When developing a nursing diagnosis for a 76-year-old client, the nurse assesses that the client has an external locus of control. Which of the following would be a nursing diagnosis derived from this assessment?
1. Social isolation
2. Powerlessness
3. Hopelessness
4. Disturbed personal identity
ANS: 2
Individuals with an external locus of control believe they have no control over their destiny and that their behaviors have no effect on outcomes. Option 1 is not a nursing diagnosis associated with external locus of control. Option s 3 and 4 are incorrect; no data support these diagnoses.
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The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?
a. Slope of the earpieces should point posteriorly (toward the occiput). b. Although the stethoscope does not magnify sound, it does block out extraneous room noise. c. Fit and quality of the stethoscope are not as important as its ability to magnify sound. d. Ideal tubing length should be 22 inches to dampen the distortion of sound.
The mother of a 16-year-old female reports that the teen began menstruating at age 14 but has stopped for about 5 months. Which response would be the highest priority for the nurse to make to this mother?
1. "That's normal for a 16-year-old. That happened to me when I was 16.". 2. "Does she have a boyfriend?" 3. "It's probably psychological.". 4. "Have you noticed any other changes in diet, activity, or weight loss?"
The first action that should be taken when the umbilical cord prolapses is to:
a. Administer oxygen by face mask at 8 to 10 L/minute. b. Have the woman get on her hands and knees. c. Prepare for a rapid vaginal delivery or cesarean. d. Position the woman so that her hips are higher than her head.
________ If the answer results in a mixed number be sure to include a space between the whole number and the fraction. Example: 1 1/4 (read as one and one-fourth).
Fill in the blank(s) with the appropriate word(s).