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A nurse is collecting data from an older adult client as part of a neurosensory examination. Which of the following findings should the nurse expect as changes associated w/aging? Select all.
- A. Slower light touch sensation
- B. Some vision & hearing decline
- C. Slower fine finger movement
- D. Some short-term memory decline
- E. Slower superficial pain sensation
Correct Answer: B, C, D
Rationale: The correct answer is B, C, D. Vision and hearing decline, slower fine finger movement, and some short-term memory decline are all changes associated with aging. Vision and hearing tend to decline due to changes in the eyes and ears. Fine finger movement slows down due to changes in muscle strength and coordination. Short-term memory may decline as a result of changes in the brain's ability to process information. Slower light touch sensation and slower superficial pain sensation are not typically associated with normal aging.
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A nurse is preparing info for a change-of-shift report. Which of the following info should the nurse include in the report?
- A. The client's input & output for the shift
- B. The client's BP from the previous day
- C. A bone scan that is scheduled for today
- D. The med routine from the med administration record
Correct Answer: C
Rationale: The correct answer is C: A bone scan that is scheduled for today. Including this information in the report is crucial as it alerts the oncoming nurse about the upcoming procedure, allowing them to plan and prepare accordingly. This is important for ensuring the client receives timely and appropriate care. The other choices are incorrect because: A (input & output) is important but may not be the priority for a change-of-shift report; B (BP from the previous day) is outdated information and may not be relevant for the current shift; D (med routine) should be documented in the client's chart and can be accessed by the oncoming nurse as needed.
A nurse is counseling a young adult who describes having difficulty dealing with several issues. Which of the following problems the client verbalized should the nurse identify as the priority for further assessment & intervention?
- A. I have my own apartment now, but it's not easy living away from my parents.'
- B. It's been so stressful for me to even think about having my own family.'
- C. I don't even know who I am yet, & now I'm supposed to know what to do.'
- D. My girlfriend is pregnant, & I don't think I have what it takes to be a good father.'
Correct Answer: C
Rationale: The correct answer is C: "I don't even know who I am yet, & now I'm supposed to know what to do." This statement highlights an existential crisis and identity confusion, which are common developmental challenges in young adulthood. It indicates a lack of self-awareness and direction, which can significantly impact the individual's overall well-being and decision-making capabilities. Addressing this issue is crucial as it forms the foundation for addressing other concerns effectively. Choices A, B, and D focus on external stressors and specific situations, which are important but secondary to the core issue of self-identity. Therefore, prioritizing assessment and intervention for the client's self-identity crisis is essential to promote holistic growth and resolution of other challenges.
A goal for a client who has difficulty w/self-feeding due to rheumatoid arthritis is to use adaptive devices. The nurse caring for the client should initiate a referral w/which of the following members of the interprofessional care team?
- A. Social worker
- B. Certified nursing assistant
- C. Registered dietitian
- D. Occupational therapist
Correct Answer: D
Rationale: The correct answer is D: Occupational therapist. Occupational therapists specialize in helping individuals with physical limitations to maximize their ability to perform daily activities, such as self-feeding. They can assess the client's specific needs, recommend appropriate adaptive devices, and provide training on how to use them effectively. Social workers (A) focus more on psychosocial support, certified nursing assistants (B) provide direct care but may not have the expertise in adaptive devices, and registered dietitians (C) focus on nutrition-related issues. Therefore, the occupational therapist (D) is the most appropriate member of the interprofessional care team to address the client's self-feeding difficulties due to rheumatoid arthritis.
A nurse is reviewing safety precautions with a group of young adults at a community health fair. Which of the following recommendations should the nurse include specifically for this age group? Select all.
- A. Install bath rails & grab bars in bathrooms
- B. Wear a helmet while skiing
- C. Install a carbon monoxide detector
- D. Secure firearms in a safe location
- E. Remove throw rugs from the home
Correct Answer: B, C, D
Rationale: The correct recommendations for young adults are B, C, and D. Young adults are more likely to engage in activities like skiing that pose a risk of head injuries, hence wearing a helmet (B) is crucial. Carbon monoxide poisoning can occur from faulty heating systems or appliances, making it important to install a detector (C). Additionally, young adults may be more likely to own firearms, so securing them in a safe location (D) is essential to prevent accidents. Installing bath rails (A) and removing throw rugs (E) are more relevant to older adults to prevent falls.
A nurse is preparing to administer a med to a client. The med was scheduled for administration at 0900. Which of the following are acceptable administration times for this med? Select all.
- A. 905
- B. 825
- C. 1,000
- D. 840
- E. 935
Correct Answer: A,D
Rationale: The correct answers are A and D. Medications can generally be administered within 30 minutes before or after the scheduled time. A (905) and D (840) fall within this window for a 0900 scheduled administration. B (825) is too early, C (1,000) is too late, and E (935) is also too late. It's important to administer medications close to the scheduled time to maintain therapeutic levels in the body.