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A middle adult client tells the nurse, 'I feel so useless now that my children do not need me anymore.' Which of the following responses should the nurse make?
- A. Validate the client's feelings by saying, 'People in middle adulthood often find satisfaction in nurturing and guiding young people.'
- B. Encourage the client to explore the reasons behind feeling useless.
- C. Reassure the client by saying, 'You should be proud that your children are becoming independent.'
- D. Provide information by saying, 'Most people are happy when their children grow up and leave home.'
Correct Answer: A
Rationale: The correct answer is A because it validates the client's feelings by acknowledging the common experience of middle adults feeling a sense of purpose through nurturing others. This response shows empathy and understanding, which can help the client feel heard and supported.
Choice B is incorrect because it immediately delves into exploring the reasons behind the feelings without first acknowledging or validating them. This approach may come off as dismissive or insensitive.
Choice C is incorrect because it brushes off the client's feelings by emphasizing the positive aspect of children becoming independent, without addressing the client's emotional distress.
Choice D is incorrect because it makes a generalization about happiness related to children leaving home without directly addressing the client's specific feelings of uselessness. It does not acknowledge or validate the client's emotions.
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The staff in the emergency department has presented the nurse leader with a suggestion for streamlining the triage process, cutting down on wait times. Which of the following qualities does the leader specifically need to implement the suggestion?
- A. Courage
- B. Integrity
- C. Energy
- D. Initiative
Correct Answer: D
Rationale: The correct answer is D: Initiative. In this scenario, the nurse leader needs to take the initiative to implement the suggested changes for streamlining the triage process. By showing initiative, the leader demonstrates the willingness to take action and drive the necessary changes forward. Courage (A) may be needed to face challenges, but it doesn't directly address the need for proactive action. Integrity (B) is important but doesn't specifically relate to implementing changes. Energy (C) is beneficial for motivation but doesn't focus on taking the first step to make changes happen. Therefore, the key quality required in this situation is initiative to drive process improvements efficiently.
A client who is postoperative is verbalizing pain as a 2 on a pain scale of 0 to 10. Which of the following statements should the nurse identify as an indication that the client understands the preoperative teaching they received about pain management?
- A. ''I think I should take my pain medication more often, since it is not controlling my pain.''
- B. ''Breathing faster will help me keep my mind off of the pain.''
- C. ''It might help me to listen to music while I'm lying in bed.''
- D. ''I don't want to walk today because I have some pain.''
Correct Answer: D
Rationale: Step 1: The client is verbalizing pain as a 2 indicating mild pain.
Step 2: The client understands the preoperative teaching if they prioritize mobility despite mild pain.
Step 3: Choice D reflects this understanding, as the client is aware of the importance of walking postoperatively.
Step 4: Choices A, B, and C do not demonstrate understanding of preoperative teaching as they focus on increasing medication, distracting from pain, and using music for comfort rather than prioritizing mobility.
Summary: Choice D is correct as it aligns with the goal of postoperative pain management, while choices A, B, and C do not address the importance of mobility in pain management.
Which of the following is an example of a secondary prevention activity?
- A. Blood pressure screening
- B. Administering medications
- C. Developing a care plan
- D. Providing rehabilitation
Correct Answer: A
Rationale: Step-by-step rationale:
1. Secondary prevention aims to detect and treat diseases early to prevent complications.
2. Blood pressure screening helps identify individuals at risk for hypertension-related issues.
3. Early detection through screening allows for timely interventions to prevent further health problems.
4. Administering medications, developing a care plan, and providing rehabilitation are tertiary prevention activities focused on managing existing conditions rather than early detection.
Summary:
Blood pressure screening is the correct example of a secondary prevention activity as it focuses on early detection and intervention to prevent the progression of health issues. Administering medications, developing a care plan, and providing rehabilitation are not considered secondary prevention activities as they are more related to managing existing conditions.
1. To monitor for complications in a patient with type 2 diabetes, which tests will the nurse in the diabetic clinic schedule at least annually (select one that doesn't apply)?
- A. Blood pressure
- B. Serum creatinine
- C. Chest x-ray
- D. Urine for microalbuminuria
Correct Answer: C
Rationale: Step-by-step rationale for correct answer (C):
1. Chest x-ray is not routinely recommended for monitoring complications of type 2 diabetes.
2. Annual blood pressure monitoring is crucial for assessing cardiovascular risk in diabetic patients.
3. Serum creatinine test helps evaluate kidney function, which is often impaired in diabetes.
4. Urine microalbuminuria test detects early signs of kidney damage, common in diabetes.
Summary of incorrect choices:
A: Blood pressure monitoring is essential for assessing cardiovascular risk in diabetes.
B: Serum creatinine test is important for evaluating kidney function in diabetic patients.
D: Urine microalbuminuria test helps detect early kidney damage in diabetes.
An RN is working through an ethical dilemma involving a patient on his unit. He has just identified the decision-makers involved. Which step best describes the current stage the RN is working through?
- A. Assessment
- B. Diagnosis
- C. Planning
- D. Implementation
Correct Answer: C
Rationale: The correct answer is C: Planning. In an ethical dilemma, once the decision-makers are identified, the next step is to plan the course of action to address the issue. Planning involves considering the ethical principles, potential outcomes, and identifying the best course of action to resolve the dilemma. Assessment (A) involves gathering information, Diagnosis (B) involves analyzing the information, and Implementation (D) involves executing the chosen plan. Therefore, the RN is currently in the planning stage as he is strategizing on how to address the ethical dilemma effectively.