Nokea
Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities? (Select all that apply.)
- A. Develop acceptance of diminished strength & increased dependence on others
- B. Feel frustrated that time is too short for trying to start another life
- C. Welcome opportunities to be creative & productive
- D. Commit to finding friendship & companionship
- E. Become involved in community issues & activities
Correct Answer: C,E
Rationale: The correct choices, C and E, align with Erikson's theory of psychosocial development for middle adulthood. Choice C, "Welcome opportunities to be creative & productive," reflects Erikson's stage of generativity versus stagnation, where individuals in middle adulthood seek to contribute to society and leave a legacy. Choice E, "Become involved in community issues & activities," relates to the desire for social involvement and making a positive impact on the community. Choices A, B, and D are incorrect because they do not align with the typical capabilities of middle adults according to Erikson's theory. Choice A contradicts the idea of middle adults striving for independence and self-reliance, while choice B reflects feelings of regret or despair, which are more characteristic of Erikson's later stages. Choice D, while important, does not capture the full scope of middle adulthood psychosocial development as outlined by Erikson.
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Nurse is caring for client with SARS. Nurse is aware that healthcare professionals are required to report communicable & infectious diseases. Which of these illustrate rationale for reporting?
- A. Planning & evaluating control & prevention strategies
- B. Determining public health priorities
- C. Ensuring proper medical treatment
- D. Identifying endemic disease
- E. Monitoring for common-source outbreaks
Correct Answer: A,B,C,E
Rationale: The correct answer is A, B, C, and E. Reporting communicable diseases like SARS is essential for planning and evaluating control and prevention strategies. It helps determine public health priorities by identifying areas of concern. Reporting ensures proper medical treatment for affected individuals and helps in monitoring for common-source outbreaks to prevent further spread. Choices D, F, and G are incorrect as they do not directly relate to the rationale for reporting communicable diseases. Identifying endemic diseases may be a part of reporting, but it is not the primary reason.
As part of admission process
- A. nurse at long-term care facility is gathering nutrition history for client with dementia. Which component is priority to determine from their family?
- B. BMI
- C. Usual times for meals/snacks
- D. Favorite foods
- E. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Favorite foods. This is because knowing the client's favorite foods is crucial in ensuring they receive proper nutrition and enjoy their meals, especially for someone with dementia who may have difficulty remembering or expressing preferences. It helps enhance their quality of life and promotes adequate food intake.
Other choices are less critical:
A: Nutrition history can include various components, not just family input.
B: BMI is important but not the priority when gathering nutrition information.
C: Knowing meal/snack times is relevant but not as crucial as favorite foods.
E: Swallowing difficulty is important but not the priority in this scenario.
A nurse manager of a med-surg unit is assigning care responsibilities for the oncoming shift. A client is awaiting transfer from PACU following thoracic surgery. To which staff member should the nurse assign this client?
- A. Charge nurse
- B. RN
- C. LPN
- D. Assistive personnel (AP)
Correct Answer: B
Rationale: The correct answer is B: RN. A registered nurse (RN) is the most appropriate staff member to care for a client awaiting transfer from PACU after thoracic surgery. RNs have the education and training to assess the client's condition, monitor vital signs, manage postoperative pain, and recognize any complications that may arise. They can also provide the necessary interventions and communicate effectively with the healthcare team. Assigning this client to an RN ensures safe and competent care.
Choice A (Charge nurse) may have administrative duties and may not be available to provide direct care. Choice C (LPN) may not have the scope of practice or training to manage postoperative care for a client following thoracic surgery. Choice D (AP) does not have the qualifications to assess and manage a client with complex postoperative needs.
A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.
By the 2nd post-op day
- A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
- B. Reassess client to determine reasons for pain
- C. See whether pain lessens during next 24h
- D. Change plan to ensure adequate pain relief
- E. Teach client about pain management plan
Correct Answer: A
Rationale: Correct Answer: A
Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.