Week 10 F.A. Davis Ch. 32, 46, 31, 10

Which type of pain scale uses illustrations to help describe pain? A. The Simple Descriptor Scale B. The Numerical Rating Scale C. The Wong-Baker FACES Pain Rating Scale.

C. The Wong-Baker FACES Pain Rating Scale. The Wong-Baker FACES pain rating scale was originally designed for children but is now used in many settings, especially for those with communication or cognitive impairments. This scale is also helpful if the client speaks a different language from that of the healthcare providers.

Roseanne has rheumatoid arthritis. The pain impairs her ability to be physically active. She has bad days and worse days, but the pain is always there. Acute Pain Chronic Pain. Intractable Pain

Chronic Pain. Chronic pain lasts several months or longer and may interfere with activities of daily living. It is often a result of a progressive disorder and can come and go with remission and exacerbation. It often is accompanied by a psychological pain response.

Esther puts on her call light during the night, telling the nurse that her backaches from being in bed so long and she cannot sleep. Which pain intervention would be most beneficial? A. Contralateral Stimulation B. Massage. C. Application of Cold D. Immobilization E. Application of Heat F. Distraction G. Relaxation Techniques H. Expressive Writing

B. Massage Rationale: Massage is effective in relaxing muscles, reducing pain, and promoting sleep. The nurse should use slow, long strokes for the best level of relaxation, especially in the laboring and bed-bound client. The nurse should obtain verbal consent first because some people are uncomfortable being touched.

Andrew is experiencing signs of appendicitis with right lower quadrant pain. He is being prepared for surgery. What type of pain is he experiencing? Acute Pain. Chronic Pain Intractable Pain

Acute Pain. Acute pain is of rapid onset and short duration, usually only a few months. It is usually associated with injury or surgery and may be indicative of a more significant injury.

Which type of pain assessment tool rates pain on a scale of 0 to 10? A. The Wong-Baker FACES Pain Rating Scale B. The Numerical Rating Scale. C. The Simple Descriptor Scale

B. The Numerical Rating Scale. The numerical rating scale uses the numbers 0 to 10 to rate the pain. A rating of "0" is no pain and a "10" is the worse pain possible. Patients choose a number from 0 to 10 to denote their pain level. This is the most commonly used pain scale for adults because it gives objective data for pain assessment comparisons.

Pain intensity words (adjectives) are used to describe pain. Which type of pain scale is this? A. The Wong-Baker FACES Pain Rating Scale B. The Simple Descriptor Scale. C. The Intensity Word Scale

B. The Simple Descriptor Scale. This simple descriptor scale uses words such as mild, moderate, and severe to explain pain level. Nurses should use a few descriptive words to prevent confusion.

Adrianne is in labor. She is moaning and crying out during contractions. Which nonverbal response is being demonstrated? Psychological Pain Response Behavioral Pain Response Physiological Pain Response

Behavioral Pain Response. Behavioral pain response is considered voluntary and assessments include withdrawing from painful stimuli, moaning, facial grimacing, crying, agitation, and guarding the painful area.

The nurse is caring for a client with postsurgical pain. At what point is it important to assess the pain level? Select all that apply. a. After physical activity b. Before physical activity c. Every 30 minutes during the shift d. At the beginning of the shift e. When there are nonverbal cues of pain

a. After physical activity b. Before physical activity d. At the beginning of the shift e. When there are nonverbal cues of pain

Which areas are considered common CAM practices? Select all that apply. a. Alternative medical systems b. Mind-body medicine c. Biologically based therapies d. Manipulative and body-based methods e. Energy therapies

a. Alternative medical systems b. Mind-body medicine c. Biologically based therapies d. Manipulative and body-based methods e. Energy therapies

The nurse is assessing a client after an abdominal surgery who speaks a different language. Which nonverbal assessment changes could indicate pain is present? Select all that apply. a. Confusion b. Restlessness c. Poor eye contact d. Moaning e. Irritability

a. Confusion b. Restlessness d. Moaning e. Irritability

Elenore is an older adult who lives alone and has fallen and fractured her hip. She cannot get to the phone to call for help. Her pain worsens as time passes and she becomes confused as she waits for someone to find her. What factors are exacerbating the situation? Select all that apply. a. Fear b. Helplessness c. Cognitive impairment d. Need to be independent e. Hunger

a. Fear b. Helplessness c. Cognitive impairment

The nurse is preparing for heat and cold application. Which of the following statements are true? Select all that apply. a. Heat/cold devices can cause superficial tissue damage. b. Heat/cold devices should never come in direct contact with the skin. c. Heat/cold devices are safe to use for all clients. d. Heat/cold devices should be used intermittently. e. Heat/cold devices should be in place for 30 minutes at a time.

a. Heat/cold devices can cause superficial tissue damage. b. Heat/cold devices should never come in direct contact with the skin. d. Heat/cold devices should be used intermittently.

