Nokea
The client’s family approaches the nursing supervisor with a complaint about the NA’s inappropriate communication with their 89-year-old father. When evaluating the NA’s communication, which statements does the nurse determine most likely caused the family’s complaint? Select all that apply.
- A. Are you ready for the nurse to give you your medicine?'
- B. Would you like to go to breakfast now, Grandpa?'
- C. Would you prefer to wear the brown socks today?'
- D. Your family will be visiting today. Isn’t that nice?'
- E. Honey, this is your bath day. Are you ready to go?'
Correct Answer: B;D;E
Rationale: Grandpa,' 'Isn’t that nice?,' and 'Honey' are infantilizing or clichéd, likely causing the complaint. Other statements are appropriate.
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The nurse is caring for the 50-year-old client who reports having difficulty falling asleep. Which recommendations should the nurse make to this client? Select all that apply.
- A. Drink a glass of wine or a beer before bedtime
- B. Avoid exercising 2 to 3 hours before bedtime
- C. Go to bed at the same time each night
- D. Watch television in bed just before bedtime
- E. Avoid eating large or spicy meals in the evening
Correct Answer: B;C;E
Rationale: Avoiding exercise near bedtime, maintaining a consistent bedtime, and avoiding large/spicy meals promote sleep. Alcohol and TV in bed can disrupt sleep.
The nurse is teaching an 86-year-old about glaucoma and how to administer eye drops. Which interventions should the nurse implement? Select all that apply.
- A. Plan the session at a time when a support person can attend
- B. Provide an environment that is private, quiet, and well lit
- C. Be detailed with the explanations to ensure understanding
- D. Engage as many of the client’s five senses as possible
- E. Give extensive written materials and a schedule to follow
Correct Answer: A;B;D
Rationale: A support person aids learning with vision issues, a private environment enhances focus, and engaging senses improves retention. Detailed explanations may overwhelm, and written materials should be concise.
The 73-year-old client receiving palliative care comments to the nurse, 'I am such a feeble old man. My life is such a waste, and I hate having my wife see me like this. just wish I could die now.' Which statement is the nurse’s best interpretation of the client’s comments?
- A. The client is feeling ashamed and ready to die
- B. The client is feeling anxious knowing that he is terminally ill
- C. The client is facing Havighurst’s developmental tasks of later maturity
- D. The client is in Erikson’s developmental state of integrity versus despair
Correct Answer: D
Rationale: The client’s contempt for self and desire to die reflect despair in Erikson’s integrity versus despair stage. No shame or anxiety is evident, and Havighurst’s tasks involve positive adjustments.
During a nursing home visit, the son notices multiple healing bruises on his father’s arms and legs and calls a friend who is a nurse. Which initial recommendations should the nurse provide to the son? Select all that apply.
- A. Ask your father how the bruises occurred and whether he was abused.'
- B. Contact Adult Protective Services immediately to report the abuse.'
- C. Verify with the nursing staff whether your father is on anticoagulants.'
- D. Inform the agency’s nursing supervisor that your father is being abused.'
- E. Contact the state ombudsman who can help you make an anonymous report.'
Correct Answer: A;C
Rationale: Asking about bruise causes and checking for anticoagulants (which cause bruising) are initial steps. Reporting abuse or contacting authorities requires more evidence.
The nurse is assessing the 88-year-old client. Which finding should the nurse associate with the normal aging process?
- A. Arm muscle strength 4 on a 0 to 5 scale
- B. Multiple fractures to the thoracic spine
- C. Ulnar deviation of the left hand fingers
- D. Slight pain in the right and left heel
Correct Answer: A
Rationale: Muscle strength of 4/5 is normal with aging. Fractures, ulnar deviation (rheumatoid arthritis), and heel pain (bone spurs) are not normal aging changes.