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The home health nurse is caring for the middle-aged client who is disabled due to a recent accident. The client has few interests, spends most days watching TV, and has become estranged from the family. Which of Erikson’s developmental stages should the nurse conclude that the client is not meeting?
- A. Industry versus inferiority
- B. Initiative versus guilt
- C. Generativity versus stagnation
- D. Intimacy versus isolation
Correct Answer: C
Rationale: The client’s isolation and lack of interests indicate stagnation, failing to meet generativity versus stagnation, the central task of middle adulthood. Other stages apply to younger age groups.
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The nurse plans to teach the client progressive muscle relaxation. Prioritize the steps that the nurse should teach to correctly perform progressive muscle relaxation.
- A. Relax the feet, imagining the tension flowing out with each exhalation
- B. Lie down in a quiet place where you are undisturbed
- C. Contract the muscles of your feet first as you inhale and hold the contraction briefly
- D. Relax your body, allowing it to feel heavy
- E. Lie still for a few minutes after the contraction and relaxation of all muscles
- F. Imagine the tension flowing out with each breath you take
- G. Move up the body, contracting then relaxing each muscle
Correct Answer: B;D;F;C;A;G;E
Rationale: Steps: 1) Lie in a quiet place to focus; 2) Relax body to feel heavy; 3) Imagine tension flowing out with breaths; 4) Contract feet muscles; 5) Relax feet; 6) Move up body; 7) Lie still to monitor relaxation.
The experienced nurse is observing the new nurse recommend screening tests to the 80-year-old female client. Which recommendation made by the new nurse should the experienced nurse correct?
- A. Hearing screen annually
- B. Colonoscopy every 10 years
- C. Pneumococcal vaccine annually
- D. Mammogram every 1 to 2 years
Correct Answer: C
Rationale: Pneumococcal vaccine is given at 65 and every 10 years, not annually. Hearing screens, colonoscopies, and mammograms are correctly recommended.
The nurse is assessing the 88-year-old client. Which finding should the nurse associate with the normal aging process?
- A. Arm muscle strength 4 on a 0 to 5 scale
- B. Multiple fractures to the thoracic spine
- C. Ulnar deviation of the left hand fingers
- D. Slight pain in the right and left heel
Correct Answer: A
Rationale: Muscle strength of 4/5 is normal with aging. Fractures, ulnar deviation (rheumatoid arthritis), and heel pain (bone spurs) are not normal aging changes.
The 32-year-old has been trying to get pregnant for the past 10 years- The client consults a family planning clinic after being unsuccessful with the calendar and basal body temperature methods in determining the time of ovulation. Which statement by the nurse would be most appropriate?
- A. Let me review the methods with you; maybe you have not been using them correctly.'
- B. Have you considered that you might not be ovulating and that adoption is an option?'
- C. Test kits are available that will detect an enzyme in cervical mucus that signals ovulation.'
- D. If your spouse wears restrictive underwear, this can reduce your chance of conception.'
Correct Answer: C
Rationale: Suggesting an ovulation test kit, which detects guaiacol peroxidase in cervical mucus to signal ovulation, is most appropriate after 10 years of unsuccessful methods. Reviewing methods is less helpful, adoption is premature, and male underwear addresses sperm count, not ovulation timing.
The nurse educator is planning teaching for other nurses after noting that some nurses need additional education on insulin types and how to use the new insulin injection pens. When planning teaching, which question by the educator best reflects consideration that the nurses are adult learners?
- A. Does anyone want to volunteer to prepare a poster board and help with handouts?'
- B. What do you need to learn about insulin, and what teaching method would you prefer?'
- C. Can you attend a presentation if I post various times during the day and evening shift?'
- D. What don’t you understand about the information in the policy and procedure manual?'
Correct Answer: B
Rationale: Adult learners are independent and benefit from identifying their own learning needs and preferred methods. Asking about specific needs and teaching preferences supports this, unlike posters, presentations, or implying misunderstanding.