A nursing student is listing points to remember about wellness promotion in older adults. Which points mentioned by the nursing student need correction? Select all that apply. Show
B. "It is essential to focus on curing diseases or other illnesses completely in older adults to promote wellness." C. "It is essential to assess the level of fear of falling and provide support accordingly when caring for older adults." D. "It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." E. "It is necessary to consider the older adult's social environment and ensure that he or she lives in social isolation to prevent stress." B, D, E Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. A. Difficulty in swallowing B. Increased sensitivity to heat C. Increased sensitivity to glare D. Diminished sensation of pain E. Heightened response to stimuli C, D An older adult client states, "I walk 2 miles [3.2 km] a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the clinic nurse teach the client? A. "Drink fruit juices if you start to feel dehydrated." B. "Thirst is a good guide to use to determine fluid intake." C. "Fluids should be increased if the urine is getting darker." D. "Water should be consumed when the skin becomes dry." C. Fluids should be increased if the urine is getting darker What important points should the nurse keep in mind when caring for an older adult to promote health? Select all that apply. A. Focus on achieving the highest level of health and absence of disease B, D, E What is the main reason a nurse raises three of the four side rails on the bed of an 83-year-old client who had surgery for a fractured hip? A. As a safety measure because of the client's age A. As a safety measure because of the client's age A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective? A. "I can drink beer with this, but not wine." D. "I have to be careful about which OTC cold preparations I take when I have a cold" The nurse is providing home care to an older adult client with decreased bone density. Which nursing intervention will be most beneficial for the client? A. Teaching isometric exercises B. Encouraging the client to do weight-bearing exercises The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate? A. Asking the family member to step out of the room so the client can rest D. Requesting the nursing assistant to stay with the client while the nurse calls the primary healthcare provider What interventions should the nurse follow when giving health education to an elderly client? Select all that apply. A. Assess the client for pain before teaching. A, C, D Which intrinsic factors may contribute to falls in older adults? Select all that apply. A. Deconditioning A, B Which principles are appropriate for promoting older adult learning? Select all that apply. A. Emphasize abstract material B, D, E A nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply. A. Scaly skin B, C, D, E An older adult fell at home and fractured the left hip. Which response should the emergency department nurse identify as a typical clinical indicator associated with a fractured hip? A.Affected hip is ecchymotic. B. Left leg is noticeably shorter than the right The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? A. Thinning subcutaneous layer C. Decreased dermal blood flow A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. A. Hips A, B A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? A. Relieving muscle spasm and pain A. Relieving muscle spasm and pain Which client would the nurse consider to have the highest risk of pneumonia? Client 1: 16 y/o; has a poor nutritional status; received pneumococcal vaccine in the last 3 months Client 2: 28 y/o; uses tobacco; received pneumococcal vaccine 2 years ago Client 3: 45 y/o; consumes alcohol regularly; received pneumococcal vaccine a year ago Client 4: 67 y/o; chronic lung disease; received pneumococcal vaccine more than 5 years ago Client 4 A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply. A. Loss of turgor A, C, D A nurse is educating an older adult for the purpose of promoting wellness. What instruction should the nurse give to 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." A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply. A. Suggest that the client have annual Papanicolaou (Pap) smears and mammograms B, C, D Which musculoskeletal system change is associated in older adult clients? Decreased in height Decreased neck rigidity Increased fine-motor dexterity Increased range of motion (ROM) Decreased in height What should the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging? Achievement of a personal philosophy Adaptation to the children leaving home Attainment of a sense of worth as a person Adjustment to life in an assisted-living facility Attainment of a sense of worth as a person An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? Assess the client's mobility. Monitor respirations and breathing effort. Teach coughing and deep-breathing exercises. Determine normal activity levels and note when the client tires. Teach coughing and deep-breathing exercises. An older female client is seen in the primary healthcare provider's office. Upon initial nursing assessment the nurse notes the client's height has decreased by 1 inch (2.5 cm) since the last visit 1 year ago. The nurse knows that what is the most likely reason for this finding? The nurse was in error. Older adults are not active enough so they lose bone mass. Older adults have poor posture so they are shorter. Older adults may have osteoporosis-related height changes. Older adults may have osteoporosis-related height changes. Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? Encouraging frequent naps Strengthening the concept of ageism Reinforcing the client's strengths and promoting reminiscing Teaching the client to increase calories and focusing on a high-carbohydrate diet Reinforcing the client's strengths and promoting reminiscing 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. A. Dry cerumen A, C A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings 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 Which intrinsic factor is associated with the fall of an older adult? Wet floors Poor lighting Deconditioning Inappropriate footwear Deconditioning Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? Carelessness Fragility of bone Sedentary existence Rheumatoid diseases Fragility of bone When teaching about aging, the nurse explains that older adults usually have what characteristic? Inflexible attitudes Periods of confusion Slower reaction times Some senile dementia Slower reaction times A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. What clinical finding requires the nurse to notify the primary healthcare provider? Lack