Nokea
A nurse in an extended-care facility is reinforcing teaching with a group of newly licensed nurses about the expected physiologic changes of aging. Which of the following information should the nurse include? (Select all that apply.)
- A. More difficulty seeing due to a greater sensitivity to glare
- B. Decreased cough reflex
- C. Decreased bladder capacity
- D. Decreased systolic blood pressure
- E. Dehydration of intervertebral discs
Correct Answer: A,B,C,E
Rationale: Correct Answer: A, B, C, E
Rationale:
A: With aging, the lens of the eye becomes less flexible, leading to difficulty seeing due to glare.
B: Aging affects the cough reflex, making it less effective in clearing the respiratory tract.
C: Bladder capacity decreases with age due to decreased muscle tone and elasticity.
E: Intervertebral discs lose water content with age, leading to dehydration and decreased flexibility.
Incorrect Choices:
D: Systolic blood pressure tends to increase with age, not decrease.
F, G: No information provided to analyze these options.
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A nurse is performing chest physiotherapy for a client with a respiratory infection. Which of the following techniques should the nurse use to increase the velocity and turbulence of the air the client exhales?
- A. Postural drainage
- B. Nebulization
- C. Percussion
- D. Vibration
Correct Answer: D
Rationale: Vibration increases air turbulence and helps loosen secretions, facilitating expectoration.
A nurse is collecting data from a client who has isotonic fluid-volume deficit. Which of the following findings should the nurse expect?
- A. Weak pulse
- B. Bradycardia
- C. Hypertension
- D. Distended neck veins
Correct Answer: A
Rationale: A weak, thready pulse is a classic sign of hypovolemia. Bradycardia and hypertension are more common with fluid overload.
A nurse is collecting data from a client who has ataxia. Which of the following is appropriate to evaluate the client's ability to safely ambulate?
- A. Auscultate for Korotkoff's sounds.
- B. Perform a Romberg test.
- C. Check the function of cranial nerve V.
- D. Inspect for the presence of clubbing.
Correct Answer: B
Rationale: The correct answer is B: Perform a Romberg test. This test evaluates the client's ability to maintain balance with eyes closed, which is essential for safe ambulation in a client with ataxia. Auscultating for Korotkoff's sounds (A) is related to blood pressure assessment, not ambulation. Checking cranial nerve V function (C) is important for facial sensation and chewing, not directly related to ambulation. Inspecting for clubbing (D) is related to respiratory or cardiovascular conditions, not relevant to assessing ambulation.
A nurse is admitting a client who has a partial hearing impairment. Which of the following actions is the nurse's priority?
- A. Speak using a normal tone of voice.
- B. Stand directly in front of the client.
- C. Rephrase statements as needed.
- D. Determine if the client uses a hearing aid.
Correct Answer: D
Rationale: Determining if the client uses a hearing aid is a priority because it can significantly impact communication and care planning.
A nurse is contributing to the plan of care for a client who is a Seventh-Day Adventist. To provide spiritually and culturally sensitive care, which of the following interventions should the nurse suggest for this client?
- A. Do not schedule diagnostic tests for Saturday.
- B. Arrange for him to receive the sacrament of the sick.
- C. Assign same-gender caregivers.
- D. Offer him a kosher dietary menu.
Correct Answer: A
Rationale: The correct answer is A: Do not schedule diagnostic tests for Saturday. Seventh-Day Adventists observe Saturday as a holy day of rest and worship, known as the Sabbath. By avoiding scheduling diagnostic tests on Saturdays, the nurse respects the client's religious beliefs and practices. This intervention promotes culturally sensitive care by acknowledging and accommodating the client's spiritual needs.
Choice B (Arrange for him to receive the sacrament of the sick) is incorrect as this intervention is specific to the Catholic faith, not Seventh-Day Adventist beliefs. Choice C (Assign same-gender caregivers) is not directly related to the client's religious preferences and may not be necessary for providing culturally sensitive care in this context. Choice D (Offer him a kosher dietary menu) is more aligned with Jewish dietary laws, which do not specifically apply to Seventh-Day Adventist beliefs.