Nokea
The nurse should expect the adolescent to be in which of the following of erikson stages of psychosocial development.
- A. Identity versus role confusion
- B. Autonomy versus shame and doubt
- C. Initiative versus guilt
- D. Intimacy versus isolation
Correct Answer: A
Rationale: The correct answer is A: Identity versus role confusion. During adolescence, individuals are in Erikson's stage of developing a sense of identity and may struggle with role confusion. This stage typically occurs during the teenage years, where adolescents are exploring their personal values, beliefs, and goals. They are trying to establish a sense of self and may question their identity and place in the world. Choices B, C, and D are incorrect because Autonomy versus shame and doubt relates to toddlers, Initiative versus guilt relates to preschoolers, and Intimacy versus isolation relates to young adults. This makes A the most appropriate choice for an adolescent's stage of psychosocial development.
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Which of the following actions should the nurse plan to take?
- A. Use a solution of 0.9% sodium chloride to flush the transfusion tubing.
- B. Prime the transfusion tubing with lactated Ringer's solution.
- C. Administer the transfusion through a 24-gauge IV catheter.
- D. Infuse the blood over a maximum of 6 hours.
Correct Answer: A
Rationale: The correct answer is A. Using a solution of 0.9% sodium chloride to flush the transfusion tubing is essential to ensure compatibility and prevent potential reactions between the blood product and other solutions. This is a standard practice to maintain the integrity of the blood product and prevent contamination. Flushing with lactated Ringer's solution (B) would introduce a different electrolyte composition that may affect the blood product. Administering the transfusion through a 24-gauge IV catheter (C) may not be appropriate for blood transfusions due to the risk of hemolysis or clotting. Infusing the blood over a maximum of 6 hours (D) is a general guideline for blood transfusions but is not the immediate action the nurse should plan to take.
Which of the following actions should the nurse take to prevent dislocation of the prosthesis?
- A. Raise the head of the client's bed to a high-fowlers position.
- B. Elevate the clients effected leg on a pillow when in bed.
- C. Position the clients knees slightly higher than the hips when up in a chair
- D. Keep an abduction pillow between the client's legs.
Correct Answer: D
Rationale: The correct answer is D: Keep an abduction pillow between the client's legs. This helps maintain proper alignment and prevents excessive internal rotation of the hip, reducing the risk of dislocation. Elevating the affected leg on a pillow (B) may not provide adequate support. Raising the head of the bed to a high-fowlers position (A) and positioning the knees higher than the hips (C) do not directly address hip alignment.
Which action should the nurse include in the plan?
- A. Offer the client three large meals each day
- B. Provide small, frequent meals to reduce fatigue and improve intake.
- C. Encourage the client to drink fluids immediately before or after meals to prevent early satiety.
- D. Offer high-calorie, nutrient-dense foods to support weight maintenance.
- E. Monitor the client's weight regularly to assess nutritional status.
Correct Answer: B
Rationale: The correct answer is B: Provide small, frequent meals to reduce fatigue and improve intake. This option is the most appropriate because small, frequent meals can help prevent fatigue and improve nutrient intake by ensuring a steady supply of energy throughout the day. Offering three large meals (option A) may overwhelm the client and lead to fatigue. Encouraging fluid intake before or after meals (option C) may cause early satiety and reduce food intake. Offering high-calorie, nutrient-dense foods (option D) can be beneficial, but the frequency of meals is more crucial in this scenario. Monitoring weight (option E) is important but does not directly address the issue of fatigue and intake.
Which actions should the nurse take to address suspicion of elder abuse?
- A. Privately interview the client about the injuries
- B. Document the injuries in detail, including size, location, and appearance.
- C. Report the findings to the appropriate authorities, following facility protocol.
- D. Take photographs of the injuries if permitted, as part of the documentation process.
- E. Ensure that the client is not left alone with the suspected abuser during the interview or assessment.
Correct Answer: A,B,C,D,E
Rationale: The correct actions to address suspicion of elder abuse are A, B, C, D, and E.
A: Privately interviewing the client allows for open communication and confidentiality.
B: Documenting injuries in detail provides objective evidence for reporting and potential legal action.
C: Reporting findings to authorities is crucial to protect the elder and comply with legal obligations.
D: Taking photographs, if permitted, supports documentation and investigation.
E: Ensuring the client is not left alone with the suspected abuser protects the client during the assessment. Each action plays a crucial role in addressing elder abuse comprehensively.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A,C,F,G
Rationale: The correct answers (A, C, F, G) indicate potential prenatal complications. Urine protein (A) suggests preeclampsia, a serious condition characterized by high blood pressure (C) and proteinuria. Headaches (F) can also be a sign of preeclampsia. Gravida/parity (G) provides important obstetric history, identifying high-risk pregnancies. Fetal activity (B) and respiratory rate (E) are not specific to prenatal complications. Urine ketones (D) may indicate dehydration but not necessarily a prenatal complication.