VNSG 1226: Unit 2 & 3 Prep U Questions

A nurse is providing care for an older adult population. Which statement demonstrates an understanding of effective medication therapy safety?

"Beer's criteria is a valuable tool for managing potential medication risks for older adults." Explanation: Beers criteria is a listing of drugs that carry high risks for older adults and criteria for potentially inappropriate medication use in older adults. Pharmacokinetics refers to the absorption, distribution, metabolism, and excretion of drugs and is effected by a variety of factors including age and gender. Pharmacodynamics relates to how the body is effected by the drug at the cellular level and in relation to the target organ.

What advice should a gerontological unit manager give to a new staff nurse regarding the legal aspects of practice?

"Familiarize yourself with individual state laws, because then may vary." Explanation:Many laws were developed at the state and local levels, and variation exists among the states. There are both public and private laws. Public law governs relationships between private parties and the government. Private law governs relationships between individuals and organizations. In addition to laws, there are voluntary standards by which a nurse can be judged.

The nurse is discussing a client's end-of-life care with the client's designated surrogate's role in decision making. Which question, asked by the nurse, serves to assess for a major breakdown in the decision making process?

"Have you discussed the client's end-of-life care wishes?" Explanation: Advance directives designate surrogate decision makers, but the surrogates do not always have a good understanding of the person's wishes, and this can be a barrier to appropriate implementation. The correct option attempts to assess whether the surrogate has a clear understanding of the client's end-of-life care wishes. The remaining options focus on the surrogate and not the issue of decision making.

An older client with a history of stroke and congestive heart failure demonstrates left-sided weakness, dysphasia and fatique. The caregiver shares that that the client often refuses to take medications as prescribed. Which assessment question should the nurse ask to best determine the possible cause of the non-adherence behaviors?

"Have you noticed the client having any difficult swallowing?" Explanation: The client's history of stroke with muscle weakness and dysphagia should lead the nurse to assess for dysphagia (difficulty swallowing). While the other options are appropriate assessment question, none address the cause of the behaviors as directly as assessing for a problem swallowing.

The nurse provides diet teaching to an older client with gout. Which client statement indicates that additional instruction is required?

"I can eat bacon with my eggs for breakfast." Explanation: The client should be instructed on a low-purine diet which includes not eating bacon, turkey, sardines, and salmon.

Which statement made by an older adult client indicates to the nurse that the client is no longer experiencing a anticholinergic adverse affect to the antacids he or she takes regularly?

"My bowel movements are much more regular now," Explanation: Specific adverse effects commonly associated with anticholinergic medications include falls, constipation, somnolence, urinary retention, dry mouth, and dry eyes. Indication of normal bowel function would indicate the absence of the anticholingeric effect on a prescribed medication. Antacids are often taken to deal with heartburn triggered by spicy foods. Neither skin rashes nor headaches are considered anticholinergic adverse reactions.

An older client asks why sleep is not as restful as it was when at a younger age. What should the nurse respond to this client?

"Rapid eye movement sleep reduces with aging and causes lest restful sleep." Explanation: For sleep to be most restful, the person experiences a series of sleep stages. Changes in the amount of time spent in each stage occur with aging. Reductions in non-rapid eye movement stage sleep and rapid eye movement (REM) stage sleep begin to occur after midlife. Older people sleep less soundly, shift in and out of stage I sleep to a greater degree than do younger adults, and spend more time in stages I and II sleep. They have a decline in the proportion of time spent in the deeper stages III and IV sleep.

An older female expresses that she want to avoid hormone replacement therapy (HRT) for her menopausal symptoms. What is the nurse's best response?

"Talk to your healthcare provider before you begin taking any herbal supplements." Explanation: Clients should consult with healthcare providers before taking any herbal supplements. Calcium is not known to help relieve menopausal symptoms. There are risks the client needs to be screened for before taking HRT, which is not risk-free. It is paternalistic to state that the client will likely change her mind.

A nurse in a postoperative unit educates peers to overcome myths about pain in older adults. Which statement by a peer most clearly warrants further teaching?

"We have to be more conservative in the treatment of the older adults' pain than the younger clients." Explanation: The statement that warrants more teaching is that older adults' pain should be treated more conservatively than younger clients. Studies have found no age-related difference in appropriate doses of postoperative morphine. Multimorbidities and chronic health problems are associated with pain. Recent studies focused on the development of persistent postoperative pain, finding that its incidence can be reduced with the use of aggressive and early analgesic therapy. It is true that older adults have no age-related change in the sensation of pain.

A 59-year-old female client is 5 feet 7 inches tall and weighs 186 lbs. If the nurse uses the Harris-Benedict equation (655 + [4.35 x weight in lbs.] + [4.7 x height in inches] - [4.7 x age in years]), how many calories should this client consume to meet basal metabolic needs? Round to the nearest whole number

1502 Explanation: If using the Harris-Benedict equation for females, the nurse should calculate the basal metabolic rate for this client as follows: 655 + [4.35 x weight in lbs.] + [4.7 x height in inches] - [4.7 x age in years]. For this client, the calculation would be: 655 + [4.35 x 186] + [4.7 x 67] - [4.7 x 59]; 655 + 809.1 + 314.9 - 277.3 = 1501.7 calories or 1502 calories when rounded.

An older client says food does not taste the same as it used to. What should the nurse consider this client is experiencing?

Tongue atrophy Explanation: Atrophy of the tongue affects the taste buds and decreases taste sensation. Presbyesophagus causes weaker esophageal contractions and weakness of the sphincter. Gingival recession causes teeth to become loose. Thinner oral mucosa affects the ability to chew food.

A client weights 176 lbs. How many grams of protein should the nurse instruct this client to ingest each day?

80 grams Explanation: At least 1 g protein per kilogram of body weight is necessary to renew body protein and protoplasm and to maintain enzyme systems. For this client, 176 lbs. equals 80 kg and therefore 80 grams of protein should be ingested each day. Forty grams is half the recommended amount. One hundred and 120 grams would be too much protein for the client to ingest each day.

A 99-year-old resident has fallen. Which functional consequence of this fall most strongly affects the plan of care?

A 99-year-old is at much higher risk of a fracture from a fall than a younger adult. Explanation: The functional consequence of the fall is risk for future falls, which may include a risk for fractures. Osteoporotic fractures occur with little or no trauma to the older adult, and risk of fractures increases in direct relation to age. While a 99-year-old may have slowed performance of ADLs and decreased muscle mass, the high risk for falls is the most important factor (also note these are not consequences of the fall). Fear of falling is a major concern that affects many residents of long-term care facilities.

An older client reports leg cramps when falling asleep. Which nursing diagnosis should the nurse identify to address this client's health problem?

Acute Pain Explanation: The diagnosis of Acute pain is appropriate for this client since the muscle cramps occur during resting states. Visual and hearing deficits contributes to the diagnosis of Anxiety and fear. Ineffective coping is not a nursing diagnosis appropriate for a client having difficulty sleeping. Alteration in sleep cycles and nocturia contributes to the diagnosis of Disruption in sleep pattern.

Following hip surgery, what is the best way for the nurse to encourage early ambulation in the older adult?

Administer pain medication before assisting the client out of bed. Explanation: If movement causes pain, the client may limit mobility. Administering pain medication before ambulation may help the client tolerate movement after surgery. Coughing and deep breathing may not be comfortable for the client after surgery and do not best encourage early ambulation. Administering a stool softener helps prevent constipation due to pain medications and decreased mobility. Assessing for pressure ulcers is important but does not encourage early ambulation.

A nurse admits an older adult client to the hospital with a diagnosis of failure to thrive. Which laboratory data should the nurse expect?

Albumin 2.8 mg/dL and red blood cells 4.1 cells/mcL Explanation: Anemia and low serum albumin levels are consistent with malnutrition. Elevated white blood cells, calcium, and magnesium and low platelets and prothrombin time are not characteristic of malnutrition.

