A nurse is caring for a client who is on bed rest. Which of...

A nurse is caring for a client who is on bed rest. Which of the following interventions should the nurse implement to maintain the patency of the client's airway?

A. Encourage isometric exercises
B. Suction Q8 hr
C. Give low-dose heparin
D. Promote incentive spirometer use

Correct Answer: D

Rationale: The correct answer is D: Promote incentive spirometer use. This intervention helps prevent atelectasis, a common complication of prolonged bed rest. Using the incentive spirometer helps the client take deep breaths and improve lung function, thereby maintaining airway patency. Encouraging isometric exercises (choice A) does not specifically target airway patency. Suctioning every 8 hours (choice B) is not necessary unless there is a specific indication. Giving low-dose heparin (choice C) is used to prevent blood clots, not to maintain airway patency.

A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all.

A. Install bath rails & grab bars in bathrooms
B. Wear a helmet while skiing
C. Install a carbon monoxide detector
D. Secure firearms in a safe location
E. Remove throw rugs from the home

Correct Answer: B, C, D

Rationale: The correct recommendations for young adults are B, C, and D. Young adults are more likely to engage in activities like skiing that pose a risk of head injuries, hence wearing a helmet (B) is crucial. Carbon monoxide poisoning can occur from faulty heating systems or appliances, making it important to install a detector (C). Additionally, young adults may be more likely to own firearms, so securing them in a safe location (D) is essential to prevent accidents. Installing bath rails (A) and removing throw rugs (E) are more relevant to older adults to prevent falls.

A nurse is assessing a client who takes haloperidol (Haldol) for the treatment of schizophrenia. Which of the following findings should the nurse document as extrapyramidal symptoms (EPS)? Select all.

A. Orthostatic hypotension
B. Fine motor tremors
C. Acute dystonias
D. Decreased level of consciousness
E. Uncontrollable restlessness

Correct Answer: B, C, E

Rationale: The correct answer is B, C, and E. Fine motor tremors, acute dystonias, and uncontrollable restlessness are all extrapyramidal symptoms (EPS) commonly associated with haloperidol use. Fine motor tremors refer to involuntary shaking movements, acute dystonias are sudden muscle contractions causing abnormal postures, and uncontrollable restlessness is known as akathisia. These are classic EPS manifestations caused by dopamine blockade in the basal ganglia. Orthostatic hypotension (A) is a side effect related to alpha-adrenergic blockade, not EPS. Decreased level of consciousness (D) is not typically associated with EPS but may indicate overdose or other complications.

A nursing instructor is explaining the various stages of the lifespan to a group of nursing students. The nurse should offer which of the following behaviors by a young adult as an example of appropriate psychosocial development?

A. Becoming actively involved in providing guidance to the next generation
B. Adjusting to major changes in roles and relationships due to losses
C. Devoting a great deal of time to establishing an occupation
D. Finding oneself 'sandwiched' in between & being responsible for two generations

Correct Answer: C

Rationale: The correct answer is C: Devoting a great deal of time to establishing an occupation. This is an example of appropriate psychosocial development for a young adult as per Erikson's theory of psychosocial development. During the stage of young adulthood, individuals focus on establishing their careers and personal identities. This is a crucial developmental task during this stage, as it helps individuals gain a sense of purpose and direction in life. Choices A, B, and D involve responsibilities and challenges more commonly associated with other stages of life, such as middle adulthood or late adulthood. Therefore, they are not appropriate examples of psychosocial development for a young adult.

A nurse is performing a neurosensory examination for a client. Which of the following tests should the nurse perform to test the client's balance? Select all.

A. Romberg test
B. Heel-to-toe walk
C. Snellen test
D. Spinal accessory function
E. Rosenbaum test

Correct Answer: A, B

Rationale: The correct tests to assess balance are the Romberg test and heel-to-toe walk. The Romberg test evaluates proprioception and balance by having the client stand with feet together and eyes closed. If the client sways, it indicates balance impairment. The heel-to-toe walk assesses gait and balance by asking the client to walk in a straight line placing the heel of one foot in front of the toes of the other foot. Choices C, D, and E are incorrect as they are not related to balance assessment. The Snellen test evaluates visual acuity, spinal accessory function assesses shoulder movement, and Rosenbaum test measures near vision acuity.

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? Select all.

A. Older adults are more prone to dehydration than younger adults.
B. Older adults need the same amount of most vitamins and minerals as younger adults.
C. Many older men and women need calcium supplementation.
D. Older adults need more calories than they did when they were younger.
E. Older adults should consume a diet low in carbohydrates.

Correct Answer: A, B, C

Rationale: The correct answer is A, B, and C.
A: Older adults are more prone to dehydration due to age-related physiological changes that decrease the body's ability to conserve water.
B: While older adults generally need the same amount of vitamins and minerals as younger adults, they may require higher amounts of certain nutrients like vitamin D and calcium.
C: Many older men and women may need calcium supplementation to prevent osteoporosis and maintain bone health.
Incorrect choices:
D: Older adults typically need fewer calories as they age due to decreased metabolism and physical activity.
E: There is no specific recommendation for older adults to consume a diet low in carbohydrates, as carbohydrates are an essential energy source.