Nokea
Nurse is preparing a discharge summary for a client who had knee surgery and is going home. Which of the following info about the client should the nurse include in it? (Select all that apply.)
- A. Advance directives status
- B. Where to go for follow-up care
- C. Instructions for diet/meds
- D. Most recent vital sign data
- E. Contact info for home healthcare agency
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Providing information on where to go for follow-up care ensures the client continues to receive proper medical attention post-surgery.
C: Instructions for diet/meds are crucial for the client's recovery and to prevent complications.
E: Providing contact info for a home healthcare agency ensures the client has access to additional support and care at home.
Incorrect answers:
A: Advance directives status is important but not directly related to immediate post-operative care.
D: Most recent vital sign data is important for monitoring but does not need to be included in a discharge summary.
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Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I spent my whole life dreaming about retirement
- B. & now I wish I had my job back"
- C. It's been so stressful for me to have to depend on my son to help around the house
- D. I just heard my friend Al died. That's the 3rd one in 3 months.
- E. I'm struggling with helping out in my community. I just don't know what I can do.
Correct Answer: D
Rationale: The correct answer is D. The nurse should prioritize assessing and intervening in the older adult's grief over losing friends. This is crucial as multiple recent losses can lead to increased risk of depression and isolation. It is essential to address feelings of loss and provide support. Choice A focuses on retirement dreams, which may not be as urgent. Choice B indicates job-related regret. Choice C mentions stress from dependence on son. These issues are important but do not pose immediate risks to mental health and well-being compared to dealing with multiple recent deaths. Choices E, F, and G do not provide relevant information to prioritize over grief from recent losses.
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 at elementary school is planning health promotion & primary prevention class. Which topics are appropriate for parents of school-age children?
- A. "childhood obesity"
- B. substance use disorders
- C. scoliosis screening
- D. front-seat seatbelt use
- E. stranger awareness
Correct Answer: A, B, C, E
Rationale: The correct topics for parents of school-age children are A, B, C, and E. A- Childhood obesity is relevant for promoting healthy habits. B- Substance use disorders prevention can educate parents on risks. C- Scoliosis screening is important for early detection. E- Stranger awareness is crucial for child safety. Choices D and any other options not selected are inappropriate as they do not directly relate to health promotion and primary prevention for school-age children.
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. The nurse should prioritize assessing and intervening in the middle adult's difficulty with intimate relationships because it can significantly impact their emotional well-being and ability to form healthy connections. Intimate relationships play a crucial role in one's overall quality of life and can affect various aspects of mental health. By addressing this issue first, the nurse can help the individual work through their stress and potentially improve their relationships and overall psychological health.
Choices A, C, and D are not as critical as choice B because they involve different aspects of the individual's life that may not have an immediate impact on their emotional well-being and relationships. While accepting aging parents or volunteering are important, they do not directly address the middle adult's current emotional distress. Similarly, the expectation from the son regarding grandparenting, while challenging, may not be as urgent as addressing the stress related to intimate relationships.
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.