A gerontological nurse is preparing information for an older adult sexual health awareness course. Which contributing factors to sexual dysfunction in older adults should the nurse address? (Select all that apply.)

Cardiovascular disease Diabetes mellitus Obesity Religious conflict Explanation:There are numerous causative or contributing factors to sexual dysfunction in older adults, including all of the answer options except antiplatelet aggregators; these are not among the medications known to contribute to sexual dysfunction in older adults.

A newly admitted client requests a bedside commode however Central Supply currently has none available. The nurse is aware of a bedside commode that was placed in the dirty utility room from a recently discharged client. What should the nurse do?

Ask Central Supply to disinfect the used bedside commode for the client Explanation: Although the nurse should act in the best interest of the client, the nurse needs to adhere to infection control and safety practices. The best action would be for the nurse to inform Central Supply of the dirty bedside commode in the utility room and ask if that commode can be cleaned and provided to the client. Taking the used bedside commode to the client's room violates infection control practices. Having nursing assistive personnel clean the commode is beyond the personnel's scope of practice and may violate infection control practices. Explaining to the client that no bedside commodes are available at this time does not take the client's needs into consideration. The nurse can do more than just saying that the client's request cannot be honored.

An older client agrees to an experimental medication to treat a disease because of a family member working for the pharmaceutical company. Which action is the best for the nurse to take at this time?

Ask if the client feels obligated to take the medication Explanation: Since a family member works for the pharmaceutical company that makes the experimental medication, the nurse needs to ensure that the client is not being coerced into any decision or feeling intimidated to state a refusal to give consent. Explaining the effects of the medication would beyond the scope of practice of the nurse. An experimental medication would have a series of consents and discussions that would be discussed by the health care provider. It would be beyond the nurse's scope of practice to suggest another route. The client has the right to make the decision. The nurse not agreeing with the client's decision not a reason to complete a neurologic assessment.

While completing a home health assessment, the nurse discovers that this older adult enjoys sitting alone on the porch while enjoying nature. What is nurse's best initial action?

Ask the older adult about the adjustment to being alone. Explanation: Before assuming the client feels alone and is sedentary most of the time, the nurse should assess the client's feelings and daily activities. The nurse should appreciate the client's choices in achieving wholeness of the body, mind, and spirit. For some individuals, this can mean exercising at the gym, attending church, doing crafts, or enjoying nature. Some individuals may enjoy sitting on the porch for a period of time just thinking and reflecting. An individual who lives alone is not necessarily lonely and it would be premature to recommend moving.

The nurse prepares teaching material on exercises that a client can do while in bed. Which exercises will the nurse include? Select all that apply.

Bicycling Raise the chest Roll from side to side Explanation: Exercises that can be done in bed include bicycling, raising the chest, and rolling from side to side. Exercises performed in a seated position include rotating the head and flexing and extending the neck.

An older adult states he takes his aspirin first thing in the morning, before breakfast, so he doesn't forget. What priority sign or symptom should the nurse assess for in this client?

Blood in the stool Explanation: Gastrointestinal (GI) bleeding is one of the most serious side effects of aspirin use. To prevent GI irritation, the nurse should suggest taking the aspirin after eating. Aspirin is not known to decrease kidney function or cause jaundice. Aspirin is commonly taken for joint pain.

Near the end of a shift, an older adult client received an overdose of potassium chloride intravenously due to a pump malfunction. The charge nurse had called central supply and asked that the pump be replaced immediately at the beginning of the shift, but the malfunctioned pump remained in the client's room. Who is ultimately responsible and can be held liable if the client is harmed?

Charge nurse Explanation: The charge nurse is ultimately responsible and can be held liable for not following up on a delegated task of removing and replacing the IV pump. Some liability may lie with the nurse who administered the potassium, but would not be limited to just this person. The charge nurse is more directly involved in the situation - and more likely to be liable - than the manufacturer or central supply because he or she failed to remove the pump.

A client reports drinking 4 to 6 cups of caffeinated coffee each day. Which prescribed medication should the nurse expect to be affected by this client's intake of caffeine?

Cimetidine Explanation:A high caffeine intake can decrease the effects of cimetidine. Caffeine intake is not identified as affecting aspirin, cinacalcet, or acetaminophen.

Which persons are the best candidates to serve on a hospital ethics committee? (Select all that apply.)

Clergy Attorneys Physicians Nurses Explanation:The client's family members may not be unbiased and able to provide objective input during a case review. Health care team members, clergy, and attorneys are usual ethics committee members.

An older client is found crying because of throbbing pain in both wrists. Which approach should the nurse use to help comfort this client?

Cold pack Explanation:Application of a cold pack may help reduce the inflammation in the wrist joints. Massage and range of motion may irritate the joints causing an increase in pain. It is unlikely that the nurse would be skilled in hypnosis.

An older adult is experiencing an age-related decrease in hydrochloric acid production. The nurse should assess for what potential consequences of this? Select all that apply.

Decrease in calcium absorption Decrease in vitamin B12 absorption Decrease in iron absorption Decrease in folic acid absorption Explanation:Decrease in hydrochloric acid production causes decreased calcium, vitamin B12, iron, and folic acid absorption. Reduced pepsin causes a decrease in protein absorption.

When educating a client about andropause, the nurse should address what topic?

Decreased energy due to lower testosterone levels Explanation: Some men, not all, experience hormonal changes with age. Andropause, or male menopause, occurs as a result of a decline in testosterone levels. Symptoms (but not causes) include reduced muscle mass, energy levels, strength, and stamina. Cortisol is not involved in the physiology of andropause.

An older client, who has been taking the same medication for months, reports developing diarrhea and a headache over the last several days. What should the nurse consider when assessing this client further?

Development of a new adverse side effect Explanation Be aware that an older client can develop adverse effects to drugs that have been taken for years without problems. The symptoms should be reviewed with the health care provider. The symptoms should be compared with any other symptoms of a new disease. The health care provider will be able to determine if the symptoms are those of a former illness or an exacerbation of a current illness.

After reviewing a client's list of medications the nurse asks if the client ever experiences a dry mouth. Which medication on the list caused the nurse to ask the client this question?

Diuretic Explanation:Many of the medications used by older persons, such as diuretics, can affect salivation and cause a dry mouth. Vasodilators, anticoagulants, and oral hypoglycemic agents are not identified as adversely affecting salivation.

An older female client is diagnosed with a cystocele. The nurse should assess for what sign or symptom?

Dribbling urine Explanation: A cystocele affects the bladder and results in discomfort and dribbling urine. The treatment for a cystocele is surgery. Itching is not a common complaint of this disorder. A subsequent urinary tract infection may result in an elevated temperature, but a cystocele itself is not an infectious process. Vaginal dryness usually results from hormonal changes.

An older client says that medications have not been taken because of not understanding when to take the dose and the amount. What limitation is this client demonstrating?

Educational Explanation: Persons with limited education may have difficulty reading and understanding instructions and labels. Limited funds could cause the older person to not fill prescriptions, skip dosages, or use an old prescription or someone else's similar medication. Older adults could have impairments that prevent them from remembering to take the medications, make them forget that they did take the medication and retake them, and cause them to confuse medications, dosage, or schedule. Impairments in the person's ability to perform activities of daily living or instrumental activities of daily living could create challenges in the ability to administer medications.

When caring for an older client who practices Hinduism, what is the nurse's best action in addressing the client's spiritual needs?

Encourage the expression of concerns Explanation: Encouraging the client to express any concerns is best in this case. The Koran is revered in the Islam faith, while the Torah is read in the Jewish faith. Hindus do not practice common worship, such as prayer. As well, prayer should be initiated by clients, not the nurse.

