While preparing a teaching plan on a technique for administering insulin, the nurse described what the patient will be able to accomplish after the teaching session. The nurse can document the patient best understood the teaching session by which of the following prior to the patient being discharged from the hospital to home?

The patient verbalized understanding by repeating back the technique.

The patient demonstrated the technique back to the nurse after the training session.

The patient signed a form to document he understood the training session.

The patient was able to repeat facts and knowledge back to the nurse from the training session.

Answer and Explanation

The Correct Answer is B

Choice A reason: Verbalizing understanding by repeating the technique shows comprehension but does not confirm skill. Insulin administration requires practical ability to ensure accuracy and safety. Demonstration is superior, as verbalization alone may miss errors in technique, per patient education and skill-based learning principles.

Choice B reason: Demonstrating the insulin technique back to the nurse confirms understanding and competency, ensuring safe self-administration at home. This return demonstration validates psychomotor skills, critical for correct dosing and preventing complications like hypoglycemia, aligning with effective teaching outcomes, per nursing education standards.

Choice C reason: Signing a form documents acknowledgment but not understanding or skill. Insulin administration requires observed performance to confirm competence. A signature does not verify the ability to perform the technique, risking errors, per patient education and legal documentation standards.

Choice D reason: Repeating facts shows knowledge but not practical ability to administer insulin. Technique requires psychomotor skills, assessed through demonstration. Knowledge alone may not prevent administration errors, making demonstration essential for discharge readiness, per diabetes education and skill validation protocols.

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Correct Answer is D

Explanation

Choice A reason: Ambulatory tachycardia is not a recognized condition. Tachycardia (elevated heart rate) may occur with orthostatic changes but does not define the condition. Orthostatic hypotension, marked by a blood pressure drop (90/50 mmHg) upon standing, causes dizziness due to reduced cerebral perfusion from impaired vascular response, making this incorrect.

Choice B reason: Ambulatory bradycardia is not a standard term. Bradycardia (low heart rate) is unrelated to the symptoms of dizziness and low blood pressure (90/50 mmHg) upon standing. Orthostatic hypotension results from inadequate vasoconstriction and reduced venous return, decreasing cerebral blood flow, causing faintness, making this option incorrect.

Choice C reason: Orthostatic hypertension involves elevated blood pressure upon standing, opposite to the client’s 90/50 mmHg. Orthostatic hypotension, characterized by a drop in blood pressure, causes dizziness due to reduced cerebral perfusion from impaired baroreceptor-mediated vasoconstriction. This mismatch in symptoms and blood pressure response makes orthostatic hypertension incorrect.

Choice D reason: Orthostatic hypotension is a drop in blood pressure (e.g., 90/50 mmHg) upon standing, causing dizziness and faintness. It results from inadequate autonomic compensation, reducing venous return and cerebral perfusion. Post-surgical fluid shifts or autonomic dysfunction exacerbate this, impairing brain oxygenation, making this the correct term for the client’s condition.

A. Cranial nerve I B. Cranial nerves II and III C. Cranial nerve VII D. Cranial nerve VIII

Correct Answer is C

Explanation

Choice A reason: Cranial nerve I (olfactory) assesses smell, not facial movements. Smiling or frowning involves facial muscles, unrelated to olfactory function. Testing nerve I involves odor identification, not motor actions, making it irrelevant to this assessment, per cranial nerve examination protocols.

Choice B reason: Cranial nerves II (optic) and III (oculomotor) control vision and eye movement, not facial expressions. Actions like smiling or puffing cheeks involve facial muscles, not pupil response or gaze, which are tested for II and III, per neurological assessment standards.

Choice C reason: Cranial nerve VII (facial) controls facial expressions, including smiling, frowning, wrinkling the forehead, and puffing cheeks. Testing these actions assesses motor function, confirming nerve integrity. This is a key part of neurological exams, detecting deficits like Bell’s palsy, per cranial nerve assessment guidelines.

Choice D reason: Cranial nerve VII (vestibulocochlear VIII (auditory) assesses hearing and balance, not facial movements. Actions like smiling or puffing cheeks are unrelated to auditory or vestibular function, making this nerve irrelevant to the described assessment, per neurological examination protocols.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who is ambulating for the first time after surgery. Upon standing, the client reports dizziness and faintness. The client’s blood pressure is 90/50 mmHg. What is the name for this condition?

Correct Answer is D

Explanation

During an assessment of the cranial nerves, the nurse asks the client to smile, frown, wrinkle the forehead, and puff out the cheeks. Which nerve is affected? being tested?

Correct Answer is C

Explanation

The nurse is evaluating outcomes for a patient with insomnia. Which key principle will the nurse consider during this process?

The patient complains of abdominal pain. Before palpating the abdomen, which action should the nurse perform?

The nurse is taking vital signs. The patient’s radial pulse has an irregular rhythm. What should the nurse do next?

While caring for a client near end of life, a nurse talks to the client. An unlicensed assistive personnel asks why the nurse is talking to someone who is dying. Which response is accurate?

The nurse is assessing a client with dark skin for the presence of a Stage I pressure ulcer. Which is the best approach to making this assessment?

The nurse is to administer eye drops four times per day to a patient diagnosed with conjunctivitis. The nurse should administer the medication by gently dropping the medication onto which of the following areas?

The nurse is providing preoperative teaching to a patient to have an operation on their colon for cancer. The nurse should take which of the following actions regarding informed consent?

A nurse is caring for a patient who is experiencing fluid volume deficit. Which signs should the nurse document as part of the assessment which correlates with a fluid volume deficit? (Select all that apply)