Nokea
The nurse plans to teach the client progressive muscle relaxation. Prioritize the steps that the nurse should teach to correctly perform progressive muscle relaxation.
- A. Relax the feet, imagining the tension flowing out with each exhalation
- B. Lie down in a quiet place where you are undisturbed
- C. Contract the muscles of your feet first as you inhale and hold the contraction briefly
- D. Relax your body, allowing it to feel heavy
- E. Lie still for a few minutes after the contraction and relaxation of all muscles
- F. Imagine the tension flowing out with each breath you take
- G. Move up the body, contracting then relaxing each muscle
Correct Answer: B;D;F;C;A;G;E
Rationale: Steps: 1) Lie in a quiet place to focus; 2) Relax body to feel heavy; 3) Imagine tension flowing out with breaths; 4) Contract feet muscles; 5) Relax feet; 6) Move up body; 7) Lie still to monitor relaxation.
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The nurse is assessing the 88-year-old client. Which finding should the nurse associate with the normal aging process?
- A. Arm muscle strength 4 on a 0 to 5 scale
- B. Multiple fractures to the thoracic spine
- C. Ulnar deviation of the left hand fingers
- D. Slight pain in the right and left heel
Correct Answer: A
Rationale: Muscle strength of 4/5 is normal with aging. Fractures, ulnar deviation (rheumatoid arthritis), and heel pain (bone spurs) are not normal aging changes.
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.
The 70-year-old client, hospitalized with chest pain, has been functioning independently at home. During the night, the client is found wandering in the hallway and states, 'I can’t find my kitchen. I need a glass of milk.' What is the nurse’s best interpretation of the client’s behavior?
- A. The client most likely had a stroke
- B. The stress of being in unfamiliar surroundings has caused the client’s confusion
- C. The decline in mental status, especially at night, is a normal part of aging
- D. This is an insidious change, and it likely means the client has early dementia
Correct Answer: B
Rationale: Stress from unfamiliar surroundings can cause confusion in older adults. No stroke symptoms are noted, mental decline isn’t normal aging, and the change is abrupt, not insidious.
During a nursing home visit, the son notices multiple healing bruises on his father’s arms and legs and calls a friend who is a nurse. Which initial recommendations should the nurse provide to the son? Select all that apply.
- A. Ask your father how the bruises occurred and whether he was abused.'
- B. Contact Adult Protective Services immediately to report the abuse.'
- C. Verify with the nursing staff whether your father is on anticoagulants.'
- D. Inform the agency’s nursing supervisor that your father is being abused.'
- E. Contact the state ombudsman who can help you make an anonymous report.'
Correct Answer: A;C
Rationale: Asking about bruise causes and checking for anticoagulants (which cause bruising) are initial steps. Reporting abuse or contacting authorities requires more evidence.
The 50-year-old asks the nurse how to calculate BM]. The client weighs 134 1b and is 5’3” tall. Together, the client and nurse calculate the client’s BMI rounded to the nearest tenth. What is the client’s BMI?
Correct Answer: 23.8
Rationale: BMI = [weight (lb) / height (in)²] × 703 = [134 / (63)²] × 703 = [134 / 3969] × 703 ≈ 23.75, rounded to 23.8.