Age Specific Nursing Care

Age Specific Nursing Care Related

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A 91-year-old female client with dementia is being seen by the home health nurse. Both she and her husband, who is 92 years old, were very active until her dementia became debilitating. Since that time, the client does not recognize her husband or children, forgets how to eat and dress, and wanders about the house day and night. Her husband wants to keep her at home to care for her, but the nurse notices that he is increasingly tired with each visit. What is the nurse's priority intervention for the nursing diagnosis of caregiver role strain?

  • A. Discuss strategies to coordinate care and other responsibilities
  • B. Encourage involvement in support groups
  • C. Identify resources to include financial, legal, and respite care
  • D. Stress the importance of self-nurturing
Correct Answer: A

Rationale: The correct answer is A: Discuss strategies to coordinate care and other responsibilities. The priority intervention for caregiver role strain is to help the husband effectively manage caring for his wife with dementia. By discussing strategies to coordinate care and other responsibilities, the nurse can assist the husband in creating a plan to ensure the client's needs are met while also addressing his own well-being. This intervention will help alleviate the husband's increasing tiredness and provide support in managing the caregiving responsibilities.

Summary of other choices:
B: Encourage involvement in support groups - While support groups can be beneficial, the immediate priority is to address the husband's caregiving responsibilities.
C: Identify resources to include financial, legal, and respite care - While important, these resources may not directly address the husband's current strain in caring for his wife.
D: Stress the importance of self-nurturing - While self-care is important, the immediate focus should be on assisting the husband in managing his caregiving responsibilities.

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In the OB follow-up clinic, your patient, who is 4 weeks post-delivery, tells you she is sleeping for long hours, wants to avoid taking care of the baby, and wishes she had never had the baby. What would be your first response?

  • A. Its normal to feel overwhelmed at first.
  • B. Tell me more about these feelings.
  • C. Report her to Child Protective Services.
  • D. Ill call your husband right away to get you back home to rest.
Correct Answer: B

Rationale: The open-ended question (B) will give you more information and be less judgmental to this patient. This behavior is not normal at 4 weeks post-delivery and more rest is probably not adequate treatment. You would like a lot more information before reporting this as neglect.

A nurse planning teaching for a parent group concerned with preventing family violence can discuss the fact that exposure to violence in the media:

  • A. Has no effect on the increase of violence in society
  • B. Assists individuals to distinguish appropriate behaviors from inappropriate behaviors
  • C. Desensitizes people to the violence around them
  • D. Broadens the viewer's knowledge about world happenings
Correct Answer: C

Rationale: The correct answer is C: Desensitizes people to the violence around them. Exposure to violence in the media can desensitize individuals, leading them to become less sensitive or responsive to violent acts in real life. This desensitization can contribute to a normalization of violence and reduce the perceived severity of violent behaviors. This can potentially lead to an increase in tolerance for violence in society.

Incorrect choices:
A: Has no effect on the increase of violence in society - This is incorrect because research has shown that exposure to media violence can have an impact on behavior.
B: Assists individuals to distinguish appropriate behaviors from inappropriate behaviors - This is incorrect as exposure to violence in the media may blur the lines between appropriate and inappropriate behaviors.
D: Broadens the viewer's knowledge about world happenings - This is incorrect as exposure to violence in the media may not necessarily lead to a broader understanding of world events, especially if the focus is on sensationalized or graphic content.

An individual accompanied by a friend was brought by ambulance to the emergency room. A nurse notes that the patient's skin is flushed and dry. Further assessment reveals the patient has not voided or ingested food or fluid in 18 hours. Temperature, pulse, blood pressure, and respirations are elevated, and sensorium alternates between clouded and clear. The physician diagnoses fever of unknown origin. Because the patient is restless and agitated, the plan is to make an effort to orally hydrate before attempting to start an IV line. The intervention most likely to be effective will be:

  • A. placing a pitcher of water at the patient's bedside.
  • B. placing a "force fluids" sign at the head of the bed.
  • C. asking the friend to give the patient a drink whenever the patient is alert.
  • D. staying with the patient to ensure that a glass of liquid is ingested once every hour.
Correct Answer: D

Rationale: The correct answer is D: staying with the patient to ensure that a glass of liquid is ingested once every hour. This choice is the most effective intervention because the patient is in a state of restlessness and agitation, making it crucial to closely monitor fluid intake. By staying with the patient and ensuring regular liquid consumption, the nurse can help maintain hydration and potentially alleviate symptoms.

Choice A (placing a pitcher of water at the patient's bedside) may not be effective as the patient may not be able to independently drink the water when needed. Choice B (placing a "force fluids" sign at the head of the bed) might not address the patient's agitation and restlessness and could lead to increased anxiety. Choice C (asking the friend to give the patient a drink whenever the patient is alert) may not provide consistent monitoring and support needed for the patient's condition.

Therefore, choice D is the best option as it addresses the patient's need for hydration, agitation, and restlessness effectively

A patient has not come out of her room for breakfast. The nurse finds the patient moving restlessly about her room in a disorganized manner. The patient is talking to herself, and her verbal responses to the nurse are nonsensical and suggest disorientation. The nurse notices that the patient's skin is hot and dry, and her pupils are somewhat dilated. All these symptoms are significant departures from the patient's recent presentation. The patient is likely experiencing ______, and the nurse should ______.

  • A. anticholinergic toxicity"¦check vital signs and prepare to use a cooling blanket stat
  • B. relapse of her psychosis"¦administer PRN antipsychotic drugs and notify her physician
  • C. neuroleptic malignant syndrome"¦contact her physician for a transfer to intensive care
  • D. agranulocytosis"¦hold her antipsychotic and draw blood for a complete blood count
Correct Answer: A

Rationale: The correct answer is A: anticholinergic toxicity. The patient's symptoms align with this diagnosis due to the disorganized behavior, nonsensical speech, disorientation, hot and dry skin, dilated pupils, and recent presentation changes. Anticholinergic toxicity can cause confusion, delirium, hyperthermia, and dilated pupils. Checking vital signs and preparing to use a cooling blanket are appropriate actions to manage the symptoms.

Choice B (relapse of psychosis) is incorrect because the symptoms are not typical of a psychotic relapse. Choice C (neuroleptic malignant syndrome) is incorrect as the symptoms do not completely align with this syndrome, which typically includes muscle rigidity and autonomic dysfunction. Choice D (agranulocytosis) is incorrect because it presents with low white blood cell count and not the symptoms described in the scenario.

Which nursing intervention will assist a client being treated in the Emergency Department for extensive soft tissue injuries to disclose an experience of domestic violence?

  • A. Interviewing her in the presence of another professional
  • B. Speaking with the client in the absence of her husband
  • C. Providing a safe, nonintimidating environment
  • D. Allowing the client to initiate the topic of violence
Correct Answer: C

Rationale: Rationale for Correct Answer (C): Providing a safe, nonintimidating environment is crucial to encourage the client to disclose domestic violence. This approach helps establish trust and confidentiality, making the client feel secure to share sensitive information. It creates a conducive setting for open communication without fear of repercussions.

Summary of Incorrect Choices:
A: Interviewing her in the presence of another professional may not ensure privacy and could potentially increase the client's discomfort or fear of being overheard.
B: Speaking with the client in the absence of her husband might not guarantee safety and confidentiality, as the client may still feel threatened or hesitant to reveal the abuse.
D: Allowing the client to initiate the topic of violence puts the burden on the client, who may already be feeling overwhelmed or unable to bring up the sensitive issue without support and encouragement.

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