The nurse is providing comfort to a person who has fallen on the hiking trail and broken his ankle. Which techniques can be used until medical help arrives? Select all that apply. a. Massage b. Relaxation c. Meditation d. Controlled Imagery

a. Massage b. Relaxation c. Meditation d. Controlled Imagery

John retired from work last month after 38 years with the same corporation. He's been looking forward to retirement at the age of 65, but is concerned that the days are beginning to wear on him. Physically he does "okay." His hypertension is under control with medications and he runs 2 miles three mornings a week. He is planning a trip overseas this summer with Martha, his wife of 43 years. John has noticed that his knees feel stiff and painful in the mornings as he gets out of bed, so he decides to give up his morning run. What suggestion would be best for John? a.) "Joint pain is common at this age, but biking is less impactful on the joints." b.) "Take pain medicines daily when you wake up to make the run less uncomfortable." c.) "Seek medical attention; you may have an injury." d.) "Consider running at bedtime so the pain will be less intense."

a.) "Joint pain is common at this age, but biking is less impactful on the joints." Rationale: Physical activity is healthy at all ages, but may require modification as the body changes. Joint pain, limited range of motion, and activity intolerance are anticipated age-related changes. With biking, John can remain active without further damage to joints.

Which pain scales are used to determine a client's level of pain? Select all that apply. a. OPQRST-AAA b. FACES c. Visual analog scale d. Numeric e. The intensity word scale

b. FACES c. Visual analog scale d. Numeric

The nurse is caring for a client with untreated prolonged pain sustained in an automobile accident. Which assessment findings could result from the pain? Select all that apply. a. Increased urine output b. Hypertension c. Fever d. Nausea and vomiting e. Atelectasis

b. Hypertension c. Fever d. Nausea and vomiting

The nurse is speaking with a group of nursing students about the use of heat and ice for pain control. Which situations are best for this modality? Select all that apply. a. Acute abdominal pain b. Low back pain with spasticity c. Activity-induced muscle pain d. Pain from obstetric procedures e. Migraine headache

b. Low back pain with spasticity c. Activity-induced muscle pain d. Pain from obstetric procedures

The nurse is caring for a client after a large abdominal surgery. He is restless and uncomfortable. Which positioning change could be most beneficial? Select all that apply. a. Trendelenburg b. Side-lying c. Head of bed flat d. Fetal position e. Head elevation

b. Side-lying e. Head elevation

The nurse is teaching the client to integrate biofeedback for relaxation techniques. How will the nurse know the technique is working? a. The client will explain something she is imagining. b. The heart rate will drop from 97 to 76 beats/min. c. The client will achieve a trance-like state. d. Deep breathing will improve strength and flexibility.

b. The heart rate will drop from 97 to 76 beats/min.

Throughout the day, John has to urinate every 2 to 3 hours. Although it's only a small amount each time, there is a feeling of urgency. He has limited the amount of liquid he drinks, but it doesn't seem to help. What could be causing this issue? a.) Dehydration b.) An enlarged prostate gland c.) Decreased kidney filtration d.) Medication

b.) An enlarged prostate gland Rationale: As men age, the prostate often enlarges, making it difficult to fully empty the bladder. The urgent feeling results from the full bladder, but the enlarged prostate blocks the urethra, allowing only small amounts of urine to pass.

Viewed as "natural" but lacks standardization and a formulary Herbal Products Aromatherapy Dietary Therapies

Herbal Products Rationale: Many prescribed medications are made of herbs, but herbal products are those that can be purchased from health food stores without a prescription. A common misconception is that they are harmless because a prescription is not required, but it is important to confirm that they are not being abused or interacting with traditional medicine. Aromatherapy is the use of herbs as essential oils—concentrated extracts of roots, leaves, or blossoms to enhance well-being. Dietary therapies are often used with traditional medicine as a part of treatment plan.

