Nokea
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: Correct Answer: A,B,C,E
A: Helping the client see the benefits of their actions promotes motivation and adherence to health promotion strategies.
B: Identifying the client's support systems ensures they have a network to help maintain healthy behaviors and cope with stress.
C: Suggesting and recommending community resources expands the client's access to services that support cardiovascular health.
E: Teaching stress management strategies helps the client reduce risk factors associated with cardiovascular disease.
Incorrect Answer: D
Setting goals for the client without involving them in the process may not be effective in promoting long-term behavior change.
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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 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.
Nurse performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.
During evaluation, nurse must gather info about the client to...
- A. identify whether client outcomes have been met
- B. organize resources to proceed with implementing interventions
- C. establish client-centered, measurable & realistic outcomes
- D. determine priority of care & appropriate interventions
Correct Answer: A
Rationale: The correct answer is A because during evaluation, nurses must gather information about the client to identify whether client outcomes have been met. This step is crucial in determining the effectiveness of the care provided and if the client's needs have been addressed. Gathering this information helps in assessing the success of the interventions implemented.
Choice B is incorrect as organizing resources is part of the planning phase, not evaluation. Choice C is incorrect because establishing client-centered outcomes is part of the planning phase, not evaluation. Choice D is incorrect as determining priority of care and appropriate interventions is typically done during the assessment and planning phases, not evaluation.
Charge nurse is designating room assignments for clients. Based on her knowledge of fall prevention, which should be assigned to room closest to nursing station?
- A. 43 yo client post-op following laparoscopic cholecystectomy
- B. 61 yo client being admitted for telemetry to rule out MI
- C. 50 yo client post-op following open reduction internal fixation of ankle
- D. 79 yo client post-op following below-the-knee amputation
Correct Answer: D
Rationale: The correct answer is D. The 79 yo client post-op following below-the-knee amputation should be assigned to a room closest to the nursing station for fall prevention. This client may have mobility challenges, increased risk of falls due to recent surgery, and may require closer monitoring and immediate assistance if needed. Placing the client near the nursing station allows for quick response to any fall risk or postoperative complications.
A: The 43 yo client post-op following laparoscopic cholecystectomy is not at high risk for falls compared to the amputee.
B: The 61 yo client being admitted for telemetry to rule out MI does not necessarily have a higher fall risk than the amputee.
C: The 50 yo client post-op following open reduction internal fixation of ankle may have mobility limitations but is not as high risk for falls as the amputee.