Nokea
Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. Affective domain involves emotions, attitudes, and feelings. In this scenario, the mother's change in willingness to postpone toilet training shows a shift in her emotional response and attitude towards the situation. This indicates a change in the affective domain, as the mother's feelings and attitudes have been influenced by the nurse's teaching.
Choices A, C, and D are incorrect:
A: Cognitive domain involves knowledge, understanding, and thinking skills. While there may be some cognitive processing involved in the mother's decision-making, the primary change observed is in her emotions and attitudes.
C: Psychomotor domain relates to physical skills and movements, which are not the focus of the scenario.
D: Kinesthetic refers to the sense of body position and movement, which is not relevant to the mother's change in willingness to postpone toilet training.
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When entering client's room to change dressing
- A. nurse notes client is coughing & sneezing. When preparing sterile field
- B. it's important the nurse...
- C. Keep sterile field at least 6 ft away from client's bedside
- D. Instruct client to not cough/sneeze during dressing change
- E. Place mask on client to limit spread of microorganisms into surgical wound
Correct Answer: C
Rationale: The correct answer is C because keeping the sterile field at least 6 feet away from the client's bedside helps to maintain its integrity and prevent contamination. Placing the field further away reduces the risk of microorganisms reaching it during the dressing change procedure. Choice A is incorrect as the nurse should address the client's coughing and sneezing before proceeding with the dressing change. Choice B is vague and does not directly relate to maintaining sterility. Choice D is ineffective as instructing the client to stop coughing or sneezing is unrealistic. Choice E, while a good practice in general, does not directly address the maintenance of the sterile field.
Nurse is caring for client with SARS. Nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate rationale for reporting?
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A,B,C,E
Rationale: The correct answer is A, B, C, and E. Reporting communicable diseases like SARS is essential for planning and evaluating control and prevention strategies. It helps determine public health priorities by identifying areas of concern. Reporting ensures proper medical treatment for affected individuals and helps in monitoring for common-source outbreaks to prevent further spread. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases. Identifying endemic diseases may be a part of reporting, but it is not the primary reason.
Nurse is caring for many clients during mass casualty event. Which client is highest priority?
- A. Client with crush injuries to chest/abdomen & expected to die
- B. Client with 4-inch laceration to head
- C. Client with partial & full-thickness burns to face
- D. neck
- E. chest
Correct Answer: C
Rationale: The correct answer is C: Client with partial & full-thickness burns to face. This client is the highest priority due to airway compromise risk from facial burns. Airway is a top priority in mass casualty events to prevent respiratory distress or failure. Crush injuries (A) may be severe but not immediately life-threatening. Laceration (B) to head can be managed with proper wound care. Clients with neck (D) or chest (E) injuries may have potential serious complications, but airway takes precedence in this scenario.
A nursing instructor is reviewing steps of the nursing process with students. Which of the following data are objective?
- A. Respiratory rate 22/min
- B. I can only walk 3 blocks before pain starts
- C. Pain level 3/10
- D. Skin pink warm
- E. Urine output 300mL/8hr
- F. Dressing clean dry intact
Correct Answer: A,D,E,F
Rationale: The correct answers are A, D, E, and F. Objective data are measurable and observable.
A: Respiratory rate 22/min is measurable.
D: Skin pink warm is observable.
E: Urine output 300mL/8hr is measurable.
F: Dressing clean dry intact is observable.
Choices B and C are subjective as they are based on the patient's perception and cannot be measured or observed directly. Choice G is incomplete.
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion? (Select all that apply.)
- A. Rotavirus
- B. Varicella
- C. Herpes zoster
- D. HPV
- E. Seasonal influenza
Correct Answer: B,D,E
Rationale: The correct answers are B, D, and E. Varicella (B) vaccine is recommended for adolescents who haven't been vaccinated before. HPV (D) vaccine is crucial for preventing certain types of cancers. Seasonal influenza (E) vaccine helps protect against the flu, which can be severe. Rotavirus (A) vaccine is typically given to infants, not adolescents. Herpes zoster (C) vaccine is for adults over 50. No information is given for choices F and G.