Sarah fell while downhill skiing and fractured her tibia. The bone has a compound fracture and has broken through the skin. Which pain intervention would be most beneficial? Contralateral Stimulation Massage Application of Cold Immobilization Application of Heat Distraction Relaxation Techniques Expressive Writing

Immobilization Rationale: Immobilization of a painful body part with splints can offer some relief. Because Sarah will need to be moved, splinting is especially helpful in preventing further tissue damage and minimizing pain.

Interventions to improve visual senses a.) Place client in private room. b.) Clean glasses. c.) Encourage visitors. d.) Hang artwork on walls. e.) Close window curtains. f.) Provide reading material. g.) Arrange family pictures in room. h.) Offer colorful clothing.

b.) Clean glasses. d.) Hang artwork on walls. g.) Arrange family pictures in room. h.) Offer colorful clothing. Rationale: Clients needing stimulation of their visual senses should be in brightly lit rooms with natural sunlight when possible. Colors, pictures, and surroundings should be brightly colored. Apply clean glasses daily, only removing them when the client is in bed.

The nurse suspects that an older adult patient may have difficulty hearing. Which strategies will the nurse use to improve communication? Select all that apply. a.) Use sign language. b.) Look directly at the patient when speaking. c.) Speak more slowly than usual. d.) Speak loudly toward the patient's ears. e.) Allow some extra time for the patient to respond.

b.) Look directly at the patient when speaking. c.) Speak more slowly than usual. d.) Speak loudly toward the patient's ears. e.) Allow some extra time for the patient to respond.

Marjorie is an 80-year-old female. After a car accident 3 years ago, she lost her driver's license because of her poor vision. Her husband died shortly afterward and she could no longer care for herself. Her daughter placed her in an assisted living facility that provides meals and 24-hour supervision and care. Marjorie tells the nurse that she feels "worthless" and wants to become more active. What would be the nurse's best suggestion? a.) Walk around the block three times a day. b.) Participate in chair aerobics in the recreational center. c.) Lift weights in the gym after meals. d.) Take dancing lessons at the city dance hall.

b.) Participate in chair aerobics in the recreational center. Rationale: With Marjorie's advanced age, she is at risk for fall and injury. Chair aerobics is a safe option that still allows her to be active and social.

Interventions to improve auditory senses a.) Speak in a normal voice. b.) Place hearing aids daily. c.) Check hearing aid batteries regularly. d.) Move within 3 inches of the ears when speaking. e.) Increase audio on television. f.) Place in quiet area. g.) Confirm ears are clean.

b.) Place hearing aids daily. c.) Check hearing aid batteries regularly. e.) Increase audio on television. f.) Place in quiet area. g.) Confirm ears are clean. Rationale: To stimulate hearing, hearing devices should be used daily with fresh batteries and placed in clean ears. The client should be in a quiet area for conversations and you should speak directly toward the client's face so he or she can see your mouth move. Increase audio on television or stereo when in use. Talking directly into the ear can be considered an invasion of privacy in many cultures and so should be avoided.

Sallie Jo, an older adult, is being admitted with confusion. What actions should the nurse take in preparing for her stay? a.) Place her in a semiprivate hospital room. b.) Place her bed in the lowest position. c.) Assign a team of caregivers. d.) Restrict visitation.

b.) Place her bed in the lowest position.

The nurse is planning a teaching workshop about maintaining an active lifestyle at the local community center for a group of older adults. What information is most important to discuss at the workshop? a.) Prevention of injury and falls b.) Planning and participating in leisure activities and exercise c.) Use of social media to stay connected with family members d.) Resources for assisted living centers and nursing homes

b.) Planning and participating in leisure activities and exercise

Marjorie notices that she is less able to control her urine. She speaks with the nurse about it, saying, "It used to be an issue only when I coughed or laughed and now it's all the time." Which step should the nurse make? a.) Insert a Foley catheter. b.) Use padded briefs. c.) Change undergarments more frequently. d.) Encourage use of the restroom more frequently.

b.) Use padded briefs. Rationale: Urinary incontinence can be embarrassing to older adults. Encouraging more frequent use of the restroom can lessen the problem but may not be realistic for those with decreased mobility. Use of padded briefs is helpful provided they are changed frequently to prevent skin breakdown.

