Introductory Maternity and Pediatric Nursing 4th Edition Hatfield Test Bank

Introductory Maternity and Pediatric Nursing 4th Edition Hatfield Test Bank 3. Which most therapeutic response to the clients statement, Im afraid to have a cesarean birth should be made by the nurse? a. Everything will be OK. b. Dont worry about it. It will be over soon. c. What concerns you most about a cesarean birth? d. The physician will be in later and you can talk to him. ANS: C The response, What concerns you most about a cesarean birth focuses on what the client is saying and asks for clarification, which is the most therapeutic response. The response, Everything will be ok is belittling the clients feelings. The response, Dont worry about it. It will be over soon will indicate that the clients feelings are not important. The response, The physician will be in later and you can talk to him does not allow the client to verbalize her feelings when she wishes to do that. PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: Nursing Process Step: Implementation MSC: Client Needs: Psychosocial Integrity 4. Which action should the nurse take to evaluate the clients learning about performing infant care? a. Demonstrate infant care procedures. b. Allow the client to verbalize the procedure. c. Routinely assess the infant for cleanliness. d. Observe the client as she performs the procedure. ANS: D The clients correct performance of the procedure under the nurses supervision is the best proof of her ability. Demonstration is an excellent teaching method, but not an evaluation method. During verbalization of the procedure, the nurse may not pick up on techniques that are incorrect. It is not the best tool for evaluation. Routinely assessing the infant for cleanliness will not ensure that the proper procedure is carried out. The nurse may miss seeing that unsafe techniques being used. PTS: 1 DIF: Cognitive Level: Application REF: 21 OBJ: Nursing Process Step: Evaluation MSC: Client Needs: Health Promotion and Maintenance 5. A nurse is reviewing teaching and learning principles. Which situation is most conducive to learning? a. An auditorium is being used as a classroom for 300 students. b. A teacher who speaks very little Spanish is teaching a class of Hispanic students. c. A class is composed of students of various ages and educational backgrounds. d. An Asian nurse provides nutritional information to a group of pregnant Asian women. ANS: D A clients culture influences the learning process; thus, a situation that is most conducive to learning is one in which the teacher has knowledge and understanding of the clients cultural beliefs. A large class is not conducive to learning. It does not allow questions, and the teacher cannot see nonverbal cues from the students to ensure understanding. The ability to understand the language in which teaching is done determines how much the client learns. Clients for whom English is not their primary language may not understand idioms, nuances, slang terms, informed usage of words, or medical terms. The teacher should be fluent in the language of the student. Developmental levels and educational levels influence how a person learns best. For the teacher to present the information in the best way, the class should be at the same level. PTS: 1 DIF: Cognitive Level: Application REF: 20 OBJ: Nursing Process Step: Planning MSC: Client Needs: Psychosocial Integrity 6. Which is the step of the nursing process in which the nurse determines the appropriate interventions for the identified nursing diagnosis? a. Planning b. Evaluation c. Assessment d. Intervention ANS: A The third step in the nursing process involves planning care for problems that were identified during assessment. The evaluation phase is determining whether the goals have been met. During the assessment phase, data are collected. The intervention phase is when the plan of care is carried out. PTS: 1 DIF: Cognitive Level: Understanding REF: 24 OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment 7. Which goal is most appropriate for the collaborative problem of wound infection? a. The client will not exhibit further signs of infection. b. Maintain the clients fluid intake at 1000 mL/8 hr. c. The client will have a temperature of 98.6 F within 2 days. d. Monitor the client to detect therapeutic response to antibiotic therapy. ANS: D In a collaborative problem, the goal should be nurse-oriented and reflect the nursing interventions of monitoring or observing. Monitoring for complications such as further signs of infection is an independent nursing role. Intake and output is an independent nursing role. Monitoring a clients temperature is an independent nursing role. PTS: 1 DIF: Cognitive Level: Application REF: 18 OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment 8. Which nursing intervention is correctly written? a. Force fluids as necessary. b. Observe interaction with the infant. c. Encourage turning, coughing, and deep breathing. d. Assist to ambulate for 10 minutes at 8 AM, 2 PM, and 6 PM. ANS: D Interventions might not be carried out if they are not detailed and specific. Force fluids is not specific; it does not state how much. Encouraging the client to turn, cough, and breathe deeply is not detailed and specific. Observing interaction with the infant does not state how often this procedure should be done. PTS: 1 DIF: Cognitive Level: Application REF: 25 OBJ: Nursing Process Step: Planning MSC: Client Needs: Safe and Effective Care Environment 9. The client makes the statement: Im afraid to take the baby home tomorrow. Which response by the nurse would be the most therapeutic? a. Youre afraid to take the baby home? b. Dont you h