NUR 220 Exam 2 Solution Manual Fully Solved Latest Update 2025 Already Passed
The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast
placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she
states, "You don't have to go over those—I'll read them at home." What should the nurse do?
a. Contact the physician immediately.
b. Consider the possibility of health literacy limitations and assess further.
c. Stop the teaching, because the mother obviously has taken care of casts before.
d. Explain to the mother that reading the instructions with her is required. - Answers Consider the
possibility of health literacy limitations and assess further.
The patient's mother may have limited reading skills or health literacy and should be further assessed.
Contacting the physician in this situation would not be appropriate because ensuring that the patient
and family understand discharge instructions is the responsibility of the nurse. Assuming that the
mother has taken care of casts in the past may be inaccurate. Stating that reading the instructions with
the nurse is a requirement does not ensure that the patient or mother comprehends the instructions.
A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The nurse obtains
admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction.
During the assessment, the nurse determines that the patient does not speak English. What should the
nurse do before placing the NG tube?
a. Assess the presence of any family members who may speak English and the patient's native language.
b. Take two additional staff members into the room when placing the tube so the patient can be
restrained if needed.
c. Request an interpreter by leaving a voicemail on his or her office extension.
d. Do not place the NG tube because the physician would not want to frighten the patient. - Answers
Assess the presence of any family members who may speak English and the patient's native language.
Although an interpreter employed by the hospital would be the best choice, eliciting the help of family
members that speak both the patient's primary language as well as English may be the best option
because the procedure is needed now. This will provide comfort and familiarity for the patient. Taking
additional staff into the room may increase the patient's anxiety, thereby decreasing his ability to
comprehend the instructions. Leaving a message on a voicemail for an interpreter is also incorrect
because the intervention has a level of urgency that may have a detrimental effect if the message is not
retrieved in a relatively short amount of time because it is late on Saturday. Although the physician
,would not want to frighten the patient, he or she ordered the NG tube for the benefit of the patient;
therefore, it needs to be carried out.
Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.)
a. Noncompliance
b. Readiness for Enhanced Knowledge
c. Ineffective Coping
d. Health-Seeking Behaviors
e. Anxiety - Answers b, d
Readiness for Enhanced Knowledge and Health-Seeking Behaviors are appropriate nursing diagnoses for
use in developing a patient teaching plan. Noncompliance would be an appropriate nursing diagnosis for
a patient who has not followed a teaching plan or treatment regimen. Ineffective Coping is not a nursing
diagnosis used in developing a teaching plan, but if a patient is not coping effectively, it may affect the
ability to learn. A nursing diagnosis of Anxiety may affect the patient's ability to learn but is not directly
related to developing a teaching plan.
Which nursing diagnosis is appropriate if a patient expresses an interest in learning?
a. Readiness for Enhanced Knowledge
b. Knowledge Deficit
c. Information Processing
d. Health-Seeking Behaviors - Answers Readiness for Enhanced Knowledge
A patient's expression of an interest in learning is one of the defining characteristics of the nursing
diagnosis, Readiness for Enhanced Knowledge. Knowledge Deficit would indicate that the patient has a
deficiency of knowledge on a particular subject. Information Processing is an outcome rather than a
nursing diagnosis and is the patient's ability to acquire use information. Health-Seeking Behaviors is
active seeking by a person in stable health of ways to alter habits to enhance health.
A 61-year-old male is undergoing an emergency cardiac catheterization when the nurse gives his wife a
packet of registration paperwork and asks her to complete the forms. Which observed actions may
indicate a health literacy issue? (Select all that apply.)
,a. Putting on glasses before beginning the paperwork.
b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses—
these just don't work"
c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the
forms
d. Setting the clipboard aside and staring tearfully out the window
e. Returning the forms only partially filled out, with missing or inaccurate information - Answers b, c, e
Asking someone else to read the form, waiting for help with the forms, and partially or inaccurately
filled-out forms are behaviors indicative of potential health literacy issues. Needing glasses does not
correlate directly with health literacy. A tearful spouse requires additional assessment to see whether
health literacy is a problem. The wife may be overwhelmed and feel unable to complete the forms, or
she may need to collect her thoughts in the midst of a stressful time.
A weight-loss program that combines nutrition instruction with exercise is an example of teaching based
on which domain of learning?
a. Psychomotor
b. Affective
c. Psychosocial
d. Cognitive - Answers Psychomotor
Weight management that combines instruction and exercise is an example of psychomotor domain
learning. Affective domain learning integrates new knowledge by recognizing an emotional component.
