EDAPT THE OLDER ADULT WK 3

The nurse is caring for a terminally ill child who is receiving palliative care. When explaining the purpose of palliative care to the child's caregiver, the nurse recognizes the need for additional teaching when the caregiver makes which statement?

"Palliative care interventions hasten death."

The spouse of a terminally ill client steps out of the room in tears. The spouse tells the nurse, "I don't know what I'm going to do when my spouse is gone!" What is the nurse's best response?

"This must be very hard for you."

Place the stages of general adaptation syndrome in the order that they occur.

1. ALARM 2. Resistance 3. Exhaustation

When a nurse conducts an assessment about how a client is coping, data often comes from which of the following sources? Select all that apply.

Input from a neighbor who visits the client daily An observation of how a client reacts non-verbally to instructions Information that the client shares verbally

A healthy 78-year-old woman who is considering marriage to a healthy 79-year-old neighbor tells the nurse that she wonders if they will be able to have sexual intercourse. Which is the nurse's most appropriate response?​

Both of you may have slower responses to sexual stimulation​

A nurse enters a client's room and observes the client sobbing. The client states being scared of the upcoming surgery and feeling really stressed. The nurse identifies a nursing diagnosis of "Ineffective coping related to stress of surgery". What is an attainable outcome for this client prior to surgery?

Client will practice relaxation techniques.

During a community visit, volunteer nurses teach stress management to the participants. The nurses will most likely advocate which belief as a method of coping with stressful life events?

Control over one's response to stress is possible.

It's 15:00 and the nurse is discharging a client who just received a diagnosis of pancreatic cancer. The nurse notices the client appears to have no emotional response and does not ask any questions. Which factor is most likely contributing to the client's response to this stressor?

Cultural or ethnic background

A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal finding?​

Decreased elasticity​

The nurse is speaking with the daughter of an older adult client about bringing her mother home to live with her family. Which of the following statements, made by the daughter, presents the greatest concern for the nurse?​

I don't think she will react very well to me making decisions for her."

The nurse monitors a terminally ill client for which physical signs of approaching death? Select all that apply.

Loss of consciousness Loss of bowel control Decreased blood pressure Decreased tactile sensation Loss of bladder control

Ageism is characterized by​ which of the following?

Negative attitudes towards the older adult based on age

When is the risk of abuse of an older adult family member the greatest?

Older adult has more than one chronic illness​

​A nurse in a long-term care facility is caring for several older adults with noticeable hearing losses. Which is the best way for the nurse to communicate with these clients?​

Speak in a low and distinct voice tone​

A new nurse is working in a highly stressful nursing unit and accepting additional shifts. Which strategy will be best for the nurse to use to prevent burnout?

Strengthen friendships outside the workplace

While performing discharge planning for a client recovering from a stroke, the nurse may use which factor as an indication of a client's potential for effective coping?

The client has a supportive home environment.

When caring for the older adult, which information is important to consider?​

Treat the client as an individual with a unique history of their own​

A client has been in the dying process for about 10 days. The client's spouse has left only for very short periods during this time, and looks pale and exhausted. The nurse, realizing the spouse has not eaten much, suggests that they take a break to eat and rest. The spouse declines, saying, "I don't want to leave. We won't have much more time together and I'm afraid I won't be here when my love dies." What is the best action for the nurse?

Arrange for a cot at the bedside and arrange to have food brought in.

The nurse cares for a dying client who, on admission, shared their religious practices. Based on this information, what should the nurse do to demonstrate sensitivity to the client's preferred practices?

Arranging for the requested religious leader to sit with the client.

The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's 'sweet 16' birthday party, I'll be ready to die." Which phase of coping is this client experiencing?​

Bargaining

Your 54-year-old client with a bowel infection has just died. How should the nurse care for this client?

Bathe the client adhering to standard precautions.

An older adult recently diagnosed with a urinary tract infection displays sudden onset of confusion. What is the client most likely experiencing?

Delirium​

A client who was sexually assaulted a month ago presents to the emergency room. The provider suspects that the client is experiencing post-traumatic stress response. The nurse recognizes which signs and symptoms that best support this?

Recurrent nightmares and flashbacks

When assessing the older adult, the nurse should review the client's achievement of developmental tasks. Which outcome(s) indicates achievement of developmental tasks?​ Select all that apply.

