med surg ch 14&15

The nurse is caring for a patient with a chronic illness and whose spouse is the caregiver. What should the nurse do to assist the caregiver with coping? (select all that apply)

A#Empower the caregiver B#Share community resources D#Encourage a realistic, hopeful attitude E#Assist the caregiver in identifying a support network

An older patient with diabetes mellitus reports difficulty sleeping. Which manifestation should the nurse recognize as being related to sleep deprivation? (select all that apply)

A#Fatigue C#Irritability

The nurse is assisting in the preparation of a teaching session for older patients on respiratory health. What information should the nurse suggest be included in the is program? (select all that apply)

A#Instruct regarding the importance of frequent position changes to stimulate lung lobes B#Recommend deep breathing and coughing as part of a daily exercise program C#Encourage receiving pneumonia vaccination and annual influenza vaccination E#Remind that life-long habits and exposure to respiratory irritants may influence breathing

The nurse is contributing to the plan of care for an older adult. What should the nurse recognize as being age related changes in the cardiovascular system? (select all that apply)

A#Less efficient leg veins C#Decreased cardiac output E#An increase in irregular heartbeats

The nurse is working with a patient and family to achieve wellness goals. What actions should the nurse take when creating this plan? (select all that apply)

A#Mobilizing resources B#Recognizing potential crises C#Providing an adaptable environment E#Teaching the patient and family about the health problem

The nurse is contributing to a staff education program about the physical changes of aging. What should the nurse include as a common change in the skeletal system of an older adult? (select all that apply)

A#Osteoporosis B#Eroded cartilage E#Shortening in height

The nurse is contributing to a staff education program about chronic illness. What should the nurse include as reasons for the increasing incidence of chronic illness? (select all that apply)

A#People are living longer C#More people have an active lifestyle D#Fewer people are dying from acute illness F#Medical advances reduced mortality from chronic illnesses

The nurse is identifying ways to ensure environmental safety for an older patient. Which actions should the nurse recommend for this patients plan of care? (select all that apply)

A#Place call light within reach C#Ask for permission before moving items D#Return Items to patient preferred location

A patient with a chronic illness is receiving care at home by a caregiver. What should the nurse discuss with the patient and caregiver about respite care? (select all that apply)

A#Prevent patient neglect C#Allow the caregiver to go shopping D#Allow the caregiver to reduce stress E#Provide the caregiver with a vacation

The nurse is contributing to the plan of care for an older adult. What should the nurse recognize as being are related changes to the integumentary system?

A#Thinning of the scalp hair C#Decreased sweat production D#Increased dryness of the skin F#Increased growth of nose, ear, and facial hair

The nurse is contributing to a staff education program to prevent falls in the older population. What should the nurse include as areas to assess for fall prevention?

A#Use of alcohol B#History of falls C#Medication side effects E#Gait and balance screening

During a home visit the nurse suspects that an older patient from an acute illness is not taking medications as prescribed. What should the nurse asses to determine the patients adherence to prescribed medications? (select all that apply)

A#Use of over the counter or herbal remedies D#Frequency with which medication doses are being skipped E#Frequency with which medications are being taken as prescribed.

The nurse has been providing interventions to address an older patients nutritional status. Which observation should the nurse use to determine if nursing care has been effective?

Body weight

The nurse is caring for a patient who is prone to developing constipation. Which action should the nurse take to help this patient?

Help the patient develop an exercise routine

The nurse is contributing to a staff education program on grooming techniques for older adults. Which methods should the nurse recommend to reduce the potential for nail infections? (select all that apply)

C#File nails with emery board D#Use residents own grooming equipment

The nurse is contributing to the care plan of an immobile patient. What should the nurse recognize as increasing the patients risk of developing a pressure ulcer on the heels? (select all that apply)

C#Lying on we linens D#Impaired circulation

During a visit to the wellness clinic, an older patient with arthritis asks what can be done to improve joint motion. What should the nurse suggest to this patient? (select all that apply)

C#Perform range of motion exercises in warm water E#Take prescribed anti-inflammatory medications before exercising

The nurse is collecting data for a patient who has a developing pressure ulcer. What should the nurse expect to assess as early manifestations of a pressure ulcer? (Select all that apply)

C#Report of redness at the site D#Report of burning at the site E#Tenderness at site when touched

During a health history, the nurse learns that a young adult smokes cigarettes, drinks alcohol, and does not exercise routinely. What should this information suggest to the nurse? (select all that apply)

C#The patient has poor coping mechanisms for stress D#The patient is participating in risky lifestyle choices

The nurse has finished drawing blood from an older patient. How long should the nurse apply pressure to the puncture site?

