EAQ Nursing Process - Evaluation

A licensed practical nurse discusses the role of a clinical nurse specialist in caring for a client with muscular dystrophy with a nursing student. Which statement by the nursing student about the duties of the clinical nurse specialist is correct?

"A clinical nurse specialist provides the client's care instructions to the caregivers."

A client with diabetes is given instructions about foot care. The nurse determines that the instructions are understood when the client makes which statement?

"I will break in my new shoes over the course of several weeks."

A parent who has been physically abusing a 7-year-old son is undergoing treatment for anger management. What statement by the client indicates the development of some insight into the abusive behavior?

"If I feel upset at my son, I'm going to go into the bedroom and punch a pillow."

A nurse is evaluating a newly-hired nurse after an education session on sexual disorders. Which of these statements made by the newly-hired nurse need correction? Select all that apply.

*Increased estrogen leads to vaginitis. *The risk of breast cancer decreases after 40 years of age.

A client experiences a hypoglycemic reaction to insulin. Which client responses should the nurse document as clinical manifestations of hypoglycemia? Select all that apply.

*Pallor *Tremors *Diaphoresis

After a difficult birth, a neonate has an Apgar score of 8 after 5 minutes. Which signs met the criteria of 2 points? Select all that apply.

*Reflex irritability: cry *Respiratory rate: good cry *Heart rate: 110 beats/min

A nursing instructor asks a nursing student to explain the importance of play in toddlers. Which statement by the student indicates adequate teaching? Select all that apply.

*Toddlers prefer to play beside other children. *Toddlers prefer to stay close to parents while playing.

A 4-year-old child is brought to the emergency department with a fractured tibia. Which type of fracture is most common in children of this age?

Greenstick

A student is anxious about an upcoming examination but is able to study intently and does not become distracted by a roommate's talking and loud music. What level of anxiety is demonstrated by the student's ability to shut out the distractions?

Mild

The nurse presents a program on breast self-examination. After a return demonstration the nurse concludes that she needs to review certain aspects of the teaching program. Which behavior by one of the students supports this conclusion?

Palpating each breast while in the sitting position

A client at 36 weeks gestation is admitted to the high-risk unit with the diagnosis of severe preeclampsia, and antiseizure therapy is instituted. A fetal monitor and an electronic blood pressure machine are applied. Which complication of severe preeclampsia requires diligent monitoring of the blood pressure?

Stroke

A nurse is assessing an adolescent after the administration of epinephrine. What side effect is most important for the nurse to identify?

Tachycardia

The parents of a 2½-year-old child whose older sibling recently died tell a nurse in the pediatric well-child clinic that their child has started to hit them and refuses to go to bed at night. What is the best explanation the nurse can give for this behavior?

This is an appropriate reaction to anxiety within the household.

What does the nurse identify as an early sign of chronic lead poisoning (plumbism) in school-aged children?

Anemia

A nurse withholds methylergonovine maleate (Methergine) from a postpartum client. What clinical finding supports the withholding of the medication?

Blood pressure of 160/90 mm Hg

A female client who is severely incapacitated by obsessive-compulsive behavior has been admitted to the mental health hospital. The client's compulsive ritual involves changing her clothing 8 to 12 times a day. She continually asks the nurse for advice regarding her problems but then ignores it. This is an example of which conflict?

Dependence versus independence

On the third postpartum day after a cesarean birth a client tells the nurse that her breasts feel warm, firm, and tender. The skin is shiny and taut. What does the nurse suspect as the cause of the client's breast discomfort?

Extended vascular and lymphatic circulation in the breasts

A nonstress test is scheduled for a client with preeclampsia. During the nonstress test the nurse concludes that if nonperiodic accelerations of the fetal heart rate occur with fetal movement, this probably indicates what?

Fetal well-being

What is the primary outcome for client care in the third stage of labor?

Firmly contracted uterine fundus

A client is admitted to the hospital with the diagnosis of cancer of the thyroid and a thyroidectomy is scheduled. What is important for the nurse to consider when caring for this client during the postoperative period?

Hoarseness and airway obstruction may result from laryngeal nerve damage.

A complete blood count is ordered for a 5-month-old infant with Tetralogy of Fallot. What does the nurse expect to see when reviewing the laboratory results?

Polycythemia

Sitz baths are prescribed for a client with an episiotomy during the postpartum period. How do the sitz baths aid the healing process?

Promoting vasodilation

When a client at 39 weeks' gestation arrives at the birthing suite she says, "I've been having contractions for 3 hours, and I think my water broke." What will the nurse do to confirm that the membranes have ruptured?

Test the leaking fluid with nitrazine paper

A 3-year-old boy has been observed in the clinic waiting room taking toys from others, tearing pages out of books, and striking his mother. Why does the nurse take time when interviewing the mother to ask about the child's television habits?

Viewing violent programs is positively correlated with the development of aggression

A new nurse has been assigned to a school-aged child who is in contact isolation for methicillin-resistant Staphylococcus aureus (MRSA). The primary nurse observes the new nurse during morning care. Which behavior should the primary nurse address to improve isolation technique?

While changing the bed the nurse wears gloves but no gown.