Redefining relationships with children​ Accepting himself or herself as aging​ Coping with the loss of the work role​

A nurse is assessing a client's coping after a recent stressful life event. Which of the following questions best assists the nurse in assessing the client's level of coping?

"Are you having difficulty sleeping?"

A staff nurse is telling their nursing supervisor that they are feeling increasingly stressed at work. Which statement by the nursing supervisor is most appropriate?

"Can you tell me more about what is contributing to your stress?"

A nurse is caring for a 72-year-old client who is recovering from a stressful and prolonged abdominal surgery. The nurse notes that the client's blood sugars are elevated. The client has no history of diabetes. To what does the nurse attribute this elevation in blood sugars?

"Fight-or-flight" reaction

A college student is having difficulty dealing with being dismissed from college due to poor grades. Which statement by the student indicates the defense mechanism of denial?

"I don't think the grades are right. I can stay in school."

The nurse is conducting an initial assessment of a client in crisis. When assessing the client perception of the precipitating event that led to the crisis, which is the most appropriate question?​

"What leads you to seek help now?"

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.

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

Which of the following are normal physiological changes associated with aging?​ Select all that apply.

-Reduced ability to see in darkness​ -Smooth, brown, irregularly shaped spots on the backs of hands and forearms​ -Decreased cardiac output​

The nurse provides care for an older adult whose spouse died 8 months ago. Which of the following behaviors indicates that the client is experiencing effective coping? Select all that apply.​

-Visits spouse's grave every 2 weeks​ -Attends church on a regular basis​ -Shows the nurse family photographs

A nurse is discussing medication safety with a group of older adults. Which of the following information, when discussed with clients, will increase medication safety? Select all that apply.

Ask healthcare provider before taking over the counter medication Names of the medications Undesirable effects of the medications When to take the medications Question the healthcare provider about new prescribed medications

The nurse is caring for a client with cancer. The client tells the nurse that a lawyer will be arriving today to prepare a living will and asks the nurse to act as one of the witnesses for the will. What is the most appropriate nursing action?

Ask the client who might be available to serve as a witness

A client expresses to the nurse that they constantly feel irritated and lose their temper. During the course of the interview, the nurse finds that the client is taking care of their mother who is bedridden following a stroke. The client struggles to balance caring for their family and their mother. Which nursing diagnosis would the nurse most likely identify for this client?

Caregiver role strain

The nurse is completing a health history with the daughter of a newly admitted client. The daughter reports that the client was diagnosed with Alzheimer's disease 1 year ago. According to the daughter, last night the client became agitated, confused, and was seeing spiders that were not present. The daughter was unable to calm the client and reported that the client did not recognize her. According to this history, what does the nurse suspect the client is experiencing?

Delirium

A nurse is supervising the postmortem care of a client. Which action by the unlicensed assistive personnel (UAP) performing the care is appropriate?

Elevates the head of the bed 30 degrees as soon as possible after death

The nurse is preparing to care for a dying client, and several family members are at the client's bedside. Which therapeutic techniques should the nurse use when communicating with the family? Select all that apply.

Encourage expression of feelings, concerns, and fears. Assist client and family with decision making, if asked. Be honest and keep the client and family informed.

The nurse is providing support for a caregiver who is feeling burnt out. Which of the following are appropriate suggestions for coping? Select all that apply.

Encourage the caregiver to participate in a support group Introduce stress-reducing methods to the caregiver Tell the caregiver to set aside time for self Listen to the caregiver's concerns and feelings

The nurse is caring for a terminally ill adolescent client. When caring for this client the nurse should implement which intervention?

Encourage the client to maintain maximum self-control.

The nurse is planning client education for an older adult being prepared for discharge home after hospitalization with a new cardiac diagnosis. Which nursing action addresses a priority need for this client?​

Encourage the client to use a compartmentalized pill storage container for their daily medications.

A nurse is developing a care plan for a client who is lacking confidence and experiencing stress at home. Which of the following should the nurse do initially?

Encourage the client to verbalize thoughts and feelings

A group of nurses attended a professional development course on coping mechanisms and supporting client needs. Afterwards, they shared the gained knowledge they learned with their peer colleagues. Which of the following statements demonstrates knowledge of coping mechanisms? Select all that apply.

Evaluate the constructive use of defense mechanisms by a client. Assess the client's reaction to a diagnosis of acute or chronic mental illness (hopefulness, anger). Evaluate whether the client has successfully adapted to situational role changes.

