Nokea
A nurse plans to reinforce discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?
- A. Pain
- B. Hearing loss
- C. The client's culture
- D. Motor impairment
Correct Answer: A
Rationale: The correct answer is A: Pain. Pain can significantly impair a client's ability to concentrate and retain information during a teaching session. It may cause distress and make it difficult for the client to focus on the instructions provided. Therefore, addressing the pain as a priority before proceeding with teaching is crucial for effective learning.
Hearing loss (B), the client's culture (C), and motor impairment (D) can also present barriers to learning, but these can be accommodated through appropriate communication methods and cultural sensitivity. However, pain directly affects the client's cognitive function and must be managed before effective teaching can take place.
You may also like to solve these questions
A nurse is collecting data from an adolescent client. Which of the following behaviors should the nurse expect an adolescent who has achieved successful resolution of the developmental tasks of identity vs. role confusion to exhibit?
- A. Expresses her opinions
- B. Uses time effectively
- C. Starts and completes a task
- D. Establishes a close relationship with another person
Correct Answer: A
Rationale: The correct answer is A: Expresses her opinions. Adolescents who have successfully resolved the developmental task of identity vs. role confusion are more likely to express their opinions confidently and assertively as they have a clear sense of self and have developed their own identity. This behavior reflects their ability to articulate their thoughts and beliefs, showing autonomy and independence.
Summary of other choices:
B: Using time effectively is a good skill but not directly related to resolving identity vs. role confusion.
C: Starting and completing tasks is important, but not indicative of resolving identity issues.
D: Establishing close relationships is important, but it is not the primary behavior associated with resolving identity vs. role confusion.
A nurse is caring for a client who has a wound infection. Which of the following actions should the nurse take when obtaining a wound drainage specimen for culture?
- A. Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen.
- B. Irrigate the wound with an antiseptic prior to obtaining the specimen.
- C. Include intact skin at the wound edges in the culture.
- D. Swab an area of skin away from the wound to identify normal flora.
Correct Answer: A
Rationale: The correct answer is A: Cleanse the wound with 0.9% sodium chloride irrigation before obtaining the specimen. This step is essential to remove debris and contaminants from the wound, ensuring that the specimen obtained is not contaminated. Cleansing with a normal saline solution helps to minimize the risk of introducing outside pathogens into the culture sample. It also helps to provide a more accurate representation of the microorganisms present specifically within the wound.
Choices B, C, and D are incorrect. Choice B suggests using an antiseptic, which may interfere with the accuracy of the culture results. Choice C is incorrect because intact skin should not be included in the culture sample, as it does not reflect the microorganisms present in the wound. Choice D is incorrect as swabbing an area away from the wound will not provide relevant information about the wound infection.
A nurse in an urgent care center is caring for a client who fell and injured her ankle. The ankle appears swollen and ecchymotic. While the client waits for the x-ray technician, which of the following actions should the nurse take? (Select all that apply.)
- A. Apply ice to the ankle.
- B. Encourage range-of-motion exercises of the foot.
- C. Provide the client with a light snack.
- D. Apply a compression bandage.
- E. Elevate the foot.
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
- Apply ice to the ankle (A): Ice helps reduce swelling and inflammation by constricting blood vessels. It is essential for reducing pain and promoting healing.
- Apply a compression bandage (D): Compression helps reduce swelling and provides support to the injured area, promoting healing and preventing further damage.
- Elevate the foot (E): Elevating the foot above the heart level helps reduce swelling and promotes circulation, aiding in the healing process.
Incorrect Choices:
- Encourage range-of-motion exercises of the foot (B): Performing range-of-motion exercises on an injured ankle may worsen the injury and cause further damage.
- Provide the client with a light snack (C): Providing a snack is not a priority in this situation and does not contribute to the client's immediate care.
A nurse is caring for a client who has pneumonia. The nurse should place the client on his right side in Trendelenburg position to help mobilize secretions from which of the following lung segments?
- A. Lateral segment of the left lower lobe
- B. Lateral segment of the right lower lobe
- C. Posterior segment of the left upper lobe
- D. Posterior segment of the right lower lobe
Correct Answer: D
Rationale: The Trendelenburg position promotes drainage of secretions from specific lung segments, improving oxygenation.
A nurse is collecting data from a client who has Bell's palsy. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Muscle distortion
- B. Pain behind the ear
- C. Hearing loss
- D. Facial twitching
- E. Impaired taste
Correct Answer: A,B,E
Rationale: The correct answers are A, B, and E. Bell's palsy is characterized by muscle distortion due to facial nerve paralysis, leading to asymmetry in facial expressions (A). Pain behind the ear may occur due to inflammation or compression of the facial nerve (B). Impaired taste can result from altered function of the chorda tympani nerve, affecting taste sensation on the anterior two-thirds of the tongue (E). Choices C, D, F, G are incorrect as hearing loss is not a typical feature of Bell's palsy (C), facial twitching is more characteristic of conditions like hemifacial spasm (D), and there are no specific findings associated with F and G in Bell's palsy.