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Which activities should the nurse evaluate in an assessment of an older patient’s functional status? (Select all that apply.)
- A. Possessing the ability to prepare nutritious meals independently.
- B. Having the financial resources available to live independently
- C. Performing regular, simple maintenance on their primary residence.
- D. Effectively toileting themselves for both bowel and bladder elimination.
Correct Answer: A,C
Rationale: The correct answers are A and C. A nurse should evaluate if the older patient can prepare nutritious meals independently, as this indicates their ability to meet basic nutritional needs and maintain independence in daily living. Additionally, assessing if the patient can perform regular, simple maintenance on their primary residence is important for gauging their ability to live safely and comfortably. Choices B and D are incorrect as financial resources and toileting abilities, while important, do not directly reflect functional status in the same way as meal preparation and home maintenance.
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A 70-year-old male has the nursing diagnosis of situational low self-esteem related to forced retirement. Using Maslow’s hierarchy, the nurse is confident the patient is meeting self-worth outcomes when the patient:
- A. Moves to a secure apartment building
- B. Exercises regularly with friends at the gym
- C. Attends his grandchildren’s school functions
- D. Volunteers at the local homeless shelter weekly
Correct Answer: D
Rationale: The correct answer is D because volunteering at the local homeless shelter fulfills the self-actualization need in Maslow's hierarchy. By helping others and contributing to the community, the patient gains a sense of purpose and fulfillment, boosting self-esteem.
A: Moving to a secure apartment building addresses safety needs, not self-esteem.
B: Exercising with friends promotes social belonging but does not directly address self-esteem.
C: Attending grandchildren's functions fosters social connections, but it may not directly impact self-esteem like volunteering does.
A patient asks, “What advantage does a durable power of attorney for health care have over a living will?” The nurse should reply, A durable power of attorney for health care:
- A. Gives your agent authority to make decisions during any illness if you are incapacitated.
- B. Can be given only to a relative, usually the next of kin, who has your best interests at heart.
- C. Can be used only if you have a terminal illness and become incapacitated.
- D. Cannot be implemented until 30 days after the documents are signed.
Correct Answer: A
Rationale: Correct Answer: A: Gives your agent authority to make decisions during any illness if you are incapacitated.
Rationale:
1. A durable power of attorney for health care allows you to appoint a trusted individual (agent) to make medical decisions on your behalf if you are unable to do so.
2. This authority is not limited to a specific type of illness or condition, ensuring your agent can make decisions for any illness that renders you incapacitated.
3. This flexibility ensures that your wishes are carried out regardless of the circumstances.
Summary of Other Choices:
B: Incorrect - A durable power of attorney can be given to any trusted individual, not just a relative.
C: Incorrect - A durable power of attorney can be used in any situation where you are unable to make decisions, not just in terminal illness.
D: Incorrect - A durable power of attorney can be implemented immediately upon signing, providing timely decision-making support.
The Omnibus Budget Reconciliation Act (OBRA) provides standards of care for which of the following?
- A. Very young
- B. Older adults
- C. Those who have certain intellectual communication difficulties Those who have certain intellectual communication difficulties
- D. Those without medical insurance
Correct Answer: B
Rationale: The correct answer is B: Older adults. OBRA primarily focuses on setting standards of care for older adults in long-term care facilities, ensuring their safety and well-being. This is because older adults are a vulnerable population requiring specialized care and attention. Choices A, C, and D are incorrect because OBRA does not specifically address very young individuals, those with intellectual communication difficulties, or individuals without medical insurance. The Act mainly pertains to the care and rights of older adults in long-term care settings.
During the first family therapy session, the mother of a child being treated for truancy and emotional outbursts asks the nurse, “Why are you bothering to ask the rest of us questions? My son is the one with the problems.” The best response for the nurse would be:
- A. “We’ll get more accurate information if the entire family is involved.”
- B. “It may seem strange to you, but we’ll get better results doing it this way.”
- C. “When one family member is sick, the whole family system is sick as well.”
- D. “Every family member’s perceptions are very important to the total picture.”
Correct Answer: A
Rationale: The correct answer is A because involving the entire family in therapy sessions allows for a more comprehensive understanding of the family dynamics and how they may be contributing to the child's issues. By including all family members, the nurse can gather diverse perspectives and insights that can inform the treatment plan. This approach also promotes family unity and collaboration in addressing the child's problems.
Option B is not the best response as it lacks a clear rationale for involving the whole family. Option C, while partially true, does not directly address the question raised by the mother. Option D emphasizes the importance of every family member's perceptions but does not specifically address the benefits of involving the entire family in therapy sessions.
A teenage boy has lost his best friend as a result of a hunting accident. His parents report that he is eating and sleeping very little and expresses little interest in school. They are concerned that he talks about the accident repeatedly. These behaviors are generally seen as:
- A. Expressing responsibility for his friends death
- B. Attempts to avoid dealing with his pain
- C. Expressions of a normal grief reaction
- D. Indications of a risk for self-harm
Correct Answer: C
Rationale: The correct answer is C: Expressions of a normal grief reaction. The teenage boy's behaviors of poor appetite, insomnia, lack of interest in school, and repetitive discussions about the accident are common manifestations of grief. This grief reaction is a normal response to losing a close friend in a traumatic manner like a hunting accident. It is important to acknowledge and validate his emotions during this difficult time.
Incorrect Choices:
A: Expressing responsibility for his friend's death - This choice suggests guilt or blame on the part of the boy, which is not evident in the scenario.
B: Attempts to avoid dealing with his pain - The boy's behaviors indicate he is processing his grief rather than avoiding it.
D: Indications of a risk for self-harm - While it is important to monitor for signs of self-harm, the behaviors described are more indicative of grief rather than immediate self-harm risk.