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1. Which nursing action can the nurse delegate to unlicensed assistive personnel (UAP) working in the diabetic clinic?
- A. Measure the ankle-brachial index.
- B. Check for changes in skin pigmentation.
- C. Assess for unilateral or bilateral foot drop.
- D. Ask the patient about symptoms of depression.
Correct answer: A
Rationale: The correct answer is A: Measure the ankle-brachial index. This task involves using a Doppler ultrasound device to assess blood flow, which can be safely delegated to UAP. Choices B, C, and D require a higher level of assessment and interpretation that should be performed by licensed nursing staff. Checking for changes in skin pigmentation (B) and assessing for foot drop (C) involve more complex assessments that require nursing judgment. Asking about symptoms of depression (D) involves a psychosocial assessment, which should be performed by licensed personnel qualified to address mental health concerns.
2. After discussing alternatives to dressing change procedures to minimize discomfort, the nursing staff accepted a new procedure. This is an example of which stage of Havelock's model of change?
- A. Moving
- B. Self-renewal
- C. Refreezing
- D. Unfreezing
Correct answer: A
Rationale: The correct answer is A: Moving. In the moving stage of Havelock's model of change, the focus is on selecting a solution or alternative. In this scenario, the nursing staff accepting a new procedure after discussing alternatives aligns with the moving stage, where the decision to adopt a change is made. Choices B, C, and D are incorrect. Self-renewal refers to personal growth, refreezing involves stabilizing the change, and unfreezing is related to preparing for change, none of which directly correspond to the situation described in the question.
3. There are many ways to ensure that your appraisal system is nondiscriminatory. Which of the following is one way to ensure this?
- A. Giving the appraisal once per year
- B. Having no appeal process
- C. Withholding information from the employee
- D. Not allowing any input from the employee
Correct answer: A
Rationale: To ensure that an appraisal system is nondiscriminatory, one important step is to provide the appraisal once per year. This allows for ongoing evaluation and helps prevent bias. Choice B is incorrect because having no appeal process can lead to unfair treatment without a chance for review. Choice C is incorrect as withholding information from the employee can hinder transparency and objectivity. Choice D is incorrect as not allowing any input from the employee can overlook valuable insights and perspectives that could contribute to a fair evaluation process.
4. A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?
- A. Validate the client's feelings by saying, 'People in middle adulthood often find satisfaction in nurturing and guiding young people.'
- B. Encourage the client to explore the reasons behind feeling useless.
- C. Reassure the client by saying, 'You should be proud that your children are becoming independent.'
- D. Provide information by saying, 'Most people are happy when their children grow up and leave home.'
Correct answer: A
Rationale: The correct response is to validate the client's feelings by acknowledging that individuals in middle adulthood often derive satisfaction from nurturing and guiding young people. This response shows empathy and understanding towards the client's emotions. Choice B is incorrect because it may come across as dismissive of the client's feelings. Choice C is incorrect as it does not address the client's emotional state and could be perceived as minimizing their concerns. Choice D is incorrect as it generalizes feelings and may not be applicable to the client's specific situation.
5. Which action by a patient indicates that the home health nurse�s teaching about glargine and regular insulin has been successful?
- A. The patient administers the glargine 30 minutes before each meal
- B. The patient�s family prefills the syringes with the mix of insulins weekly.
- C. The patient draws up the regular insulin and then the glargine in the same syringe.
- D. The patient disposes of the open vials of glargine and regular insulin after 4 weeks
Correct answer: D
Rationale:
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