Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.)
- A. Metabolism
- B. Ability to hear low-pitched sounds
- C. Gastric secretion
- D. Far vision
- E. Glomerular filtration
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. As individuals age, metabolism decreases due to changes in muscle mass and activity levels. Gastric secretion decreases, leading to decreased absorption of certain nutrients. Glomerular filtration rate decreases with age, affecting kidney function. Choice B is incorrect as hearing high-pitched sounds is more commonly affected with age. Choice D is incorrect as near vision is usually affected, not far vision.
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Home health nurse is discussing dangers of food poisoning with client. What information should the nurse include? (Select all that apply)
- A. Most food poisoning is caused by viruses
- B. Immunocompromised individuals are at risk for complications from food poisoning
- C. Clients who are at risk should eat/drink only pasteurized dairy products
- D. Healthy people usually recover from illness in a few weeks
- E. Handling raw & fresh food separately to avoid cross-contamination may prevent food poisoning
Correct Answer: B,C,E
Rationale: The correct answers are B, C, and E.
B: Immunocompromised individuals are at higher risk for complications from food poisoning due to weakened immune systems.
C: Clients at risk should consume only pasteurized dairy products to reduce the risk of foodborne illnesses.
E: Handling raw and fresh food separately prevents cross-contamination, a common cause of food poisoning.
Incorrect options:
A: Most food poisoning is caused by bacteria, not viruses.
D: Healthy individuals typically recover from food poisoning in a few days, not weeks.
In summary, the correct answers focus on specific preventive measures and risks for vulnerable populations, while the incorrect options provide inaccurate information regarding the causes and outcomes of food poisoning.
A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal calculi
- C. Pressure ulcers
- D. Thrombus formation
Correct Answer: B
Rationale: The correct answer is B: Renal calculi. Hypercalcemia can lead to the formation of kidney stones (renal calculi) due to increased levels of calcium in the blood being excreted by the kidneys. The nurse should monitor for signs and symptoms of renal colic, such as severe flank pain, hematuria, and urinary urgency.
Incorrect choices:
A: Hypostatic pneumonia - Hypercalcemia does not directly lead to pneumonia.
C: Pressure ulcers - Hypercalcemia does not increase the risk of pressure ulcers.
D: Thrombus formation - While hypercalcemia can predispose to blood clot formation, it is not the most closely monitored condition in this scenario.
Nurse observes smoke coming from under the door of the staff lounge. What is the priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The correct answer is C: Evacuate the clients. This is the priority action because ensuring the safety of the clients is the nurse's primary responsibility. Evacuating the clients from the area of potential danger is crucial to prevent harm. A: Extinguishing the fire should be left to trained personnel. B: Pulling the fire alarm is important, but evacuating clients takes precedence. D: Closing doors may help contain the fire but doesn't ensure immediate safety.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents
- B. It's been so stressful for me to even think about having my own family
- C. I don't even know who I am yet, & now I'm supposed to know what to do
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father
Correct Answer: C
Rationale: The correct answer is C because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.
A mother tells nurse that her 2 yo has temper tantrums. Child says 'no' every time mother tries to help her get dressed. Nurse explains that developmentally the toddler is...
- A. Trying to gain her independence
- B. Developing sense of trust
- C. Manifesting anger management problem
- D. Attempting to finish a project she started
Correct Answer: A
Rationale: The correct answer is A: Trying to gain her independence. This is because at the age of 2, children often exhibit behaviors such as saying 'no' and resisting help as they start to assert their independence and autonomy. This behavior is a normal part of their development as they strive to explore their own abilities and assert control over their environment. Choices B, C, and D are incorrect because at this age, the child is not yet focused on developing a sense of trust, managing anger, or finishing projects. It is important to recognize and support the child's need for independence while providing guidance and setting appropriate boundaries.