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Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. Because doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.
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Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Removing the crib gym is crucial as it can pose a choking hazard. Infants should sleep on a firm mattress to reduce the risk of suffocation, making option B incorrect. Option C is unsafe as soft pillows increase the risk of suffocation. Option D, while mentioning a safety gate, doesn't directly address infant safety.
As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client with dementia. Which component is the priority to determine from their family?
- A. BMI
- B. Usual times for meals/snacks
- C. Favorite foods
- D. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Any difficulty swallowing. This is the priority component to determine because clients with dementia are at higher risk for dysphagia, which can lead to aspiration pneumonia and malnutrition. Identifying swallowing difficulties early can help prevent complications.
A: BMI is important but not the priority in this case.
B: Usual times for meals/snacks may be important but not as critical as identifying swallowing issues.
C: Favorite foods can provide insight into preferences but do not address immediate health risks.
In summary, identifying any difficulty swallowing is crucial for the safety and well-being of the client with dementia.
Nurse planning diversionary activities for children on peds unit. Which should nurse incorporate as appropriate play activities for school-age children? (Select all that apply.)
- A. Building models
- B. Playing video games
- C. Reading books
- D. Using toy carpentry tools
- E. Shaping modeling clay
Correct Answer: A,B,C
Rationale: The correct answers are A, B, and C. Building models (A) can enhance creativity and fine motor skills. Playing video games (B) can provide entertainment and cognitive stimulation. Reading books (C) promotes literacy and imagination. Using toy carpentry tools (D) may pose safety risks. Shaping modeling clay (E) is more suitable for younger children. No other choices are as developmentally appropriate and beneficial for school-age children as building models, playing video games, and reading books.
Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client's question shows readiness to learn about the procedure, indicating an active interest in understanding the surgery process. This demonstrates the client's engagement and willingness to absorb information, which is crucial for pre-op teaching. Choices A, B, and D do not directly relate to seeking information about the surgery itself and do not demonstrate readiness for learning. Therefore, they are incorrect.
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.