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A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. In Erikson's psychosocial development theory, school-age children (around 6-12 years old) are in the stage of industry vs. inferiority. During this stage, children seek to develop a sense of competence and accomplishment by mastering new skills and tasks. This is crucial to consider in planning home care for a child recovering from an acute asthma attack as fostering a sense of industry can positively impact their self-esteem and motivation to manage their health.
Choice A: Autonomy vs. shame and doubt is more relevant to toddlers, not school-age children. Choice B: Initiative vs. guilt is about preschoolers. Choice D: Identity vs. role confusion is for adolescents. Choices E, F, G are not provided, but they would not be relevant to the developmental stage of school-age children.
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A nurse is developing a therapeutic relationship with a client. The nurse should perform which of the following actions during the working phase of a therapeutic relationship?
- A. Determine the reason the client sought care.
- B. Instruct the client about methods to achieve goals.
- C. Discuss the client's new skill sets.
- D. Review the client's demographic information.
Correct Answer: B
Rationale: The correct answer is B: Instruct the client about methods to achieve goals. During the working phase of a therapeutic relationship, the nurse focuses on helping the client achieve their goals through guidance, education, and collaboration. Instructing the client about methods to achieve goals empowers them to actively participate in their care and progress towards wellness. This action promotes client autonomy and self-efficacy, key components of a therapeutic relationship.
Incorrect choices:
A: Determining the reason the client sought care is typically done in the initial phase of the relationship.
C: Discussing the client's new skill sets may be more appropriate in the termination phase where progress is reviewed.
D: Reviewing the client's demographic information is necessary but not a primary action during the working phase.
When auscultating a client's lungs, the nurse identifies crackles in the left posterior base. Which of the following actions should the nurse take?
- A. Repeat the auscultation after asking the client to breathe deeply and cough.
- B. Instruct the client to limit fluid intake to less than 2,000 mL/day.
- C. Prepare to administer antibiotics.
- D. Initiate bedrest in semi-Fowler's position.
Correct Answer: A
Rationale: The correct answer is A. By asking the client to breathe deeply and cough, the nurse can assess if the crackles persist or change, helping to determine if they are related to secretions. This action can provide more information for a more accurate diagnosis and appropriate intervention. Option B is incorrect as limiting fluid intake is not directly related to addressing crackles. Option C is incorrect without further assessment or indication of infection. Option D is incorrect as bedrest in semi-Fowler's position is not the initial intervention for crackles.
A nurse is checking the apical pulse of a client who is taking several cardiovascular medications. Which of the following actions should the nurse take?
- A. Count the apical pulsations for a full minute.
- B. Check the apical pulse with a Doppler device.
- C. Use the diaphragm of the stethoscope to listen to the apical pulsations.
- D. Press the stethoscope firmly against the client's skin.
Correct Answer: A
Rationale: The correct answer is A: Count the apical pulsations for a full minute. This is because counting the apical pulse for a full minute provides the most accurate and reliable measurement of the heart rate, especially in clients taking cardiovascular medications where variations may occur. Checking for a full minute allows the nurse to capture any irregularities or changes in the pulse rhythm.
Choice B is incorrect because using a Doppler device is not necessary for routine assessment of the apical pulse. Choice C is incorrect as the bell of the stethoscope, not the diaphragm, is used to listen to the apical pulse for better sound transmission. Choice D is incorrect as pressing the stethoscope firmly against the skin can distort the sound of the pulse.
A nurse is caring for a client who has hypertension and is afraid to take medication. Which of the following nursing responses uses reflection?
- A. You seem upset about your blood pressure.'
- B. What time do you take your medication?'
- C. How do you feel when you take the medication?'
- D. I understand your reluctance to use medication.'
Correct Answer: A
Rationale: Reflection restates the client's emotions, encouraging further discussion.
A nurse is reviewing the plan of care for a client who has a respiratory infection. The nurse should plan to have the client lie on his stomach with pillows elevating his chest and stomach to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: C
Rationale: Prone positioning with elevation allows mucus drainage from posterior lung segments.