Exam 4 MS - Wk 13

A client has died after a long hospital stay. The family was present at the time of the client's death. Which postmortem nursing action is appropriate? A. Asking the family if they wish to help wash the client B. Asking the family to leave during post-death care C. Raising the head of the bed and opening the client's eyes D. Removing dentures and any prosthetics

A The nurse may ask the family if they wish to be involved in washing the client after the client's death. The family should be allowed to grieve at the bedside of the client. The head of the bed should be flat, and the client's eyes closed. The client's dentures and prosthetics should be replaced, not removed.

The nurse in critical care unit notes that most clients admitted with a COVID-19 infection are people of color. What social determinants of health may contribute to this health inequity? (Select all that apply.) A. Low-income level B. Multiple chronic health conditions C. Inadequate health care access D. Living in multigenerational households E. Low educational level

A, B, C, D, E Many factors contribute to the lack of health equity between people of color and white individuals related to outcomes of many conditions, including COVID-19 infection. The nurse needs to assess for these social determinants of health (SDOH) and consider them as part of the client's plan of care. All of the choices are examples of common SDOH that affect health equity today.

The nurse is assessing an older adult client to identify possible factors that may negatively impact the client's nutritional status. For which risk factors would the nurse assess? (Select all that apply.) A. Tooth loss or poorly fitting dentures B. Constipation C. Inadequate financial resources D. Loneliness or depression E. Lack of transportation F. Decreased mobility

A, B, C, D, E, F All of these factors can prevent clients from eating adequate amounts of or healthy foods (Choice A, B, C, D, E, & F).

The nurse is teaching an older adult about the importance of keeping active and mobile for overall health benefits. Which statements by the nurse would be included in the health teaching? (Select all that apply.) A. "Keeping active will help you sleep better at night because you'll be more tired." B. "Moving as much as you can will help decrease your risk for falling as you age." C. "Walking and other exercise will help prevent unwanted weight gain." D. "Keeping active will help promote your mental health and prevent impaired cognition." E. "Maintaining an active lifestyle will expand your lungs and prevent lung disease." F. "Staying active will help prevent heart disease and type 2 diabetes mellitus."

A, B, C, D, F Staying active to maintain mobility is essential for healthy aging because regular movement helps improve sleep, decrease fall risk, prevent weight gain, improve mental health, and prevent common chronic health problems such as heart disease and diabetes (Choice A, B, C, D, & F). Activity does not directly expand one's lungs to prevent lung disease (Choice E).

The nurse is caring for a client who is actively dying. What nursing action is appropriate? (Select all that apply.) A. Use moist swabs to keep the mouth and lips moist. B. Place warm blankets on the client to keep them warm. C. Make sure the room is well-lit. D. Encourage the client to eat ice chips and drink as much as possible. E. Do not encourage the client to stay awake. F. Offer to insert a Foley catheter for comfort.

A, E, F When caring for a client actively dying, the skin may become cold and mottled. Do not apply heating blankets. Using moist swabs will help to keep the client's mouth and lips more comfortable. The room should be dimly lit, with minimal noise and stimulation. The client should be offered ice chips or drink but do not force to drink as much as possible. Allow the client to rest, do not force them to stay awake. The nurse can offer a Foley catheter for comfort.

The nurse manager for home health and hospice is scheduling daily client visits. Which client is appropriate for the assistive personnel to visit? A. Advanced cirrhosis of the liver and just called the hospice agency reporting nausea B. Aggressive brain tumor and needs daily assistance with ambulation and bathing C. Inoperable lung cancer and considering whether to have radiation and chemotherapy D. Prostate cancer with bone metastases and new-onset leg weakness and tingling

B Assisting clients with activities of daily living such as ambulation and bathing is a common role for assistive personnel working in home health or hospice agencies. Assessing and acting upon a new symptom (nausea), helping clients make decisions, and evaluating a new-onset symptom all require more complex assessment skills and interventions within the RN scope of practice.

