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The healthcare professional is using the Glasgow Coma Scale to perform a neurologic assessment. A comatose client winces and pulls away from a painful stimulus. What action should the healthcare professional take next?
- A. Document that the client responds to a painful stimulus.
- B. Observe the client's response to verbal stimulation.
- C. Place the client on seizure precautions for 24 hours.
- D. Report decorticate posturing to the healthcare provider.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The client is being taught about the use of syringes and needles for home administration of medications. Which action by the client indicates an understanding of standard precautions?
- A. Remove needle before discarding used syringes
- B. Wear gloves to dispose of the needle and syringe
- C. Don a face mask before administering the medication
- D. Wash hands before handling the needle and syringe
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A policy requiring the removal of acrylic nails by all nursing personnel was implemented 6 months ago. Which assessment measure best determines if the intended outcome of the policy is being achieved?
- A. Number of staff-induced injuries
- B. Client satisfaction survey
- C. Healthcare-associated infection rate
- D. Rate of needle-stick injuries by nurses
Correct Answer: C
Rationale: The correct answer is C - Healthcare-associated infection rate. Acrylic nails can harbor bacteria, increasing the risk of healthcare-associated infections. By implementing a policy to remove acrylic nails, the goal is to reduce the infection rate. Monitoring the healthcare-associated infection rate will provide a direct measure of the policy's effectiveness in achieving its intended outcome. This measure is more specific and directly related to the objective of reducing the risk of infections compared to the other choices.
A client in the early stages of Alzheimer's disease is very anxious and frequently asks about her deceased parents. Which intervention should the nurse implement to reduce the client's anxiety?
- A. Remind the client that her parents have passed away
- B. Ask the client about her favorite memories with her parents
- C. Engage the client in an activity to distract her from thinking about her parents
- D. Reorient the client to the present reality and surroundings
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is attempting to pass an indwelling catheter in an adult male and is having difficulty. What is the most appropriate action for the nurse?
- A. Remove the catheter and reinsert it with the client positioned differently.
- B. Try a straight catheter instead.
- C. Try a smaller catheter.
- D. Discontinue the procedure and notify the physician.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What is the most effective way to implement a teaching plan?
- A. Teach the information that the learner wants to learn first.
- B. Streamline the teaching plan to include only essential information.
- C. Present to the learner all the necessary information to meet the objectives.
- D. Provide the learner with written material to review before teaching sessions.
Correct Answer: A
Rationale: The most effective way to implement a teaching plan is to teach the information that the learner wants to learn first. Teaching should be learner-centered, responding to the individual's needs and preferences. Learning is most successful when it addresses the specific interests and goals of the learner, as it increases motivation and engagement. By starting with what the learner is interested in, you can create a more effective and engaging learning experience.