The nurse is teaching newly hired NAs in a long term care facility. What information about skin care for older adults should the nurse emphasize?
- A. Avoid skin products purchased for the resident by family that contain alcohol
- B. Apply perfumed skin lots after the resident’s bath when the skin is still moist
- C. When taking residents outdoors, apply sunscreen with a sun protection factor of 8
- D. Apply a strong detergent to clothing with food stains before sending to laundry
Correct Answer: A
Rationale: Avoiding alcohol-containing products prevents skin drying in older adults with fragile skin. Perfumed lotions, low SPF, and strong detergents increase irritation risk.
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The nurse is caring for the hospitalized 60-year-old client of Korean American ethnicity. Which statement, if made by the client, correctly reflects the Korean American culture and should alert the nurse that intervention is needed?
- A. Since 60 is considered old age, I retired as expected. I’m now worried about insurance.'
- B. Value is on youth and beauty; so little attention is paid to problems of the elderly.'
- C. Fathers are expected to continue to contribute financially even for their adult children.'
- D. Grandchildren are raised by the grandparents until school age, so we have a full house.'
Correct Answer: A
Rationale: In Korean American culture, 60 is considered old age, and retirement is expected, but this client’s concern about insurance requires a social worker consult for coverage options. Other statements reflect different cultural norms or lack specific cultural ties.
Pre-hospital admission medications for the older adult client include warfarin and atenolol. Which statement made by the client should prompt the nurse to initiate a referral to a social worker?
- A. I crush my medications and take them with applesauce because they are hard to swallow.'
- B. I stopped taking my blood pressure pill; I can’t afford it, and my blood pressure is normal.'
- C. I feel more alert after starting to take ginkgo, but I forgot to ask my doctor if it were okay.'
- D. I have my daughter set up my medications for two weeks at a time in a medication bar.'
Correct Answer: B
Rationale: Stopping medication due to cost indicates a financial concern, warranting a social worker referral. Swallowing issues, ginkgo use, and medication setup require different interventions.
The nurse completes teaching for the 80-year-old female client. Which statement made by the client indicates further teaching is needed?
- A. Instead of using sodium seasonings, I plan to try one with herbs and lemon.'
- B. Although I find my lavender-scented hand cream relaxing, I should not use it.'
- C. I should place a towel on the floor outside my shower so I don’t slip when getting out.'
- D. Rather than relying on laxatives, I should increase my intake of fruits and vegetables.'
Correct Answer: C
Rationale: Placing a towel on the floor increases fall risk; a slip-resistant mat is needed. Nonsodium seasonings, avoiding scented lotions, and increasing roughage are correct.
A 72-year-old woman reports she is sexually active. It is most important for the nurse to follow up by asking which question?
- A. Can you tell me more about your sexual partners?'
- B. Have you tried artificial water-based lubricants?'
- C. Are any medications having any drying effects?'
- D. Do you need to use different sexual positions?'
Correct Answer: A
Rationale: Assessing sexual partners is critical due to rising STI/HIV rates in older adults. Lubricants, medication effects, and positions are secondary to infection risk.
The nurse assesses the 75-year-old client and concludes that some findings are not age-related changes and require further follow-up. Which report by the client represents a non-age-related finding that requires additional investigation?
- A. Reports a decreased ability to see at night
- B. Reports seeing halos around lights
- C. Reports difficulty distinguishing some colors
- D. Reports diminished visual acuity
Correct Answer: B
Rationale: Seeing halos is a symptom of glaucoma, not an age-related change, requiring investigation. Night vision, color distinction, and acuity changes are normal with aging.