GERO EAQ QUESTIONS
A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? "My ankles are swollen." "I am tired at the end of the day." "When I eat a large meal, I feel bloated." "I have trouble breathing when I walk rapidly."
"I have trouble breathing when I walk rapidly."
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? -Increased skin elasticity and an increase in testosterone production -Impaired fat digestion and an increase in pepsin production -Increased blood pressure and decreased cardiac output -An increase in body warmth and some swallowing difficulties
Increased blood pressure and decreased cardiac output
Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. Difficulty in swallowing Increased sensitivity to heat Increased sensitivity to glare Diminished sensation of pain Heightened response to stimuli
Increased sensitivity to glare Diminished sensation of pain
A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective? "I can drink beer with this, but not wine." "I need to limit my intake of acetaminophen to 650 mg a day." "I should take an emetic if I accidentally overdose on the acetaminophen." "I have to be careful about which over-the-counter cold preparations I take when I have a cold."
"I have to be careful about which over-the-counter cold preparations I take when I have a cold."
An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in response to this client's question? Select all that apply. "Ask your healthcare provider how and when you should be taking your medications." "Stop taking a prescribed medication if you are not feeling better in a few days." "Discard medications into the toilet that have exceeded the expiration date on the bottle." "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." "Inform your healthcare provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."
"Ask your healthcare provider how and when you should be taking your medications." "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." "Inform your healthcare provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."
The nurse is preparing a client who is on metformin therapy and is scheduled to undergo renal computed tomography with contrast dye. What does the nurse anticipate the primary healthcare provider to inform the client regarding the procedure? "Discontinue metformin 1 day prior to procedure." "Discontinue metformin a half-day prior to procedure." "Discontinue metformin 3 days following the procedure." "Discontinue metformin 7 days following the procedure."
"Discontinue metformin 1 day prior to procedure."
A nurse is educating an older adult for the purpose of promoting wellness. What instruction should the nurse give to reduce the risk of disability? "Engage in physical activities to stay fit." "Don't exhaust yourself by engaging in physical activities." "Pay no heed to your financial problems if you want to stay healthy." "Stay away from people so as to prevent anxiety and stress disorders."
"Engage in physical activities to stay fit."
An older adult client states, "I walk 2 miles [3.2 km] a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the clinic nurse teach the client? "Drink fruit juices if you start to feel dehydrated." "Thirst is a good guide to use to determine fluid intake." "Fluids should be increased if the urine is getting darker." "Water should be consumed when the skin becomes dry."
"Fluids should be increased if the urine is getting darker."
The healthcare provider prescribes nitroglycerin ointment for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? "I may experience a headache." "Confusion is a common adverse effect." "A slow pulse rate in an expected side effect." "Increased blood pressure readings may occur initially."
"I may experience a headache."
A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? "I am unable to run a mile (1.6 kilometers) now." "I wake up at night short of breath." "My wife says I snore very loudly." "My shoes seem larger lately."
"I wake up at night short of breath."
A client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? "You will need to decrease your exercise." "An extra tablet will help your body use glucose correctly." "When taking medicine, your diet will not be affected by exercise." "No, but you should observe for signs of hypoglycemia while exercising."
"No, but you should observe for signs of hypoglycemia while exercising."
A registered nurse is supervising a student nurse while assessing a 70-year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition requires correction? "The client may have deterioration of the cochlea." "The client may have thinning of the tympanic membrane." "The client may have an inability to hear high-frequency sounds." "The client may have an inability to differentiate between consonants."
"The client may have thinning of the tympanic membrane."
A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? -"Your primary healthcare provider must have forgotten to prescribe it." -"Your condition is not severe enough to have physical therapy approved." -"Your joints are still inflamed, and physical therapy can be harmful." -"Physical therapy is not helpful for persons who suffer from RA."
"Your joints are still inflamed, and physical therapy can be harmful."
A nursing student is listing points to remember about wellness promotion in older adults. Which points mentioned by the nursing student need correction? Select all that apply. -"It is essential to prevent injuries in older adults when promoting wellness." -"It is essential to focus on curing diseases or other illnesses completely in older adults to promote wellness." -"It is essential to assess the level of fear of falling and provide support accordingly when caring for older adults." -"It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." -"It is necessary to consider the older adult's social environment and ensure that he or she lives in social isolation to prevent stress."
