aging patient 1

.A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Prior to percussing the abdomen

A nurse is preparing to administer cephalexin oral suspension to an older adult client who has difficulty swallowing pills. Which of the following actions should the nurse take?

Check the client for a penicillin allergy.

A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?

Cystitis

A nurse is teaching a class at a community center to a group of young adult, adult, and older adult clients regarding regular screening recommendations for cancer prevention. Which of the following information should the nurse include?

Clients should have a yearly test for fecal occult blood.

.A nurse is caring for a client who is postoperative following abdominal surgery and reports incisional pain. The surgeon has prescribed morphine 4 mg IV bolus every 6 hr as needed. Before administering this medication, the nurse should complete which priority assessment?

Respiratory rate

A nurse is assessing a client prior to the administration of morphine. The nurse should recognize that which of the following assessments is the priority?

Respiratory rate

A nurse administers an incorrect medication to a client. Following an assessment of the client, the nurse determines that the client has experienced no untoward effects as a result of the medication. The nurse does not complete an incident report because no harm came to the client. Which of the following ethical principles did the nurse violate?

Veracity

.A nurse is teaching a client who needs to increase their daily fluid intake. Which of the following foods has the highest percentage of water by weight?

Lettuce

.A nurse is caring for an older adult client whose provider will discharge him to an extended-care nursing facility the following morning. The client asks the nurse why he has to go to "that place." Which of the following responses should the nurse make?

"Did your doctor or anyone else talk to you about going to the nursing home?"

A nurse is planning care for an older adult client who has herpes zoster. Which of the following interventions should the should the nurse include in the plan?

Administer analgesics for pain

A nurse is reviewing the diagnostic test results of an older adult female client who is preoperative for a knee arthroplasty. The nurse should notify the surgeon of which of the following results?

WBC count 20,000/mm3

.A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following responses should the nurse make?

"I will check your medication order again."

.A nurse is caring for an older adult client. The nurse informs the client that straining while defecating can cause which of the following?

Dysrhythmias

.A nurse is completing a client assessment for admission to the medical unit. Which of the following abdominal assessment findings require further investigation by the nurse?

Ecchymosis

A nurse is preparing to administer 2 units of packed RBCs to an older adult client. Which of the following actions should the nurse take?

Administer each unit over 3 hr.

A nurse is assessing an older adult client who is receiving IV therapy. The nurse should recognize that which of the following findings indicates fluid volume excess? (Select all that apply.)

-Bounding pulse -Pitting edema -Crackles upon auscultation

A nurse is completing the initial admission assessment and history for a client. Which of the following is the priority action for the nurse to take?

Document the client's allergies in the electronic medical record.

.A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication the client might be experiencing a hemolytic reaction?

Hypotension

A nurse is applying a cold compress for a client who has pain and minor swelling in a sutured laceration on the forearm. Which of the following assessments should the nurse use to determine whether the treatment is effective?

Asking the client to rate the pain

A nurse working for a home health agency is assessing an older adult male client. Which of the following findings is the priority for the nurse to address?

Dysphagia

.A nurse is monitoring a client who is receiving a unit of packed RBCs following surgery. Which of the following assessments is an indication that the client might be experiencing circulatory overload?

Dyspnea

A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?

Grapefruit juice

.A nurse in a clinic is caring for an older adult client who reports dry, flaky skin on her upper back. Which of the following is an interventions should the nurse complete?

Pinch up a fold of skin to check for turgor.

A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?

Scatter rugs are present in the kitchen

.A nurse is caring for an older adult client who has a WBC count of 2,000/mm3 after three rounds of chemotherapy. Which of the following actions should the nurse take?

Serve cooked fruit with meals.

.A nurse is engaging in relationship counseling with a male client. Which of the following is a characteristic of men that the nurse should consider when beginning the nurse-client relationship?

They are more direct when discussing issues.

.A nurse is caring for an older adult client who has a fractured hip and will require rehabilitative care. The client's family asks the nurse for information about this type of care. Which of the following explanations should the nurse provide?

This service began with the client's admission to the hospital.

.A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend?

Walking

A nurse is teaching an older adult client who has osteoporosis about beginning a program of regular physical activity. Which of the following recommendations should the nurse make?