of a productive cough 2 days postoperatively Rectal temperature of 100.2° F (37.9° C) 3 days postoperatively Complaints of right-sided chest pain 6 days postoperatively Fatigue in the leg on the unaffected side 5 days postoperatively Complaints of right-sided chest pain 6 days postoperatively An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? Providing psychotherapy to the client Teaching strategies to overcome depression Encouraging the client to walk for 30 minutes Requesting that the physician change the drug Requesting that the physician change the drug When nurses are conducting health assessment interviews with older clients, what step should be included? Leave a written questionnaire for clients to complete at their leisure. Ask family members rather than the client to supply the necessary information. Spend time in several short sessions to elicit more complete information from the clients. Keep referring to previous questions to ascertain that the information given by clients is correct. Spend time in several short sessions to elicit more complete information from the clients. When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? Slide slowly to the floor to prevent a fall and injury. Sit on the edge of the bed while they hold the client upright. Bend forward because this will increase blood flow to the brain. Lie down quickly so the legs can be raised above the heart level. Sit on the edge of the bed while they hold the client upright. A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? "Your primary healthcare provider must have forgotten to prescribe it." "Your condition is not severe enough to have physical therapy approved." "Your joints are still inflamed, and physical therapy can be harmful." "Physical therapy is not helpful for persons who suffer from RA." "Your joints are still inflamed, and physical therapy can be harmful." The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? Ulnar drift Heberden nodes Swan-neck deformity Boutonnière deformity Heberden nodes The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? Oxygen therapy Cardiac monitoring Nutrition supplements Venous thromboembolism (VTE) prevention Venous thromboembolism (VTE) prevention An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in response to this client's question? Select all that apply. A. "Ask your healthcare provider how and when you should be taking your medications." A, D, E While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)? Barrel chest Cyanosis Hyperventilation Lordosis
Barrel Chest A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? Side-lying with head elevated 45 degrees Sims with head elevated 90 degrees Semi-Fowler with legs elevated High-Fowler using the bedside table to rest the arms High-Fowler using the bedside table to rest the arms The nurse is caring for an older client admitted to the hospital with type 2 diabetes. What is important for the nurse to remember about older adults and type 2 diabetes? Older adults seldom develop ketoacidosis. Older adults secrete no endogenous insulin. Older adults have a lower risk of complications. Older adults develop a sudden onset of symptoms. Older adults seldom develop ketoacidosis. What principle of teaching specific to an older adult should the nurse consider when providing instruction to such a client recently diagnosed with diabetes mellitus? Knowledge reduces general anxiety. Capacity to learn decreases with age. Continued reinforcement is advantageous. Readiness of the learner precedes instruction. Continued reinforcement is advantageous. A nurse teaches a client with chronic renal failure that salt substitutes cannot be used in the diet. What is the rationale for the nurse's instruction? A person's body tends to retain fluid when a salt substitute is included in the diet. Limiting salt substitutes in the diet prevents a buildup of waste products in the blood. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. A substance in the salt substitute interferes with the transfer of fluid across capillary membranes, resulting in anasarca. Salt substitutes contain potassium, which must be limited to prevent abnormal heartbeats. A nurse is caring for a client with end-stage renal disease. Which clinical indicators of end-stage renal disease should the nurse expect? Select all that apply. A.Polyuria C, D A nurse is reviewing the laboratory reports of a client with a diagnosis of end-stage renal disease. Which test result should the nurse anticipate? Arterial pH of 7.5 Hematocrit of 54% Potassium of 6.3 mEq/L (6.3 mmol/L) Creatinine of 1.2 mg/dL (106 mcmol/L) Potassium of 6.3 mEq/L (6.3 mmol/L) Which instructions will be most beneficial for a diabetic client with renal disease? Select all that apply. A. Recommend the client drink boiled water C, D, E A nurse is caring for a client with a diagnosis of right ventricular heart failure. The nurse expects what assessment findings associated with right-sided heart failure? Select all that apply. A. Dependent edema A, B, D A nurse is teaching a group of clients about risk factors for heart disease. Which factors will the nurse include that increase a client's risk for a myocardial infarction (MI)? Select all that apply. A. Obesity A, B A client is receiving warfarin. The nurse explains the need for careful regulation of dietary intake of vitamin K. What is the rationale for the nurse's teaching? Vitamin K promotes platelet aggregation. Vitamin K promotes ionization of blood calcium. Vitamin K promotes fibrinogen formation by the liver. Vitamin K promotes prothrombin formation by the liver. Vitamin K promotes prothrombin formation by the liver. Nitroglycerin sublingual tablets are prescribed for a client with the diagnosis of angina. The client asks the nurse how long it should take for the chest pain to subside after nitroglycerin is taken. What should the nurse tell the client? 