Nokea
The 18 year-old tells the clinic nurse, 'Thinking about college is stressing me out. I am used to getting A’s and B’s.' Which statement should the nurse reserve until a follow-up visit with the client?
- A. Expressing your feelings of anxiety to a friend or nurse helps you cope emotionally.'
- B. I will check with the provider about prescribing paroxetine hydrochloride.'
- C. Exercise increases the release of endorphins and can enhance your sense of well-being.'
- D. If you like drawing or painting, register for an art class during your first semester in college.'
Correct Answer: B
Rationale: The nurse should reserve suggesting an antidepressant until other interventions have been tried. Paroxetine influences neurotransmitters related to anxiety, but non-pharmacological coping strategies like expressing feelings, exercise, and art therapy should be prioritized initially.
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The nurse is assessing the older adult. Which tool should the nurse select to identify the client’s needs and care deficits?
- A. Katz Index of Activities of Daily Living
- B. Maslow’s Hierarchy of Needs
- C. Mini Mental State Exam (MMSE)
- D. Erikson’s Developmental Tasks
Correct Answer: A
Rationale: The Katz Index assesses functional ability in daily activities, identifying care deficits. Maslow’s is a general needs theory, MMSE assesses cognition, and Erikson’s is developmental.
The 66-year-old client recently retired after working 30 years as a bank manager. Which statement to the nurse during a clinic visit best suggests that the client is achieving the developmental stage of 'integrity versus despair'?
- A. Now that I have some free time, I want to treat my wife to a trip to Hawaii.'
- B. I seem to be staying in bed longer and longer each day. There isn’t a reason to get up now.'
- C. I am noticing the little aches and pains more; before I was just too busy to notice them.'
- D. I get calls a few times a week for advice; my coworkers still value my suggestions.'
Correct Answer: D
Rationale: Integrity versus despair involves accepting one’s life’s worth. Valued advice from coworkers indicates positive resolution. A trip reflects generativity, staying in bed suggests despair, and aches are unrelated.
The nurse plans to teach the client progressive muscle relaxation. Prioritize the steps that the nurse should teach to correctly perform progressive muscle relaxation.
- A. Relax the feet, imagining the tension flowing out with each exhalation
- B. Lie down in a quiet place where you are undisturbed
- C. Contract the muscles of your feet first as you inhale and hold the contraction briefly
- D. Relax your body, allowing it to feel heavy
- E. Lie still for a few minutes after the contraction and relaxation of all muscles
- F. Imagine the tension flowing out with each breath you take
- G. Move up the body, contracting then relaxing each muscle
Correct Answer: B;D;F;C;A;G;E
Rationale: Steps: 1) Lie in a quiet place to focus; 2) Relax body to feel heavy; 3) Imagine tension flowing out with breaths; 4) Contract feet muscles; 5) Relax feet; 6) Move up body; 7) Lie still to monitor relaxation.
The 50-year-old asks the nurse how to calculate BM]. The client weighs 134 1b and is 5’3” tall. Together, the client and nurse calculate the client’s BMI rounded to the nearest tenth. What is the client’s BMI?
Correct Answer: 23.8
Rationale: BMI = [weight (lb) / height (in)²] × 703 = [134 / (63)²] × 703 = [134 / 3969] × 703 ≈ 23.75, rounded to 23.8.
The nurse observes the NA providing a stuffed animal to the hospitalized older adult client who is experiencing delirium. Which action by the nurse is most appropriate?
- A. Reprimand the NA for treating the client like a child
- B. Remove the stuffed animal before anyone else sees it
- C. Report the NA’s action to the unit’s nurse manager
- D. Thank the NA for providing it for the client’s fidgeting
Correct Answer: D
Rationale: A stuffed animal can occupy a delirious client’s hands, preventing line removal, and may be comforting. Thanking the NA is appropriate; other actions are unnecessary or punitive.