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A nurse is emptying a client's urinal when she notices the urine is dark amber, cloudy, and has an unpleasant odor. The nurse should identify that these findings are likely to be the result of which of the following?
- A. Urinary tract infection
- B. Urinary incontinence
- C. Urinary frequency
- D. Urinary retention
Correct Answer: A
Rationale: The correct answer is A: Urinary tract infection. The dark amber color, cloudy appearance, and unpleasant odor of the urine indicate a possible infection. Dark amber color suggests concentrated urine due to dehydration, common in UTIs. Cloudiness indicates presence of bacteria or pus, typical in UTIs. Unpleasant odor is often caused by bacteria breaking down urine. Choices B, C, and D are unlikely to cause these specific findings. Urinary incontinence refers to involuntary leakage of urine and does not directly affect urine appearance. Urinary frequency means urinating more often but doesn't typically change urine color or odor. Urinary retention is the inability to empty the bladder completely, which may lead to overflow incontinence, but doesn't directly cause dark amber, cloudy, and foul-smelling urine.
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A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions?
- A. Encourage the client to ambulate more often.
- B. Encourage coughing and deep breathing.
- C. Encourage the client to drink more fluids.
- D. Encourage regular use of the incentive spirometer.
Correct Answer: C
Rationale: The correct answer is C: Encourage the client to drink more fluids. Increased fluid intake helps to thin respiratory secretions, making it easier for the client to cough them up and clear the airways. This action promotes effective airway clearance and reduces the risk of complications such as pneumonia worsening. Encouraging ambulation (A) is beneficial for overall lung health but does not directly address thinning of respiratory secretions. While coughing and deep breathing (B) are important for clearing secretions, increasing fluids is more effective in thinning them. Using the incentive spirometer (D) helps with lung expansion but does not directly thin secretions.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe the Sabbath on Saturdays and refrain from work or secular activities. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and promotes culturally sensitive care.
Incorrect options:
B: Arrange for him to receive the sacrament of the sick - This option pertains to a Catholic sacrament, not relevant to Seventh-Day Adventist beliefs.
C: Assign same-gender caregivers - This is related to privacy and modesty, not specific to Seventh-Day Adventist beliefs.
D: Offer him a kosher dietary menu - Kosher dietary laws are specific to Jewish beliefs, not Seventh-Day Adventist practices.
A client comes to the clinic reporting chronic low back pain. He asks the nurse to recommend specific exercises for him. Which of the following activities should the nurse suggest?
- A. Tennis
- B. Canoeing
- C. Swimming
- D. Archery
Correct Answer: C
Rationale: The correct answer is C: Swimming. Swimming is a low-impact exercise that helps strengthen the muscles in the back and core without putting excessive strain on the spine. It also promotes flexibility and improves cardiovascular health, which can aid in managing chronic low back pain. Other options like A (Tennis), B (Canoeing), and D (Archery) involve movements that may exacerbate back pain due to potential twisting, impact, or strain on the back muscles. Therefore, swimming is the most suitable recommendation for the client to alleviate and manage chronic low back pain effectively.
A nurse is monitoring a client for complications of immobility. Which of the following findings should the nurse expect? (Select all that apply.)
- A. Contractures of extremities
- B. Hypertension
- C. Diarrhea
- D. Crackles in the lungs
- E. Pressure ulcers
Correct Answer: A,D,E
Rationale: The correct answers are A, D, and E. Contractures of extremities occur due to prolonged immobility. Crackles in the lungs can result from immobility-related respiratory complications. Pressure ulcers are common in immobile clients due to prolonged pressure on bony prominences. Hypertension and diarrhea are not typically associated with complications of immobility.
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. According to Erikson's psychosocial theory, the stage of intimacy versus isolation occurs in young adulthood. This stage focuses on forming close relationships and commitments with others. This is a critical time for individuals to develop intimate relationships and establish long-term commitments. Choosing option C is correct as it aligns with the primary task of this stage.
A: Generativity versus stagnation occurs in middle adulthood and focuses on contributing to society.
B: Identity versus role diffusion happens in adolescence and centers on forming a sense of self.
D: Trust versus mistrust is in infancy and relates to developing trust in others.
Thus, option C is the most appropriate choice for the stage involving establishing relationships with commitment.