Nokea
The nurse is evaluating the older adult client’s hydration status. Which information should the nurse include? Select all that apply.
- A. Urine color
- B. Serum blood urea nitrogen (BUN) and creatinine
- C. Serum white blood cell (WBC) and differential count
- D. Urine specific gravity
- E. 24-hour fluid intake and urine output
Correct Answer: A;B;D;E
Rationale: Urine color, BUN/creatinine, specific gravity, and 24-hour intake/output assess hydration. WBC count evaluates infection, not hydration.
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The home health nurse is caring for the middle-aged client who is disabled due to a recent accident. The client has few interests, spends most days watching TV, and has become estranged from the family. Which of Erikson’s developmental stages should the nurse conclude that the client is not meeting?
- A. Industry versus inferiority
- B. Initiative versus guilt
- C. Generativity versus stagnation
- D. Intimacy versus isolation
Correct Answer: C
Rationale: The client’s isolation and lack of interests indicate stagnation, failing to meet generativity versus stagnation, the central task of middle adulthood. Other stages apply to younger age groups.
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 unsteady 20S-year-old client persists in ambulating to the bathroom alone despite being reminded to call for assistance. The nurse concludes that, according to Havighurst’s developmental tasks, this behavior reflects which need of the client?
- A. Adjusting to physiological changes
- B. Independence
- C. Industry
- D. Integrity
Correct Answer: B
Rationale: The client is attempting to perform self-care and to demonstrate the ability to be self-sufficient and independent from other adults. Adjusting to physiological changes is a developmental task of middle age. Industry and integrity are Erikson’s tasks, not Havighurst’s, and apply to different age groups.
While attending a health fair, the 62-year-old female is found to have many risk factors for osteoporosis. The nurse at the booth recommends that she contact her HCP about scheduling a DEXA (dual-energy x-ray absorptiometry) scan. Which risk factors influenced the nurse’s recommendation? Select all that apply.
- A. Hyperthyroidism
- B. Postmenopausal
- C. Overweight
- D. African American
- E. 62-year-old female
Correct Answer: A;B;E
Rationale: Hyperthyroidism, postmenopausal status, and being a 62-year-old female are risk factors for osteoporosis, warranting a DEXA scan. Being overweight and African American are not major risk factors.
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.