Nokea
Nursing instructor explaining various stages of lifespan to students. Nurse should offer which following behavior by young adult as example of appropriate psychosocial development?
- A. Becoming actively involved in providing guidance to next generation
- B. Adjusting to major changes in roles/relationships due to losses
- C. Devoting great deal of time to establishing occupation
- D. Finding oneself 'sandwiched' between being responsible for 2 generations
Correct Answer: C
Rationale: The correct answer is C because in young adulthood, individuals typically focus on establishing their careers and developing a sense of identity. This behavior aligns with Erikson's psychosocial stage of intimacy vs. isolation. Choices A, B, and D are incorrect for a young adult's appropriate psychosocial development. A focuses on generativity, which is more typical of middle adulthood. B suggests dealing with losses, which is more aligned with later stages of life. D describes the 'sandwich generation' phenomenon, which occurs later in life when individuals are responsible for both their children and aging parents.
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Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.)
- A. Do you eat alone or with someone?
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A,C,D,E
Rationale: The correct answers are A, C, D, and E.
A: Asking if the person eats alone or with someone helps to assess social factors influencing eating habits, such as loneliness or lack of social interaction affecting appetite.
C: Inquiring about new medications can reveal potential side effects like appetite changes, nausea, or malabsorption leading to weight loss.
D: Knowing the foods consumed in the past 24 hours helps identify dietary patterns that may contribute to weight loss, such as poor nutrition or reduced intake.
E: Asking about a fixed income can uncover financial constraints affecting food choices and access to nutritious meals, potentially leading to weight loss.
Summary:
B: Watching TV while eating is not directly related to weight loss causes.
F and G: Not provided in the question, so no basis to consider them as relevant questions for investigating weight loss.
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 talking with adolescent who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I kind of like this girl in my class, but she doesn't like me back like that.
- B. I like hanging out with the guys in the science club, but the jocks pick on them.
- C. I just don't seem to be good at anything. I can't play sports at all.
- D. My dad wants me to be a lawyer like him, but I don't want to learn all that stuff
Correct Answer: C
Rationale: The correct answer is C because the adolescent's self-perception of not being good at anything can indicate low self-esteem and potential mental health concerns. This could impact their overall well-being and ability to cope with various stressors. Identifying and addressing self-esteem issues is crucial for their emotional development. Choices A, B, and D are not immediate priorities as they involve interpersonal relationships and career aspirations, which are important but not as urgent as addressing the adolescent's self-perception and mental health.
The nurse is assessing a patient who reports a previous fall and is using the SPLATT acronym. Which questions will the nurse ask the patient? Select all that apply.
- A. Where did you fall?
- B. What time did the fall occur?
- C. What were you doing when you fell?
- D. What types of injuries occurred after the fall?
- E. Did you obtain an electronic safety alert device after the fall?
- F. What are your medical problems that may have caused the fall?
Correct Answer: A, B, C, D
Rationale: The correct answers are A, B, C, and D. The SPLATT acronym stands for Symptoms, Previous falls, Location, Activity during the fall, Time of the fall, and Trauma sustained. Therefore, the nurse should ask where the patient fell (A), what time the fall occurred (B), what the patient was doing when they fell (C), and what types of injuries occurred after the fall (D) to gather comprehensive information about the fall event. These questions help assess the circumstances surrounding the fall, potential risk factors, and any resulting injuries. Choices E and F are incorrect as they do not directly align with the components of the SPLATT acronym and may not provide relevant information for assessing the fall event.
A nurse receives a prescription for an antibiotic for a client with cellulitis. Upon review
- A. the nurse finds the client is allergic and calls the provider. Which attitude does the nurse demonstrate?
- B. Fairness
- C. Responsibility
- D. Risk taking
- E. Creativity
Correct Answer: B
Rationale: The correct answer is B: Fairness. The nurse demonstrates fairness by acknowledging the client's allergy and taking the necessary steps to address it, ensuring the client's safety and well-being. Responsibility (C) could also be a consideration, but fairness is more directly related to this specific scenario. Risk taking (D) and Creativity (E) are not relevant in this situation as the nurse's actions are based on standard protocols and patient safety.