1 to 3 minutes 4 to 5 seconds 30 to 45 seconds 20 to 45 minutes 1 to 3 minutes Sublingual nitroglycerin is prescribed for a client with a history of a myocardial infarction and atrial tachycardia. The nurse instructs the client about the prophylactic use of these tablets. Which statement by the client indicates the teaching was effective? "I should take the medicine three times a day." "I will be sure to take my pulse after I have exercised." "It will be important to avoid activities that are too strenuous." "I should take one tablet before attempting to climb two flights of stairs." "I should take one tablet before attempting to climb two flights of stairs." The nurse is educating a client who is being discharged after insertion of a coronary artery stent. For what signs and symptoms should the nurse instruct the client to seek immediate medical attention? Select all that apply. A. Dyspnea on exertion B, C, E, F A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? Nervousness and tachycardia Erythema toxicum rash and pruritus Diaphoresis and altered mental state Deep respirations and fruity odor to the breath Deep respirations and fruity odor to the breath The nurse is assessing a client experiencing diabetic ketoacidosis (DKA). Which unique response associated with DKA that is not exhibited with hyperglycemic hyperosmolar nonketotic syndrome (HHNS) should the nurse identify when assessing this client? Fluid loss Glycosuria Kussmaul respirations Increased blood glucose level Kussmaul respirations Several hours after administering insulin, the nurse is assessing a client for an adverse response to the insulin. Which client responses are indicative of a hypoglycemic reaction? Select all that apply. A. Tremors A, C, E A client with type 2 diabetes has been receiving insulin in the hospital while being treated for sepsis. The client's infection is resolving and the primary healthcare provider writes a prescription to discontinue the 7:00 AM dose of insulin and to administer glyburide 5 mg twice daily (8:00 AM and 8:00 PM). The nurse on the day shift (8:00 AM to 4:00 PM) administers the glyburide at 8:30 AM. When recording its administration in the client's record, the nurse sees that the insulin had already been administered at 7:00 AM. What initial action should the nurse take? Measure the vital signs. Notify the primary healthcare provider. Assess for signs of ketoacidosis. Check blood glucose for hypoglycemia. Check blood glucose for hypoglycemia. At 4:30 pm, a client who is receiving NPH insulin every morning states, "I feel very nervous." The nurse observes that the client's skin is moist and cool. What is the nurse's most accurate interpretation of what the client is likely experiencing? Polydipsia Ketoacidosis Glycogenesis Hypoglycemia Hypoglycemia The nurse is educating the client newly diagnosed with type 2 diabetes on oral antidiabetic medications. What should the nurse include in the teaching plan? Select all that apply. A. The client should obtain a finger stick blood glucose
reading before each meal. A, C, E client with type 2 diabetes is taking one oral hypoglycemic tablet daily. The client asks whether an extra tablet should be taken before exercise. What is the best response by the nurse? "You will need to decrease your exercise." "An extra tablet will help your body use glucose correctly." "When taking medicine, your diet will not be affected by exercise." "No, but you should observe for signs of hypoglycemia while exercising." "No, but you should observe for signs of hypoglycemia while exercising." The nurse is preparing a client who is on metformin therapy and is scheduled to undergo renal computed tomography with contrast dye. What does the nurse anticipate the primary healthcare provider to inform the client regarding the procedure? "Discontinue metformin 1 day prior to procedure." "Discontinue metformin a half-day prior to procedure." "Discontinue metformin 3 days following the procedure." "Discontinue metformin 7 days following the procedure." "Discontinue metformin 1 day prior to procedure." A nurse prepares to administer extended-release metformin to an older adult who has asked that it be crushed because it is difficult to swallow. What will prompt the nurse to ask the provider for a different form of metformin? This drug has a wax matrix frame that is difficult to crush. The drug has an unpleasant taste, which most clients find intolerable if crushed. If crushed, this drug irritates mucosal tissue and can cause oral and esophageal ulcer formation. Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring. Extended-release formulations are designed to be released slowly, and crushing the tablet will prevent this from occurring. Metformin 2 g by mouth is prescribed for a client with type 2 diabetes. Each tablet contains 500 mg. How many tablets should the nurse administer? Record your answer using a whole number. 4 The nurse is assessing the client admitted with diabetic ketoacidosis. Which statement made by the client indicates a need for further education on sick day management? I will stop taking my insulin when I am ill because I am not eating. I will check my urine for ketones when my blood sugar is over 250. I will alternate drinking Gatorade and water throughout the day while ill. I will continue all my insulin including my glargine when I am sick. I will stop taking my insulin when I am ill because I am not eating. An 85-year-old client has a serum potassium level of 6.7 mEq/L (6.7 mmol/L). Which nursing action is the priority at this time? Monitor for cardiovascular irregularities. Inquire about changes in bowel patterns. Assess for leg muscle twitching or weakness. Assess for signs and symptoms of dehydration. Monitor for cardiovascular irregularities. The blood urea nitrogen (BUN)/creatinine ratio of a client is 3. Which condition does the nurse suspect in the client? Fluid volume excess Obstructive uropathy Severe hepatic damage Gastrointestinal (Gl) bleeding Fluid volume excess After reviewing the laboratory reports, the nurse anticipates that the client has renal impairment. Which test reports support the nurse's concern? Select all that apply. A. Serum albumin: 4.7 g/dL(6.815 µmol/L) B, C, E A client with an intractable infection is receiving vancomycin. Which laboratory blood test result should the nurse report? Hematocrit: 45% Calcium: 9.0 mg/dL (2.25 mmol/L) White blood cells (WBC): 10,000 mm 3 (10 X 10 9/L) Blood urea nitrogen (BUN): 30 mg/dL (10.2 mmol/L) Blood urea nitrogen (BUN): 30 mg/dL (10.2 mmol/L) A nurse is assessing a client with a diagnosis of early left ventricular heart failure. Specific to this type of heart failure, what statement by the client would the nurse expect? "My ankles are swollen." "I am tired at the end of the day." "When I eat a large meal, I feel bloated." "I have trouble breathing when I walk rapidly." "I have trouble breathing when I walk rapidly." An older adult client is diagnosed with left-sided congestive heart failure. Which assessments should the nurse expect to find? Select all that apply. A. Dyspnea A, B, C The nurse is caring for a client who is admitted to the hospital with early heart failure. Which client statement indicates a clinical manifestation that is related to heart failure? I see spots before my eyes. I am tired at the end of the day. I feel bloated when I eat a large meal. I have trouble breathing when I climb a flight of stairs. I have trouble breathing when I climb a flight of stairs. A client is diagnosed with heart failure and is admitted for medical management. Which statement made by the client may indicate worsening heart failure? "I am unable