John and Martha are on vacation and John is unable to perform sexually as he normally does. He's quite concerned and sees his healthcare provider when the problem continues at home. What statement from his healthcare provider is most accurate? a.) "Maybe you are not as aroused by your wife as you used to be." b.) "It's probably the change of environment causing the problem." c.) "It's a common problem of aging. I know some things we can try that will help." d.) "You were probably exhausted from the long flight."

c.) "It's a common problem of aging. I know some things we can try that will help." Rationale: Changes in libido, energy level, and sexual patterns are common in the older adult, and can be caused by a decrease in estrogen and testosterone levels. Treatments may include the use of hormone therapy, phosphodiesterase type 5 inhibitors, or nonmedication alternatives.

The nurse is caring for a client who says, "Food just doesn't taste good anymore." What priority action should the nurse take? a.) Determine who fixes the client's meals. b.) Ask what dietary restriction he follows. c.) Monitor dietary intake. d.) Determine what medications are taken.

c.) Monitor dietary intake.

The nurse is caring for a client who has been in the intensive care unit for a week. The nurse notes that the client is experiencing restlessness, anxiety, and intermittent confusion. What could be contributing to the behavior changes? a.) Sensory deficit b.) Sensory deprivation c.) Sensory overload d.) Sensory withdrawal

c.) Sensory overload

The nurse is teaching a family about phantom pain. Which statement is correct? a. The pain is deadened from the surgery. b. Phantom pain occurs before an amputation. c. Phantom pain is a psychological condition. d. Phantom pain is real and should be treated as such.

d. Phantom pain is real and should be treated as such.

What is the leading cause of injury and preventable source of mortality and morbidity in older adults? a.) Heart disease b.) Car accidents c.) Pneumonia d.) Falls

d.) Falls

Anne is experiencing chest pain and shortness of breath. She has tachycardia, hypertension, and tachypnea. Which nonverbal response is demonstrated? Psychological Pain Response Behavioral Pain Response Physiological Pain Response

Physiological Pain Response. The physiological pain response is involuntary and includes both sympathetic and parasympathetic responses. The sympathetic responses are seen in acute pain and include increased systolic blood pressure, heart rate, respiratory rate, dilated blood vessels to the brain, increased alertness, dilated pupils, and rapid speech. The parasympathetic responses are a result of deep or prolonged pain and include decreased diastolic blood pressure, syncope, decreased heart rate, changeable breathing patterns, withdrawal, constricted pupils, and slow, monotonous speech.

What type of pain scale consists of a horizontal line delineating "No pain" on one end and "Worst pain imaginable" on the other? 1. The Visual Analog Scale. 2. The Numerical Rating Scale 3. The Simple Descriptor Scale

1. The Visual Analog Scale. With the visual analog scale (VAS), a patient points to the location on the horizontal line that reflects his or her current pain level. It is simple and quick, but can be confusing because of its abstract nature.

The nurse knows that essential oils are becoming more popular in complementary therapies. What are essential oils considered? A) Aromatherapy B) Dietary therapy C) Herbal products D) Probiotics

A) Aromatherapy

Katrina is experiencing lower abdominal cramping from her menstrual cycle. Which pain intervention would be most beneficial? Contralateral Stimulation Massage Application of Cold Immobilization Application of Heat Distraction Relaxation Techniques Expressive Writing

Application of Heat Rationale: Heat promotes circulation and reduces muscle spasms from menstrual cramping. It can also be used to manage low back pain and treat nausea, vomiting, and diarrhea. Heat devices should never be in direct contact with the skin because they can cause burns, and they should be used intermittently for no more than 15 minutes.

Offers a core belief that there is a sense of harmony with nature and our inner being that produces health Traditional Chinese Medicine Prayer Ayurveda

Ayurveda Rationale: Ayurveda is a healing system that includes all aspects of health and wellness. Traditional Chinese medicine considers the balance of the yin and yang energies and the five elements of earth, water, wood, fire, and air/metal. Prayer is a dialogue with a spiritual being and the most commonly used CAM.