Psychosocial is not one of the domains of learning. Cognitive domain learning is based on knowledge
and material that is remembered, memorized, and recalled.
The nurse is providing home care to a 62-year-old female who was recently diagnosed with insulin-
dependent diabetes mellitus. What is the most important reason for the nurse to document the
teaching session?
a. The patient's insurance company requires documentation.
b. The nurse's employer requires documentation of home care sessions.
, c. Other members of the health care team need to know the patient's progress.
d. Insulin is a potentially dangerous medication and needs to be documented. - Answers Other members
of the health care team need to know the patient's progress.
Although the remaining options may be true, the primary reason for specific documentation of a
patient's progress in a teaching plan is to ensure that other nurses or members of other disciplines can
pick up the teaching plan and know precisely what the patient has accomplished and where to begin
additional sessions.
Written instructions showing pictures of the steps necessary to test a blood sugar, along with
demonstration and a return demonstration of the steps, would most benefit which learners?
a. Affective
b. VARK
c. Psychomotor
d. Cognitive - Answers Psychomotor
Psychomotor learning involves physical movement and the use of motor skills such as demonstration
and return demonstration. The affective domain involves emotion, and the cognitive domain is
memorization and recall. VARK (verbal, aural, read/write, kinesthetic) refers to a method of assessing
learning style.
The nurse is providing care to an 88-year-old male patient who just returned from the recovery room
after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein
thrombosis. What is the best time to provide teaching?
a. Do it right before the patient's next intravenous pain medication.
b. Wait until tomorrow morning because he is in too much pain today.
c. Leave written materials on his over-the-bed tray that he can read at his convenience.
d. Wait until 10 to 15 minutes after his next intravenous pain medication - Answers Wait until 10 to 15
minutes after his next intravenous pain medication
Patients in pain are unable to focus on learning. Waiting 10 to 15 minutes after the administration of
intravenous pain medication allows it to provide relief, but the patient is not sedated or resting soundly.
Waiting until the following day is inappropriate because early intervention and prevention are necessary
The nurse is caring for a 6-year-old patient in the emergency department who just had a full left leg cast
placed for a fracture. As the nurse is reviewing the discharge instructions with the patient's mother, she
states, "You don't have to go over those—I'll read them at home." What should the nurse do?
a. Contact the physician immediately.
b. Consider the possibility of health literacy limitations and assess further.
c. Stop the teaching, because the mother obviously has taken care of casts before.
d. Explain to the mother that reading the instructions with her is required. - Answers Consider the
possibility of health literacy limitations and assess further.
The patient's mother may have limited reading skills or health literacy and should be further assessed.
Contacting the physician in this situation would not be appropriate because ensuring that the patient
and family understand discharge instructions is the responsibility of the nurse. Assuming that the
mother has taken care of casts in the past may be inaccurate. Stating that reading the instructions with
the nurse is a requirement does not ensure that the patient or mother comprehends the instructions.
A 58-year-old male is admitted for a small-bowel obstruction late Saturday night. The nurse obtains
admitting orders, which include the need to place a nasogastric (NG) tube to low intermittent suction.
During the assessment, the nurse determines that the patient does not speak English. What should the
nurse do before placing the NG tube?
a. Assess the presence of any family members who may speak English and the patient's native language.
b. Take two additional staff members into the room when placing the tube so the patient can be
restrained if needed.
c. Request an interpreter by leaving a voicemail on his or her office extension.
d. Do not place the NG tube because the physician would not want to frighten the patient. - Answers
Assess the presence of any family members who may speak English and the patient's native language.
Although an interpreter employed by the hospital would be the best choice, eliciting the help of family
members that speak both the patient's primary language as well as English may be the best option
because the procedure is needed now. This will provide comfort and familiarity for the patient. Taking
additional staff into the room may increase the patient's anxiety, thereby decreasing his ability to
comprehend the instructions. Leaving a message on a voicemail for an interpreter is also incorrect
because the intervention has a level of urgency that may have a detrimental effect if the message is not
retrieved in a relatively short amount of time because it is late on Saturday. Although the physician
,would not want to frighten the patient, he or she ordered the NG tube for the benefit of the patient;
therefore, it needs to be carried out.
Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.)
a. Noncompliance
b. Readiness for Enhanced Knowledge
c. Ineffective Coping
d. Health-Seeking Behaviors
e. Anxiety - Answers b, d
Readiness for Enhanced Knowledge and Health-Seeking Behaviors are appropriate nursing diagnoses for
use in developing a patient teaching plan. Noncompliance would be an appropriate nursing diagnosis for
a patient who has not followed a teaching plan or treatment regimen. Ineffective Coping is not a nursing
diagnosis used in developing a teaching plan, but if a patient is not coping effectively, it may affect the
ability to learn. A nursing diagnosis of Anxiety may affect the patient's ability to learn but is not directly
related to developing a teaching plan.
Which nursing diagnosis is appropriate if a patient expresses an interest in learning?
a. Readiness for Enhanced Knowledge
b. Knowledge Deficit
c. Information Processing
d. Health-Seeking Behaviors - Answers Readiness for Enhanced Knowledge
A patient's expression of an interest in learning is one of the defining characteristics of the nursing
diagnosis, Readiness for Enhanced Knowledge. Knowledge Deficit would indicate that the patient has a
deficiency of knowledge on a particular subject. Information Processing is an outcome rather than a
nursing diagnosis and is the patient's ability to acquire use information. Health-Seeking Behaviors is
active seeking by a person in stable health of ways to alter habits to enhance health.
A 61-year-old male is undergoing an emergency cardiac catheterization when the nurse gives his wife a
packet of registration paperwork and asks her to complete the forms. Which observed actions may
indicate a health literacy issue? (Select all that apply.)
,a. Putting on glasses before beginning the paperwork.
b. Asking someone in the waiting area to read the forms to her "because I need to get new glasses—
these just don't work"
c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the
forms
d. Setting the clipboard aside and staring tearfully out the window
e. Returning the forms only partially filled out, with missing or inaccurate information - Answers b, c, e
Asking someone else to read the form, waiting for help with the forms, and partially or inaccurately
filled-out forms are behaviors indicative of potential health literacy issues. Needing glasses does not
correlate directly with health literacy. A tearful spouse requires additional assessment to see whether
health literacy is a problem. The wife may be overwhelmed and feel unable to complete the forms, or
she may need to collect her thoughts in the midst of a stressful time.
A weight-loss program that combines nutrition instruction with exercise is an example of teaching based
on which domain of learning?
a. Psychomotor
b. Affective
c. Psychosocial
d. Cognitive - Answers Psychomotor
Weight management that combines instruction and exercise is an example of psychomotor domain
learning. Affective domain learning integrates new knowledge by recognizing an emotional component.
Psychosocial is not one of the domains of learning. Cognitive domain learning is based on knowledge
and material that is remembered, memorized, and recalled.
The nurse is providing home care to a 62-year-old female who was recently diagnosed with insulin-
dependent diabetes mellitus. What is the most important reason for the nurse to document the
teaching session?
a. The patient's insurance company requires documentation.
b. The nurse's employer requires documentation of home care sessions.
, c. Other members of the health care team need to know the patient's progress.
d. Insulin is a potentially dangerous medication and needs to be documented. - Answers Other members
of the health care team need to know the patient's progress.
Although the remaining options may be true, the primary reason for specific documentation of a
patient's progress in a teaching plan is to ensure that other nurses or members of other disciplines can
pick up the teaching plan and know precisely what the patient has accomplished and where to begin
additional sessions.
Written instructions showing pictures of the steps necessary to test a blood sugar, along with
demonstration and a return demonstration of the steps, would most benefit which learners?
a. Affective
b. VARK
c. Psychomotor
d. Cognitive - Answers Psychomotor
Psychomotor learning involves physical movement and the use of motor skills such as demonstration
and return demonstration. The affective domain involves emotion, and the cognitive domain is
memorization and recall. VARK (verbal, aural, read/write, kinesthetic) refers to a method of assessing
learning style.
The nurse is providing care to an 88-year-old male patient who just returned from the recovery room
after a right hip replacement. The nurse plans to teach the patient prevention techniques for deep vein
thrombosis. What is the best time to provide teaching?
a. Do it right before the patient's next intravenous pain medication.
b. Wait until tomorrow morning because he is in too much pain today.
c. Leave written materials on his over-the-bed tray that he can read at his convenience.
d. Wait until 10 to 15 minutes after his next intravenous pain medication - Answers Wait until 10 to 15
minutes after his next intravenous pain medication
Patients in pain are unable to focus on learning. Waiting 10 to 15 minutes after the administration of
intravenous pain medication allows it to provide relief, but the patient is not sedated or resting soundly.
Waiting until the following day is inappropriate because early intervention and prevention are necessary
