Nokea
The nurse has been teaching adult clients about cardiac risks when they visit the hypertension clinic. Which evaluation data would best measure learning?
- A. Performance on written tests
- B. Responses to verbal questions
- C. Completion of a mailed survey
- D. Reported behavioral changes
Correct Answer: D
Rationale: Reported behavioral changes. If the client alters behaviors such as smoking, drinking alcohol, and stress management, these suggest that learning has occurred. Additionally, physical assessments and lab data may confirm risk reduction.
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A client is admitted with a diagnosis of schizophrenia. The client refuses to take medication and states "I don't think I need those medications. They make me too sleepy and drowsy. I insist that you explain their use and side effects." The nurse should understand that
- A. a referral is needed to the psychiatrist who is to provide the client with answers
- B. the client has a right to know about the prescribed medications
- C. such education is an independent decision of the individual nurse whether or not to teach clients about their medications
- D. clients with schizophrenia are at a higher risk of psychosocial complications when they know about their medication side effects
Correct Answer: B
Rationale: The client has a right to know about the prescribed medications. Clients have a right to informed consent which includes information about medications, treatments, and diagnostic studies.
While the nurse is administering medications to a client, the client states 'I do not want to take that medicine today.' Which of the following responses by the nurse would be best?
- A. That's OK, its all right to skip your medication now and then.'
- B. I will have to call your doctor and report this.'
- C. Is there a reason why you don't want to take your medicine?'
- D. Do you understand the consequences of refusing your prescribed treatment?'
Correct Answer: C
Rationale: When a new problem is identified, it is important for the nurse to collect accurate assessment data. This is crucial to ensure that client needs are adequately identified in order to select the best nursing care approaches. The nurse should try to discover the reason for the refusal which may be that the client has developed untoward side effects.
The nurse is caring for clients in a hospital setting. Which observations made by the nurse require intervention? Select all that apply.
- A. The client's infusion pump is noted to have a cut in the center of the cord.
- B. The client's bed is in the high position after a nursing assistant left the room.
- C. The client's battery-operated CD player does not have an agency inspection tag.
- D. The client's bed exit alarm is beeping, and another nurse just left the room.
- E. The client's bedside table is placed in front of the chair where the client is sitting.
Correct Answer: A,B,D
Rationale: A: A cut cord poses an electrical shock risk. B: A high bed increases fall risk. D: A beeping bed exit alarm indicates a potential fall risk requiring immediate response.
The experienced nurse is instructing the new nurse on client safety. Which statement made by the new nurse should the experienced nurse correct?
- A. "It is very important for school-aged children to be taught_statistics related to sports."
- B. "The leading causes of death in young adults are due to substance abuse and suicide."
- C. "Older adults especially should be asked whether they have ever accidentally fallen at home."
- D. "Preschooler activity should be monitored because falls are a major cause of nonfatal injuries."
Correct Answer: B
Rationale: The leading cause of death in young adults is motor vehicle accidents, not substance abuse and suicide, which requires correction.
Which of the following microorganisms are considered normal body flora?
- A. staphylococcus on the skin
- B. streptococcus in the nares
- C. candida albicans in the vagina
- D. pseudomonas in the blood
Correct Answer: A
Rationale: Of the choices given, only staphylococcus is considered a normal resident of the body.