-"It is essential to focus on curing diseases or other illnesses completely in older adults to promote wellness." -"It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." -"It is necessary to consider the older adult's social environment and ensure that he or she lives in social isolation to prevent stress."
A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. -Dry cerumen -Tears in the tympanic membrane -Difficulty hearing high pitched voices -Decrease of hair in the auditory canal -Overgrowth of the epithelial auditory lining
-Dry cerumen -Difficulty hearing high pitched voices
Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client? 1 to 3 minutes 4 to 5 seconds 30 to 45 seconds 20 to 45 minutes
1 to 3 minutes
The laboratory international normalized ratio (INR) results of a client receiving warfarin have been variable. The nurse interviews the client to determine factors contributing to the problem. Which is most important for the nurse to identify? Use of analgesics Serum glucose level Serum potassium levels Adherence to the prescribed drug regimen
Adherence to the prescribed drug regimen
A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? An increase in the pressure within the eyeball An opacity of the crystalline lens or its capsule A curvature of the cornea that becomes unequal A separation of the neural retina from the pigmented retina
An increase in the pressure within the eyeball
What is the main reason a nurse raises three of the four side rails on the bed of an 83-year- old client who had surgery for a fractured hip? -As a safety measure because of the client's age -Because clients older than 60 years of age should use side rails -To be used as handholds to facilitate the client's ability to move in bed -Because all older adults are disoriented for several days after anesthesia
As a safety measure because of the client's age
A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? Aspirin Midazolam Gabapentin Alprazolam
Aspirin
What interventions should the nurse follow when giving health education to an elderly client? Select all that apply. Assess the client for pain before teaching. Take down notes while talking to the client. Ensure the client is not preoccupied or anxious. Teach one concept at a time according to the client's interest. Teach a family caregiver if the client does not respond quickly.
Assess the client for pain before teaching. Ensure the client is not preoccupied or anxious. Teach one concept at a time according to the client's interest.
What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging? -Achievement of a personal philosophy -Adaptation to the children leaving home -Attainment of a sense of worth as a person -Adjustment to life in an assisted-living facility
Attainment of a sense of worth as a person
A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply. Polyuria Jaundice Azotemia Hypertension Polycythemia
Azotemia Hypertension
An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply. Dyspnea Crackles Hacking cough Peripheral edema Jugular distention
Dyspnea Crackles Hacking cough
While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)? Barrel chest Cyanosis Hyperventilation Lordosis
Barrel chest
Aspirin is prescribed for a client with rheumatoid arthritis. Which clinical indicators of aspirin toxicity should the nurse teach the client to report? Select all that apply. Bradycardia Joint pain Blood in the stool Ringing in the ears Increased urine output
Blood in the stool Ringing in the ears
A client with an intractable infection is receiving vancomycin. Which laboratory blood test result should the nurse report? Hematocrit: 45% Calcium: 9.0 mg/dL (2.25 mmol/L) White blood cells (WBC): 10,000 mm 3 (10 X 10 9/L) Blood urea nitrogen (BUN): 30 mg/dL (10.2 mmol/L)
Blood urea nitrogen (BUN): 30 mg/dL (10.2 mmol/L)
The nurse is caring for a client who reports excessive tearing. Which disorders does the nurse suspect could be responsible for the client's condition? Select all that apply. Chalazion Entropion Hordeolum Conjunctivitis Keratoconjunctivitis sicca
Chalazion Entropion Conjunctivitis
A 62-year-old client reports to the nurse, "My eyes don't feel right and I have a gritty and sandy sensation in my eyes." What condition might this client have? Retinal detachment Infection of the cornea Changes in tear composition Hemorrhage in the vitreous humor
Changes in tear composition
A client with type 2 diabetes has been receiving insulin in the hospital while being treated for sepsis. The client's infection is resolving and the primary healthcare provider writes a prescription to discontinue the 7:00 AM dose of insulin and to administer glyburide 5 mg twice daily (8:00 AM and 8:00 PM). The nurse on the day shift (8:00 AM to 4:00 PM) administers the glyburide at 8:30 AM. When recording its administration in the client's record, the nurse sees that the insulin had already been administered at 7:00 AM. What initial action should the nurse take? Measure the vital signs. Notify the primary healthcare provider. Assess for signs of ketoacidosis. Check blood glucose for hypoglycemia.
