Nokea
Nurse is reviewing safety precautions with group of young adults at community health fair. Which recommendations should nurse include specifically for this age group? (Select all that apply.)
- A. Install bath rails & grab bars in bathrooms
- B. Wear helmet while skiing
- C. Install carbon monoxide detector
- D. Secure firearms in safe location
- E. Remove throw rugs from the home
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. Young adults are more likely to engage in risky activities like skiing, hence wearing a helmet (B) is crucial for head protection. Carbon monoxide exposure is a concern in any age group, so installing a detector (C) is important. Young adults may have access to firearms, making it vital to secure them in a safe location (D) to prevent accidents. Choices A and E are more relevant for older adults to prevent falls, while F and G are not provided in the question.
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Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. Confidence
- B. Perseverance
- C. Integrity
- D. Discipline
Correct Answer: D
Rationale: The correct answer is D: Discipline. The nurse demonstrated discipline by using the head-to-toe approach, ensuring a systematic and thorough assessment. This approach helps in identifying any abnormalities or potential issues before surgery. Confidence (A) is important but not specific to the method used. Perseverance (B) and integrity (C) are valuable traits but not directly related to the assessment approach. The nurse's systematic and methodical approach reflects discipline, making it the most appropriate choice.
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 of the heart-healthy diet by evaluating their ability to articulate the key concepts and apply them practically. By explaining the process of selecting or preparing meals, the client demonstrates comprehension and application of the information provided during the teaching session. Encouraging questions (choice A) is important but may not directly assess the client's ability to implement the information. Encouraging the client to fill out an evaluation form (choice C) focuses more on feedback rather than assessing learning. Asking about additional resources (choice D) is relevant but doesn't directly assess the client's understanding of the heart-healthy diet.
A nurse is caring for a client 24h post-op following abdominal surgery and suspects inadequate pain management. Which findings support this suspicion?
- A. Client seems easily agitated
- B. Client is nonadherent with coughing and deep breathing
- C. Client accepts pain medication every 6-7h instead of 4-6h
- D. Client reports tenderness in right lower leg
- E. Client's vital signs: HR 110/min
Correct Answer: B,C,E
Rationale: The correct answer is B, C, and E. Choice B indicates nonadherence with coughing and deep breathing, which is essential for preventing postoperative complications such as pneumonia. Choice C suggests the client is not taking pain medication as frequently as prescribed, indicating inadequate pain relief. Choice E shows an elevated heart rate, which can be a sign of uncontrolled pain. Choices A and D do not directly relate to inadequate pain management post-op. A client being agitated (choice A) can have various causes, and tenderness in the right lower leg (choice D) is not specific to poor pain management.
Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules, he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him because he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A. The nurse should identify the child's inability to keep up with other kids in physical activities as the priority for more assessment and intervention. This is because physical activity is crucial for a child's overall development and well-being. The inability to participate in activities like running and jumping could indicate underlying physical health issues, developmental delays, or coordination problems that need to be addressed promptly to prevent further complications. Choices B, C, and D are not as critical as they focus on behavioral or academic concerns which may be important but do not pose an immediate risk to the child's health and well-being.
Nurse is reviewing nutrition guidelines with parents of 2 yo. Which parent statement should indicate to nurse that they understand feeding guidelines for this age group?
- A. I should keep feeding my son whole milk until he's 3 yo
- B. It's okay for me to give him a cup of apple juice with each meal
- C. I'll give my son about 2 tablespoons of each food at mealtimes
- D. My son loves popcorn, & I know it's better for him than sweets
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Giving a 2-year-old about 2 tablespoons of each food at mealtimes aligns with appropriate portion sizes for toddlers. This indicates an understanding of feeding guidelines for this age group, promoting balanced nutrition and preventing overfeeding.
Incorrect Answers:
A: Keeping a child on whole milk until 3 yo is not recommended due to the risk of excess fat intake.
B: Offering a cup of apple juice with each meal can lead to excessive sugar intake and may displace more nutritious foods.
D: Popcorn, while a better choice than sweets, may still pose a choking hazard for young children and may not provide balanced nutrition.