The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? A. "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods." B. "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at least three times a week." C. "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day." D. "With less activity and exercise in my life these days, I should reduce my total calorie intake."

B Fast food is a contributor to high carbohydrate and caloric intake in older adults. Because fast food is relatively inexpensive and convenient, this population tends to abuse it, thus gaining weight from unhealthy calories (Choice B). Older adults do enjoy sweets and desserts because their taste acuity changes, but they still need to eat a variety of foods that are high in protein and vitamins, as well as with different textures and fiber content (Choice A). Consuming fresh fruits and vegetables is characteristic of a healthy lifestyle in older adults; this practice will help keep bowel habits routine (Choice C). As older adults begin to lead a more sedentary lifestyle, they need to decrease their caloric intake to match a diminished basal metabolic rate (Choice D).

The nurse is caring for an older adult at risk for experiencing delirium following surgery. Which nursing action is most important when caring for this client? A. Use a calm voice when communicating with the client. B. Screen the client at least twice a day for delirium. C. Reduce environmental stimulation where feasible. D. Reorient the client as often as the client needs it.

B The client is at risk for delirium and, therefore, the most important action is to detect it early so that it can be managed by screening the client at least twice a day (Choice B). If the client develops this condition, the other choices are appropriate nursing interventions (Choice A, C, & D).

The family of an older adult client states that they have noticed progressive periods of forgetfulness in the client over the past year. After noting the family's comments and assessing the client, which cognitive problem does the nurse suspect the client may have? A. Adverse drug event B. Delirium C. Dementia D. Depression

C Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline and recent progressive periods of forgetfulness, which this older adult has (Choice C). It is sometimes referred to as chronic confusion. An adverse drug event would be related to a specific medication and not appear progressively over time. Further cognitive and medical/neurologic testing would be needed to establish this diagnosis, which would not be done by a nurse (Choice A). Delirium is an acute state of confusion, which differs from dementia in that it is usually short term and reversible within 3 weeks. It is often seen in older adults when they are in an unfamiliar setting (Choice B). Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations (Choice D).

Which condition, when assessed in a client who is dying, requires the nurse to take action? A. Alternating apnea and rapid breathing B. Anorexia C. Cool extremities D. Moaning

D Moaning indicates pain and requires pain medication. Alternating apnea and rapid breathing, anorexia, and cool extremities are normal assessment findings in the client who is dying.

The nurse is preparing to give multiple prescribed medications to an older adult client. Which serum laboratory test value would the nurse review as the priority prior to medication administration? A. Blood urea nitrogen B. Hematocrit C. Sodium D. Creatinine

D Most drugs are excreted via the kidneys so it is important that the client has adequate kidney function. Creatinine is a protein waste product that is excreted by the kidneys with only a small amount remaining in the bloodstream. Therefore, it is the most important laboratory test value to review (Choice D). Blood urea nitrogen values are affected by kidney function, hydration status, and protein intake. Therefore, it is not the priority value to review before giving medications (Choice A). Hematocrit and sodium values may be affected by kidney disease, but they are not specific indicators of kidney function (Choice B & C).

A dying client becomes increasingly withdrawn and begins to refuse to eat and drink. What intervention will the nurse implement? A. Bring in the client's favorite food. B. Call the family to come in right away. C. Administer intravenous hydration. D. Offer ice chips.

D The client who is dying should not be forced to eat or drink, but small sips of liquids or ice chips at frequent intervals can be offered if the client is alert and able to swallow. This helps the client with problems of dehydration and "dry mouth." The client's metabolic needs have decreased, so the client will not want any food or drink. Calling the family is not yet necessary in this client's case. Because the dying client's metabolic needs have decreased, invasive procedures are not currently necessary.