An older client with a weight loss of 7 kg the last month asks what can be done for constant hiccuping. Which health problem should the nurse suspect this client is experiencing?

Esophageal cancer Explanation: Manifestations of esophageal cancer include weight loss and hiccups. Weight loss and hiccups are not associated with stomatitis, hiatal hernia, or a stomach ulcer.

Which is an appropriate goal for an older female to indicate normal sexual function?

Expresses sexual satisfaction Explanation: The goal to achieving normal sexual function is the client's expression of sexual satisfaction. Sexual satisfaction can be subjective. Two orgasms per week, no vaginal dryness, and quicker erections my equate to sexual satisfaction for some, but not all persons.

The nurse suspects that an older client is experiencing a small bowel obstruction. What finding did the nurse use to make this clinical determination?

High-pitched bowel sounds Explanation:Bowel obstruction can cause high-pitched peristaltic rushes to be heard on auscultation. Flatus would not develop with a bowel obstruction. Epigastric burning is associated with a peptic ulcer. Aching pain in the left lower abdominal quadrant is associated with diverticulosis/diverticulitis and colorectal cancer.

An older client asks a nurse to explain the benefits of exercise. The nurse should include which of the following? Select all that apply.

Improved body tone Improved circulation Improved appetite Improved digestion Explanation: Improved body tone, circulation, appetite, and digestion are benefits of exercise in the older client. Improved hair growth is not a known benefit of exercise in the older client.

A nurse has administered metoprolol intravenously to a critically-ill older client with a blood pressure of 191/118. When should the nurse reassess the client's blood pressure?

In 5 minutes Explanation: Drugs given intravenously are absorbed and take action very quickly. Most oral medications take at least 30 minutes or longer to take effect. Waiting until the next vital sign could prove dangerous for the client if the medication is not effective and the blood pressure continues to rise.

The nurse reviews medications prescribed for a client with severe osteoarthritis pain. Which medication should the nurse question before administering to the client?

Indomethacin Explanation: It is recommended that indomethacin not be used for pain relief in older clients because of the high risk of adverse effects. Aspirin, ibuprofen and acetaminophen are not identified as contraindicated for pain control in the older client.

An older adult black woman minimizes pain in the joints and back as "normal aging." Which action by the nurse is most appropriate?

Offer warm packs for joints Explanation: Racial and ethnic minorities and women are at high risk for receiving inadequate pain relief. The nurse must discuss nonpharmacologic interventions as well as dispel myths regarding the functional consequences of aging and pain treatment. This client does not express concerns regarding addiction. Older adults commonly fear negative consequences of analgesics.

A client with heel pain is diagnosed with plantar fasciitis. What treatment should the nurse expect to be prescribed for this client?

Orthotics Explanation: For plantar fasciitis, the most effective means of relieving pain and preventing inflammation is to have the foot realigned through the use of custom-made orthotics. Splints, surgery, and antibiotics are not indicated in the treatment of plantar fasciitis.

The nurse is caring for a client who practices Eastern Orthodoxy. It is Friday during Lent. What is the nurse's most appropriate meal to offer the client?

Pinto beans and cornbread Explanation:Many Eastern Orthodoxy-practicing clients fast from meat and dairy products on Wednesdays and Fridays during Lent.

The nurse evaluates the environment of an assistive living facility. What should the nurse suggest to reduce the risk of resident falls when walking down two steps to gain access to the dining area?

Place a strip of red tape along each step Explanation: Older clients may have a change in depth perception and be unable to see the steps. The use of a contrasting color helps to identify the location of the steps. Rubber matting can be slippery. Bannisters should be on both sides of the steps. Carpeting will help reduce sliding when walking down the steps.

A nurse plans the diet for an older adult with congestive heart failure. Which of these nursing interventions would be most successful to encourage optimal nutrition?

Provide 55% from complex Carbohydrates Explanation: Dietary guidelines for older adults recommend a daily intake of five to nine servings of fruits and vegetables; 55% of calories need to come from complex carbohydrates. Older adults need fewer calories with increased quality of nutrients in their nutritional requirements. Older adults with presbyesophagus must sit upright for 30 minutes to 1 hour after eating. Flavor enhancers (except lemon) contain sodium and need to be used in small amounts for older adults who have a diminished sense of taste.

An older adult has been diagnosed with macular degeneration. What is the nurse's best intervention to enhance safety?

Provide a magnifier for reading directions Explanation: Macular degeneration makes vision more difficult, and more magnification is needed. Reduced olfaction (sense of smell) and hearing are not related to macular degeneration. Glare is more bothersome when the client suffers from cataracts.

A series of transient ischemic attacks have caused an older adult to become dysphagic. The client is opposed to eating minced and pureed foods and wishes to eat a regular diet. How should the care team respond to this request?

Provide the client's requested diet after ensuring the client understands the risks. Explanation:A common ethical dilemma is a desire by the client or the client's family to continue an activity at risk. In general, an individual has the autonomy to choose this unless the client is declared incompetent.

The nurse notes that an older client has difficulty swallowing a bolus of food when eating. Which suggestion should the nurse make to the health care provider based upon this observation?

Referral for a speech-language pathologist Explanation: For the client with a problem swallowing, a referral to a speech-language pathologist is essential to developing an effective plan of care. A fluid restriction would not enhance this client's ability to swallow. A liquid diet could lead to aspiration. A nasogastric tube for enteral feedings is an extreme intervention at this time.

An older male of Jewish faith enjoys seafood and is not wearing a skullcap. Which branch of Judaism does this client likely practice?

Reformed Explanation:The reform branch of Judaism involves less stringent adherence to laws; do not strictly follow Kosher diet; do not wear skullcaps; attend temples on Fridays for worship but do not follow restrictions during Sabbath; men can touch women. The three branches of Judaism are: Orthodox, Conservative, and Reform.

The nurse is teaching a peer about the concept of spirituality. What should the nurse teach this colleague?

Religion is an expression of spirituality. Explanation: Religion is a significant expression of spirituality, but highly spiritual individuals may not identify with a specific religion. Spirituality differs from religion, which consists of human-created structures.

The nurse sees the letters "DNR" posted on the wall at the head of the bed of a resident in a skilled nursing facility and notes that no other documentation about this designation is in the medical record. What should the nurse do first?

Remove the designation from the head of the bed Explanation: Nurses must ensure that do not resuscitate (DNR) orders are legally sound. DNR orders are medical orders and must be written and signed on the health care provider's order sheet to be valid. DNR placed on the care plan or a special symbol at the patient's bedside is not legal without the medical order. The first thing that the nurse should do is take the posting down. Asking the charge nurse about the posting can be done afterwards. Contacting the health care provider to write an order may or may not be appropriate. Doing nothing could lead to negligence or malpractice if the client requires resuscitation but did not receive it because of an incorrect posting.

Which nursing diagnosis is associated with the aging client and risk to maintaining an active state when diagnosed with low bone density?

Risk for injury Explanation: Risk for injury is associated with lower bone density. Activity intolerance related to muscle weakness and fatigue is associated with decrease in muscle mass, strength, and movement. Low bone density does not affect the individual's risk for infection or decreased perfusion.

What is the best nursing action when faced with an ethical decision?

Seek guidance from a clinical ethics consultant or the multidisciplinary care team Explanation: Clinical ethics consultants provide education, mediate moral conflict, facilitate moral reflection, and advocate for clients. It's recommended that the nurse should talk with others and seek guidance and support such as those on the client's multidisciplinary care team. Several cases should be reviewed and various resources should be consulted when facing ethical dilemmas. Each case is individual. The nurse should review his or her personal value system, not ignore it.

A client's family brings their older female family member to the emergency department, stating, "She is not eating well." The nurse should assess for which sign of malnutrition?

Serum albumin level 2.7 g/100 mL Explanation: Some of the clinical signs of malnutrition include: weight 10% below or 20% above the ideal range; serum albumin level lower than 3.5 g/100 mL; hemoglobin level below 12 g/dL; hematocrit value below 35%.

