Despair autonomy versus shamedoubt is the stage of

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despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair. Question 195 The registered nurse is teaching a student nurse about making assumptions with an open mind when looking at information about a client. Which critical thinking skill is being referred to?
Analysis Inference Evaluation Interpretation Rationale The critical thinking skill called analysis involves making assumptions carefully with open-mind when looking for information about a client. Inference involves looking at the meaning and significance of findings of a client. Evaluation involves looking at the situations objectively. Interpretation involves being orderly in collection of client’s data. Question 196 Which is an indirect nursing care intervention? Administering medications Managing the client’s environment Counseling the family during a time of grief Inserting intravenous infusion Rationale Indirect nursing care interventions are treatment actions not performed directly to the client but are done to aid the client. Indirect care intervention includes managing the client’s environment. Direct care interventions include administration of medications, counseling the family during a time of grief, and insertion of an intravenous infusion. Question 197 A weak, dyspneic, terminally ill client is visited frequently by the spouse and teenage children. What should the client’s plan of care include? Foster self-activity whenever possible. Plan care to be completed at one time followed by a long rest. Teach family members how to assist with the client’s basic care.
Limit visiting to evening hours before the client goes to sleep. Rationale Because the family members are old enough to understand the client’s needs, they should be encouraged to participate in the care. Self-care increases oxygen use, thereby increasing fatigue and dyspnea. Overworking the client causes undue fatigue; there should be frequent rest periods between different aspects of care. Limiting visiting to evening hours deprives the client of a support system. Question 198 The client receives a prescription for tap water enemas until clear. The nurse is aware that no more than two enemas should be given at one time to prevent the occurrence of what? Hypercalcemia Hypocalcemia Hyperkalemia Hypokalemia Rationale Repeated tap water enemas deplete cells and extracellular fluid of potassium and sodium, resulting in hypokalemia, hyponatremia, and the potential for water intoxication. Repeated tap water enemas do not have a direct effect on hyper- or hypocalcemia. Potassium is depleted from cells, and extracellular fluid and does not result in hyperkalemia. A nurse assesses a client's serum electrolyte levels in the laboratory report. What electrolyte in intracellular fluid should the nurse consider most important?

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