FUNDAMENTA 102Fundamental of Adaptive quizzes (1) 2022.
A NURSE ASSESSES DRAINAGE ON A SURGICAL DRESSING AND
DOCUMENTS THE FINDINGS. WHICH DOCUMENTATION IS MOST
INFORMATIVE?
" "Moderate amount of drainage."
" "No change in drainage since yesterday."
" "A 10-mm-diameter area of drainage at 1900 hours."
" "Drainage is doubled in size since last dressing change."
Rationale
A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details
regarding the assessment and a timeframe. By providing size, it establishes parameters to
compare with previous assessments and to further evaluate the drainage. "Moderate amount of
drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last
dressing change" are not specific, objective, or measurable.
WHEN PLANNING DISCHARGE TEACHING FOR A YOUNG ADULT, THE
NURSE SHOULD INCLUDE THE POTENTIAL HEALTH PROBLEMS COMMON
IN THIS AGE GROUP. WHAT SHOULD THE NURSE INCLUDE IN THIS
TEACHING PLAN?
Kidney dysfunction
Cardiovascular diseases
Eye problems, such as glaucoma
Accidents, including their prevention
Rationale
Accidents are common during young adulthood because of immature judgment and impulsivity
associated with this stage of development. Kidney dysfunction is not a problem specific to any
,FUNDAMENTA 102Fundamental of Adaptive quizzes (1) 2022.
one stage of growth. Cardiovascular disease is a common health problem in middle adulthood.
Glaucoma is a common health problem in older adults.
A CLIENT HAS CLOSTRIDIUM DIFFICILE. THE NURSE IS PROVIDING
DISCHARGE INSTRUCTIONS RELATED TO DECREASING THE RISK OF
TRANSMISSION TO FAMILY MEMBERS. WHAT WOULD BE APPROPRIATE
TO INCLUDE IN THE CLIENT'S TEACHING?
Increase fluids.
,FUNDAMENTA 102Fundamental of Adaptive quizzes (1) 2022.
Increase fiber in the diet.
Wash hands with soap and water.
Wash hands with an alcohol-based hand sanitizer.
Rationale
Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-
based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission
of C. difficile.
A CLIENT WHO IS IN THE ADVANCED STAGES OF ILLNESS ASKS THE
NURSE TO CONTACT PASTORAL SERVICES FOR SUPPORT. ACCORDING TO
THE MACMILLAN MODEL, WHAT IS THE BEST NURSING INTERVENTION
IN THIS SITUATION?
Immediately involve pastoral services while caring for the client.
Involve the family member in the client’s care instead of pastoral support.
Listen to the client’s request for support then carry on with the clinical work.
Falsely promise that pastoral services has been contacted and plan to see the client.
Rationale
The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty
training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social,
and psychologic needs and the pathophysiology of clients living with advanced diseases.
Therefore, the nurse involves pastoral services while caring for the client. Involving a family
member may decrease anxiety in the client but may not fulfill the wishes of the client. Just
listening to the client’s request without implementation or giving false promises can cause loss
of trust in the client.
, FUNDAMENTA 102Fundamental of Adaptive quizzes (1) 2022.
DURING FOLLOW-UP VISITS, THE CLIENT’S CHILD REPORTS TO THE
NURSE, "I TELL MY PARENT EVERY DAY ABOUT WHAT MAY HAPPEN IF
MEDICATIONS AREN’T TAKEN AS PRESCRIBED. DESPITE THAT, MY
PARENT DOES NOT TAKE THE MEDICATION REGULARLY AND IS
DEPRESSED." WHAT CAN BE INFERRED ABOUT THE CLIENT’S
MOTIVATIONAL LEVEL?
Not motivated
Intrinsically motivated
A NURSE ASSESSES DRAINAGE ON A SURGICAL DRESSING AND
DOCUMENTS THE FINDINGS. WHICH DOCUMENTATION IS MOST
INFORMATIVE?
