physiological response to heat stroke.
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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: It's been so stressful for me to think about having intimate relationships. This issue should be prioritized for more assessment and intervention because difficulties with intimate relationships can significantly impact one's mental and emotional well-being. It may indicate underlying issues such as fear of intimacy, past trauma, or self-esteem issues. Addressing these issues can help improve overall quality of life.
Choice A is not the priority as accepting aging parents is a common life transition and may not have an immediate negative impact on mental health. Choice C, feeling selfish for not volunteering, is important but may not be as urgent as addressing intimate relationship stress. Choice D, feeling pressured by son about grandparenting, is important but may not directly affect the individual's mental well-being.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer from PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from PACU after thoracic surgery. RNs have the education and training to assess the client's condition, monitor vital signs, manage postoperative pain, and recognize any complications that may arise. They can also provide the necessary interventions and communicate effectively with the healthcare team. Assigning this client to an RN ensures safe and competent care.
Choice A (Charge nurse) may have administrative duties and may not be available to provide direct care. Choice C (LPN) may not have the scope of practice or training to manage postoperative care for a client following thoracic surgery. Choice D (AP) does not have the qualifications to assess and manage a client with complex postoperative needs.
The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? Select all that apply
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Close all doors - By closing doors, the nurse can prevent the spread of smoke and fire, protecting patients.
B: Note evacuation routes - Knowing evacuation routes ensures a safe and efficient evacuation if needed.
C: Note oxygen shut-offs - Turning off oxygen can reduce the risk of fire spreading and explosions.
D: Move bedridden patients in their bed - Moving bedridden patients quickly and safely is crucial for their well-being during an emergency.
Summary:
E: Waiting for the fire department is not proactive and can waste valuable time in ensuring patient safety.
F: Using type B fire extinguishers for electrical fires is incorrect as type C extinguishers are recommended for electrical fires.
G: There is no information provided for this option.
A nursing instructor is reviewing steps of the nursing process with students. Which of the following data are objective?
- A. Respiratory rate 22/min
- B. I can only walk 3 blocks before pain starts
- C. Pain level 3/10
- D. Skin pink warm
- E. Urine output 300mL/8hr
- F. Dressing clean dry intact
Correct Answer: A,D,E,F
Rationale: The correct answers are A, D, E, and F. Objective data are measurable and observable.
A: Respiratory rate 22/min is measurable.
D: Skin pink warm is observable.
E: Urine output 300mL/8hr is measurable.
F: Dressing clean dry intact is observable.
Choices B and C are subjective as they are based on the patient's perception and cannot be measured or observed directly. Choice G is incomplete.
Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. Affective domain involves emotions, attitudes, and feelings. In this scenario, the mother's change in willingness to postpone toilet training shows a shift in her emotional response and attitude towards the situation. This indicates a change in the affective domain, as the mother's feelings and attitudes have been influenced by the nurse's teaching.
Choices A, C, and D are incorrect:
A: Cognitive domain involves knowledge, understanding, and thinking skills. While there may be some cognitive processing involved in the mother's decision-making, the primary change observed is in her emotions and attitudes.
C: Psychomotor domain relates to physical skills and movements, which are not the focus of the scenario.
D: Kinesthetic refers to the sense of body position and movement, which is not relevant to the mother's change in willingness to postpone toilet training.