An older client is returns to the assisted living facility after being hospitalized for pneumonia. Which activity should the nurse suggest that the client skip in the days ahead?

Shopping trip to the mall Explanation:The client recovering from an acute illness should avoid crowds in shopping malls. The client is healthy enough to return to the assisted living facility and should be able to safely shower unattended. The client can sit away from others in the day room. There is no reason for the client to avoid walking to the lobby to check for mail.

The nurse is upset about the outcome from an ethics committee. What should the nurse do?

Talk with the nurse manager about the outcome Explanation: Although guidelines exist, no solid answers can solve all of the ethical dilemmas that nurses face. Nurses should, however, minimize their struggles in making ethical decisions by using critical thinking and sharing. When faced with a difficult ethical decision, the nurse should talk with others and seek guidance and support. There is not enough information to determine if the nurse should recommend that the client seek a second opinion or petition the committee to reconsider the decision. The nurse should not share a personal opinion about the outcome with the client.

A new resident is being admitted to a skilled nursing facility. Which vaccinations should the nurse ensure that this client has received? Select all that apply.

Tetanus Pneumonia Annual influenza Explanation:Vaccines should be kept up-to-date. The CDC recommends that persons aged over 65 years, nursing home residents, and persons who have close contact with either of these groups be vaccinated against influenza annually. Pneumonia vaccinations should be current. Tetanus vaccines every 10 years should also be current. There is no information to support when the shingles vaccination should be provided. Measles-mumps-rubella vaccination is required for younger individuals.

A nurse evaluates the plan of care for a client who experienced an ischemic stroke. Which assessment finding should signal the nurse to the possibility that the client has developed dysphagia?

The client pockets food in the affected cheek during meals. Explanation: Pocketed food suggests dysphagia. Sitting upright after meals prevents, rather than indicates, dysphagia and neither hunger nor high fluid intake is indicative of dysphagia.

A nurse is working with an older adult female client newly diagnosed with osteoporosis. Which interaction promotes achievement of wellness outcomes?

The nurse teaches the client about bone density in older women and the role of vitamin D and calcium intake. Explanation: Teaching about bone density and the role of vitamin D reflects an acknowledgment that the client's diagnosis is attributable to both the client's age-related changes and risk factors such as inadequate nutrient and mineral intake. Strength and mobility training may well be an appropriate intervention, but it does not necessarily acknowledge the interplay of risk factors and age in the client's diagnosis. The body-mind-spirit interconnectedness is a component of the Functional Consequences Theory, but it does not address the relationship between risk factors and age. Teaching about risk factors as a consequence of age implies that these factors are an inevitable consequence of age, which is not the case.

An older client with controlled chronic illnesses has no interest in eating and is losing weight. What should the nurse assess first?

The reason for no interest in eating Explanation:The initial step when managing anorexia is to identify the cause. Finances, dentition, and the ability to swallow all may be reasons why the client is losing weight however there might be another reason why the client has lost interest in eating.

An older client has esophageal dysphagia. What intervention should the nurse plan for this client?

Thicken liquids Explanation:Thickening of liquids would help promote ease of swallowing in the client with esophageal dysphagia. There is no need to restrict this client's fluids. Avoiding foods 3 hours before bedtime and raising the head of the bed will help with esophageal reflux.

A nurse plans care for an older adult with advanced dementia. Which plan is most appropriate regarding the pain treatment plan?

Treat pain that is implied by contractures and diagnoses of arthritis. Explanation: Dementia does not directly affect one's experience of pain but it does alter the ability to express pain, as well as other needs. Disruptive behaviors that do not involve locomotion were more strongly correlated with pain in comparison to behaviors (e.g., wandering) that involved locomotion. Compare current assessment findings with the client's baseline function but recognize that the client's usual level of functioning may be affected by undiagnosed and undertreated pain. Assess for indicators of underlying causes of pain, such as chronic conditions, and treat this potential pain.

An older adult client is admitted to a long-term care facility because of the progression to the moderate stage of Alzheimer's disease. How should the nurse proceed with functional assessment?

Use an assessment tool that is designed for use with cognitively impaired clients. Explanation: The presence of cognitive deficits presents a challenge to the assessment of a client's ADLs. However, there are assessment instruments designed for this explicit purpose, and these should be utilized. The nurse should not forgo functional assessment. Observation and input from family should be included in assessment, but these do not replace a formal, functional assessment.

The nurse is teaching a class to older adults about oral health practices. What health promotion activity should the nurse recommend?

Visit a dentist every six months to detect oral diseases Explanation:Visiting a dentist every six months to detect oral diseases in the older population is necessary due to the risk for oral disease in the older population. Less frequent visits are acceptable with a full set of dentures. Dental care should be proactive, not only on the basis of pain. Clients over 80 do not normally need to see a dentist every three months.

An older client waits in the emergency department for hours until a bed is assigned even though other clients in the emergency room have already been admitted. Which approach by the nurse indicates an absolutist philosophy?

consider that there is a spiritual reason for the client to remain in the emergency department and accept it Explanation:In absolutism there are specific truths to guide actions. For this situation, the nurse believes that the client is to remain in the emergency room for some spiritual reason. Doing nothing exemplifies egoism. Contacting the admission's office exemplifies utilitarianism. Realizing that it does not matter exemplifies relativism.

The nurse suspects that an older client is having problems with eating. What assessment finding caused the nurse to make this clinical determination?

dentures in a glass of water in the bathroom Explanation: Not wearing the dentures could indicate that they are ill-fitting or uncomfortable. Conducting mouth care, seeing a dentist regularly, and having the dentures fitted and adjusted would not indicate a problem with the dentures.

A nurse assesses an older adult client in a long-term care facility admitted for rehab following injuries received in a fall. The client develops new onset confusion and combativeness. Which factors must the nurse investigate as a source of these changes? (Select all that apply.)

hyponatremia medication interactions urinary tract infection Explanation: Sodium level, medications, and urinary tract infections can each lead to confusion and combativeness. While pain and social separation may be associated with confusion, they are unlikely to be the root cause of these new onset issues.

A client is prescribed spironolactone. Which electrolyte should the nurse monitor closely in this client?

potassium Explanation:Spironolactone decreases the excretion of potassium which can lead to potassium toxicity. Spironolactone does not affect sodium, calcium, or magnesium balance.

The nurse notes that an older client has a history of osteoarthritis. Which joint should the nurse expect to cause the client the most discomfort?

Knee Explanation: The knee is the joint that causes the most pain. The hip, wrist, and elbow are not identified as being the joint that causes the most pain.

An older female client insists on wearing her head covering throughout her hospital stay. What denomination of Protestantism is most consistent with this client's practice?

Mennonite Explanation:Women of the Mennonite faith may desire to wear a head covering during hospitalization. This is not typical of clients who are Baptist, Episcopal or Methodist.

The nurse identifies a skin tear on a client's coccyx and plans interventions to prevent additional wounds. Which ethical principle is the nurse implementing?

nonmaleficence Explanation: Nonmaleficence means to do no harm. By planning interventions to prevent additional wounds the nurse is preventing harm to the client. Fidelity means to respect words said to a client. Veracity means to be truthful. Justice means to be fair and treat clients equally.

An older client taking digoxin is experiencing bradycardia and diarrhea. What should the nurse evaluate as the potential reason for this drug reaction?

potassium level Explanation: Signs of digoxin toxicity include bradycardia and diarrhea. Hypokalemia increases a client's risk of developing toxicity. Because of this, the potassium level should be evaluated. Fluid intake, oxygen level, and body weight have no effect on the metabolism of digoxin.

A nurse is using the Functional Consequences Theory for planning client care in a health care facility. Which statement would assist the nurse in implementing this theory?

