Nokea
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.
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After performing an assessment and determining that there are no other causes, the nurse concludes that the older adult’s recent hearing loss in one ear may be from cerumen accumulation from age-related changes. The nurse’s conclusion was based on which age-related changes that contribute to the cerumen accumulation?
- A. Reduced sweat gland activity; thinning and drying of the skin lining the ear canal
- B. Ossicular bone calcification; longer and thicker hair growth in the ear canal
- C. Degenerative structural changes of the eardrum preventing cerumen passage
- D. Over activity of the sweat glands contributing to the development of presbycusis
Correct Answer: A
Rationale: Reduced sweat gland activity and thinning/drying of the ear canal skin cause cerumen buildup, affecting sound perception. Ossicular calcification, eardrum changes, and presbycusis are unrelated.
The nurse is caring for the 94-year-old hospitalized client of the Muslim faith who is near death. Which nursing action is most inappropriate?
- A. Spraying perfume in the client’s room
- B. Placing the client supine facing Mecca
- C. Offering grief counseling to family members
- D. Checking records for wishes of organ donation
Correct Answer: C
Rationale: Grief counseling is discouraged in Muslim faith, making it inappropriate. Perfuming, facing Mecca, and checking organ donation are culturally appropriate.
The nurse is interviewing an 80-year-old client who has urinary incontinence. The client is taking furosemide. When asked about daily fluid intake, the client states, 'I drink 2 glasses of water, 1 glass of milk, and a half glass of juice. I don’t drink coffee or tea.' Which responses by the nurse are appropriate? Select all that apply.
- A. Your fluid intake should be 6 to 8 glasses of water, plus other fluids.'
- B. Your fluid intake is adequate and may help to reduce your incontinence.'
- C. Caffeine increases urination; it is good that you avoid drinking coffee.'
- D. Your fluid intake is limited; this increases your risk for dehydration.'
- E. Your fluid intake is sufficient to maintain a fluid and electrolyte balance.'
Correct Answer: A;C;D
Rationale: The client’s 3.5 glasses of fluid are inadequate, increasing dehydration risk, especially with furosemide. Older adults need 6-8 glasses of water plus other fluids, and avoiding caffeine reduces diuresis. Inadequate fluid may worsen incontinence.
The nurse is caring for the older adult client. The nurse should identify that the client is at risk for developing skin breakdown when making which observations? Select all that apply.
- A. A nursing assistant applies a perfumed lotion to the client’s skin
- B. Two nursing assistants are elevating the client’s heels off the bed
- C. A family member brings the client’s favorite custard from home
- D. The nurse applies an alcohol-based hand wash to the client’s hands
- E. The nurse is directing the client to push with the heels to move up in bed
Correct Answer: A;D;E
Rationale: Perfumed lotion, alcohol-based wash, and heel friction increase skin breakdown risk. Elevating heels and nutrition reduce risk.
The nurse is caring for the chronically ill middle-aged adult who has had numerous hospitalizations. Which behaviors may interfere with the client’s achievement of the developmental task associated with middle adulthood? Select all that apply.
- A. Writes thank-you notes to friends
- B. Stays at home and refuses visitors
- C. Self-absorbed in own psychological needs
- D. Attempts to perform own personal cares
- E. Continually relays feelings of inadequacy
Correct Answer: B;C;E
Rationale: Staying home, self-absorption, and feelings of inadequacy interfere with maintaining social relationships and generativity. Thank-you notes and self-care support generativity.