Gerontology Final
A home-health nurse is caring for a client who has cancer and is using a fentanyl transdermal patch for pain control. Which of the following actions should the nurse take when caring for this client? a. Avoid using a heating pad on the area with the patch. b. To decrease the dose, cut the patch in half. c. Dispose of the used patch by placing it in the trash can. d. Assess the client for urinary retention every 8 hr.
Avoid using a heating pad on the area with the patch. *RATIONALE* Applying heat over the site of the transdermal patch will increase the rate of absorption of the opioid medication and might cause respiratory depression. *FYI* The nurse should dispose of a used patch by folding it with the adhesive edges together and placing it in a tamper-proof receptacle ... The nurse should assess the client using a fentanyl patch for urinary retention every 4 to 6 hr.
A nurse is caring for an older adult client who is expressing feelings of grief and longing for his earlier life. Which of the following actions should the nurse take? a. Listen attentively and allow the client to talk about the past. b. Change the topic of conversation. c. Let the client know that this is a common issue for older adult clients. d. Tell the client about some younger clients who are in worse shape than he is.
Listen attentively and allow the client to talk about the past. *RATIONALE* The nurse should encourage the client to reminisce as a means of dealing with his feelings of grief and longing. This is the therapeutic technique of offering self. Listening to the client allows for venting of the client's feelings about the loss of a healthy, active life. According to Erikson's theory, reminiscence is a necessary activity for older adults, who are in the stage of integrity vs despair.
A nurse is reviewing the medical record of an older adult client. For which of the following medications should the nurse conduct a hearing assessment of the client? a. Omeprazole b. Ferrous sulfate c. Digoxin d. Furosemide
Furosemide *RATIONALE* Furosemide can cause ototoxicity, especially in the older adult client, because there is a decrease in medication metabolism in the kidneys. The nurse should monitor clients taking ototoxic medications, such as furosemide, and teach the client the signs and symptoms of ototoxicity, such as tinnitus and difficulty hearing. *FYI* The nurse should monitor the client who is taking omeprazole for bone loss ... The nurse should monitor the client who is taking ferrous sulfate for gastrointestinal effects, such as bloating or changes in elimination ... The nurse should monitor the client who is taking digoxin for manifestations of hypokalemia, such as muscle weakness.
A nurse is caring for an older adult client who has a hip fracture and is rating his pain at 8 on a scale of 0 to 10. Which of the following medications should the nurse administer? a. Capsaicin topical gel b. Oxycodone/acetaminophen 7.5/325 tablet PO c. Celecoxib 200 mg capsule PO d. Aspirin 325 mg tablet PO
Oxycodone/acetaminophen 7.5/325 tablet PO *RATIONALE* A client who rates his pain as 8 on a scale of 0 to 10 is experiencing severe pain, and the nurse should administer an opioid for this type of pain. Oxycodone/acetaminophen is a combination of an opioid and a nonopioid analgesic medication and is an appropriate medication to administer to the client. The nurse should monitor the client for adverse effects, such as respiratory depression, and proactively address constipation that occurs with opioid use. *FYI* Capsaicin topical gel is used for a client who has minor pain ... Celecoxib and aspirin, both NSAIDs, are used to treat mild to moderate pain.
A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take? a. Present one idea in a sentence. b. Avoid using nonverbal communication techniques. c. Speak loudly. d. Use simplified language.
Present one idea in a sentence. *RATIONALE* The nurse should present one idea or thought in a sentence to avoid creating frustration for the client. Additionally, the nurse should allow time for the client to process and respond to the nurse. *FYI* The nurse should use nonverbal techniques, such as body language, to help convey meaning to the client through gestures, body movements, and touch; it can reinforce verbal communication ... The nurse should speak slowly and clearly to the client who has aphasia; speaking loudly will not assist the client in understanding what is being said ... The nurse should use language that is appropriate for an adult and avoid using childish tones; the inability to speak does not reflect on the client's intelligence.
