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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.
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A nurse is reinforcing teaching with a client who has atelectasis. The nurse tells the client how to position herself to promote drainage of the apical lung segments. Which of the following statements by the client should the nurse identify as understanding of the teaching?
- A. I will sit up on the side of the bed with my legs dangling.
- B. I will turn on my left side with my legs elevated higher than my chest.
- C. I will position myself on my back with my head lower than my feet.
- D. I will lie on my abdomen with pillows under my stomach and chest.
Correct Answer: D
Rationale: Prone positioning with pillows under the chest promotes postural drainage of apical lung segments. Other positions are ineffective.
A 46-year-old African-American man is in an outpatient clinic for a physical examination. His BP is 126/84 mm Hg, his BMI is 24, and he reports no previous medical problems. Which of the following actions should the nurse take?
- A. Schedule his next appointment for 1 year from now.
- B. Provide information about how to reduce risk factors of hypertension.
- C. Schedule an appointment for a prostate-specific antigen (PSA) test.
- D. Provide information for a weight loss plan that includes increasing physical activity.
Correct Answer: B
Rationale: The correct answer is B: Provide information about how to reduce risk factors of hypertension. The rationale is as follows: The patient is at risk for developing hypertension based on his age, ethnicity, and BP reading. Providing information on reducing risk factors such as maintaining a healthy diet, regular exercise, stress management, and avoiding tobacco and excess alcohol can help prevent the development of hypertension. This proactive approach aligns with preventive healthcare measures.
Choices A, C, and D are incorrect because scheduling the next appointment for 1 year from now does not address the potential risk of hypertension, a PSA test is unrelated to the patient's current presentation, and weight loss is not indicated as the patient's BMI is within the normal range.
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.
A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?
- A. An NG tube to suction
- B. An indwelling urinary catheter to gravity drainage
- C. A chest tube to water-seal drainage
- D. A nephrostomy tube to a drainage bag
Correct Answer: A
Rationale: NG suction removes gastric contents, leading to loss of potassium and increased risk of hypokalemia.
A nurse is assisting with the plan of care for a client who does not speak the same language as the nurse. Which of the following interventions should the nurse include in the plan?
- A. Ensure that a family member is present who can interpret health care information.
- B. Use pictures to reinforce instructions given to the client.
- C. Speak in a loud voice when talking to the client.
- D. Encourage the client to nod to indicate understanding.
Correct Answer: B
Rationale: Using pictures as reinforcement supports effective communication and understanding.