NU470 Week 9: EAQ Communication
Which action relates with the relevance strategy of the motivational learning model proposed by Keller? 1 Extrinsic and intrinsic reinforcements for any learning effort 2 Linking the person's needs, interests, and motives for learning 3 Arousing and sustaining a person's curiosity and interest in learning 4 Having positive hope for successful achievements as a result of learning
2 Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involve linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.
For which clinical indicator would the nurse question an order for a gastric lavage? 1 Decreased serum pH 2 Increased serum oxygen level 3 Increased serum bicarbonate level 4 Decreased serum osmotic pressure
3 Gastric lavage causes an excessive loss of gastric fluid, resulting in excessive loss of hydrochloric acid (HCl), which can lead to alkalosis; the HCl is not available to neutralize the sodium bicarbonate (NaHCO3) secreted into the duodenum by the pancreas. The intestinal tract absorbs the excess bicarbonate, and alkalosis results. Gastric lavage will lead to alkalosis, which is associated with increased pH. Gastric lavage will not affect oxygen levels. Gastric lavage may lead to dehydration, which will increase osmotic pressure.
To prevent thrombophlebitis in the immediate postoperative period, which action is important for the nurse to include in the client's plan of care? 1 Increase fluid intake. 2 Restrict fluids. 3 Encourage early mobility. 4 Elevate the knee gatch of the bed.
3 In the immediate postoperative period, mobility is encouraged because veins require the assistance of the surrounding muscle beds to help pump blood toward the heart. This reduces venous stasis and the risk of thrombophlebitis. Increased fluid intake, if not contraindicated, will prevent dehydration and venous stasis. Restriction of fluids may promote venous stasis and increase risk. Elevating the knee gatch of the bed will impede venous blood flow and increase the risk for thrombophlebitis.
While communicating with a client, the nurse determines that the client has realized the harmful effects of alcohol consumption and plans to stop drinking within 6 months. Which stage of the transtheoretical model of change would the nurse correlate the client's behavior with? 1 Action 2 Preparation 3 Maintenance 4 Contemplation
4 The transtheoretical model of change model defines the changing patterns in an individual in five stages based on beliefs of readiness to change. They are precontemplation, contemplation, preparation, action, and maintenance. In the contemplation stage, the client recognizes the beneficial effects of the change and thinks about the change within 6 months. In the action stage, the client does not think; instead, he or she actively starts making changes. In the preparation stage, the client sets goals and intends to change in the next 60 days. In the maintenance stage, the client sustains the changed action for 6 months and follows preventive measures to prevent relapse.
Which actions demonstrate the "analyticity" concept of a critical thinker? Select all that apply. One, some, or all responses may be correct. 1 The nurse is organized and focused. 2 The nurse trusts his or her own reasoning process. 3 The nurse accepts multiple solutions to a problem. 4 The nurse uses evidence-based knowledge for clinical decision-making. 5 The nurse anticipates possible results or consequences in a given situation.
4,5 Analyticity is one of the concepts of a critical thinker and involves the use of evidence-based knowledge for clinical decision-making. This skill may also help in anticipating the possible results or consequences of a procedure or a given situation. Being organized and focused reflects systematicity. Trusting one's own reasoning process reflects self-confidence. Accepting multiple solutions to a problem reflects maturity.
The registered nurse (RN) is evaluating the statements of a new nurse about wound dressings. Which statement made by the new nurse is incorrect? o "I should wash my hands with alcohol." o "I should use the cotton swab placed on the table." o "I should wash my hands before touching the wound." o "I should wear gloves before touching the site of injury."
o "I should use the cotton swab placed on the table." · Materials used for dressing of wounds must be sterile and free from contamination. The cotton swab placed on the table may not be sterile and if used may cause infections in the client. This statement made by the new orienting nurse indicates the need for further teaching. Alcohol is an antiseptic and can be used to reduce the risk of infections. Clean hands ensure minimum or no risk of infection. Bare hands may be a source of infective organisms; therefore gloves should be worn before touching the site of injury.
The nurse assists in the care of four older clients whose clinical features are shown in the accompanying chart. Which client may have dementia? o Client 1 o Client 2 o Client 3 o Client 4 Client 1 Psychomotor Behavior: Normal Attention: Normal Perception: Misperceptions absence Client 2 Psychomotor Behavior: Hypokinetic Attention: Impaired attention Perception: Difficult to distinguish between reality and perceptions Client 3 Psychomotor Behavior Hyperkinetic Attention: Inattentive Perception: Hallucinations Client 4 Psychomotor Behavior: Psychomotor retardation Attention: Easily distractible Perception: Illusions present
o Client 1 · Client 1 has normal psychomotor behavior. The attention of the client is also indicated to be normal. Moreover, misperceptions are absent. Client 1 may likely have dementia. Hypokinetic psychomotor behavior, impaired attention, and difficulty in distinguishing between reality and perceptions may signify delirium. Hyperkinetic behavior and inattention with hallucinations may also signify delirium. Psychomotor retardation, easily distractible attention, and illusions may be caused by depression.
Which pressure change does the nurse determine to be the cause of edema for a client with albuminuria? o Decrease in tissue hydrostatic pressure o Increase in plasma hydrostatic pressure o Increase in tissue colloid osmotic pressure o Decrease in plasma colloid oncotic pressure
o Decrease in plasma colloid oncotic pressure · Because the plasma colloid oncotic pressure is the major force drawing fluid from the interstitial spaces back into the capillaries, a drop in colloid oncotic pressure caused by albuminuria results in edema. Hydrostatic tissue pressure is unaffected by alteration of protein levels; colloidal pressure is affected. Hydrostatic pressure is influenced by the volume of fluid and the diameter of the blood vessel, not directly by the presence of albumin. The osmotic pressure of tissues is unchanged.
