Nokea
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. "I spent my whole life dreaming about retirement
- B. & now I wish I had my job back"
- C. It's been so stressful for me to have to depend on my son to help around the house
- D. I just heard my friend Al died. That's the 3rd one in 3 months.
- E. I'm struggling with helping out in my community. I just don't know what I can do.
Correct Answer: D
Rationale: The correct answer is D. The nurse should prioritize assessing and intervening in the older adult's grief over losing friends. This is crucial as multiple recent losses can lead to increased risk of depression and isolation. It is essential to address feelings of loss and provide support. Choice A focuses on retirement dreams, which may not be as urgent. Choice B indicates job-related regret. Choice C mentions stress from dependence on son. These issues are important but do not pose immediate risks to mental health and well-being compared to dealing with multiple recent deaths. Choices E, F, and G do not provide relevant information to prioritize over grief from recent losses.
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As part of the admission process, a nurse at a long-term care facility is gathering a nutrition history for a client with dementia. Which component is the priority to determine from their family?
- A. BMI
- B. Usual times for meals/snacks
- C. Favorite foods
- D. Any difficulty swallowing
Correct Answer: D
Rationale: The correct answer is D: Any difficulty swallowing. This is the priority component to determine because clients with dementia are at higher risk for dysphagia, which can lead to aspiration pneumonia and malnutrition. Identifying swallowing difficulties early can help prevent complications.
A: BMI is important but not the priority in this case.
B: Usual times for meals/snacks may be important but not as critical as identifying swallowing issues.
C: Favorite foods can provide insight into preferences but do not address immediate health risks.
In summary, identifying any difficulty swallowing is crucial for the safety and well-being of the client with dementia.
Nurse tells client that she will call surgeon & ask about his request. Surgeon hears nurse's report & prescribes full liquid diet. Nurse used which of following levels of critical thinking?
- A. basic
- B. commitment
- C. complex
- D. integrity
Correct Answer: A
Rationale: The correct answer is A: basic. In this scenario, the nurse is simply relaying information and following a routine procedure by contacting the surgeon for a prescription. This level of critical thinking involves basic understanding and application of knowledge without deeper analysis or evaluation. The other choices are incorrect because: B: commitment involves making decisions and taking responsibility; C: complex involves analyzing and evaluating information; D: integrity involves ethical decision-making. In this case, the nurse's action aligns with basic thinking as she is following a standard protocol without engaging in higher-level critical thinking processes.
Nurse is talking with parents of toddler. Which should nurse suggest regarding discipline?
- A. Establish consistent boundaries
- B. Place him in room with door closed
- C. Have him learn by trial & error
- D. Use favorite snacks as rewards
Correct Answer: A
Rationale: The correct answer is A: Establish consistent boundaries. This is important in toddler discipline as it provides structure and teaches the child what behaviors are acceptable. Consistency helps in setting clear expectations and enforcing consequences. Option B is incorrect as isolation can lead to feelings of abandonment. Option C is incorrect as trial and error may not provide clear guidance for the child. Option D is incorrect as using food rewards may lead to unhealthy eating habits.
Nurse preparing instructional session about managing stress incontinence for older adult. Which actions should nurse take first when meeting with client?
- A. Encourage client to participate actively in learning
- B. Select instructional materials appropriate for older adult
- C. Identify goals nurse & client can agree are reasonable
- D. Determine what client knows about stress incontinence
Correct Answer: D
Rationale: The correct answer is D because determining what the client already knows about stress incontinence is essential for tailoring the instructional session effectively. By assessing the client's existing knowledge, the nurse can avoid repeating information that the client already understands and focus on areas where the client needs more education. This approach ensures that the session is individualized and meets the client's specific needs. Encouraging active participation (choice A) and setting goals (choice C) can come after assessing the client's knowledge. Selecting appropriate materials (choice B) is important but should be based on the client's knowledge level.
Nurse caring for a client who reports severe sore throat, pain with swallowing, and swollen lymph nodes. The client is experiencing which of the following stages of infection?
- A. Prodromal
- B. Incubation
- C. Convalescence
- D. Illness
Correct Answer: D
Rationale: The correct answer is D: Illness. In this stage, the client exhibits specific signs and symptoms of infection, such as severe sore throat, pain with swallowing, and swollen lymph nodes. This indicates active replication of the pathogen and the body's immune response. Other choices are incorrect because: A: Prodromal is the initial stage with vague, non-specific symptoms. B: Incubation is the period between exposure to the pathogen and the onset of symptoms. C: Convalescence is the recovery stage after the illness.