ATI Msn De5320 Fundamentals Exam | Nurselytic

Correct Answer: B,C,D

Rationale:
Correct
Answer: B, C, D


Rationale:
B: Turning the client on their side helps prevent aspiration in case of vomiting due to the decreased level of consciousness.
C: Placing a fan to blow lightly toward the client can provide comfort and help with air circulation.
D: Administering an opioid narcotic can help manage pain and provide comfort in end-of-life care.
Incorrect

Choices:
A: Telling the client there is nobody else in the room is not a priority in addressing the client's physiological needs.
E: Providing deep nasotracheal suctioning is invasive and not indicated unless there is a clear need for airway clearance.
In summary, the correct actions focus on maintaining the client's comfort, safety, and symptom management during end-of-life care, while the incorrect actions are either not relevant or potentially harmful in this context.

Correct Answer: C

Rationale: The correct answer is C: Return demonstration. This teaching strategy involves the client showing their understanding and ability to perform a skill after being taught by the nurse. By asking the client to perform the skill with the walker, the nurse can assess the client's comprehension and ability to execute the task correctly. This hands-on approach helps reinforce the learning process and allows for immediate feedback.

Incorrect answers:
A: Question-and-answer - This strategy involves the nurse asking the client questions to assess understanding, but it does not involve the client physically demonstrating the skill.
B: Role-play - This strategy involves acting out scenarios, which is not the same as the client physically performing the skill.
D: Discussion - This involves verbal exchange of ideas but not necessarily the physical demonstration of a skill like in return demonstration.

Correct Answer: A

Rationale: The correct answer is A. Providing educational material written at an eighth-grade reading level is essential for effective preoperative teaching. This ensures that the information is easily understood by the client. Turning on the television (
B) may distract the client and is not a focused educational strategy. Using technical language (
C) can confuse the client and hinder comprehension. Starting with the most important information (
D) is beneficial, but ensuring the material is at an appropriate reading level takes precedence in effective teaching.

Correct Answer: A

Rationale: The correct answer is A: Ask the client to demonstrate walking with the cane. This is the evaluation step of the teaching plan because it assesses the client's ability to apply the knowledge and skills learned. By asking the client to demonstrate, the nurse can observe if the client has understood and can perform the task correctly. This step provides direct evidence of the client's progress and comprehension.
Explanation for other choices:
B: Showing a video is a teaching method, not an evaluation step.
C: Identifying short-term goals is a planning step, not an evaluation.
D: Determining readiness to learn is an assessment step, not evaluation.

Correct Answer: C

Rationale: The correct answer is C: Acute pain related to unknown etiology. This is the most appropriate nursing diagnosis because it acknowledges that the pain is present but the underlying cause is unknown. It allows the nurse to focus on managing the pain and exploring potential causes without making assumptions.
Choice A is incorrect as it only focuses on the client's report of pain without addressing the cause.
Choice B is incorrect as it assumes the pain is related to a psychosomatic condition without evidence.
Choice D is incorrect as it is too vague and does not provide direction for addressing the pain.