A nurse managing an adult day care is developing treatment plans for older adult clients. Which of the following therapeutic strategies should the nurse use to help the clients achieve Erikson's developmental task for this age group? a. Music therapy b. Reminiscence therapy c. Meditation therapy d. Pet therapy
Reminiscence therapy *RATIONALE* The nurse should incorporate reminiscence therapy as a therapeutic strategy for the purpose of encouraging clients to engage in life review. The process of sharing memories helps clients to achieve a sense of fulfillment and self-worth and allows a positive outcome to Erikson's developmental task of integrity vs despair. *FYI* The nurse should use music therapy for the purposes of providing sensory and intellectual stimulation, as well as maintaining or increasing the clients' levels of physical, mental, social, or emotional functioning ... The nurse should encourage meditation therapy to quiet the mind and improve overall health, such as promoting sleep, decreasing pain, and improving cognitive function ... Pet therapy is beneficial for older adult clients by mitigating loneliness, promoting better physical and mental health, and providing loving companionship.
A nurse is caring for an older adult client who is unresponsive following a stroke. Which of the following actions should the nurse take while providing oral care? a. Turn the client on his side before starting oral care. b. Use the thumb and index finger to keep the client's mouth open. c. Cleanse the client's oral mucosa with a toothbrush. d. Perform oral care using sterile gloves.
Turn the client on his side before starting oral care. *RATIONALE* The nurse should place the client in a lateral position to allow excess fluids to run out of his mouth into a basin, which reduces the risk of aspiration of fluids and secretions. *FYI* The nurse should use a padded tongue blade or an oral airway, not a thumb and index finger, to keep the client's mouth open; the client might suddenly bite down and injure the nurse's fingers ... The nurse should use a moistened foam swab to clean the oral mucosa; the nurse should cleanse each area of the mouth with a separate swab to avoid transferring microorganisms from one area to another.
A nurse at a long-term care facility is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan? a. Vary the staff members caring for the client. b. Use photographs as memory triggers. c. Provide a minimum of three activity choices to the client. d. Break client tasks down to three or four steps at a time.
Use photographs as memory triggers. *RATIONALE* The nurse should place photographs on the unit that trigger the client's memories, such as a picture of a toilet at the entrance to the bathroom, or a picture of the client as a young adult at the entrance to her room. *FYI* The nurse should use consistent staff to provide care for the client because changing staff increases client confusion ... Providing the client with a number of activity choices and steps to complete causes confusion and frustration.
A nurse is teaching an older adult client about osteoporosis. Which of the following statements should the nurse include in the teaching? a. "Cottage cheese is a good source of calcium." b. "Increase your caffeine intake." c. "Brisk walking will help prevent bone loss." d. "Hormone replacement therapy with estrogen will increase your risk of osteoporosis."
"Brisk walking will help prevent bone loss." *RATIONALE* The nurse should encourage weight-bearing exercises to help minimize bone loss in the older adult client. A sedentary lifestyle, on the other hand, leads to a loss of minerals in the bones, especially calcium and phosphorus. *FYI* Cottage cheese is not a good source of calcium as it loses the calcium during processing ... The client should limit caffeine intake because it enhances the excretion of calcium ... Estrogen can reduce the fracture rate in women who have osteoporosis, although there are other complications related to its use, such as cancer.
A nurse is conducting an in-service for a group of assistive personnel about the basic needs of older adult clients. Which of the following statements should the nurse include in the teaching? a. "Caloric needs are increased." b. "Renal function is increased." c. "Deep sleep is decreased." d. "Exercise needs are decreased."
"Deep sleep is decreased." *RATIONALE* The sleep architecture, or time spent in various stages of sleep, changes with aging. The older adult spends less time in stages III and IV, which are the stages of deep sleep. This decrease in time spent in deep sleep can delay healing. *FYI* The caloric needs of an older adult client are decreased. The basal metabolic rate in older adult clients slows and can decline by 10% from the metabolic rate of a younger adult ... Older adult clients have decreased renal function, affecting the body's ability to concentrate urine and filter wastes ... Exercise needs for older adult clients are the same as for younger adults, with recommendations of 30 min a day for 5 or more days a week; regular exercise provides health benefits for older adult clients, including improvements in blood pressure, lipid profile, and neurocognitive function; older adults who perform regular physical activity have decreased mortality and age-related morbidity.
