A nurse is preparing a teaching plan for a client who is learning to walk with a cane. The nurse should identify that which of the following actions is a evaluation step of the teaching plan?
Ask the client to demonstrate walking with the cane.
Show the client a video about walking with a cane.
Identify short-term goals for the client.
Determine the client's readiness to learn.
The Correct Answer is A
A. Ask the client to demonstrate walking with the cane: Correct. Evaluation involves assessing the client’s ability to perform the learned skill, which is done by asking the client to demonstrate walking with the cane.
B. Show the client a video about walking with a cane: This is part of the teaching process, not evaluation. It is used to provide information but does not assess the client's understanding or ability.
C. Identify short-term goals for the client: This is part of the planning stage, where goals are set to guide the teaching and learning process, not part of evaluation.
D. Determine the client's readiness to learn: This is an initial assessment step before teaching begins, not part of the evaluation process after teaching has occurred.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Bronchial airway constriction: During the fight-or-flight response, bronchial airways typically dilate to increase airflow to the lungs, not constrict.
B. Hypoglycemia: The fight-or-flight response typically increases blood glucose levels to provide quick energy, leading to hyperglycemia rather than hypoglycemia.
C. Dilated pupils: Pupils dilate during the fight-or-flight response to enhance vision and perception of potential threats. This is a correct manifestation of the stress response.
D. Decreased blood pressure: The fight-or-flight response usually causes an increase in blood pressure due to the release of adrenaline and other stress hormones that prepare the body for immediate action.
Correct Answer is B
Explanation
A. Use a square knot. Using a square knot is not recommended for securing restraints because it can be difficult to quickly release in an emergency. Instead, restraints should be secured with a quick-release tie to ensure they can be removed promptly if necessary.
B. Assess the extremity for circulation and neurological integrity every 2 hours. Regular assessment of the extremity is essential to ensure that the restraint is not impairing circulation or causing nerve damage. This frequent monitoring helps prevent complications and ensures the client’s safety.
C. Secure the restraint to the side rail. Securing restraints to the side rail is not recommended as it can cause injury or entrapment. The restraint should be secured to the bed frame or a fixed part of the bed that does not move or pose a risk to the client.
D. Assess restraints and skin integrity every 12 hours. Assessing restraints and skin integrity every 12 hours is inadequate. More frequent assessments, such as every 2 hours, are necessary to prevent skin breakdown and ensure that the restraints are not causing harm.
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