Which action would the nurse take when observing that a postsurgical client has a urine output of 800 mL total in the first 24 hours after surgery? o Notify the provider. o Increase oral fluid intake. o Document the normal finding. o Begin an intravenous infusion of normal saline.
o Document the normal finding. · A low urine output of 800 to 1500 mL is normal in the first 24 hours after surgery. The nurse would document the normal finding and continue to monitor urine output in the postoperative period. It is not necessary to increase oral or intravenous fluid intake or notify the provider unless urine output does not increase.
To ensure the safety of a client who is receiving a continuous intravenous normal saline infusion, the nurse would change the administration set how often? o Every 4 to 8 hours o Every 12 to 24 hours o Every 24 to 48 hours o Every 72 to 96 hours
o Every 72 to 96 hours · Best practice guidelines recommend replacing administration sets no more frequently than 72 to 96 hours after initiation of use in clients not receiving blood, blood products, or fat emulsions. This evidence-based practice is safe and cost effective. Changing the administration set every 4 to 48 hours is not a cost-effective practice.
Which action relates with the relevance strategy of the motivational learning model proposed by Keller? o Extrinsic and intrinsic reinforcements for any learning effort o Linking the person's needs, interests, and motives for learning o Arousing and sustaining a person's curiosity and interest in learning o Having positive hope for successful achievements as a result of learning
o Linking the person's needs, interests, and motives for learning · Keller proposed a motivational learning model that includes four factors: attention, relevance, confidence, and satisfaction (ARCS). Relevance strategies involve linking the person's needs, interests, and motives for learning. The attention strategies include arousing and sustaining one's curiosity and interest. Confidence strategies include helping people develop a positive expectation for goal achievement. Satisfaction strategies provide extrinsic and intrinsic reinforcement for efforts.
Which action would the nurse take to decrease the risk of transmission of vancomycin-resistant enterococci (VRE)? o Insert a urinary catheter. o Initiate droplet precautions. o Move the client to a private room. o Use a high-efficiency particulate air (HEPA) respirator during care.
o Move the client to a private room. · Contact precautions are used for clients with known or suspected infections transmitted by direct contact or contact with items in the environment; therefore infectious clients must be placed in a private room. There is no need to insert an indwelling catheter, because this can increase the risk for additional infection. Droplet precautions are used for clients known or suspected to have infections transmitted by the droplet route. These infections are caused by organisms in droplets that may travel 3 feet but are not suspended for long periods.
An older adult is experiencing emotional stress after a recent surgery. Which intervention would be most appropriate for the client? o Touch o Reminiscence o Reality orientation o Validation therapy
o Reality orientation · A client who has undergone surgery may experience emotional stress leading to disorientation. Reality orientation is an appropriate intervention to minimize the client's disorientation. Touch is a therapeutic tool that helps induce relaxation, provide physical and emotional comfort, and communicate interest. Reminiscence helps bring meaning and understanding to the present and resolve current conflicts by recollecting the past. Validation therapy is a communication technique that can help the client in a confused state.
The nursing team is providing care for a client. The team leader develops client care plans and coordinates care among the team members. Which member of the team acts as a team leader? o Charge nurse o Registered nurse (RN) o Licensed practical nurse (LPN) o Unlicensed assistive personnel (UAP)
o Registered nurse (RN) · The RN acts as a team member by creating a care plan for the client and coordinating care among the team members. The RN works directly with the client, family, and health care team members. The charge nurse assigns tasks to the other health care professionals if the RN is absent. The LPN provides care to the client under the supervision of RN. The UAP are team members who provide care to the client under the supervision of the RN.
Which would the nurse include in dietary teaching for a client with a colostomy? o Liquids should be limited to 1 L per day. o Nondigestible fiber and fruits should be eliminated. o A formed stool is an indicator of constipation. o The diet should be adjusted to result in manageable stools.
o The diet should be adjusted to result in manageable stools. · Each person will need to experiment with diet after a colostomy to determine what foods are best tolerated and produce stools that are manageable depending on the type of colostomy. Liquids are typically not limited unless there is a specific reason such as cardiac or renal disease. Foods high in fiber such as fruit should be included in the diet as tolerated. Depending on the type of colostomy and the diet, a formed stool is acceptable and does not indicate a constipating diet.
A client in the second (acute) phase of burn recovery may exhibit an increase in which value? o Serum sodium o Urinary output o Hematocrit level o Serum potassium
o Urinary output · As fluid returns to the vascular system, increased renal flow and diuresis occur. An increase in the serum sodium level (hypernatremia) is not a common response identified during the second (acute) phase of burn recovery. An increase in the hematocrit level indicates hemoconcentration and hypovolemia; in the second phase of burn recovery, hemodilution and hypervolemia occur. During the second phase of burn recovery, potassium moves back into the cells, decreasing serum potassium.
Which example in nursing practice would demonstrate Watson's carative factor called forming a human-altruistic value system? o Assisting clients with their basic needs o Creating a healing environment at all levels o Allowing spiritual forces to provide a better understanding o Using self-disclosure to promote a therapeutic alliance with the client
o Using self-disclosure to promote a therapeutic alliance with the client The carative factor, called instilling faith-hope, includes the use of self-disclosure to promote a therapeutic alliance with the client. The carative factor of meeting human needs involves the nurse addressing the basic needs of the clients. The nurse allowing the use of spiritual forces to provide a better understanding is associated with the carative factor called allowing existential, phenomenological, and spiritual forces. When the nurse uses self-disclosure for promoting a therapeutic alliance with the client, this action is a part of forming a human-altruistic value system.