Nokea
Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities? (Select all that apply.)
- 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 choices, C and E, align with Erikson's theory of psychosocial development for middle adulthood. Choice C, "Welcome opportunities to be creative & productive," reflects Erikson's stage of generativity versus stagnation, where individuals in middle adulthood seek to contribute to society and leave a legacy. Choice E, "Become involved in community issues & activities," relates to the desire for social involvement and making a positive impact on the community. Choices A, B, and D are incorrect because they do not align with the typical capabilities of middle adults according to Erikson's theory. Choice A contradicts the idea of middle adults striving for independence and self-reliance, while choice B reflects feelings of regret or despair, which are more characteristic of Erikson's later stages. Choice D, while important, does not capture the full scope of middle adulthood psychosocial development as outlined by Erikson.
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The nurse is caring for a group of medical-surgical patients. The unit has been notified of a fire on an adjacent wing of the hospital. The nurse quickly formulates a plan to keep the patients safe. Which actions will the nurse take? Select all that apply
- A. Close all doors.
- B. Note evacuation routes.
- C. Note oxygen shut-offs.
- D. Move bedridden patients in their bed.
- E. Wait until the fire department arrives to act.
- F. Use type B fire extinguishers for electrical fires.
Correct Answer: A, B, C, D
Rationale: Correct Answer: A, B, C, D
Rationale:
A: Close all doors - By closing doors, the nurse can prevent the spread of smoke and fire, protecting patients.
B: Note evacuation routes - Knowing evacuation routes ensures a safe and efficient evacuation if needed.
C: Note oxygen shut-offs - Turning off oxygen can reduce the risk of fire spreading and explosions.
D: Move bedridden patients in their bed - Moving bedridden patients quickly and safely is crucial for their well-being during an emergency.
Summary:
E: Waiting for the fire department is not proactive and can waste valuable time in ensuring patient safety.
F: Using type B fire extinguishers for electrical fires is incorrect as type C extinguishers are recommended for electrical fires.
G: There is no information provided for this option.
Nurse is caring for newly admitted client with history of falls. What is the priority action by the nurse?
- A. Complete fall-risk assessment
- B. Educate client & family on fall risks
- C. Complete physical assessment
- D. Survey client's belongings
Correct Answer: A
Rationale: The correct answer is A: Complete fall-risk assessment. This is the priority action because it allows the nurse to identify specific risk factors contributing to the client's falls. By completing a fall-risk assessment, the nurse can implement appropriate interventions to prevent future falls. Choice B is incorrect because education should come after assessing the risk factors. Choice C is not the priority as the client's risk for falls needs to be addressed first. Choice D is irrelevant to addressing the immediate safety concern of falls.
Nurse educator is discussing facility protocol for tornados with staff. Which should nurse include in instructions? (Select all that apply.)
- A. Open doors to client rooms
- B. Place blankets over clients who are confined to beds
- C. Move beds away from windows
- D. Draw shades & close drapes
- E. Relocate ambulatory clients in hallways back to rooms
Correct Answer: B,C,D
Rationale: The correct answers are B, C, and D. Placing blankets over clients in beds provides protection from debris. Moving beds away from windows minimizes the risk of glass injuries. Drawing shades and closing drapes can prevent glass shards from entering the room. Opening doors to client rooms (A) is incorrect as it can create a draft and increase the risk of injury. Relocating ambulatory clients back to rooms (E) is unnecessary if they are safe in hallways. Choices F and G are not provided in the question. In summary, the correct instructions focus on protecting clients from debris and glass injuries during a tornado.
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.
Nurse manager is reviewing care of client with seizures with nurses on unit. Which statement by a nurse requires more instruction?
- A. I will place the client on his side
- B. I will go to the nurses' station for assistance
- C. I will administer meds as prescribed
- D. I will be prepared to insert an airway
Correct Answer: B
Rationale: Correct Answer: B - "I will go to the nurses' station for assistance" requires more instruction.
Rationale: Going to the nurses' station may waste crucial time during a seizure. The nurse should stay with the client, ensure a safe environment (A), administer prescribed meds (C), and be prepared to insert an airway (D) if needed. Going to the nurses' station could delay necessary interventions. Placing the client on their side helps prevent aspiration, administering meds is essential for seizure management, and being prepared to insert an airway is crucial in case of respiratory compromise.