N128 Week 1 - Adaptive Quizzing #1

Which instruction would the nurse give an older adult to promote wellness and reduce the risk of disability? 'Engage in physical activities to stay fit.' 'Don't exhaust yourself by engaging in physical activities.' 'Pay no heed to your financial problems if you want to stay healthy.' 'Stay away from people so as to prevent anxiety and stress disorders.'

'Engage in physical activities to stay fit.'

The registered nurse (RN) is teaching the nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? 'I should serve food that is easy to eat.' 'I should assist the client with eating.' 'I should monitor weight and food intake once a month.' 'I should offer food supplements that are tasty and easy to swallow.'

'I should monitor weight and food intake once a month.' Rationale: The nurse would monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse would serve food that is easy to eat and provide assistance with eating. The nurse would also offer food supplements that are tasty and easy to swallow.

Which step listed by the nursing student indicates a need for additional training regarding communicating with older adults with hearing problems? 'Refrain from speaking extremely slowly.' 'Speak clearly by exaggerating his or her lip movements.' 'Allow the client to ask questions when necessary.' 'Ensure that the client knows that the nurse is talking.'

'Speak clearly by exaggerating his or her lip movements.' Rationale: The nurse would not speak by exaggerating his or her lip movements when communicating with older adults with hearing problems. The nurse would speak clearly to facilitate understanding. The nurse would speak slowly but not extremely slowly. When communicating with the client, the nurse would allow the client to ask questions when necessary to facilitate better understanding. The nurse would ensure that the client knows that the nurse is speaking to facilitate good communication.

An 80-year-old client is admitted to the hospital with severe dehydration. The client's daughter asks the nurse how her mother could have become dehydrated. Which response by the nurse is correct? 'The body's fluid needs decrease with age because of tissue changes.' 'Access to fluid may be insufficient to meet the daily needs of the older adult.' 'Memory declines with age, and the older adult may forget to ingest adequate amounts of fluid.' 'The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased.'

'The thirst reflex diminishes with age, and the recognition of the need for fluid is decreased.' Rationale: For reasons that are still unclear, the thirst reflex diminishes with age, and this may lead to a concomitant decline in fluid intake. There are no data to support the statement 'The body's fluid needs decrease with age because of tissue changes.' the statement 'Access to fluid may be insufficient to meet the daily needs of the older adult' is not true for an alert person who is able to perform the activities of daily living. Research does not support progressive memory loss in normal aging as a contributor to decreased fluid intake.

Which action would the nurse take for an older adult resident with Alzheimer disease who often talks about the 'good old days' at the ranch? Allowing the resident to reminisce about the past and listening with interest Involving the resident in interesting diversional activities with a small group Reminding the resident that those times are in the past and should focus on the present Introducing the resident to other residents with the same diagnosis to share past experiences

Allowing the resident to reminisce about the past and listening with interest

Which approach would the nurse use for a nursing home client with Alzheimer disease who is confused, agitated, and at time unaware of the presence of others? Initiating a program of unplanned interaction Explaining the nature and routines of the unit Exploring in depth the reasons for the admission Arranging for the constant presence of a staff member

Arranging for the constant presence of a staff member

Which type of bone tumor occurs most commonly in elderly clients? Endochroma Osteosarcoma Chondrosarcoma Osteochondroma

Chondrosarcoma Rationale: Chondrosarcoma occurs most commonly in cartilage in the arm, leg, and pelvic bones of older adults in the age group of 50 to 70 years old. Endochroma occurs in clients in the age group of 10 to 20 years old. Osteosarcoma and osteochondroma occur in the age group of 10 to 25 years old.

Which findings in the older adult client are associated with a urinary tract infection (UTI)? Select all that apply. One, some, or all responses may be correct. Fever Urgency Confusion Incontinence Slight rise in temperature

Confusion Incontinence Slight rise in temperature Rationale: An older adult client with a urinary tract infection (UTI) is likely to appear confused and may experience incontinence, whereas a younger client is cognitively intact and typically experiences urgency. The older adult client may develop only a slight rise in temperature, whereas the hallmark symptoms of a UTI in a younger client are fever, dysuria, and urgency.

