Nokea
The older adult client is experiencing relocation stress after being admitted to a nursing home. Which intervention is best for the nurse to implement?
- A. Ask family members to explore placing the client in another nursing home
- B. Change the client’s room every week until a compatible roommate is found
- C. Place the client’s favorite items, such as a family picture, at the client’s bedside
- D. Ask that family members avoid talking to the client about being in the nursing home
Correct Answer: C
Rationale: Familiar items like a family picture reduce relocation stress. Moving facilities, changing rooms, or avoiding discussion may increase stress.
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When the office nurse completes height measurement for the 72-year-old female, the client says that she lost half an inch. Which explanation by the nurse is most accurate?
- A. As we age, we lose muscle mass.'
- B. Bone loss is due to lack of exercise.'
- C. As we age, we lose knee and hip cartilage.'
- D. The vertebral column shortens with aging.'
Correct Answer: D
Rationale: Aging causes vertebral column shortening due to water and bone density loss, leading to height reduction. Muscle mass, exercise, and cartilage loss don’t primarily affect height.
The nurse is collecting information from the young adult client. Which psychosocial questions should the nurse ask during the admission assessment? Select all that apply.
- A. Do you have any pets?'
- B. How many hours of sleep do you get?'
- C. When was your last bowel movement?'
- D. How much alcohol do you drink?'
- E. Can you describe your sexual activity?'
Correct Answer: A;B;D;E
Rationale: The nurse should ask about pets (enhances mental well-being), sleep (affects coping and immunity), alcohol use (impacts health risks), and sexual activity (STI/HIV risks). Bowel movement is physiological, not psychosocial.
The nurse is planning a health promotion program for a group of middle-aged adults. Which topic is most appropriate for the nurse to include?
- A. Methods of contraception
- B. Stress management skills
- C. Reduction of caloric intake
- D. A safe home environment
Correct Answer: B
Rationale: Stress management skills are most important for middle-aged adults facing stressors like aging, family support, and retirement planning, which contribute to stress-related diseases. Contraception is more relevant for young adults, caloric reduction is secondary, and home safety suits families or older adults.
The nurse is caring for the 55-year-old client. Which statement by the client related to psychosocial changes should the nurse most definitely explore?
- A. I really don’t want to color my hair, even though it seems to be getting grayer every day.'
- B. I can’t see as sharp anymore. I get frustrated by the small lettering on the medicine bottles.'
- C. My husband and I have a more active sexual life now that the children are out of the house.'
- D. My house is empty; I thought I’d be happy when my children finally left, but I feel lonely.'
Correct Answer: D
Rationale: The client’s statement suggests empty nest syndrome, a psychosocial concern requiring further exploration. Graying hair is a normal physiological change, vision issues are physiological, and an active sexual life indicates a healthy relationship.
The nurse has limited time to teach the middle-aged adult client. The nurse should initially plan to take which action?
- A. Provide brochures and handouts that the client can discuss with family members
- B. Make a referral to outpatient resources for the client to receive the needed teaching
- C. Establish the highest-priority learning needs and teach with each client or family contact
- D. Answer the client’s questions and leave the extensive teaching for the nurse on the next shift
Correct Answer: C
Rationale: Prioritizing learning needs ensures important teaching is completed efficiently during limited time. Brochures alone, referrals, or deferring teaching are less effective initially.