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.
Right Ans - b. Consider the possibility of health literacy limitations and assess
further.
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?
a. Take two additional staff members into the room 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. Right Ans - b. Request an interpreter per facility protocol.
Which nursing diagnoses are used in developing a patient teaching plan?
(Select all that apply.)
a. Moral Distress
b. Ready to Learn
c. Difficulty Coping
d. Literacy Problem
e. Anxiety Right Ans - b. Ready to Learn
d. Literacy Problem
, 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 Right Ans - a. Ready to Learn
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.)
a. Putting on glasses before beginning the paperwork.
b. Asking someone in the waiting area to read the forms to her "because I need
to get new glasses—these just don't work."
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. Right Ans - b. Asking someone in the waiting area to read the
forms to her "because I need to get new glasses—these just don't work."
c. Waiting until her daughter arrives to begin the paperwork so that her
daughter can complete the forms.
e. Returning the forms only partially filled out, with missing or inaccurate
information.
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 Right Ans - a. Psychomotor
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