Which age-related skin change occurs in older adult clients and increases their potential for developing pressure ulcers? Atrophy of the sweat glands Decreased subcutaneous fat Stiffening of the collagen fibers Degeneration of the elastic fibers

Decreased subcutaneous fat Rationale: In older adults, a decrease in subcutaneous fat leads to skin shearing, which may lead to pressure ulcers. Atrophy of the sweat glands will cause dry skin and decreased body odor. Stiffening of the collagen fibers and degeneration of the elastic fibers will result in the development of wrinkles.

Which essential approach would the nurse use when caring for a confused older client? Offer space for privacy. Provide group involvement. Establish trusting relationships. Encourage activities that are varied.

Establish trusting relationships.

Which gerontologic assessment findings of the auditory system are related to the inner ear? Select all that apply. One, some, or all responses may be correct. Hair cell degeneration Reduced blood supply to the cochlea Atrophic changes of the tympanic membrane Decline in the ability to filter out unwanted sounds Less effective vestibular apparatus in the semicircular canals

Hair cell degeneration Reduced blood supply to the cochlea Less effective vestibular apparatus in the semicircular canals Rationale: Hair cell degeneration, reduced blood supply to the cochlea, and less effective vestibular apparatus in the semicircular canals are assessment findings related to the inner ear. Atrophic changes of the tympanic membrane is an assessment finding associated with the middle ear. A decline in an ability to filter out unwanted sounds is an assessment finding related to the brain.

Which age-related effects on the immune system occur in the older client? Increased autoantibodies Increased expression of IL-2 receptors Increased delayed hypersensitivity reaction Increased primary and secondary antibody responses

Increased autoantibodies Rationale: The effects of aging on the immune system include increased autoantibodies. Expression of IL-2 receptors, delayed hypersensitivity reaction, and primary and secondary antibody responses decrease in older adults because of the effects of aging on the immune system.

Which action would the nurse take for an older client with Alzheimer disease who sleeps very little and becomes more disoriented from sleep deprivation? Shut the client's door during the night. Apply a vest restraint when the client is in bed. Leave a dim light on in the client's room at night. Administer the client's prescribed as-needed sedative medication.

Leave a dim light on in the client's room at night. Rationale: The nurse would leave a dim light on in the client's room at night. A small light in the room may prevent misinterpretation of shadows, which can heighten fear and alter the client's perception of the environment. A disoriented and confused client should be closely observed, not isolated by closing the door. Restraints are a last resort; less restrictive interventions should be used first. Sedatives should be used sparingly in older adults, because they may cause further confusion and agitation.

The registered nurse is teaching isometric exercises to an 80-year-old client. Which change as a result of aging requires this intervention? Kyphotic posture Muscular atrophy Decreased bone density Cartilaginous degeneration

Muscular atrophy

Which important step(s) would the community nurse take when dealing with older adults with a confusional states problem? Select all that apply. One, some, or all responses may be correct. Provide a protective environment. Monitor blood pressure and weight. Recommend applicable community resources. Demonstrate proper hygiene to the primary caretaker. Educate about polypharmacy and drug-drug and drug-food interactions.

Provide a protective environment. Recommend applicable community resources. Demonstrate proper hygiene to the primary caretaker. Rationale: When dealing with older adults with a confusional states problem, the nurse should ideally provide a protective environment for the client. In addition, the nurse should recommend applicable community resources like adult day care, home care aides, and homemaker services. When dealing with community-dwelling older adults with a confusional states problem, the nurse should assist with adequate personal hygiene, nutrition, and hydration. When dealing with the community-dwelling older adults with a hypertension problem, the nurse should monitor blood pressure and weight. When dealing with the community-dwelling older adults with a medication use and abuse problem, the nurse should educate about polypharmacy and drug-drug and drug-food interactions.

Which intervention would the nurse implement first when providing care for an older adult male client who is immobile and incontinent of urine? Restrict the client's fluid intake. Regularly offer the client a urinal. Apply incontinence pants. Insert an indwelling urinary catheter.

Regularly offer the client a urinal. Rationale: Regularly offering the urinal is the first step. Retraining the bladder includes a routine pattern of attempts to void, which may increase bladder muscle tone and produce a conditioned response. Restricting fluid intake can result in dehydration and a urinary tract infection in an older client. Applying incontinence pants does not address the cause of the incontinence, promotes skin breakdown, and may lower the client's self-esteem. Inserting an indwelling urinary catheter increases the risk of a urinary tract infection. Insertion of an indwelling urinary catheter requires a primary health care provider's prescription.

