Which nursing intervention would be provided to a hospitalized client during the identity versus role confusion stage quizlet?

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When the nurse assesses an adult client, which client behavior may indicate an unresolved developmental task of infancy?

a. Avoiding assistance of others.
b. Rationalizing unacceptable behaviors.
c. Being overly concerned about cleanliness.
d. Apologizing constantly for small mistakes.

Correct answer: A
Rationale: People who avoid help from others and would rather do things themselves generally have not completely resolved the developmental task of Trust versus Mistrust during infancy. If an infant has a caregiver that does not respond promptly to their needs, it is difficult for them to complete this task.

The nurse is caring for several children on a pediatric unit. Children in which age group should the nurse expect will be most unstable and challenging with regard to development of personal identity?

a. Toddlerhood
b. Adolescence
c. Childhood
d. Infancy

Correct Answer: B
Rationale: Adolescents (12-20=identity versus role confusion). This group has multiple and more complex milestones than individuals in any other stage of development. These milestones are physiological (puberty), psychological (self-identity and independence), and social. Adolescents want to fit in and belong in a group. They may feel peer pressure and are at high risk for using drugs and ETOH.

Which common physiological change associated with aging should the nurse assess for in an older adult? Select all that apply.

a.Increase in sebaceous gland activity.
b.Deterioration of joint cartilage.
c.Loss of social support system.
d.Decreased hearing acuity.
e.Increased need for sleep.

Correct answers: B, D
Rationale: Older adults generally experience a deterioration of joint cartilage and decreased hearing acuity. The nurse should modify care to best accommodate these changes. Physical activity should be adapted for what the client is capable of they should still participate in care. There is actually a decrease in sebum production, which leads to dry, cracked skin. The skin of older adults in very fragile and soap should be used sparingly. Loss of social support is a psychosocial, not a physiologic change. Older adults have the same need for sleep as younger individuals, but may sleep less or have decreased sleep quality.

A nurse plans to meet the hygiene needs of a hospitalized client who is experiencing hemiparesis because of a brain attack (cerebrovascular accident). Which is an appropriate nursing intervention?

a.Assisting the client to bathe as needed.
b.Giving total assistance with a complete bath.
c.Providing minimal supervision during the bath.
d.Encouraging a family member to bathe the client.

Correct answer: A
Rationale: Hemiparesis is a weakness on one side of the body that can interfere with performing ADLs. Encouraging the client to do as much as possible will support self-esteem, and assisting when necessary will ensure the hygiene needs are met. This client may require active assist ROM. Hemiplegia is total paralysis of one side of the body. This client would require passive ROM.

A cognitively impaired client is incontinent of loose stools. Which action should the nurse implement to help the client prevent skin breakdown?

a.Wash the buttocks with strong soap and water.
b.Clean the perineal area immediately after a bowel movement.
c.Apply talcum powder after the bath.
d.Put a pad under the buttocks.

Correct answer: B
Rationale: Loose stool contains digestive enzymes that are irritating to the skin and should be cleaned from the skin as soon as possible after soiling. Strong soap may further irritate the skin. The use of talcum powder is unsafe because it is a respiratory irritant. Placing a pad under the buttocks will not keep the stool off the skin.

A nurse gives a bed-bound client a bed bath. Which is the primary reason why the nurse provides hygiene care to this client?

a.Support a sense of well-being by increasing self-esteem.
b.Promote circulation by stimulating peripheral nerve endings.
c.Remove excess oil, perspiration, and bacteria by mechanical cleansing.
d.Exercise muscles by contraction and relaxation of muscles when bathing.

Correct answer: C
Rationale: The removal of accumulated oil, perspiration, dead cells, and bacteria from the skin limits the environment conducive to the growth of bacteria and skin breakdown. Intact, healthy skin is one of the body's first lines of defense. Providing a bath does promote circulation, but this is not the primary reason for bathing. The client should have Kendalls or sequential compression devices (SCDS) to promote circulation and prevent blood clots (unless contraindicated). ROM exercises may be performed during bathing, but this is not the purpose of the bath.

