EAQ WEEK 3
When teaching about aging, the nurse explains that older adults usually have what characteristic?
A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.
The nurse recognizes that which are important components of a neurovascular assessment? Select all that apply.
A neurovascular assessment involves evaluation of nerve and blood supply to an extremity involved in an injury. The area involved may include an orthopedic or soft tissue injury. A correct neurovascular assessment should include evaluation of capillary refill, pulses, warmth and paresthesias, and movement and sensation. Orientation, pupillary response, and respiratory rate are components of a neurologic assessment.
Health promotion efforts within the healthcare system should include efforts related to secondary prevention. Which activities reflect secondary prevention interventions in relation to health promotion? Select all that apply.
Encouraging regular dental checkups is a secondary prevention activity because it emphasizes early detection of health problems, such as dental caries and gingivitis. Teaching the procedure for breast self-examination is a secondary prevention activity because it emphasizes early detection of problems of the breast, such as cancer. Facilitating smoking cessation programs is a primary prevention activity because it emphasizes health protection against heart and respiratory diseases. Administering influenza vaccines to older adults is a primary prevention activity because it emphasizes health protection against influenza. Referring clients with a chronic illness to a support group is a tertiary prevention activity because it emphasizes care that is provided after illness already exists.
When assessing a client, the nurse auscultates a murmur at the second left intercostal space (ICS) along the sternal border. This reflects sound from which valve?
The second left intercostal space (ICS) along the sternal border reflects sounds from the pulmonic valve. The correct landmark for auscultating the aortic valve is at the right second ICS at the sternal border; for the mitral valve (apical pulse) at the left fifth ICS in the midclavicular line; and for the tricuspid valve at the left fifth ICS at the sternal border.
A client who was exposed to hepatitis A asks why an injection of gamma globulin is needed. Before responding, what should the nurse consider about how gamma globulin provides passive immunity?
Gamma globulin, which is an immune globulin, contains most of the antibodies circulating in the blood. When injected into an individual, it prevents a specific antigen from entering a host cell. Gamma globulin does not stimulate antibody production. It does not affect antigen-antibody function.
Which nursing activities are examples of primary prevention? Select all that apply.
Immunization programs prevent the occurrence of disease and are considered primary interventions. Stopping smoking prevents the occurrence of disease and is considered a primary intervention. Preventing disabilities is a tertiary intervention. Correcting dietary deficiencies is a secondary intervention. Establishing goals for rehabilitation is a tertiary intervention.
The nurse should place the client in which position to obtain the most accurate reading of jugular vein distention?
Jugular vein pressure is measured with a centimeter ruler to obtain the vertical distance between the sternal angle and the point of highest pulsation. This procedure is most accurate when the head of the bed is elevated between 30 and 45 degrees. The internal and external jugular veins should be inspected while the client is gradually elevated from a supine position to an upright 30-45 degrees. Jugular vein distention cannot accurately be assessed if the client is supine, at 90 degrees, or at 10 degrees.
The nurse is admitting a confused 80-year-old client to the mental health unit. Which is one factor associated with the aging process?
Neurologic responses are slowed because of reduced sensory-receptor sensitivity. Excluding pathologic processes, the personality will be consistent with that of earlier years. There is no loss of intellectual ability unless there is a pathologic problem. Short-term, not long-term, memory is reduced because of a shortened attention span, delayed transmission of information to the brain, and perceptual deficits.
A nurse is conducting a health class for adolescents. What modifiable risk factor, most closely associated with the development of coronary heart disease (CHD) in both men and women, should the nurse discuss?
Nicotine in cigarette smoke constricts blood vessels, including coronary arteries, which contributes to the occurrence of angina and CHD. Opioid use is not a risk factor for CHD. Judicious alcohol intake may promote relaxation, decreasing stress and limiting the development of CHD. Inactivity, not moderate exercise, is a risk factor for CHD. Exercise decreases hypertension, blood clotting, and heart rate. Exercise also increases metabolism, the plasma level of high-density lipoprotein cholesterol, and cardiac capillary blood flow.
A 93-year-old client in a nursing home has been eating less food during mealtimes. What is the priority nursing intervention?
Older clients may display psychomotor retardation and need more time to complete the tasks associated with the activities of daily living; mealtimes should be relaxing and social. Supplemental drinks should augment meals and be offered between meals, not as a substitute for meals. Clients should be encouraged to feed themselves to remain as independent as possible; spoon-feeding may not mirror the pace of eating preferred by the client, and forcing the client to eat all of the food may precipitate anxiety, frustration, and agitation. Placement of a gastrostomy tube is premature.