For which condition is an adult client with a weakened urinary sphincter at risk? Bladder distention Skin irritation Tendency to fall Urinary retention

Skin irritation Rationale: The weakening of the urinary sphincter results in involuntary dribbling of urine, which increases the risk of skin irritation and infections. Maintaining thorough hygiene in the perineum area reduces the chance of occurrence of infection or skin rash. The nurse should observe for signs of bladder distention in clients who have a tendency to retain urine. Keeping a bedside light at night is an intervention to prevent night falls in clients who have nocturia. A weakened urinary sphincter will cause loss of urine.

Which physiological changes of the musculoskeletal system would the nurse associate with aging? Select all that apply. One, some, or all responses may be correct. Slowed movement Cartilage degeneration Increased bone density Increased range of motion Increased bone prominence

Slowed movement Cartilage degeneration Increased bone prominence Rationale: The physiological changes of the musculoskeletal system related to aging are slowed movements, cartilage degeneration, increased bone prominence, decreased bone density, and decreased range of motion.

Which action would be used to decrease risk for postoperative respiratory complications in an older client with decreased vital capacity? Give prescribed intravenous antibiotic. Administer oxygen per nonrebreather mask. Teach the client coughing and deep-breathing exercises. Keep the client on the mechanical ventilation for several days.

Teach the client coughing and deep-breathing exercises.

Which intervention would the nurse provide while caring for an older adult client who is reported to have decreased estrogen production? Use minimal tape on client's skin Cover the client with warm clothing Perform blood glucose test for the client Monitor for bradycardia

Use minimal tape on client's skin Rationale: Decreased estrogen production associated with aging affects skin texture and makes the skin dry and thin. Therefore the nurse should refrain from using tape on the client's skin to prevent skin injury. Warm clothing and monitoring heart rate are needed for older adult clients with decreased general metabolism or hypothyroidism but are not relevant with estrogen deficiency. A client exhibiting signs of decreased glucose tolerance, such as slow wound healing and recurrent yeast infections, should be tested for blood glucose levels.

Which response would the nurse make to the son who says, 'I should never have allowed my father to live alone like he wanted to because he has Alzheimer disease. I'm to blame! He didn't even recognize me?'? 'I don't think that anybody can blame you. You did what he wanted. Your being here tells us that you care.' 'I realize that you're upset now. You can visit again when he is more responsive. I'm sure you'll see a change.' 'Why do you think your father's condition has deteriorated? His forgetfulness is temporary. You'll help if you don't cry.' 'This must be a difficult time for both of you. Please share some of your other observations with us--that will help us plan his care.'

'This must be a difficult time for both of you. Please share some of your other observations with us--that will help us plan his care.' Rationale: The nurse would say,' This must be a difficult time for both of you. Please share some of your other observations with us--that will help us plan his care.' Noting that this must be a difficult time for both father and son and asking the son to share some of his other observations to help the nursing staff plan the father's care focuses on feelings and promotes verbalization, which may ease anxiety and feelings of guilt. Also, it may help the son feel useful. Saying that no one could blame the son because he did what the father wanted and telling the son that his presence indicates caring is a generalized personal opinion; the nurse at this time does not know about the family's relationship. Telling the son t hat the father will certainly show a change in his behavior provides false reassurance. Asking the son why he thinks that his father's condition has deteriorated is confrontational (using 'why') and may precipitate a defensive response. Moreover, Alzheimer disease is not temporary, and crying should not be discouraged because it helps relieve tension.

The nurse is caring for an older adult who was admitted to the hospital to be treated for dehydration. While the nurse is providing discharge teaching, the client asks what to do about itchy, dry skin. Which response by the nurse is appropriate? 'Wear plenty of warm clothes to keep moisture in the skin.' 'Use a moisturizer on the skin daily to help reduce itching.' 'Take hot tub baths only twice a week to reduce drying of the skin.' 'Expose the skin to the air to help reduce the sensation of itching.'

'Use a moisturizer on the skin daily to help reduce itching.' Rationale: Lubricating the skin with a moisturizer effectively relieves dryness and, thus, the pruritis (itching). Wearing warm clothing will not lubricate the skin or relieve pruritis. Warm or cool, not hot, tub baths will reduce itching. Exposing the skin to the air causes further drying and will not relieve pruritis.