Check blood glucose for hypoglycemia.
A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. What clinical finding requires the nurse to notify the primary healthcare provider? Lack of a productive cough 2 days postoperatively Rectal temperature of 100.2° F (37.9° C) 3 days postoperatively Complaints of right-sided chest pain 6 days postoperatively Fatigue in the leg on the unaffected side 5 days postoperatively
Complaints of right-sided chest pain 6 days postoperatively
At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing? Polydipsia Ketoacidosis Glycogenesis Hypoglycemia
Hypoglycemia
What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? Knowledge reduces general anxiety. Capacity to learn decreases with age. Continued reinforcement is advantageous. Readiness of the learner precedes instruction.
Continued reinforcement is advantageous.
A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply. Loss of turgor Urinary incontinence Decreased night vision Decreased mobility of ribs Increased sensitivity to odors
Loss of turgor Decreased night vision Decreased mobility of ribs
Which intrinsic factor is associated with the fall of an older adult? Wet floors Poor lighting Deconditioning Inappropriate footwear
Deconditioning
Which intrinsic factors may contribute to falls in older adults? Select all that apply. Deconditioning Impaired vision Inappropriate foot wear Improper use of assistive devices Unfamiliar environment of hospital room
Deconditioning Impaired vision
The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? Thinning subcutaneous layer Degeneration of elastic fibers Decreased dermal blood flow Benign proliferation of capillaries
Decreased dermal blood flow
Which musculoskeletal system change is associated in older adult clients? Decreased in height Decreased neck rigidity Increased fine-motor dexterity Increased range of motion (ROM)
Decreased in height
A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? Nervousness and tachycardia Erythema toxicum rash and pruritus Diaphoresis and altered mental state Deep respirations and fruity odor to the breath
Deep respirations and fruity odor to the breath
A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. Dependent edema Swollen hands and fingers Collapsed neck veins Right upper quadrant discomfort Oliguria
Dependent edema Swollen hands and fingers Right upper quadrant discomfort
The nurse frequently provides care for clients with hearing aids. Which condition does the nurse recall responds best to hearing aids? Destruction of the auditory nerve Diminished sensitivity of the cochlea Perforation of the tympanic membrane Immobilization of the auditory ossicles
Diminished sensitivity of the cochlea
A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. Dry cerumen Tears in the tympanic membrane Difficulty hearing high pitched voices Decrease of hair in the auditory canal Overgrowth of the epithelial auditory lining
Dry cerumen Difficulty hearing high pitched voices
What important points should the nurse keep in mind when caring for an older adult to promote health? Select all that apply. Focus on achieving the highest level of health and absence of disease Encourage regular physical activity and the use of stress-management strategies Encourage the client to accept help for carrying out activities of daily living (ADLs) Consider the client's social environment and strengthen social support to promote health Assess the client for fear of falling and provide support by making environmental changes
Encourage regular physical activity and the use of stress-management strategies Consider the client's social environment and strengthen social support to promote health Assess the client for fear of falling and provide support by making environmental changes
The nurse is providing home care to an older adult client with decreased bone density. Which nursing intervention will be most beneficial for the client? Teaching isometric exercises Encouraging the client to do weight-bearing exercises Instructing the client to sit in supportive chairs with arms Providing moist heat such as shower or moist compresses
Encouraging the client to do weight-bearing exercises
A nurse prepares to administer extended-release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. What will prompt the nurse to ask the provider for a different form of metformin? This drug has a wax matrix frame that is difficult to crush. The drug has an unpleasant taste, which most clients find intolerable if crushed. If crushed, this drug irritates mucosal tissue and can cause oral and esophageal ulcer formation. Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring.
Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring.
