Nokea
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. "I already had my immunizations as a child
- B. so I'm protected in that area."
- C. It's important to schedule routine healthcare visits even if I'm feeling well.
- D. If I'm having any discomfort, I'll just go to an urgent care center.
- E. 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 because the statement demonstrates an understanding of the importance of immunizations in preventing diseases. By acknowledging that immunizations from childhood offer protection, the client shows awareness of the role of vaccines in health promotion. Choice A only mentions past immunizations but does not indicate understanding of their ongoing importance. Choices C and D do not directly address health promotion or illness prevention. Choice E focuses on stress management rather than health maintenance.
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Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. Affective domain involves attitudes, beliefs, and emotions. In this scenario, the mother's change in willingness to postpone toilet training indicates a shift in her emotions and attitudes towards the topic. The nurse's teaching likely influenced her feelings and perceptions, leading to a change in her decision-making process. The other choices are incorrect because: A) Cognitive domain focuses on knowledge and understanding, which is not directly reflected in the scenario. C) Psychomotor domain involves physical skills, such as toilet training itself, which are not the focus of the learning described. D) Kinesthetic domain relates to movement and physical sensations, which are not the primary factors influencing the mother's change in decision.
Nurse is caring for client receiving enteral tube feedings due to dysphagia. Which of following bed positions is appropriate for safe care of this client?
- A. Supine
- B. Semi-Fowler's
- C. Semi-prone
- D. Trendelenburg
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler's position. This position helps prevent aspiration during enteral tube feedings by aiding in proper digestion and reducing the risk of reflux. Semi-Fowler's position also helps facilitate optimal absorption of nutrients. Supine position (A) can increase the risk of aspiration. Semi-prone (C) and Trendelenburg (D) positions are not recommended for enteral feedings as they can lead to complications such as regurgitation and aspiration.
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 apt now
- B. but it's not easy living away from my parents."
- C. It's been so stressful for me to even think about having my own family.
- D. I don't even know who I am yet, & now I'm supposed to know what to do.
- E. 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: "It's been so stressful for me to even think about having my own family." This is the priority issue as it indicates the young adult is struggling with the idea of starting a family, which can have long-term implications. This concern may affect their mental health, relationships, and decision-making. Option A is about independence, B about transitioning from parents, D about self-identity, and E about impending fatherhood. While important, these issues are not as urgent as the stress related to starting a family.
Nurse is caring for client sitting in chair & asks to return to bed. Which is priority action for nurse to take at this time?
- A. Obtain walker for client to use to transfer back to bed
- B. Call for additional personnel to assist with transfer
- C. Use transfer belt & assist client to bed
- D. Assess client's ability to help with transfer
Correct Answer: D
Rationale: The correct answer is D: Assess client's ability to help with transfer. The priority action for the nurse is to evaluate the client's capability to assist with the transfer safely. This assessment is crucial to prevent any potential injury to the client during the transfer process. By determining the client's ability to help, the nurse can make an informed decision on the level of assistance required.
Choice A (Obtain walker), B (Call for additional personnel), and C (Use transfer belt) are all important interventions but assessing the client's ability to help is the priority as it informs the next steps in the transfer process. Without knowing the client's capacity to assist, the nurse cannot effectively determine the appropriate interventions needed.
Overall, assessing the client's ability to help with the transfer ensures the safety and well-being of the client during the transfer process.
Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss?
- A. "Do you eat alone or with someone?"
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A, C, D, E
Rationale: Correct Answer: A, C, D, E
Rationale:
A. "Do you eat alone or with someone?" - This question helps determine social eating habits and potential lack of appetite due to loneliness.
C. "Have you started any new meds in the past 6 months?" - This helps identify medication side effects that may cause weight loss.
D. "What foods have you eaten in the past 24 hours?" - This assesses dietary intake and nutritional status.
E. "Are you on a fixed income?" - Financial constraints can impact food choices and access to nutritious meals.
Summary:
B. "Do you watch TV while eating your meals?" - This does not directly address the potential reasons for weight loss in an older adult.
F. - No information given to evaluate this choice.
G. - No information given to evaluate this choice.