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A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal calculi
- C. Pressure ulcers
- D. Thrombus formation
Correct Answer: B
Rationale: The correct answer is B: Renal calculi. Hypercalcemia can lead to the formation of kidney stones (renal calculi) due to increased levels of calcium in the blood being excreted by the kidneys. The nurse should monitor for signs and symptoms of renal colic, such as severe flank pain, hematuria, and urinary urgency.
Incorrect choices:
A: Hypostatic pneumonia - Hypercalcemia does not directly lead to pneumonia.
C: Pressure ulcers - Hypercalcemia does not increase the risk of pressure ulcers.
D: Thrombus formation - While hypercalcemia can predispose to blood clot formation, it is not the most closely monitored condition in this scenario.
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Nursing instructor is explaining various stages of lifespan to students. Nurse should offer which of following behaviors by young adult as example of accomplishing Erikson's tasks for psychosocial development during middle adulthood?
- A. Client evaluates his behavior after social interaction
- B. Client states he is learning to trust others
- C. Client wishes to find meaningful relationships
- D. Client expresses concerns about next generation
Correct Answer: D
Rationale: The correct answer is D: Client expresses concerns about the next generation. This behavior aligns with Erikson's task of generativity vs. stagnation in middle adulthood. This stage involves contributing to future generations through mentoring, guiding, and caring for others. Expressing concerns about the next generation demonstrates a sense of responsibility and investment in the well-being of future individuals.
A: Evaluating behavior after social interaction pertains more to self-reflection and self-awareness, not specifically related to generativity.
B: Learning to trust others is more aligned with Erikson's earlier stage of trust vs. mistrust in infancy.
C: Wishing to find meaningful relationships is associated with Erikson's intimacy vs. isolation stage in young adulthood, not middle adulthood.
Nurse providing discharge instructions to client with a prescription for oxygen use at home. What should the nurse teach about using oxygen safely? (Select all that apply)
- A. Family members who smoke must be at least 10 ft from client when oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish shouldn't be used near client receiving oxygen to prevent flammability risk as it contains volatile chemicals that can ignite.
C: A 'No Smoking' sign should be placed on the front door to remind visitors and family members to not smoke near oxygen, reducing fire risk.
E: Fire extinguisher should be readily available in the home to quickly address any potential fires related to oxygen use, ensuring safety.
Summary:
A: Keeping family members who smoke at least 10 ft away is important, but not the most critical safety measure.
D: Replacing cotton with wool clothing does not directly impact oxygen safety.
F & G: No information provided.
Nurse caring for client just admitted after falling. This client is oriented x3 & can follow directions. Which action(s) by nurse are appropriate to decrease risk of fall? (Select all that apply)
- A. Place belt restraint on him when he's sitting on bedside commode
- B. Keep bed in low position with full side rails up
- C. Ensure client's call light is within reach
- D. Provide client with nonskid footwear
- E. Complete fall-risk assessment
Correct Answer: C,D,E
Rationale: Correct Answer: C, D, E
Rationale:
C: Ensuring client's call light is within reach allows the client to easily call for assistance, reducing the risk of attempting to get up independently and potentially falling.
D: Providing the client with nonskid footwear increases traction and stability, reducing the risk of slipping and falling.
E: Completing a fall-risk assessment helps identify specific factors contributing to the client's risk of falling, allowing for tailored interventions to prevent falls.
Incorrect Choices:
A: Placing a belt restraint on the client when he's on the bedside commode is inappropriate as it restricts movement and can lead to increased agitation or attempts to remove the restraint, potentially causing a fall.
B: Keeping the bed in a low position with full side rails up can actually increase the risk of injury in case of a fall, as the client may try to climb over the rails or could become trapped between the rails and the bed.
Nurse uses head-to-toe approach to conduct physical assessment of a client who will undergo surgery in 1 week. Which of following attitudes did nurse demonstrate?
- A. Confidence
- B. Perseverance
- C. Integrity
- D. Discipline
Correct Answer: D
Rationale: The correct answer is D: Discipline. The nurse demonstrated discipline by using the head-to-toe approach, ensuring a systematic and thorough assessment. This approach helps in identifying any abnormalities or potential issues before surgery. Confidence (A) is important but not specific to the method used. Perseverance (B) and integrity (C) are valuable traits but not directly related to the assessment approach. The nurse's systematic and methodical approach reflects discipline, making it the most appropriate choice.
Nurse reviewing CDC's immunization recommendations for young adult. Which should nurse include in this discussion? (Select all that apply.)
- A. HPV
- B. Measles, mumps, rubella
- C. Varicella
- D. Haemophilus influenzae type b
- E. Polio
Correct Answer: A,B,C
Rationale: The correct answer is A, B, and C. The nurse should include HPV, measles, mumps, rubella, and varicella in the discussion as these are recommended immunizations for young adults by the CDC. HPV vaccination helps prevent certain types of cancers and genital warts. Measles, mumps, and rubella vaccines protect against highly contagious diseases. Varicella vaccine prevents chickenpox. Choices D, E, F, and G are incorrect. Haemophilus influenzae type b and polio vaccines are typically given during infancy and childhood, not young adulthood. The options F and G are incomplete.