The blood urea nitrogen (BUN)/creatinine ratio of a client is 3. Which condition does the nurse suspect in the client? Fluid volume excess Obstructive uropathy Severe hepatic damage Gastrointestinal (Gl) bleeding
Fluid volume excess
Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? Carelessness Fragility of bone Sedentary existence Rheumatoid diseases
Fragility of bone
The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? Ulnar drift Heberden nodes Swan-neck deformity Boutonnière deformity
Heberden nodes
After a left cataract extraction, a client reports severe discomfort in the operated eye. The nurse concludes that this problem may be caused by which condition? Hemorrhage into the eye Expected postoperative discomfort Isolation related to sensory deprivation Pressure on the eye from the protective shield
Hemorrhage into the eye
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? -Side-lying with head elevated 45 degrees -Sims with head elevated 90 degrees -Semi-Fowler with legs elevated -High-Fowler using the bedside table to rest the arms
High-Fowler using the bedside table to rest the arms
A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. Hips Knees Ankles Shoulders Metacarpals
Hips Knees
The nurse is assessing the client admitted with diabetic ketoacidosis. Which statement made by the client indicates a need for further education on sick day management? I will stop taking my insulin when I am ill because I am not eating. I will check my urine for ketones when my blood sugar is over 250. I will alternate drinking Gatorade and water throughout the day while ill. I will continue all my insulin including my glargine when I am sick.
I will stop taking my insulin when I am ill because I am not eating.
Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? Constant blurring Abrupt attacks of acute pain Sudden, complete loss of vision Impairment of peripheral vision
Impairment of peripheral vision
Which instructions will be most beneficial for a diabetic client with renal disease? Select all that apply. Recommend the client drink boiled water Suggest the client to go for a morning walk Instruct the client to check blood pressure regularly Contact the primary healthcare provider before taking ibuprofen Encourage the client to undergo a microalbuminuria test yearly
Instruct the client to check blood pressure regularly Contact the primary healthcare provider before taking ibuprofen Encourage the client to undergo a microalbuminuria test yearly
A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? International normalized ratio (INR) Accelerated partial thromboplastin time (APTT) Bleeding time Sedimentation rate
International normalized ratio (INR)
The nurse caring for a client with diabetic ketoacidosis (DKA) can expect to implement which intervention? Intravenous administration of regular insulin Administer insulin glargine subcutaneously at hour of sleep Maintain nothing prescribed orally (NPO) status Intravenous administration of 10% dextrose
Intravenous administration of regular insulin
The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? Fluid loss Glycosuria Kussmaul respirations Increased blood glucose level
Kussmaul respirations
An older adult fell at home and fractured the left hip. Which response should the emergency department nurse identify as a typical clinical indicator associated with a fractured hip? Affected hip is ecchymotic. Left leg is noticeably shorter than the right. Left extremity is internally rotated. Affected hip is tender when touched.
Left leg is noticeably shorter than the right.
A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? Loss of central vision Attacks of acute pain Constant blurred vision Decreased peripheral vision
Loss of central vision
An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? Monitor for cardiovascular irregularities. Inquire about changes in bowel patterns. Assess for leg muscle twitching or weakness. Assess for signs and symptoms of dehydration.
Monitor for cardiovascular irregularities.
A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? Metabolic alkalosis Myocardial hypoxia Decreased catecholamine secretion Increased parasympathetic nervous system stimulation
Myocardial hypoxia
A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply. Obesity Hypertension Diabetes insipidus Asian-American ancestry Increased high-density lipoprotein (HDL)
Obesity Hypertension
An older female client is seen in the primary healthcare provider's office. Upon initial nursing assessment the nurse notes the client's height has decreased by 1 inch (2.5 cm) since the last visit 1 year ago. The nurse knows that what is the most likely reason for this finding? The nurse was in error. Older adults are not active enough so they lose bone mass. Older adults have poor posture so they are shorter. Older adults may have osteoporosis-related height changes.
Older adults may have osteoporosis-related height changes.
The nurse is caring for an older client admitted to the hospital with type 2 diabetes. What is important for the nurse to remember about older adults and type 2 diabetes? Older adults seldom develop ketoacidosis. Older adults secrete no endogenous insulin. Older adults have a lower risk of complications. Older adults develop a sudden onset of symptoms.