A public health nurse routinely performs health screenings in the local senior citizen center. What concept about older adults is essential for the nurse to remember when working with these clients?
Optimal health is central to optimal retirement; with good health, objectives and goals are more likely to be achieved. Reviewing the past is an essential part of the life review that older adults must engage in to eventually reach integrity. The person may be in despair when reviewing the past is depressing. Most older adults prefer familiar routines and environments and desire independence even when coping with the effects of aging and chronic illness.
Health promotion efforts for a chronically ill client should include interventions related to primary prevention. What should this include?
Primary prevention activities are directed toward promoting a healthful lifestyle and increasing the level of well-being. Performing yearly physical examinations is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Providing hypertension screening programs is a secondary prevention. Emphasis is on early detection of disease, prompt intervention, and health maintenance for those experiencing health problems. Teaching a person with diabetes how to prevent complications is a tertiary prevention. Emphasis is on rehabilitating individuals and restoring them to an optimal level of functioning.
What is the most appropriate communication strategy for the nurse working with adolescents in a clinic in a large city health center?
Several meetings with an adolescent provide an opportunity to develop trust and establish a relationship. Relating on a peer level is unrealistic because the nurse is not an adolescent's peer. Using teenage language is not necessary and may even impede the establishment of a relationship. It is not necessary to use concrete terms, because the adolescent is capable of abstract thought.
The nurse pulls up on the client's skin and releases it to determine whether the skin returns immediately to its original position. What is the nurse assessing for?
Skin turgor is assessed by gently pinching the skin and releasing it while observing the degree of elasticity. If the skin pinch remains elevated or is slow to return to its original position, this may be an indication of dehydration or deficient fluid volume. This assessment technique is not appropriate for assessing pain tolerance, checking for ecchymosis formation, or measuring tissue mass.
A nurse is performing a neurologic assessment of an adolescent with a seizure disorder. How should the nurse test cranial nerve XI?
The accessory nerve (cranial nerve XI) innervates the sternocleidomastoid and trapezius muscles; the nurse evaluates this nerve by asking the client to shrug the shoulders. The glossopharyngeal nerve (cranial nerve IX) is assessed by stimulating the pharynx with a tongue blade. The vagus nerve (cranial nerve X) controls muscles of the larynx and is assessed by asking the client to swallow. Stroking the plantar surface of the foot is a test for the presence or absence of the Babinski reflex; this test is not used for assessment of a cranial nerve.
Which landmark is correct for a nurse to use when auscultating the mitral valve?
The correct landmark for auscultating the mitral valve (apical pulse) is found at the left fifth intercostal space (ICS) in the midclavicular line. Auscultation at the fifth ICS in the midaxillary line would yield breath sounds of the lateral lung field. Auscultation at the left second ICS at the sternal border is best to hear the pulmonic valve, and at the left fifth ICS at the sternal border for the tricuspid valve.
Nurses care for clients in a variety of age groups. In which age group is the occurrence of chronic illness the greatest?
The incidence of chronic illness increases in older adults because of the multiple stresses of aging. Younger individuals have greater physiologic reserves, and chronic illnesses are not common.
An older adult with a chronic degenerative disease progresses to the stage at which self-care is no longer possible, and admission to a long-term care facility becomes necessary. What is the major developmental conflict for this client, according to Erikson?
The need for acceptance of life as fulfilling and meaningful is the major task of the older adult. Intimacy versus isolation is the task of young adulthood (18 to 25 years); it involves establishment of an intimate relationship and occupation. The task of the adolescent (12 to 20 years) is establishing identity through work and development of relationships and an occupation. Generativity versus stagnation is the task of adulthood (21 to 45 years); it involves establishment of a family and guidance of the next generation.
The mother of an adolescent asks the nurse, "What's the best way to remove a tick from the skin?" What is the best response by the nurse?
The tick must be carefully removed with tweezers or forceps so the body and head are both removed; this technique prevents further inoculation of the individual. Using a lit cigarette, ammonia, or insect repellent is unsafe; the tick may further inoculate the child, and the method may hurt the child.
How should the nurse prevent footdrop in a client with a leg cast?
To prevent footdrop (plantar flexion of the foot because of weakness or paralysis of the anterior muscles of the lower leg) in a client with a cast, the foot should be supported with 90 degrees of flexion. Bed rest can cause footdrop, and 45 degrees is not enough flexion to prevent footdrop. Application of an elastic stocking for support also will not prevent footdrop; a firmer support is required.