Walking briskly

A home health care nurse is visiting an older adult client who tells the nurse that she is feeling tired, is unable to shop for groceries, and would like the nurse to shop for her. Shopping and performing personal errands for the client is prohibited in the nurse's job description. Which of the following is an appropriate nursing response?

"Let's look at some other resources to solve this problem."

A nurse is teaching an older adult client who has left-sided weakness about cane use. Which of the following instructions should the nurse include?

"When walking, move your left foot forward first."

An older adult client is scheduled to have an elective surgical procedure and informs the nurse that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the following responses should the nurse provide?

"Your provider needs to talk with you concerning your request."

A nurse is reviewing the medical records of four older adult clients. The nurse should plan to administer the herpes zoster vaccine to which of the following clients?

A client who takes omeprazole for peptic ulcer disease

.A nurse is educating a group of older adults in a community center on weight management using the BMI scale. Using the client's height and weight to calculate BMI, which of the following clients has a healthy BMI?

A client with a weight of 150 lb and height of 68 inches

A nurse is caring for a client in the emergency department who, 2 hr earlier, severed the tip of a finger in an accident. During the assessment, the nurse detects a strong smell of alcohol from the client's breath. For which of the following findings should the nurse assess first?

Date of the client's last tetanus immunization

A nurse is preparing an older adult client for a physical examination the provider is about to perform. Which of the following actions should the nurse take?

Explain to the client what is about to happen.

.A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take?

Leave a nightlight on in the client's room.

.A nurse is formulating a teaching plan about herpes zoster for a group of older adults at a community center. The nurse should include which of the following information in the plan?

Many clients experience pain in the affected area for weeks after the lesions have resolved

An older adult client who lives alone tells a clinic nurse that he is unable to drive himself to the store and is afraid to cook on the stove. Which of the following community resources should the nurse recommend for this client?

Meals on Wheels

A nurse is inserting an IV catheter for an older client in preparation for an outpatient procedure. Which of the following veins should the nurse select?

Median vein in the forearm

.A nurse is discussing culturally competent care at a nursing staff inservice. Which of the following information should the nurse include when discussing clients' cultures?

Nurses should focus on clients' cultures, rather than their ethnicity, when providing care

A nurse is performing a cardiac assessment. Identify where the nurse should place the stethoscope to auscultate the client's apical pulse. (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)

Rationale: The nurse should auscultate the client's apical pulse over the apex of the heart, at the anatomical landmarks of the 5th intercostal space and below the left nipple line 7.6 cm (about 3 in) to the left of the sternum.

A nurse is preparing to administer an intramuscular (IM) injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

Respiratory rate

A nurse is performing a pain assessment for a client who is alert. The nurse should recognize that which of the following measures is the most reliable indicator of pain?

Self-report of pain

A nurse is teaching a group of older adults about health tests and screenings. Which of the following information should the nurse include? (Select all that apply.)

- "You should have a single dose of the shingles vaccine at age 60." - "You should have the pneumococcal vaccine at age 65 and then every 10." - "You should have visual acuity screening every year."

A nurse is caring for an older adult client. The nurse should recognize the client is at risk for which of the following physiological changes? (Select all that apply.)

-Decreased gastric motility -Decreased skin elasticity - Increased pain threshold

A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)

-More difficulty seeing due to a greater sensitivity to glare -Decreased cough reflex -Decreased bladder capacity -Dehydration of intervertebral discs

A nurse is preparing to perform an abdominal assessment on a client. Identify the sequence of steps the nurse should take to conduct the assessment. (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1. Ask the client about having a history of abdominal pain. 2. Inspect the abdomen for skin integrity. 3. Auscultate the abdomen for bowel sounds. 4. Percuss the abdomen in each of the four quadrants. 5. Palpate the abdomen lightly for tenderness.

A nurse in an acute care facility is admitting an older adult client who has dementia due to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He states that he is finding it more and more difficult to care for his wife. Which of the following interventions is the nurse's priority?

Ask the partner to talk about his difficulties in caring for the client

The family of an older adult client brings him to the emergency department after finding him wandering outside. During the initial assessment, the nurse notes that the client flinches when she palpates his abdomen yet responds to questions only by nodding and smiling. Which of the following factors should the nurse identify as a likely explanation for the client's behavior?

Confusion