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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The nurse overhears a person say, 'I’m having a senior moment because I forgot.' How should the nurse interpret this statement?
- A. This phrase is a comical statement without age bias and is acceptable to others
- B. This phrase is a stereotypical reference to older adults that can be termed ageism
- C. This phrase admits that the older adult’s ability to learn new information is limited
- D. This phrase recognizes that all older adults have short- and long-term memory issues
Correct Answer: B
Rationale: The phrase is a stereotypical reference to older adults, perpetuating ageism. It’s not comical, doesn’t imply learning limits, and not all older adults have memory issues.
The home health nurse suspects elder mistreatment of the 93-year-old client by the live-in caregiver. Which findings support the nurse’s conclusion? Select all that apply.
- A. Client has urine burns
- B. Client has wrist bruises
- C. Client states there have been some unexplained financial expenditures
- D. Client is more talkative than during previous home visits
- E. Smell of alcohol noted on live-in caregiver’s breath
Correct Answer: A;B;C;E
Rationale: Urine burns (neglect), wrist bruises (physical abuse), unexplained expenditures (financial abuse), and caregiver alcohol use (abuser characteristic) support mistreatment. Increased talkativeness suggests comfort, not abuse.
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 teaches the 18-year-old diabetic client to perform self-administration of insulin. Each time the client makes even a small mistake, the client apologizes for getting it wrong- The client also profusely apologizes when making a minimal mistake in other activities. Based on Erikson’s developmental stages, the nurse concludes that the client may have an unresolved developmental task of which age period?
- A. Infancy
- B. Early childhood
- C. School-aged childhood
- D. Adolescence
Correct Answer: B
Rationale: The behavior indicates an unresolved conflict of 'autonomy versus shame and doubt' associated with the 18-month to 3-year-old age group. When parents are overly critical, the child may develop an overly critical superego, manifesting as constant apologizing for small mistakes.
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.