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A nurse admits an older client from a home environment where she lives with her adult son and daughter-in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate?
- A. Ask the family how these problems occurred
- B. Call the police department and file a report
- C. Assist with Adult Protective Services
- D. Report the findings as per agency policy
Correct Answer: D
Rationale: These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. This person can then assess the situation further. If the police need to be notified, that is the person who will notify them. Adult Protective Services is notified in a community setting.
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A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult?
- A. Building strength and flexibility
- B. Improving exercise endurance
- C. Increasing cardiovascular capacity
- D. Enhancing balance and coordination
Correct Answer: A
Rationale: This older adult is mostly homebound. Exercise regimens for homebound clients include activities to increase functional ability for activities of daily living. Strength and flexibility exercises will help the client maintain independent living. The other options are beneficial but do not specifically address the client's functional abilities.
An older client is concerned about dehydration. What is the best advice for this client?
- A. Cut some sodium out of your diet
- B. Dehydration can cause incontinence
- C. Have something to drink every 1 to 2 hours
- D. Take your diuretic in the morning
Correct Answer: C
Rationale: Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not they are thirsty. Cutting some sodium from the diet will not address this issue. Although dehydration can cause incontinence from the urine irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue.
A nurse is caring for an older adult who reports not eating well. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Ask about transportation to buy food
- B. Inquire about access to dentures
- C. Encourage the client to continue the current exercise plan
- D. Have the client complete a 3-day diet recall diary
- E. Teach the client about proper nutrition in the older population
Correct Answer: A,B,D
Rationale: Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging them to continue the current exercise plan is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client's needs, which the nurse does not yet know.
A nurse is delegating care of an older client with a high risk for skin breakdown to unlicensed assistive personnel (UAP). Which statements by the nurse are appropriate? (Select all that apply.)
- A. Assess the client's skin daily and report any redness
- B. Order a special mattress if you notice skin breakdown
- C. Keep the client's skin dry and free of moisture
- D. Turn the client every 2 hours to prevent pressure ulcers
- E. Reassess the Braden Scale results every shift
Correct Answer: C,D,E
Rationale: The nurse's aide or UAP can assist in keeping the client's skin dry, order a special mattress on direction of the RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should be instructed to report any redness noticed. Reassessing the Braden Scale results is the RN's responsibility, as the RN is the one who performs the main assessment.
A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?
- A. Barley soup
- B. Black beans
- C. White rice
- D. Whole wheat bread
Correct Answer: C
Rationale: Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.