A nurse is providing teaching to a client who is to start taking alendronate sodium. Which of the following recommendations should the nurse include in the teaching? a. "The medication may be crushed if you have difficulty swallowing it." b. "Drink a full glass of milk when you take the medication." c. "Take the medication at bedtime." d. "Discontinue the medication if you develop heartburn."
"Discontinue the medication if you develop heartburn." *RATIONALE* The nurse should instruct the client to stop taking the medication if she develops heartburn or if it worsens and to contact her provider. This is an indication that esophageal irritation has occurred. Ways to avoid this are to take alendronate with 240 mL (8 oz) of water and to avoid lying down for 30 to 60 min after taking the medication. *FYI* Crushing or chewing alendronate can cause esophagitis or esophageal cancer ... Food or fluids other than water interfere with the medication's absorption ... The client should take alendronate in the morning before eating or drinking.
A nurse is caring for an older adult client who reports that he has just retired and expresses feeling of loneliness due to the loss of daily interactions with coworkers. Which of the following responses should the nurse make? a. "Do you know about the local senior citizen group?" b. "You need to take a vacation." c. "But now you can finally relax and enjoy your life." d. "Why don't you go into work and visit with your old friends?"
"Do you know about the local senior citizen group?" *RATIONALE* The nurse should assist the client in the resocialization process by using the therapeutic communication technique of giving information. Becoming involved in an organization might assist the client in resocialization, which is beneficial to clients who have depended upon their employment for social interaction.
A nurse is teaching an older adult client about methods to improve sleep. Which of the following statements should the nurse include in the teaching? a. "Go to bed at the same time every night." b. "Watch television in bed until you are sleepy." c. "Drink a glass of wine before going to bed." d. "Engage in physical activity in the evenings."
"Go to bed at the same time every night." *RATIONALE* The nurse should recommend that the client keep consistent sleep and wake times, even on the weekends. Having a regular sleep schedule will help minimize the alterations to the circadian rhythm that occurs in the older adult client. *FYI* The nurse should discourage the client from watching television or performing any work in bed because this disrupts sleep quality; instead, the nurse should recommend light reading or listening to relaxing music to assist the client in falling asleep ... The nurse should discourage the use of alcohol or caffeine products prior to bedtime because these are stimulants and diuretics and inhibit sleep; instead, the client can have a light carbohydrate or a glass of milk as a bedtime snack ... The nurse should recommend the client participate in physical activity during the daytime as this can enhance sleep; however, the client should not participate in physical activity within 3 hr prior to bedtime because this can impair sleep.
A nurse at a long-term care facility is teaching an older adult client about ambulating with a quad-cane. Which of the following statements should the nurse include in the teaching? a. "Adjust the height of the cane so that you can flex your elbow at 45 degrees." b. "Hold the cane in the hand on the stronger side of your body." c. "Place the flat side of the cane away from your foot." d. "Move the cane and your stronger leg at the same time."
"Hold the cane in the hand on the stronger side of your body." *RATIONALE* The client should hold the cane with the hand on the stronger side of her body so that she can move the cane to support the weaker leg. This action allows for a more normal gait, with the ipsilateral arm and weaker leg moving at the same time. *FYI* The nurse should instruct the client that the cane's height should allow the elbow to be slightly flexed; having a flexion of 45º would make the cane too tall for safe use ... The client should place the flat edge of the base of the cane facing toward her foot; this allows the client to ambulate without the risk of getting her foot caught in the base of the cane and falling.
A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) and has been losing weight about ways to improve his nutritional intake. Which of the following statements by the client indicates an understanding of the teaching? a. "I will choose hot foods to decrease the sense of fullness when eating." b. "I should add grated cheese to sauces and vegetables." c. "I will eat my largest meal of the day in the evening." d. "I should consume a diet high in carbohydrates."
"I should add grated cheese to sauces and vegetables." *RATIONALE* The nurse should reinforce that adding cheese to side dishes will increase the protein and calcium intake as well as increase calories. This will assist the client in regaining weight and stamina. *FYI* The nurse should emphasize to the client that consuming cold foods will decrease his sense of satiety, allowing him to consume more calories ... The nurse should recommend that the client consumes his largest meal early in the day, when energy is highest- this will allow him to consume more calories without causing fatigue ... The nurse should emphasize that the client who has COPD should consume a high-protein diet; the client should limit carbohydrates because these break down into carbon dioxide and increase food-related dyspnea.
