Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities?
- A. "develop acceptance of diminished strength & increased dependence on others"
- B. feel frustrated that time is too short for trying to start another life
- C. welcome opportunities to be creative & productive
- D. commit to finding friendship & companionship
- E. become involved in community issues & activities
Correct Answer: C, E
Rationale: The correct answers are C and E. Middle adults are typically in the generativity vs. stagnation stage, where they seek to contribute to society and make a positive impact. Choice C, welcoming opportunities to be creative and productive, aligns with generativity. Additionally, becoming involved in community issues and activities (choice E) reflects their desire to engage with society. Choices A and B are incorrect as middle adults do not typically accept diminished strength and do not feel frustrated about time constraints for starting a new life. Choice D is incorrect as seeking friendship and companionship is more characteristic of young adulthood.
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Nurse performing an admission assessment for an older adult client. After gathering assessment data & performing a review of systems, which of the following actions is the priority for nursing?
- A. Orient client to his room
- B. Conduct client care conference
- C. Review client's medical orders
- D. Develop plan of care
Correct Answer: A
Rationale: The correct answer is A: Orient client to his room. This is the priority because it ensures the client's safety and comfort by helping them become familiar with their surroundings. Orienting the client first establishes a foundation for effective care delivery. Conducting a client care conference (choice B) can come later once the client is settled. Reviewing medical orders (choice C) is important but can be done after the client is oriented. Developing a plan of care (choice D) is essential but should be based on a thorough assessment, including orienting the client.
Nurse is talking with 45 yo client with no specific family hx of cancer or DM, about planning routine screenings. Which client statement indicates client understands how to proceed?
- A. So I don't need colon cancer procedure for another 2-3 yrs
- B. For now, I should continue to have mammogram each year
- C. Because doctor just did pap smear, I'll come back next year for another
- D. I had my blood glucose test last year so I won't need it again till next year
Correct Answer: B
Rationale: The correct answer is B: "For now, I should continue to have a mammogram each year." This response shows understanding of the need for annual mammograms for breast cancer screening, which is recommended for women aged 45 and older. The other choices are incorrect because: A suggests delaying colon cancer screening, which is typically recommended starting at age 50; C implies annual pap smears, which are usually done every 3-5 years depending on age and risk factors; D indicates a lack of understanding about the frequency of blood glucose testing for diabetes screening.
Security officer reviewing actions to take in event of bomb threat by phone. Which statement indicates proper understanding of procedure?
- A. I will get the caller off the phone ASAP to alert the staff
- B. I will use overhead paging to alert entire facility
- C. I will not ask any questions & just let the caller talk
- D. I will listen for background noises
Correct Answer: D
Rationale: The correct answer is D because listening for background noises can provide crucial information such as location, type of environment, and potential threats. By gathering this information discreetly, security personnel can better assess the situation and coordinate an appropriate response.
Choice A is incorrect because abruptly ending the call can hinder the ability to gather vital details. Choice B is incorrect as using overhead paging may cause panic and compromise safety. Choice C is incorrect because not asking questions can lead to missing important information.
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 attitudes, beliefs, and emotions. In this scenario, the mother's change in willingness to postpone toilet training indicates a shift in her emotions and attitudes towards the topic. The nurse's teaching likely influenced her feelings and perceptions, leading to a change in her decision-making process. The other choices are incorrect because: A) Cognitive domain focuses on knowledge and understanding, which is not directly reflected in the scenario. C) Psychomotor domain involves physical skills, such as toilet training itself, which are not the focus of the learning described. D) Kinesthetic domain relates to movement and physical sensations, which are not the primary factors influencing the mother's change in decision.
Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss?
- A. "Do you eat alone or with someone?"
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A, C, D, E
Rationale: Correct Answer: A, C, D, E
Rationale:
A. "Do you eat alone or with someone?" - This question helps determine social eating habits and potential lack of appetite due to loneliness.
C. "Have you started any new meds in the past 6 months?" - This helps identify medication side effects that may cause weight loss.
D. "What foods have you eaten in the past 24 hours?" - This assesses dietary intake and nutritional status.
E. "Are you on a fixed income?" - Financial constraints can impact food choices and access to nutritious meals.
Summary:
B. "Do you watch TV while eating your meals?" - This does not directly address the potential reasons for weight loss in an older adult.
F. - No information given to evaluate this choice.
G. - No information given to evaluate this choice.