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A nurse is discussing pressure ulcer staging with a newly licensed nurse. Which of the following statements should the nurse use to describe a stage 3 pressure ulcer?
- A. Unbroken skin with un-blancheable erythema
- B. Full-thickness tissue loss extending to underlying support structures
- C. A shallow, ruptured or intact skin blister without slough
- D. A deep crater without visible bone, tendon, or muscle
Correct Answer: D
Rationale: Stage 3 ulcers involve full-thickness skin loss with damage to subcutaneous tissue but without exposed bone or muscle.
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A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?
- A. Autonomy vs. Shame and Doubt
- B. Generativity vs. Stagnation
- C. Identity vs. Role Diffusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: The correct answer is D: Integrity vs. Despair. According to Erikson's psychosocial development theory, acceptance of death occurs during the final stage of life, which is Integrity vs. Despair. In this stage, individuals reflect on their lives and come to terms with their mortality, finding a sense of fulfillment and wisdom. Option A (Autonomy vs. Shame and Doubt) focuses on developing a sense of independence in early childhood. Option B (Generativity vs. Stagnation) pertains to middle adulthood and concerns contributing to society and future generations. Option C (Identity vs. Role Diffusion) relates to adolescence and the formation of a sense of self. These stages do not specifically address acceptance of death.
A nurse is caring for a client who has a new diagnosis of type 1 diabetes mellitus. To focus on affective learning with this client, which of the following interventions should the nurse use?
- A. Ask the client to perform a return demonstration of insulin injection.
- B. Review the action of insulin therapy.
- C. Explore the client's feelings about dietary modifications.
- D. Have a family member practice blood glucose monitoring using a glucometer.
Correct Answer: C
Rationale: The correct answer is C because exploring the client's feelings about dietary modifications focuses on the affective domain of learning, which involves emotions, attitudes, and values. By understanding the client's feelings, the nurse can address any concerns, fears, or resistance the client may have towards changing their diet. This approach helps to create a supportive and empathetic environment for the client to embrace necessary dietary changes.
Regarding the incorrect choices:
A: Asking the client to perform a return demonstration of insulin injection focuses on psychomotor skills, not affective learning.
B: Reviewing the action of insulin therapy focuses on cognitive learning, not affective learning.
D: Having a family member practice blood glucose monitoring is not directly related to addressing the client's emotional response to dietary modifications.
A nurse is caring for an older adult client who has dementia and wanders at night. Which of the following interventions should the nurse take?
- A. Assign the client to a quiet room away from the nurses' station.
- B. Elevate the four side rails on the client's bed at night time.
- C. Encourage the client to rest during the day.
- D. Take the client to the bathroom on a regular schedule.
Correct Answer: D
Rationale: The correct answer is D: Take the client to the bathroom on a regular schedule. This intervention helps reduce the risk of falls and incontinence by ensuring the client's regular toileting needs are met. It also helps maintain the client's dignity and comfort. Assigning the client to a quiet room away from the nurses' station (A) may increase feelings of isolation and anxiety. Elevating all four side rails on the bed (B) can be considered a restraint and is not recommended as a first-line intervention. Encouraging the client to rest during the day (C) may disrupt the client's circadian rhythm and worsen nighttime wandering.
A nurse is reinforcing teaching with a client who reports constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.)
- A. Excessive laxative use
- B. Ignoring the urge to defecate
- C. Inadequate fluid intake
- D. Increased fiber in the diet
- E. Increased activity
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. A: Excessive laxative use can lead to constipation by causing dependency on laxatives. B: Ignoring the urge to defecate can disrupt the normal bowel movement pattern, leading to constipation. C: Inadequate fluid intake can result in hard, dry stools that are difficult to pass, causing constipation. D: Increased fiber in the diet actually helps prevent constipation by adding bulk to the stool. E: Increased activity generally promotes bowel regularity and helps prevent constipation. By discussing A, B, and C with the client, the nurse can address common causes of constipation and provide appropriate interventions.
A nurse is caring for a client who ingested a poison and is now having seizures. Which of the following is the priority action the nurse should take?
- A. Maintain the patency of the client's airway.
- B. Identify the poison the client ingested.
- C. Measure the client's blood pressure.
- D. Position the client on her side.
Correct Answer: A
Rationale: Airway patency is the priority during seizures to prevent aspiration and ensure adequate oxygenation.