ANS- A, B, D, E - A nurse is caring for an older adult client who...

NCLEX RN Questions & Answers A nurse is caring for an older adult client who has a new diagnosis of type 2 diabetes mellitus and reports difficulty following the diet and remembering to take the prescribed medication.Which of the following actions should the nurse take to promote client compliance? (SATA)

• Ask the dietitian to assist with meal planning
• Contact the client's support system
• Assess for age-related cognitive awareness
• Encourage the use of a daily medication dispenser
• Provide educational materials for home use

(ANS- A, B, D, E

A client with diabetes mellitus has a glycosylated hemoglobin A1c level of 8%. On the basis of this test result, the nurse plans to teach the client about the need for which measure?

• Avoiding infection
• Taking in adequate fluids
• Preventing and recognizing hypoglycemia
• Preventing and recognizing hyperglycemia

(ANS- D

Rationale:

The normal reference range for the glycosylated hemoglobin A1c is less than 6.0%. This test measures the amount of glucose that has become permanently bound to the red blood cells from circulating glucose. Erythrocytes live for about 120 days, giving feedback about blood glucose for the past 120 days. Elevations in the blood glucose level will cause elevations in the amount of glycosylation. Thus, the test is useful in identifying clients who have periods of hyperglycemia that are undetected in other ways. The estimated average glucose for a glycosylated 1 / 4

hemoglobin A1c of 8% is 205 mg/dL (11.42 mmol/L). Elevations indicate continued need for teaching related to the prevention of hyperglycemic episodes.

The nurse is instructing a client how to perform a testicular self-examination (TSE). The nurse should explain that which is the best time to perform this exam?

• After a shower or bath
• While standing to void
• After having a bowel movement
• While lying in bed before arising

(ANS- A

Rationale:

The nurse needs to teach the client how to perform a TSE. The nurse should instruct the client to perform the exam on the same day each month. The nurse should also instruct the client that the best time to perform a TSE is after a shower or bath when the hands are warm and soapy and the scrotum is warm. Palpation is easier and the client will be better able to identify any abnormalities. The client would stand to perform the exam, but it would be difficult to perform the exam while voiding. Having a bowel movement is unrelated to performing a TSE.

The clinic nurse prepares to perform a focused assessment on a client who is complaining of symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of assessment? Select all that apply.

• Auscultating lung sounds
• Obtaining the client's temperature
• Assessing the strength of peripheral pulses
• Obtaining information about the client's respirations
• Performing a musculoskeletal and neurological examination
• Asking the client about a family history of any illness or disease

(ANS- A, B, D

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Rationale:

A focused assessment focuses on a limited or short-term problem, such as the client's complaint. Because the client is complaining of symptoms of a cold, a cough, and lung congestion, the nurse would focus on the respiratory system and the presence of an infection. A complete assessment includes a complete health history and physical examination and forms a baseline database. Assessing the strength of peripheral pulses relates to a vascular assessment, which is not related to this client's complaints. A musculoskeletal and neurological examination also is not related to this client's complaints. However, strength of peripheral pulses and a musculoskeletal and neurological examination would be included in a complete assessment. Likewise, asking the client about a family history of any illness or disease would be included in a complete assessment.

The clinic nurse is preparing to explain the concepts of Kohlberg's theory of moral development with a parent. The nurse should tell the parent that which factor motivates good and bad actions for the child at the preconventional level?

• Peer pressure
• Social pressure
• Parents' behavior
• Punishment and reward

(ANS- D

Rationale:

In the preconventional stage, morals are thought to be motivated by punishment and reward. If the child is obedient and is not punished, then the child is being moral. The child sees actions as good or bad. If the child's actions are good, the child is praised. If the child's actions are bad, the child is punished. Options 1, 2, and 3 are not associated factors for this stage of moral development.

The maternity nurse is providing instructions to a new mother regarding the psychosocial development of the newborn infant. Using Erikson's psychosocial development theory, the nurse instructs the mother to take which measure?

• Allow the newborn infant to signal a need. 3 / 4

• Anticipate all needs of the newborn infant.
• Attend to the newborn infant immediately when crying.
• Avoid the newborn infant during the first 10 minutes of crying.

(ANS- A

Rationale: According to Erikson, the caregiver should not try to anticipate the

newborn infant's needs at all times but must allow the newborn infant to signal needs. If a newborn infant is not allowed to signal a need, the newborn will not learn how to control the environment. Erikson believed that a delayed or prolonged response to a newborn infant's signal would inhibit the development of trust and lead to mistrust of others.

A nursing student is presenting a clinical conference to peers regarding Freud's psychosexual stages of development, specifically the anal stage. The student explains to the group that which characteristic relates to the anal stage?

• This stage is associated with toilet training.
• This stage is characterized by the gratification of self.
• This stage is characterized by a tapering off of conscious biological and sexual

urges.

• This stage is associated with pleasurable and conflicting feelings about the

genital organs.

(ANS- A

Rationale:

In general, toilet training occurs during the anal stage. According to Freud, the child gains pleasure from the elimination of feces and from their retention. Option

• relates to the oral stage. Option 3 relates to the latency period. Option 4 relates to

the phallic stage.

The nurse is describing Piaget's cognitive developmental theory to pediatric nursing staff. The nurse should tell that staff that which child behavior is characteristic of the formal operations stage?

• The child has the ability to think abstractly.
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