to run a mile (1.6 kilometers) now." "I wake up at night short of breath." "My wife says I snore very loudly." "My shoes seem larger lately." "I wake up at night short of breath." A client is admitted to the emergency department with crushing chest pain. A diagnosis of acute coronary syndrome is suspected. The nurse expects that the client's initial treatment will include which medication? Aspirin Midazolam Gabapentin Alprazolam Aspirin Serum cardiac marker studies are prescribed for a client after a myocardial infarction. Which laboratory test is most important for the nurse to monitor? Troponin Myoglobin Homocysteine Creatine kinase (CK) Troponin A nurse is monitoring a client admitted with a diagnosis of myocardial infarction (MI) for dysrhythmias. Which reason for increased incidence of dysrhythmias in this client should the nurse monitor? Metabolic alkalosis Myocardial hypoxia Decreased catecholamine secretion Increased parasympathetic nervous system stimulation Myocardial hypoxia A client arrives at the emergency room complaining of chest pain and dizziness. The client has a history of angina. The primary healthcare provider prescribes an electrocardiogram (ECG) and lab tests. A change in which component of the ECG tracing should the nurse recognize as the client actively having a myocardial infarction (MI)? QRS complex S-T segment P wave R wave ST Segment The healthcare provider prescribes nitroglycerin ointment for a client who was admitted for chest pain and a myocardial infarction (MI). Which statement, if made by the client, would indicate understanding of the side effects of nitroglycerin ointment? "I may experience a headache." "Confusion is a common adverse effect." "A slow pulse rate in an expected side effect." "Increased blood pressure readings may occur initially." "I may experience a headache." The laboratory international normalized ratio (INR) results of a client receiving warfarin have been variable. The nurse interviews the client to determine factors contributing to the problem. Which is most important for the nurse to identify? Use of analgesics Serum glucose level Serum potassium levels Adherence to the prescribed drug regimen Adherence to the prescribed drug regimen A client is receiving warfarin. Which test result should the nurse use to determine whether the daily dose of this anticoagulant is therapeutic? International normalized ratio (INR) Accelerated partial thromboplastin time (APTT) Bleeding time Sedimentation rate International normalized ratio (INR) A client has a history of progressive carotid and cerebral atherosclerosis and experiences transient ischemic attacks (TIAs). How does the nurse explain TIAs to the client? Temporary episodes of neurologic dysfunction Intermittent attacks caused by multiple small clots Ischemic attacks that result in progressive neurologic deterioration Exacerbations of neurologic dysfunction alternating with remissions Temporary episodes of neurologic dysfunction A client who recently experienced a brain attack (cerebrovascular accident, CVA) and who has limited mobility reports constipation. What is most important for the nurse to determine when collecting information about the constipation? Presence of distention Extent of weight gained Amount of high-fiber food consumed Length of time this problem has existed Length of time this problem has existed A client is admitted to a rehabilitation unit after a brain attack (cerebrovascular accident, CVA) with residual hemiparesis. To help achieve the goal of safe walking with a cane, what should the nurse teach the client to do? Shorten the stride of the unaffected extremity. Advance the cane and the affected extremity simultaneously. Lean the body toward the side with the cane when ambulating. Hold the cane on the same side as the affected extremity and increase the base of support. Advance the cane and the affected extremity simultaneously. The nurse is caring for a client two days after the client had a brain attack (cerebrovascular accident, CVA). To prevent the development of plantar flexion, which action should the nurse take? Place a pillow under the thighs. Elevate the knee gatch of the bed. Encourage active range of motion. Maintain the feet at right angles to the legs. Maintain the feet at right angles to the legs. A client who had a cerebrovascular accident (CVA, "brain attack") is starting to eat lunch. Which client behavior indicates to the nurse that the client may be experiencing left hemianopsia? Asks to have food moved to the left side of the tray Drops the coffee cup when trying to use the right hand Ignores the food on the left side of the tray when eating Reports not being able to use the right arm to help eat meals Ignores the food on the left side of the tray when eating A client with a history of hypertension is admitted to the hospital immediately after a brain attack (cerebrovascular accident, CVA). The client is unconscious, and the vital signs are temperature 98° F (36.7° C), pulse 78 beats per minute, respiration 16 breaths per minute, and blood pressure 120/80 mm Hg. Which nursing concern is a priorityfor this client? Injury Constipation Respiratory distress Decreased fluid volume Respiratory distress The family members of a client with the diagnosis of cerebrovascular accident (CVA, also known as "brain attack") express concern that the client often becomes uncontrollably tearful during their visits. What should the nurse include in a response? Emotional lability is associated with brain trauma. Their presence allows the client to express feelings. The client is depressed about the loss of functional abilities. Nonverbal expressions of feelings are more accurate than verbal ones. Emotional lability is associated with brain trauma. A client is diagnosed with a brain attack (cerebrovascular accident, CVA). The baseline vital signs are a pulse rate of 78 bpm and a blood pressure (BP) of 120/80 mm Hg. The nurse continues to monitor the vital signs and recognizes that which changes in vital signs indicate increased intracranial pressure (ICP)? Pulse 50 bpm and BP 140/60 mm Hg Pulse 56 bpm and BP 130/110 mm Hg Pulse 60 bpm and BP 126/96 mm Hg Pulse 120 bpm and BP 80/60 mm Hg Pulse 50 bpm and BP 140/60 mm Hg A nursing student is listing the steps that need to be considered when preparing discharge planning for a client. Which steps listed by the nursing student are accurate? Select all that apply. A. "Plan the client's discharge at the time of leaving the hospital." B, C, E A nurse is preparing to discharge a client who is partially paralyzed following a stroke. What should the nurse teach the client's family about recognizing caregiver role strain? Select all that apply. A. The caregiver has disturbed sleep patterns. A, B, E