Nokea
The unsteady 20S-year-old client persists in ambulating to the bathroom alone despite being reminded to call for assistance. The nurse concludes that, according to Havighurst’s developmental tasks, this behavior reflects which need of the client?
- A. Adjusting to physiological changes
- B. Independence
- C. Industry
- D. Integrity
Correct Answer: B
Rationale: The client is attempting to perform self-care and to demonstrate the ability to be self-sufficient and independent from other adults. Adjusting to physiological changes is a developmental task of middle age. Industry and integrity are Erikson’s tasks, not Havighurst’s, and apply to different age groups.
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The nurse is caring for the 87-year-old hospitalized client. The nurse should assess for which age-related changes to best protect the client from friction injury?
- A. Increased tissue vascularity
- B. Increase in subcutaneous tissue
- C. Increased rate of cellular replacement
- D. Loss of skin thickness and elasticity
Correct Answer: D
Rationale: Loss of skin thickness and elasticity increases friction injury risk due to a thinner epidermis and reduced strength. Vascularity, subcutaneous tissue, and cellular replacement decrease with aging.
The nurse is teaching an 86-year-old about glaucoma and how to administer eye drops. Which interventions should the nurse implement? Select all that apply.
- A. Plan the session at a time when a support person can attend
- B. Provide an environment that is private, quiet, and well lit
- C. Be detailed with the explanations to ensure understanding
- D. Engage as many of the client’s five senses as possible
- E. Give extensive written materials and a schedule to follow
Correct Answer: A;B;D
Rationale: A support person aids learning with vision issues, a private environment enhances focus, and engaging senses improves retention. Detailed explanations may overwhelm, and written materials should be concise.
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 evaluating the older adult client’s hydration status. Which information should the nurse include? Select all that apply.
- A. Urine color
- B. Serum blood urea nitrogen (BUN) and creatinine
- C. Serum white blood cell (WBC) and differential count
- D. Urine specific gravity
- E. 24-hour fluid intake and urine output
Correct Answer: A;B;D;E
Rationale: Urine color, BUN/creatinine, specific gravity, and 24-hour intake/output assess hydration. WBC count evaluates infection, not hydration.
The 32-year-old has been trying to get pregnant for the past 10 years- The client consults a family planning clinic after being unsuccessful with the calendar and basal body temperature methods in determining the time of ovulation. Which statement by the nurse would be most appropriate?
- A. Let me review the methods with you; maybe you have not been using them correctly.'
- B. Have you considered that you might not be ovulating and that adoption is an option?'
- C. Test kits are available that will detect an enzyme in cervical mucus that signals ovulation.'
- D. If your spouse wears restrictive underwear, this can reduce your chance of conception.'
Correct Answer: C
Rationale: Suggesting an ovulation test kit, which detects guaiacol peroxidase in cervical mucus to signal ovulation, is most appropriate after 10 years of unsuccessful methods. Reviewing methods is less helpful, adoption is premature, and male underwear addresses sperm count, not ovulation timing.