Nokea
A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors?
- A. Decreased residual volume
- B. Urethral stenosis
- C. Increased bladder capacity
- D. Decreased muscle tone
Correct Answer: D
Rationale: Factors that alter elimination patterns in the older adult include decreased bladder capacity, decreased muscle tone, increased residual volumes, and delayed perception of elimination cues. The other noted phenomena are atypical.
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An adult patients current goals of rehabilitation focus primarily on self-care. What is a priority when teaching a patient who has self-care deficits in ADLs?
- A. To provide an optimal learning environment with minimal distractions
- B. To describe the evidence base for any chosen interventions
- C. To help the patient become aware of the requirements of assisted-living centers
- D. To ensure that the patient is able to perform self-care without any aid from caregivers
Correct Answer: A
Rationale: The nurses role is to provide an optimal learning environment that minimizes distractions. Describing the evidence base is not a priority, though nursing actions should indeed be evidence-based. Assistedliving facilities are not relevant to most patients. Absolute independence in ADLs is not an appropriate goal for every patient.
A patient who is receiving rehabilitation following a spinal cord injury has been diagnosed with reflex incontinence. The nurse caring for the patient should include which intervention in this patients plan of care?
- A. Regular perineal care to prevent skin breakdown
- B. Kegel exercises to strengthen the pelvic floor
- C. Administration of hypotonic IV fluid
- D. Limited fluid intake to prevent incontinence
Correct Answer: A
Rationale: Reflex incontinence is associated with a spinal cord lesion that interrupts cerebral control, resulting in no sensory awareness of the need to void. Total incontinence occurs in patients with a psychological impairment when they cannot control excreta. A patient who is paralyzed cannot perform Kegel exercises. Intravenous fluids would make no difference in reflex incontinence. Limited fluid intake would make no impact on a patients inability to sense the need to void.
You are creating a nursing care plan for a patient who is hospitalized following right total hip replacement. What nursing action should you specify to prevent inward rotation of the patients hip when the patient is in a partial lateral position?
- A. Use of an abduction pillow between the patients legs
- B. Alignment of the head with the spine using a pillow
- C. Support of the lower back with a small pillow
- D. Placement of trochanter rolls under the greater trochanter
Correct Answer: A
Rationale: Abduction pillows can be used to keep the hip in correct alignment if precautions are warranted following hip replacement. Trochanter rolls and back pillows do not achieve this goal.
You are the nurse creating the care plan for a patient newly admitted to your rehabilitation unit. The patient is an 82-year-old patient who has had a stroke but who lived independently until this event. What is a goal that you should include in this patients nursing care plan?
- A. Maintain joint mobility.
- B. Refer to social services.
- C. Ambulate three times every day.
- D. Perform passive range of motion twice daily.
Correct Answer: A
Rationale: The major goals may include absence of contracture and deformity, maintenance of muscle strength and joint mobility, independent mobility, increased activity tolerance, and prevention of further disability. The other listed actions are interventions, not goals.
An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patients healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency?
- A. Hemoglobin
- B. Bilirubin
- C. Albumin
- D. Cortisol
Correct Answer: C
Rationale: Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than3 \mathrm{~g}/\mathrm{mL}$ are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.