Nokea
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.
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Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.)
- A. Open doors to client rooms
- B. Place blankets over clients who are confined to beds
- C. Move beds away from windows
- D. Draw shades & close drapes
- E. Relocate ambulatory clients in hallways back to rooms
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. B: Placing blankets over confined clients helps protect them from debris. C: Moving beds away from windows reduces the risk of injury from shattered glass. D: Drawing shades and closing drapes can prevent glass from shattering and flying into the room. A: Opening doors to client rooms can increase the risk of debris entering and injuring clients. E: Relocating ambulatory clients back to rooms can expose them to more danger in case of a tornado.
Nurse in clinic caring for 21 yo client who reports sore throat. Client tells nurse he hasn't seen a doctor since high school. Which health screening should nurse expect provider to perform for this client?
- A. Testicular exam
- B. Blood glucose
- C. Fecal occult blood
- D. Prostate-specific antigen
Correct Answer: A
Rationale: The correct answer is A: Testicular exam. The nurse should expect the provider to perform a testicular exam because the client is a 21-year-old male. Testicular cancer is most common in young men, with the highest incidence between ages 15-35. Since the client has not had a doctor visit since high school, it is important to screen for testicular cancer as part of routine health maintenance. This exam can help detect any abnormalities early on, leading to better outcomes. Blood glucose (choice B) screening is more relevant for diabetes, which typically affects older individuals. Fecal occult blood (choice C) screening is used for detecting colorectal cancer, typically recommended for individuals over 50. Prostate-specific antigen (choice D) screening is for prostate cancer, which is more common in older men.
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 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.
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. "becoming actively involved in providing guidance to next generation"
- B. adjusting to major changes in roles/relationships due to losses
- C. devoting great deal of time to establishing occupation
- D. finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because young adults typically focus on establishing their occupation during this stage of development, as per Erikson's theory of psychosocial development. This behavior reflects the stage of intimacy vs. isolation, where individuals strive to form strong relationships and establish a sense of identity through their work. Choice A is incorrect as it pertains more to the generativity vs. stagnation stage, which occurs in middle adulthood. Choice B is incorrect as it aligns with the crisis of integrity vs. despair in late adulthood. Choice D refers to the sandwich generation, which involves caring for both children and aging parents, a challenge typically faced in middle adulthood.