Nokea
A nurse is performing chest physiotherapy for a client with a respiratory infection. Which of the following techniques should the nurse use to increase the velocity and turbulence of the air the client exhales?
- A. Postural drainage
- B. Nebulization
- C. Percussion
- D. Vibration
Correct Answer: D
Rationale: Vibration increases air turbulence and helps loosen secretions, facilitating expectoration.
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A nurse is collecting data from a client about pitting edema and notes an indentation of 6 mm (0.25 in) at the point of pressure. Which of the following numbers should the nurse document to indicate the intensity of the client's edema?
- A. 4+
- B. 3+
- C. 2+
- D. 1+
Correct Answer: B
Rationale: A 6-mm indentation corresponds to 3+ pitting edema, indicating moderate to severe fluid retention.
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. During the stage of Intimacy versus isolation in Erikson's psychosocial development theory, individuals focus on forming deep, meaningful relationships and developing a sense of commitment to others. This stage typically occurs in young adulthood. By establishing relationships with commitment, individuals achieve intimacy and avoid feelings of isolation.
A: Generativity versus stagnation focuses on contributing to society and future generations.
B: Identity versus role diffusion involves developing a sense of self and a coherent identity.
D: Trust versus mistrust occurs in infancy and is about developing a sense of trust in the world.
Overall, C is the correct choice as it aligns most closely with the task of establishing relationships with commitment.
A nurse is caring for a client who practices Orthodox Judaism. The nurse should identify that which of the following foods together on the same dinner tray violates the client's religious practices?
- A. Kosher roast beef and ice cream
- B. Carrot sticks and cottage cheese
- C. Macaroni and cheese
- D. Kosher chicken breast and boiled potatoes
Correct Answer: A
Rationale: The correct answer is A: Kosher roast beef and ice cream. In Orthodox Judaism, meat and dairy products cannot be consumed together. Kosher laws prohibit mixing meat and dairy in the same meal or on the same plate to maintain dietary restrictions. Choices B, C, and D do not violate this rule as they do not mix meat and dairy products. Carrot sticks and cottage cheese (B), macaroni and cheese (C), and kosher chicken breast and boiled potatoes (D) are all permissible combinations in Orthodox Judaism.
A nurse is assisting with the admission of a client who is about to have elective surgery. The client tells the nurse she feels anxious. Which of the following responses should the nurse make?
- A. You have nothing to worry about.
- B. Others who have had this procedure have had great results.
- C. Tell me more about your concerns.
- D. Why are you feeling so anxious?
Correct Answer: C
Rationale: The correct response is C: "Tell me more about your concerns." This is the best response because it shows active listening and empathy towards the client's feelings. By encouraging the client to express their concerns, the nurse can address specific fears or worries, providing reassurance and support tailored to the individual's needs. This open-ended question allows the client to share their feelings, leading to better communication and trust between the nurse and client.
Other choices are incorrect because:
A: "You have nothing to worry about." is dismissive and does not acknowledge the client's feelings.
B: "Others who have had this procedure have had great results." may minimize the client's anxiety and not address their specific concerns.
D: "Why are you feeling so anxious?" is a closed-ended question that may put the client on the spot and not facilitate open communication.
A nurse is caring for a client whose partner asks to speak with the nurse. The client's partner relates that she is concerned because her partner abuses alcohol and has difficulty maintaining employment. Which of the following responses should the nurse make?
- A. If I were you, I would contact a support group.
- B. I'm so sorry to hear about this.
- C. I suggest you talk with the hospital chaplain about your concern.
- D. What have you done in the past to cope with this issue?
Correct Answer: D
Rationale: Exploring the partner's past coping strategies encourages problem-solving and emotional support.