NUR 260 Test 3
A client who has suffered a compound fracture is preparing for discharge to home. During the teaching session, the client asks why he needs antibiotics for a broken bone. Which response by the nurse is most appropriate?
"Antibiotic therapy has been prescribed as a precaution because your bone was exposed to the environment at the time of your injury."
A daughter complains that her mother, who has Alzheimer's disease, thinks and acts so slowly that everything must be done for her. Which suggestion would be most appropriate for the nurse to provide initially to the daughter that might be helpful for both the client and herself?
"Encourage you mother's self-care, but do it under supervision"
The nurse discusses dental health with an 81-year-old client. Which of the following statements, when made by the client is identified as true?
"Fluoride treatments might help strengthen the enamel on my teeth."
RN provides diet teaching to older adult client w/gout. Which statement indicates additional instruction required?
"I can eat bacon with my eggs for breakfast."
Which of the following statements by older adult clients should the nurse interpret as a potential pathological process rather than a normal age-related change?
"I tend to regurgitate a lot of my food after a meal these days."
The older adult patient with a catheter asks the RN "How long will I need to have this catheter?" How will the nurse respond?
"I will assess daily to determine whether the catheter is still needed"
A nurse is teaching a client with osteoporosis about dietary selections. What client statement indicates the teaching was effective?
"I will eat more dairy products to increase my calcium intake."
Pt w/rheumatoid arthritis in remission without s/s. Tells RN they don't need meds anymore. Best RN response?
"Important to continue to take meds to avoid an acute exacerbation"
The nurse teaches a group of older adults about diet. Which of following recommendations made by the nurse is most likely to result in the promotion of gastrointestinal (GI) health?
"It's important to emphasize fiber and fluid intake."
Pt w/rheumatoid arthritis asks RN what to do to help ease s/s of the disease. Best response by RN?
"The health care provider could prescribe anti-inflammatory drugs."
Priority teaching for older adult with gout?
"You should avoid alcohol, as well as many kinds of meat and seafood."
Older adult with hip fracture expresses disappointment at not being able to drive to church. Best holistic RN response?
"Your spirituality sounds important to you."
Son of an older client asks why a urinary catheter is not being used to control their dad's incontinence. What should RN respond?
"a catheter is the last resort to control incotinence"
RN assessing GU status of older adult female patient experiencing stress incontinence. What finding is a common gerontologic finding?
"bladder capacity decreases w/ advances age"
RN completes discharge teaching for older adult client with renal calculi. The nurse would emphasize which?
"fluid intake of at least 2 L each day"
Pt reports GI upset since starting allopurinol to treat gout. Which will RN give to prevent these symptoms?
"keep record of each dose, note when s/s begin, contact provider"
A nurse is assessing a 71-year-old client's urinary function. Which finding would the nurse identify as a cause for concern?
"the pH of urine sample is 9.0"
Depression in older adults s/s
** Cognitive + physical s/s** exhausted, aches, pains, hard to remember/concentrate/focus (can include withdrawal, helpless, useless, losing interest, weight loss)
The nurse develops a plan of care for a 75-year-old male patient who has had a myocardial infarction (MI). Which of following characteristics of the man's history and present conditions predispose him to constipation? (Select all that apply.)
- The man's activity level is significantly reduced as a result of his MI. - The man has received several doses of morphine since admission. - The man's fluid intake has been minimal since admission.
Hammer toe
Flexion deformity (can involve several toes) that can be d/t tight socks + shoes pushing toes upward and back
The nurse assists the aging client to create a menu. Which of the following foods, if requested by the client will require further teaching as it should not be included on this list?
Fried chicken
RN emphasizes measures to reduce risk of falls based on understanding that which fracture is most common in older adults
Hip
The environment of a client with dementia includes photographs of the client's family, soft music and low lighting. The client wears personal items received as gifts. Unused electrical outlets are covered. Once a day, the client exercises with a group. Which item would the nurse identify as missing from this picture?
ID bracelet
The nurse teaches an 87-year-old inactive client about avoiding constipation. Which of the following fluid and diet choices should the nurse include in the teaching?
Increase intake of fruit juices
The client with a fractured femur is upset and agitated that skeletal traction will be necessary for 6 to 8 weeks. The client states, "How can I stay like this for weeks? I can't even move!" Based on these statements, the nurse would identify which of the following as the most appropriate nursing diagnosis?
Ineffective Coping related to prolonged immobility
Plantar Fasciitis
Inflammation of the foot-supporting fascia (acute onset of heel pain)
Dementia
Irreversible, progressive impairment in cognitive function **Pt w/ dementia can experience delirium**
RN works on a unit with elderly clients. Which of following clients would RN visit first? The client who reports
It feels like I have food stuck in my throat
A nurse is assisting with the education of a family of a client with dementia. Which response by the nurse would be the most accurate definition of dementia?
