Nokea
Which of the following nursing actions is most effective when evaluating a kinetic family drawing?
- A. telling the child to draw their family doing something
- B. offering specific suggestions of what to include in the drawing
- C. discouraging the child from talking about the drawing
- D. noting the omission of any family members
Correct Answer: D
Rationale: There are several guidelines for evaluating kinetic family drawings, including Choice 4. Effective nursing actions include asking the client to explain what each family member is doing, encouraging him or her to tell as much as possible about the drawing, noting physical intimacy or distance, noting placement of family members in the drawing, noting facial expressions of family members and noting if they are facing each other or turned away. Choice 1 is initial instruction, not evaluation. Only general encouragement should be given to avoid suggesting themes to the child.
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Which of the following is not true of clinical pathways?
- A. They need to be updated daily.
- B. They show how the client is expected to respond to their diagnosis.
- C. The goal is improvement or discharge from the facility.
- D. They are evidence based.
Correct Answer: A
Rationale: Clinical pathways may be daily or weekly, so they may not need to be updated every day.
Which of these is true regarding advance directives?
- A. They must be reviewed and re-signed every 10 years in order to remain valid.
- B. An advanced directive is legally valid in every state, no matter which state it was created in.
- C. A physician must determine when a client is unable to make medical decisions for himself.
- D. They cannot be honored by EMTs (emergency medical technicians) unless signed by a doctor.
Correct Answer: D
Rationale: If summoned, EMTs are legally obligated to provide emergency care to a client, regardless of advance directive status, unless the directive is signed by a doctor. If the client is brought to the hospital, physicians will evaluate the client and implement the advance directive, if necessary. Two physicians, not one, are needed to determine if a client is unable to make decisions for himself/herself. Advance directives do not expire and remain in effect until they are changed. Some states do not honor advance directives created in other states, so if a client moves, he/she should check with his/her new state policies on this topic.
A client who is experiencing infertility says to the nurse, 'I feel I will be incomplete as a man/woman if I cannot have a child.' Which of the following nursing diagnoses is likely to be appropriate for this client?
- A. Risk for Self Harm
- B. Body Image Disturbance
- C. Ineffective Role Performance
- D. Powerlessness
Correct Answer: B
Rationale: Of the nursing diagnoses listed, the client's statement most represents Body Image Disturbance because it directly refers to loss of the function of having a child. Nothing in the statement indicates that the client is at risk for harming herself. Ineffective Role Performance could be correct but is not the best choice because the statement does not reflect a disruption of the parent's role. Powerlessness could be an appropriate nursing diagnosis if the client described feeling powerless about the infertility.
An LPN works on an adult medical/surgical unit and has been pulled to work on the burn unit, which cares for clients of all ages. What should he do?
- A. He should take the assignment, but make it clear he will only care for adult clients.
- B. He should take the assignment, but explain the situation to the charge nurse and ask for a quick orientation before starting.
- C. He should refuse to take the assignment, as caring for infant and child population is not within his scope of practice.
- D. He should take the assignment, but ask to be paired with a more experienced LPN.
Correct Answer: B
Rationale: While the LPN may specialize in a certain type of nursing or feel more comfortable caring for a specific client population, he should be able to use his skill set to safely and independently care for other populations as well. However, the LPN should let the charge nurse know his background before beginning his shift so he can familiarize himself with new equipment, ask questions, and identify resources.
An 85-year-old client is eligible for Medicare reimbursable home care services. Referral is contingent on meeting which of the following criteria?
- A. homebound status, requiring skilled therapy care
- B. immediate previous hospitalization for acute care
- C. age
- D. requirement of nursing and social work support
Correct Answer: A
Rationale: The requirements for Medicare-reimbursable home care services include the client being homebound and requiring a skilled service, such as PT/OT/ST/nursing/social work.