Nokea
The nurse assesses that a hospitalized 20-year-old college student is anxious and not able to concentrate when given self-care instructions. Which intervention should the nurse implement to assist the client to deal with the stress of hospitalization?
- A. Have one parent stay in the room when the client is anxious
- B. Encourage using a cell phone or Internet to talk with friends
- C. Contact psychiatry to discuss treatments for depression
- D. Reinforce multiple times how best to perform self-care
Correct Answer: B
Rationale: To enhance coping, the nurse should focus on the developmental needs of a young adult, which include interaction with peers. Using a cell phone or Internet to communicate with friends assists in dealing with hospitalization stress. Parental presence may be intrusive, the client shows no depression, and reinforcing self-care doesn’t address emotional needs.
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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.
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 educator is planning teaching for other nurses after noting that some nurses need additional education on insulin types and how to use the new insulin injection pens. When planning teaching, which question by the educator best reflects consideration that the nurses are adult learners?
- A. Does anyone want to volunteer to prepare a poster board and help with handouts?'
- B. What do you need to learn about insulin, and what teaching method would you prefer?'
- C. Can you attend a presentation if I post various times during the day and evening shift?'
- D. What don’t you understand about the information in the policy and procedure manual?'
Correct Answer: B
Rationale: Adult learners are independent and benefit from identifying their own learning needs and preferred methods. Asking about specific needs and teaching preferences supports this, unlike posters, presentations, or implying misunderstanding.
During a nursing home visit, the son notices multiple healing bruises on his father’s arms and legs and calls a friend who is a nurse. Which initial recommendations should the nurse provide to the son? Select all that apply.
- A. Ask your father how the bruises occurred and whether he was abused.'
- B. Contact Adult Protective Services immediately to report the abuse.'
- C. Verify with the nursing staff whether your father is on anticoagulants.'
- D. Inform the agency’s nursing supervisor that your father is being abused.'
- E. Contact the state ombudsman who can help you make an anonymous report.'
Correct Answer: A;C
Rationale: Asking about bruise causes and checking for anticoagulants (which cause bruising) are initial steps. Reporting abuse or contacting authorities requires more evidence.
The nurse is teaching an 86-year-old about glaucoma and how to administer eye drops. Which interventions should the nurse implement? Select all that apply.
- A. Plan the session at a time when a support person can attend
- B. Provide an environment that is private, quiet, and well lit
- C. Be detailed with the explanations to ensure understanding
- D. Engage as many of the client’s five senses as possible
- E. Give extensive written materials and a schedule to follow
Correct Answer: A;B;D
Rationale: A support person aids learning with vision issues, a private environment enhances focus, and engaging senses improves retention. Detailed explanations may overwhelm, and written materials should be concise.