"Wellness is a concept that is broader than just physiologic functioning." Explanation: Within the Functional Consequences Theory, wellness is a central concept that encompasses more than the older adult's level of physiologic function. Most problems affecting older adults are attributable to risk factors, even though age-related changes are indeed relevant and inevitable. Nursing interventions can address functional consequences. Holistic care is not an alternative to Functional Consequences Theory, but rather a component of the theory.

The health care provider has recommended that an older adult client increase his intake of flavonoids. Which food examples should the nurse suggest?

Blueberries, green tea, chocolate Explanation: Flavonoids inhibit enzymes that affect the inflammatory process. Sources of flavonoids include red, purple, and blue fruits, black or green tea, red wine, chocolate, and cocoa.

An older male speaks often about reaching nirvana. Which religious faith does this client most likely practice?

Buddhism

An older male who consumes an excessive amount of calcium reports lower, right-sided abdominal pain. What should be the nurse's first action?

Collect a urine specimen Explanation:Excess calcium consumption can lead to problems such as kidney stones. Therefore, with the client's history of excessive calcium intake, a urine specimen should be collected to assess for signs of kidney stones. There is no indication for a chest x-ray or illegal drug use. Pain medication may be ordered after assessing for kidney stones.

An older client has reduced tactile sensation of the feet. What should the nurse instruct the client to do to reduce the risk of injury?

Examine the bottom of the feet every day with a mirror Explanation: Reduced tactile sensation to pressure from shoes can lead to skin breakdown. The nurse should instruct the client to examine the bottom of the feet every day with a mirror to assess for areas of pressure and sores. The client should be instructed to never walk barefoot. Shoes should be purchased later in the day when the feet have expanded. This ensures that the shoes will fit without causing sores. Bedroom slippers should only be worn inside the home.

An older client desires to begin an exercise program. What should the nurse recommend as a first step for this client?

Have a recent physical examination Explanation: The nurse should ensure that a recent physical examination has been done to detect any conditions that could affect or be affected by an exercise program. Clothing will depend upon the activity. Well-fitting shoes should be worn at all times. Selection of activities will depend upon the client's physical status.

During a physical examination the nurse notes flaccid skin around the entrance to an older client's anus. What should the nurse suspect is occurring with this client?

Hemorrhoids Explanation: Flaccid skin around the entrance to the anus are hemorrhoids. This tissue is not a rectal tumor. A rectal fissure is not visible when inspecting the anus. The flaccid tissue is not caused by an infection.

A resident of an assisted living facility asks others about the noise from the street construction. What affect might the environmental noise have on the client?

Increased Anxiety Explanation: Environmental sounds compete with the sounds that older adults want or need to hear resulting in poor hearing and frustration. Unwanted, disharmonic, or chronic noise can be a stressor and cause physical and emotional symptoms. Noise has not been associated with causing fatigue. It is unlikely that noise will help reduce sadness or frustration.

An older adult client is scheduled to undergo hip replacement surgery after a fracture resultant from a fall. Which age-related change may have contributed to the client's susceptibility to bone fracture?

Increased bone resorption Explanation: The process of bone resorption (break down bone) accelerates with age, resulting in lower bone density. Changes in various aspects of the nervous system accompany the aging process, but a loss of neural control of balance is not normally among these. Infection is never a normal, age-related change, and protein synthesis decreases, not increases, with age.

A couple is renovating their garage into an apartment for the husband's mother to move into. What safety recommendations should the nurse suggest?

Install electric versus a gas stove Explanation: Because older adults may not be able to detect a gas odor, electric stoves may be better options than gas stoves. A decreased sense of taste leads older adults to add extra salt to foods, which increases the chance for nutritional safety hazards. Reduced tactile sensation causes the older adult to be more prone to burns if water temperature is too high. Older adults can visualize bright colors better than dark colors.

Which factor in an older client's history is most likely a contraindication to taking bulk-forming laxatives?

Intestinal Obstruction Explanation: Bulk formers absorb fluid in the intestines and create extra bulk, which distends the intestines and increases peristalsis. These compounds should not be used when there is any indication of intestinal obstruction. Decreased peristalsis, bowel distention, and abdominal cramping call all be indicators for taking laxatives, not contraindications.

Which religious group believes in one true God that specially chose this group of people to receive God's laws?

Jews Explanation: Jews believe in one true universal God and that that they were specially chosen to receive God's laws. Hindus have no fixed doctrine or common worship. Buddhists believe in enlightenment based on individual meditation. Muslims believe in one God as well and that a prophet, Mohammed, who was a human messenger that communicated His word.

The nurse is assessing for pain in an older adult with early stage Alzheimer disease. What is the nurse's best action?

Mcgill Pain Questionnaire Explanation: The McGill pain questionnaire is effective with persons who are either congnitively normal or impaired. The numerical rating scale has been found to be unreliable in persons who are cognitively impaired. The client's pain could be elsewhere besides joints, so range of motion is not the most thorough assessment. Persons with cognitive impairments may exhibit signs other than just crying or moaning.

An older adult suffering from shingles complains of sharp, stabbing, burning pain that suddenly occurs from the back around to her sides. Which type of pain is this client describing?

Neuropathic pain Explanation:Neuropathic pain occurs from an abnormal processing of sensory stimuli by the central or peripheral nervous system and is decribed as sharp, stabbing, burning, tingling, with a sudden onset of high intensity. Nociceptive pain arises from mechanical, thermal, or chemical noxious stimuli to the A-delta and C afferent nociceptors. Types of nociceptive pain are somatic and visceral. Somatic pain is usually described as throbbing or aching. Visceral pain is described as deep and aching.

An older client asks for the window curtains to be pulled closed in the evening before going to sleep. Why should the nurse honor this client's request?

Prevents morning light from waking the client Explanation: Older individuals are more likely than the young to be awakened by light. This is the primary reason for the nurse to honor the client's request. Closing the drapes may or may not affect room temperature. Older clients do not experience photophobia from sunlight. It is unlikely that avoiding natural light reduces pain and promotes relaxation.

After interviewing an older adult, the nurse is unable to determine what may be the cause of the client's reported sexual dysfunction. What is the nurse's next best action?

Refer the client for a comprehensive physical examination. Explanation: If the cause of sexual dysfunction is not readily available through the history, refer the older person for a comprehensive physical examination. If the client suffers from a physical problem, interviewing the partner and sexual counseling may not be necessary. Lab studies are part of a physical examination after the client has been evaluated head to toe to determine what lab tests are needed.

A nurse is responsible for assessing an older adult in an acute care setting. Which statement most accurately captures the complexity involved in assessing the older adult?

Signs and symptoms of illness are often obscure and less predictable among older adults. Explanation: The manifestations of illness in older adults can be less clear and less predictable than among younger clients. Older adults often show different, but not necessarily fewer, symptoms than do younger clients. Age-related changes must be recognized and acknowledged, not excluded from the assessment process. Older adults do not experience fewer acute health problems than do younger adults but rather different manifestations of health problems.

After reviewing a list of medications, the nurse is concerned that a client is at risk for developing osteoporosis. Which medication caused the nurse to have this concern? Select all that apply.

Steroid Furosemide Thyroid supplement Aluminum-based antacid Explanation: Medications that can lead to the development of osteoporosis include steroids, furosemide, thyroid supplements and aluminum-based antacids. Vasodilators are not identified as potentiating the development of osteoporosis.

While visiting the home of a terminally ill client the nurse finds a vial of assorted pain medication in a drawer in the kitchen. What might the nurse suspect about this situation?

The client may be considering suicide Explanation: The client is terminally ill and a vial of assorted pain medication is stored in a vial in a kitchen drawer. The nurse should suspect that the client is planning to use the medication as a form of suicide. It is unlikely that the client misplaced the medication or is waiting to properly dispose of the medication. There is no information to support that the client has family who are withholding the medication from the client.