Loss of intellectual abilities that impairs the ability to perform basic care
A client is in Buck's traction after fracturing his right hip. The nurse should include which action in the care plan?
Maintaining correct body alignment
When caring for a client diagnosed with Alzheimer's disease, which nursing intervention is a priority?
Monitor the client carefully
A patient comes to the health center reporting headache, backache, and abdominal pain. Further assessment leads the nurse to suspect that the patient has depression based on an understanding of which of the following?
Most patients experiencing depression seek treatment for somatic problems.
A family member is caring for an older adult client with osteoporosis in the home. When the home health nurse comes to evaluate the client, what should be a focus point of the visit?
Observing for safety hazards that could be a fall risk
The nurse discusses dental health with an aging client. Which of the following physiological changes should the nurse interpret as a potential pathological process rather than a normal age-related change?
Periodontal disease causing tooth loss
During hip fracture post-op care for older adult, RN should implement which principle about pain management?
Risks of adverse effects of analgesics are higher in older adults.
Which neurotransmitter is implicated in depression?
Serotonin
Dysphagia
Swallowing difficulties w/ inc age (can be d/t GERD, stroke or functional disorders of mouth/throat)
After a bone density test, an older adult female client tells the nurse, "I don't understand why I have osteoporosis because I eat well and take my calcium." What does the nurse explain as the reason that the client may have osteoporosis?
The loss is from withdrawal of estrogen and a decrease in activity levels.
Which of the following statements most accurately captures an aspect of dental health among older adults?
The presence of dental problems can be indicative of a variety of other diseases.
Callus
Thickened area of skin d/t persistent pressure or friction (can surgically remove or use orthotic devices)
Which hospitalized older adult will the nurse identify as at highest risk for hip fracture from a fall?
a client with a history of hip fractures from a fall
Dry Mouth (xerostomia)
dec saliva prod d/t aging (can be d/t meds, mouth breathing, diuretics, cognitive defects)
Differentiation between delirium and dementia
dementia is irreversible
Esophageal Dysphagia
difficulty propelling food down esophagus (d/t motiity disorders, mechanical obstruction or inefficient sphincter)
xerostomia is also known as
dry mouth
Instructions for patient with dysphagia?
eat in upright position to improve swallowing
Which instruction is appropriate for a patient with renal calculi?
fluid intake of at least 2 liters per day
Onychocryptosis (ingrown toenails)
free edge of nail plate penetrates surrounding skin (can develop secondary infection or granulation) PAINFUL
Pt w/recent fatigue, nausea, vomiting, fever, and urinalysis with proteinuria and hematuria. RN suspects?
glomerulonephritis
Client complains of pain in right great toe which is worse at night. Assessment reveals tophi. What does RN suspect?
gouty arthritis
Which assessment finding indicates the client w/osteoarthritis is having difficulty implementing self-care?
has a weight gain of 5 pounds
The client has a history of rheumatoid arthritis and a recurring problem w/pneumonia. Which theory best explains why?
immunity theory
An older adult reports having to get up several times a night to void. Which should the nurse identify as important to teach?
keep night light on in room
Which finding indicates nutritional deficiency in the older adult?
lips appear dry and cracked
What assessment finding indicates a possible UTI in the older adult?
new onset of delirium
most significant risk factor for falls in elderly community is ______
nocturia (Renal circulation when lying down = inc fluid excretion + output)
Teaching plan for colon resection related to colorectal cancer?
ostomy care
Oropharyngeal Dysphagia
problem transferring food from mouth to pharynx/esophagus (d/t neurological deficit)
Pt on SQ heparin after surgery to repair fracture hip. Rationale for this therapy is to reduce risk for?
pulmonary embolism
Which finding indicates pathology rather than normal age-related changes?
red and swollen gums
Pt with weak gag reflex, which RN diagnosis is priority?
risk of aspiration
An older client reports having xerostomia. What should the nurse suggest to this client?
sip water
RN concerned that a client is at risk for developing osteoporosis. What finding caused the nurse to have this concern?
smokes cigs
Management of corn (Hyperkeratosis)
soak, scrape, protect, surgery, injections
Fecal Impaction
stool stuck in rectum or lower bowel d/t chronic constipation
RN working w/older adult female client w/osteoporosis. Which interaction promotes achievement of wellness outcomes?
teaching about bone density in older women and the role of vitamin D + calcium
RN suggests client with fractured hip should increase intake of which of following to facilitate calcium absorption?
