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A nurse is caring for a client whose partner died 3 years ago and reports that they are still unable to accept the loss. The nurse should identify that the client has manifestations of which of the following types of grief?
- A. Uncomplicated grief
- B. Prolonged grief
- C. Anticipatory grief
- D. Disenfranchised grief
Correct Answer: B
Rationale: The correct answer is B: Prolonged grief. This is because the client is still struggling to accept the loss after 3 years, which is indicative of prolonged grief. Uncomplicated grief (Choice A) typically resolves within a reasonable timeframe. Anticipatory grief (Choice C) occurs before the actual loss. Disenfranchised grief (Choice D) is when the individual's grief is not openly acknowledged or socially supported. In this scenario, the client's grief extends beyond the normal grieving process, indicating prolonged grief.
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A nurse is teaching a class about expected physiological changes in older adult clients. Which of the following changes should the nurse include?
- A. Increase in startle reflex
- B. Increase in muscle mass
- C. Decrease in body fat
- D. Decrease in systolic blood pressure
Correct Answer: A
Rationale: The correct answer is A: Increase in startle reflex. As individuals age, their neurological system undergoes changes leading to increased sensitivity and exaggerated responses, including an increase in the startle reflex. This change is attributed to alterations in neurotransmitter levels and sensory processing.
Incorrect Answers:
B: Increase in muscle mass - Muscle mass typically decreases with age due to hormonal changes and decreased physical activity.
C: Decrease in body fat - Older adults tend to experience an increase in body fat and a decrease in muscle mass, contributing to changes in body composition.
D: Decrease in systolic blood pressure - While blood pressure tends to increase with age due to changes in blood vessel elasticity and hormonal changes, a decrease in systolic blood pressure is not a common expected physiological change in older adults.
A nurse is teaching a client about the Rinne test. Which of the following client statements indicates an understanding of the teaching?
- A. I will wear earphones during this test
- B. A small probe is placed inside my ear
- C. A tuning fork is placed on my head
- D. Small electrodes are placed on my scalp
Correct Answer: C
Rationale: The correct answer is C: A tuning fork is placed on my head. In the Rinne test, a tuning fork is first placed against the client's mastoid bone behind the ear and then moved near the ear canal. The client should hear the sound louder when the fork is near the ear if the test is normal. Choice A is incorrect because earphones are not used in the Rinne test. Choice B is incorrect as a probe is not inserted into the ear. Choice D is incorrect as electrodes are not part of the Rinne test. Placing a tuning fork on the head is the correct step in performing the Rinne test to assess hearing conduction.
A nurse is using the NURSE mnemonic when speaking with a client who is experiencing grief. The client reports that they are feeling overwhelmed. Which of the following responses by the nurse demonstrates the 'E' in the NURSE mnemonic?
- A. It sounds like you are exhausted
- B. You have so much to deal with, how can I be of help to you?
- C. Tell me more about how you are feeling
- D. It is impressive how you have managed to deal with this situation
Correct Answer: A
Rationale: The correct answer is A. In the NURSE mnemonic, 'E' stands for empathy. By acknowledging the client's feeling of being overwhelmed and reflecting it back by saying "It sounds like you are exhausted," the nurse demonstrates empathy. This response shows understanding and validation of the client's emotions, which can help the client feel heard and supported.
Choice B focuses more on offering help without directly addressing the client's emotional state. Choice C is about exploring the client's feelings but does not directly acknowledge the expressed emotion of being overwhelmed. Choice D praises the client's coping skills but does not address the current emotional state of feeling overwhelmed.
A nurse in a public clinic is planning a health fair for older adult clients in the community. In teaching medication safety, which of the following foods should the nurse advise the clients to avoid when taking their prescriptions?
- A. Orange juice
- B. Grapefruit juice
- C. Milk
- D. Carbonated beverage
Correct Answer: B
Rationale: The correct answer is B: Grapefruit juice. Grapefruit juice can interact with many medications by inhibiting the enzyme that metabolizes the drugs, leading to higher drug levels in the body and potentially causing adverse effects. Orange juice (A), milk (C), and carbonated beverages (D) do not have significant interactions with most medications. It is important for the nurse to advise older adult clients to avoid grapefruit juice to prevent medication interactions and ensure their safety.
A nurse is caring for a client who has a terminal diagnosis and states, 'I am ready to update my will.' The nurse should identify that the client is experiencing which of the following Kubler-Ross stages of grief?
- A. Denial
- B. Acceptance
- C. Anger
- D. Bargaining
Correct Answer: B
Rationale: The correct answer is B: Acceptance. The client expressing readiness to update their will indicates acceptance, one of the stages of grief according to Kubler-Ross. This stage involves coming to terms with the reality of the situation and making necessary preparations. Denial (choice A) involves refusing to accept the diagnosis, anger (choice C) involves feelings of frustration and unfairness, and bargaining (choice D) involves seeking ways to avoid the inevitable. In this scenario, the client's statement aligns with the acceptance stage, as they are taking practical steps to prepare for the future.