The nurse is assessing an older adult for risk of falling as a basis for planning client care. Which of the following evidence-based risk factors contribute to the client's risk for falls? Select all that apply. A. 16-seconds to complete the Timed Up and Go test B. Urinary incontinence C. Acute confusion, especially at night D. Taking lorazepam at night E. History of recent falls F. Use of walker when ambulating

A, B, C, D According to the most current research conducted by Hendrich, seven risk factors best predict falling, including altered mental status and elimination. This client has acute confusion, which is an altered mental status, and urinary incontinence, which is a common alteration in elimination (Choices B and C). The older adult also has a mobility issue as evidenced by a decreased ability to rise from a chair and walk using the Timed Up and Go (TUG) Test. Clients who take 12 seconds or more to perform this activity have impaired mobility and are at a high risk for falls (Choice A). Older adults who take antiepileptics and/or benzodiazepines are at high risk for falls. This client takes lorazepam every night; lorazepam is a benzodiazepine, making Choice D a correct response. Although using a walker when ambulating suggests impaired mobility, this finding is not an evidence-based risk factor as stated (Choice F). A history of falls is an important finding but is no longer considered a major predictor of additional falls (Choice E).

The nurse is caring for a client in hospice care who is experiencing dyspnea, with a respiratory rate of 30. Which of the following nursing interventions are appropriate? Select all that apply. A. Direct a bedside fan toward the client's face. B. Apply oxygen at 2L per nasal cannula. C. Administer an anticholinergic sublingually. D. Administer low-dose morphine orally. E. Consult the provider for possible intubation.

A, B, C, D It is appropriate for the nurse to direct a fan toward the client's face as this is a comfort measure that can decrease the perception of dyspnea (Choice A). It is also appropriate to apply oxygen at the end of life regardless of the oxygen saturation (Choice B). Administering an anticholinergic can help to dry up secretions that contribute to dyspnea near death (Choice C). Administering morphine is the standard treatment for dyspnea near death (Choice D). It is not appropriate to consult the provider for possible intubation for a hospice client (Choice E).

The nurse recognizes that older adult clients when admitted to the hospital are at high risk for complications and even death. Which risk factors are considered "markers" that can contribute to these negative outcomes? (Select all that apply.) A. Sleep disorders B. Falls C. Confusion D. Incontinence E. Nutritional problems

A, B, C, D, E, F All of these evidence-based risk factors, or "markers" can increase hospital stays, lead to complications, and hasten death of older adults and are used as a basis for Fulmer's SPICES Assessment Tool (Choice A, B, C, D, & E).

In which newly admitted client situations does the nurse initiate a conversation about advance directives? (Select all that apply.) A. A client with a non-life-threatening illness B. A person who currently has advance directives C. The client with end-stage kidney disease D. The comatose client who was injured in an automobile crash E. The laboring mother expecting her first child

A, B, C, E All clients who are hospitalized need to be asked about advance directives by the nurse when they are admitted to a hospital. This is a requirement of the Patient Self-Determination Act. Many nurses feel uncomfortable discussing advance directives with "healthy" clients, but the circumstances of admission do not relieve the nurse of this responsibility. The client with preexisting advance directives still needs to be questioned; it is possible that the client's wishes have changed since the documents were established. Clients with potentially life-threatening diseases or conditions should establish advance directives while they can do so. The comatose client is not considered capable of making decisions about his or her wishes concerning advance directives.

The nurse assesses an older adult and notes the following findings. Which of the following assessment findings are expected as common problems or usual physiologic changes associated with aging? Select all that apply. A. Presbyopia B. Constipation C. Chronic confusion D. Tooth loss E. Decreased sense of taste

A, B, D, E Older adults commonly have vision changes in which farsightedness worsens, a condition called presbyopia (Choice A). Decreased intestinal peristalsis frequently causes constipation among older adults (Choice B). Tooth loss and a decreased sense of smell and taste are also common (Choices D and E). However, it is not a normal or usual change of aging for older adults to have chronic confusion (Choice C).

