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A nurse is caring for a client who has atelectasis. The nurse should instruct the client to lie on his back with a quarter turn elevating his right side and his head lower than his feet 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: D
Rationale: Postural drainage in this position helps mobilize secretions from the lower lobes and prevent complications.
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A nurse is caring for a client who says, 'I'm feeling a bit nervous today.' Which of the following responses should the nurse make?
- A. Please explain what you mean by nervous.
- B. Why are you nervous?
- C. Would a backrub ease your nervousness?
- D. You look like you feel nervous.
Correct Answer: A
Rationale: Seeking clarification helps the nurse understand the client's feelings more accurately.
A nurse is reinforcing teaching with a 40-year-old female client about preventive health screenings. Which of the following statements by the client indicates an understanding of the teaching?
- A. I should have my skin checked every 5 years for cancer.
- B. I will need to have a mammogram every year now.
- C. I should have my first colonoscopy when I turn 65.
- D. I will be checked for uterine cancer every 2 years.
Correct Answer: B
Rationale: The correct answer is B: "I will need to have a mammogram every year now." This statement indicates an understanding of preventive health screenings for a 40-year-old female. Mammograms are recommended annually starting at age 40 to screen for breast cancer. Choice A is incorrect as skin checks for cancer should be more frequent than every 5 years. Choice C is incorrect as the first colonoscopy is recommended at age 50, not 65. Choice D is incorrect as uterine cancer screening is typically not done every 2 years.
A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?
- A. After palpating the abdomen
- B. Prior to percussing the abdomen
- C. After checking for kidney tenderness
- D. Prior to inspecting the abdomen
Correct Answer: B
Rationale: The correct answer is B: Prior to percussing the abdomen. Auscultation of bowel sounds should be done before percussing as it helps to assess the presence and quality of bowel sounds without causing any interference from other assessment techniques. Palpation (choice A) can stimulate bowel sounds, leading to inaccurate assessment. Checking for kidney tenderness (choice C) and inspecting the abdomen (choice D) are unrelated to auscultating bowel sounds.
A nurse is reinforcing teaching about health promotion with a group of older adults. Which of the following health promotion measures should the nurse recommend? (Select all that apply.)
- A. Yearly blood pressure screening
- B. Use of lotions with a SPF of 15 or higher
- C. Immunization for influenza
- D. Annual visual acuity screening
- E. Reduce calcium intake.
Correct Answer: A,B,C,D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Yearly blood pressure screening is important for early detection and management of hypertension, a common health issue in older adults.
B: Using lotions with SPF of 15 or higher helps prevent skin damage and reduces the risk of skin cancer, a common concern in older adults.
C: Immunization for influenza is crucial in older adults to prevent serious complications from the flu due to their weakened immune systems.
D: Annual visual acuity screening is essential for detecting age-related vision changes and preventing accidents or falls.
Summary:
E: Reducing calcium intake is not a recommended health promotion measure for older adults, as adequate calcium is essential for bone health and preventing osteoporosis.
A nurse is reinforcing teaching with a client about relationship development. The nurse should explain that, according to Erikson, establishing relationships with commitment is a primary task of which of the following stages of psychosocial development?
- A. Generativity versus stagnation
- B. Identity versus role diffusion
- C. Intimacy versus isolation
- D. Trust versus mistrust
Correct Answer: C
Rationale: The correct answer is C: Intimacy versus isolation. During the stage of Intimacy versus isolation in Erikson's psychosocial development theory, individuals focus on forming deep, meaningful relationships and developing a sense of commitment to others. This stage typically occurs in young adulthood. By establishing relationships with commitment, individuals achieve intimacy and avoid feelings of isolation.
A: Generativity versus stagnation focuses on contributing to society and future generations.
B: Identity versus role diffusion involves developing a sense of self and a coherent identity.
D: Trust versus mistrust occurs in infancy and is about developing a sense of trust in the world.
Overall, C is the correct choice as it aligns most closely with the task of establishing relationships with commitment.