Which nursing intervention most requires the nurse to consider the concept of intimate space?

a.Providing a bed bath.
b.Obtaining the vital signs.
c.Performing a health history.
d.Ambulating the client down the hall.

Correct answer: A
Rationale: Touching a client during a bed bath invades the person's intimate space (physical contact to 1.5 feet) because of the need to expose and touch personal body parts. Although obtaining vital signs requires touching the client, it is less intrusive. Performing a health history can be accomplished by remaining in a client's personal space (1.5-4 feet) or social space (4-12 feet).

A nurse is caring for a client with excessively dry mouth. Which nursing action is important when providing care for this client? Select all that apply.

a.Wearing clean gloves.
b.Providing oral care every 2 hours.
c.Rinsing frequently with mouthwash
d.Cleansing 4 times a day with a water pick.
e.Thorough assessment of client's ability to chew and swallow.

Correct answers: A, B, E
Rationale: Wearing clean gloves protects the nurse and the client. This interrupts the chain of infection. The nurse should provide oral care at least every 2 hours to keep the oral mucosa moist. Client's with an excessively dry mouth should be further assessed. The nurse should determine the client's ability to chew and swallow properly. Mouthwash contains astringents that can injure sensitive, delicate, dry mucous membranes. Oral hygiene four times per day for a client with dry mouth is inadequate. A water pick in contraindicated because the force of the water can damage mucous membranes.

A nurse is performing passive range-of-motion exercises for a client who is in the supine position. Which motion occurs when the nurse bends the client's ankle so the toes are pointed toward the ceiling?

a.Adduction
b.Supination
c.Dorsal flexion
d.Plantar extension

Correct answer: C
Rationale: Dorsal flexion (dorsiflexion) of the joint of the ankle occurs when the toes of the foot point upward and backward toward the anterior portion of the lower leg. Adduction occurs when an arm or leg moves toward or beyond the midline of the body. Abduction is when an arm or leg is moved away from the body. Supination occurs when the hand and forearm rotate so that the palm of the hand is facing upward. There is no ROM called plantar extension.

Which stage pressure ulcer requires the nurse to measure the extent of undermining?

a.Stage 0
b.Stage I
c.Stage II
d.Stage III

Correct answer: D
Rationale: In a stage III pressure ulcer, there is full thickness skin loss involving damage to subcutaneous tissue that may extend to the fascia. There may or may not be undermining, which is tissue destruction underneath intact skin along wound margins. There is no Stage 0. Normal skin should be blanchable (i.e. skin blanches with pressure and color returns immediately with release). Skin is still intact in a Stage I pressure ulcer. In a Stage II pressure ulcer, the tissue damage is superficial and there is no undermining.

A client states, "My wife is going to be very upset that my prostate surgery probably is going to leave me impotent." Which is the best response by the nurse?

a."I'm sure your wife will be willing to make this sacrifice in exchange for your well-being."
b.The surgeons are getting greater results with nerve-sparing surgery these days."
c."Your wife may not put as much emphasis on sex as you think."
d.Let's talk about how you feel about this surgery."

Correct answer: D
Rationale: This response indicates that it is acceptable to talk about sexuality and invites the client to express concerns. Always invite the client to further discuss their concerns. A is false reassurance. B may be a true statement, but it negates the client's concerns and cuts off communication. C may or may not be a true statement. Only the wife can make this statement.

The patient is placed on a fluid restriction of 1,200mL/day. On the 7a.m. to 7p.m. shift the patient drank a cup of juice, 4 ounces of coffee with breakfast, 8 ounces of ice chips, 12 ounces of tea with lunch, and 3 ounces of water with medications. What amount of fluid can the 7p.m. to 7a.m. nurse give the patient?

a. 930 ml
b. 270 ml
c. 810ml
d. 390ml

Correct answer: B
Rationale: Pay close attention to what the question is asking you. In this case, we need to calculate the intake and then subtract that amount from the total fluid allowed. We include the full amount of fluid listed, except in the case of the ice chips. We count this as half. Include all medications given IV, including IV push and IVPB. See Treas page 1495. If the question is only asking about intake, you can ignore output. Only subtract output from intake when asked.