A nurse is providing teaching to a client who is to start taking finasteride. Which of the following statements by the client indicates an understanding of the teaching? a. "I will see improvement in my symptoms within one week." b. "I can expect an increased libido with this medication." c. "I should see a decrease in my PSA levels." d. "I must take this medication within 60 min of sexual activity."
"I should see a decrease in my PSA levels." *RATIONALE* The nurse should emphasize that the decrease in prostate specific antigen (PSA) levels with this medication will be measured 6 months after starting treatment. The expected decline is 30% to 50% in the PSA level. *FYI*The nurse should reinforce that this medication might take up to 6 months before the client responds ... The nurse should inform the client that one of the adverse effects of this medication is a decrease in libido; other side effects include orthostatic hypotension, gynecomastia, and decreased ejaculate volume ... The nurse should emphasize that this medication decreases mechanical obstruction of the prostate, and it has no effect on sexual activity
A nurse is teaching an older adult client who is healthy and has chronic constipation about establishing a bowel retraining program. Which of the following statements should the nurse include in the teaching? a. "Limit physical activity during the day." b. "Set a time limit of 10 minutes when attempting to defecate." c. "Increase the fiber content of your diet." d. "Increase your fluid intake to 5,000 milliliters per day."
"Increase the fiber content of your diet." *RATIONALE* The purpose of a bowel training program is to manipulate factors within the client's control to produce the elimination of a soft-formed stool at regular intervals. The increase of fiber in the client's diet will help to increase the effectiveness of a bowel training program. *FYI* The client can walk, perform modified sit-ups, and perform pelvic tilt exercises to stimulate peristalsis ... The nurse should encourage the client to attempt defecation for a period of 15 to 20 min ... The client should increase his fluid intake to 2,500 to 3,000 mL per day; increasing fluid intake to 5,000 mL is unreasonable.
A nurse is admitting an older adult client who has urinary incontinence and smells strongly of urine. The client's partner, who has been caring for her at home, states that he is sorry and embarrassed about the unpleasant smell. Which of the following responses should the nurse make? a. "A lot of clients who are cared for at home have the same problem." b. "Don't worry about it. She will get a bath, and that will take care of the odor." c. "It must be difficult to care for someone who has incontinence." d. "When was the last time that she had a bath?"
"It must be difficult to care for someone who has incontinence." *RATIONALE* The nurse should use therapeutic responses such as acknowledgement and empathy when addressing the client's partner. This response is nonjudgmental and acknowledges the effort the client's partner has made. The use of therapeutic communication also encourages further discussion and provides the nurse with an opportunity to teach and to evaluate the need for assistance in the home.
A nurse is teaching a group of older adult clients about dietary needs. Which of the following dietary recommendations should the nurse include in the teaching? a. "You should consume 1,200 milligrams of calcium daily." b. "Consume 4 percent of your diet as fat." c. "You should drink 1,500 milliliters of fluid daily." d. "Consume 40 percent of your diet as protein."
"You should consume 1,200 milligrams of calcium daily." *RATIONALE* The nurse should encourage the older adult client to increase dietary calcium intake to 1,200 mg daily in divided doses. Good sources of dietary calcium include dairy products, green leafy vegetables, beans, and tofu. *FYI* The nurse should encourage the older adult client to limit fat intake to 20% to 30% of his total daily intake; increased fat consumption leads to cardiovascular disease and inflammation ... The nurse should recommend a fluid intake of 3.7 L for male clients and 2.7 L for female clients; insufficient intake of fluids leads to constipation and dehydration ... The nurse should emphasize that protein requirements for the older adult client ranges from 10% to 35% of total daily intake; less than the recommended amount of protein leads to protein calorie malnutrition and an excess amount causes ketosis and can be harmful to kidney function.