" "Moderate amount of drainage."
" "No change in drainage since yesterday."
" "A 10-mm-diameter area of drainage at 1900 hours."
" "Drainage is doubled in size since last dressing change."
Rationale
A 10-mm-diameter area of drainage at 1900 hours is objective data and gives specific details
regarding the assessment and a timeframe. By providing size, it establishes parameters to
compare with previous assessments and to further evaluate the drainage. "Moderate amount of
drainage," "No change in drainage since yesterday," and "Drainage is doubled in size since last
dressing change" are not specific, objective, or measurable.
WHEN PLANNING DISCHARGE TEACHING FOR A YOUNG ADULT, THE
NURSE SHOULD INCLUDE THE POTENTIAL HEALTH PROBLEMS COMMON
IN THIS AGE GROUP. WHAT SHOULD THE NURSE INCLUDE IN THIS
TEACHING PLAN?
Kidney dysfunction
Cardiovascular diseases
Eye problems, such as glaucoma
Accidents, including their prevention
Rationale
Accidents are common during young adulthood because of immature judgment and impulsivity
associated with this stage of development. Kidney dysfunction is not a problem specific to any
,FUNDAMENTA 102Fundamental of Adaptive quizzes (1) 2022.
one stage of growth. Cardiovascular disease is a common health problem in middle adulthood.
Glaucoma is a common health problem in older adults.
A CLIENT HAS CLOSTRIDIUM DIFFICILE. THE NURSE IS PROVIDING
DISCHARGE INSTRUCTIONS RELATED TO DECREASING THE RISK OF
TRANSMISSION TO FAMILY MEMBERS. WHAT WOULD BE APPROPRIATE
TO INCLUDE IN THE CLIENT'S TEACHING?
Increase fluids.
,FUNDAMENTA 102Fundamental of Adaptive quizzes (1) 2022.
Increase fiber in the diet.
Wash hands with soap and water.
Wash hands with an alcohol-based hand sanitizer.
Rationale
Alcohol does not kill C. difficile spores. Use of soap and water is more efficacious than alcohol-
based hand rubs. Increased fluids and increased fiber do not decrease the risk of transmission
of C. difficile.
A CLIENT WHO IS IN THE ADVANCED STAGES OF ILLNESS ASKS THE
NURSE TO CONTACT PASTORAL SERVICES FOR SUPPORT. ACCORDING TO
THE MACMILLAN MODEL, WHAT IS THE BEST NURSING INTERVENTION
IN THIS SITUATION?
Immediately involve pastoral services while caring for the client.
Involve the family member in the client’s care instead of pastoral support.
Listen to the client’s request for support then carry on with the clinical work.
Falsely promise that pastoral services has been contacted and plan to see the client.
Rationale
The Macmillan nurse usually has the knowledge of advanced practice and possesses specialty
training. This practice enhances the nurse to gain an in-depth knowledge about spiritual, social,
and psychologic needs and the pathophysiology of clients living with advanced diseases.
Therefore, the nurse involves pastoral services while caring for the client. Involving a family
member may decrease anxiety in the client but may not fulfill the wishes of the client. Just
listening to the client’s request without implementation or giving false promises can cause loss
of trust in the client.
, FUNDAMENTA 102Fundamental of Adaptive quizzes (1) 2022.
DURING FOLLOW-UP VISITS, THE CLIENT’S CHILD REPORTS TO THE
NURSE, "I TELL MY PARENT EVERY DAY ABOUT WHAT MAY HAPPEN IF
MEDICATIONS AREN’T TAKEN AS PRESCRIBED. DESPITE THAT, MY
PARENT DOES NOT TAKE THE MEDICATION REGULARLY AND IS
DEPRESSED." WHAT CAN BE INFERRED ABOUT THE CLIENT’S
MOTIVATIONAL LEVEL?
Not motivated
Intrinsically motivated
