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When nurse is observing client drawing up & mixing insulin injections, which best demonstrates psychomotor learning has taken place?
- A. Client able to discuss appropriate technique
- B. Client able to demonstrate appropriate technique
- C. Client states he understands
- D. Client is able to write steps on piece of paper
Correct Answer: B
Rationale: The correct answer is B because demonstrating the appropriate technique shows psychomotor learning has taken place. This means the client can physically perform the actions involved in drawing up and mixing insulin injections. Merely discussing the technique (choice A) or stating understanding (choice C) doesn't necessarily mean the client can apply the knowledge in practice. Writing steps on paper (choice D) assesses cognitive understanding, not physical skill. In summary, the ability to physically demonstrate the technique is a direct indicator of psychomotor learning, making choice B the best option.
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Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss?
- A. "Do you eat alone or with someone?"
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A, C, D, E
Rationale: Correct Answer: A, C, D, E
Rationale:
A. "Do you eat alone or with someone?" - This question helps determine social eating habits and potential lack of appetite due to loneliness.
C. "Have you started any new meds in the past 6 months?" - This helps identify medication side effects that may cause weight loss.
D. "What foods have you eaten in the past 24 hours?" - This assesses dietary intake and nutritional status.
E. "Are you on a fixed income?" - Financial constraints can impact food choices and access to nutritious meals.
Summary:
B. "Do you watch TV while eating your meals?" - This does not directly address the potential reasons for weight loss in an older adult.
F. - No information given to evaluate this choice.
G. - No information given to evaluate this choice.
Nurse caring for 19 yo client who is sexually active & has come to college health clinic for first time for checkup. Which intervention should nurse perform to determine client's health promotion & disease prevention?
- A. Measure the vital signs
- B. Encourage HIV screening
- C. Determine client's risk factors
- D. Instruct client to use condoms
Correct Answer: C
Rationale: The correct answer is C: Determine client's risk factors. This intervention is essential to assess the client's current health status, identify potential health risks, and develop a personalized health promotion plan. By understanding the client's risk factors, the nurse can provide targeted education and interventions to prevent diseases and promote overall well-being.
A: Measuring vital signs is important but does not directly address health promotion and disease prevention specific to the client's sexual activity.
B: Encouraging HIV screening is important, but it focuses on a specific disease rather than a comprehensive assessment of risk factors.
D: Instructing the client to use condoms is important for safe sex practices but does not address broader health promotion and disease prevention strategies effectively.
Nurse has removed a sterile pack from its outside cover & placed it on a clean work surface in preparation for an invasive procedure. Which of the following flaps should the nurse unfold first?
- A. Flap closest to body
- B. Right side flap
- C. Left side flap
- D. Flap farthest from the body
Correct Answer: D
Rationale: The correct answer is D: Flap farthest from the body. Unfolding this flap first ensures that the sterile contents inside the pack remain protected from contamination by the nurse's body and hands. Starting with the farthest flap minimizes the risk of accidental touching or contamination of the sterile instruments or supplies. Unfolding the closest flap (choice A) or the side flaps (choices B and C) first could potentially expose the sterile contents to contamination. Therefore, unfolding the flap farthest from the body is the most appropriate and logical step to maintain sterility and ensure safe patient care during the procedure.
Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules; he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him b/c he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A because the child's inability to keep up with other kids in physical activities like running and jumping could indicate underlying physical or developmental issues that require further assessment and intervention. This could be a sign of motor skill delays, muscle weakness, or coordination problems that may impact the child's overall physical health and well-being. Options B, C, and D focus on behavioral, academic, and social issues which are important but not as urgent as addressing potential physical limitations that could affect the child's daily functioning and quality of life.
Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan?
- A. Irrigate affected area with running water
- B. Wash affected area with antibacterial soap
- C. Brush chemical off skin & clothing
- D. Apply neutralizing agent
Correct Answer: C
Rationale: The correct answer is C: Brush chemical off skin & clothing. This intervention is crucial to prevent further exposure and damage from the unknown chemical. By brushing off the chemical, the nurse can minimize the contact time and reduce the risk of more severe burns. Irrigating with water (choice A) may spread the chemical or react with it, worsening the burn. Washing with antibacterial soap (choice B) can also react with the chemical and cause more harm. Applying a neutralizing agent (choice D) can potentially worsen the burn if the wrong agent is used. Therefore, choice C is the best initial intervention to prevent further harm.