A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. A. Dementia B, C An older client is admitted to the hospital with the diagnosis of dementia of the Alzheimer type and depression. Which signs of depression does the nurse identify? Select all that apply. A. Loss of memory B, C, D, E A nurse is assessing a client and attempting to distinguish between dementia and delirium. Which factors are unique to delirium? Select all that apply. A. Slurred speech A, D, F A client with a disturbed state of mind is under observation. Which statement made by the nurse indicates that the client is suffering from dementia? Select all that apply. A. "The client is very depressed." B, D A nurse is assessing an older adult with the diagnosis of dementia. Which manifestations are expected in this client? Select all that apply. A. Resistance to change A, B, D, E An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions should the nurse follow to prevent future falls? Select all that apply. A. Minimizing medications A, B, D Which health problem does the nurse identify from an older client's history that increases the client's risk factors for a cerebrovascular accident (CVA, also known as "brain attack")? Glaucoma Hypothyroidism Continuous nervousness Transient ischemic attacks (TIAs) Transient ischemic attacks (TIAs) A client is admitted to the hospital with weakness in the right extremities, and speech that is slightly slurred. A diagnosis of brain attack (cerebrovascular accident, CVA) is suspected. During the first 24 hours after symptom onset, which action is priority? Assess the temperature Monitor bowel sounds Evaluate motor status Obtain a urinalysis Evaluate motor status A client manifests right-sided hemianopsia as a result of a brain attack (cerebrovascular accident, CVA). Which goal does the nurse include in the plan of care? Correct the client's misuse of equipment. Instruct the client to scan surroundings. Teach the client to look at the position of the left extremities. Provide the client with tactile stimulation to the affected extremities. Instruct the client to scan surroundings. An older client experiences a cerebral vascular accident (CVA) and has right-sided hemiplegia and expressive aphasia. The client's children ask the nurse which functions will be impaired. Which abilities does the nurse explain will be affected? Stating wishes verbally Recognizing familiar objects Comprehending written words Understanding verbal communication Stating wishes verbally A client experiences expressive aphasia as a result of a brain attack (cerebrovascular accident, CVA). The client's spouse asks whether the client's speech will ever return. What is the best response by the nurse? "It should return in several months." "You will have to ask the primary healthcare provider." "It is hard to say how much improvement will occur." "Unfortunately, your spouse will no longer be able to speak." "It is hard to say how much improvement will occur." A nurse begins planning for the discharge of a client who had a brain attack (cerebrovascular accident, CVA) with residual hemiparesis and hemianopsia. Which information should the nurse include in the discharge teaching plan for this client? Necessity for bed rest at home Use of oxygen therapy at home Significance of a safe environment Need for decreased protein in the diet Significance of a safe environment A client has left hemiplegia because of a cerebrovascular accident (CVA, "brain attack"). What can the nurse do to contribute to the client's rehabilitation? Begin active exercises. Make a referral to the physical therapist. Position the client to prevent contractures. Avoid moving the affected extremities unless necessary. Position the client to prevent contractures. Bed rest is prescribed after a client's cerebrovascular accident (CVA, "brain attack") results in right hemiplegia. Which exercises should the nurse incorporate into the client's plan of care 24 hours after the brain attack? Passive range-of-motion exercises Active exercises of the extremities Light weight-lifting exercises of the right side Isotonic exercises that will capitalize on returning muscle function Passive range-of-motion exercises A client who had a brain attack (cerebrovascular accident, CVA) has left-sided hemiparesis but is able to ambulate with assistance. When getting up from a lying position, the client reports feeling lightheaded and dizzy. The nurse explains that these clinical manifestations are a result of which condition? Inflamed peripheral nerves Loss of blood and blood volume Demyelination of peripheral nerves Blood pooling in the lower extremities Blood pooling in the lower extremities Four days after the client's total hip arthroplasty, the nurse is preparing to transfer the client to a rehabilitation center. Before admission the client took warfarin sodium daily for a history of pulmonary embolus. While hospitalized, the client received subcutaneous heparin two times a day. The nurse does not see any anticoagulant therapy listed on the client's transfer prescriptions. What should the nurse do? Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. Arrange for a supply of heparin for the client to take to the rehab center. Explain to the client that anticoagulant therapy will no longer be needed. Instruct the client to talk about anticoagulant needs with the healthcare provider at the rehabilitation center. Contact the healthcare provider to determine which anticoagulant therapy should be prescribed for this client. The home healthcare nurse visits an elderly couple living independently. The wife cares for the husband who has dementia. Which interventions should the nurse implement for them? Select all that apply. A. Assess the wife for caregiver burden. A, D, E An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. What does the nurse know about this disorder? Problem that first emerges in the third decade of life Nonorganic disorder that occurs in the later years of life Cognitive problem that is a slow and relentless deterioration of the mind Disorder that is easily diagnosed through laboratory and psychological tests Cognitive problem that is a slow and relentless deterioration of the mind During a home visit to an older adult, the nurse observes a change in behavior and suspects delirium. The nurse assesses the client for one of several conditions that may have precipitated the delirium. Select all that apply. A. Infection A, C, D The primary objective of nursing intervention for clients with dementia, delirium, and other cognitive disorders is to maintain what? Safety within the environment Psychological faculties Participation in educational activities Face-to-face contact with other clients Safety within the environment What is the priority nursing care for a client with