Which intervention would the nurse implement with a healthy older adult client who has decreased bone density? Teaching the client to do isometric exercises Encouraging the client to do weight-bearing exercise Instructing the client to sit in supportive chairs with arms Providing moist heat such as a shower or moist compresses

Encouraging the client to do weight-bearing exercise Rationale: Older adults are at risk of developing decreased bone density. Elderly clients with decreased bone density should be encouraged to do weight-bearing exercises. Teaching isometric exercises would be beneficial for a client with muscular atrophy. A client with kyphotic posture should be instructed to sit in supportive chairs with arms. Providing moist heat would be beneficial for a client with cartilage degeneration.

Which intervention would the nurse include in the nursing home plan of care for an older adult with Alzheimer disease who has nighttime wandering? Order a vest restraint for the client to be applied at night. Obtain a prescription for a sedative so the client will sleep better at night. Request that the family provide a companion to stay with the client at night. Assign the client to a room near the nurses' station for closer supervision at night.

Assign the client to a room near the nurses' station for closer supervision at night. Rationale: The nurse would assign the client to a room near the nurse's station for closer supervision at night because the client has nighttime wandering. It is the nurse's responsibility to ensure the safety of clients; close supervision can help ensure that the client does not wander. Restraints should not be used without a primary health care provider's order; a restraint is too excessive an intervention to prevent wandering. The issue is not that the client does not sleep; the issue is that the client wanders, and sedatives can increase confusion in older adult clients. It is the responsibility of the facility (not the family), specifically the nurse, to meet the needs of and ensure the safety of clients.

Which finding in older adult clients is associated with aging? Decrease in height Decreased neck rigidity Increased fine-motor dexterity Increased range of motion (ROM)

Decrease in height Rationale: Loss of height and deformity and shortening of the trunk are common in older adults because of vertebral compression and degeneration. Rigidity in the neck, shoulders, back, hips, and knees increases with age because of loss of elasticity in ligaments, tendons, and cartilage. A decline in fine-motor dexterity occurs in the older adult because of slow impulse conduction along motor units. Range of motion (ROM) is limited in the older adult because of cartilage erosion, increased friction between the bones, and overgrowth of bone around joint margins.

Which action would the nurse take when caring for an older adult with a history of recent memory loss? Instruct the client to move slowly when changing positions. Remind the client to look where he or she places the feet while walking. Adjust the daily schedule to accommodate sleep pattern. Employ electronic devices that provide alerts.

Employ electronic devices that provide alerts. Rationale: Providing electronic devices that give alerts can help an older adult who has developed recent memory loss. Adjusting the daily schedule can aid older adults who have changes in their sleep pattern. Instructing the client to move slowly when changing positions can prevent dizziness and falls caused by orthostatic blood pressure changes or altered balance/coordination. Reminding the client to check where the feet are placed can help older adults with a decreased sensory perception of touch.

Which action would the nurse take for a daughter who states that she gives sleeping pills to her live-in mother who has dementia to stop wandering at night? Explore hiring a home health aide to stay with the client at night. Discuss the possibility of having the client placed in a nursing home. Suggest moving the client among family members on a monthly basis. Empathize with the daughter but suggest that wrist restraints would be preferable.

Explore hiring a home health aide to stay with the client at night.

Which factor would the nurse consider when planning activities for an older resident in a long-term care facility with a diagnosis of neurocognitive disorder? Varied activities that will keep the resident occupied Familiar activities that the resident can complete successfully Challenging activities to maintain the resident's contact with reality Unit activities to ensure that the resident actively participates daily

Familiar activities that the resident can complete successfully

Which interventions would the nurse take to ensure the well-being of a community-dwelling older adult with dementia? Select all that apply. One, some, or all responses may be correct. Obtain the client's medication history and educate the older adult about safe medication storage. Foster human dignity and maintain the best possible functioning, protection, and safety. Teach the client to be cautious of false advertisements that promise a cure for the disease. Show the caregiver techniques to dress, feed, and toilet the older adult. Protect the client's rights and provide support to maintain the physical and mental health of family members.