Ron is experiencing phantom pain after a left below-the-knee amputation. Which pain intervention would be most beneficial? Contralateral Stimulation Massage Application of Cold Immobilization Application of Heat Distraction Relaxation Techniques Expressive Writing

Contralateral Stimulation Rationale: Phantom pain occurs when a limb has been amputated. The client will continue to feel pain as though the extremity were still present. Doctors once believed this postamputation phenomenon was psychological, but experts now recognize that these real sensations originate in the spinal cord and brain. Contralateral stimulation is the stimulation of the skin in an area opposite to the painful site by scratching, rubbing, or applying heat or cold. In this case, the stimulation would occur to the right lower leg.

A client asks the nurse the difference between homeopathy and naturopathy. Which description is best? A) Homeopathy is based on healing at home; naturopathy is based on using natural foods. B) They are the same but the training of the provider is different. C) Homeopathy uses homemade products; naturopathy uses organically made products. D) Homeopathy is based on the body independently healing itself; naturopathy is based on nature helping the body heal itself.

D) Homeopathy is based on the body independently healing itself; naturopathy is based on nature helping the body heal itself.

The nurse just gave an immunization to Jonathan, a 2-year-old. Which pain intervention would be most beneficial? Contralateral Stimulation Massage Application of Cold Immobilization Application of Heat Distraction Relaxation Techniques Expressive Writing

Distraction Rationale: Distraction allows the nurse to pull the patient's attention away from the pain by focusing on toys, videos, or sound. It is most effective with children for mild to moderate pain and for brief periods of time.

Tim, a teenager, lands on his knee during a basketball game and it begins to swell. The nurse in the audience comes to assist with his discomfort. Which pain intervention would be most beneficial? A. Contralateral Stimulation B. Massage. C. Application of Cold D. Immobilization E. Application of Heat F. Distraction G. Relaxation Techniques H. Expressive Writing

E. Application of Cold. Rationale: Cold application causes vasoconstriction and can help prevent swelling and bleeding. It is especially effective in reducing pain as a result of procedures. Cold devices should never be in direct contact with the skin as this can cause frostbite. Take a break at least every 15 minutes.

Donna would like a way to manage her pain on a long-term basis. She struggles with the emotions that come from living with chronic pain. Which pain intervention would be most beneficial? Contralateral Stimulation Massage Application of Cold Immobilization Application of Heat Distraction Relaxation Techniques Expressive Writing

Expressive Writing Rationale: Expressive writing helps reduce chronic pain by allowing for an outlet of emotions, fear, and frustration common when dealing with pain on a daily basis.

Based on the principles of the law of similars, the law of minimum dose, and the single remedy Biofeedback Homeopathy Naturopathy

Homeopathy Rationale: Homeopathy, the understanding of how the body heals itself and an acceptance that all symptoms represent the body's attempt to restore itself to health, is based on these three principles: (1) The law of similars: The substance that would cause symptoms in a healthy person is the substance that is most likely to produce a curative response in the patient who already has the symptoms. (2) The law of minimum dose: Use of minute doses of medication stimulates the body's defenses against disease and limits side effects. (3) The single remedy: Homeopathic practitioners should select one remedy that encompasses the totality of the person's symptoms. Biofeedback provides a state of relaxation that can slow the heart rate, breathing, and other body systems. Naturopathy includes the consumption of natural foods, medicines, and minerals.

Keith experienced a back injury at work. The pain shoots down his left leg and he can't find a comfortable position that relieves his distress. He's tried every pain management suggestion and multiple prescription pain medications with minimal relief. Acute Pain Chronic Pain Intractable Pain

Intractable Pain. Intractable pain is highly resistant to relief. It is especially frustrating for the patient and caregiver because multiple interventions and medications are tried without adequate pain relief.

Used to draw energy, increase blood flow, and aid in healing Magnet Therapy Reiki Qigong

Magnet Therapy Rationale: Magnet therapy works on the pretense that the iron in hemoglobin is attracted to the magnet placed on the skin, improving blood flow and reducing fatigue. Reiki, which originated in Japan, seeks to balance energy to enhance the body's ability to heal itself. Qigong is a biofield therapy that is a series of relaxation movements, deep breathing, and meditation used to build strength and flexibility.