delirium? Providing a body massage Arranging for music therapy Teaching relaxation techniques Creating a calm and safe environment Creating a calm and safe environment What is the priority nursing intervention for a client with stroke who is transitioned from ED to other settings? Monitoring vital signs Reassuring the client and family Assessing the level of consciousness Monitoring specific client manifestations of stroke Assessing the level of consciousness What nursing action is essential when a client experiences hemianopsia as the result of a left ischemic stroke? Place objects within the visual field. Teach passive range-of-motion exercises. Instill artificial teardrops into the affected eye. Reduce time client is positioned on the left side. Place objects within the visual field. An older adult client is talking to the nurse about his Vietnam experiences and shares that he still has flashbacks. While assessing him the nurse notes that he is jumpy and exhibits startle reactions and poor concentration. With which mental health disorder does the nurse associate these symptoms? Delusions Hallucinations Posttraumatic stress disorder (PTSD) Obsessive-compulsive disorder (OCD) Posttraumatic stress disorder (PTSD) A client is receiving heparin sodium intravenously at 1500 units/hour. The concentration in the bag is 25,000 units/500 milliliters. The nurse determines that how many milliliters will infuse during the nurse's 8-hour shift? Record your answer using a whole number. 240 mL A farmer seeks medical care for a large crusty patch of skin on the cheek. The client states that even after using different remedies, it still bleeds easily and has not gotten better. From the client's history, the nurse suspects skin cancer. Which factor in the client's history helped the nurse form this conclusion? Exposure to radiation Location of the lesion Self-treatment of lesions Contact with soil contaminants Exposure to radiation What are the clinical manifestations of actinic keratosis in a client? Select all that apply. A. Firm, nodular lesions B, C A client receiving chemotherapy for cancer develops sores in the mouth and asks the nurse why this happened. What is the nurse's best response? "The sores occur because of the direct irritating effects of the drug." "These tissues are poorly nourished because you have a decreased appetite." "The frequently dividing cells of the gastrointestinal tract are damaged by the drug." "This side effect occurs because it targets the cells of the gastrointestinal system." "The frequently dividing cells of the gastrointestinal tract are damaged by the drug." The registered nurse is teaching a nursing student about interventions that reduce the risk of pressure ulcers in a client. Which statements made by the nursing student indicate effective learning? Select all that apply. A. "I will elevate the head of
the client's bed to no more than 30 degrees." A, B, D An older adult in an acute care setting is having urinary incontinence. Which interventions would help the client? Select all that apply. A. Provide nutritional support B, C, E On the first day after a mastectomy, a nurse encourages the client to perform exercises such as flexion and extension of the fingers and pronation and supination of the hand. The client asks why she has to do these exercises. What is the best response by the nurse? "They preserve muscle tone." "They prevent joint contractures." "They help us assess the extent of lymphedema." "They will help stimulate peripheral circulation." "They will help stimulate peripheral circulation." An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontologic implications the nurse must consider? Select all that apply. A. Assessment of skin turgor A,D, E An older adult who is in acute care has a risk of skin breakdown. Which interventions are beneficial to the client? Select all that apply. A. Providing meticulous skin care A, B, E A client with cancer develops pancytopenia during the course of chemotherapy. The client asks the nurse why this has occurred. What explanation will the nurse provide? Steroid hormones have a depressant effect on the spleen and bone marrow. Lymph node activity is depressed by radiation therapy used before chemotherapy. Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs. Dehydration caused by nausea, vomiting, and diarrhea results in hemoconcentration. Noncancerous cells also are susceptible to the effects of chemotherapeutic drugs. What are the priority care issues during chemotherapy? Select all that apply. A. Resources available for the nurse C, D During chemotherapy, altered nutrition is a common side effect. Knowing that compromised nutrition can contribute to an increased risk of infection and other problems, what can the nurse do to offset nutritional deficiencies? Provide oral supplements. Offer the client's favorite foods. Restrict intake from dairy products. Encourage the client to drink low-protein shakes. Provide oral supplements. A client who had a history of chicken pox arrived at the hospital complaining of itching and deep pain on the skin. Which assessment finding made by the nurse helps to confirm the diagnosis? Appearance of red, moist, irritated skin Appearance of red-colored raised rash with pustules Appearance of sore-looking raised bumps on the skin Appearance of multiple lesions in a segmental distribution on the skin Appearance of multiple lesions in a segmental distribution on the skin An older adult has undergone chemotherapy. Which intervention would be beneficial for the client in preventing the risk of a potentially contagious common viral infection? Administering famciclovir Administering gabapentin Administering the zoster vaccine Administering vaccines for herpes simplex virus type 1 (HSV-1) and type 2 (HSV-2) Administering the zoster vaccine A 37-year-old client with a nontender palpable breast mass has an inconclusive mammogram. She is undergoing further diagnostic tests to determine whether the mass is malignant. What information should the nurse take into consideration before planning health teaching for this client? Squamous cell carcinomas are neoplasms arising from glandular tissues. Results of a biopsy are necessary before a specific form of therapy is selected. Mammographies should be repeated to confirm the presence of malignancies. Waiting for several weeks before receiving confirmation of cancer is helpful to the client. Results of a biopsy are necessary before a specific form of therapy is selected. For which clinical manifestation should the nurse assess a client with melanoma? Firm, nodular lesion with a crusty top Irregularly shaped, pigmented papule Small papule with dry, rough brown scale Pearly papule with a central crater and waxy border Irregularly shaped, pigmented