Nokea
A nursing instructor is reviewing documentation with students. Which of the following legal guidelines should they follow when documenting in a client record?
- A. Cover errors with correction fluid and write in correct info
- B. Put date & time on all entries
- C. Document objective data
- D. leaving out opinions
- E. Use as many abbreviations as possible
Correct Answer: B,C
Rationale: The correct answers are B and C. Putting date and time on all entries ensures accuracy and accountability. Documenting objective data maintains professionalism and avoids subjective bias. Choice A is incorrect as it can be considered tampering with records. Choice D is incorrect as opinions should be avoided for objectivity. Choice E is incorrect as excessive abbreviations can lead to misinterpretation.
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Nurse educator is reviewing with newly hired nurse the difference in clinical manifestations of localized vs. systemic infection. Nurse indicates understanding when she states that which are manifestations of systemic?
- A. Fever
- B. Malaise
- C. Edema
- D. Pain/tenderness
- E. Increase in pulse & respiratory rate
Correct Answer: A,B,E
Rationale: The correct answer is A, B, and E. Systemic infection manifests with fever, malaise, and an increase in pulse and respiratory rate. Fever is the body's response to infection, malaise is a general feeling of discomfort, and increased pulse and respiratory rate indicate the body's effort to fight infection. Edema and pain/tenderness are more indicative of localized infection rather than systemic. In summary, the correct manifestations of systemic infection are fever, malaise, and an increase in pulse and respiratory rate, while edema and pain/tenderness are more likely to be seen in localized infections.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. This is because at the age of 2, children often exhibit behaviors such as saying 'no' and resisting help as they start to assert their independence and autonomy. This behavior is a normal part of their development as they strive to explore their own abilities and assert control over their environment. Choices B, C, and D are incorrect because at this age, the child is not yet focused on developing a sense of trust, managing anger, or finishing projects. It is important to recognize and support the child's need for independence while providing guidance and setting appropriate boundaries.
Nurse is planning diversionary activities for children on inpatient peds unit. Which should nurse incorporate as appropriate play activities for preschoolers? (Select all that apply.)
- A. Assembling puzzles
- B. Pulling wheeled toys
- C. Using musical toys
- D. Using finger paints
- E. Coloring with crayons
Correct Answer: A,C,E
Rationale: The correct activities for preschoolers are A, C, and E. A: Assembling puzzles promotes problem-solving and fine motor skills. C: Using musical toys enhances auditory skills and creativity. E: Coloring with crayons supports fine motor skills and creativity. B: Pulling wheeled toys may not be safe or developmentally appropriate. D: Using finger paints can be messy and may not be suitable for all children, especially those with sensory sensitivities.
Nurse is caring for client with many risk factors for CV disease. When planning health promotion & disease prevention strategies for this client, which intervention should nurse include? (Select all that apply.)
- A. Help client see benefits of her actions
- B. Identify client's support systems
- C. Suggest & recommend community resources
- D. Devise & set goals for client
- E. Teach stress management strategies
Correct Answer: A,B,C,E
Rationale: The correct interventions for the nurse to include are A, B, C, and E. A is correct because helping the client see the benefits of their actions can motivate them to engage in health promotion activities. B is important to identify the client's support systems to provide a strong network for the client. C is crucial to suggest and recommend community resources that can further support the client in maintaining cardiovascular health. E is necessary to teach stress management strategies as stress can impact cardiovascular health. Choices D, F, and G are incorrect because setting goals for the client without their input may not be effective, and leaving options blank does not contribute to the client's care plan.
Nurse is teaching young adult about health promotion & illness prevention. Which client statement indicates understanding?
- A. I already had my immunizations as a child, so I'm protected in that area.
- B. It's important to schedule routine healthcare visits even if I'm feeling well
- C. If I'm having any discomfort, I'll just go to an urgent care center
- D. 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: It's important to schedule routine healthcare visits even if I'm feeling well. This statement indicates understanding of health promotion and illness prevention as it emphasizes the importance of preventive care and early detection of potential health issues. By attending routine healthcare visits, the individual can monitor their health status, receive necessary screenings, and address any underlying health concerns before they escalate.
Choice A is incorrect because having immunizations as a child does not provide lifelong protection against all diseases. Choice C is incorrect as urgent care centers are typically for urgent medical needs, not routine preventive care. Choice D is incorrect as stress management is important, but it does not directly relate to health promotion and illness prevention.