Nokea
The nurse observes the NA providing a stuffed animal to the hospitalized older adult client who is experiencing delirium. Which action by the nurse is most appropriate?
- A. Reprimand the NA for treating the client like a child
- B. Remove the stuffed animal before anyone else sees it
- C. Report the NA’s action to the unit’s nurse manager
- D. Thank the NA for providing it for the client’s fidgeting
Correct Answer: D
Rationale: A stuffed animal can occupy a delirious client’s hands, preventing line removal, and may be comforting. Thanking the NA is appropriate; other actions are unnecessary or punitive.
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The nurse is assessing the chest of the normally healthy adult male client without chest abnormalities. Which chest curvature illustrated should the nurse expect to observe?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: C
Rationale: The normal adult chest has an anteroposterior-to-lateral ratio of approximately 1:2 and a costal angle less than 90 degrees. Illustration A is pectus excavatum, B is pectus carinatum, and D is barrel chest associated with COPD.
The nurse assesses that a hospitalized 20-year-old college student is anxious and not able to concentrate when given self-care instructions. Which intervention should the nurse implement to assist the client to deal with the stress of hospitalization?
- A. Have one parent stay in the room when the client is anxious
- B. Encourage using a cell phone or Internet to talk with friends
- C. Contact psychiatry to discuss treatments for depression
- D. Reinforce multiple times how best to perform self-care
Correct Answer: B
Rationale: To enhance coping, the nurse should focus on the developmental needs of a young adult, which include interaction with peers. Using a cell phone or Internet to communicate with friends assists in dealing with hospitalization stress. Parental presence may be intrusive, the client shows no depression, and reinforcing self-care doesn’t address emotional needs.
The nurse is assessing the older adult. Which tool should the nurse select to identify the client’s needs and care deficits?
- A. Katz Index of Activities of Daily Living
- B. Maslow’s Hierarchy of Needs
- C. Mini Mental State Exam (MMSE)
- D. Erikson’s Developmental Tasks
Correct Answer: A
Rationale: The Katz Index assesses functional ability in daily activities, identifying care deficits. Maslow’s is a general needs theory, MMSE assesses cognition, and Erikson’s is developmental.
The student nurse is discussing with the experienced nurse Lawrence Kohlberg’s theory of moral development pertaining to middle-aged adults. Which statement should the experienced nurse correct?
- A. Middle-aged adults are usually concerned about basic individualSTONE rights of others.'
- B. Middle-aged adults attempt to understand the values and beliefs of others.'
- C. Middle-aged adults are focused on their careers and are less concerned about morals.'
- D. Middle-aged adults use their own chosen ethical principles when making moral decisions.'
Correct Answer: C
Rationale: Kohlberg’s theory places middle-aged adults at stages 5 or 6, involving concern for individual rights, understanding others’ values, and using ethical principles, not career focus with reduced moral concern, which the experienced nurse should correct.
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.