Older adults seldom develop ketoacidosis.
A nurse is caring for a client who is admitted to the hospital with a diagnosis of unstable angina. Sublingual nitroglycerin has been prescribed. What client response indicates that nitroglycerin is effective? Pain subsides as a result of arteriole and venous dilation. Pulse rate increases because the cardiac output has been stimulated. Sublingual area tingles because sensory nerves are being triggered. Capacity for activity improves as a response to increased collateral circulation.
Pain subsides as a result of arteriole and venous dilation.
A nurse is reviewing the laboratory reports of a client with a diagnosis of end-stage renal disease. Which test result should the nurse anticipate? Arterial pH of 7.5 Hematocrit of 54% Potassium of 6.3 mEq/L (6.3 mmol/L) Creatinine of 1.2 mg/dL (106 mcmol/L)
Potassium of 6.3 mEq/L (6.3 mmol/L)
A client who just has been diagnosed with primary open-angle glaucoma (POAG) refuses therapy. The nurse reinforces that it is important for the client to seek treatment. Which goal is the nurse trying to achieve? Prevent cataracts Prevent blindness Prevent retinal detachment Prevent blurred distance vision
Prevent blindness
A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply. Suggest that the client have annual Papanicolaou (Pap) smears and mammograms Promote dietary modifications by using varied techniques Assess the client's current lifestyle and promote lifestyle changes Monitor the client's blood pressure and weight and establish blood pressure screening programs Teach the client about correct body mechanics and the availability of mechanical appliances
Promote dietary modifications by using varied techniques Assess the client's current lifestyle and promote lifestyle changes Monitor the client's blood pressure and weight and establish blood pressure screening programs
Nursing actions for an older adult should include health education and promotion of self- care. Which is most important when working with an older adult client? -Encouraging frequent naps -Strengthening the concept of ageism -Reinforcing the client's strengths and promoting reminiscing -Teaching the client to increase calories and focusing on a high-carbohydrate diet
Reinforcing the client's strengths and promoting reminiscing
A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? Relieving muscle spasm and pain Preventing contractures from developing Keeping the client from turning and moving in bed Maintaining the limb in a position of external rotation
Relieving muscle spasm and pain
An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? Providing psychotherapy to the client Teaching strategies to overcome depression Encouraging the client to walk for 30 minutes Requesting that the physician change the drug
Requesting that the physician change the drug
The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate? Asking the family member to step out of the room so the client can rest Placing a vest restraint on the client to prevent the client from falling out of bed Explaining to the family that it is common for older clients to get confused while in the hospital Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider
Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider
The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should instruct the client on which eye problem most associated with diabetes? Cataracts Glaucoma Retinopathy Astigmatism
Retinopathy
A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The primary healthcare provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)? QRS complex S-T segment P wave R wave
S-T segment
A nurse teaches a client with chronic renal failure that salt substitutes cannot be used in the diet. What is the rationale for the nurse's instruction? A person's body tends to retain flui d when a salt substitute is included in the diet. Limiting salt substitutes in the diet prevents a buildup of waste products in the blood. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. A substance in the salt substitute interferes with the transfer of fluid across capillary membranes, resulting in anasarca.
Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats.
After reviewing the laboratory reports, the nurse anticipates that the client has renal impairment. Which test reports support the nurse's concern? Select all that apply. Serum albumin: 4.7 g/dL(6.815 μmol/L) Serum creatinine: 2.0 mg/dL (176.8 μmol/L) Serum potassium: 5.9 mEq/L (5.9 mmol/L) Serum cholesterol: 120 mg/dL (3.108 mmol/L) Blood urea nitrogen: 32 mg/dL (11.424 mmol/L)
Serum creatinine: 2.0 mg/dL (176.8 μmol/L) Serum potassium: 5.9 mEq/L (5.9 mmol/L) Blood urea nitrogen: 32 mg/dL (11.424 mmol/L)
When two nurses are getting an older adult out of bed, the client reports feeling light- headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? Slide slowly to the floor to prevent a fall and injury. Sit on the edge of the bed while they hold the client upright. Bend forward because this will increase blood flow to the brain. Lie down quickly so the legs can be raised above the heart level.