Foster human dignity and maintain the best possible functioning, protection, and safety. Show the caregiver techniques to dress, feed, and toilet the older adult. Protect the client's rights and provide support to maintain the physical and mental health of family members. Rationale: When caring for a community-dwelling older adult with dementia, the nurse would maintain the best possible functioning, protection, and safety in addition to fostering human dignity. The nurse would demonstrate to the caregiver techniques to dress, feed, and toilet the client, and protect the client's rights and provide support to maintain the physical and mental health of the family members. When a community-dwelling older adult has medication use and abuse issues, the nurse would obtain the client's medication history. Educating an older adult with dementia about safe medication storage is not appropriate because he or she may not understand the process. If a community-dwelling older adult has arthritis, the nurse would teach the adult to be cautious of false advertisements that promise a cure for the disease.

An 85-year-old client is alert and able to participate in care. According to Erikson, which developmental stage will the client need to adjust to? Industry versus inferiority Identity versus role confusion Generativity versus stagnation Autonomy versus shame/doubt

Generativity versus stagnation Rationale: The generativity versus stagnation stage precedes integrity versus despair; Erikson theorized that how well people adapt to a present stage depends on how well they adapted to the immediately preceding stage. Industry versus inferiority is the stage of school-age children; it precedes identity versus role confusion, not integrity versus despair. Identity versus role confusion is the stage of adolescence; it precedes intimacy versus isolation, not integrity versus despair. Autonomy versus shame/doubt is the stage of early childhood; it precedes initiative versus guilt, not integrity versus despair.

Which theory proposes that older adults experience a shift from a materialistic to cosmic view of the world? Activity theory Continuity theory Disengagement theory Gerotranscendence theory

Gerotranscendence theory Rationale: The gerotranscendence theory is a recent theory that proposes that the older adult experiences a shift in perspective with age. The person moves from a materialistic and national view of the world to a more cosmic and transcendent one. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory suggests that a person's personality remains stable and behavior becomes more predictable as people age. The disengagement theory states that aging individuals withdraw from customary roles and engage in more introspective, self-focused activities.

Which action would the nurse take for an older resident in a nursing home with Alzheimer disease who hoards leftover food and other seemingly valueless articles and stuffs them into pockets 'so the others won't steal them'? Remove the resident's unsafe and soiled articles during the night. Give the resident a small bag in which to place selected personal articles and food. Explain to the resident why the nursing home's policy for cleanliness and safety must be followed. Tell the resident that the staff is required to keep harmful objects out of reach in the resident's closet.

Give the resident a small bag in which to place selected personal articles and food. Rationale: The nurse would give the resident a small bag in which to place selected personal articles and food. This action allows the client to exercise the right to decide which articles to keep and helps ensure safety and cleanliness. Removing the resident's unsafe and soiled articles during the night deceives the client and will create mistrust toward the staff. Because of the client's decreased attention span and memory, explanations alone will not help ensure safety or meet this client's needs. Telling the resident that the staff is required to keep harmful objects out of reach in the resident's closet does not address the client's needs and with the loss of short-term memory, this may be futile; no data indicate that the resident is hoarding harmful objects.

Which initial nursing intervention would the nurse take for an older adult with delirium who begins acting out while in the dayroom? Instructing the client to be quiet Allowing the client to act out until fatigue sets in Guiding the client from the room by gently holding the client's arm Giving the client one simple direction at a time in a firm, low-pitched voice

Giving the client one simple direction at a time in a firm, low-pitched voice Rationale: Clients with delirium typically respond to simple directions stated one at a time in a firm, low-pitched voice. 'Be quiet' is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client's arm is done only after giving simple directions and attempting to calm the client has failed. Touch should also be used cautiously in clients who have delirium because the client may misinterpret the gesture as aggressive.

Which action would the nurse take for an older client with Alzheimer disease who has laid out several outfits on the bed to wear to a recreational session but is still wearing nightclothes? Assist the client to dress and explain when residents are expected at the activity. Prompt the client to dress more quickly to avoid delaying the other residents. Help the client select appropriate attire and offer to help the client get dressed. Allow the client time to dress but explain that the client has missed the opportunity to attend the activity.

Help the client select appropriate attire and offer to help the client get dressed. Rationale: Helping the client select appropriate attire and offering help in getting dressed is the action the nurse would take. This aids the client in decision-making; new situations may be stressful and may lead to ambivalent feelings. Assisting the client to dress and explaining when residents are expected at the activity is not sharing decision-making; the client may not remember this explanation in the future. Reminding the client to dress more quickly to avoid delaying the other residents may make the client more anxious and frustrated. Because of Alzheimer disease, the client needs help, not punishment, for getting dressed to attend an activity.