An older adult is diagnosed with hyperactive delirium. Which of the following assessment findings would the nurse anticipate? Select all that apply. A. Agitation B. Disorganized thinking C. Lethargy D. Chronic confusion E. Restlessness

A, B, E Delirium, sometimes called acute brain failure, is a mental health disorder that affects older adults more often than their younger adult counterparts. Delirium causes an acute cognitive impairment, or acute confusion; chronic confusion is associated with dementia (Choice D). The most common type is hyperactive delirium, indicating that the client would be expected to exhibit behaviors that include agitation, disorganized thinking, and restlessness (Choices A, B, and E). Being withdrawn, apathetic, and lethargic are behaviors that commonly occur in clients who have hypoactive delirium, or quiet delirium (Choice C).

The nurse is preparing to interview a home family caregiver as part of an older adult's hospital admission. Which questions would be appropriate to include in the interview? (Select all that apply.) A. "What matters most to you about the client's care either here or at home?" B. "How did you get selected to be the client's caregiver at home? C. "How do you think the client has been functioning recently?" D. "What matters most to you about the client's hospitalization?" E. "What concerns you the most now and in the future about the client's health?"

A, C, D, E Family caregivers should be considered as partners with the health care team when caring for an older client. Therefore, the nurse would interview them to obtain their perspective on what matters the most to older adults related to their health. All of the questions listed are appropriate to include in an interview except for Choice B which is not professional or therapeutic related to ascertaining what matters to the client.

The nurse is assessing a client who is receiving in-home hospice care. Which of the following assessment data indicate signs of approaching death? Select all that apply. A. Periods of apnea with alternating rapid breathing B. No bowel movement for 2 days C. Gurgling sound with inspiration D. Heart rate 130 beats/min; blood pressure 80/40 mm Hg E. Unable to lie still in the bed

A, C, D, E Periods of apnea that alternate with rapid breathing are referred to as Cheyne-Stokes respirations and are a sign of approaching death (Choice A). A gurgling sound, often referred to as the death rattle, can occur when death is approaching (Choice C). An elevated heart rate (130 beats/min) and low blood pressure (80/40 mm Hg), as well as restlessness (unable to lie still in bed), are also signs of approaching death (Choices D and E). While bowel function does decrease during the dying process, the client's lack of bowel movement in a short time frame (2 days) does not indicate that death is impending (Choice B).

The spouse of a client who has just died starts to cry and hug the client. Which of the following nursing responses are appropriate? Select all that apply. A. Allow the spouse to grieve. B. Ask the spouse not to touch the body. C. State, "Don't be upset; they are in a better place." D. State, "I am sorry this is happening." E. Leave the spouse alone with the client.

A, D When a client dies, the family should be allowed to grieve (Choice A). This will look different in every situation as expressions of grief vary widely. Crying and touching the deceased person are common reactions to death and should not be suppressed (Choice B). The nurse who states "I am sorry this is happening" is showing empathy and acknowledging the grief response (Choice D). The nurse would not state, "Don't be upset; they are in a better place." This statement diminishes the way the spouse feels and ascribes the nurse's belief system into the grieving process (Choice C). While the spouse may request some time alone with the deceased, the nurse should remain with the spouse unless this is requested (Choice E). Some family members do not want to be alone with the deceased.

The nurse reviews an older adult's medication profile during a home visit. Which drug classifications can cause the most serious adverse drug events in the older adult population? (Select all that apply.) A. Opioids B. Antihypertensives C. Diuretics D. Anticoagulants E. Anticholinergics

A, E Opioids can cause respiratory depression in older adults who do not have an oxygen reserve and acute confusion (Choice A). Anticoagulants are likely to cause more bleeding and bruising in older adults who have increased capillary fragility (Choice D). Anticholinergic agents can cause urinary retention, constipation, dry mouth, blurred vision, and acute confusion (Choice E). These classifications of drugs can cause harmful adverse drug events (ADEs). Antihypertensives and diuretics can also cause side effects and ADEs in older adults but are usually started at a low dose and increased as needed (Choice B & C).