Manipulation of muscles and other soft tissues Massage Osteopathy Chiropractic

Massage Rationale: Massage works to relieve stress, improve mobility, and lessen pain by promoting muscle relaxation, increasing lymphatic circulation, and reducing inflammation.

Quiets and focuses the mind and induces relaxation Music Therapy Meditation Humor

Meditation Rationale: There are two major forms of meditation: concentration mediation and mindfulness meditation. It is often incorporated into healing systems such as Ayurveda and traditional Western medicine. Music therapy is evidence-based use of music interventions with a therapeutic relationship to achieve individualized goals. Humor may include funny literature, cartoons, and videos.

A nonherbal dietary supplement T'ai Chi Acupuncture Probiotics

Probiotics Rationale: Probiotics are live bacteria or yeasts that have health benefits and are found in food such as yogurt and in dietary supplements. T'ai chi is a martial art that develops physical stamina and decreases pain and stiffness. Acupuncture is the use of thin needles inserted into anatomical structures to change the energy fields.

Ralph has degenerative joint disease and experiences pain with any physical activity, including waking. He is irritable and wants to be left alone to sleep all the time. Which nonverbal response is being demonstrated? Psychological Pain Response. Behavioral Pain Response Physiological Pain Response

Psychological Pain Response. Psychological or affective responses are a result of the mental impact of the pain. These can include anxiety, depression, anger, fear, exhaustion, hopelessness, and irritability.

Michael experiences chronic low back pain. The pain is especially significant while bending to put on his socks and shoes. Which pain intervention would be most beneficial? Contralateral Stimulation Massage Application of Cold Immobilization Application of Heat Distraction Relaxation Techniques Expressive Writing

Relaxation Techniques Rationale: Relaxation techniques are useful for reducing chronic pain. For Michael, knowing that bending exacerbates the pain will make it worse with anticipation. Relaxation techniques would help minimize the discomfort.

A biofield therapy that uses the hands-on or near the body to provide comfort, pain relief, and healing Osteopathy Chiropractic Therapeutic Touch

Therapeutic Touch Rationale: Therapeutic touch uses hand placement near the body to provide comfort. Osteopathy is a hands-on, whole-body approach to medical care that emphasizes the musculoskeletal system. Chiropractic is a conventional medical technique that focuses on the relationship between the spine and body.

A practice that combines physical postures, breathing techniques, and meditation or relaxation Yoga Hypnosis Imagery

Yoga Rationale: Yoga emphasizes a lifestyle of awareness, integrity, and compassion. Although many practice yoga as a form of exercise, it also integrates body, mind, and spirit. Hypnosis places a person in a trance-like state and heightened imagination. It promotes relaxation and weight loss and suppresses cravings and withdrawals during smoking cessation. Imagery uses imagination to create a peaceful atmosphere that reduces stress.

Interventions for improving taste a.) Allow client to select favorite foods. b.) Monitor dietary intake. c.) Provide oral hygiene. d.) Eat smaller meals more frequently. e.) Assess for sores in the mouth. f.) Add cookies and candy to the diet. g.) Encourage sucking on a breath mint between meals. h.) Encourage spices, salt substitutes, and seasonings.

a.) Allow client to select favorite foods. b.) Monitor dietary intake. c.) Provide oral hygiene. e.) Assess for sores in the mouth. Rationale: When a person's taste is impaired, nutritional deficits and weight loss can occur, so monitoring of dietary intake is important. Provide favorite foods that offer a variety of appealing flavors. Be sure to assess the mouth for sores and provide routine oral care.

A frail elderly man lives at a senior independent living apartment complex. He is weak, stays in bed most of the time, and becomes fatigued after taking only two or three steps with a walker. His personal hygiene is poor. He moves very slowly when doing even small tasks such as eating a meal. Which interventions are most appropriate for this person? Select all that apply. a.) Arrange for an aide to assist with activities of daily living. b.) Refer the client to a senior center for an adapted physical activity program. c.) Assess the patient for symptoms of depression and memory loss. d.) Arrange for nutritious meals to be delivered to the patient's home. e.) Contact his children to move in with him.

a.) Arrange for an aide to assist with activities of daily living. c.) Assess the patient for symptoms of depression and memory loss. d.) Arrange for nutritious meals to be delivered to the patient's home.

