Nokea
The experienced nurse is observing the new nurse recommend screening tests to the 80-year-old female client. Which recommendation made by the new nurse should the experienced nurse correct?
- A. Hearing screen annually
- B. Colonoscopy every 10 years
- C. Pneumococcal vaccine annually
- D. Mammogram every 1 to 2 years
Correct Answer: C
Rationale: Pneumococcal vaccine is given at 65 and every 10 years, not annually. Hearing screens, colonoscopies, and mammograms are correctly recommended.
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The student nurse is discussing with the experienced nurse Lawrence Kohlberg’s theory of moral development pertaining to middle-aged adults. Which statement should the experienced nurse correct?
- A. Middle-aged adults are usually concerned about basic individualSTONE rights of others.'
- B. Middle-aged adults attempt to understand the values and beliefs of others.'
- C. Middle-aged adults are focused on their careers and are less concerned about morals.'
- D. Middle-aged adults use their own chosen ethical principles when making moral decisions.'
Correct Answer: C
Rationale: Kohlberg’s theory places middle-aged adults at stages 5 or 6, involving concern for individual rights, understanding others’ values, and using ethical principles, not career focus with reduced moral concern, which the experienced nurse should correct.
The 70-year-old client, hospitalized with chest pain, has been functioning independently at home. During the night, the client is found wandering in the hallway and states, 'I can’t find my kitchen. I need a glass of milk.' What is the nurse’s best interpretation of the client’s behavior?
- A. The client most likely had a stroke
- B. The stress of being in unfamiliar surroundings has caused the client’s confusion
- C. The decline in mental status, especially at night, is a normal part of aging
- D. This is an insidious change, and it likely means the client has early dementia
Correct Answer: B
Rationale: Stress from unfamiliar surroundings can cause confusion in older adults. No stroke symptoms are noted, mental decline isn’t normal aging, and the change is abrupt, not insidious.
The nurse is assessing the chest of the normally healthy adult male client without chest abnormalities. Which chest curvature illustrated should the nurse expect to observe?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: C
Rationale: The normal adult chest has an anteroposterior-to-lateral ratio of approximately 1:2 and a costal angle less than 90 degrees. Illustration A is pectus excavatum, B is pectus carinatum, and D is barrel chest associated with COPD.
The nurse is assessing the older adult client experiencing problems sleeping. Which statements, if made by the client, indicate that the client may benefit from teaching? Select all that apply.
- A. I am so tired that I need to take a nap in the middle of the day.'
- B. My routine includes a glass of warm chocolate milk at bedtime.'
- C. I installed room-darkening shades after my doctor advised these.'
- D. I’m in my bed a lot; it is the most comfortable place in my home.'
- E. I often take my pain pill for my leg pain just before going to bed.'
Correct Answer: A;B;D
Rationale: Daytime napping, chocolate milk (caffeine), and excessive bed time disrupt sleep, indicating teaching needs. Darkening shades and pain management are appropriate.
The 32-year-old has been trying to get pregnant for the past 10 years- The client consults a family planning clinic after being unsuccessful with the calendar and basal body temperature methods in determining the time of ovulation. Which statement by the nurse would be most appropriate?
- A. Let me review the methods with you; maybe you have not been using them correctly.'
- B. Have you considered that you might not be ovulating and that adoption is an option?'
- C. Test kits are available that will detect an enzyme in cervical mucus that signals ovulation.'
- D. If your spouse wears restrictive underwear, this can reduce your chance of conception.'
Correct Answer: C
Rationale: Suggesting an ovulation test kit, which detects guaiacol peroxidase in cervical mucus to signal ovulation, is most appropriate after 10 years of unsuccessful methods. Reviewing methods is less helpful, adoption is premature, and male underwear addresses sperm count, not ovulation timing.