A client with terminal pancreatic cancer is near death and reports increasing shortness of breath with associated anxiety. Which hospice protocol order will the nurse implement first? A. Albuterol solution per nebulizer B. Morphine sulfate sublingually as needed C. Oxygen 2 to 6 L/min per nasal cannula D. Prednisone elixir 10 mg orally

B Morphine sulfate is the standard treatment for the dyspneic client near death. Albuterol, oxygen, and steroids may be useful but should be used as adjuncts to therapy with morphine.

A client who is dying cannot swallow and is accumulating audible mucus in the upper airway (death rattles). These noises are upsetting to family members. What nursing action is appropriate? A. Assist the family in leaving the room so that they can compose themselves. B. Place the client in a side-lying position so secretions can drain. C. Position the client in a high-Fowler position to minimize secretions. D. Use a Yankauer suction tip to remove secretions from the client's upper airway.

B Placing the client in a side-lying position to facilitate the draining of secretions (by gravity) is the appropriate nursing care intervention. As secretions diminish, noisy respirations will decrease. Asking the family to leave at this important time is not appropriate. Placing the client in a high-Fowler position is ineffective in helping the client who has lost the ability to swallow and increases the danger of choking and aspiration. Oropharyngeal suctioning is not recommended for removing secretions because it is ineffective and may even agitate the client.

A client admitted to the hospital states, "Someone asked me to fill out an advance directive when I was admitted, but I was too stressed. What is that for?" How will the nurse respond? A. "Advance directives are for those individuals who are critically ill." B. "Advance directives allow a client to convey health care wishes." C. "You will need to see a lawyer to complete advance directives." D. "You need to complete that paperwork before admission."

B The nurse responds by stating that advanced directives allow a client to convey his or her wishes about health care. This best addresses the client's comments. Most advance directives are in place before the client becomes severely ill. Many Americans do not have advance directives in place. Legal assistance is not necessary to complete them. Although completing paperwork pertaining to advance directives before admission would be ideal, any time is a good to do this.

The daughter of a client who is dying states, "I don't want my father to be uncomfortable." How will the nurse respond? A. "Do you want to talk to the bereavement nurse?" B. "Your father will be closely monitored and cared for." C. "Your father will be sedated and comfortable." D. "We will send him to hospice when the time comes."

B The nurse responds by telling the daughter that her father will be closely monitored and cared for. This would reassure the daughter as well as provide support and comfort. The daughter's comment does not require the expertise of a bereavement nurse. Also, asking if the daughter wants to talk to a bereavement nurse is a "yes-or-no" question, it is a nontherapeutic response and may shut off the dialog. The dying client is not typically sedated; clients are comfortable with as little or as much pain medication as needed. A goal is to keep the client alert and able to communicate. Telling the daughter that her father will be sent to hospice when the time comes does not address the daughter's concern about her father's comfort, and it closes the dialog.

A client who is dying is having difficulty swallowing oral medications. Which intervention will the nurse implement for this client? A. Ask the pharmacy to substitute intramuscular (IM) equivalents for the medications. B. Ask the provider if the medications can be discontinued or substituted. C. Crush the pills, open the sustained-release capsules, and mix them with a spoonful of applesauce. D. Do not administer the medications and document: "Unable to swallow."

B The nurse will contact the provider to ask if the medications can be discontinued or substituted. Since the client is in the dying process, he or she may no longer require some of the medications prescribed, and other routes may be available for medications that will promote comfort. The IM route is almost never used for clients at the end of life because this method is invasive and painful, and can cause infection. Although some pills may be crushed, sustained-release capsules should not be taken apart and their contents administered directly. The client may still need the medications prescribed for comfort; withholding them could cause discomfort throughout the dying process.

The nurse is caring for a client with terminal dehydration. The family wants the client to receive intravenous fluids. Which nursing response is appropriate? A. "Intravenous fluids will be a good addition to the plan of care." B. "Intravenous fluids may increase the client's discomfort." C. "Intravenous fluids may be started, but this may prolong life." D. "Pain medication can be used to treat terminal dehydration."

