A client needs to learn how to self-administer a subcutaneous injection.
What should the nurse do first?
Ask Questions that identify the client's level of knowledge.
Create an environment for teaching that is quiet when demonstrating the procedure.
Present the information from simple to complex.
Gather written materials to reinforce the information.
The Correct Answer is A
Choice A rationale
Assessment is always the first step of the nursing process and is essential for effective patient education. By identifying the client's current knowledge level, the nurse can tailor the teaching plan to bridge specific gaps rather than repeating known information. This ensures the session is efficient and respects the client's prior experiences. Determining what the client already knows about subcutaneous injections, such as insulin or heparin, allows the nurse to set realistic and individualized learning goals.
Choice B rationale
Creating a quiet and conducive environment is an important implementation step during the teaching process, but it is not the very first action. While a distraction-free area helps the client focus on the complex steps of a subcutaneous injection, the nurse cannot effectively teach without first assessing the learner. Once the nurse knows the client's baseline, they can then arrange the environment to demonstrate the procedure, ensuring that the physical setting supports the cognitive and psychomotor learning required.
Choice C rationale
Organizing information from simple to complex is a teaching strategy used during the planning and implementation phases. It helps the learner build a foundation before moving to more difficult tasks, such as mastering the aseptic technique before learning the specific needle angles. However, the nurse must first assess the client to determine what they consider simple or complex. Without an initial assessment of the client's cognitive ability and readiness, this structural approach may not be effectively applied.
Choice D rationale
Gathering written materials is part of the planning phase to provide the client with resources for later review. Written instructions reinforce the verbal and visual demonstration given by the nurse. While helpful, this action should follow the initial assessment of the client's literacy level and preferred learning style. If a client has visual impairments or low literacy, certain written materials may be inappropriate. Therefore, assessment must precede the selection of supplemental educational tools to ensure they are useful.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
As individuals age, the kidneys often lose their ability to concentrate urine effectively due to a decrease in the number of functioning nephrons and a reduced response to antidiuretic hormone. This physiological change results in a larger volume of dilute urine being produced, which frequently leads to nocturia, the need to urinate multiple times during the night. Normal urine specific gravity ranges from 1.005 to 1.030, but this may fluctuate significantly in the elderly population.
Choice B rationale
Aging is associated with a gradual loss of elasticity and muscle tone in the bladder wall. This reduction in tone decreases the total capacity of the bladder, meaning the older adult feels the urge to void more frequently even with smaller amounts of urine. This change is a normal part of the aging process and contributes to the increased frequency of urination often reported by geriatric patients. It explains why they may not be able to hold urine.
Choice C rationale
A decrease in the contractility of the detrusor muscle is a common age-related change that affects the emptying phase of micturition. When the bladder muscle cannot contract with sufficient force or duration, the bladder may not empty completely, leading to an increase in post-void residual volume. This state of urinary retention increases the risk for urinary tract infections and overflow incontinence. Normal post-void residual is generally considered to be less than 50 mL.
Choice D rationale
The statement is incorrect because aging actually leads to a decrease in pelvic floor muscle tone rather than an increase. Weakened pelvic floor muscles, often due to hormonal changes or previous physical stressors, fail to provide adequate support to the urethra and bladder neck. This loss of structural support is a primary contributor to stress incontinence in older adults. Therefore, the student mentioning an increase in tone requires further teaching to correct their understanding of anatomy.
Correct Answer is D
Explanation
Choice A rationale
Safety and security needs represent the second level of Maslow's hierarchy, focusing on protection from environmental threats and emotional stability. While important, these needs cannot be effectively addressed if the individual is experiencing physical discomfort or a breach of physiological integrity. In this scenario, the presence of a wet brief primarily affects the skin and physical comfort. Therefore, safety concerns are secondary to the immediate biological requirement for cleanliness and dryness to prevent skin breakdown and infection.
Choice B rationale
Love and belonging needs involve social interactions, friendships, and the feeling of being part of a group. These are higher-level needs that usually emerge once basic survival and safety requirements are satisfied. A client who is physically uncomfortable due to incontinence is unlikely to engage meaningfully in social activities or feel a sense of belonging. The physiological distress caused by the wet brief creates a barrier to social participation, making it necessary to prioritize physical care first.
Choice C rationale
Self-actualization is the highest level of Maslow's hierarchy, representing the fulfillment of one's potential and personal growth. This level of need is only pursued when all other deficiency needs, including physiological and safety needs, have been sufficiently met. A client struggling with the basic physical indignity and discomfort of being in a wet disposable brief is not in a position to pursue self-actualization. Basic hygiene is a fundamental requirement that must be addressed before any cognitive or spiritual growth.
Choice D rationale
According to Maslow's hierarchy of needs, physiological needs are the most basic and must be met first for survival and comfort. These include air, water, food, and elimination. A wet brief compromises skin integrity and causes physical discomfort, which falls under this foundational category. The client cannot focus on higher-level tasks like social interaction or learning until their physical state is stabilized. Ensuring the client is clean and dry is a priority nursing intervention to maintain homeostasis and dignity.
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