vitamin D
A client is recovering from a fractured hip. The nurse would suggest that the client increase intake of which of the following to facilitate calcium absorption from food and supplements?
vitamin d
Fecal impaction nursing interventions (to prevent + manage)
• A bowel elimination record • inc fluids + fiber • Enema • No laxative overuse • Use bathroom when body tells
Delirium
• Acute confusion, usually reversible • Disorientation of time + place, altered attention span, worsened memory, poor judgement, personality changes
Urinary System Health Promotion
• Adequate fluid intake, • Inc vitamin C intake (help dec acidic urine) • Activity • Frequent toileting (sit upright, massage bladder, rock back-and-forth, run water)
Age related changes (depression)
• Dec cerebral blood flow • Changes in neuroendocrine system • Disruptions in circadian rhythm
Fecal impaction s/s =
• Distended rectum • Abdominal/rectal discomfort • Oozing stool around impaction (mistaken for diarrhea) • Palpable hard mass • Fever
Hallux Valgus (bunion) risk factors
• Heredity • Shoes • OA • Aging
Onychocryptosis (ingrown toenails) risk factors
• Improper self-treatment • External pressure (tight shoes/socks) • Internal pressure (deformed toes) • Trauma • Infection
Muscle age related changes
• Increase in collagen and resultant fibrosis • Muscles diminish in size = atrophy • Muscle wasting • Tendons less elastic = weak + fatigue
Ligaments age related changes
• Lax ligaments = less than normal strength • Weakness • Joint pain w/ motion, swelling, crepitus + osteoarthritis
How to make sure elderly pt w/ nocturia is safe when toileting
• Night light • lear path • No throw rugs or clutter • Dec fluids before bed
Hammer toe management
• Open-toed shoes • Manipulative exercises • Pads • Surgery
Sarcopenia age related changes
• Poor blood flow to muscles • Dysfunction at cellular level • Dec hormones • Inc pro-inflam cytokines
Joint age related changes
• Progressive deterioration of cartilage • Thinning of intervertebral discs • Stiff, dec flexibility + pain (all interfere w/ ADLs)
Hallux Valgus (bunion) management
• Shoe fitting (want to prevent pressure) • Fam history • Corticosteroids • Surgery
Risk factors for depression or suicide
• Social isolation • Childhood trauma • Family history • Trauma (stroke, cancer, parkinson's etc.) • Disability/limitations
Plantar Fasciitis management
• Stretching • Shoe support • Orthotic devices • Corticosteroids
Causes of Flatulence
• Swallowing air • End result of digestion in large intestine (can hurt if inability to expel)
Onychocryptosis (ingrown toenails) prevention + management
• foot care (wash daily) • trim nails straight across + file edges • Dec pressure around foot • Surgical removal
Bone age related changes
•Gradual, progressive loss of bone mass after 30 years of age (Kyphosis, loss of flexibility, back pain, osteoporosis) •Vertebral collapse
A client is complaining of severe pain in the left great toe. What lab studies that the nurse reviews indicate that the client may have gout?
Elevated uric acid levels
A client who is blind comes to the clinic for a routine check-up. The nurse notes the client is exhibiting signs and symptoms of depression. What nursing action is recommended when helping a blind client who is depressed?
Acknowledge the client's grief.
A nurse is managing care of a client w/ osteoarthritis. What is appropriate treatment strategy the nurse will teach?
Administer NSAIDs (nonsteroidal anti-inflam)
Sarcopenia
Age-related reduction of muscle mass/function d/t dec protein synthesis + inc muscle protein degeneration **can lead to disability/immobility, disease**
A nurse is providing care to an older adult client with dementia. Which intervention would the nurse identify as a priority?
Ensuring client safety
Flatulence in older adult
Can be from constipation, high fiber foods, irregular bowel movements, age r/t changes to sphincter function *very common*
The most common affective or mood disorder of old age is
Depression
The nurse is assessing a 73-year-old client who was diagnosed with metastatic prostate cancer. The nurse notes that the client is exhibiting signs of loss, grief, and intense sadness. Based on this assessment
Depression
The nurse discusses nutritional health with an 89-year-old client whose total protein level is 5 (abnormally low). Which of the following physiological changes should the nurse interpret as a potential pathological process rather than a normal age-related change?
Decreased teeth and chewing ability
Hallux Valgus (bunion)
Deformity where great toe deviates laterally (2nd to pressure + inflammation)
Older adult client is admitted to nursing home. What aspect of health status is most likely to pose risk to nutrition?
Dementia
Which medication should the nurse explain as being the most commonly used pain reliever for arthritic pain?
acetaminophen
Corn (Hyperkeratosis)
area of overgrowth of horny layer of epidermis (can be d/t internal or external bone pressure)