B The nursing statement "Intravenous fluids may increase the client's discomfort" is accurate and will provide education to the family (Choice B). Once the system has slowed down and the client is in a terminal dehydration status, administering fluid can increase discomfort and end-of-life dyspnea; as such, intravenous fluids are not a good addition to this client's plan of care (Choice A). Intravenous fluids will not prolong life; however, they may increase discomfort (Choice C). Pain medications are used to manage pain and dyspnea, not terminal dehydration (Choice D). Terminal dehydration generally does not cause distress.

Which of the following determinants would the nurse expect to negatively impact health outcomes of older adults of color when compared to White older adults? Select all that apply. A. Higher income level B. Lower educational attainment C. Multigenerational housing D. Decreased access to health care E. Lack of transportation

B, C, D, E : When compared to White older adults, diverse older adults, especially people of color, are at higher risk of negative health outcomes due to factors called social determinants of health (SDOH). Diverse older adults typically have a lower income level, not a higher income (Choice A). According to research, this group of older adults has lower educational attainment, lives more often in multigenerational housing, and has less access to health care and transportation when compared to Euro-Caucasian older adults. Therefore, Choices B, C, D, and E are the correct responses to this question

The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a total hip arthroplasty. With Beers Criteria used as a resource, which drug poses a potential risk for this client? A. Acetaminophen B. Celecoxib C. Amitryptyline D. Lisinopril

C Beers Criteria is a guideline for health care professionals to help improve the safety of prescription medications for older adults. It involves potentially inappropriate medication use in older adults. Amitryptyline, a tricyclic antidepressant, is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems (Choice C). Clients receiving this medication are at greater risk for serious side effects and interactions. Acetaminophen, celecoxib, and lisinopril are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems (Choice A, B, & D).

The nurse is planning care for an ambulatory older adult recently admitted to the hospital. Which aspect of the client's care would be the priority for the nurse at this time? A. Relocation stress B. History of recent loss C. Maintenance of mobility D. Caregiver support

C Relocation stress syndrome is the physical and emotional distress that can occur after an older adult transitions from one setting to another, such as home to a hospital (Choice A). However, this potential problem is not the priority for client care. There is no evidence that the older adult experienced a loss (Choice B). Mobility needs to be maintained because many older adults experience impaired mobility as a result of hospitalization and are at high risk for falling. Therefore, Choice C is the priority for care because falls are potentially life threatening. Caregiver support is not the correct choice because it is not clear if the client had a caregiver in the community and would not be the priority for client care (Choice D).

The nurse is performing a spiritual assessment on a dying client. Which question provides the most accurate data on this aspect of the client's life? A. "Do you believe in God?" B. "Tell me about religion in your life." C. "What gives you purpose in life?" D. "Where have you been attending church?"

C The most accurate data about the client's spirituality would come from the question, "What gives you purpose in your life?" Spirituality arises from whatever or whoever provides the client ultimate purpose and meaning. It is not necessarily God, but it could be. It could be the client's definition of a higher power. The client may not believe in God and may find an inquiry about believing in God offensive and judgmental. Religion is considered by many people to be affiliation or membership in a faith community. Members of such a community may support the client if the client is a member, but this is not the best way to determine the client's spirituality. Church attendance is one way some individuals express their religion, but it does not necessarily define a person's spirituality; asking about church could put the client on the defensive.

The nurse is teaching a class on advance directives. What will the nurse include? (Select all that apply.) A. Advance directives are the same from state to state. B. A durable power of attorney for health care is the same as a durable power of attorney for one's health care. C. A living will identify health care wishes regarding end-of-life treatment. D. A health care proxy can only make decisions once a person no longer has their own ability to make decisions. E. In order to make a health care decision, a person much be totally oriented. F. A living will contains funeral directives as well as last wishes for the family.