papule A client has a basal cell carcinoma that is scheduled to be removed. The client expresses concerns that the cancer has metastasized. Which is the best response by the nurse? "You are a low surgical risk." "I can understand how you must feel." "Basal cell tumors usually do not spread." "The primary healthcare provider probably caught it just in time." "Basal cell tumors usually do not spread." A client is admitted with a suspected malignant melanoma on the arm. When performing the physical assessment, what would the nurse expect to find? Large area of petechiae Red birthmark that has recently become lighter in color Brown or black mole with red, white, or blue areas Patchy loss of skin pigmentation Brown or black mole with red, white, or blue areas The nurse is caring for a surgical client who develops a wound infection during hospitalization. How is this type of infection classified? Primary Secondary Superinfection Nosocomial Nosocomial Which intervention would be most beneficial in preventing a catheter-associated urinary tract infection in a postoperative client? Pouring warm water over the perineum Ensuring the patency of the catheter Removing the catheter within 24 hours Cleaning the catheter insertion site Removing the catheter within 24 hours 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 ulcer? Stage I Stage II Stage III Unstageable Unstageable Which client responses does the nurse determine represent the highest risk for the development of pressure ulcers? Incontinence and inability to move independently Periodic diaphoresis and occasional sliding down in bed Reaction to just painful stimuli and receiving tube feedings Adequate nutritional intake and spending extensive time in a wheelchair Incontinence and inability to move independently A nurse is caring for a client who is experiencing urinary incontinence. The client has an involuntary loss of small amounts (25 to 35 mL) of urine from an overdistended bladder. How should this be documented in the client's medical record? Urge incontinence Stress incontinence Overflow incontinence Functional incontinence Overflow incontinence A nurse is caring for a client who has urinary incontinence as the result of a cerebrovascular accident (also known as "brain attack"). What action should the nurse include in the plan of care to limit the occurrence of urinary incontinence? Insert a urinary retention catheter. Institute measures to prevent constipation. Encourage an increase in the intake of caffeine. Suggest that a carbonated beverage be ingested daily. Institute measures to prevent constipation. A client seeks help for dealing with incontinence. A nursing intervention is to teach Kegel exercises. Which type of incontinence is the client most likely experiencing? Reflex incontinence Stress incontinence Overflow incontinence Functional incontinence Stress incontinence A nurse is taking care of a client who is extremely confused and experiencing bowel incontinence. What measures can the nurse take to prevent skin breakdown in this client? Instruct the client to call for help with elimination needs; answer the client's call light immediately to prevent incontinence. Place a waterproof pad under the client to prevent incontinence and soiling the linens. Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence. Offer toileting to the client every 2 hours to prevent incontinence. Check the client's buttocks at least every 2 hours; clean the client immediately after discovering incontinence. A nurse is reviewing the clinical record of a client with a diagnosis of benign prostatic hyperplasia (BPH). Which test result will the nurse check to confirm the diagnosis? Rectal examination Serum phosphatase level Biopsy of prostatic tissue Massage of prostatic fluid Biopsy of prostatic tissue The nurse finds that a client has dysuria, hesitancy, urinary urgency, and leaking. The laboratory reports of the client reveal serum PSA levels of 5 ng/mL and elevated prostatic acid phosphatase (PAP) levels. Which disease condition does the nurse suspect? Orchitis Hydrocele Prostatitis Prostate cancer Prostate Cancer The nurse is teaching a nursing student about the care given to a client before a prostate specific antigen (PSA) test. Which statement made by the nursing student indicates a need for further teaching? "Clients should not take saw palmetto for 2 weeks before the test." "I will ask the client to have nothing by mouth (NPO) before the test." "I need to assess the venipuncture site for hematoma and bleeding." "PSA is produced by cancerous and noncancerous prostate tissue." "I will ask the client to have nothing by mouth (NPO) before the test." A 26-year-old woman whose sister recently had a lumpectomy for breast cancer calls the local women's health center for an appointment for a mammogram. What guidance should the nurse provide the client in preparation for the test? Do not eat for 6 hours before the test. The room will be darkened throughout the procedure. The first mammogram is usually performed at 50 years of age. During the procedure, each breast will be compressed firmly between two plates. During the procedure, each breast will be compressed firmly between two plates. A nurse is reviewing a postmenopausal client's history, which reveals that the client previously received hormonal therapy (HT) as treatment for osteoporosis. The nurse recognizes that HT increases the risk of which condition? Breast cancer Rapid weight loss Accelerated bone loss Vaginal tissue atrophy Breast Cancer What is the most important information for the nurse to teach to a client who has had a total simple mastectomy before she leaves the hospital? Why a breast prosthesis is necessary Which of the more strenuous activities to curtail What household tasks that require stretching to avoid Why self-examination of the remaining breast is important Why self-examination of the remaining breast is important The primary healthcare provider of a woman who had a mastectomy has arranged for a mastectomy peer support visit. What does the nurse identify as the primary reason for the referral? To learn arm exercises To prevent social isolation To meet her physical needs To view her surgical incision To prevent social isolation A client is scheduled for a modified radical mastectomy. What nursing intervention is most important in the client's preoperative plan of care? Allowing her to express her feelings about surgery Encouraging range-of-motion exercise of the arms Increasing her knowledge about postoperative expectations Arranging for a visit by a woman who has had a mastectomy Allowing her to express her feelings about surgery The nurse assesses an elderly client with a diagnosis of dehydration and recognizes which finding as an early sign of dehydration? Sunken eyes Dry, flaky skin Change in mental status Decreased bowel sounds Change in mental status A 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? What is the best response by the nurse? 