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Nurse counseling middle adult who describes having difficulty with many issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I'm struggling to accept my parents are aging & need so much help"
- B. It's been so stressful for me to think about having intimate relationships
- C. I know I should volunteer my time for good cause, but maybe I'm just selfish
- D. I love my grandchildren, but my son expects me to relive my parenting days
Correct Answer: B
Rationale: The correct answer is B. The nurse should prioritize assessing and intervening in the middle adult's difficulty with intimate relationships because it can significantly impact their emotional well-being and ability to form healthy connections. Intimate relationships play a crucial role in one's overall quality of life and can affect various aspects of mental health. By addressing this issue first, the nurse can help the individual work through their stress and potentially improve their relationships and overall psychological health.
Choices A, C, and D are not as critical as choice B because they involve different aspects of the individual's life that may not have an immediate impact on their emotional well-being and relationships. While accepting aging parents or volunteering are important, they do not directly address the middle adult's current emotional distress. Similarly, the expectation from the son regarding grandparenting, while challenging, may not be as urgent as addressing the stress related to intimate relationships.
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A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP?
- A. Feeding client who was admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching w/ client who is learning to walk using quad cane
- C. Reapplying a condom catheter for client who has urinary incontinence
- D. Applying sterile dressing to pressure ulcer
Correct Answer: C
Rationale: The correct answer is C. The nurse can assign the task of reapplying a condom catheter for a client with urinary incontinence to an unlicensed assistive personnel (AP) because it is a routine, non-invasive procedure that does not require specialized nursing skills. The AP can be trained to perform this task safely under the nurse's supervision.
A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse.
B: Teaching a client to walk using a quad cane involves assessing the client's safety and gait, which should be done by a licensed nurse.
D: Applying a sterile dressing to a pressure ulcer requires knowledge of wound care principles and infection control, which should be done by a licensed nurse.
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 because expressing concerns about the next generation aligns with Erikson's task of generativity vs. stagnation during middle adulthood. This stage involves contributing to the well-being of future generations. Choice A focuses on self-reflection, not generativity. Choice B refers to Erikson's trust vs. mistrust stage in infancy. Choice C relates to forming intimate relationships in young adulthood. This highlights the importance of understanding Erikson's psychosocial stages to identify appropriate behaviors.
RN is making assignments for client care to LPN at beginning of shift. Which of following assignments should LPN question?
- A. Assisting a client who is 24h post-op to use incentive spirometer
- B. Collecting clean-catch urine specimen from client who was admitted on previous shift
- C. Providing nasopharyngeal suctioning for client with pneumonia
- D. Replacing cartridge & tubing on PCA pump
Correct Answer: D
Rationale: The correct answer is D: Replacing cartridge & tubing on PCA pump. This is the assignment the LPN should question. The rationale is that LPNs are not typically trained to handle complex medical devices like PCA pumps, which deliver controlled doses of pain medication. LPNs should question this task as it involves intricate technical skills and potential risks if done incorrectly.
A: Assisting a client with an incentive spirometer is within an LPN's scope of practice and does not require specialized training.
B: Collecting a clean-catch urine specimen is a routine task that LPNs are typically trained to perform.
C: Providing nasopharyngeal suctioning for a client with pneumonia is a common nursing intervention that LPNs are qualified to carry out.
In summary, LPNs should question assignments that are outside their scope of practice or involve technical procedures beyond their training to ensure safe and effective care for the clients.
Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan?
- A. Irrigate affected area with running water
- B. Wash affected area with antibacterial soap
- C. Brush chemical off skin & clothing
- D. Apply neutralizing agent
Correct Answer: C
Rationale: The correct answer is C: Brush chemical off skin & clothing. This intervention is crucial to prevent further exposure and damage from the unknown chemical. By brushing off the chemical, the nurse can minimize the contact time and reduce the risk of more severe burns. Irrigating with water (choice A) may spread the chemical or react with it, worsening the burn. Washing with antibacterial soap (choice B) can also react with the chemical and cause more harm. Applying a neutralizing agent (choice D) can potentially worsen the burn if the wrong agent is used. Therefore, choice C is the best initial intervention to prevent further harm.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. "I have my own apt now
- B. but it's not easy living away from my parents."
- C. It's been so stressful for me to even think about having my own family.
- D. I don't even know who I am yet, & now I'm supposed to know what to do.
- E. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.
Correct Answer: C
Rationale: The correct answer is C: "It's been so stressful for me to even think about having my own family." This is the priority issue as it indicates the young adult is struggling with the idea of starting a family, which can have long-term implications. This concern may affect their mental health, relationships, and decision-making. Option A is about independence, B about transitioning from parents, D about self-identity, and E about impending fatherhood. While important, these issues are not as urgent as the stress related to starting a family.