left leg cast placed for a fracture. As the nurse is reviewing the discharge instructions with the

NUR 220 Evolve

• 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?

• Contact the physician immediately.
• Consider the possibility of health literacy limitations and assess further.
• Stop the teaching, because the mother obviously has taken care of casts before.
• Explain to the mother that reading the instructions with her is required.

Answer

• 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 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 man 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. Which action(s) should the nurse do before placing the NG tube?

• Take two additional staff members into the room when placing the tube so the patient can be

restrained if needed.

• Request an interpreter per facility protocol.
• Do not place the NG tube because the physician would not want to frighten the patient.
• Document the inability to place the NG tube due to lack of ability to communicate.

Answer B.

• Which nursing diagnoses are used in developing a patient teaching plan? (Select all that

apply.)

• Moral Distress
• Ready to Learn
• Difficulty Coping
• Literacy Problem 1 / 3

• Anxiety

Answer B, D

• Ready to Learn and Literacy Problem are appropriate nursing diagnoses for use in

developing a patient teaching plan. Moral Distress is a nursing diagnosis for those facing ethical decisions. Difficulty 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?
• Ready to Learn
• Lack of Knowledge
• Effective Information Processing
• Health-Seeking Behaviors

Answer A

• A 61-year-old man 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.)

• Putting on glasses before beginning the paperwork.
• Asking someone in the waiting area to read the forms to her "because I need to get new

glasses—these just don't work."

• Waiting until her daughter arrives to begin the paperwork so that her daughter can complete

the forms.

• Setting the clipboard aside and staring tearfully out the window.
• Returning the forms only partially filled out, with missing or inaccurate information.

Answer

B, C, E

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.

• Teaching a patient to use an incentive spirometer by demonstration, with a return 2 / 3

demonstration by the patient is an example of teaching based on which domain of learning?

• Psychomotor
• Affective
• Psychosocial

• Cognitive

Answer A

Affective domain learning integrates new knowledge by recognizing an emotional component.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 woman who was recently diagnosed with

insulin-dependent diabetes mellitus. What is the most important reason for the nurse to document the teaching session?

• The patient's insurance company requires documentation.
• The nurse's employer requires documentation of home care sessions.
• Other members of the health care team need to know the patient's progress.
• Insulin is a potentially dangerous medication and needs to be document- ed.

Answer

• (other answers are true but this is the most true?)

• Written instructions showing pictures of the steps necessary to test blood glucose, along

with demonstration and a return demonstration of the steps, would most benefit which learners?

• Affective
• VARK
• Psychomotor
• Cognitive

Answer C

• 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?

• Do it right before the patient's next intravenous pain medication.
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