Nokea
A man is presently employed as a night watchman. When he comes to the clinic for a visit, he tells the nurse he is having difficulty sleeping and is fatigued much of the time.
Which of the following responses by the nurse is BEST?
- A. Tell me about your usual sleeping habits.'
- B. You probably sleep when you can during your night tour.'
- C. This is normal for your age group.'
- D. Working the night shift is known to disrupt sleep patterns.'
Correct Answer: A
Rationale: Strategy: Answers are a mix of assessments and implementations. Does this situation require assessment? Yes. (1) correct-assessment, open-ended, encourages discussion (2) judgment based on inadequate information, nontherapeutic (3) generalization with no factual basis, closed communication (4) closed communication, generalization
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Which playroom activities should the nurse organize for a small group of 7 year-old hospitalized children?
- A. Sports and games with rules
- B. Finger paints and water play
- C. Dress-up clothes and props
- D. Chess and television programs
Correct Answer: A
Rationale: Sports and games with rules. The purpose of play for the 7 year-old is developing cooperation. Rules are very important. Logical reasoning and social skills are developed through play.
A client with clotting disorder has an order to continue Lovenox (Enoxaparin) injections after discharge. In assessing the client's readiness for teaching, the most important factor for the nurse to assess is the client's:
- A. Prior knowledge of anticoagulants and their role in controlling his disease
- B. Willingness to learn about injection techniques and site selection
- C. Adaptation to the need for daily injections to control his symptoms
- D. Overall intelligence and developmental level
Correct Answer: B
Rationale: Willingness to learn is critical for effective teaching about self-administering injections. Knowledge, adaptation, and intelligence are secondary.
An older man is being prepared for discharge after treatment for dehydration.
Which of the following statements, if made by the patient to the nurse, indicates that further teaching is needed?
- A. I should weigh myself daily.'
- B. I should drink fluids throughout the day.'
- C. I can use a measuring cup to find out how much I drink during the day.'
- D. I should let my doctor know if I get dizzy when I change positions.'
Correct Answer: A
Rationale: Strategy: Determine how each answer choice relates to dehydration. Be careful, this is a negative question. (1) correct-would only indicate overhydration, not response to dehydration (2) will help prevent recurrence of dehydration, should force fluids to 3,000 cc/day (3) would give good indication of total intake (4) would indicate postural hypotension resulting from volume deficit
A client with a marked depression of T cells.
To promote safety in the environment of a client with a marked depression of T cells, the nurse should
- A. keep a linen hamper immediately outside the room.
- B. restrict eating utensils to spoons made of plastic.
- C. provide masks for anyone entering the room.
- D. remove any standing water left in containers or equipment.
Correct Answer: D
Rationale: Strategy: Answers are implementations. Determine the outcome of each answer choice. Is it desired? (1) protocol for handling soiled articles is accomplished within universal guidelines with double biohazard bags (2) universal precautions and client protection may call for plastic utensils, but not just spoons (3) not protocol unless the client has an active pulmonary infection (4) correct-water should not be allowed to stand in containers, such as respiratory or suction equipment, because this could act as a culture medium
The nurse is assigned to work with the parents of a retarded child.
- A. What should the nurse include in the care plan for the parents of a retarded child?
- B. Interpret the grieving process for the parents.
- C. Discuss the reality of institutional placement.
- D. Assist the parents in making decisions and long-term plans for the child.
- E. Perform a family assessment to assist in the planning of intervention.
Correct Answer: D
Rationale: A family assessment is essential to understand the parents’ grieving, coping, and support needs, guiding tailored interventions. Interpreting grief, discussing placement, or assisting with plans are premature without first assessing the family’s situation.