As Marjorie is trying to brush her teeth at the bathroom sink, she loses his balance and falls. What actions by the nursing care facility could have prevented this injury? Select all that apply. a.) Assistance with all activities b.) Use of grab bars in the bathroom c.) An emergency call light that is accessible in all areas d.) Use of a walker e.) Not allowing her to brush her teeth

a.) Assistance with all activities b.) Use of grab bars in the bathroom c.) An emergency call light that is accessible in all areas Rationale: Older adults are at high risk for falls. Falls often lead to greater health problems and even death. Integration of fall precautions such as closer observation and assistance, grab bars, and call lights can help prevent injury.

Interventions for communicating with the visually impaired a.) Call the client by name. b.) Introduce yourself when entering room. c.) Don't say "look" or "see." d.) Describe the room layout. e.) Explain unfamiliar sounds. f.) Speak loudly when entering the room. g.) Speak before you touch the client. h.) Let the client know when you are leaving the room

a.) Call the client by name. b.) Introduce yourself when entering room. d.) Describe the room layout. e.) Explain unfamiliar sounds. g.) Speak before you touch the client. h.) Let the client know when you are leaving the room Rationale: Visual deficits can range from minor impairment (use of glasses) to total blindness. The nurse should communicate in a normal tone of voice to make the patient aware of the environment and presence while in the room.

Interventions for confused clients. Select all that apply. a.) Decrease anxiety. b.) Promote orientation. c.) Increase stimulation. d.) Maintain safety. e.) Provide independence. f.) Promote alone time. g.) Provide continuity of care. h.) Simplify communication.

a.) Decrease anxiety. b.) Promote orientation. d.) Maintain safety. g.) Provide continuity of care. h.) Simplify communication Rationale: The confused person can be a danger to himself. Safety is a top priority, so placing the bed in the lowest position and frequently rounding on the client is critical. Decreasing stress, promoting orientation, and simplifying communications may lessen confusion and frustration. Providing a constant caregiver will also improve confusion.

The nurse is caring for an older adult who is hearing impaired and cannot wear his glasses because they are broken. What interventions would be appropriate? Select all that apply. a.) Explain things before performing them. b.) Talk in a quiet tone of voice. c.) Speak slowly, articulating clearly. d.) Validate understanding of verbal communication. e.) Ask whether he has a "good ear."

a.) Explain things before performing them. c.) Speak slowly, articulating clearly. d.) Validate understanding of verbal communication. e.) Ask whether he has a "good ear."

The nurse practitioner is performing an annual physical examination on an 88-year-old female. Which assessments are most important to include? Select all that apply. a.) Height and weight b.) Pap test c.) Breast cancer screening d.) Gait and balance e.) Visual acuity exam

a.) Height and weight d.) Gait and balance e.) Visual acuity exam

Interventions to improve smelling and tactile senses a.) Place fresh fruits nearby. b.) Ask before touching a client. c.) Hold a client's hand when giving bad news. d.) Place fresh flowers nearby. e.) Use aromatherapy. f.) Dress him or her in tight clothing. g.) Give a firm back massage when he or she is upset.

a.) Place fresh fruits nearby. c.) Hold a client's hand when giving bad news. d.) Place fresh flowers nearby. e.) Use aromatherapy. Rationale: The stimulation of smell can be achieved by placing fresh fruits, flowers, and aromatherapy near the client. The use of essential oils can be helpful. Pleasant smells may also improve appetite. Touch should be gentle and adjusted according to the client's reaction. Restrictive clothing is irritating to people who are sensitive to touch

While helping Marjorie with her morning care, the nurse notices several skin tears and bruises on her arms. Marjorie notices the nurse looking at them and says, "My skin used to look smooth and pretty, but now it gets damaged so easily." What steps should the nurse make? Select all that apply. a.) Provide a foam mattress for the bed. b.) Pad the corners of hard objects in the room. c.) Encourage wearing long sleeves. d.) Avoid contact with tape and adhesive bandages. e.) Use gentle soaps and lotions.

a.) Provide a foam mattress for the bed. b.) Pad the corners of hard objects in the room. c.) Encourage wearing long sleeves. d.) Avoid contact with tape and adhesive bandages. e.) Use gentle soaps and lotions. Rationale: Because of loss of elasticity and thinning of the skin, the older adult's skin is more prone to tears and bruises. Limiting trauma by providing padding and avoiding tape is helpful. Use of gentle soaps and lotions can improve skin's dryness, a factor that can lead to tissue breakdown.