2 minutes

The nurse is reinforcing teaching provided to an older patient on how to safely rise from a seated to a standing position. Which age-related change does the nurse use to emphasize the need to change positions gradually for safety?

Decreased circulatory efficiency

The nurse is collecting data for an older patient. Which characteristic should the nurse identify in a patient with an age-related loss of water n the vertebral discs?

Decreased height

The nurse is contributing to a patients plan of care for comfort needs. What age-related change would explain why an 84yr old patient is chronically cold even with the thermostat set at 80F (26.6C)?

Decreased subcutaneous fat layer

The nurse is evaluating the skin of an older patient who has been lying in bed for most of the day. How long would it take a pressure ulcer to begin to form in this patient?

20 mins

The nurse is caring for a patient who has a chronic illness. What should the nurse encourage the patient to use as a coping resource?

Develop a power base

The nurse is contributing to the plan of care for a patient. What should the nurse do to promote health in this patient?

Teach healthful lifestyle practices

The nurse is planning care for an older male patient who is recovering from a failed suicide attempt. What nursing diagnosis should the nurse use to guide this patients care?

Hopelessness

The nurse is caring for a 21yr old patient with a disfiguring injury. Which statement should the nurse expect related to the patients developmental stage?

Im afraid my fiancé wont want me anymore

The nurse has reinforced teaching about age-related mouth changes. Which client statement indicates a correct understanding of the cause of tooth loss in an older adult?

Poor dental care

The nurse is contributing to a staff education program about chronic illness. Which illnesses should the nurse explain as being acquired (not congenital or genetic) chronic illnesses? (select all that apply)

A#Cancer B#Cataracts C#Multiple sclerosis F#Chronic obstructive pulmonary disease

The nurse is concerned that an older patient is demonstrating signs of depression. What id the nurse observe to come to this conclusion? (select all that apply)

A#Difficulty sleeping B#Change in behavior D#Increase in physical complaints

The nurse is reviewing the ages of assigned patients in a skilled nursing facility. Which patient represents the fastest growing segment of individuals in the United States?

87

The nurse is caring for a patient with Alzheimers disease. Which environment should the nurse provide to decrease the patients symptoms?

A familiar, non-stimulating environment

An older patient has accomplished expected developmental tasks. What term should the nurse use to describe this patients accomplishments?

Accepting

The nurse determines that a patient has satisfactorily fulfilled the developmental task of integrity. which phrase should the nurse use to describe this patient?

Accepts life lived

The nurse is caring for a patient with a chronic illness. What would be a priority outcome for this patient?

Achieving optimal personal level of health

The nurse is caring for a patient who had a stroke that caused permanent physical changes. Which developmental task should the nurse recognize that the patient needs to accomplish for a positive outcome?

Adapting to the changes

A middle-aged person expresses fear of aging. Which intervention should the nurse use to help this patient?

Allow the patient to express fears

The nurse is caring for a patient who has a chronic illness and is depressed over being a burden to others. Which nursing action would increase the self-esteem of this patient?

Allowing the patient self-care opportunities

The nurse is making a home health visit to a frail but basically healthy 86yr old patient. The nurse assesses a heart rate of 104beats/min. what action should the nurse take?

Ask about liquids the patient is drinking and urination frequency

The nurse is contributing to a staff education program about chronic illness. What should the nurse include as being congenital diseases? (select all that apply)

B# Spina Bifida F#Malabsorption syndrome

A middle-aged patient is upset that her oldest daughter is moving out of state and her patents are getting older and need more assistance. What terms should the nurse use to describe the situations in which the patients is experiencing? (select all that apply"

B#Empty nest E#Sandwich generation

The nurse is contributing to a staff education program about health concerns. Which common health concerns of middle-aged adults should the nurse include? (select all that apply)

B#Hypertension D#Visual changes F#Cardiovascular disease

The nurse is reinforcing teaching to assist the patient adapt to a chronic illness. What should the nurse include in the teaching? (select all that apply)

B#Plan ways to compensate for your limitations D#Understand you medical regimen and follow it carefully E#Revise your daily schedule as needed to adjust to your illness

The nurse is assisting in the care of the patient with small cell lung cancer who regrets a long-term history of smoking and verbalizes a desire to stop smoking. Which intervention should the nurse recommend be included in the patients plan of care? (select all that apply)

B#Provide info related to smoking cessation C#Encourage the patient to establish short-term goals D#Discuss the patients previous efforts to stop smoking E#Discuss the benefits of smoking cessation with the patient and family.