The nurse is preparing to teach a community health program for senior citizens. Which physical findings would the nurse include that are typical in older adults? Increased skin elasticity and an increase in testosterone production Impaired fat digestion and an increase in pepsin production Increased blood pressure and decreased cardiac output An increase in body warmth and some swallowing difficulties

Increased blood pressure and decreased cardiac output Rationale: With aging, narrowing of the arteries causes some increase in the systolic and diastolic blood pressures. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. Changes in libido may occur. Testosterone appears to influence the frequency of nocturnal erections; however, low testosterone levels do not affect erections produced by erotic stimuli. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70 to 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in subcutaneous fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse medication reactions.

The nurse recognizes that a common conflict experienced by older adults is the conflict between which? Youth and old age Retirement and work Independence and dependence Wishing to die and wishing to live

Independence and dependence Rationale: A common conflict confronting older adults is between the desire to be taken care of by others and the desire to be in charge of their own destiny. The conflict between the young and old age may occur but is not common. The conflict between retirement and working may occur but is not common. The conflict between wishing to die and wishing to live may occur but is not common.

Which action is appropriate when caring for an elderly client admitted to a health care facility? Ensure that the room is brightly lit. Speak to the client in a loud voice. Stand close to the client's ear while speaking. Invite a family member to join the conversation.

Invite a family member to join the conversation. Rationale: The nurse would invite a family member to join the conversation. This action helps reassure the client. The nurse would ensure that the room is adequately lit and the ambience is comfortable for the client. Bright lights may be disturbing for an elderly client. The nurse would speak to the client in a slow, normal tone of voice. The nurse would not assume that the client has a hearing problem. The nurse need not stand close to the client's ear while speaking. The nurse would sit in front of the client so that the client can see the nurse's lip movement and facial expressions.

Which program would the nurse suggest for the 70-year-old client who needs to undergo heart surgery but cannot afford it? Medicaid Medicare Managed care organization Preferred care organization

Medicare Rationale: The nurse would discuss the Medicare program with this client. This health insurance program is designed for clients 65 years of age and older. There are four parts of Medicare; part A takes care of medical, surgical, and psychiatric costs. Medicaid is a state-operated program that provides long-term care to low-income families and disabled older clients. The nurse may suggest this program in the case of disabilities, but Medicare is the preferred choice. Managed care organization (MCOs) provide comprehensive preventive and treatment services to a specific group of voluntarily enrolled people. Preferred care organizations (PCOs) narrow down the list of hospitals, primary health care providers, and health care providers available to the member. PCO and MCO members need to pay from their own pockets to afford these facilities.

While caring for an older adult client, which symptom would require an immediate reassessment of the client's needs and plan of care? Memory loss or confusion Neglect of self-care Increased daily fatigue Withdrawal from usual activities

Memory loss or confusion Rationale: Memory loss or confusion would require an immediate reassessment. All are common signs of depression due to the aging process; however, memory loss or confusion requires immediate intervention. The development of confusion indicates that the client's ability to maintain equilibrium has not been achieved and that further disequilibrium is occurring, setting the client up for safety issues. Confusion may also be related to more serious physical conditions that can occur which require medical intervention. Although neglect of self-care can occur, it is not the immediate need. Although increased daily fatigue is important, it does not require immediate follow-up. It is common for clients with depression to withdraw from usual activities, so it does not need immediate assessment.

Which characteristic about confusion would the nurse keep in mind when an older client with Alzheimer disease is admitted to a long-term care facility? Occurs with a transfer to new surroundings Will be unchanged despite reality orientation Is a common finding and expected with normal aging Results from brain changes that make interventions futile

Occurs with a transfer to new surroundings Rationale: A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with Alzheimer disease; with appropriate intervention, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. Although confusion may be a common finding in Alzheimer disease, it is not expected with normal aging. Although brain changes do not occur with Alzheimer disease, interventions can be instituted to decrease confusion.

Which intervention would the nurse include when developing a plan of care for an older client with dementia? Explain to the client the details of the regimen. Demonstrate interest in the client's various likes and dislikes. Be firm when dealing with the client's attitudes and behaviors. Provide consistency in carrying out nursing activities for the client.

Provide consistency in carrying out nursing activities for the client. Rationale: The nurse would include providing consistency in carrying out nursing activities for the client. Familiarity with situations and continuity add to the client's sense of security and foster trust in the relationship. Detailed explanations will be forgotten; instructions should be simple and to the point and given when needed for clients with dementia. Although demonstrating interest in the client's likes and dislikes helps individualize care, in a client with dementia likes and dislikes may be hard to remember.