Sit on the edge of the bed while they hold the client upright.
When teaching about aging, the nurse explains that older adults usually have what characteristic? -Inflexible attitudes -Periods of confusion -Slower reaction times -Some senile dementia
Slower reaction times
When nurses are conducting health assessment interviews with older clients, what step should be included? -Leave a written questionnaire for clients to complete at their leisure. -Ask family members rather than the client to supply the necessary information. -Spend time in several short sessions to elicit more complete information from the clients. -Keep referring to previous questions to ascertain that the information given by clients is corr
Spend time in several short sessions to elicit more complete information from the clients.
An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? -Assess the client's mobility. -Monitor respirations and breathing effort. -Teach coughing and deep-breathing exercises. -Determine normal activity levels and note when the client tires.
Teach coughing and deep-breathing exercises.
A nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply. Scaly skin Tenting of skin Transparent skin Increased wrinkles Pigmented lesions
Tenting of skin Transparent skin Increased wrinkles Pigmented lesions
The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply. The client should obtain a finger stick blood glucose reading before each meal. The client does not need to follow a specific diet until insulin is required. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan does not need to include signs and symptoms of hypoglycemia, as the client is not on insulin. The teaching plan should include sick day rules.
The client should obtain a finger stick blood glucose reading before each meal. The teaching plan should include signs and symptoms of hypoglycemia. The teaching plan should include sick day rules.
A client with diabetes mellitus complains of difficulty seeing. What would the nurse suspect as the causative factor? Lack of glucose in the retina The growth of new retina blood vessels or "neovascularization" Inadequate glucose supply to rods and cones Destructive effect of ketones on retinal metabolism
The growth of new retina blood vessels or "neovascularization"
Which beta-adrenergic blocker is used to reduce a client's intraocular pressure? Timolol Travopost Carbachol Apraclonidine
Timolol
Several hours after administering insulin, the nurse is assessing a client for an adverse response to the insulin. Which client responses are indicative of a hypoglycemic reaction? Select all that apply. Tremors Anorexia Confusion Glycosuria Diaphoresis
Tremors Confusion Diaphoresis
Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? Troponin Myoglobin Homocysteine Creatine kinase (CK)
Troponin
The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply. Dyspnea on exertion Unexplainable profuse diaphoresis Indigestion not relieved by antacids Fatigue the day after a rigorous walk Acute chest pain after rigorous exercise Nonremitting chest pain after three sublingual nitroglycerine tablets
Unexplainable profuse diaphoresis Indigestion not relieved by antacids Acute chest pain after rigorous exercise Nonremitting chest pain after three sublingual nitroglycerine tablets
Which principles are appropriate for promoting older adult learning? Select all that apply. Emphasize abstract material Use past experiences while teaching Teach by presenting multiple examples at a time Keep the environmental distractions to a minimum Use audio, visual, and tactile cues to enhance learning
Use past experiences while teaching Keep the environmental distractions to a minimum Use audio, visual, and tactile cues to enhance learning
The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? Oxygen therapy Cardiac monitoring Nutrition supplements Venous thromboembolism (VTE) prevention
Venous thromboembolism (VTE) prevention
A client is receiving warfarin. The nurse explains the need for careful regulation of dietary intake of vitamin K. What is the rationale for the nurse's teaching? Vitamin K promotes platelet aggregation. Vitamin K promotes ionization of blood calcium. Vitamin K promotes fibrinogen formation by the liver. Vitamin K promotes prothrombin formation by the liver.
Vitamin K promotes prothrombin formation by the liver.
After cataract surgery the nurse teaches a client how to self-administer eyedrops. The nurse reinforces the use of what technique? Placing the drops on the cornea of the eye Raising the upper eyelid with gentle traction Holding the dropper tip above the conjunctival sac Squeezing the eye shut after instilling the medication
Holding the dropper tip above the conjunctival sac
The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is related to heart failure? I see spots before my eyes. I am tired at the end of the day. I feel bloated when I eat a large meal. I have trouble breathing when I climb a flight of stairs.
I have trouble breathing when I climb a flight of stairs.
