FUNDAMENTALS OF ADAPTIVE QUIZZES REVIEW

A nurse assesses drainage on a surgical dressing and documents the findings. Which documentation is most informative? " "Moderate amount of drainage." " "No change in drainage since yesterday." " "A 10-mm-diameter area of drainage at 1900 hours." " "Drainage is doubled in size since last dressing change." Rationale A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details regarding the assessment and a timeframe. By providing size, it establishes parameters to compare with previous assessments and to further evaluate the drainage. "Moderate amount of drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last dressing change" are not specific, objective, or measurable. When planning discharge teaching for a young adult, the nurse should include the potential health problems common in this age group. What should the nurse include in this teaching plan? Kidney dysfunction Cardiovascular diseases Eye problems, such as glaucoma Accidents, including their prevention Rationale Accidents are common during young adulthood because of immature judgment and impulsivity associated with this stage of development. Kidney dysfunction is not a problem specific to any one stage of growth. Cardiovascular disease is a common health problem in middle adulthood. Glaucoma is a common health problem in older adults. A client has Clostridium difficile. The nurse is providing discharge instructions related to decreasing the risk of transmission to family members. What would be appropriate to include in the client's teaching? Increase fluids. Increase fiber in the diet. Wash hands with soap and water. Wash hands with an alcohol-based hand sanitizer. Rationale Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol- based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission of C. difficile. A client who is in the advanced stages of illness asks the nurse to contact pastoral services for support. According to the Macmillan model, what is the best nursing intervention in this situation? Immediately involve pastoral services while caring for the client. Involve the family member in the client’s care instead of pastoral support. Listen to the client’s request for support then carry on with the clinical work. Falsely promise that pastoral services has been contacted and plan to see the client. Rationale The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social, and psychologic needs and the pathophysiology of clients living with advanced diseases. Therefore, the nurse involves pastoral services while caring for the client. Involving a family member may decrease anxiety in the client but may not fulfill the wishes of the client. Just listening to the client’s request without implementation or giving false promises can cause loss of trust in the client. During follow-up visits, the client’s child reports to the nurse, "I tell my parent every day about what may happen if medications aren’t taken as prescribed. Despite that, my parent does not take the medication regularly and is depressed." What can be inferred about the client’s motivational level? Not motivated Intrinsically motivated Extrinsically motivated with self-determination Extrinsically motivated without self-determination Rationale If the client is not motivated, then the client may not attempt to eradicate the illness and feel depressed because of the illness. If the client is intrinsically motivated, then the client shows more interest in taking their medications on their own rather than because of pressure from other individuals. The client is motivated extrinsically with or without self-determination when they may take medication regularly when reminded to do so or when pressured by others.