A nurse in an assisted living facility is assessing an older adult client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits to feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief? a. Anticipatory grief b. Delayed grief c. Acute grief d. Disenfranchised grief
Acute grief *RATIONALE* The client experiencing acute grief will have both somatic and psychological manifestations of distress, such as the inability to sleep well or profound sadness. The nurse should identify that this client is experiencing acute grief and further assess his support system, concurrent stressors in his life, and his ability to manage stress. *FYI* Anticipatory grief is an expected response occurring prior to an actual loss; clients experiencing anticipatory grief might be preoccupied with the impending loss, make extensive funeral arrangements, or exhibit a change in attitude toward the lost thing or individual ... The client experiencing delayed grief is unable to accept the reality of a loss; the client remains in the denial stage of grief and is unable to allow himself to experience feelings of sorrow and loss ... The client experiencing disenfranchised grief cannot openly acknowledge the loss because of societal or religious norms.
A public health nurse is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine? a. Once during the client's lifetime b. Every 10 years c. Every 5 years d. Annually in the fall
Annually in the fall *RATIONALE* The nurse should recommend that older adult clients receive the influenza vaccine annually. Influenza outbreaks occur annually, and the influenza virus changes constantly. Consequently, an influenza vaccine from a previous year will not protect a client exposed to this year's influenza strain. Influenza in older adults can result in the development of primary viral influenza pneumonia, which causes several deaths a year. An influenza vaccine given in the fall, prior to the onset of flu season, will be most effective in preventing influenza in this target population.
A nurse is assessing an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. Which of the following factors should the nurse identify as a factor in the client's sleep pattern? a. Older adults require much less sleep than young adults. b. Older adults seldom awake at night once they have fallen asleep. c. Older adults have an increase in stages III and IV of sleep. d. Anxiety can cause disturbed sleep patterns.
Anxiety can cause disturbed sleep patterns. *RATIONALE* The sleep patterns of older adults are different from those of young adults. However, anxiety and emotional stress can result in sleep disturbances in people of all ages. The nurse should further assess the client's sleep problems and anxiety. *FYI* Older adult clients experience more awakenings during the night along with shorter time periods spent in stages III and IV, which is where deep sleep occurs.
A nurse is completing medication reconciliation for an older adult client who is receiving multiple medications. Which of the following actions should the nurse take first? a. Clarify the client's list of medications with the pharmacist. b. Compare the current list against the new medication prescriptions. c. Investigate any discrepancies on the list. d. Ask the client about over-the-counter medications she is taking.
Ask the client about over-the-counter medications she is taking. *RATIONALE* The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. When performing medication reconciliation, it is important that the nurse collect a list of all the medications the client takes in order to compare the full list of medications against any new medications the client will take. The list should include prescriptions, over-the-counter medications, and herbal and nutritional supplements.
A nurse at a long-term care facility is planning care for a client who has Alzheimer's disease and wanders at night. Which of the following interventions should the nurse include in the plan? a. Place the client in wrist restraints at night. b. Request a prescription for a psychotropic medication. c. Assign the client to a room closer to the nurse's station. d. Keep the television on at night.
Assign the client to a room closer to the nurse's station. *RATIONALE* The nurse should place the client who wanders in a room that allows for close observation. The nurse should provide clients who wander a safe place to walk and supervision when the client is ambulating. *FYI* The nurse should avoid the use of excessive light and sound stimulation for the client who has Alzheimer's disease; this can cause further agitation and confusion for the client.
A nurse is caring for an older adult client who has a terminal illness. The client tells the nurse, "I just want to live one more month so I can see my grandchild get married." Which of the following Kübler-Ross stages of grief should the nurse identify the client is experiencing? a. Depression b. Acceptance c. Denial d. Bargaining
Bargaining *RATIONALE* Bargaining is the third stage of grief, according to Kübler-Ross. Bargaining represents a last effort at overcoming death by earning longer life. Trying to put off death for one last major celebration in the client's life, like the marriage of a grandchild, is a form of bargaining. *FYI* Denial of death is the first stage of grief; clients in denial are unable to admit to themselves that they might die ... Anger is the second stage of grief; clients experience a range of emotion from irritation to frustration to anxiety ... Depression is the fourth stage of grief; in the depression stage, the client deals with the full impact of imminent death and grieves for losses both in the past and in the future ... Acceptance is the fifth and last stage of grief; in the acceptance stage, the client comes to grips with eventual death and makes preparations for it.
