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A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What is the best action by the nurse?
- A. Call Adult Protective Services
- B. Discuss concerns with the health care team
- C. Assist with Adult Protective Services
- D. Have the client's family sign the consent
Correct Answer: B
Rationale: In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client's perceived incompetence, and the team can evaluate and determine the appropriate course of action.
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An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful for preventing falls in this client?
- A. Keep the light on in the bathroom at night
- B. Order a wheelchair for the client
- C. Put the client on a toileting schedule
- D. Use side rails to keep the client in bed
Correct Answer: A
Rationale: Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom at night helps ensure the client can see their surroundings, reducing the risk of falls.
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 working with older adults in the community plans programming to improve morale and emotional health. This a group potential. What a group would best meet this goal?
- A. Exercise program to improve physical function
- B. Financial planning seminar series for older adults
- C. Social events such as dances and group victim
- D. Workshop on prevention from becoming an abuse victim
Correct Answer: A
Rationale: All activities would be beneficial for the older population in the community. However, failure in performing ones own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who have the ability to function independently direct food wellnesses and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need.
A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the home. Which statement would be most helpful to keeping the older adult safe on the steps?
- A. Have the client use a walker or cane on the steps
- B. Install contrasting color strips at the edge of each step
- C. Advise the client to avoid the steps altogether
- D. Tell the client to use a two-footed gait on the steps
Correct Answer: B
Rationale: As a person ages, they may experience a decreased sense of touch. The older adult may not be aware of where their foot is on the step. Installing contrasting color strips at the edge of each step will help increase visibility and safety for the older adult.
A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant indicates strong social network coping?
- A. I have had the same best friend for decades
- B. I think I am coping very well on my own
- C. My kids come to see me over the weekend
- D. Oh, I have lots of friends at the senior center
Correct Answer: A
Rationale: Friendship and support enhance coping. The quality of the relationship is most important. People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crises.