An older client is moving into a smaller townhouse. What should the nurse recommend for floor coverings to ensure safety?

Tile flooring in a solid color Explanation: Tiled floor covering, if installed over a wood foundation, has better insulation and cushion. The solid color reduces the risk of dizziness or falling. Hard wood floors with scatter rugs can increase the risk of falls. Wavy or checker box patterns can cause dizziness and confusion when ambulating.

The nurse completes a medication history with an older client. Which question should the nurse ask when examining each medication that the client takes?

Why is the drug ordered? Explanation: The nurse should ask questions when reviewing an older client's medications. The question "why is the drug ordered" should be asked. The questions "how often is the drug taken," "what does the drug cost," and "where is the drug stored" are not questions that should be the focus when examining an older client's medications.

A nurse administers medications to a group of older adults in a residential facility. Which client is most likely to experience adverse effects?

a 77-year-old man with a creatinine of 3.6' Explanation: Although age-related changes can influence skills related to taking medications, risk factors that commonly occur in older adults exert a stronger influence. A creatinine of 3.6 reflects renal failure, which will lead to an increase in serum levels of medications. Iron deficiency anemia, obesity, and constipation exhibit no impacts to the risk of adverse and altered effects.

A nurse assesses the eating habits of an older adult client who takes iron supplements. Which statements indicate client understanding? (Select all that apply.)

"I drink orange juice with my iron." "I take my iron in between my meals." "I take all my pills with a glass of warm water." Explanation: Foods that change the pH of the gastrointestinal (GI) system interfere with the absorption of iron. The preferable method is to take iron on an empty stomach, but if it causes GI upset, it can be taken with orange juice, which helps absorption. Caffeine and some foods interfere with iron absorption. The temperature of the water should not affect the medication absorption. Stools will be dark in color and normal consistency; however, the patient can become constipated with the iron.

The nurse instructs a client with a hiatal hernia. Which statement indicates that teaching has been effective?

"I need to stop drinking coffee." Explanation: The client should be discouraged from consuming caffeinated beverages. The client should be instructed to eat five to six small meals during the day. The client should be instructed to sit upright for at least an hour after eating. The client should be advised to avoid eating for at least 2 hours before bedtime.

The nurse, who participates in prolife activities, is assigned to care for a client with a perforated uterus that occurred during an abortion procedure. What should the nurse do after learning of the assignment?

Ask to have the assignment changed Explanation:The nurse needs to "know thyself." The influences of religion, cultural beliefs, and personal experiences should be explored to understand one's unique comfort zone with specific ethical issues. It is unacceptable for the nurse to impose personal beliefs onto the client. This includes talking about the prolife philosophy and providing teaching material on tubal ligation. There is no reason for this client's case to be taken to the ethics committee.

An older client is admitted for treatment of a chronic health problem. Which action should the nurse take if functioning in the role of caregiver?

Assess current status Explanation:As a caregiver the nurse assesses and provides direct care. Explaining the health problem is the role of an educator. Supporting the client's decisions for care and discussing the client's concerns with the health care provider demonstrate advocacy.

Which process should a nurse address first when assessing sexual function in older adults?

Assess own personal attitudes toward sexuality and aging. Explanation:A personal attitude assessment about sexuality and aging is a nurse's prerequisite to discussing sexual function with older adults. The next step would be to obtain permission from the individual to initiate discussion about sexual relations.

An older adult with heart failure and mild dementia states: "It's important to me to live free, without restrictions on what I eat." The family is supportive. Which action by the nurse takes priority?

Assure that the client understands the consequences of this decision. Explanation:All of these actions are appropriate; however, the primary concern is that the nurse assess the client's understanding of the consequences. During mild-to-moderate stages of dementia, assessment of decision-making ability is based upon the person's ability to describe the importance or implications of the choice on his or her future health. Medical decision making is a complex process in which information is shared between clients and clinicians and among family and others who are affected by the outcomes.

The nurse prepares an intramuscular injection for an older client. What should the nurse keep in mind when administering this medication?

Avoid the limb that is immobile Explanation:Medication should not be injected into an immobile limb because the inactivity of the limb will reduce the rate of absorption. The upper, outer quadrant of the buttocks is the best site for intramuscular injections. Frequently, the older person will bleed or ooze after the injection because of decreased tissue elasticity; a small pressure bandage may be helpful. The nurse should check for signs of infection at the injection site; reduced subcutaneous sensation in older persons or absence of sensation may prevent the person from being aware of a complication at the injection site.

The nurse writes in a journal every evening before going to sleep. What is the advantage of using this self-care technique?

Helps work through issues Explanation: Writing personal notes in a journal records current activities and provides a way for the nurse to work through issues. Journaling is not done to document the nurse's life story, serve as a to-do list, or record past events.

A new nurse asks the staff educator what preparation is needed to become a gerontological advanced practice nurse. What is the staff educator's most appropriate response?

Completion of at least a master's degree Explanation: Most advanced practice roles require the completion of a master's degree at a minimum. Certification is not equivalent to a degree. A bachelor's degree is not the minimum level of entry for advanced practice, even with specialty certification. There is an increased, not decreased, need for gerontological nurses.

A nurse reads up on some of the more common cultural groups in the local area. How should the nurse interpret the information that is available about cultural groups?

Cultural generalizations can be useful and accurate, but they do not replace individualized assessment and care. Explanation: Nurses need to be knowledgeable about different cultural groups, but they need to use this information as a backdrop for exploring the ways in which individuals identify with the characteristics of the various cultural groups to which they belong. Generalized knowledge may be accurate and clinically useful, but it is not replacement for individualized knowledge. Nurses need to recognize that the culture of each individual person forms based on his or her membership in many groups and is internalized in a unique and personal way.

A nurse in the ambulatory clinic assesses a 53-year-old woman who states, "Last night all of a sudden I got really sick, got really hot, and started sweating; then I had chills, and my chest was pounding." Which action by the nurse is priority?

Discuss the client's menstrual cycle with her. Explanation: Asking about "anyone who was ill" is broad and generic. Illness is often spread in the prodromal phase when there are no symptoms. Troponin and BNP are indicators of cardiac functioning; women who have a myocardial infarction are more likely to experience severe fatigue, not heat and chills. Hot flashes are a vasomotor symptom characterized by the sudden onset of heat, perspiration, and flushing that spreads from the head to the trunk. Symptoms last from 1 to 5 minutes and may be accompanied by chills, nausea, anxiety, palpitations, and clamminess. Medications do not relate to these symptoms.

An older adult who lives alone without air conditioning during the summer months is admitted and diagnosed with dehydration. Which assessment finding does the nurse expect to see with this condition?

Increased creatinine Explanation:Deficient fluid volume results in an elevated serum creatinine, blood urea nitrogen, and hematocrit. Older adults normally have a lower blood pressure. A pressure of 110/68 is average for an older adult and is not as indicative of deficient fluid volume as an elevated creatinine level.

An older adult reports that stress is interfering with his sleep and he asks the nurse about coping strategies. Which technique is the nurse's best recommendation?

Exercise and Time Management Explanation: Exercise and good time management are among the main coping strategies recommended during times of stress. Medications are used as a last resort and it is unrealistic to avoid all challenging relationships. Meditation can reduce stress, but weight loss is not normally considered to be a stress reduction method.

The adult daughter of an older client is upset because the client won't let her wash the dishes. What should the nurse explain about the physical advantages of this activity?

Exercises the fingers in warm water Explanation: For someone unable to participate in a formal exercise program, it can be beneficial to build less aggressive exercise into daily activities and promote maximum activity during routine care activities. Washing dishes exercises the fingers with the benefit of warm water. Washing the dishes is not being done by the client to clear the mind or improve focus. Doing this activity may help the client feel useful however this is not a physical benefit.

