The nurse is giving preoperative instructions to a 14-year old female client who is scheduled for
surgery to correct a spinal curvature. Which statement by the client best demonstrates that
learning has taken place?
...
The nurse is giving preoperative instructions to a 14-year old female client who is scheduled for
surgery to correct a spinal curvature. Which statement by the client best demonstrates that
learning has taken place?
A. I will read all the literature you gave me before surgery.
B. I have had surgery before when I broke my wrist in a bike accident, so I know what to expect.
C. All the things people have told me will help me take care of my back.
D. I understand that I will be in a body cast and I will show you how you taught me to turn. AnsD. I understand that I will be in a body cast and I will show you how you taught me to turn.
Outcome of learning is best demonstrated when the client not only verbalizes an understanding,
but also can provide a return demonstration. A 14-year old may or may not follow through with
reading material and there is no way of measuring that way of learning. Have a previous surgery
may help the client understand the surgical process, but wrist surgery is very different from
spinal surgery and emergency surgery is different than elective surgery. In (C), the client may be
saying what the nurse wants to hear, without expressing any real understanding of what to do
after surgery.
To take the vital signs of a 4-month old child, which order will give the most accurate results?
A. Respiratory rate, heart rate, then rectal temperature
B. Heart rate, rectal temperature, then respiratory rate.
C. Rectal temperature, heart rate, then respiratory rate
D. Rectal temperature, respiratory rate, then heart rate Ans- A. Respiratory rate, heart rate, then
rectal temperature
The respiratory rate should be taken first in infants, since touching them or performing
unpleasant procedures usually makes them cry, elevating the heart rate and making respirations
difficult to count. Rectal temperature is the most invasive procedure, and is mot likely to
precipitate crying, so should be done last.
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a
tympanic membrane that is pearly gray, slightly bulging, and not movable. What action should
the nurse take next?
A. No action required, as this is an expected finding for a school-aged child
B. Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
C. Send a note home advising the parents to have the child evaluated by a healthcare provider as
soon as possible.
d. Call the parents and have them take the child home from school for the rest of the day. Ans- B.
Ask the child if he/she has had a cold, runny nose, or any ear pain lately.
More information is needed to interpret these findings. The tympanic membrane is normally
pearly gray, not bulging, and moves when the client blows against resistance or a small puff of
air is blown into the ear canal. Since this child's findings are not completely normal, further
assessment of history and related signs and symptoms is indicated for accurate interpretation of
the findings. (A), (C), and (D) are inappropriate actions based on the data obtained from the
otoscope examination.
Which restraint should be used for a toddler after a cleft palate repair?
A. clove hitch
B. Mummy
C. elbow
D. jacket Ans- C. elbow
Elbow restraints
Elbow restraints prevent children from bendi
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