Nurse is preparing discharge summary for client whose had kn...

Nurse is preparing discharge summary for client whose had knee surgery & is going home. Which following info about client should nurse include in it?

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
F. Follow-up care
G. medication

Correct Answer: B,C,E

Rationale: The correct answer includes where to go for follow-up care, instructions for diet/meds, and contact info for home healthcare agency. Follow-up care ensures continuity of care post-surgery. Instructions for diet/meds are crucial for recovery. Contact info for home healthcare agency facilitates additional support at home. Advance directives status is important but not directly related to post-surgery care. Most recent vital sign data is essential for monitoring during hospitalization, not for discharge summary. Just mentioning follow-up care or medication without specific details is not as comprehensive as providing detailed instructions and contact information.

Nurse educator is reviewing with newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. Nurse indicates understanding when she states that which are manifestations of systemic?

A. Fever
B. Malaise
C. Edema
D. Pain/tenderness
E. Increase in pulse & respiratory rate

Correct Answer: A,B,E

Rationale: The correct answer is A, B, and E. Systemic infection manifests with fever, malaise, and an increase in pulse and respiratory rate. Fever is the body's response to infection, malaise is a general feeling of discomfort, and increased pulse and respiratory rate indicate the body's effort to fight infection. Edema and pain/tenderness are more indicative of localized infection rather than systemic. In summary, the correct manifestations of systemic infection are fever, malaise, and an increase in pulse and respiratory rate, while edema and pain/tenderness are more likely to be seen in localized infections.

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 apartment now, but it's not easy living away from my parents
B. It's been so stressful for me to even think about having my own family
C. I don't even know who I am yet, & now I'm supposed to know what to do
D. 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 because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.

Nurse is caring for client with SARS. Nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate rationale for reporting?

A. Planning & evaluating control & prevention strategies
B. Determining public health priorities
C. Ensuring proper medical treatment
D. Identifying endemic disease
E. Monitoring for common-source outbreaks

Correct Answer: A,B,C,E

Rationale: The correct answer is A, B, C, and E. Reporting communicable diseases like SARS is essential for planning and evaluating control and prevention strategies. It helps determine public health priorities by identifying areas of concern. Reporting ensures proper medical treatment for affected individuals and helps in monitoring for common-source outbreaks to prevent further spread. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases. Identifying endemic diseases may be a part of reporting, but it is not the primary reason.

Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?

A. I already had my immunizations as a child, so I'm protected in that area.
B. It's important to schedule routine healthcare visits even if I'm feeling well
C. If I'm having any discomfort, I'll just go to an urgent care center
D. If I'm feeling stressed, I will remind myself that this is something I should expect

Correct Answer: B

Rationale: The correct answer is B: It's important to schedule routine healthcare visits even if I'm feeling well. This statement indicates understanding of health promotion and illness prevention as it emphasizes the importance of preventive care and early detection of potential health issues. By attending routine healthcare visits, the individual can monitor their health status, receive necessary screenings, and address any underlying health concerns before they escalate.

Choice A is incorrect because having immunizations as a child does not provide lifelong protection against all diseases. Choice C is incorrect as urgent care centers are typically for urgent medical needs, not routine preventive care. Choice D is incorrect as stress management is important, but it does not directly relate to health promotion and illness prevention.

By the 2nd post-op day

A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
B. Reassess client to determine reasons for pain
C. See whether pain lessens during next 24h
D. Change plan to ensure adequate pain relief
E. Teach client about pain management plan

Correct Answer: A

Rationale: Correct Answer: A

Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.