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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 using the head-to-toe approach, ensuring a systematic and thorough assessment. This approach helps in identifying any abnormalities or potential issues before surgery. Confidence (A) is important but not specific to the method used. Perseverance (B) and integrity (C) are valuable traits but not directly related to the assessment approach. The nurse's systematic and methodical approach reflects discipline, making it the most appropriate choice.
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A nursing instructor is reviewing steps of the nursing process with students. Which of the following data are objective?
- A. Respiratory rate 22/min
- B. I can only walk 3 blocks before pain starts
- C. Pain level 3/10
- D. Skin pink warm
- E. Urine output 300mL/8hr
- F. Dressing clean dry intact
Correct Answer: A,D,E,F
Rationale: The correct answers are A, D, E, and F. Objective data are measurable and observable.
A: Respiratory rate 22/min is measurable.
D: Skin pink warm is observable.
E: Urine output 300mL/8hr is measurable.
F: Dressing clean dry intact is observable.
Choices B and C are subjective as they are based on the patient's perception and cannot be measured or observed directly. Choice G is incomplete.
Nurse providing pre-op teaching for client scheduled for mastectomy next day. Which client statement indicates client is ready to learn?
- A. I don't want my spouse to see my incision
- B. Will you be able to give me pain meds after surgery?
- C. Can you tell me about how long the surgery will take?
- D. My roommate listens to everything I say
Correct Answer: C
Rationale: The correct answer is C because the client is showing readiness to learn by asking a relevant question about the surgery process. This indicates an active interest in understanding what will happen during the procedure, which is crucial for preparing mentally and emotionally. Choice A is more focused on personal discomfort, not readiness to learn. Choice B is about pain management, not understanding the surgical process. Choice D is unrelated to the situation.
Home health nurse is discussing dangers of food poisoning with client. What information should the nurse include? (Select all that apply)
- A. Most food poisoning is caused by viruses
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are at risk should eat/drink only pasteurized dairy products
- D. Healthy people usually recover from illness in a few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Immunocompromised individuals are at higher risk for complications from food poisoning due to weakened immune systems.
C: Clients at risk should consume only pasteurized dairy products to reduce the risk of foodborne illnesses.
E: Handling raw and fresh food separately prevents cross-contamination, a common cause of food poisoning.
Incorrect options:
A: Most food poisoning is caused by bacteria, not viruses.
D: Healthy individuals typically recover from food poisoning in a few days, not weeks.
In summary, the correct answers focus on specific preventive measures and risks for vulnerable populations, while the incorrect options provide inaccurate information regarding the causes and outcomes of food poisoning.
A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal calculi
- C. Pressure ulcers
- D. Thrombus formation
Correct Answer: B
Rationale: The correct answer is B: Renal calculi. Hypercalcemia can lead to the formation of kidney stones (renal calculi) due to increased levels of calcium in the blood being excreted by the kidneys. The nurse should monitor for signs and symptoms of renal colic, such as severe flank pain, hematuria, and urinary urgency.
Incorrect choices:
A: Hypostatic pneumonia - Hypercalcemia does not directly lead to pneumonia.
C: Pressure ulcers - Hypercalcemia does not increase the risk of pressure ulcers.
D: Thrombus formation - While hypercalcemia can predispose to blood clot formation, it is not the most closely monitored condition in this scenario.
Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable with the nurse.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction during procedures.
E: Engaging the child in pretend play with a toy medical kit can help familiarize the child with medical procedures in a non-threatening way.
Summary:
B: Clustering invasive procedures may not directly address the child's fear and can still be overwhelming.
C: Assigning caregivers familiar to the child may help in general care but may not directly address the fear of painful procedures.
F, G: No additional answer choices provided.