An older adult resident of an assisted living center has become increasingly withdrawn from friends, cries often, and asks the nurse to call a family member three times a day.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. Blood pressure is 142/88 mm Hg. B. 2+ edema of fingers and hands. C. Capillary refill time is 2 seconds. D. Radial pulse volume is 3+.

Correct Answer is B

Explanation

A. Elevated blood pressure can be a concern for overall cardiovascular health but it does not directly affect the accuracy of pulse oximetry readings.
B. Edema, or swelling, of the fingers and hands can affect the accuracy of pulse oximeter readings. Edema can impede proper light transmission through the finger, leading to falsely low oxygen saturation readings.
C. A capillary refill time of 2 seconds is within normal limits, indicating adequate peripheral perfusion. It is unlikely to affect pulse oximeter readings significantly, so this is not a likely cause of a low oxygen saturation reading.
D. A radial pulse volume of 3+ indicates a strong, full pulse. This finding typically suggests good peripheral circulation and is not likely to impact the accuracy of pulse oximetry readings.

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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 attaches a pulse oximeter to a client's finger and obtains an oxygen saturation reading of 91%. Which assessment finding most likely contributes to this reading?

Correct Answer is B

Explanation

Which explanation is best for the nurse to provide a client who asks the purpose of using the log rolling technique for turning?

The nurse is assessing an older female client who was admitted to a long-term facility two days ago. The resident refuses to go to the dining room for meals and calls for help with all activities of daily living. Which nursing problem is best to include in this client's plan of care?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?

A client is ambulating with a two wheeled walker by rolling the walker forward and then moving each foot forward. The nurse notes that the client's elbows are slightly flexed when grasping the hand bar. After the client returns to the chair, which action should the nurse implement?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?