Nokea
The nurse is assessing the 88-year-old client. Which finding should the nurse associate with the normal aging process?
- A. Arm muscle strength 4 on a 0 to 5 scale
- B. Multiple fractures to the thoracic spine
- C. Ulnar deviation of the left hand fingers
- D. Slight pain in the right and left heel
Correct Answer: A
Rationale: Muscle strength of 4/5 is normal with aging. Fractures, ulnar deviation (rheumatoid arthritis), and heel pain (bone spurs) are not normal aging changes.
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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 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 caring for the middle-aged client. Which client behavior should indicate to the nurse that the client may have difficulty achieving Erikson’s developmental stage of generativity?
- A. Talks about accomplishments that made the workplace a better place
- B. Volunteers at the local nursing home reading to residents one day a week
- C. Focuses conversation on self and displays disinterest in the activities of others
- D. Shows pictures of the client’s grandchildren and the client at various sports events
Correct Answer: C
Rationale: Self-focus and disinterest in others suggest self-absorption and stagnation, indicating difficulty with generativity. Workplace accomplishments, volunteering, and involvement with grandchildren demonstrate generativity.
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 73-year-old client receiving palliative care comments to the nurse, 'I am such a feeble old man. My life is such a waste, and I hate having my wife see me like this. just wish I could die now.' Which statement is the nurse’s best interpretation of the client’s comments?
- A. The client is feeling ashamed and ready to die
- B. The client is feeling anxious knowing that he is terminally ill
- C. The client is facing Havighurst’s developmental tasks of later maturity
- D. The client is in Erikson’s developmental state of integrity versus despair
Correct Answer: D
Rationale: The client’s contempt for self and desire to die reflect despair in Erikson’s integrity versus despair stage. No shame or anxiety is evident, and Havighurst’s tasks involve positive adjustments.