C, D Advance directives vary from state to state. While all have similarities, each state is unique. A durable power of attorney for health care is not the same as a durable power of attorney for finances. This can be the same person—but must be defined specifically for both roles. A living will identifies would an individual would (or would not) want when he or she is near death. A living will contains information specific to artificial ventilation, nutrition or hydration, and resuscitation directives. It does not contain funeral directives or last wishes for family. In order to make health care decisions, a person does not need to be totally oriented. However, they must be able to receive information and then evaluate, deliberate, and manipulate the information as well as communicate a treatment preference.

The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions would be most helpful for them? (Select all that apply.) A. Allowing for increased rest and relaxation time B. Having solitary times to grieve about losses C. Joining a peer group with a common learning goal D. Learning a new skill E. Meditating for 30 minutes every day F. Starting a new physical activity

C, D, F Cognitive health problems (depression, delirium, and dementia) can be prevented or delayed by social engagement with a peer group, learning a new skill, and physical activity (Choice C, D, & F). Increased rest time, meditation, and increased solitude may be helpful for other aspects of aging but do not benefit the older adult's cognitive capabilities (Choice A, B, & E).

A hospice client becomes too weak to swallow. What does the nurse do initially to increase the client's comfort? A. Administers nutrition and fluids through a nasogastric tube. B. Explains to the family that aspiration may be a concern. C. Obtains a provider order to initiate an IV line. D. Teaches the family how to provide oral care.

D Because the oral mucosa will become dry, the initial action taken by the nurse would be to teach the family members how to moisten the lips and mouth. Although fluids can be given through a nasogastric tube and through an IV line, these are generally considered to increase discomfort by prolonging the client's suffering. Aspiration is not a concern in terminally ill clients, because fluids are not given orally to clients with decreased swallowing.

The nurse is preparing to review the medications that an older client has been taking independently at home. Which medication would the nurse question as being inappropriate for an older adult? A. Losartan B. Apixaban C. Acetaminophen D. Diazepam

D Diazepam is a benzodiazepine medication that has anticholinergic effects. For older adults, these effects can cause acute confusion, blurred vision, dry mouth, urinary retention, and constipation; this drug should therefore not be prescribed for older adults (Choice D). The nurse would contact the older adult's prescriber to question this medication and recommend that it be discontinued. The other medications in appropriate doses would be appropriate for an older adult to take (Choices A, B, and C).

The nurse is coordinating interprofessional palliative care interventions for the client who is dying. Which goal is the nurse seeking to meet? A. Avoiding symptoms of client distress B. Ensuring an expedited death C. Meeting all of the client's needs D. Facilitating a peaceful death for the client

D Facilitating a peaceful death for the client is one of the goals of palliative care. Symptoms of distress cannot be avoided but can be controlled. Expedited death is not a goal of palliative care. Identifying client needs is a goal of palliative care, but it is not always possible to meet all of the client's needs (e.g., to prevent death or lengthen life).

An older adult client is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome? A. Explaining all procedures and routines to the client's family at the time of relocation B. Keeping the room clear of personal belongings to reduce the risk of falling C. Providing the client with limited decision making to avoid stressful situations D. Reorienting the client frequently to his or her new location

D Relocation stress syndrome usually occurs in older adults shortly after moving from a private residence to a nursing home or assisted-living facility. Characteristic symptoms can include anxiety, confusion, hopelessness, and loneliness. Reorienting the client to the new location best helps minimize relocation stress syndrome effects (Choice D). All procedures and routines should be explained to the client as well as to the family just before they occur. Familiar and special personal belongings are helpful to keep at the client's bedside to minimize the effects of relocation stress syndrome. The client needs opportunities to assist in decision making, which helps the client feel more in control (Choice A, B, & C). However, these other actions are not as useful as orientation and reorientation.

