Nokea
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. During the stage of Intimacy versus isolation in Erikson's psychosocial development theory, individuals focus on forming deep, meaningful relationships and developing a sense of commitment to others. This stage typically occurs in young adulthood. By establishing relationships with commitment, individuals achieve intimacy and avoid feelings of isolation.
A: Generativity versus stagnation focuses on contributing to society and future generations.
B: Identity versus role diffusion involves developing a sense of self and a coherent identity.
D: Trust versus mistrust occurs in infancy and is about developing a sense of trust in the world.
Overall, C is the correct choice as it aligns most closely with the task of establishing relationships with commitment.
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A nurse is caring for a client who requires a clear liquid diet. Which of the following foods should the nurse allow the client to have?
- A. Grape juice
- B. Lemon sherbet
- C. Skim milk
- D. Carrot juice
Correct Answer: A
Rationale: The correct answer is A: Grape juice. A clear liquid diet includes transparent liquids like water, broth, tea, and clear juices without pulp. Grape juice fits this criteria as it is a clear liquid that is easily digestible. Lemon sherbet (B) contains dairy and solid components, not suitable for a clear liquid diet. Skim milk (C) is a dairy product and not transparent. Carrot juice (D) has pulp and is not considered a clear liquid.
A nurse is caring for a client who has a respiratory infection. The nurse should have the client sit in a high-Fowler's position to help mobilize secretions from which of the following lung segments?
- A. Apical segments
- B. Both upper lobes
- C. Anterior segments of both lower lobes
- D. Posterior segments of both lower lobes
Correct Answer: B
Rationale: High-Fowler's position enhances lung expansion and secretion clearance from the upper lobes.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe the Sabbath on Saturdays and refrain from work or secular activities. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and promotes culturally sensitive care.
Incorrect options:
B: Arrange for him to receive the sacrament of the sick - This option pertains to a Catholic sacrament, not relevant to Seventh-Day Adventist beliefs.
C: Assign same-gender caregivers - This is related to privacy and modesty, not specific to Seventh-Day Adventist beliefs.
D: Offer him a kosher dietary menu - Kosher dietary laws are specific to Jewish beliefs, not Seventh-Day Adventist practices.
A nurse is reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night. Which of the following statements should the nurse identify as an indication that the client understands the instructions?
- A. I'll use a humidifier beside my bed at night.
- B. I'll sleep better if I take a sleeping pill at night.
- C. I am going to try to lose about 50 pounds.
- D. I am going to have a glass of red wine before bedtime.
Correct Answer: C
Rationale: The correct answer is C: "I am going to try to lose about 50 pounds." This statement indicates the client's understanding of how weight loss can help reduce obstructive sleep apnea episodes in obese individuals. Excess weight can contribute to airway obstruction during sleep, leading to apneic episodes. Losing weight can alleviate this pressure on the airway, improving breathing during sleep.
A: Using a humidifier may help with dry air but does not directly address the underlying cause of obstructive sleep apnea.
B: Taking a sleeping pill can mask symptoms but does not address the root cause of the issue.
D: Consuming alcohol before bedtime can worsen sleep apnea symptoms as it relaxes the throat muscles, potentially increasing the risk of apneic episodes.
A nurse is obtaining a urine specimen for culture and sensitivity via a straight catheterization. Which of the following actions should the nurse take?
- A. Collect urine from the catheter's port.
- B. Use a sterile specimen container.
- C. Use sterile water to inflate the balloon.
- D. Instruct the client to clean from front to back with an antiseptic solution.
Correct Answer: B
Rationale: The correct answer is B: Use a sterile specimen container. This is crucial to prevent contamination of the urine sample, ensuring accurate culture and sensitivity results. Sterile container minimizes the risk of introducing bacteria from the environment. Option A is incorrect because collecting urine from the catheter's port may introduce contaminants. Option C is incorrect as sterile water is not used to inflate the balloon but rather sterile saline. Option D is incorrect because cleaning from front to back is not relevant to obtaining a urine specimen via catheterization.