Nokea
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to next generation
- B. Adjusting to major changes in roles/relationships due to losses
- C. Devoting great deal of time to establishing occupation
- D. Finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because in young adulthood, individuals typically focus on establishing their careers and developing a sense of identity. This behavior aligns with Erikson's psychosocial stage of intimacy vs. isolation. Choices A, B, and D are incorrect for a young adult's appropriate psychosocial development. A focuses on generativity, which is more typical of middle adulthood. B suggests dealing with losses, which is more aligned with later stages of life. D describes the 'sandwich generation' phenomenon, which occurs later in life when individuals are responsible for both their children and aging parents.
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Nurse observes smoke coming from under the door of the staff lounge. What is the priority action by the nurse?
- A. Extinguish fire
- B. Pull fire alarm
- C. Evacuate the clients
- D. Close all open doors on the unit
Correct Answer: C
Rationale: The correct answer is C: Evacuate the clients. This is the priority action because ensuring the safety of the clients is the nurse's primary responsibility. Evacuating the clients from the area of potential danger is crucial to prevent harm. A: Extinguishing the fire should be left to trained personnel. B: Pulling the fire alarm is important, but evacuating clients takes precedence. D: Closing doors may help contain the fire but doesn't ensure immediate safety.
A nurse is performing passive range of motion (ROM) and splinting on an at-risk patient. Which finding will indicate goal achievement for the nurse's action?
- A. Prevention of atelectasis
- B. Prevention of renal calculi
- C. Prevention of pressure ulcers
- D. Prevention of joint contractures
Correct Answer: D
Rationale: The correct answer is D, prevention of joint contractures. Passive ROM and splinting help maintain joint flexibility and prevent contractures in immobile patients. Contractures are abnormal shortening of muscles causing joints to remain in fixed positions. Preventing joint contractures is essential for preserving mobility.
A: Prevention of atelectasis is unrelated to passive ROM and splinting.
B: Prevention of renal calculi is not a direct outcome of passive ROM and splinting.
C: Prevention of pressure ulcers is important but not directly related to joint mobility.
In summary, the goal of the nurse's action is to prevent joint contractures, as immobility can lead to loss of joint motion.
A home health nurse is discussing dangers of carbon monoxide poisoning with a client. What information should the nurse include?
- A. Carbon monoxide has a distinct odor
- B. Water heaters should be inspected every 5 years
- C. Lungs are damaged from carbon monoxide inhalation
- D. Carbon monoxide binds with hemoglobin in body
Correct Answer: D
Rationale: The correct answer is D: Carbon monoxide binds with hemoglobin in the body. This is correct because carbon monoxide binds with hemoglobin in the blood more easily than oxygen, leading to decreased oxygen delivery to tissues. This can result in symptoms of carbon monoxide poisoning.
A: Carbon monoxide is odorless, so this is incorrect.
B: While regular inspection of appliances like water heaters is important for safety, it is not directly related to carbon monoxide poisoning.
C: Carbon monoxide primarily affects the body by interfering with oxygen transport, not by directly damaging the lungs.
In summary, choice D is correct because it explains the mechanism of carbon monoxide poisoning, while the other choices are incorrect as they do not directly relate to the dangers of carbon monoxide poisoning.
A nurse is preparing to reposition a patient. Which task can the nurse delegate to the nursing assistive personnel?
- A. Determining the level of comfort
- B. Changing the patient's position
- C. Identifying immobility hazards
- D. Assessing circulation
Correct Answer: B
Rationale: The correct answer is B: Changing the patient's position. This task can be delegated to nursing assistive personnel as it involves physically moving the patient, which does not require advanced nursing knowledge or assessment skills. Nursing assistive personnel are trained to safely reposition patients under the supervision of a nurse. Choices A, C, and D involve critical thinking, assessment, and decision-making skills that require a nurse's expertise, so they cannot be delegated.
Nurse preparing wellness presentation for families at community center. When discussing health screenings for adolescents, which info about scoliosis should nurse include? (Select all that apply.)
- A. Scoliosis is more common in girls than in boys
- B. Loss of height is often first sign of scoliosis
- C. Scoliosis screening is essential during adolescent growth spurt
- D. Slouching is common cause of scoliosis, especially in adolescents
- E. Scoliosis is forward curvature of spine
Correct Answer: A,C
Rationale: Correct Answer: A, C
A: Scoliosis is more common in girls than in boys - This is correct. Scoliosis is indeed more prevalent in girls compared to boys, with a ratio of about 7:1.
C: Scoliosis screening is essential during adolescent growth spurt - This is correct. Screening during the adolescent growth spurt is crucial as this is when scoliosis progression is most likely to occur.
B: Loss of height is often first sign of scoliosis - This is incorrect. The first sign of scoliosis is typically asymmetry or a visible curvature of the spine.
D: Slouching is a common cause of scoliosis, especially in adolescents - This is incorrect. Slouching is not a direct cause of scoliosis; it can exacerbate existing curvature but does not cause scoliosis.
E: Scoliosis is a forward curvature of the spine - This is incorrect. Scoliosis involves a lateral (side