Nokea
A health care provider writes these new prescriptions for a resident in a skilled care facility: '2 g sodium diet; restraint as needed; limit fluids to 2000 mL daily; 1 dose milk of magnesia 30 mL orally if no bowel movement occurs for 3 days.' Which prescription should the nurse question?
- A. Restraint
- B. Fluid restriction
- C. Milk of magnesia
- D. Sodium restriction
Correct Answer: A
Rationale: Restraints may be applied only on the written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used.
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An older adult patient brings a bag of medication to the clinic. The nurse found one bottle labeled 'Ativan' and one labeled 'lorazepam,' and both are labeled 'Take two times daily.' Bottles of hydrochlorothiazide, Inderal, and rofecoxib, each labeled 'Take one daily,' are also included. Which conclusion is accurate?
- A. Rofecoxib should not be taken with Ativan.
- B. The patient's blood pressure is likely to be very high.
- C. This patient should not self-administer any medication.
- D. Lorazepam and Ativan are the same drug; consequently, the dose is excessive.
Correct Answer: D
Rationale: Lorazepam and Ativan are generic and trade names for the same drug, creating an accidental overdose situation.
A student nurse visiting a senior center tells the instructor, 'It's so depressing to see all these old people. They are so weak and frail. They are probably all confused.' The student is expressing what attitude?
- A. Reality
- B. Ageism
- C. Empathy
- D. Distrust
Correct Answer: B
Rationale: Ageism is defined as a bias against older people because of their age. None of the other options can be identified from the ideas expressed by the student.
Which beliefs facilitate provision of safe, effective care for older adult patients?
- A. Sexual interest declines with aging.
- B. Older adults are able to learn new tasks.
- C. Aging results in a decline in restorative sleep.
- D. Older adults are prone to become crime victims.
- E. Older adults are usually lonely and socially isolated.
Correct Answer: B,C,D
Rationale: Older adults are more prone to become crime victims, experience a decline in restorative sleep, and can continue learning new tasks, which affect care delivery.
A nurse asks the following questions while assessing an older adult. The nurse will add the Geriatric Depression Scale as part of the assessment if the patient answers 'yes' to which question?
- A. Would you say your mood is often sad?'
- B. Are you having any trouble with your memory?'
- C. Have you noticed an increase in your alcohol use?'
- D. Do you often experience moderate-to-severe pain?'
Correct Answer: A
Rationale: Sadness may be a symptom of depression. Sad moods occurring with regularity should signal the need to assess further for other symptoms of depression.
A nurse wants to perform a preliminary assessment for suicidal ideation in an older adult patient. Which question would obtain the desired data?
- A. What thoughts do you have about a person's right to take his or her own life?'
- B. If you felt suicidal, would you communicate your feelings to anyone?'
- C. Do you have any risk factors that potentially contribute to suicide?'
- D. Do you think you are vulnerable to developing a depressed mood?'
Correct Answer: A
Rationale: The correct response is clear, direct, respectful, and open-ended, producing information relative to the acceptability of suicide as an option.