The nurse is teaching a group of middle-aged female nurses about middle-aged moral development applicable only to women. Which point should the nurse most specifically address?
- A. Gilligan’s moral development theory includes responsibility and caring for self and others
- B. Kohlberg’s moral development theory includes living according to universally agreed-upon principles
- C. Westerhoff’s stages of faith include putting faith into personal and social action and standing up for beliefs
- D. Fowler’s stages of spiritual development include becoming aware of truth from a variety of viewpoints
Correct Answer: A
Rationale: Gilligan’s theory, specific to women, emphasizes morality as integrity in relationships and caring for others and self, unlike Kohlberg’s justice-based theory. Westerhoff and Fowler address spiritual, not moral, development.
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The nurse is completing an assessment on the 19 year - old female who participates in strenuous physical activities many hours daily. Which nursing assessment is most important?
- A. Check for the presence of lordosis
- B. Look for signs of an eating disorder
- C. Examine muscles for increased mass
- D. Ask about excessive bleeding with menses
Correct Answer: B
Rationale: Females who participate in strenuous physical activities are at risk for eating disorders. Strenuous activity does not cause lordosis, increased muscle mass is expected, and delayed menses, not excessive bleeding, is a concern with strenuous activity.
The nurse overhears a person say, 'I’m having a senior moment because I forgot.' How should the nurse interpret this statement?
- A. This phrase is a comical statement without age bias and is acceptable to others
- B. This phrase is a stereotypical reference to older adults that can be termed ageism
- C. This phrase admits that the older adult’s ability to learn new information is limited
- D. This phrase recognizes that all older adults have short- and long-term memory issues
Correct Answer: B
Rationale: The phrase is a stereotypical reference to older adults, perpetuating ageism. It’s not comical, doesn’t imply learning limits, and not all older adults have memory issues.
The nurse assesses the 75-year-old client and concludes that some findings are not age-related changes and require further follow-up. Which report by the client represents a non-age-related finding that requires additional investigation?
- A. Reports a decreased ability to see at night
- B. Reports seeing halos around lights
- C. Reports difficulty distinguishing some colors
- D. Reports diminished visual acuity
Correct Answer: B
Rationale: Seeing halos is a symptom of glaucoma, not an age-related change, requiring investigation. Night vision, color distinction, and acuity changes are normal with aging.
The nurse’s assessment findings of the hospitalized older adult include: BP 96/64 mm Hg, P 118 bpm, RR 20/minute, weight 110 lb with an 8-lb weight loss in the last 3 months due to severe loss of appetite from chemotherapy, and BMI of 19. The client reports fatigue so does not go out, but is able to get around the house. Though tired, the client responds appropriately and clearly to questions and denies psychological issues. What score should the nurse assign to the client when completing the Geriatric Mini Nutrition Assessment?
Correct Answer: 4
Rationale: Score: Severe appetite loss = 0; >3 kg weight loss = 0; mobility (bed/chair but not out) = 1; acute disease (cancer) = 0; no psychological issues = 2; BMI 19 = 1. Total = 4.
The nurse is caring for the older adult client. The nurse should identify that the client is at risk for developing skin breakdown when making which observations? Select all that apply.
- A. A nursing assistant applies a perfumed lotion to the client’s skin
- B. Two nursing assistants are elevating the client’s heels off the bed
- C. A family member brings the client’s favorite custard from home
- D. The nurse applies an alcohol-based hand wash to the client’s hands
- E. The nurse is directing the client to push with the heels to move up in bed
Correct Answer: A;D;E
Rationale: Perfumed lotion, alcohol-based wash, and heel friction increase skin breakdown risk. Elevating heels and nutrition reduce risk.