The nurse has discussed with a group of new mothers appropriate support of the young infant to prevent injuries from falls. The mother who needs further education is the mother who states:

a."My baby is not allowed to crawl or play near the stairs."
b."I never leave my baby unattended on my bed."
c."By the time my baby is 6 months old, he will be able to sit without support."
d."Before my child is standing, I need to place the crib mattress at its lowest level."

Correct answer: C
Rationale: By age 8 months, infants can sit well while unsupported. Infants can now explore their environment. Avoid playing near stairs and fence stairways. Childproofing is essential (especially in the toddler years). At age 4 months, the infant rolls over, by age 6 months, the baby sits with support, and at age 12 months, the baby stands and cruises around furniture.

A recently hospitalized 2-year old client screams and shouts that he wants a "bottle." His parents are puzzled, and state that he has been drinking from a cup for the past year. The nurse explains that:
a.Irritability is exhibited in all age groups.
b.Temper tantrums often represent the child's need for parental attention.
c.Various forms of punishment are necessary when such behaviors occur.
d.Regression to an earlier behavior often helps the child cope with stress and anxiety.

Correct answer: D
Rationale: For toddlers, regression is common with hospitalization. Regression usually occurs in instances of stress when the child attempts to copy by reverting to patterns of behavior from earlier stages of development. It should be explained to parents that regression is temporary. Praise appropriate behavior. Punishment would not be necessary or appropriate.

The nurse has been teaching a student how to perform mouth care for her unconscious patient. The student will show evidence of learning if the patient is placed in which position?

a.Supine
b.Prone
c.Semi-fowler's
d.Side-lying

Correct answer: D
Rationale: The unconscious client is at a high risk for aspiration. The client should be placed in the side-lying position for mouth care.

How should the nurse facilitate communication with an older adult? Select all that apply.

a.Assess for hearing deficit at the beginning of the interaction.
b.Speak in a more loudly than normal tone, and at a slightly higher pitch.
c.Pay special attention to cues from body language.
d.Speak slowly, allowing time for the client to word his answers.
e.Use a focused assessment if the client appears confused.

Correct answers: A, C, D, E
Rationale: The nurse should check for sensory deficits at the beginning of the interaction. Speaking slowly does not mean the nurse should speak loudly or at a higher pitch. Many older adults have high-pitch hearing loss. Because older adults sometimes have difficulty expressing themselves, body language is especially important. Because older adults process information slowly, the nurse should speak slowly, allowing them to formulate their answers. Be aware that some older adults are confused at one time and not another. A client may begin by giving you credible information, but as the conversation progresses, he may lose track of the topic or talk about something irrelevant. When a client seems confused, use focused assessment to determine his mental status.

A 9-year-old girl builds a clubhouse in her backyard. She hangs a sign outside her clubhouse that has "No boys allowed" printed on it. The child's parents are concerned that she is excluding their neighbor's son, and they are upset. What should the school nurse tell the child's parents?

a.Her behavior is cause for concern and should be addressed.
b.Her behavior is common among school-age children.
c.Her feelings about boys will subside within the next year.
d.They should have their daughter speak with the school counselor.

Correct answer: B
Rationale: This is common behavior for school age children. Girls of 9 and 10 generally prefer to have friends who are the same gender. School-age children tend to want to be just like their friends. These feelings will generally not subside within the next year. There is no need for the child to see the counselor.

Which should the nurse recommend to the parents of a 9-year-old hospitalized following a bicycle injury? To prevent further injury, the cheir child should:
a.Wear safety equipment while riding bicycles.
b.Read educational material on bicycle safety.
c.Watch a video on bicycle safety.
d.Ride his bike in the presence of adults only.

Correct Answer: A
Rationale: Safety equipment is essential for bicycling, skateboarding, and participating in contact sports. Most injuries occur during the school-age years, when children are more active and participate in contact sports. Seat belt use and car safety should also be emphasized in this age group. Educational material is a good way to reinforce the use of safety equipment, but the parents must insist the child uses it. The child's parents may not always be present when he rides his bike, so the safety equipment is the primary concern.

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