Nokea
During a nursing home visit, the son notices multiple healing bruises on his father’s arms and legs and calls a friend who is a nurse. Which initial recommendations should the nurse provide to the son? Select all that apply.
- A. Ask your father how the bruises occurred and whether he was abused.'
- B. Contact Adult Protective Services immediately to report the abuse.'
- C. Verify with the nursing staff whether your father is on anticoagulants.'
- D. Inform the agency’s nursing supervisor that your father is being abused.'
- E. Contact the state ombudsman who can help you make an anonymous report.'
Correct Answer: A;C
Rationale: Asking about bruise causes and checking for anticoagulants (which cause bruising) are initial steps. Reporting abuse or contacting authorities requires more evidence.
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The 50-year-old asks the nurse how to calculate BM]. The client weighs 134 1b and is 5’3” tall. Together, the client and nurse calculate the client’s BMI rounded to the nearest tenth. What is the client’s BMI?
Correct Answer: 23.8
Rationale: BMI = [weight (lb) / height (in)²] × 703 = [134 / (63)²] × 703 = [134 / 3969] × 703 ≈ 23.75, rounded to 23.8.
The nurse is assessing the chest of the normally healthy adult male client without chest abnormalities. Which chest curvature illustrated should the nurse expect to observe?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: C
Rationale: The normal adult chest has an anteroposterior-to-lateral ratio of approximately 1:2 and a costal angle less than 90 degrees. Illustration A is pectus excavatum, B is pectus carinatum, and D is barrel chest associated with COPD.
The 66-year-old client recently retired after working 30 years as a bank manager. Which statement to the nurse during a clinic visit best suggests that the client is achieving the developmental stage of 'integrity versus despair'?
- A. Now that I have some free time, I want to treat my wife to a trip to Hawaii.'
- B. I seem to be staying in bed longer and longer each day. There isn’t a reason to get up now.'
- C. I am noticing the little aches and pains more; before I was just too busy to notice them.'
- D. I get calls a few times a week for advice; my coworkers still value my suggestions.'
Correct Answer: D
Rationale: Integrity versus despair involves accepting one’s life’s worth. Valued advice from coworkers indicates positive resolution. A trip reflects generativity, staying in bed suggests despair, and aches are unrelated.
The nurse is caring for the 50-year-old client who reports having difficulty falling asleep. Which recommendations should the nurse make to this client? Select all that apply.
- A. Drink a glass of wine or a beer before bedtime
- B. Avoid exercising 2 to 3 hours before bedtime
- C. Go to bed at the same time each night
- D. Watch television in bed just before bedtime
- E. Avoid eating large or spicy meals in the evening
Correct Answer: B;C;E
Rationale: Avoiding exercise near bedtime, maintaining a consistent bedtime, and avoiding large/spicy meals promote sleep. Alcohol and TV in bed can disrupt sleep.
The student nurse is discussing with the experienced nurse Lawrence Kohlberg’s theory of moral development pertaining to middle-aged adults. Which statement should the experienced nurse correct?
- A. Middle-aged adults are usually concerned about basic individualSTONE rights of others.'
- B. Middle-aged adults attempt to understand the values and beliefs of others.'
- C. Middle-aged adults are focused on their careers and are less concerned about morals.'
- D. Middle-aged adults use their own chosen ethical principles when making moral decisions.'
Correct Answer: C
Rationale: Kohlberg’s theory places middle-aged adults at stages 5 or 6, involving concern for individual rights, understanding others’ values, and using ethical principles, not career focus with reduced moral concern, which the experienced nurse should correct.