Nokea
A nurse is preparing a care plan for a patient who is immobile. Which psychosocial aspect will the nurse consider?
- A. Loss of bone mass
- B. Loss of strength
- C. Loss of weight
- D. Loss of hope
Correct Answer: D
Rationale: The correct answer is D: Loss of hope. When a patient is immobile, they may experience feelings of hopelessness, leading to negative psychosocial impacts. The nurse must address this aspect in the care plan to promote the patient's mental well-being. Loss of bone mass (A), loss of strength (B), and loss of weight (C) are physical aspects related to immobility, not psychosocial. These factors are important but do not directly address the patient's emotional state. It is crucial for the nurse to focus on the psychosocial well-being of the patient to provide holistic care.
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Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I spent my whole life dreaming about retirement, & now I wish I had my job back
- B. It's been so stressful for me to have to depend on my son to help around the house
- C. I just heard my friend Al died. That's the 3rd one in 3 months
- D. I'm struggling with helping out in my community. I just don't know what I can do
Correct Answer: D
Rationale: The correct answer is D. The priority issue for assessment & intervention is the older adult struggling with helping out in the community. This indicates a potential loss of purpose and meaning in life, which can negatively impact mental health. It may also suggest decreased social engagement, which is crucial for overall well-being in older adults. This issue requires immediate attention to prevent further decline in mental health and overall quality of life.
A: While feeling regret about retirement is important, it does not pose an immediate risk to the individual's well-being.
B: Depending on family for help is common in older age but does not indicate an urgent need for intervention.
C: Grieving the loss of friends is significant, but it may not be the priority issue for immediate intervention.
E, F, G: Choices are not provided, but they would likely be incorrect as they are not the priority issue for assessment & intervention.
Nurse is collecting data from mother of 1 yo. Client states her child is old enough for toilet training. Following teaching by nurse, client now states her earlier ideas have changed. She's now willing to postpone toilet training until child is older. Learning has occurred in which of following domains?
- A. Cognitive
- B. Affective
- C. Psychomotor
- D. Kinesthetic
Correct Answer: B
Rationale: The correct answer is B: Affective. Affective domain involves emotions, attitudes, and feelings. In this scenario, the mother's change in willingness to postpone toilet training shows a shift in her emotional response and attitude towards the situation. This indicates a change in the affective domain, as the mother's feelings and attitudes have been influenced by the nurse's teaching.
Choices A, C, and D are incorrect:
A: Cognitive domain involves knowledge, understanding, and thinking skills. While there may be some cognitive processing involved in the mother's decision-making, the primary change observed is in her emotions and attitudes.
C: Psychomotor domain relates to physical skills and movements, which are not the focus of the scenario.
D: Kinesthetic refers to the sense of body position and movement, which is not relevant to the mother's change in willingness to postpone toilet training.
Nurse collecting hx & physical exam data from middle adult. Nurse should expect to find decreases in which physiologic functions? (Select all that apply.)
- A. Metabolism
- B. Ability to hear low-pitched sounds
- C. Gastric secretion
- D. Far vision
- E. Glomerular filtration
Correct Answer: A,C,E
Rationale: The correct answers are A, C, and E. As individuals age, metabolism decreases due to changes in muscle mass and activity levels. Gastric secretion decreases, leading to decreased absorption of certain nutrients. Glomerular filtration rate decreases with age, affecting kidney function. Choice B is incorrect as hearing high-pitched sounds is more commonly affected with age. Choice D is incorrect as near vision is usually affected, not far vision.
Nurse is caring for a client receiving enteral tube feedings due to dysphagia. Which bed position is appropriate for safe care of this client?
- A. Supine
- B. Semi-Fowler's
- C. Semi-prone
- D. Trendelenburg
Correct Answer: B
Rationale: The correct answer is B: Semi-Fowler's. This position helps prevent aspiration during enteral tube feedings by promoting proper digestion and reducing the risk of reflux. Semi-Fowler's allows gravity to assist in the movement of food through the gastrointestinal tract, decreasing the likelihood of regurgitation. Supine (A) can increase the risk of aspiration as it may cause reflux. Semi-prone (C) and Trendelenburg (D) positions are not recommended for enteral feedings due to increased risk of reflux and aspiration.
By the 2nd post-op day
- A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
- B. Reassess client to determine reasons for pain
- C. See whether pain lessens during next 24h
- D. Change plan to ensure adequate pain relief
- E. Teach client about pain management plan
Correct Answer: A
Rationale: Correct Answer: A
Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.