Nokea
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. This stage in Erikson's theory occurs during school age (6-11 years), where children develop a sense of competence and mastery in their skills and tasks. Considering this stage in the planning for a child recovering from an asthma attack is crucial. By emphasizing the child's abilities and encouraging them to engage in self-care activities, the nurse can promote a sense of industry and competence, which can boost the child's self-esteem. Choices A, B, and D are not directly related to the developmental stage of school-age children and do not address the specific needs and challenges this age group faces. Autonomy vs. shame and doubt (A) is more relevant to toddlers, Initiative vs. guilt (B) is more relevant to preschoolers, and Identity vs. role confusion (D) is more relevant to adolescents.
You may also like to solve these questions
A nurse is caring for a client whose arterial blood gases include a pH of 7.30, an HCO3- of 18 mEq/L and a PaCO2 of 28 mm Hg. The nurse should suspect that the client has developed which of the following acid-base imbalances?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Metabolic alkalosis
- D. Respiratory alkalosis
Correct Answer: A
Rationale: The correct answer is A: Metabolic acidosis. The pH is low (acidosis) and the HCO3- is also low, indicating a primary metabolic acidosis. The low PaCO2 (respiratory alkalosis compensation) further supports metabolic acidosis. Other choices are incorrect because B: Respiratory acidosis would have a high PaCO2, C: Metabolic alkalosis would have a high HCO3-, and D: Respiratory alkalosis would have a low PaCO2 with a high pH.
A nurse is reinforcing teaching with a client who is to collect stool at home for a fecal occult blood test (FOBT). Which of the following should the nurse instruct the client to avoid for at least 3 days before the test?
- A. Whole grain cereal
- B. Magnesium hydroxide
- C. Orange juice
- D. Acetaminophen
Correct Answer: B
Rationale: The correct answer is B: Magnesium hydroxide. This is because magnesium hydroxide, commonly found in antacids and laxatives, can cause false-positive results in a fecal occult blood test (FOBT) due to its chemical reaction with the test reagents. Instructing the client to avoid magnesium hydroxide for at least 3 days before the test ensures accurate results.
Incorrect choices:
A: Whole grain cereal - Whole grain cereal does not interfere with FOBT results.
C: Orange juice - Orange juice does not impact FOBT results.
D: Acetaminophen - Acetaminophen does not affect FOBT results.
Therefore, avoiding magnesium hydroxide is crucial to obtaining reliable results in the FOBT.
A nurse is reviewing the laboratory results of a client and notes a calcium level of 7.2 mg/dL. Which of the following findings should the nurse expect?
- A. Hypoactive deep-tendon reflexes
- B. Numbness of extremities
- C. Dry, sticky mucous membranes
- D. Decreased bowel sounds
Correct Answer: B
Rationale: The correct answer is B: Numbness of extremities. A calcium level of 7.2 mg/dL indicates hypocalcemia, which can lead to neuromuscular excitability and tingling sensations. Numbness of extremities is a common symptom of hypocalcemia due to its effect on nerve function. Hypoactive deep-tendon reflexes (choice A) are associated with hypercalcemia, not hypocalcemia. Dry, sticky mucous membranes (choice C) are more indicative of dehydration. Decreased bowel sounds (choice D) may be seen in conditions affecting the gastrointestinal tract, but are not directly related to calcium levels.
A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first?
- A. Disconnect the tube from the wall suction.
- B. Perform hand hygiene and don gloves.
- C. Observe the amount and color of drainage.
- D. Verify provider order to discontinue the tube.
Correct Answer: D
Rationale: The correct answer is D: Verify provider order to discontinue the tube. This is the first step the nurse should take before removing the NG tube to ensure that the removal is in line with the provider's instructions. Removing the tube without a valid order can lead to complications. Disconnecting the tube from wall suction (A) should be done after verifying the order. Performing hand hygiene and donning gloves (B) is important but can be done after verifying the order. Observing the amount and color of drainage (C) is important but should come after verifying the order.
A nurse notes that the left eyelid of a client who is unconscious remains partially open. To protect the eye, which of the following actions should the nurse take?
- A. Irrigate the eye daily with 0.9% sodium chloride irrigation solution.
- B. Dim the lights in the room.
- C. Instill ophthalmic ointment into the lower lid.
- D. Keep the client off her left side.
Correct Answer: C
Rationale: The correct answer is C: Instill ophthalmic ointment into the lower lid. This action helps prevent corneal abrasions by keeping the eye moist and lubricated. Irrigating the eye with saline solution (choice A) may not provide adequate protection. Dimming the lights (choice B) doesn't directly address eye protection. Keeping the client off her left side (choice D) is unrelated to eye care.