Nokea
When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
- A. "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes."?
- B. "If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age."?
- C. "When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch."?
- D. "You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time."?
Correct Answer: A
Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.
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What effect can medication bound to protein have?
- A. reduced drug availability
- B. limited distribution of the drug to receptor sites
- C. less availability to produce desired medicinal effects
- D. decreased metabolism of the drug by the liver
Correct Answer: C
Rationale: Medication bound to protein leads to less availability to produce desired medicinal effects because only unbound drugs can interact with active receptor sites. If a drug is bound to protein, it cannot bind with a receptor site, reducing its effectiveness. Choice A is incorrect because binding to protein reduces drug availability. Choice B is incorrect because distribution to receptor sites is ineffective if the drug is bound to protein. Choice D is incorrect because metabolism does not occur until the drug is removed from the protein molecule by the liver, allowing the protein to return to circulation.
A paraplegic client is in the hospital to be treated for an electrolyte imbalance. Which level of care is the client currently receiving?
- A. primary prevention
- B. secondary prevention
- C. tertiary prevention
- D. health promotion
Correct Answer: B
Rationale: The correct answer is B: secondary prevention. The client is currently receiving secondary prevention care. Secondary prevention focuses on early detection of disease, prompt intervention, and health maintenance for clients experiencing health problems. In this case, the electrolyte imbalance is a health problem that requires treatment to prevent further complications. Choices A, C, and D are incorrect because primary prevention is focused on health promotion and specific protections against illness before it occurs, tertiary prevention is aimed at helping rehabilitate clients after the illness is diagnosed and treated, and health promotion is a broader concept that includes activities aimed at improving overall health and well-being rather than targeting a specific health problem like an electrolyte imbalance.
A nurse is providing information to a group of pregnant clients and their partners about the psychosocial development of an infant. Using Erikson's theory of psychosocial development, the nurse tells the group that infants have which developmental need?
- A. Must have needs ignored for short periods to develop a healthy personality
- B. Need to rely on the fact that their needs will be met
- C. Need to experience frustration, so it is best to allow an infant to cry for a while before meeting his or her needs
- D. Need to tolerate a great deal of frustration and discomfort to develop a healthy personality
Correct Answer: B
Rationale: According to Erikson's theory of psychosocial development, infants struggle to establish a sense of basic trust rather than a sense of basic mistrust in their world, their caregivers, and themselves. If provided with consistent satisfying experiences that are delivered in a timely manner, infants come to rely on the fact that their needs are met and that, in turn, they will be able to tolerate some degree of frustration and discomfort until those needs are met. This sense of confidence is an early form of trust and provides the foundation for a healthy personality. Therefore, options A, C, and D are incorrect as they do not align with Erikson's theory that emphasizes the importance of infants trusting that their needs will be met.
A nurse auscultating the fetal heart rate (FHR) of a pregnant client in the first trimester of pregnancy notes that the FHR is 160 beats/min. With this information, what should be the nurse's next action?
- A. Notify the healthcare provider of the finding.
- B. Document the findings.
- C. Tell the client that the FHR is faster than normal but that it is nothing to be concerned about at this time.
- D. Wait 15 minutes and then recheck the FHR.
Correct Answer: B
Rationale: An FHR of 160 beats/min in the first trimester of pregnancy is within the normal range, which is generally 120 to 160 beats/min. The appropriate action for the nurse in this situation is to document the findings. There is no need to notify the healthcare provider as this is a normal finding. Informing the client that the FHR is faster than normal may cause unnecessary anxiety, as it falls within the expected range. Waiting to recheck the FHR is not necessary since the rate is already within the normal range.
Client self-determination is the primary focus of:
- A. malpractice insurance.
- B. nursing's advocacy for clients.
- C. confidentiality.
- D. health care.
Correct Answer: B
Rationale: Client self-determination is the primary focus of nursing's advocacy for clients. Nurses advocate for their clients' right to autonomy and self-determination, ensuring that the clients' preferences and choices are respected. Confidentiality, on the other hand, involves maintaining the privacy of the client and their information. Health care is a broad term encompassing various aspects of medical services. Malpractice insurance is a type of insurance that provides coverage for professionals in case of negligence or malpractice, not directly related to client self-determination.