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. Before a transurethral resection of the prostate (TURP), a client asks about what to expect postoperatively. Which response by the nurse is most appropriate? "Your urine will be pink and free of clots." "You will have an abdominal incision and a dressing." "There will be an incision between your scrotum and rectum." "There will be an indwelling urinary catheter and a continuous bladder irrigation in place." "There will be an indwelling urinary catheter and a continuous bladder irrigation in place." The nurse is developing a postprocedure plan of care for a client with a continuous bladder irrigation after a transurethral vaporization of the prostate. What should the nurse include in the plan? Measure the output hourly. Monitor the specific gravity of the urine. Irrigate the catheter with saline three times daily. Exclude the amount of irrigant instilled from the output. Exclude the amount of irrigant instilled from the output. A client developed acute herpes zoster and was treated with antiviral medication within 72 hours of the appearance of the rash. The client is reporting persistent pain 1 week later. What does the nurse identify as the cause of the posttherapeutic neuralgia? Damage to the nerves Untreated major depression Scarring in the area of the rash Continued presence of the skin rash Damage to the nerves A registered nurse is supervising a student nurse while assessing a 70-year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition requires correction? "The client may have deterioration of the cochlea." "The client may have thinning of the tympanic membrane." "The client may have an inability to hear high-frequency sounds." "The client may have an inability to differentiate between consonants." "The client may have thinning of the tympanic membrane." A 62-year-old client reports to the nurse, "My eyes don't feel right and I have a gritty and sandy sensation in my eyes." What condition might this client have? Retinal detachment Infection of the cornea Changes in tear composition Hemorrhage in the vitreous humor Changes in tear composition The nurse is caring for a client who reports excessive tearing. Which disorders does the nurse suspect could be responsible for the client's condition? Select all that apply. A. Chalazion A, B, D After a left cataract extraction, a client reports severe discomfort in the operated eye. The nurse concludes that this problem may be caused by which condition? Hemorrhage into the eye Expected postoperative discomfort Isolation related to sensory deprivation Pressure on the eye from the protective shield Hemorrhage into the eye Which beta-adrenergic blocker is used to reduce a client's intraocular pressure? Timolol Travopost Carbachol Apraclonidine Timolol Which clinical indicator is the nurse most likely to identify when exploring the history of a client with open-angle glaucoma? Constant blurring Abrupt attacks of acute pain Sudden, complete loss of vision Impairment of peripheral vision Impairment of peripheral vision A client asks for information about glaucoma. How should the nurse explain glaucoma to the client? An increase in the pressure within the eyeball An opacity of the crystalline lens or its capsule A curvature of the cornea that becomes unequal A separation of the neural retina from the pigmented retina An increase in the pressure within the eyeball A nurse is assessing a client with a diagnosis of dry age-related macular degeneration. Which ocular symptom should the nurse expect the client to report? Loss of central vision Attacks of acute pain Constant blurred vision Decreased peripheral vision Loss of central vision Aspirin is prescribed for a client with rheumatoid arthritis. Which clinical indicators of aspirin toxicity should the nurse teach the client to report? Select all that apply. A. Bradycardia C, D The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should instruct the client on which eye problem most associated with diabetes? Cataracts Glaucoma Retinopathy Astigmatism Retinopathy A client with diabetes mellitus complains of difficulty seeing. What would the nurse suspect as the causative factor? Lack of glucose in the retina The growth of new retina blood vessels or "neovascularization" Inadequate glucose supply to rods and cones Destructive effect of ketones on retinal metabolism The growth of new retina blood vessels or "neovascularization" After cataract surgery the nurse teaches a client how to self-administer eyedrops. The nurse reinforces the use of what technique? Placing the drops on the cornea of the eye Raising the upper eyelid with gentle traction Holding the dropper tip above the conjunctival sac Squeezing the eye shut after instilling the medication Holding the dropper tip above the conjunctival sac The nurse frequently provides care for clients with hearing aids. Which condition does the nurse recall responds best to hearing aids? Destruction of the auditory nerve Diminished sensitivity of the cochlea Perforation of the tympanic membrane Immobilization of the auditory ossicles Diminished sensitivity of the cochlea 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.
A. Dry cerumen A, C Which instruction would the nurse give an older adult to promote wellness and reduce risk of disability?The nurse should instruct the older adult to engage in physical activities as a means of extending the years of active independent life and reducing the risk of disability. To promote a healthy lifestyle, the nurse should encourage the older adult to engage in physical activities.
How can older adults promote health and wellness?Click here now.. Exercise regularly. ... . Don't smoke. ... . Get enough sleep. ... . Avoid chronic stress. ... . Maintain a healthy weight. ... . Eat a “healthy diet.”. Which intervention would the nurse implement with a healthy older adult client who has decreased bone density?Exercise. Regular weight-bearing exercise promotes bone formation, such as a 20-30-minute aerobic exercise, 3x a week, is recommended.
What are nursing interventions for older adults?Nursing interventions with the elderly or family include:. Giving sickness care including intensive care or daily care such as feeding, bathing, range of motion, turning.. Enabling the senior to perform his or her own hygiene and grooming.. Implementing medical procedures and treatments as ordered by the physician.. |
Which instructions would the nurse give an older adult to promote wellness and reduce the risk of disability?
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