Nokea
A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct Answer: B
Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.
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An older client reports that she has been awakening during the night, awakes early in the morning and is unable to fall back to sleep, and feels sleepy during the daytime. Based on these reported data, what should the nurse do?
- A. Encourage the client to consume stimulants such as caffeinated coffee or tea during the daytime hours.
- B. Ask the registered nurse to obtain a prescription for a nighttime sedative.
- C. Report the findings to the registered nurse.
- D. Document the findings in the medical record.
Correct Answer: D
Rationale: Age-related changes in sleep include reduced sleep efficiency, increased incidence of nocturnal awakening, increased incidence of early-morning awakening, and increased daytime sleepiness. Since the reported data are normal age-related changes, the appropriate action for the nurse would be to document the findings in the medical record. Reporting the findings to the registered nurse is unnecessary as these changes are expected with aging and do not indicate a need for immediate intervention. Prescribing sedatives should be avoided as a first-line approach due to potential side effects and risks, especially in older adults. Encouraging the consumption of stimulants like caffeinated beverages during the daytime may further disrupt sleep patterns, which is counterproductive in addressing the client's reported sleep issues.
A nurse is planning care for a hospitalized toddler. To best maintain the toddler's sense of control and security and ease feelings of helplessness and fear, the nurse should perform which action?
- A. Allow the toddler to play with other children in the nursing unit playroom.
- B. Spend as much time as possible with the toddler.
- C. Allow the toddler to select toys from the nursing unit playroom that can be brought into the toddler's hospital room.
- D. Keep hospital routines as similar as possible to those at home.
Correct Answer: D
Rationale: The best action for the nurse to take to help a hospitalized toddler maintain a sense of control and security and ease feelings of helplessness and fear is to keep hospital routines as similar as possible to those at home. By incorporating the toddler's usual rituals and routines from home into nursing care activities, the nurse can reduce the stress of hospitalization. This approach gives the toddler a sense of familiarity, control, and security, which can alleviate feelings of helplessness and fear. Allowing the toddler to play with other children in the nursing unit playroom and selecting toys are beneficial activities, but maintaining hospital routines similar to those at home is the most effective way to support the toddler's emotional well-being during hospitalization.
According to Erik Erikson's developmental theory, which choice is a developmental task of the middle adult?
- A. Redefining self-perception and capacity for intimacy
- B. Making decisions concerning career, marriage, and parenthood
- C. Providing guidance during interactions with his children
- D. Verbalizing readiness to assume parental responsibilities
Correct Answer: C
Rationale: According to Erikson's developmental theory, the primary developmental task of the middle adult is to achieve generativity. Generativity is the willingness to care for and guide others. Middle adults can achieve generativity with their own children or the children of close friends or through guidance in social interactions with the next generation. Providing guidance during interactions with his children aligns with this developmental task. Choices A, B, and D are not specific to the middle adult stage as they are tasks associated with young adults. Redefining self-perception and capacity for intimacy, making decisions concerning career, marriage, and parenthood, and verbalizing readiness to assume parental responsibilities are all developmental tasks of the young adult according to Erikson's theory.
How should a client's neck be positioned for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct Answer: A
Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.
A school nurse provides information to the parents of school-age children regarding appropriate dental care. The nurse tells the parents that their children should perform which action?
- A. Brush and floss their teeth after meals and at bedtime
- B. Brush their teeth every morning and at bedtime and floss the teeth once a day, preferably at bedtime
- C. Brush their teeth every morning and at bedtime
- D. Brush and floss their teeth every morning and at bedtime
Correct Answer: A
Rationale: School-age children are capable of taking responsibility for their own dental hygiene. Establishing good oral health habits during childhood can lead to a lifetime of cavity prevention. The nurse advises the parents that their children should brush with fluoride toothpaste and floss between their teeth after meals and before bedtime. This routine helps maintain good oral health and teaches children the importance of dental care. Choice A is the correct answer as it emphasizes both brushing and flossing after meals and at bedtime, which are crucial for effective dental care. Choices B, C, and D are incorrect as they do not stress the significance of both brushing and flossing after meals, which is essential for proper oral hygiene.