Nokea
Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable with the nurse.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction during procedures.
E: Engaging the child in pretend play with a toy medical kit can help familiarize the child with medical procedures in a non-threatening way.
Summary:
B: Clustering invasive procedures may not directly address the child's fear and can still be overwhelming.
C: Assigning caregivers familiar to the child may help in general care but may not directly address the fear of painful procedures.
F, G: No additional answer choices provided.
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During evaluation
- A. the nurse must gather information about the client to...
- B. Identify whether client outcomes have been met
- C. Organize resources for interventions
- D. Establish client-centered
- E. measurable outcomes
Correct Answer: A
Rationale: The correct answer is A because during evaluation, the nurse needs to gather information about the client to assess the effectiveness of interventions and progress towards goals. This step involves collecting data to determine if the client's needs are being met and if adjustments are necessary. Option B is incorrect as it focuses on outcomes rather than the client's current status. Option C is incorrect as organizing resources is more related to planning than evaluation. Option D is incorrect as it pertains to establishing goals rather than evaluating progress. Option E is incorrect as it emphasizes measurable outcomes without considering the client's specific information needed for evaluation.
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. B/c doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B. The client's statement indicates an understanding of the recommended screening guideline for mammograms for a 45-year-old individual with no specific family history of cancer. Yearly mammograms are typically recommended starting at age 40 for early detection of breast cancer. Choice A is incorrect as colon cancer screening is recommended starting at age 45-50, not in 2-3 years. Choice C is incorrect as Pap smears are typically recommended every 3-5 years, not yearly. Choice D is incorrect as blood glucose testing is usually recommended annually for individuals at risk for diabetes.
Nurse caring for 19-year-old 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 is the most appropriate intervention to assess the client's health promotion and disease prevention needs. By identifying the client's risk factors such as sexual behaviors, substance use, family history, and lifestyle choices, the nurse can tailor health education and intervention strategies to promote overall well-being.
A: Measure the vital signs - While important, vital signs do not directly assess health promotion and disease prevention needs in a sexually active young adult.
B: Encourage HIV screening - Important for sexual health but does not address a comprehensive assessment of health promotion and disease prevention.
D: Instruct client to use condoms - Important recommendation for safe sex practices but does not address the broader health promotion and disease prevention needs of the client.
Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Crib gyms can pose a suffocation risk for infants, so removing it shows understanding of safety.
2. Soft mattresses increase the risk of Sudden Infant Death Syndrome.
3. Fluffy pillows pose suffocation hazard; infants should sleep on a firm, flat surface.
4. Child-safety gates should not fold like accordions as they can trap fingers.
Summary:
B and C pose suffocation risks. D is incorrect as accordion-style gates can be hazardous. A demonstrates understanding of infant safety by removing the crib gym.
Nurse providing discharge instructions to client with a prescription for oxygen use at home. What should the nurse teach about using oxygen safely? (Select all that apply)
- A. Family members who smoke must be at least 10 ft from client when oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish shouldn't be used near client receiving oxygen to prevent flammability risk as it contains volatile chemicals that can ignite.
C: A 'No Smoking' sign should be placed on the front door to remind visitors and family members to not smoke near oxygen, reducing fire risk.
E: Fire extinguisher should be readily available in the home to quickly address any potential fires related to oxygen use, ensuring safety.
Summary:
A: Keeping family members who smoke at least 10 ft away is important, but not the most critical safety measure.
D: Replacing cotton with wool clothing does not directly impact oxygen safety.
F & G: No information provided.