Nokea
Nurse observes smoke coming from under door of staff lounge. Which is priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The priority action for the nurse in this scenario is to evacuate the clients (Choice C). This is because ensuring the safety of the clients is the most critical responsibility in a healthcare setting. Evacuating them immediately helps prevent harm and ensures their well-being. Pulling the fire alarm (Choice B) may be necessary but not the top priority as it does not directly ensure client safety. Extinguishing the fire (Choice A) may put the nurse at risk and delay client evacuation. Closing doors (Choice D) may contain the fire but does not address the immediate need of client safety.
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Nurse caring for 19 yo client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?
- A. Measure the vital signs
- B. Encourage HIV screening
- C. Determine client's risk factors
- D. Instruct client to use condoms
Correct Answer: C
Rationale: The correct answer is C: Determine client's risk factors. This intervention is essential to assess the client's current health status, identify potential health risks, and develop a personalized health promotion plan. By understanding the client's risk factors, the nurse can provide targeted education and interventions to prevent diseases and promote overall well-being.
A: Measuring vital signs is important but does not directly address health promotion and disease prevention specific to the client's sexual activity.
B: Encouraging HIV screening is important, but it focuses on a specific disease rather than a comprehensive assessment of risk factors.
D: Instructing the client to use condoms is important for safe sex practices but does not address broader health promotion and disease prevention strategies effectively.
Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities?
- A. "develop acceptance of diminished strength & increased dependence on others"
- B. feel frustrated that time is too short for trying to start another life
- C. welcome opportunities to be creative & productive
- D. commit to finding friendship & companionship
- E. become involved in community issues & activities
Correct Answer: C, E
Rationale: The correct answers are C and E. Middle adults are typically in the generativity vs. stagnation stage, where they seek to contribute to society and make a positive impact. Choice C, welcoming opportunities to be creative and productive, aligns with generativity. Additionally, becoming involved in community issues and activities (choice E) reflects their desire to engage with society. Choices A and B are incorrect as middle adults do not typically accept diminished strength and do not feel frustrated about time constraints for starting a new life. Choice D is incorrect as seeking friendship and companionship is more characteristic of young adulthood.
During evaluation, nurse must gather info about the client to...
- A. identify whether client outcomes have been met
- B. organize resources to proceed with implementing interventions
- C. establish client-centered, measurable & realistic outcomes
- D. determine priority of care & appropriate interventions
Correct Answer: A
Rationale: The correct answer is A because during evaluation, nurses must gather information about the client to identify whether client outcomes have been met. This step is crucial in determining the effectiveness of the care provided and if the client's needs have been addressed. Gathering this information helps in assessing the success of the interventions implemented.
Choice B is incorrect as organizing resources is part of the planning phase, not evaluation. Choice C is incorrect because establishing client-centered outcomes is part of the planning phase, not evaluation. Choice D is incorrect as determining priority of care and appropriate interventions is typically done during the assessment and planning phases, not evaluation.
Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include?
- A. "scoliosis is more common in girls than in boys"
- B. loss of height is often first sign of scoliosis
- C. scoliosis screening is essential during adolescent growth spurt
- D. slouching is common cause of scoliosis, esp. in adolescents
- E. scoliosis is forward curvature of spine
Correct Answer: A, C
Rationale: Correct Answer: A, C
Rationale:
A: "Scoliosis is more common in girls than in boys" - Correct. Scoliosis is indeed more prevalent in girls, especially during adolescence.
C: "Scoliosis screening is essential during adolescent growth spurt" - Correct. Screening during growth spurts is crucial for early detection and intervention.
Summary:
B: Loss of height as the first sign of scoliosis is incorrect, as it is not a common symptom.
D: Slouching is not a cause of scoliosis; it is a misconception.
E: Scoliosis is a sideways curvature of the spine, not a forward curvature.
When entering a client's room to change a dressing, the nurse notes the client is coughing & sneezing. When preparing a sterile field, it's important the nurse...
- A. Keep sterile field at least 6 ft away from client's bedside
- B. Instruct client to not cough/sneeze during dressing change
- C. Place mask on client to limit the spread of microorganisms into the surgical wound
- D. Keep box of Kleenex nearby for client to use during dressing change
Correct Answer: C
Rationale: The correct answer is C because placing a mask on the client helps limit the spread of microorganisms into the surgical wound. This is crucial to prevent infection. Choice A is incorrect because the distance does not necessarily prevent microorganism spread. Choice B is unrealistic as it's difficult for a client to control coughing/sneezing. Choice D does not address the prevention of microorganism spread.