A 40-year-old client is alarmed at their recent diagnosis of type 2 diabetes. Which of the following actions by the client best indicates a problem-focused coping strategy?

Exercising three times weekly

An older-adult client with no acute distress reports being less able to taste and smell. What is the nurse's best response to this information?​

Explain to the client that diminished senses are normal

A nurse caring for clients in a hospital setting uses anticipatory guidance to prepare them for painful procedures that the patient is feeling anxious about. Which teaching would the nurse provide?

Explaining pain involved in the procedure and methods for coping

An 80-year-old client is receiving palliative care for heart failure. What are the primary purposes for receiving palliative care? Select all that apply.

Focus on reducing the severity of disease symptoms Improve quality of life

During a home visit with an 83-year-old client diagnosed with dementia, who is visibly upset and insists that people are throwing away his medals. ​The nurse observes the daughter telling her father that he is hiding them in the back of the closet and forgetting where he put them. The nurse notices the client becoming increasingly upset and anxious. The nurse offers to role-play a response with the daughter that could help reduce the client's anxiety. ​Which statement shared by the nurse would best support the client and his daughter?​

I know those medals are important to you. Tell me more about them.​"

An adolescent client is being seen for their annual healthcare provider visit. The client shares being stressed and unhappy about their progress in losing weight, despite their efforts of increasing exercise. The client's body mass index (BMI) is 31. Which of the following actions should the nurse perform to incorporate modeling for managing the stress the weight loss is causing the client?

Introduce the client to someone with a positive attitude towards weight loss.

A hospice nurse is visiting a client in the client's home. The client has had several episodes of dyspnea, and there is a prescription for morphine elixir. The client's spouse states, "I don't understand why morphine is needed. My spouse is telling me there is no pain. What should the nurse explain for the rationale of administering morphine to this client?

It helps to reduce anxiety and oxygen consumption

The nurse is caring for a terminally ill client who is experiencing dyspnea. When caring for this client, the nurse should place the client in which position?

Lateral

A nurse is teaching about coping strategies to use at home to family members of a client who is having difficulty coping. Which strategy should be avoided?

Make decisions for the client to reduce their stress level.

What is the best resource for identifying information regarding an older adult's current functional ability?​

Neighbor who visits daily and helps the client to the store weekly

The nurse is caring for a client who has a medical diagnosis of end-stage chronic obstructive pulmonary disease (COPD). The client is in severe respiratory distress and tells the nurse, "Put me on the machine." The client's family says, "No, we are not going to do this again." The client has a do-not-resuscitate (DNR) order. What is the nurse's priority action?

Notify the health care provider that the client is rescinding the DNR order

A charge nurse is ready to bring the family in to see their loved one who has recently passed away. They do one final check of the client to ensure the post mortem process has been completed. What would the nurse need to change before the family comes in the room? Select all that apply.

Old linens are folded at the end of the bed Room is brightly lit and IV poles are in the corner of the room

The nurse is caring for a terminally ill client who is experiencing Cheyne-Stokes respirations. Which best describes Cheyne-Stokes respirations?

Periods of apnea followed by deep rapid breathing

What should the nurse consider when developing the plan of care for an older adult who is hospitalized for an acute illness?

Preadmission functional abilities

A client has been admitted for restorative care in a long-term care setting following hip replacement. Which of the following interventions promote independence in activities of daily living (ADL)? Select all that apply.​

Provide the client with a toothbrush. Collaborate with a physical therapist to promote mobility. Involve the client in the plan of care. Ask the client when they need assistance.

In reviewing changes in the older adult, the nurse recognizes which of the following statements related to cognitive functioning in the older client as true?​

Reversible systemic disorders are often a cause of delirium.

The nurse is planning care for a 16-year-old client, taking into consideration that stressors experienced most commonly by adolescents include which of the following?

Search for identity with peer groups and independence from family

An 89-year-old client is confused and disoriented. Which of these interventions promotes reminiscence?​

Showing the client a picture of when they baked cookies with their grandchildren.

Which of the following are developmental stressors for clients? Select all that apply.

Starting a family Starting retirement Turning 50 years old

A nurse expresses that they constantly feel stressed and don't feel like they are handling their workload well. ​Which of the following behaviors are examples of ineffective coping and increased stress? ​

Struggling to make client care decisions​ Difficulty waking up and arriving late for work Inability to delegate​ Inability to complete nursing charts Excessive use of alcohol Calling in sick frequently​ Falling asleep at work​

When assessing an older adult, the nurse knows which of the following is a normal and physiological change related to aging?

