Nokea
A nurse is evaluating an older adult client who is receiving end-of-life care and has Cheyne-Stokes respirations. Which of the following observations should the nurse identify as confirmation of this respiratory pattern?
- A. Breathing ranging from very deep to very shallow with periods of apnea
- B. Shallow breathing alternating with periods of apnea
- C. Rapid respirations that are unusually deep and regular
- D. An inability to breathe without dyspnea unless sitting upright
Correct Answer: A
Rationale: The correct answer is A: Breathing ranging from very deep to very shallow with periods of apnea. Cheyne-Stokes respirations are characterized by a cyclical pattern of breathing that starts with shallow breaths and gradually becomes deeper, followed by a period of apnea. This pattern repeats itself. Option B is incorrect because it describes shallow breathing alternating with periods of apnea, which is not characteristic of Cheyne-Stokes respirations. Option C describes rapid and deep regular respirations, which is not consistent with Cheyne-Stokes respirations. Option D describes an inability to breathe without dyspnea unless sitting upright, which is not a feature of Cheyne-Stokes respirations. It is important for the nurse to be able to identify this specific respiratory pattern in the older adult client to provide appropriate care and support.
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A nurse is collecting data from an adolescent client. Which of the following behaviors should the nurse expect an adolescent who has achieved successful resolution of the developmental tasks of identity vs. role confusion to exhibit?
- A. Expresses her opinions
- B. Uses time effectively
- C. Starts and completes a task
- D. Establishes a close relationship with another person
Correct Answer: A
Rationale: The correct answer is A: Expresses her opinions. Adolescents who have successfully resolved the developmental task of identity vs. role confusion are more likely to express their opinions confidently and assertively as they have a clear sense of self and have developed their own identity. This behavior reflects their ability to articulate their thoughts and beliefs, showing autonomy and independence.
Summary of other choices:
B: Using time effectively is a good skill but not directly related to resolving identity vs. role confusion.
C: Starting and completing tasks is important, but not indicative of resolving identity issues.
D: Establishing close relationships is important, but it is not the primary behavior associated with resolving identity vs. role confusion.
Which of the following should the nurse recognize as a sign of possible infection in a postoperative client? (Select all that apply.)
- A. Increased urine output
- B. Adventitious breath sounds
- C. Decreased level of consciousness
- D. Dry crust on the incision line
- E. Oral temperature of 38.3°C (101°F)
Correct Answer: B,C,E
Rationale: Adventitious breath sounds suggest pneumonia, decreased consciousness may indicate sepsis, and fever is a systemic infection response. Increased urine output is not a sign, and dry crust is part of normal healing.
A nurse is preparing to remove a client's urinary catheter. After performing hand hygiene, which of the following actions should the nurse take?
- A. Position the client supine.
- B. Have the client bear down during removal.
- C. Cleanse the perineal area with an antiseptic.
- D. Deflate the balloon halfway and then pull out the catheter.
Correct Answer: A
Rationale: The correct answer is A: Position the client supine. This position allows for easier access to the urinary catheter and minimizes the risk of spillage or contamination. Supine position also provides better comfort and stability for the client during the catheter removal process.
Summary of other choices:
B: Having the client bear down during removal can increase the risk of injury and discomfort.
C: Cleaning the perineal area with an antiseptic is important but should be done after removing the catheter.
D: Deflating the balloon halfway and pulling out the catheter can cause pain and discomfort for the client and may lead to trauma.
A nurse is caring for a client who has diabetes mellitus and had a below-the-knee amputation 2 days ago. Which of the following statements by the client should the nurse identify as an indication that the client has a body image disturbance?
- A. When I look in the mirror, all I see is a person without a leg.
- B. I have not always made good choices in life. I deserve to lose my leg.
- C. If my wife had paid more attention to my blood sugar levels I would not have needed an amputation.
- D. No matter how hard I work in physical therapy, I can't seem to make any progress.
Correct Answer: A
Rationale: A body image disturbance is reflected in the client's negative perception of their physical self.
A nurse is observing an assistive personnel (AP) who is preparing to deliver a meal tray to a client who practices Orthodox Judaism. On the tray is a roast beef dinner with nonfat milk. Which of the following actions should the nurse take?
- A. Allow the AP to deliver the food tray to the client.
- B. Call the dietary department and ask for a kosher meal tray.
- C. Replace the nonfat milk with apple juice.
- D. Explain to the client that he needs the protein in the milk and the beef.
Correct Answer: B
Rationale: Orthodox Jewish dietary laws prohibit consuming dairy and meat together, so a kosher meal should be requested.