concorde eaq 4A
A client is scheduled to receive phenytoin (Dilantin) 100 mg orally at 6 PM but is having difficulty swallowing capsules. What method should the nurse use to help the client take the medication?
Contact the prescriber to determine if a change to a suspension form would be possible.
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult the nurse recalls the expected sensory losses associated with aging. (Select all that apply.)
Diminished sensation of pain Impaired hearing of high-frequency sounds
A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? (Select all that apply.)
Dry cerumen Difficulty hearing high-pitched voices
A nurse is caring for a client who is having diarrhea. To prevent an adverse outcome, the nurse should most closely monitor what patient data or assessment finding?
Fluid and electrolyte balance
An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods of time. The family blames the nurses and threatens to sue. What is considered when determining the source of blame for the pressure ulcer?
The client should have been turned regularly.
Remove and dispose of the patch in an appropriate receptacle.
detachment
A home health nurse checks the client's vital signs and completes a follow- up visit. After completion of these tasks, the client asks the nurse to straighten the blankets on the bed. What is the nurse's most appropriate response?
"Of course. I want to do whatever I can for you.
A client with a diagnosis of uncontrolled diabetes began receiving Lasix (Furosemide) two days ago. The nurse reviews the morning lab results and discovers that the client's potassium level is 2.8 mEq/L. What is the most appropriate action for the nurse to take?
Notify the primary healthcare provider of the result, which is critically low
A nurse has provided discharge instructions to a client who received a prescription for a walker to use for assistance with ambulation. The nurse determines that the teaching has been effective when the client:
Moves the walker no more than 12 inches in front of the client during use.
An 89-year-old client with osteoporosis is admitted to the hospital with a compression fracture of the spine. The nurse identifies that a factor of special concern when caring for this client is the client's:
Inability to maintain an optimal level of functioning
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that the physical findings that are typical in older people include:
Increased blood pressure and decreased hormone production
Which age-related change should the nurse consider when formulating a plan of care for an older adult? (Select all that apply.)
Increased sensitivity to glare Diminished sensation of pain
What physiological changes that occur with aging must be taken into consideration when the nurse provides care for the older adult? (Select all that apply.)
Urinary urgency Loss of skin elasticity Swallowing difficulties Elevated blood pressure
A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include?
Wash your hands before performing the procedure."
What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental task associated with aging?
Attainment of a sense of worth as a person
The nurse administers a pneumococcal vaccine to a 70-year-old client. The client asks "Will I have to get this every year like I do with the flu shot?" How should the nurse respond?
It is unnecessary to have any follow-up injections of the pneumococcal vaccine after this dose."
Which action by a home care nurse would be considered an act of euthanasia?
Knowing that a dying client is overmedicating and not acting on this information.
A health care provider prescribes digoxin (Lanoxin) for a client. The nurse teaches the client to be alert for which common early indication of digoxin toxicity?
nausea
When teaching about aging, the nurse explains that older adults usually have:
slower reaction times
A client has a pressure ulcer that is full thickness with necrosis into the subcutaneous tissue down to the underlying fascia. The nurse should document the assessment finding as which stage of pressure ulcers?
stage 3
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer's dementia. The client lives alone. The client's adult children live nearby. According to the prescribed medication regimen the client is to take medications six times throughout the day. What is priority nursing intervention to assist the client with compliance with medication-taking?
Contact the primary healthcare provider and discuss the possibility of simplifying the medication regimen
As a nurse prepares an older adult client for sleep, actions are taken to help reduce the likelihood of a fall during the night. What nursing action is most appropriate when targeting older adults' most frequent cause of falls?
Instructing the client to call the nurse before going to the bathroom.
The most effective time to teach clients who have sustained a sudden, traumatic, major loss is most often during the acceptance or adaptation stage of coping. The rationale for this fact is that clients in this stage are:
Less anxious and more aware of reality and therefore ready to learn
A postoperative client says to the nurse, "My neighbor—I mean the person in the next room—sings all night and keeps me awake." The neighboring client has dementia and is awaiting transfer to a nursing home. How can the nurse best handle this situation?
Move the post-operative client to a room at the end of the hall.
While instructing a community group regarding risk factors for coronary artery disease, the nurse provides a list of risk factors that cannot be modified. What should be included on the list?
heredity
A client with limited mobility is being discharged. To prevent urinary stasis and formation of renal calculi, the nurse should instruct the client to:
increase oral fluid intake to 2 to 3 L per day.
A client using fentanyl (Duragesic) transdermal patches for pain management in late-stage cancer dies. What should the hospice nurse who is caring for this client do about the patch?
Remove and dispose of the patch in an appropriate receptacle.
A client, who is in a late stage of pancreatic cancer, intellectually understands the terminal nature of the illness. Behaviors that indicate the client is emotionally accepting of impending death are that the client is:
Revising the client's will and planning a visit to a friend
The nurse recognizes that a common conflict experienced by the older adult is the conflict between:
independence and dependence
A nurse is supportive of a child receiving long-term rehabilitation in the home rather than in a health care facility. Why is living with the family so important to a child's emotional development?
it is where child's identity and roles are learned.
A dying client is coping with feelings regarding impending death. The nurse bases care on the theory of death and dying by Kübler-Ross. During which stage of grieving should the nurse primarily use nonverbal interventions?
acceptance
A nurse is caring for an elderly client with dementia who has developed dehydration as a result of vomiting and diarrhea. Which assessment best reflects the fluid balance of this client?
blood lab result
A client reports vomiting and diarrhea for three days. What clinical finding most accurately will indicate that the client has a fluid deficit?
loss of body weight
While assessing an immobilized client, the nurse notes that the client has shortened muscles over a joint, preventing full extension. This condition is known as:
contracture
The nurse reviews a medical record and is concerned that the client may develop hyperkalemia. Which disease increases the risk of hyperkalemia?
end stage renal
