Nokea
While assisting a client from bed to chair, the nurse observes that the client looks pale and is beginning to perspire heavily. The nurse would then do which of the following activities as a reassessment?
- A. Help client into the chair more quickly
- B. Document client's vital signs taken just prior to moving the client
- C. Help client back to bed immediately
- D. Observe client's skin color and take another set of vital signs
Correct Answer: D
Rationale: In this scenario, the nurse has observed concerning signs in the client during the transfer process. The appropriate action for reassessment would be to observe the client's skin color and take another set of vital signs. This will provide essential data to evaluate the client's condition more accurately. Options A, B, and C are interventions that do not address the need for reassessment. Moving the client more quickly, documenting previous vital signs, or returning the client to bed do not directly address the need to reassess the client's current condition.
You may also like to solve these questions
Digestion, elimination, and ___________ are the three functions of the digestive system.
- A. constriction
- B. relaxation
- C. absorption
- D. peristalsis
Correct Answer: C
Rationale: The correct answer is 'absorption.' The three main functions of the digestive system are digestion, absorption, and elimination. Absorption refers to the process of absorbing nutrients and other substances from the digested food into the bloodstream. Choices A, B, and D are incorrect: Constriction is not a primary function of the digestive system, relaxation is not a distinct function in this context, and peristalsis is a muscular movement that aids in digestion but is not one of the three main functions of the digestive system.
What is the MOST ACCURATE statement regarding the ESR test?
- A. The results are diagnostic for certain conditions.
- B. Abnormal results are indicative of a potentially fatal illness.
- C. Abnormal results should be followed by additional testing.
- D. Results are reported in millimeters per hour.
Correct Answer: C
Rationale: The erythrocyte sedimentation rate (ESR) is a non-specific screening test for inflammation in the body. It is not used as a definitive diagnostic tool for specific conditions. When ESR results are abnormal, they indicate the presence of inflammation, which can be caused by various reasons. Therefore, abnormal results should be followed by additional testing to determine the underlying cause. The ESR test measures the rate at which red blood cells settle in a vertical tube over the span of one hour, and results are reported in millimeters per hour. Choice A is incorrect because ESR results are not solely diagnostic for any specific condition. Choice B is incorrect as abnormal ESR results do not directly indicate a potentially fatal illness without further investigation. Choice D is incorrect as the results are reported in millimeters per hour, not per minute.
During which part of the client interview would it be best for the nurse to ask, 'What's the weather forecast for today?'
- A. Introduction
- B. Body
- C. Closing
- D. Orientation
Correct Answer: A
Rationale: Asking about the weather initiates the social or introductory phase of the interview, allowing the nurse to establish rapport with the client at the beginning. This question can help assess the client's mental status and set a friendly tone. In the body phase, the client responds to the nurse's inquiries, while during the closing phase, either the nurse or the client concludes the interview. Therefore, the best time to ask about the weather forecast is during the introduction phase to facilitate a positive start to the interaction.
Which desired outcome written by the nurse is correctly written and measurable?
- A. Client will have a normal bowel pattern by April 2
- B. The client will lose 4 lbs. within the next 2 weeks
- C. The nurse will provide skin care at least 3 times each day
- D. The client will breathe better after resting for 10 minutes
Correct Answer: B
Rationale: An outcome statement must describe the observable client behavior that should occur in response to the nursing interventions. It consists of a subject, action verb, conditions under which the behavior is to be performed, and the level at which the client will perform the desired behavior. Option B is correctly written and measurable as it includes all the required elements: subject (client), action verb (lose), conditions (within the next 2 weeks), and the level at which the behavior should occur (4 lbs.). Option A lacks the conditions and a specific level, making it not measurable. Option C is a nursing intervention rather than a client goal. Option D does not provide a specific level at which the client should perform the desired behavior, making it not measurable as well.
After instructing the client on crutch walking technique, the nurse should evaluate the client's understanding by using which of the following methods?
- A. Return demonstration
- B. Explanation
- C. Achievement of 90 on written test
- D. Have the client explain the procedure to the family
Correct Answer: A
Rationale: After teaching the client on crutch walking technique, assessing the client's understanding is crucial. The most effective method to evaluate the client's comprehension of a hands-on skill like crutch walking technique is through a return demonstration. This allows the nurse to observe the client performing the technique, ensuring they have grasped the instructions correctly and can execute the skill safely. While providing an explanation can help clarify doubts, it may not confirm the client's ability to perform the skill. Achieving a high score on a written test assesses cognitive understanding but not necessarily the practical application of the skill. Having the client explain the procedure to the family does not directly assess their ability to perform the skill themselves; it tests their ability to communicate the information to others.