Nokea
Which teaching strategies should be used when it is difficult to reach the desired goals of the session (select all that apply)?
- A. DVD
- B. Role play
- C. Discussion
- D. Printed material
Correct Answer: B
Rationale: The correct answers are 'Role play,' 'Discussion,' and 'Lecture-discussion.' These strategies encourage active participation and engagement, which can help overcome barriers to achieving learning goals. DVDs and printed materials may not engage the patient as effectively in challenging situations.
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For the nursing diagnoses and written patient outcomes listed below, use the Nursing Interventions Classification (NIC) to identify a specific nursing intervention to help the patient reach the outcome.
- A. Risk for impaired skin integrity related to immobility
- B. Constipation related to inadequate fluid and fiber intake
- C. None
- D. All
Correct Answer: A
Rationale: For preventing pressure ulcers, interventions like turning and positioning are critical. For constipation, increasing fluid and fiber intake is key.
What information should be immediately reported to the physician?
- A. The ingested children's chewable vitamins contain iron
- B. The child has been treated several times for ingestion of toxic substances
- C. The child has been treated several times for accidental injuries
- D. The child was nauseated and vomited once at home
Correct Answer: A
Rationale: Iron ingestion can cause severe toxicity and requires immediate medical attention.
While teaching a client about their medications, the client asks how long it will take before the effects of lithium take place. What is the best response of the nurse?
- A. Immediately.
- B. Several days.
- C. 2 weeks.
- D. 1 month.
Correct Answer: C
Rationale: Lithium typically takes 2 weeks to show therapeutic effects.
While caring for a client with extensive partial and full-thickness burns of the head, neck, and chest, which risk should the nurse prioritize for assessment and intervention?
- A. Airway obstruction
- B. Infection
- C. Fluid imbalance
- D. Paralytic ileus
Correct Answer: A
Rationale: The correct answer is A: Airway obstruction. This should be prioritized because burns to the head, neck, and chest can lead to swelling and inflammation, potentially compromising the airway. Maintaining a clear airway is crucial for oxygenation and ventilation. If the airway becomes obstructed, it can quickly lead to respiratory distress or failure. Assessing for signs of airway compromise and intervening promptly is essential to prevent serious complications.
Choices B, C, and D are incorrect because while infection, fluid imbalance, and paralytic ileus are also important considerations in burn care, they are not as immediately life-threatening as airway obstruction in this case. Infection can be managed with appropriate wound care, fluid imbalance can be addressed with fluid resuscitation, and paralytic ileus can be treated with medications and bowel management strategies.
A nurse in an emergency room is caring for a client who sustained partial-thickness burns to both lower legs, chest, face, and both forearms. Which of the following is the priority action the nurse should take?
- A. Insert an indwelling urinary catheter.
- B. Inspect the mouth for signs of inhalation injuries.
- C. Administer intravenous pain medication.
- D. Draw blood for a complete blood cell (CBC) count.
Correct Answer: B
Rationale: The correct answer is B: Inspect the mouth for signs of inhalation injuries. This is the priority action because inhalation injuries can be life-threatening due to airway compromise. The nurse should assess for soot in the mouth, facial burns, hoarseness, and difficulty breathing. This allows for prompt intervention if respiratory distress is present.
A: Inserting an indwelling urinary catheter is not the priority as it does not address the immediate life-threatening issue.
C: Administering pain medication is important but not the priority over assessing for inhalation injuries which could lead to respiratory distress.
D: Drawing blood for a CBC count is not the priority as it does not address the immediate threat to the client's airway.