Nokea
Nurse transferring a client from an acute-care hospital to a rehab facility. Which of the following info about the client should the nurse include in the transfer report? (Select all that apply.)
- A. Alert & oriented
- B. Refuses to eat spinach
- C. Has shellfish allergy
- D. Requests morphine every 4h
- E. Misses the 2 cats he has at home
Correct Answer: A,C,D
Rationale: The correct answers are A, C, and D.
A: Including that the client is alert and oriented is crucial for providing a comprehensive overview of the client's mental status and ability to participate in the rehabilitation program.
C: Informing about the shellfish allergy is essential for ensuring the client's safety and preventing any potential allergic reactions during their stay at the rehab facility.
D: Noting the client's request for morphine every 4 hours is important for ensuring that their pain management needs are properly addressed during their transition to the rehab facility.
B, E: Refusing to eat spinach and missing cats at home are not relevant pieces of information that directly impact the client's care during their transfer to the rehab facility.
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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 following a systematic head-to-toe approach in conducting the physical assessment. This method ensures that no area is missed and all aspects of the client's health are thoroughly evaluated. Confidence (A) is important but not specific to the approach used. Perseverance (B) and integrity (C) are important traits but do not directly relate to the method of assessment. By demonstrating discipline, the nurse shows a commitment to thoroughness and professionalism in preparing the client for surgery.
Nurse planning diversionary activities for children on an inpatient unit. Which should nurse incorporate as appropriate play activities for toddler? (Select all that apply.)
- A. Building simple models
- B. Working with clay
- C. Filling & emptying containers
- D. Playing with blocks
- E. Looking at books
Correct Answer: C,D,E
Rationale: The correct activities for a toddler include filling & emptying containers (C) to promote sensory exploration, playing with blocks (D) for fine motor skills and spatial awareness, and looking at books (E) to encourage language development and cognitive skills. Building simple models (A) may be too complex for toddlers. Working with clay (B) can pose a choking hazard. The other options are not developmentally appropriate for toddlers.
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.
Nurse enters a client's room & finds him sitting in his chair. He states, 'I fell in the shower, but I got myself back up & into my chair.' How should nurse document this in client's chart?
- A. Client fell in shower
- B. Client states he fell in shower & was able to get himself back into chair
- C. Nurse shouldn't document this info in chart b/c she didn't witness the fall
- D. Client fell in shower but is now resting comfortably
Correct Answer: B
Rationale: The correct answer is B. The nurse should document the client's statement accurately without assuming the fall occurred. This option reflects the client's own account of the situation and acknowledges his ability to self-recover. Choice A assumes the fall without confirmation. Choice C is incorrect as it is important to document client reports for continuity of care. Choice D adds unnecessary information not provided by the client.
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.