A nurse is teaching a group of healthy, older adult clients about expected age-related changes and sexual response. Which of the following changes should the nurse include as an age-related change? a. Decreased refractory time b. Decreased vaginal lubrication c. Loss of female clients' orgasm ability d. Premature ejaculation
Decreased vaginal lubrication *RATIONALE* The nurse should inform the clients that a decrease in vaginal secretions is an expected age-related change in older adult female clients. Vaginal dryness might result in painful intercourse, which clients can manage with the use of water-soluble lubricants during intercourse. *FYI* The nurse should inform the clients that: Achievement of an erection is often delayed in older adult male clients due to a slower sexual response, lengthening the refractory time ... some of the physiological changes resulting from female orgasm, such as the vaginal contractions, might decrease in intensity; the ability to have an orgasm, however, is not lost ... an expected age-related change in older adult male clients is a delay in ejaculation along with a decrease in the forcefulness of emissions.
A community health nurse is assessing an older adult client who lives alone. The nurse finds that, although the client is able to answer all questions appropriately, the client has a decreased attention span, expresses feelings of overwhelming sadness, and has a low energy level. The nurse should identify that the client is exhibiting manifestations of which of the following disorders? a. Delusions b. Dementia c. Delirium d. Depression
Depression *RATIONALE* The client who has an inability to sleep or complete ADLs is exhibiting manifestations of depression. Depression involves a cluster of manifestations that include changes in sleep habits, appetite, and relationships with others. Clients who have depression might have a decreased ability to make decisions or concentrate and, in some cases, complete ADLs. Anhedonia, the inability to feel happy, is another manifestation of depression. *FYI* A client who has false personal beliefs despite evidence to the contrary is exhibiting manifestations of delusions ... A client who has severe memory loss and an inability to solve problems is exhibiting manifestations of dementia ... A client who has a sudden onset of confusion, disorientation, altered level of consciousness, and an inability to focus is exhibiting manifestations of delirium.
A nurse is assessing an 85-year-old client. Which of the following findings should the nurse report to the provider? a. A widened anterior-posterior chest diameter b. Presence of an S4 heart sound c. Differences in pulse strength between lower extremities d. Post-void residual of 75 mL
Differences in pulse strength between lower extremities *RATIONALE* A difference in pulse strength can indicate a vascular complication. Assessment of the peripheral vascular system should also include temperature, color, sensation, edema, and skin integrity of both the upper and lower extremities. The nurse should identify any differences in symmetry of these findings and report them. *FYI* A widened anterior-posterior chest diameter is an expected finding for an older adult client; this occurs as a result of a loss in skeletal muscle strength in the thorax and the diaphragm and age-related hyperinflation of the lungs ... The presence of an S4 heart sound is an expected finding in an older adult ... The older adult has decreased bladder muscle tone and contractibility leading to post-void residuals. A post-void residual of 75 mL is within the expected reference range of 50 to 100 mL of urine.
A nurse is performing an assessment on an older adult client who has chronic pain. Which of the following effects of unrelieved pain should the nurse identify as a priority finding to report? a. Impaired mobility b. Decreased independence c. Decreased self-esteem d. Impaired socialization
Impaired mobility *RATIONALE* The nurse should apply the safety and risk reduction priority-setting framework. This framework assigns priority to the factor or situation positing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which risk poses the greatest threat to the client. The nurse should identify that limited mobility will have an effect on the client's skin integrity, respiratory function, and elimination. Complications of the immobility resulting from unrelieved pain include pressure ulcers, pneumonia, and constipation.
A community health nurse is visiting the home of an older adult client and her caregiver. The client has excoriations to her wrists and ankles. Which of the following actions should the nurse take first? a. Refer the caregiver to a support group. b. Interview the client in private. c. Document the client's wounds. d. Contact adult protective services.
Interview the client in private. *RATIONALE* The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds upon the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify the provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. The nurse should interview the client in private to gain information about possible abuse because the client might be reluctant to talk with the caregiver present.
A nurse is caring for an older adult client who is having a stroke. After assessing airway, breathing, and circulation, which of the following assessments is the nurse's priority? a. Level of consciousness b. Muscle tone c. Sensory changes d. Gag reflex
Level of consciousness *RATIONALE* The nurse should apply the urgent versus nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority need because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. The nurse should assess the client's level of consciousness to evaluate for increases in intracranial pressure that might have occurred. The nurse should use the NIH stroke scale or the Glasgow coma scale to evaluate level of consciousness.