Which guideline would the nurse consider when planning care for a hospitalized older client with Alzheimer disease? Physical contact will increase dependency needs. Routines provide stability for clients with neurocognitive disorders. Regressive behavior should be interrupted immediately. Procedures do not have to be explained to clients with neurocognitive disorders.

Routines provide stability for clients with neurocognitive disorders. Rationale: Routines provide stability for clients with neurocognitive disorders. Rituals and routines in activities of daily living provide a framework and structure for clients with Alzheimer disease, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency, and touch may have to be used judiciously depending upon the stage of Alzheimer disease. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood by clients with Alzheimer disease.

An older client with Alzheimer type dementia, consistently sleeps in a semi-Fowler position in bed. Which area of the client's body would the nurse consider a high risk for developing a pressure injury? Sacrum Scapulae Ischial spine Greater trochanter

Sacrum Rationale: The sacrum is the center of the greatest body mass; an elevated torso exerts pressure toward this area. Although the scapulae are at risk, they do not bear the greatest body weight as when the client is in the semi-Fowler position. The ischial spine bears the greatest pressure when the client is in an upright sitting position. Greater trochanter is at risk when the client is in a side-lying position.

Which characteristic of a therapeutic milieu would the nurse consider important for a confused older adult with socially aggressive behavior? Sets limits Has variety Is group oriented Allows freedom of expression

Sets limits Rationale: The therapeutic milieu characteristic would be to set limits. Because clients with socially aggressive behavior have poor control, these individuals require a therapeutic environment in which appropriate limits for behavior are set for them. Variety will increase anxiety. The daily routine should be structured and repetitive. A group-oriented environment is too stimulating for a person with socially aggressive behavior. Freedom of expression may result in injury to the client or others, because the client may be unable to control impulses.

Which activity would the nurse ask the older adult client to do when testing short-term memory? Subtract serial sevens from 100. Copy one simple geometric figure. State three random words mentioned earlier in the examination. Name two common objects when the nurse points to them.

State three random words mentioned earlier in the examination. Rationale: Stating three random words mentioned earlier in the examination is a test of the client's ability to recall from short-term memory. Subtracting serial sevens from 100 is a test of the ability to calculate and pay attention. Copying one simple geometric figure is a test of visual comprehension. Naming two common objects when the nurse points to them is a test of verbal skills, not short-term memory.

Which approach would the nurse take for an older adult client who is confused, does not recognize family members, and often soils clothing with feces and urine? Toileting the client every 2 hours Placing the client in orientation therapy Supervising the client's bathroom activities closely Explaining to the client how offensive the behavior is to others

Toileting the client every 2 hours Rationale: The approach the nurse would use is to toilet the client every 2 hours. This client needs toileting every 2 hours to prevent soiling; physically seating the client on the toilet often prevents accidents and negates the need for disposable pads or underwear. The client has cognitive impairment, and reality orientation will probably be ineffective. The client who is this severely confused needs more than just supervision. The client may be unable to control the incontinence, and saying that the behavior is offensive is demeaning.

Which principles would promote learning in older adults? Select all that apply. One, some, or all responses may be correct. Emphasize abstract material. Use past experiences while teaching. Teach by presenting multiple examples at a time. Keep the environmental distractions to a minimum. Use audio, visual, and tactile cues to enhance learning.

Use past experiences while teaching. Keep the environmental distractions to a minimum. Use audio, visual, and tactile cues to enhance learning. Rationale: The nurse would use past experiences while teaching an older client; keep environmental distractions to a minimum; and use audio, visual, and tactile cues to enhance learning. This helps the client remember all the information. The nurse would emphasize concrete material. The nurse would teach clients by using one example at a time.

Which priority nursing intervention would the nurse include in the plan of care for an older adult who sustained a right hip fracture? Oxygen therapy Cardiac monitoring Nutrition supplements Venous thromboembolism (VTE) prevention

Venous thromboembolism (VTE) prevention Rationale: After hip surgery, development of a VTE commonly occurs. Nursing must implement preventive intervention; this is a component of core measures. Nutritional supplements, cardiac monitoring, and oxygen therapy may be necessary in some clients with hip fractures, but not in all.