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A nurse is providing preoperative teaching to an older adult client who is scheduled for surgery.
Which of the following actions should the nurse take to promote learning?
- A. Speak loudly when addressing the client
- B. Connect new information with the client's past experiences
- C. Present the information to the client using abstract concepts
- D. Use a 12 point font when printing written material for the client
Correct Answer: B
Rationale: The correct answer is B: Connect new information with the client's past experiences. This promotes learning by linking new concepts to existing knowledge, aiding in retention and understanding. Speaking loudly (A) may not enhance learning and can be off-putting. Presenting information abstractly (C) may confuse the client. Using a 12 point font (D) is a formatting preference and does not directly impact learning.
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Nurses' Notes
Day 1, 0915:
The client's adult child reports the client has not slept for 2 days and has become obsessed with
cleaning the house and hosting parties. At times the client is overly joyous and has a very
elevated sense of self-confidence. The adult child states that the client has also demonstrated
very impulsive spending habits and expresses concern about the client giving away large sums
of money to others.
The client's speech is very pressured, disorganized, and loud. Client unable to recall the last time
they ate.
Day 1, 0930:
Client questioned about their hallucinations and states that the same person has been following
them around inside and outside the house for days. Client asks the person what they want but
never receives an answer, Client states that this person has never told them to do anything: they
just stare and smile.
For each assessment finding, click to specify if the finding is consistent with psychosis or mania.
- A. Hallucinations
- B. Lack of sleep
- C. Excessive spending habits
- D. Disorganized thought process
- E. Pressured speech
Correct Answer: A,B,C,D,E
Rationale: The correct answer is A, B, C, D, E. Hallucinations, lack of sleep, excessive spending habits, disorganized thought process, and pressured speech are all consistent with both psychosis and mania. Hallucinations are sensory perceptions without a real external stimulus, common in both conditions. Lack of sleep is a hallmark symptom of mania and can also exacerbate psychotic symptoms. Excessive spending habits are often seen in manic episodes due to impulsivity, and disorganized thought process and pressured speech are characteristic of both psychosis and mania, reflecting the underlying cognitive and communication disturbances. Other choices are not specific or commonly associated with psychosis or mania.
An occupational health nurse is providing teaching to a group of factory workers about proper lifting techniques.
Which statement should the nurse make?
- A. Bend at the waist when lifting objects from the floor.
- B. Keep the object close to your body when lifting.
- C. Twist your torso while lifting to maintain balance.
- D. Lift heavy objects quickly to reduce strain on the muscles.
Correct Answer: B
Rationale: The correct answer is B: Keep the object close to your body when lifting. This statement is correct because keeping the object close to the body reduces the strain on the back muscles and promotes proper lifting mechanics. By keeping the object close, the center of gravity is maintained, reducing the risk of injury.
Incorrect answers:
A: Bending at the waist when lifting can strain the lower back.
C: Twisting the torso while lifting can lead to back injuries.
D: Lifting heavy objects quickly can increase the risk of muscle strains and injuries.
A community health nurse is working with a group of clients.
Which task should the nurse perform to practice distributive justice?
- A. Ensuring that a client who is homeless receives preventative medical care
- B. Allocating community resources fairly among all clients in need.
- C. Prioritizing care for clients based on medical necessity rather than financial status.
- D. Advocating for equal access to healthcare services for underserved populations.
- E. Developing programs that address social determinants of health to reduce disparities.
Correct Answer: E
Rationale: The correct answer is E because developing programs that address social determinants of health to reduce disparities aligns with the principle of distributive justice, which focuses on fair distribution of resources to reduce inequalities. By addressing social determinants of health, such as income inequality or access to education, the nurse is working towards creating equal opportunities for all individuals to achieve good health outcomes.
Choices A, B, C, and D do not directly address the root causes of health disparities and inequality. Option A focuses on providing care to a specific individual rather than addressing systemic issues. Option B talks about allocating resources fairly but lacks the focus on addressing social determinants. Option C mentions prioritizing care based on medical necessity, which may not necessarily target disparities. Option D discusses advocating for equal access, but it does not specifically address the underlying social determinants that contribute to inequalities.
A nurse is caring for a client who is pregnant. Nurses'
Notes
Day 1, 0900:
Client is at 31 weeks of gestation and presents with a severe headache unrelieved by
acetaminophen. Client also reports urinary frequency and decreased fetal movement.
Client is a G3 P2 with one preterm birth.
Vital Signs Day
1, 0900:
Temperature (oral) 36.9°C (98,4° F) Heart
rate 72/min
Respiratory rate 16/min BP
162/112 mm Hg
Oxygen saturation 97% on room air
Diagnostic Results Day 1,
1000:
Appearance cloudy (clear) Color
yellow (yellow)
pH 5.9 (4.6 to 8)
Protein 3+ (negative)
Specific gravity 1.013 (1.005 to 1.03) Leukocyte esterase
negative (negative)
Nitrites negative (negative) Ketones
negative (negative) Crystals negative
(negative) Casts negative (negative)
Glucose trace (negative) WBC 5 (0
t0 4)
WBC casts none (none)
RBC 1 (less than or equal to 2) RBC
casts none (none)
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A,C,F,G
Rationale: The correct answers (A, C, F, G) indicate potential prenatal complications. Urine protein (A) suggests preeclampsia, a serious condition characterized by high blood pressure (C) and proteinuria. Headaches (F) can also be a sign of preeclampsia. Gravida/parity (G) provides important obstetric history, identifying high-risk pregnancies. Fetal activity (B) and respiratory rate (E) are not specific to prenatal complications. Urine ketones (D) may indicate dehydration but not necessarily a prenatal complication.
A nurse is planning care for a client who has acute appendicitis.
Which of the following actions should the nurse plan to take?
- A. Place the clients head of bed flat
- B. apply heat to the client's abdomen
- C. keep the client on NPO status
- D. administer A laxative to the client
Correct Answer: C
Rationale: The correct answer is C: keep the client on NPO status. This is the correct action as it means "nothing by mouth," which is often necessary before certain medical procedures or surgeries to prevent aspiration. Choice A is incorrect as elevating the head of the bed reduces the risk of aspiration. Choice B is incorrect as heat application may not be indicated and could potentially worsen the client's condition. Choice D is incorrect as administering a laxative may not be appropriate without a proper assessment.