The family of a client who is unconscious and dying realizes that their mother will die soon. The client's children are having a difficult time letting go. How will the nurse respond to the needs of this family? A. "She would not want you to cry; she needs you to be strong." B. "She will soon be in a better place." C. "Things will be ok, just try to enjoy your time together." D. "This must be difficult for you."

D The nurse responds by stating, "This must be difficult for you." This statement tells the family that the nurse is aware of their needs. The nurse knows to accept whatever the grieving person says about the situation, and must remain present, be ready to listen attentively, and guide gently. In this way, the nurse can help the bereaved prepare for the necessary reminiscence and integration of the loss. The client's or family member's pain of loss should never be minimized. Trite assurances such as saying, "She would not want you to cry" or "Things will be ok," should be avoided. Such comments can be barriers to demonstrating care and concern. Never try to explain a client's death or impending death philosophically or religiously because such statements are not helpful when the bereaved person has yet to express anguish or anger.

The nurse is assessing an older adult client's alcohol use. Which client statement requires further assessment? A. "I am a 'teetotaler'; I never drink anything alcoholic." B. "I had three glasses of champagne at my granddaughter's wedding last month." C. "I like to have a glass of wine every once in a while." D. "I usually drink two vodkas to help me get to sleep each night."

D The recommended alcohol intake (National Institute on Alcohol Abuse and Alcoholism) for people over 65 years of age is one drink daily or seven drinks weekly. The practice of drinking two vodkas daily exceeds those recommendations and needs to be followed up by the nurse (Choice D). Although it is impossible to determine whether someone who abstains from alcohol is an alcoholic, many people choose not to drink any alcohol at all. Unless evidence is available to dispute, the client who is a "teetotaler" should be believed (Choice A). An occasional drink of an alcoholic beverage is within the range of normal consumption for older adults (Choice B & C). Unless other alcohol was reported and is used more routinely, the level of consumption for the other clients should cause no alarm on a routine assessment.

The nurse is caring for an older adult client who lives alone in a senior citizen's housing apartment. What is the most commonly occurring mental health condition for which the nurse would assess? A. Depression B. Delirium C. Dementia D. Bipolar disorder

A Depression is the most common mental health disorder in the older adult population, both primary and secondary types. Common factors that predispose this group to the disorder include loss and loneliness (Choice A). The other mental health conditions may occur in older adults, but they are not as common. In some cases, depression accompanies any of these other conditions (Choice B, C, & D).

A client with terminal lung cancer is receiving hospice care at home. Which nursing action will the RN manager ask the LPN/LVN to do? A. Administer prescribed medications to relieve the client's pain, shortness of breath, and nausea. B. Clarify family members' feelings about the meaning of client behaviors and symptoms. C. Develop a plan for care after assessing the needs and feelings of both the client and the family. D. Teach the family to recognize signs of client discomfort such as restlessness or grimacing.

A LPN/LVNs are educated to administer medications and monitor clients for therapeutic and adverse medication effects; the administration of prescribed medications to the client for pain, shortness of breath, and nausea is appropriate to delegate to the LPN/LVN. Clarifying family members' feelings, developing a plan of care, and teaching the family to recognize signs of discomfort all require broader education and are appropriate for the RN practice level.

The nurse on an inpatient hospice unit received the change-of-shift report. Which client does the nurse assess first? A. A 26 year old with metastatic breast cancer experiencing pain rated at 8 (0-10 scale) and anxiety. B. A 30 year old with AIDS-associated dementia and agitation asking for assistance calling family members. C. A 62 year old with lung cancer who has cool, clammy, dusky skin and blood pressure of 64/20 mm Hg. D. A 70 year old with cancer of the colon who has a respiratory rate of 8 with loud, wet-sounding respirations.

A Management of pain is the priority goal for hospice care, so decreasing this client's pain and anxiety should be the first action. The client with AIDS needs rapid assistance but is the second priority for the nurse in this scenario. The client with lung cancer and colon cancer are exhibiting normal signs and symptoms associated with dying.