Nokea
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statements by nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: The correct answer is B because leaving the client during a seizure to go to the nurses' station for assistance is unsafe. The nurse should stay with the client to ensure safety. A: Placing the client on their side helps prevent aspiration. C: Administering prescribed meds is appropriate. D: Being prepared to insert an airway is essential in case of respiratory compromise.
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Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline?
- A. Establish consistent boundaries
- B. Place him in room with door closed
- C. Have him learn by trial & error
- D. Use favorite snacks as rewards
Correct Answer: A
Rationale: The correct answer is A: Establish consistent boundaries. This is important in toddler discipline as it provides structure and teaches the child what behaviors are acceptable. Consistency helps in setting clear expectations and enforcing consequences. Option B is incorrect as isolation can lead to feelings of abandonment. Option C is incorrect as trial and error may not provide clear guidance for the child. Option D is incorrect as using food rewards may lead to unhealthy eating habits.
Nurse tells client that she will call surgeon & ask about his request. Surgeon hears nurse's report & prescribes full liquid diet. Nurse used which of following levels of critical thinking?
- A. basic
- B. commitment
- C. complex
- D. integrity
Correct Answer: A
Rationale: The correct answer is A: basic. In this scenario, the nurse is simply relaying information and following a routine procedure by contacting the surgeon for a prescription. This level of critical thinking involves basic understanding and application of knowledge without deeper analysis or evaluation. The other choices are incorrect because: B: commitment involves making decisions and taking responsibility; C: complex involves analyzing and evaluating information; D: integrity involves ethical decision-making. In this case, the nurse's action aligns with basic thinking as she is following a standard protocol without engaging in higher-level critical thinking processes.
Nurse educator presenting on basic first aid for new home health nurses. She evaluates teaching as effective when new nurse states client who has heat stroke will have which of following?
- A. Hypotension
- B. Bradycardia
- C. Clammy skin
- D. Bradypnea
Correct Answer: A
Rationale: The correct answer is A: Hypotension. In heat stroke, the body's temperature regulation fails, leading to vasodilation and dehydration. This results in decreased blood pressure (hypotension) as the body struggles to cool down. Choices B (Bradycardia), C (Clammy skin), and D (Bradypnea) are not typical signs of heat stroke. Bradycardia is a slower heart rate, which is usually not seen in heat stroke as the body tries to cool itself. Clammy skin may be present in heat exhaustion but not necessarily in heat stroke. Bradypnea, or slow breathing, is not a common symptom of heat stroke, which is more associated with rapid breathing due to the body's attempt to cool down.
Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?
- A. "client evaluates his behavior after social interaction"
- B. client states he is learning to trust others
- C. client wishes to find meaningful relationships
- D. client expresses concerns about next generation
Correct Answer: D
Rationale: The correct answer is D because expressing concerns about the next generation aligns with Erikson's task of generativity vs. stagnation during middle adulthood. This stage involves contributing to the well-being of future generations. Choice A focuses on self-reflection, not generativity. Choice B refers to Erikson's trust vs. mistrust stage in infancy. Choice C relates to forming intimate relationships in young adulthood. This highlights the importance of understanding Erikson's psychosocial stages to identify appropriate behaviors.
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.