Nokea
A nurse is caring for an older adult client who expresses feelings of grief for his earlier life. Which of the following actions should the nurse take to help the client cope with his feelings of loss?
- A. Let the client know that this is a common problem of the aging population.
- B. Provide the client with activities to perform so he won't have time to dwell on the past.
- C. Listen attentively when the client talks about the past.
- D. Tell the client about some of the younger clients in the hospital who have experienced loss.
Correct Answer: C
Rationale: The correct answer is C: Listen attentively when the client talks about the past. Active listening is crucial in helping the client cope with feelings of grief. By providing a supportive environment and allowing the client to express his emotions, the nurse can validate his feelings and provide emotional support. This helps the client feel understood and accepted, facilitating the grieving process.
Choice A is incorrect because simply stating that it is a common problem does not address the individual client's feelings. Choice B is incorrect as it dismisses the client's emotions and distracts rather than addressing the root of the issue. Choice D is inappropriate as it is not empathetic and may invalidate the client's experience by comparing it to others.
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A nurse is assisting in preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following alterations is appropriate for the nurse to include?
- A. Decreased muscle mass
- B. Thickened vertebral disks
- C. Decreased chest width
- D. Increased force of isometric contractions
Correct Answer: A
Rationale: The correct answer is A: Decreased muscle mass. As individuals age, there is a natural decline in muscle mass known as sarcopenia. This is due to a decrease in muscle fiber size and number. The nurse should include this alteration in the presentation because it is a common age-related musculoskeletal change that can lead to weakness, decreased mobility, and increased risk of falls in older adults.
Choices B, C, and D are incorrect because thickened vertebral disks, decreased chest width, and increased force of isometric contractions are not typical age-related musculoskeletal changes. Thickened vertebral disks are more associated with degenerative disc disease, decreased chest width is not a common age-related change, and increased force of isometric contractions is not a typical alteration seen in older adults.
A nurse is assisting with the admission of a client who is dehydrated. Which of the following BUN levels should the nurse expect the client to have?
- A. 3.6 mg/dL
- B. 9 mg/dL
- C. 18.7 mg/dL
- D. 24 mg/dL
Correct Answer: D
Rationale: The correct answer is D: 24 mg/dL. BUN (Blood Urea Nitrogen) levels typically increase in dehydration due to reduced kidney perfusion. A BUN level of 24 mg/dL is higher than normal (7-20 mg/dL) and is indicative of dehydration. Choice A (3.6 mg/dL) is too low for a dehydrated client. Choice B (9 mg/dL) is within the normal range and not high enough for dehydration. Choice C (18.7 mg/dL) is slightly elevated but may not be as indicative of dehydration as choice D.
A nurse is collecting data from a client. Which of the following findings should the nurse report to the charge nurse as an indicator of dehydration?
- A. Red mucous membranes
- B. Jugular vein distention
- C. Skin tenting
- D. BP 178/90 mm Hg
Correct Answer: C
Rationale: Skin tenting is a hallmark sign of dehydration due to decreased skin elasticity. Jugular vein distention and high BP indicate fluid overload.
A nurse is caring for a client who is in the early stages of hypoxia and is receiving oxygen therapy. When collecting data from this client, the nurse should expect to find which of the following early indications of hypoxia?
- A. Bradypnea
- B. Peripheral edema
- C. Cyanosis
- D. Hypertension
Correct Answer: D
Rationale: Early signs of hypoxia include tachypnea, restlessness, and hypertension due to sympathetic nervous system activation.
A nurse is preparing to remove an NG tube for a client. Which of the following actions should the nurse take first?
- A. Disconnect the tube from the wall suction.
- B. Perform hand hygiene and don gloves.
- C. Observe the amount and color of drainage.
- D. Verify provider order to discontinue the tube.
Correct Answer: D
Rationale: The correct answer is D: Verify provider order to discontinue the tube. This is the first step the nurse should take before removing the NG tube to ensure that the removal is in line with the provider's instructions. Removing the tube without a valid order can lead to complications. Disconnecting the tube from wall suction (A) should be done after verifying the order. Performing hand hygiene and donning gloves (B) is important but can be done after verifying the order. Observing the amount and color of drainage (C) is important but should come after verifying the order.