Nokea
A nurse is reviewing information about advance directives with a newly admitted client. Which of the following statements by the client indicates an understanding of the teaching?
- A. I understand that I can change my mind anytime
- B. I have a living will that outlines my wishes when I am unable to make a decision
- C. I need to inform my family about my wishes
- D. I don't need to worry about advance directives right now
Correct Answer: B
Rationale: Having a living will indicates the client understands that it outlines their wishes regarding medical treatment when they are unable to make decisions.
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A nurse is reviewing the medical records of a group of older adult clients. The nurse should identify which of the following as a risk factor for developing infections?
- A. Increased physical activity
- B. Lowered immune system function
- C. Regular health screenings
- D. Proper nutrition
Correct Answer: B
Rationale: Lowered immune system function in older adults increases susceptibility to infections.
A nurse is teaching about foot care to a client who has diabetes mellitus (DM). What statement indicates understanding?
- A. I should wear my slippers whenever I am out of bed
- B. I can walk barefoot at home
- C. I should apply lotion between my toes
- D. I can soak my feet in warm water
Correct Answer: A
Rationale: Wearing slippers or shoes when out of bed protects the feet from injury, which is crucial for clients with diabetes.
A nurse is updating a plan of care after evaluating a client who has dysphagia. Which interventions should the nurse include in the plan?
- A. Have the client lie down after meals
- B. Encourage the client to speak while eating
- C. Have the client sit upright for 1 hour following meals
- D. Offer thin liquids with meals
Correct Answer: C
Rationale: Having the client sit upright for 1 hour after meals facilitates swallowing and reduces the risk of aspiration.
A nurse is teaching a group of assistive personnel (AP) about the expected integumentary changes in older adults. Which should the nurse include?
- A. