Nokea
Nurse is caring for client sitting in chair & asks to return to bed. Which is priority action for nurse to take at this time?
- A. Obtain walker for client to use to transfer back to bed
- B. Call for additional personnel to assist with transfer
- C. Use transfer belt & assist client to bed
- D. Assess client's ability to help with transfer
Correct Answer: D
Rationale: The correct answer is D: Assess client's ability to help with transfer. The priority action for the nurse is to evaluate the client's capability to assist with the transfer safely. This assessment is crucial to prevent any potential injury to the client during the transfer process. By determining the client's ability to help, the nurse can make an informed decision on the level of assistance required.
Choice A (Obtain walker), B (Call for additional personnel), and C (Use transfer belt) are all important interventions but assessing the client's ability to help is the priority as it informs the next steps in the transfer process. Without knowing the client's capacity to assist, the nurse cannot effectively determine the appropriate interventions needed.
Overall, assessing the client's ability to help with the transfer ensures the safety and well-being of the client during the transfer process.
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Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include?
- A. "scoliosis is more common in girls than in boys"
- B. loss of height is often first sign of scoliosis
- C. scoliosis screening is essential during adolescent growth spurt
- D. slouching is common cause of scoliosis, esp. in adolescents
- E. scoliosis is forward curvature of spine
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: "Scoliosis is more common in girls than in boys" - Correct. Scoliosis is indeed more prevalent in girls, especially during adolescence.
C: "Scoliosis screening is essential during adolescent growth spurt" - Correct. Screening during growth spurts is crucial for early detection and intervention.
Summary:
B: Loss of height as the first sign of scoliosis is incorrect, as it is not a common symptom.
D: Slouching is not a cause of scoliosis; it is a misconception.
E: Scoliosis is a sideways curvature of the spine, not a forward curvature.
Nurse on peds unit is caring for adolescent with multiple fractures. Which interventions are appropriate for client?
- A. "suggest his parents room in with him"
- B. provide a TV & DVDs for him to watch
- C. limit visitors to immediate family
- D. devise a regular schedule for inpatient routines
- E. allow him to perform his own morning care
Correct Answer: B, E
Rationale: Correct Answer: B, E
Rationale:
B: Providing entertainment like TV and DVDs can help distract the adolescent from pain and boredom during recovery.
E: Allowing the adolescent to perform his own morning care promotes independence and self-esteem, aiding in his emotional well-being.
Summary:
A: Suggesting parents room in may not always be feasible or preferred by the adolescent.
C: Limiting visitors to immediate family can be isolating and may not address the adolescent's social needs.
D: While having a regular schedule is important, it may not address the adolescent's individual preferences and needs.
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 attitudes, beliefs, and emotions. In this scenario, the mother's change in willingness to postpone toilet training indicates a shift in her emotions and attitudes towards the topic. The nurse's teaching likely influenced her feelings and perceptions, leading to a change in her decision-making process. The other choices are incorrect because: A) Cognitive domain focuses on knowledge and understanding, which is not directly reflected in the scenario. C) Psychomotor domain involves physical skills, such as toilet training itself, which are not the focus of the learning described. D) Kinesthetic domain relates to movement and physical sensations, which are not the primary factors influencing the mother's change in decision.
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.
Nurse is receiving provider prescription by phone for morphine for client who is reporting moderate to severe pain. Which of the following actions are appropriate? (Select all that apply.)
- A. Repeat details of prescription back to provider
- B. Have another nurse listen to phone prescription
- C. Obtain prescriber’s signature on prescription within 24 hours
- D. Decline verbal prescription b/c it is not emergency situation
- E. Tell charge nurse that the provider has prescribed morphine by phone
Correct Answer: A, B, C
Rationale: Correct Answer: A, B, C
Rationale:
A: Repeating details back ensures accurate transcription and comprehension.
B: Having another nurse listen ensures a second verification of the prescription.
C: Obtaining the prescriber's signature within 24 hours ensures legal compliance and accountability.
Incorrect Choices:
D: Declining the prescription could delay pain relief for the client.
E: Informing the charge nurse alone does not ensure proper documentation and accountability.