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The nurse is teaching the parents of a child who has head lice (pediculosis capitis). Which information will the nurse include in the teaching session?
- A. Treatment involves using regular shampoo.
- B. Products containing lindane are not recommended.
- C. Head lice may spread to furniture and other people.
- D. Manual removal is essential in treatment.
Correct Answer: C
Rationale: The correct answer is C. Head lice are highly contagious and can spread to furniture and other people if not treated promptly. Informing the parents about the potential spread of head lice emphasizes the importance of thorough treatment and prevention measures. Choice A is incorrect as regular shampoo is not typically effective in treating head lice. Choice B is incorrect as products containing lindane are not recommended due to safety concerns. Choice D is incorrect as manual removal, though labor-intensive, is a crucial step in effectively treating head lice infestations, but it is not the most pertinent information to include in the teaching session.
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While interviewing a client, the nurse records the assessment in the electronic health record. Which statement is most accurate regarding electronic documentation during an interview?
- A. The client's comfort level is increased when the nurse maintains eye contact while typing notes into the record
- B. The interview process is hindered by electronic documentation and may disrupt the flow of conversation
- C. The nurse has limited ability to observe nonverbal communication while entering the assessment electronically
- D. Completing the electronic record during an interview is optional and not a legal obligation of the examining nurse
Correct Answer: C
Rationale: The most accurate statement is that the nurse has a limited ability to observe nonverbal communication while entering the assessment electronically. This is because the nurse's focus is on typing or inputting data, which may lead to missing important nonverbal cues from the client. Choices A and B are incorrect as they do not address the limitation of observing nonverbal cues. Choice A is incorrect because breaking eye contact to type notes may hinder the client's comfort level. Choice B is incorrect because it states that electronic documentation enhances the interview process, which may not always be the case. Choice D is incorrect as completing the electronic record during an interview is typically a standard practice but not a legal obligation.
The patient has been diagnosed with a spinal cord injury and needs to be repositioned using the logrolling technique. Which technique will the healthcare team use for logrolling?
- A. Involve at least three to four people.
- B. Instruct the patient not to reach for the opposite side rail when turning.
- C. Move the bottom part of the patient's torso first and then the top part.
- D. Use pillows for support before turning.
Correct Answer: A
Rationale: The correct technique for logrolling involves at least three to four people to ensure the safety and proper alignment of the patient's spine. Logrolling requires coordinated effort from multiple individuals to prevent twisting or bending of the spine, hence option A is correct. Option B is incorrect as patients with spinal cord injuries should not be instructed to reach for the opposite side rail due to the risk of causing harm. Option C is incorrect as moving the bottom part of the patient's torso first could lead to spinal misalignment. Option D is incorrect as pillows should be used for support and comfort after the patient has been successfully turned, not before.
A client is drawing up and mixing insulin under the observation of a nurse. Which of the following findings should the nurse identify as an indication that psychomotor learning has taken place?
- A. The client is able to discuss the appropriate technique.
- B. The client is able to demonstrate the appropriate technique.
- C. The client states an understanding of the process.
- D. The client is able to write the steps on a piece of paper.
Correct Answer: B
Rationale: The correct answer is B because the ability to demonstrate the appropriate technique shows that the client has acquired the psychomotor skills needed for insulin preparation. Merely discussing, stating an understanding, or writing the steps does not confirm that the client can physically perform the task correctly. Being able to demonstrate indicates practical application and mastery of the skill. Choice A is incorrect because discussing the technique does not necessarily mean the client can physically perform it. Choice C is incorrect as stating an understanding does not guarantee the client's ability to perform the task. Choice D is incorrect because writing the steps does not assess the client's physical execution of the technique.
When providing mouth care for an unconscious client, what action should the nurse take?
- A. Turn the client's head to the side.
- B. Place two fingers in the client's mouth to open it.
- C. Brush the client's teeth once per day.
- D. Inject mouth rinse into the center of the client's mouth.
Correct Answer: A
Rationale: When providing mouth care for an unconscious client, the nurse should turn the client's head to the side. This action helps prevent aspiration by allowing any fluids to drain out of the mouth, reducing the risk of choking or aspiration pneumonia. Placing fingers into the client's mouth can be dangerous and may cause injury. Brushing the client's teeth only once a day may not be sufficient for proper oral hygiene care. Injecting mouth rinse into the center of the mouth is not recommended and can potentially lead to aspiration. Therefore, the correct action for the nurse to take is to turn the client's head to the side.
A healthcare professional is admitting a client who has tuberculosis. Which of the following types of transmission precautions should the healthcare professional plan to initiate?
- A. Contact
- B. Droplet
- C. Airborne
- D. Protective environment
Correct Answer: C
Rationale: Tuberculosis is transmitted through airborne particles, so airborne precautions are necessary to prevent the spread of the disease. Airborne precautions (Choice C) involve measures such as negative pressure rooms and N95 respirators to prevent the transmission of infectious agents that remain infectious over long distances when suspended in the air. Contact precautions (Choice A) are used for diseases that spread through direct contact with the patient or their environment. Droplet precautions (Choice B) are for diseases transmitted through respiratory droplets, typically over short distances. Protective environment (Choice D) is used for clients who are immunocompromised to protect them from environmental pathogens, not for diseases like tuberculosis that spread through the air.