The nurse suspects that a patient is experiencing despair. Which characteristics did the nurse recognize in this patient? (select all that apply)

B#Stating a fear of death D#Avoiding social activities

The nurse is contributing to a staff education program about health and illness. How should the nurse characterize the relationship of health and illness?

Changing states

A 70yr old patient asks what can be done to protect his hearing. What should the nurse recommend to the patient?

Cover the ears if loud noises are expected

The nurse identifies a patient who had satisfactorily fulfilled the developmental task for middle age. What term should the nurse use to describe this patients accomplishments?

Creative

The nurse is caring for a patient who has been working on issues related to the developmental stages of young adulthood. Which behaviors indicate tot he nurse that the patient has resolved developmental task issues? (select all that apply)

D#Has large network of family and friends at bedside E#Expresses concern illness will cause strain on spouse and children

The nurse is contributing to a community health-promotion educational event for middle-aged adults. What information should the nurse include in this presentation?

Heart Disease

The nurse is contributing to a staff education program about Eriksons developmental stages. Which should the nurse present as the developmental stage for a middle-aged adult?

Generativity versus self-absorption

The nurse is collecting patient data. Which findings should the nurse expect because of a decrease in melanin?

Graying of hair

While obtaining a personal history form a 72yr old patient being admitted to a long-term care facility the nurse notices that the patient seems depressed. Which intervention should the nurse recommend be included in the patients plan of care?

Guide the patient in reminiscing about the past with a focus on the positives

The nurse is concerned about medication safety for a patient with confusion. Which action should the nurse recommend be included in the patients plan of care to address this issue?

Have the family member set up and administer the medications.

The nurse is contributing to a staff education program about Erikson's developmental stages. Which should the nurse present as the developmental stage for an older adult?

Integrity versus dispair

The nurse is reinforcing teaching with an older patient. When interacting with the patient the nurse should recognize which effect of aging on short and long term memory?

Long-term memory is retrieved more easily than short term memory

The nurse is participating in the creation of a teaching seminar about healthy behaviors for the young adult. What topics should the nurse suggest be included in this seminar? (select all that apply)

Performing self-examinations

The nurse is making recommendations to the plan of care for a patient who has limited mobility. On which skin condition should the nurse focus as the greatest risk for this patient?

Pressure ulcer

The home health nurse is visiting an older patient who fears becoming incontinent and reports restricting personal fluid intake to prevent urinary leakage. Which action should the nurse take?

Provide the patient with literature on oral fluids

The home health nurse is visiting an older adult who reports nocturia. Which night light bulb color should the nurse suggest to increase safety and enable the patient to see better at night?

Red

The nurse is monitoring a patients skin status. What should the nurse recognize as the first sign of prolonged pressure on the skin?

Redness

Which measure should the nurse recommend for inclusion in the plan of care for an older adult who has a nursing diagnosis of ineffective sexual patterns?

Schedule private time

A patient has not been able to fulfill the developmental task for middle age. Which term should the nurse use to describe this patient?

Self-focused

The nurse is identifying recommendations to help an older patient with sleeping needs. What should the nurse recognize as a sleeping pattern in the older adult?

Sleep needs remain unchanged

The nurse is making recommendations to an older patients plan of care for safety measures. Which musculoskeletal change should the nurse consider as contributing to a reduction in the older adults ability to safely perform routine tasks?

Slower muscle response time

While assisting with the admission of a new resident to the long term care facility, the nurse notes the patients feet are moist with dry skin on the heels. The toenails are long and brittle. Which action should the nurse take first?

Soak the feet in warm water

The nurse is providing care to a person who has difficulty hearing high-pitched tones. Which action should the nurse take when caring for this patient?

Speak softly, using a near-whisper tone

The nurse is administering medications to a group of older residents and monitors them for adverse reactions. In which way should the nurse recognize that a reduction in the liver enzyme production effects medication metabolism in the older patient?

The metabolism of substances decreased

The nurse is caring for a 52yr old patient who is self-absorbed. What should the nurse identify as the likely cause of this self-absorption?

Unresolved generativity