nursing nclex

The nurse caring for patients in a long-term care facility knows that the highest level on Maslow's hierarchy of needs is self-actualization needs. Which statements accurately describe the achievement of self-actualization? Select all that apply. a. Humans are born with a fully developed sense of self-actualization. b. Self-actualization needs are met by depending on others for help. c. The self-actualization process continues throughout life. d. Loneliness and isolation occur when self-actualization needs are unmet. e. A person achieves self-actualization by focusing on problems outside self. f. Self-actualization needs may be met by creatively solving problems. c, e, f. Self-actualization, or reaching one's full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on problems outside oneself and using creativity as a guideline for solving problems and pursuing interests. Humans are not born with a fully developed sense of self-actualization, and self-actualization needs are not met specifically by depending on others for help. Loneliness and isolation are not always the result of unmet self-actualization needs. A nurse works with families in crisis at a community mental health care facility. What is the best broad definition of a family? a. A father, a mother, and children b. A group whose members are biologically related c. A unit that includes aunts, uncles, and cousins d. A group of people who live together and depend on each other for support d. Although all the responses may be true, the best definition is a group of people who live together and depend on each other for physical, emotional, or financial support. A nurse performs an assessment of a family consisting of a single mother, a grandmother, and two children. Which interview questions directed to the single mother could the nurse use to assess the affective and coping family function? Select all that apply. a. Who is the person you depend on for emotional support? b. Who is the breadwinner in your family? c. Do you plan on having any more children? d. Who keeps your family together in times of stress? e. What family traditions do you pass on to your children? f. Do you live in an environment that you consider safe? a, d. The five major areas of family function are physical, economic, reproductive, affective and coping, and socialization. Asking who provides emotional support in times of stress assesses the affective and coping function. Assessing the breadwinner focuses on the economic function. Inquiring about having more children assesses the reproductive function, asking about family traditions assesses the socialization function, and checking the environment assesses the physical function. A patient with a history of mitral valve disease suddenly develops new-onset atrial fibrillation. What is the primary concern? Risk of embolic stroke due to blood stasis in the atria. A nurse is caring for a patient with hemophilia who has a bleeding episode. What is the priority intervention? Administer factor VIII replacement therapy. A patient with advanced cirrhosis has a distended abdomen and difficulty breathing. What is the most appropriate intervention? Prepare for paracentesis to relieve ascites. A nurse is caring for a patient with bacterial meningitis. What is the most critical nursing precaution? Implement droplet precautions and administer antibiotics promptly. A patient with ulcerative colitis is experiencing frequent bloody diarrhea and abdominal pain. What dietary instruction should the nurse provide? Avoid high-fiber foods and dairy products during exacerbations. A nurse is assessing a patient with right-sided heart failure. What key symptoms should be expected? Peripheral edema, jugular vein distension, and ascites. Asterixis (flapping tremor). A nurse is caring for a patient with suspected compartment syndrome. What is the priority action? Remove restrictive dressings and notify the provider immediately. A patient with known heparin-induced thrombocytopenia (HIT) is admitted for anticoagulation therapy. What medication is contraindicated? Heparin or low-molecular-weight heparins (e.g., enoxaparin). A nurse is caring for a patient with acute pancreatitis. What laboratory finding is most specific to this condition? Elevated serum lipase. A nurse is providing care based on Maslow's hierarchy of basic human needs. For which nursing activities is this approach useful? a. Making accurate nursing diagnoses b. Establishing priorities of care c. Communicating concerns more concisely d. Integrating science into nursing care b. Maslow's hierarchy of basic human needs is useful for establishing priorities of care. The nurse is prioritizing nursing care for a patient in a long-term care facility. Which examples of nursing interventions help meet physiologic needs? Select all that apply. a. Preventing falls in the facility b. Changing a patient's oxygen tank c. Providing materials for a patient who likes to draw d. Helping a patient eat his dinner e. Facilitating a visit from a spouse f. Referring a patient to a cancer support group. b, d. Physiologic needs—oxygen, water, food, elimination, temperature, sexuality, physical activity, and rest—must be met at least minimally to maintain life. Providing food and oxygen are examples of interventions to meet these needs. Preventing falls helps meet safety and security needs, providing art supplies may help meet self-actualization needs, facilitating visits from loved ones helps meet self-esteem needs, and referring a patient to a support group helps meet love and belonging needs. The nurse caring for patients postoperatively uses careful hand hygiene and sterile techniques when handling patients. Which of Maslow's basic human needs is being met by this nurse? a. Physiologic b. Safety and security c. Self-esteem d. Love and belonging b. By carrying out careful hand hygiene and using sterile technique, nurses provide safety from infection. An example of a physiologic need is clearing a patient's airway. Self-esteem needs may be met by allowing an older adult to talk about a past career. An example of helping meet a love and belonging need is contacting a hospitalized patient's family to arrange a visit. The nurse caring for patients in a long-term care facility knows that the highest level on Maslow's hierarchy of needs is self-actualization needs. Which statements accurately describe the achievement of self-actualization? Select all that apply. a. Humans are born with a fully developed sense of self-actualization. b. Self-actualization needs are met by depending on others for help. c. The self-actualization process continues throughout life. d. Loneliness and isolation occur when self-actualization needs are unmet. e. A person achieves self-actualization by focusing on problems outside self. f. Self-actualization needs may be met by creatively solving problems. c, e, f. Self-actualization, or reaching one's full potential, is a process that continues throughout life. A person achieves self-actualization by focusing on problems outside oneself and using creativity as a