Taking longer for the heart rate to return to baseline after exercise​

During a home health visit, a nurse talks with a client and their family caregiver about the client's medications. The client has a history of hypertension and renal disease. Which of the following client findings place the client at risk for an adverse drug event? Select all that apply.​

Taking two medications for hypertension ​ Taking a total of eight different medications during the day ​ Client's health history of renal disease ​

A nurse is caring for an older adult couple in their home. The couple has children and grandchildren, who live far from them and typically visit one to two times a year. The husband is 88 years old and beginning to show signs of Alzheimer's disease and has mobility issues. The wife is 88 years old and has difficulty managing her diabetes. She is the primary caregiver for her husband and wants to maintain his safety. What support could the nurse provide the wife to care for her husband?​

Teach the wife about this progressive disease and the need to promote as much independence as possible.

The nursing student is planning care for an older adult who had a total knee replacement yesterday evening. Which statement by the nurse is the priority to promote skin integrity?​

Tell the client that they need to reposition or get out of bed as much as possible.

A 68-year-old client who is hospitalized with pneumonia became disoriented and confused 3 days after admission. Which information indicates that the client is experiencing delirium rather than dementia?​

The client was oriented and alert when admitted.

The nurse is seeing an older adult client in a wellness screening clinic. The client is discussing their current medications, recent shoulder pain, exercising, and taking a daily one-mile walk. Which of the following statements by the nurse is accurate?​

"Continue to exercise your joints regularly to your tolerance level.​"

The nurse is providing education on fall prevention with an older adult client recently discharged home. Which of the following statements by the client indicates that more teaching is needed to minimize the risk of falls?

"I will limit my activities so I don't fall."

The nurse is evaluating the coping success of a client experiencing stress from being newly diagnosed with multiple sclerosis. Which statement by the client demonstrates effective coping?

"I'm going to attend a support group to learn more about multiple sclerosis."

The mother of a 38-year-old female recently died due to complications from surgery which required an unexpected colostomy. After her mother's death, the daughter exhibits an intellectualized defense mechanism. Which statement represents this?

"My mother would have never wanted to live with a colostomy."

The nurse is conducting an admission interview with an older adult client affected by a local flood. The client's spouse died two months ago and the client is having a complication of diabetes. The nurse asks the following questions. Which of the questions is about developmental crisis?

"Since your spouse died, what have you been doing in the evening when you feel lonely?"

After a healthcare provider has informed a client that they have colon cancer, the nurse enters the room to find the client gazing out the window in thought. The nurse's first response is which of the following?​

"Would you like for me to sit down with you for a few minutes so you can talk about this?"

Peter is going through a divorce and trying to juggle work and moving. He is extremely sad and worried about his family. Which of the following behaviors demonstrate that he is experiencing a conversion response? Select all that apply.

Lack of appetite Roaming the house in the middle of the night because he can't sleep

The nurse is providing client teaching for an 85-year-old client who will be going home on anticoagulant therapy. Which strategy reflects considerations of aging changes that may affect this client?​

Provide large-print handouts that reflect the verbal information presented.​

Which of the following nursing actions are appropriate for clients experiencing stress? Select all that apply.

Remaining calm Being available Attending to client's need for assistance Encouraging family participation Partnering with healthcare provider

A nurse is caring for a client in hospice care. The client's daughter shares that she has accepted that her parent will die soon and wants to know how to help during the last final days. Which of the following are ways that the daughter can cope while caring for her parent. Select all that apply.

Spend time enjoying each other's company, reminiscing about positive memories. Participate in physical care of the client during visits. Encourage the daughter to engage in self-care, such as exercise.

Which of the following statements should be included when teaching a group of active older adults about skin care? Select all that apply.​

Sunscreens are recommended to reduce the risk of skin cancer​ Generalized itching may be a symptom of a serious illness​ Generous use of moisturizers and minimum use of soap to prevent skin drying

The nurse works with elderly clients in a community clinic. The client inquires about their mobility and medication recommendations. ​

The nurse responds with "Is there anything that is causing your pain?""Your back pain is normal for your age." As far as exercise, "Continue to exercise your joints regularly to your tolerance level"Start walking 3-4 miles a day and we will evaluate how you feel next week." "Don't worry about taking the combination of medication since your doctor has prescribed it.""If you have any additional questions about your medication, please let us know."