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A nurse is reinforcing teaching with a newly licensed nurse about respecting a client's personal space. The nurse should include in the teaching that which of the following actions require client consent? (Select all that apply.)
- A. Removing the client's dentures
- B. Checking capillary refill of the client's finger
- C. Palpating for pedal edema
- D. Taking a radial pulse
- E. Observing a mole on the client's shoulder
Correct Answer: A, C
Rationale: Actions that involve physical touch or intrusion into personal space, such as removing dentures or palpating edema, require consent.
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A nurse is performing pulmonary hygiene for a client who has pneumonia. The nurse should have the client lie on his back with his head elevated to mobilize secretions from which of the following lung segments?
- A. Anterior segment of the right upper lobe
- B. Anterior segment of the right middle lobe
- C. Posterior segment of the right middle lobe
- D. Posterior segment of the right lower lobe
Correct Answer: A
Rationale: Elevating the head improves lung expansion and drainage of anterior lung segments.
A nurse is caring for a client who requires contact precautions. Which of the following actions should the nurse take?
- A. Wear a mask when entering the client's room.
- B. Remove potted plants from the room.
- C. Allow the client to leave the room every 2 hr.
- D. Dedicate equipment and supplies for use with the client.
Correct Answer: D
Rationale: The correct answer is D: Dedicate equipment and supplies for use with the client. This is essential for preventing the spread of infection. By dedicating equipment to the client, the nurse reduces the risk of contaminating other clients. Choice A is incorrect because wearing a mask is not necessary for contact precautions unless respiratory droplets are a concern. Choice B is irrelevant to contact precautions. Choice C is incorrect as allowing the client to leave the room frequently can increase the risk of spreading infection.
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.
A nurse is caring for a client who has dyspnea, crackles, and 3+ bilateral pitting pedal edema. Which of the following serum sodium levels should the nurse identify as an indication of fluid volume excess?
- A. 116 mEq/L
- B. 136 mEq/L
- C. 142 mEq/L
- D. 167 mEq/L
Correct Answer: A
Rationale: The correct answer is A (116 mEq/L). A low serum sodium level indicates dilutional hyponatremia, which can occur in fluid volume excess. In this case, the client's symptoms of dyspnea, crackles, and pedal edema point towards fluid overload. A serum sodium level of 116 mEq/L reflects dilution due to excess fluid in the body, indicating fluid volume excess. Choices B, C, and D have normal to high sodium levels, which do not correlate with fluid volume excess. Therefore, A is the most appropriate choice based on the client's clinical presentation.
A nurse is assisting with the preparation of a presentation at a community center about complementary and alternative therapies. Which of the following therapies should the nurse describe as the use of an electronic monitoring device to help clients learn to control physical responses?
- A. Reiki
- B. Biofeedback
- C. Acupuncture
- D. Yoga
Correct Answer: B
Rationale: Biofeedback uses electronic monitoring to help individuals gain control over physiological functions such as heart rate and muscle tension.