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 th...
NSG 3130 Exam 2 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? a. Contact the physician immediately. b. Consider the possibility of health literacy limitations and assess further. c. Stop the teaching, because the mother obviously has taken care of casts before. d. Explain to the mother that reading the instructions with her is required. - b. Consider the possibility of health literacy limitations and assess further. A 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 that 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 admitting orders 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 should the nurse take first before placing the NG tube? a. Use two additional staff members when placing the tube so the patient can be restrained if needed. b. Request an interpreter per facility protocol. c. Do not place the NG tube because the physician would not want to frighten the patient. d. Document the inability to place the NG tube due to lack of ability to communicate. - b. Request an interpreter per facility protocol. An interpreter employed by the hospital would be the best choice so that someone in the room can communicate and provide comfort for the patient. Taking additional staff into the room may increase the patient's anxiety, thereby decreasing his ability to co mprehend the instructions. Although the physician would not want to frighten the patient, the physician ordered the nasogastric (NG) tube for the benefit of the patient; therefore, it needs to be placed. Documenting the inability to place the NG tube due t o lack of means of communication is not acceptable and does not ensure that the patient gets the needed treatment. Which nursing diagnoses are used in developing a patient teaching plan? (Select all that apply.) a. Moral Distress b. Lack of Knowledge c. Difficulty Coping d. Teaching about Disease e. Anxiety - b Lack of Knowledge 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 developin g 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. Teaching about Disease is not a nursing diagnosis. It is an intervention performed by the nurse. Which nursing diagnosis is appropriate if a patient expresses an interest in learning? a. Ready to Learn b. Lack of Knowledge c. Effective Information Processing d. Health -Seeking Behaviors - a. Ready to Learn A patient's expression of an interest in learning would indicate correct use of the nursing diagnosis, Ready to Learn. Lack of Knowledge would indicate the patient has a deficiency of knowledge on a particular subject. Effective Information Processing is t he patient's ability to acquire useful information. Health -Seeking Behaviors is active seeking by a person of ways to alter habits to enhance health. A 61 -year-old man is undergoing an emergency cardiac catheterization. The nurse gives his wife the registration paperwork to complete. Which observed actions may indicate a health literacy issue? (Select all that apply.) a. Putting on glasses before beginning the paperwork. b. Asking someone in the waiting area to read the forms to her. c. Waiting until her daughter arrives to begin the paperwork so that her daughter can complete the forms. d. Setting the clipboard aside and staring tearfully out the window. e. Returning the forms only partially filled out, with missing or inaccurate information. - b, c, e Asking someone else to read the form, waiting for help with the forms, and partially or inaccurately filling out forms are behaviors indicative of potential health literacy issues. 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 demonstration by the patient, is an example of teaching based on which domain of learning? a. Psychomotor b. Affective c. Psychosocial d. Cognitive - a. Psychomotor Demonstration along with a return demonstration by the patient is an example of psychomotor domain learning. Affective domain learning integrates new knowledge by recognizing an emotional component. Psychosocial is not one of the domains of learning. Cogni tive 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? a. The patient's insurance company requires documentation. b. The nurse's employer requires documentation of home care sessions. c. Other members of the health care team need to know the patient's progress. d. Insulin is a potentially dangerous medication and needs to be documented. - c. Other members of the health care team need to know the patient's progress.
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