Interventions for decreasing sensory overload a.) Reduce noxious odors promptly. b.) Minimize lighting. c.) Place client near the nurses' station. d.) Lower voice and alarm sounds. e.) Minimize pain medications. f.) Encourage frequent visitors. g.) Minimize nighttime interruptions. h.) Only use the television when the client is interested.

a.) Reduce noxious odors promptly. b.) Minimize lighting. d.) Lower voice and alarm sounds. g.) Minimize nighttime interruptions. h.) Only use the television when the client is interested. Rationale: Sensory overload is an outcome of hospitalization. The constant interruptions, alarms, noise level, and stress contribute to sensory overload in most people. Creating a quiet, uninterrupted environment is best for promotion of sleep and rest

Which factors can impact a person's sensory alteration? Select all that apply. a.) Sensory deprivation b.) Sensory overload c.) Sensory deficit d.) Sensory withdrawal e.) Sensory denial

a.) Sensory deprivation b.) Sensory overload c.) Sensory deficit

Interventions for communicating with the hearing impaired a.) Speak to the client's "stronger" ear. b.) Don't speak while chewing gum or eating. c.) Use paper and pencil when needed. d.) Speak slowly and articulate clearly. e.) Repeat statements until understood. f.) Don't shout. g.) Use visual cues. h.) Validate understanding.

a.) Speak to the client's "stronger" ear. b.) Don't speak while chewing gum or eating. c.) Use paper and pencil when needed. d.) Speak slowly and articulate clearly. f.) Don't shout. g.) Use visual cues. h.) Validate understanding. Rationale: Hearing impairment can limit communication and place a person in social isolation. The nurse should face the client so she can possibly read lips. If hearing in one ear is better than in the other, then direct speech toward that side. Speak clearly and slowly in a steady voice, explaining actions clearly before performing them. Shouting can distort words, especially for those reading lips. Validate understanding by having the person explain what you said. Nodding the head is not sufficient to validate understanding.

Marjorie becomes bedridden after a fall that resulted in a hairline fracture of her pelvis. She begins to develop a cough of yellow sputum and requires higher amounts of oxygen at night to maintain adequate oxygen levels. Which physiological changes of aging contribute to her current condition? Select all that apply. a.) Weakened immune system b.) Decreased muscle strength c.) Decreased cardiac output d.) Decreased skin elasticity e.) Increased intercostal muscle strength

a.) Weakened immune system b.) Decreased muscle strength Rationale: Marjorie is exhibiting signs of pneumonia that developed after she became immobile following her fall. Her weakened immune system is contributing to her inability to fight the infection, and muscle weakness is impacting her ability to cough.

As Marjorie ages and becomes more frail, her family decides to move her to a nursing care facility. She has been hospitalized twice in the past 6 months for pneumonia and does not wear her oxygen device at night. As the nurse is helping Marjorie into her wheelchair to go to the dining hall for breakfast, she notices how loose her pants are. She decides to weigh her and finds she has lost 8 pounds in the past month. What should be the nurse's next action? a.) Change her diet to include more fattening foods. b.) Determine whether any medications she's taking would cause weight loss. c.) Make her clean her plate with each meal. d.) Monitor her daily calorie intake for a week.

d.) Monitor her daily calorie intake for a week. Rationale: Weight loss is common in older adults as they experience decreased appetite and difficulty with chewing and digestion. Weight loss can also be a sign of further problems, so monitoring calorie intake and weight can determine the next course of action.

John has taken the same blood pressure medication at the same dosage for 10 years. At his last routine physical, his blood pressure was higher than normal. Which statement best describes the reason for this change? a.) His medication was outdated and therefore less potent. b.) He was anxious when his blood pressure was taken. c.) The blood pressure was not taken correctly. d.) Vessels develop increased peripheral resistance with age, causing a rise in blood pressure.

d.) Vessels develop increased peripheral resistance with age, causing a rise in blood pressure. Rationale: The increase of peripheral resistance and rise in systolic blood pressure are expected parts of aging. Additionally, cardiac output tends to decrease. As a result of these physiological changes, John should continue a healthy lifestyle, but may also need to increase medications for better outcomes.