An older client enters a family member's home and sits down for the duration of the visit. When preparing to leave to go home, the client places one hand on the wall and the other on the counter when walking to the door. What is this client demonstrating?

Fear of falling Explanation:The client is "hanging on" to the wall and counter. This could indicate a fear of falling. There is no reason to believe that the client is experiencing confusion, discomfort, or orthostatic changes.

An older client with heart failure has a low serum albumin level. Which medication should the nurse expect to be less effective in this client?

Furosemide Explanation: Reduced serum albumin levels can be problematic if several protein-bound drugs are consumed and compete for the same protein molecules; the unbound drug concentrations increase and the effectiveness of the drugs will be threatened. Highly protein-bound drugs that may compete at protein-binding sites and displace each other include furosemide. Isoniazid, aldactone, and indomethacin are not identified as being protein-bound drugs.

A gerontological nurse is feeling depressed and frustrated due to working extra overtime and not having time to attend Bible study. The nurse's faith has always been a source of strength and stability for the nurse. What action should the nurse take to be an effective nurse healer for others?

Limit amount of overtime Explanation: Committing to engaging in one's self-care is important. This means that sacrifices and unpopular decisions must be made, such as limiting overtime in order to attend Bible study and attend to holistic self. Self-care is an ever changing, dynamic process.

An older female tells the nurse about her sexual experiences and concerns with several men. What is the nurse's best initial action?

Listen without judgement. Explanation:Nurses must recognize and respect sexuality in older adults without judgement. After listeing to the client, the nurse can assess whether she needs teaching about safe sex practices or using lubrication. Leaving the door open does not promote privacy while discussing the client's concerns.

A client does not understand why the blood calcium level remains low despite taking the prescribed amount of calcium supplement each day. For which other nutrient should the nurse assess if this client is ingesting?

Magnesium Explanation:A good intake of vitamin D and magnesium facilitates calcium absorption. Zinc helps with wound healing. Vitamin B helps with metabolic and nervous system processes. Potassium helps regular blood pressure.

An older adult with asthma avoids sex due to fear of an asthma attack. What is the nurse's best recommendation?

Plan to take medications so peak action occurs during sex. Explanation: The client should plan medications for peak effectiveness during sex. Deep breathing exercises do not prevent asthma attacks. Remaining in an upright position may not be feasible or beneficial. Sex does not need to be totally avoided if medication administration is planned accordingly.

Which of these lab data would be most important for a nurse to obtain when assessing a client who is taking furosemide?

Potassium level Explanation:Furosemide is a loop diuretic that inhibits the reabsorption of sodium and chloride and is depleting of potassium. Monitoring the client's potassium level is essential because of the severe consequences of hypokalemia.

An older client has 50% of functioning nephrons. What should the nurse expect when reviewing this client's prescribed medications?

Reduced Doses Explanation: The renal system is primarily responsible for the body's excretory functions, and among its activities is the excretion of drugs. Nephron units are decreased in number, and many of the remaining ones can be nonfunctional in older individuals. The glomerular filtration rate and tubular reabsorption are reduced. Drugs are not as quickly filtered from the bloodstream and are present in the body longer. The biological half-life, or the time necessary for half of the drug to be excreted, can increase as much as 40% and increase the risk of adverse drug reactions. The nurse should expect medication doses to be reduced. Increasing medication doses can increase the risk of adverse effects. The oral and intramuscular routes are not recommended to enhance absorption in the older client.

The nurse sees an older client sitting in a geriatric chair with a tray placed over the handrails. What should the nurse do first?

Remove the tray Explanation:Anything that physically restricts a client's movement, such as a geriatric chair, can be considered a restraint. Improperly used restraining devices can not only violate regulations concerning their use but also result in litigation for false imprisonment and negligence. The nurse should remove the tray from the chair. Unless there is an order for a restraint, the nurse should not apply a vest or wrist restraint. Checking the medical record for a restraint order should have been done prior to placing the client in the geriatric chair with the tray.

The nurse notes that an older resident of an assisted living facility has stopped drinking fluids with the evening meal. What should the nurse suspect is occurring with this resident?

Restricting fluids to reduce the need to void overnight Explanation: A self-imposed fluid restriction is a means of managing urinary frequency. This is the first thing that the nurse should suspect. Even though thirst perception declines with age, the change in fluid intake has recently changed. Fluid intake is not typically associated with a gastrointestinal disturbance. There is no indication that the client does not like the selection of fluids being provided with the meal.

The nurse notes that a client has rated pain as a 6 on a scale from 1 to 10 but selects a crying grimace when assessed with the faces scale. What should this finding suggest to the nurse?

The client is confused between the pain scales Explanation: Since the client rated the pain as 6 when using both pain scales, it could mean that the client is confused about the use of the scales. Using the same tool consistently facilitates the collection of data that are comparable and meaningful. The findings do not indicate that the client is faking the amount of pain, is not fully reporting the amount of pain, or has no idea how much pain is being experienced.

A nurse in a community setting plans wellness outcomes with an older adult client who desires to participate in a half marathon. Which outcome should the nurse document?

The client will participate in the half marathon as scheduled in 6 months. Explanation: Health is individually determined based on the functional capacities that are perceived as important by that person; in this case, it is participating in a half marathon. Positive functional consequences demonstrate that the client will compensate for age-related changes by running the half marathon. Remaining free from disease and expecting the older adult to participate in daily aerobic activity class may not be pertinent to this client. Increasing activity by only 30 minutes at a time minimizes the client's goal.

A nurse works to protect vulnerable populations and reduce health disparities. Which nursing actions work toward that goal? (Select all that apply.)

The nurse teaches each client about preventive care. The nurse incorporates clients' belief systems into the plan of care. The nurse communicates a nonjudgmental attitude toward health belief systems. The nurse asks the client how the care system can incorporate the clients' health beliefs. Explanation: Health promotion interventions, such as teaching about prevention and early detection of certain conditions, are particularly important when caring for older adults who are members of a minority group. Nurses communicate nonjudgmental attitudes and ask open-ended questions to elicit information about each person's life experiences and cultural influences. Nurses need to be aware of the health beliefs that influence their clients so they can adapt their interventions accordingly.

An older couple expresses concern over developing a relationship and possibly marrying because of the effects on their financial situation. What is the nurse's best response?

"I can recommend a financial counselor to discuss your concerns." Explanation: Financial considerations can affect sexual activity when the single older adult has concern that commitment to a relationship and marriage could reduce Many older women were socialized during a period when sex was considered appropriate only in wedlock. Suggesting alternative expressions does not address their concern.

Two nurses are discussing information about hospitalized older adult clients at their children's soccer practice. A nearby spectator hears the conversation and identifies one of the clients being discussed as her neighbor. These two nurses are potentially subject to what legal penalty?

Federal criminal penalties Explanation:Breeches in confidentiality are subject to federal criminal penalties as a result of the institution of the Health Insurance Portability and Accountability Act (HIPAA). Congress authorized civil and criminal penalties for covered entities that misuse personal health information. Termination of employment may occur in addition to federal penalties.

An older adult develops diarrhea. Which is the priority intervention for the nurse?

Review the client's medication list. Explanation: A number of medications can cause diarrhea in the older adult (e.g., cimetidine, laxatives, antibiotics, cardiovascular drugs, and cholinesterase inhibitors). Additionally, Clostridium difficile and its related diarrhea are related to antibiotic usage.

An older client suffers from erectile dysfunction. The nurse should anticipate what initial treatment?

Sildenafil citrate Explanation: Sildenafil citrate is a common first-line treatment for erectile dysfunction. Other options, less prescribed, include alprostadil (injected into penis to increased blood flow), vacuum pumps, and penile implants.

The spouse is concerned because an older client always snores and falls asleep easily during the day. For which health problem should the nurse assess this client?

