Nokea
A 90-year-old male complains of feeling cold in his room even though the thermostat is set at 75°F (24°C). The client probably feels cold because older adults have:
- A. Increased cellular cohesion.
- B. Increased moisture content of the stratum corneum.
- C. Slower cellular renewal time.
- D. Decreased ability to thermoregulate.
Correct Answer: D
Rationale: Older adults have reduced thermoregulation due to decreased subcutaneous fat, vascular changes, and slower metabolic rate, making them feel colder.
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The unliscensed assistive personnel (UAP) reports to the registered nurse that a client admitted with pneumonia is very diaphoretic. The nurse reviews the following vital signs in the chart obtained by the UAP. The nurse should:
- A. Maintain complete bed rest.
- B. Check the urine output.
- C. Ask the UAP to change the linens.
- D. Administer a beta blocker
Correct Answer: B
Rationale: A client with pneumonia experiencing diaphoresis is at risk for dehydration. The fluid status, intake, and output should be monitored closely. The client is febrile, causing an increase in heart rate. Fluid volume defi cit may also increase the heart rate. A beta blocker is not indicated since the underlying cause of the tachycardia can be treated with acetaminophen (Tylenol) and fl uid volume. Bed rest limits lung expansion and sitting up and deep breathing should be encouraged in a client with pneumonia. The blood pressure is stable enough to allow the client to get out of bed to the chair, with assistance to ensure safety
What is the primary goal collaboratively established by the client with Parkinson's disease, nurse, and physical therapist?
- A. To maintain joint flexibility.
- B. To build muscle strength.
- C. To improve muscle endurance.
- D. To reduce ataxia.
Correct Answer: A
Rationale: Maintaining joint flexibility is the primary goal to prevent contractures and maintain mobility in Parkinson's disease. Strength, endurance, and ataxia (less common in Parkinson's) are secondary.
The nurse is assessing the urine of a client who has had an ileal conduit and notes that the urine is yellow with a moderate amount of mucus. Based on the data, the nurse should?
- A. Change the appliance bag.
- B. Notify the physician.
- C. Obtain a urine specimen for culture.
- D. Encourage a high fluid intake.
Correct Answer: D
Rationale: Yellow urine with moderate mucus is normal for an ileal conduit due to intestinal segment use. Encouraging high fluid intake prevents complications like calculi or infection.
A 57-year-old client has difficulty with mobility after cancer treatment therapies and states, 'Why should I bother stretching my muscles? It doesn't seem to make any difference what I do.' The nurse responds by helping the client establish reasonable activity goals, choose their own health care from the menu, and make choices about her daily activities. These interventions represent the nurse's attempt to address which of the following nursing diagnoses?
- A. Ineffective coping.
- B. Powerlessness.
- C. Risk prone health behavior.
- D. Complicated grieving.
Correct Answer: B
Rationale: The client's statement reflects powerlessness, and the nurse's interventions aim to restore a sense of control through goal-setting and decision-making.
The nurse assesses that the client with hepatitis is experiencing fatigue, weakness, and a general feeling of malaise. The client tires rapidly during morning care. Based on this information, which of the following would be an appropriate nursing diagnosis?
- A. Impaired physical mobility related to malaise.
- B. Self-care deficit related to fatigue.
- C. Ineffective coping related to long-term illness.
- D. Activity intolerance related to fatigue.
Correct Answer: D
Rationale: Activity intolerance related to fatigue (D) best reflects the client's symptoms of tiring rapidly due to hepatitis. Impaired mobility (A), self-care deficit (B), and ineffective coping (C) are less directly supported.