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A nurse is assisting with a presentation at a senior center regarding age-related changes. Which of the following should the nurse include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. With aging, there is a natural decline in muscle mass known as sarcopenia. The nurse should include this because it is a common age-related change that can affect strength and mobility in older adults. Decreased muscle mass can lead to frailty and increased risk of falls. Thickened vertebral disks (B) are not a typical age-related change; instead, they tend to degenerate and become thinner. Decreased chest width (C) is not a significant age-related change and may vary among individuals. Increased force of isometric contractions (D) is not a typical age-related change; in fact, muscle strength tends to decrease with age, leading to reduced force production.
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A nurse is reinforcing dietary teaching with a client who is Asian-American and looks at the floor during the instruction. Which of the following actions should the nurse take to demonstrate cultural sensitivity?
- A. Check to see what is on the floor.
- B. Pause and wait until the client looks up.
- C. Move closer to the client.
- D. Continue the discussion while avoiding eye contact.
Correct Answer: D
Rationale: Avoiding direct eye contact is a cultural sign of respect in some Asian cultures, so the nurse should not force eye contact.
A nurse is caring for several clients at various developmental stages. The nurse understands that according to Erikson, acceptance of death occurs at which of the following stages of psychosocial development?
- A. Autonomy vs. Shame and Doubt
- B. Generativity vs. Stagnation
- C. Identity vs. Role Diffusion
- D. Integrity vs. Despair
Correct Answer: D
Rationale: The correct answer is D: Integrity vs. Despair. According to Erikson's psychosocial development theory, acceptance of death occurs during the final stage of life, which is Integrity vs. Despair. In this stage, individuals reflect on their lives and come to terms with their mortality, finding a sense of fulfillment and wisdom. Option A (Autonomy vs. Shame and Doubt) focuses on developing a sense of independence in early childhood. Option B (Generativity vs. Stagnation) pertains to middle adulthood and concerns contributing to society and future generations. Option C (Identity vs. Role Diffusion) relates to adolescence and the formation of a sense of self. These stages do not specifically address acceptance of death.
A nurse is caring for four clients who have drainage tubes. The nurse should identify the client who has which of the following tubes as being at risk for hypokalemia?
- A. An NG tube to suction
- B. An indwelling urinary catheter to gravity drainage
- C. A chest tube to water-seal drainage
- D. A nephrostomy tube to a drainage bag
Correct Answer: A
Rationale: NG suction removes gastric contents, leading to loss of potassium and increased risk of hypokalemia.
A nurse is collecting data from an older adult client who comes to the clinic with dry, flaky skin on her upper back. Which of the following actions should the nurse take?
- A. Note dry, flaky skin as an expected finding.
- B. Examine the back before the general inspection of the skin.
- C. Pinch up a fold of skin to check for turgor.
- D. Use a penlight to examine the back in greater detail.
Correct Answer: A
Rationale: The correct answer is A. Dry, flaky skin is a common finding in older adults due to decreased oil gland activity. The nurse should note this as an expected finding because it is often a normal part of aging and not necessarily indicative of a health concern. Option B is unnecessary as the nurse can inspect the back during the general skin assessment. Option C, checking skin turgor, is not relevant to dry, flaky skin. Option D, using a penlight for detailed examination, is excessive for this situation.
A nurse is planning home care for a school-age child who is awaiting discharge to home following an acute asthma attack. Which of the following growth and development stages according to Erikson should the nurse consider in the planning?
- A. Autonomy vs. shame and doubt
- B. Initiative vs. guilt
- C. Industry vs. inferiority
- D. Identity vs. role confusion
Correct Answer: C
Rationale: The correct answer is C: Industry vs. inferiority. This stage in Erikson's theory occurs during school age (6-11 years), where children develop a sense of competence and mastery in their skills and tasks. Considering this stage in the planning for a child recovering from an asthma attack is crucial. By emphasizing the child's abilities and encouraging them to engage in self-care activities, the nurse can promote a sense of industry and competence, which can boost the child's self-esteem. Choices A, B, and D are not directly related to the developmental stage of school-age children and do not address the specific needs and challenges this age group faces. Autonomy vs. shame and doubt (A) is more relevant to toddlers, Initiative vs. guilt (B) is more relevant to preschoolers, and Identity vs. role confusion (D) is more relevant to adolescents.