Nokea
The nurse is providing care to a newly hospitalized adolescent. What is the major threat experienced by the hospitalized adolescent?
- A. Pain management
- B. Restricted physical activity
- C. Altered body image
- D. Separation from family
Correct Answer: C
Rationale: The hospitalized adolescent may see each of these as a threat, but the major threat that they feel when hospitalized is the fear of altered body image, because of the emphasis on physical appearance during this developmental stage.
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The nurse is planning care for an 8 year-old child. Which of the following should be included in the plan of care?
- A. Encourage child to engage in activities in the playroom
- B. Promote independence in activities of daily living
- C. Talk with the child and allow him to express his opinions
- D. Provide frequent reassurance and cuddling
Correct Answer: A
Rationale: Encourage child to engage in activities in the playroom. According to Erikson, the school age child is in the stage of industry versus inferiority. To help them achieve industry, the nurse should encourage them to carry out tasks and activities in their room or in the playroom.
When planning the care for a young adult client diagnosed with anorexia nervosa which of these concerns should the nurse determine to be the priority for long term mobility?
- A. Digestive problems
- B. Amenorrhea
- C. Electrolyte imbalance
- D. Blood disorders
Correct Answer: B
Rationale: Amenorrhea. Changes in reproductive hormones and in thyroid hormones can cause absence of menstruation, called amenorrhea, which contributes to osteoporosis and bone fractures.
A 67-year-old man following a cardiac catheterization. Two hours after the procedure, the nurse checks the patient's insertion site in the antecubital space, and the patient complains that his hand is numb.
The nurse should
- A. change the position of his hand.
- B. check his grip strength in both hands.
- C. notify the physician.
- D. instruct the patient to exercise his fingers.
Correct Answer: C
Rationale: Strategy: Answers are a mix of assessments and implementations. Does the assessment answer validate what is going on? No. Determine the outcome of each answer choice. (1) assumes that numbness is related to positioning of hand, not circulatory changes (2) part of assessment, but doesn't indicate status of circulation (3) correct-absent or weak pulse or numbness could indicate problem with circulation, anticoagulants and vasodilators may be ordered (4) assumes that numbness is related to immobility of fingers, not circulatory changes
A 22 year-old patient in a mental health lock-down unit under suicide watch appears happy about being discharged. Which of the following is probably happening?
- A. The patient is excited about being around family again.
- B. The patient's suicide plan has probably progressed.
- C. The patient's plans for the future have been clarified.
- D. The patient's mood is improving.
Correct Answer: B
Rationale: The suicide plan may have been decided.
Which laboratory test conducted on the client with diabetes mellitus indicates compliance?
- A. Fasting blood glucose
- B. Two-hour post-prandial
- C. Hgb A-1C
- D. Dextrostix
Correct Answer: C
Rationale: Hgb A-1C reflects average blood glucose over 2-3 months, indicating long-term compliance. Options A, B, and D provide short-term snapshots and are less reliable for compliance.