Nokea
A nurse has accepted a position on a pediatric unit and is learning about psychosocial development. Arrange Erikson's stages of psychosocial development in order from birth to adolescence. Arrange Erikson's stages from birth to adolescence.
- A. Identity vs. role confusion
- B. Trust vs. mistrust
- C. Industry vs. inferiority
- D. Autonomy vs. shame and doubt
- E. Initiative vs. guilt
Correct Answer: B,D,E,C,A
Rationale: 1. Trust vs. mistrust comes first as it pertains to infancy and the development of basic trust in caregivers.
2. Autonomy vs. shame and doubt follows, focusing on toddlers developing independence.
3. Initiative vs. guilt is next, focusing on preschoolers exploring and taking initiative.
4. Industry vs. inferiority is about school-aged children developing competence.
5. Identity vs. role confusion is about adolescents forming a sense of self.
Therefore, the correct order is B, D, E, C, A. Other choices are incorrect as they do not align with the chronological order of Erikson's stages.
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A nurse is caring for a patient who is receiving IV fluids. The nurse notes that the IV site is red, warm, and painful. Which of the following actions should the nurse take first? What should the nurse do first for IV site issues?
- A. Slow the infusion rate.
- B. Apply a warm compress.
- C. Discontinue the IV line.
- D. Notify the provider.
Correct Answer: C
Rationale: The correct action for the nurse to take first is to discontinue the IV line (choice C). This is essential to prevent further complications such as infection or infiltration. Discontinuing the IV line will stop the source of the redness, warmth, and pain at the IV site. Slowing the infusion rate (choice A) would not address the underlying issue and could potentially worsen the situation. Applying a warm compress (choice B) could also exacerbate the symptoms if there is an infection. Notifying the provider (choice D) is important but should come after the immediate action of discontinuing the IV line to address the IV site issues promptly.
A nurse is caring for a patient who frequently tries to remove his IV catheter. A family member asks the nurse to apply restraints. What should the nurse's response be? What should the nurse respond to a request for restraints?
- A. I will call the doctor and get a prescription.
- B. I will cover the catheter so he can't see it.
- C. Let's wait until tonight to see if he continues this behavior.
- D. I will apply the restraints immediately.
Correct Answer: B
Rationale: The correct answer is B: "I will cover the catheter so he can't see it." This response addresses the root cause of the patient's behavior by removing the visual stimulus that may be prompting the patient to try to remove the IV catheter. By covering the catheter, the patient may be less likely to attempt to remove it. This approach is non-invasive and respects the patient's autonomy while also ensuring the safety of the IV site.
Choice A is incorrect because applying restraints should not be the first course of action without exploring less restrictive alternatives. Choice C delays addressing the issue and risks harm to the patient. Choice D is incorrect as applying restraints immediately is a more invasive intervention that should only be considered after less restrictive measures have been attempted.
A nurse is caring for a patient who has a new prescription for lisinopril. Which of the following laboratory values should the nurse monitor? Which lab value should the nurse monitor for lisinopril?
- A. Serum potassium
- B. Serum calcium
- C. Serum magnesium
- D. Serum chloride
Correct Answer: A
Rationale: The nurse should monitor serum potassium levels because lisinopril, an ACE inhibitor, can cause potassium retention leading to hyperkalemia. Hyperkalemia can result in serious cardiac complications. Monitoring potassium levels allows timely intervention if levels become elevated. Serum calcium, magnesium, and chloride are not typically affected by lisinopril, making choices B, C, and D incorrect. The correct answer, A, is crucial for patient safety and reflects the physiological impact of lisinopril on potassium levels.
A nurse in an emergency department is caring for a patient who has diabetic ketoacidosis (DKA) and a blood glucose level of 925 mg/dL. What prescription should the nurse anticipate from the provider? What prescription should the nurse anticipate for DKA?
- A. Glucocorticoid medications.
- B. Dextrose 5% in 0.45% sodium chloride.
- C. Oral hypoglycemic medications.
- D. 0.9% sodium chloride IV bolus.
Correct Answer: D
Rationale: The correct answer is D: 0.9% sodium chloride IV bolus. In DKA, the primary concern is severe dehydration and electrolyte imbalances due to high blood glucose levels. 0.9% sodium chloride helps to rehydrate the patient and correct electrolyte imbalances. Glucocorticoids (A) are not typically used in the treatment of DKA. Dextrose 5% in 0.45% sodium chloride (B) would worsen hyperglycemia. Oral hypoglycemic medications (C) are not appropriate for managing acute DKA. Therefore, the nurse should anticipate the prescription of 0.9% sodium chloride IV bolus to address the immediate needs of the patient with DKA.
A nurse is caring for a patient who is postoperative following a cesarean section. Which of the following findings should the nurse report to the provider? Which finding post-cesarean should the nurse report?
- A. Lochia serosa
- B. Fundus firm at the umbilicus
- C. Mild cramping
- D. Foul-smelling vaginal discharge
Correct Answer: D
Rationale: The correct answer is D: Foul-smelling vaginal discharge. This finding indicates a possible infection, which is crucial to report to the provider for prompt intervention. Foul odor may indicate endometritis or other postoperative complications.
A: Lochia serosa is a normal finding post-cesarean.
B: Fundus firm at the umbilicus is a normal finding post-cesarean, indicating proper involution.
C: Mild cramping is common post-cesarean due to uterine contractions as it returns to its pre-pregnancy size.