Nokea
A nurse caring for an older client on a medical-surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first?
- A. Auscultate bowel sounds
- B. Palpate the abdomen
- C. Review the client's medication list
- D. Assess dietary fiber intake
Correct Answer: D
Rationale: Assessing dietary fiber intake is critical as the client's preference for softer, low-fiber foods like rice, bread, and puddings may contribute to constipation. This assessment should be prioritized to identify potential causes before proceeding to other assessments like auscultating bowel sounds or palpating the abdomen.
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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.
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.
An older adult recently retired and reports being depressed and lonely. What information should the nurse assess as a priority?
- A. History of previous depression
- B. Previous stressful events
- C. Role of work in the adult's life
- D. Usual leisure time activities
Correct Answer: C
Rationale: Often older adults lose support systems when their roles change. For instance, when people retire, they may lose their entire social network, leading to feelings of depression and loneliness. The nurse should first assess the role that work played in the client's life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population.
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.
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.