A nurse is caring for a client who is using a continuous passive motion (CPM) device following a right total knee replacement. Which of the following actions should the nurse take when applying the CPM device? a. Apply the CPM device in the flexed position. b. Line up the frame joints of the CPM device with the client's knee. c. Check the range-of-motion settings on the CPM device daily. d. Place the head of the client's bed at 45º during CPM use.
Line up the frame joints of the CPM device with the client's knee. *RATIONALE* To avoid damage to the operative knee, the nurse should line up the joints of the CPM machine with the client's operative knee. *FYI* e nurse should apply the CPM device while it is in the extended position for client comfort and to ensure proper placement ... The nurse should assess the settings on the CPM device every 8 hr to ensure the appropriate flexion and extension cycle is occurring ... The nurse should initially place the client in a supine position when applying the CPM device. Following placement, the nurse should place the head of the bed at 20º if the client is able to tolerate this angle.
A nurse is performing skin assessments for a group of older adult clients. Which of the following findings should the nurse identify as a benign age-related skin change commonly seen in older clients? a. Liver spots b. Nevi c. Atopic dermatitis d. Psoriasis
Liver spots *RATIONALE* Liver spots, also known as age spots or lentigines, are flat, brownish-black macules that usually occur in sun-exposed areas of the body. Aging and exposure to sunlight, or other forms of ultraviolet light, can result in increased pigmentation. Liver spots are extremely common after 40 years of age; they occur most often on the forearms, shoulders, face, forehead, and backs of the hands, which are also the areas of highest sun exposure. They are harmless and painless, but they can affect the client's cosmetic appearance. *FYI* Nevi are moles, a growth of pigment-forming cells that might be benign or malignant; the nurse should identify that nevi occur throughout the lifespan; further evaluation of the nevi should include evaluation of any asymmetry, border irregularity, color variation, diameter, and evolution, which can indicate melanoma ... Atopic dermatitis, or eczema, is a chronic skin disorder that occurs in all ages, but is more common in infancy and childhood; clients who have atopic dermatitis can have scaly and itching rashes ... Psoriasis is a common skin inflammation with frequent episodes of redness, itching, and thick, dry, silvery scales on the skin; the nurse should identify that while generally a benign condition, psoriasis is a chronic, recurring condition in clients of all ages, most commonly in clients from 15 to 35 years of age.
A nurse is transferring an older adult client who has right-sided weakness from the bed to a wheelchair. Which of the following actions should the nurse take to provide a safe transfer? a. Keep the client at arm's length while performing the transfer. b. Bend at the waist to get down to the client's level. c. Maintain a straight back and bend at the knees. d. Place the wheelchair at the head of the bed on the client's right side.
Maintain a straight back and bend at the knees. *RATIONALE* The nurse should maintain a straight back and bend at the hips and knees when transferring a client in order to allow the larger muscles of the thighs to do the lifting. Good body mechanics are essential in preventing injury to the nurse. *FYI* The nurse should hold the client close to the body when lifting to maintain the center of gravity close to the base of support ... The nurse should place the wheelchair on the side of the bed that allows the client to move toward his stronger side; in this case, placing the wheelchair on the right side of the head of the bed will have the client moving toward his weaker side.
A nurse is reviewing the records of a group of older adult clients. Which of the following findings should the nurse identify as an unexpected manifestation of the aging process? a. Decreased absorption of nutrients b. Impaired excretion of medications c. High-pitched frequency hearing loss d. Obesity
Obesity *RATIONALE* The nurse should recognize that, although obesity is found among a large percentage of the older adult population, this is an unexpected finding and can lead to cardiovascular disease, diabetes, and stroke. *FYI* With aging, the villi in the intestine flatten and are less able to absorb nutrients such as vitamins B and D, calcium, iron, and fat ... Kidneys have a decreased ability to filter metabolites ... Impaired hearing of high-frequency sounds makes it difficult for older adult clients to discriminate voices from background noise in a room.
