An older adult resident of an assisted living center has become increasingly withdrawn from friends, cries often, and asks the nurse to call a family member three times a day. The nurse's plan of care should be based on the knowledge that the resident is exhibiting behaviors consistent with which of Erikson's stages?

Satisfaction vs. Depression.

Integrity vs. Despair.

Intimacy vs. Isolation.

Trust vs. Mistrust.

Answer and Explanation

The Correct Answer is B

A.   This option does not correspond to one of Erik Erikson's stages. Erikson's theory includes eight stages of psychosocial development, and this specific stage is not part of his framework. While depression is a relevant concern in older adults, the correct terminology and stage must be identified based on Erikson’s theory.
B.   This is Erikson's eighth and final stage of psychosocial development, typically occurring in late adulthood. In this stage, individuals reflect on their lives and either achieve a sense of integrity and fulfillment or experience despair and regret. The behaviors of withdrawing from friends, crying often, and seeking increased contact with family members are consistent with feelings of despair, as individuals may struggle with reflecting on their lives and their sense of accomplishment.
C.   This is Erikson's sixth stage, which occurs during young adulthood (approximately ages 18 to 40). In this stage, individuals focus on forming intimate relationships and avoiding isolation. The behaviors described are more characteristic of older adulthood rather than young adulthood, so this stage is not applicable to the client's situation.
D.   This is Erikson's first stage, occurring in infancy (from birth to about 18 months). During this stage, the primary task is developing trust in caregivers and the environment. The client’s behaviors are not related to the issues of trust or mistrust from early childhood but rather reflect challenges faced in older adulthood.

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Correct Answer is C

Explanation

A. This action involves assessing how the client’s current symptoms and manifestations align with the criteria of the nursing problems identified. By doing this, the nurse can ensure that the goals set are directly related to addressing these specific issues.
B. While prioritizing nursing actions is important for immediate care needs, listing these actions is more related to the implementation phase rather than the goal-setting phase. Goals are broader and focus on what outcomes are desired for the client, while nursing actions are specific steps taken to achieve those goals.
C. Reviewing the priority nursing problems helps in identifying the most urgent issues that need to be addressed. This review is essential for setting appropriate goals, as it ensures that the goals reflect the most pressing needs of the client.
D. Ensuring that prescribed treatments have been initiated is part of the implementation phase of care. While it is important for the overall management of the client’s health, this step does not directly involve goal setting.

A. Practices bicep and triceps isometric exercises. B. Progresses to foot touchdown and weight bearing of affected leg. C. Bears body weight on the palms of hands during the crutch gait. D. Inspects crutches to ensure rubber tips are intact.

Correct Answer is C

Explanation

A. While practicing strength-building exercises for the arms, such as isometric exercises for the biceps and triceps, is beneficial for overall crutch use, it does not directly indicate proper crutch walking technique.
B. This choice is not correct for a three-point gait, especially in the case of a broken foot. In a three-point gait, the client should avoid bearing weight on the affected leg, as this gait is used to promote healing of a non-weight-bearing limb.
C. This behavior indicates a correct understanding of crutch walking. In the three-point gait, the client should bear weight on the crutches' handles and not on the armpits, which helps prevent nerve damage and provides better stability.
D. While it is important for safety to ensure that the rubber tips of the crutches are intact and not worn out, this behavior does not directly demonstrate the client’s understanding of the three-point gait technique.

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Naxlex Comprehensive Predictor Exams

When identifying the goals to be included in a client's plan of care, the nurse should take which action?

Correct Answer is C

Explanation

The nurse is demonstrating three-point gait crutch walking to an older adult man who broke his foot while playing soccer with his grandchildren. Which behavior indicates that the client understands proper crutch walking?

Correct Answer is C

Explanation

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

An older female client residing at a long-term care facility receives an enteral tube feeding bolus via percutaneous endoscopic gastrostomy (PEG) tube 6 times daily. Which interventions should the nurse implement? Select all that apply.

The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

The nurse is performing a functional assessment for a client requiring nursing home care. During the client interview, which action should the nurse implement?

The client is receiving a liter of 0.9% sodium chloride with potassium chloride (KCI) 30 mEq IV to infuse over 4 hours. Which nursing action has the highest priority for this client?

Which assessment data reflects the need for the nurse to include the problem, "Risk for falls" in a client's plan of care? Reference Range: Hemoglobin [14 to 18 g/dL (140 to 180 g/L)]

The nurse is teaching another nurse about the administration of medication using the Z track technique. Which is the primary reason for using a Z track technique to administer a medication?

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?