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Nurse talking with parents of 6 mo infant about gross motor development. Which gross motor skills are expected in next 3 mo? (Select all that apply.)
- A. Rolls from back to front
- B. Bears weight on legs
- C. Walks holding onto furniture
- D. Sits unsupported
- E. Sits down from standing position
Correct Answer: A,B,D
Rationale: The correct answers are A, B, and D. In the next 3 months, the infant is expected to roll from back to front (A), bear weight on legs (B), and sit unsupported (D). Rolling develops around 4-6 months, weight-bearing on legs around 6-9 months, and sitting unsupported around 6-8 months. Choice C, walking holding onto furniture, is more characteristic of the 9-12 month age range. Choice E, sitting down from a standing position, typically occurs after the infant has mastered standing independently, which is beyond the 9-month mark.
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Nurse is reviewing hand hygiene techniques with group of AP, which instructions should nurse include when discussing handwashing?
- A. Apply 3-5 mL of liquid soap to dry hands
- B. Wash hands with soap & water for at least 15 seconds
- C. Rinse hands with hot water
- D. Use clean paper towel to turn off hand faucets
- E. Allow hands to air dry after washing
Correct Answer: B,D
Rationale: The correct answers are B and D. Option B instructs to wash hands with soap and water for at least 15 seconds, which is recommended by CDC for thorough handwashing. Option D advises using a clean paper towel to turn off hand faucets to avoid recontaminating hands after washing. This is crucial to prevent the spread of germs.
Explanation for other choices:
A: Applying 3-5 mL of liquid soap to dry hands is not mentioned in hand hygiene guidelines.
C: Rinsing hands with hot water is not necessary and can actually be harmful to the skin.
E: Allowing hands to air dry is acceptable, but it is not a crucial instruction for handwashing.
By the 2nd post-op day
- A. a client has not achieved satisfactory pain relief. What should the nurse do next according to the nursing process?
- B. Reassess client to determine reasons for pain
- C. See whether pain lessens during next 24h
- D. Change plan to ensure adequate pain relief
- E. Teach client about pain management plan
Correct Answer: A
Rationale: Correct Answer: A
Rationale: By the 2nd post-op day, if a client has not achieved satisfactory pain relief, the nurse should follow the nursing process. This involves reassessment to identify the reasons for inadequate pain relief, which is essential for developing an effective plan to address the client's pain. The nurse should not simply wait to see if the pain lessens or immediately change the pain management plan without first understanding the underlying reasons. Additionally, teaching the client about the pain management plan may be important but not the immediate priority if the pain relief is not satisfactory. It is crucial to first assess the situation comprehensively before making any changes to the plan.
Nurse collecting data to evaluate middle adult's psychosocial development. Nurse should expect middle adults to demonstrate which capabilities? (Select all that apply.)
- A. Develop acceptance of diminished strength & increased dependence on others
- B. Feel frustrated that time is too short for trying to start another life
- C. Welcome opportunities to be creative & productive
- D. Commit to finding friendship & companionship
- E. Become involved in community issues & activities
Correct Answer: C,E
Rationale: The correct choices, C and E, align with Erikson's theory of psychosocial development for middle adulthood. Choice C, "Welcome opportunities to be creative & productive," reflects Erikson's stage of generativity versus stagnation, where individuals in middle adulthood seek to contribute to society and leave a legacy. Choice E, "Become involved in community issues & activities," relates to the desire for social involvement and making a positive impact on the community. Choices A, B, and D are incorrect because they do not align with the typical capabilities of middle adults according to Erikson's theory. Choice A contradicts the idea of middle adults striving for independence and self-reliance, while choice B reflects feelings of regret or despair, which are more characteristic of Erikson's later stages. Choice D, while important, does not capture the full scope of middle adulthood psychosocial development as outlined by Erikson.
During evaluation
- A. the nurse must gather information about the client to...
- B. Identify whether client outcomes have been met
- C. Organize resources for interventions
- D. Establish client-centered
- E. measurable outcomes
Correct Answer: A
Rationale: The correct answer is A because during evaluation, the nurse needs to gather information about the client to assess the effectiveness of interventions and progress towards goals. This step involves collecting data to determine if the client's needs are being met and if adjustments are necessary. Option B is incorrect as it focuses on outcomes rather than the client's current status. Option C is incorrect as organizing resources is more related to planning than evaluation. Option D is incorrect as it pertains to establishing goals rather than evaluating progress. Option E is incorrect as it emphasizes measurable outcomes without considering the client's specific information needed for evaluation.
Nurse counseling young adult who describes having difficulty dealing with several issues. Which problem should nurse identify as priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents
- B. It's been so stressful for me to even think about having my own family
- C. I don't even know who I am yet, & now I'm supposed to know what to do
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father
Correct Answer: C
Rationale: The correct answer is C because the young adult expressing uncertainty about their own identity indicates a potential issue with self-awareness and self-esteem, which are foundational for healthy development. This can impact decision-making and overall well-being. Choices A, B, and D focus on external factors (living situation, family stress, and impending fatherhood) that can be addressed once the individual's self-identity is better understood. Prioritizing self-discovery and self-acceptance can lead to more effective coping mechanisms and decision-making skills for handling other stressors.