A nurse working in a community health center is completing an assessment of an older adult female client. Which of the following findings should the nurse identify as a priority? a. Rales heard in the bases of the lungs b. Constipation c. Urinary frequency d. Painful intercourse
Rales heard in the bases of the lungs *RATIONALE* The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore, the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilator effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable to efficiently carrying oxygen to them. Air moving into collapsed airways results in rales and can occur in clients who have bronchitis, pneumonia, or chronic pulmonary disease. This finding is the priority and requires further assessment. *FYI* Although bowel motility slows somewhat with aging, it does not normally result in constipation; more likely, this is the result of medications, life habits, immobility or inadequate fluid intake ... Bladder capacity decreases, and weakened contractions during emptying of the bladder can result in post-void residual amounts and increased risk of infection ... A report of painful intercourse is common in older adult clients due to vaginal narrowing, loss of elasticity, and decreased secretions.
A nurse is caring for an older adult client who has moderate hearing loss. Which of the following actions should the nurse take to enhance the communication? a. Speak with exaggerated lip movement. b. Speak at a moderate rate. c. Speak in a louder voice. d. Speak using a higher pitch.
Speak at a moderate rate. *RATIONALE* The nurse should slow the rate of speech for an older adult client who has hearing loss. However, the nurse should not speak with an exaggerated slowness because this can distort words and make it difficult for the client to understand. *FYI* The nurse should use a medium or lower pitch when speaking with an older adult client; higher pitches are more difficult to understand for the individual who has hearing loss.
A nurse is caring for an older adult client who is on bed rest. Which of the following foods should the nurse plan to include on the client's breakfast tray to prevent constipation? a. A banana b. Hash brown potatoes c. An egg and cheese omelet d. Stewed prunes
Stewed prunes *RATIONALE* The nurse should include foods that are high in dietary fiber, such as stewed prunes, to help prevent constipation for the client who is on bed rest.
A nurse is teaching an older adult client who had a total hip arthroplasty about ambulating with a standard walker. Which of the following actions by the client indicates an understanding of the teaching? a. The client adjusts the height of the walker so the hand grips are at the level of his waist. b. The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker. c. The client uses the walker to pull himself up from a sitting to a standing position. d. The client uses the walker to climb the stairs.
The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker. *RATIONALE* The correct technique for using a walker is to balance on both feet; lift the walker and place it in front; walk into the walker, using it for support when standing on the affected limb; and then balance on both feet before repeating the sequence. This provides maximum support for the client. *FYI* The nurse should instruct the client that placing the walker at this height will increase the strain on his upper extremities; the client should have a slight bend in the elbow when his hands are on the walker grips ... The nurse should emphasize the safe manner in which to go from a sitting to a standing position is to push up from the chair, gain balance, and then move the hands to the walker one at a time. Pulling oneself up by using the walker causes instability and can result in a client fall ... The nurse should instruct the client that the use of the walker on stairs is unsafe and might result in a fall; when climbing or descending stairs, the client should hold onto the hand rails and use the walker only on flat surfaces.
A nurse is assessing an older adult client who has right-sided heart failure. Which of the following findings is the nurse's priority? a. Oxygen saturation is 92% on room air. b. The client consumes 20% of meals. c. Weight has increased 0.91 kg (2 lb) in 24 hr. d. The client has 1+ edema in the lower extremities.
Weight has increased 0.91 kg (2 lb) in 24 hr. *RATIONALE* The nurse should apply the urgent versus nonurgent priority-setting framework. Using this framework, the nurse should consider urgent needs to be the priority need because they pose more of a threat to the client. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority-setting framework, or nursing knowledge to identify which finding is the most urgent. The nurse should evaluate daily weight of client's experiencing heart failure. A weight gain of 0.45 to 0.91 kg (1 to 2 lb) overnight or 1.36 kg (3 lb) within one week is an indication of worsening heart failure. *FYI* The nurse should monitor the oxygen saturation of the client because a decrease in oxygen saturation below 90% indicates a worsening of condition and, potentially, pulmonary edema ... The nurse should evaluate the client's food intake and appetite; anorexia and nausea are common manifestations of right-sided heart failure and place the client at risk for nutritional deficiencies ... The nurse should report pitting edema because this is an indication of fluid retention ... HOWEVER, another finding is the priority!