Sleep Apnea Explanation: Snoring and daytime sleepiness are characteristics of sleep apnea. Snoring is not considered a manifestation of insomnia. Snoring and daytime sleepiness are not manifestations of nocturnal myoclonus or restless leg syndrome.

The nurse instructs an older client on a newly prescribed diuretic. Which client statement indicates that additional teaching is required?

"I should expect to feel weak and have muscle cramps." ExplanationWeakness and muscle cramps could indicate a fluid and electrolyte imbalance caused by the diuretic. This statement requires the need for additional teaching. The client should be instructed to take the medication first thing in the morning, change position slowly to prevent orthostatic changes, and to drink adequate fluids throughout the day.

A client experiencing constipation asks which laxative should be used. What should the nurse respond to this client?

"Senna is a natural laxative that is available in tablets or tea." Explanation:Senna is an effective natural laxative that can be consumed in tablet or tea form. Laxatives should be considered only after other measure have proved unsuccessful. The nurse should not mention over-the-counter laxatives. Taking laxatives every day can cause the bowel to become sluggish when they are discontinued. Resting contributes to constipation. Activity promotes peristalsis and should be encouraged.

An older adult client reports that he often experiences "indigestion" after each fatty foods. He states that this never used to happen to him when he was younger and asks the nurse why this is now the case. What is the nurse's best response?

"With age, reduced pancreatic secretions can affect the digestion of fatty foods." Explanation:With age, reduced pancreatic secretions can affect the digestion of fatty foods is the best response. With age, pancreatic secretions are reduced, not increased, and the liver size decreases although liver functions remain within normal limits.

The nurse is changing an older Native American's large wound dressing. The client is very calm and quiet and doesn't make eye contact with the nurse. Before packing the open wound, what is the nurse's best action?

Ask client to rate pain level on 0-10 scale Explanation: Native Americans often remain calm and controlled, even in the most difficult circumstances; it's important that providers not mistake this behavior for the absence of feeling, caring, or discomfort. Though Native Americans do rely on spiritual powers to chart the course of life, suggesting prayer does not address whether the client may be in pain. Rating pain using a pain scale is the most objective means to assess pain. Telling the client it's okay to cry assumes that client is in pain; the nurse should assess for pain first.

Which nursing intervention can help the older adult achieve a spiritual attitude of gratitude?

Encourage a life review of positive aspects and achievements. Explanation: Older individuals may benefit from a guided review of the positive aspects of their lives in order to foster a sense of gratitude. Transcendence describes the need to feel one is connected to a higher power. Reminding a client of negative aspects does not foster the life review process. Feeling entitled versus thankful does not foster an attitude of gratitude.

A nurse is beginning a new job in an area with a large African American population. Which statements will assist the nurse to understand this group to better plan nursing care? (Select all that apply.)

Female-headed households are common among African Americans. Older African Americans are more likely to be caring for their grandchildren. African Americans as a group have a wide range of socioeconomic conditions. Explanation:Female-headed homes are a common family structure among African Americans. The differences in health outcomes between African Americans and other groups arise mostly to disparities in health care provision. Older African Americans are more likely to live with family. Half of those older African Americans who live with their grandchildren are the primary care provider to those children.

The healthcare provider suggests that an older client increase the intake of insoluble fiber. What item should the nurse suggest that the client ingest every day?

Fresh Vegetables Explanation: Insoluble fibers promote good bowel activity and can be found in grains and many vegetables and fruits. Soluble fiber is found in foods such as oats and pectin. Gluten-free bread is not identified as being a source of either soluble or insoluble fiber.

An older client reports experiencing problems sleeping since starting a new medication. Which medication should the nurse consider as affecting this client's sleep?

Furosemide Explanation: Drugs that can interrupt sleep include diuretics. Furosemide is a diuretic. Digoxin, tetracycline, and warfarin sodium are not identified as medications that adversely affect sleep.

A client is experiencing a new onset of hypertension. Which herbal preparation should the nurse suspect as the cause of this finding?

Ginseng Explanation: Ginseng causes an elevation in blood pressure. Garlic decreases blood pressure. Hops and mistletoe have no effect on blood pressure.

An older client asks what can be done to enhance sleep and eliminate a nagging headache that comes on towards the end of the day. Which herb should the nurse suggest that the client limit the intake?

Green Tea Explanation: Green tea can cause insomnia and headaches. Aloe can cause arrhythmias and edema. Cayenne can cause gastrointestinal discomfort and liver damage. Echinacea can cause fevers.

The nurse identifies the diagnoses Risk of trauma and acute confusion related to hypothermia as appropriate for an older client. What finding did the nurse use to select this nursing diagnosis?

Minimal subcutaneous tissue Explanation:A contributing factor to the Risk of trauma and acute confusion related to hyperthermia is a loss of subcutaneous tissue. Decreased heart efficiency could lead to Activity intolerance. Urinary retention and shallow respirations could contribute to the Risk of infection.

The nurse identifies the diagnosis of Impaired Physical Mobility for an older client. Which intervention should the nurse include in the client's plan of care? Select all that apply.

Promote a healthy nutritional intake Coach to change positions every hour Remind to maintain good body alignment Design an exercise program appropriate for the client's status Explanation: Interventions to address Impaired Physical Mobility include promoting a healthy nutritional intake, frequent position changes, maintaining good body alignment, and designing an exercise program that is appropriate for the client's physical status. Family should be encouraged to participate in efforts to increase the client's mobility.

Restraint use has been deemed necessary to keep an older adult client from removing a central line and bleeding out. The family of the client refuses to allow the use of wrist restraints. What is the nurse's first action?

Provide counseling to educate the family on restraint use. Explanation:Counseling should first be provided to help the family understand the reason for restraint use. The nurse can assume responsibility for education without initially calling the physician. If counseling does not help the client and family understand the risks involved in not using the restrains, the agency may wish to have the client and family sign a release of liability. The nurse should educate the family first rather than asking them to leave the client's room.

The nurse notes that an older client obtains approximately 3 to 4 hours of sleep a night. For what should the nurse particularly assess this client?

Risk for Suicide Explanation: Research has shown that poor sleep quality is a better predictor of suicide in older adults than depressive symptoms. Sleep quality has not been associated with gas exchange, fluid retention, or intracranial pressure regulation.

An older client is prescribed a diuretic for heart failure. What should the nurse include when teaching this client about ways to avoid hypokalemia?

avoid foods and beverages with caffeine Explanation: A high caffeine intake can heighten the hypokalemic effects of diuretics. Green leafy vegetables will not help prevent hypokalemia. Taking the medication before bedtime will not impact the development of hypokalemia. Coffee contains caffeine and would potentiate the development of hypokalemia.

A nurse has recently begun to provide care to older adults in a large, urban hospital. Having lived until recently in an ethnically homogeneous region, the nurse recognizes the significant differences in priorities and perspectives of clients from other cultural groups and has taken action to learn about these groups. What stage of cultural self-assessment is this nurse demonstrating?

consciously incompetent Explanation: Cultural competence begins with unconscious incompetence as a state of not being aware that one is lacking knowledge about another culture. When the person becomes aware of this knowledge gap, he or she progresses to a state of conscious incompetence and takes actions to learn about the cultural group. Through this, the nurse in this question demonstrates this stage. A person progresses to a stage of conscious competence by verifying generalizations and incorporating culture-specific interventions in care. The final stage is unconscious competence, when knowledge of the cultural group becomes integrated into one's thinking and approach.

An older client hesitates to agree to have a surgical procedure until the spouse arrives to discuss the situation with the healthcare provider. What most likely is causing this client's hesitation?

cultural background Explanation:Since the client wants the spouse to discuss the surgery with the healthcare provider, the client may be from a cultural group where decisions are made when family members are present. There is no evidence to suggest that the client's hesitation is because of fear, finances, or not understanding the situation.