Nokea
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I spent my whole life dreaming about retirement, & now I wish I had my job back
- B. It's been so stressful for me to have to depend on my son to help around the house
- C. I just heard my friend Al died. That's the 3rd one in 3 months
- D. I'm struggling with helping out in my community. I just don't know what I can do
Correct Answer: D
Rationale: The correct answer is D. The priority issue for assessment & intervention is the older adult struggling with helping out in the community. This indicates a potential loss of purpose and meaning in life, which can negatively impact mental health. It may also suggest decreased social engagement, which is crucial for overall well-being in older adults. This issue requires immediate attention to prevent further decline in mental health and overall quality of life.
A: While feeling regret about retirement is important, it does not pose an immediate risk to the individual's well-being.
B: Depending on family for help is common in older age but does not indicate an urgent need for intervention.
C: Grieving the loss of friends is significant, but it may not be the priority issue for immediate intervention.
E, F, G: Choices are not provided, but they would likely be incorrect as they are not the priority issue for assessment & intervention.
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Nurse talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I kind of like this girl in my class, but she doesn't like me back like that.
- B. I like hanging out with the guys in the science club, but the jocks pick on them.
- C. I just don't seem to be good at anything. I can't play sports at all.
- D. My dad wants me to be a lawyer like him, but I don't want to learn all that stuff
Correct Answer: C
Rationale: The correct answer is C because the adolescent's self-perception of not being good at anything can indicate low self-esteem and potential mental health concerns. This could impact their overall well-being and ability to cope with various stressors. Identifying and addressing self-esteem issues is crucial for their emotional development. Choices A, B, and D are not immediate priorities as they involve interpersonal relationships and career aspirations, which are important but not as urgent as addressing the adolescent's self-perception and mental health.
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. B/c doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B. The client's statement indicates an understanding of the recommended screening guideline for mammograms for a 45-year-old individual with no specific family history of cancer. Yearly mammograms are typically recommended starting at age 40 for early detection of breast cancer. Choice A is incorrect as colon cancer screening is recommended starting at age 45-50, not in 2-3 years. Choice C is incorrect as Pap smears are typically recommended every 3-5 years, not yearly. Choice D is incorrect as blood glucose testing is usually recommended annually for individuals at risk for diabetes.
Nurse manager is reviewing guidelines to prevent injury with staff nurses. Which of the following should nurse manager include in teaching? (Select all that apply.)
- A. Request assistance when repositioning a client
- B. Avoid twisting spine or bending at waist
- C. Keep knees slightly lower than hips when sitting for long periods of time
- D. Use smooth movements when lifting & moving clients
- E. Take break from repetitive movements every 2-3h to flex & stretch joints & muscles
Correct Answer: A,B,D
Rationale: The correct answers are A, B, and D.
A: Requesting assistance when repositioning a client is important to prevent injury as it reduces the risk of straining muscles or back injury.
B: Avoiding twisting the spine or bending at the waist helps maintain proper body mechanics and prevents strains.
D: Using smooth movements when lifting and moving clients reduces the risk of musculoskeletal injuries.
Incorrect choices:
C: Keeping knees slightly lower than hips when sitting for long periods of time is not directly related to preventing injury with client care.
E: Taking breaks from repetitive movements every 2-3 hours to flex and stretch joints and muscles is important for general health but not specific to preventing injury in client care.
Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.
Nurse is caring for client who presents with linear clusters of fluid-containing vesicles with some crusting. Which should nurse suspect?
- A. Allergic reaction
- B. Ringworm
- C. Systemic lupus erythematosus
- D. Herpes zoster
Correct Answer: D
Rationale: The correct answer is D: Herpes zoster. The description of linear clusters of fluid-containing vesicles with some crusting is characteristic of herpes zoster, also known as shingles. This condition is caused by the reactivation of the varicella-zoster virus, which initially causes chickenpox. The linear distribution along a dermatome is a key feature of herpes zoster. Allergic reaction (A) typically presents with generalized rash and itching, not linear clusters of vesicles. Ringworm (B) presents as circular, scaly lesions, not linear clusters of vesicles. Systemic lupus erythematosus (C) is an autoimmune disease that presents with a variety of symptoms, but not linear clusters of vesicles.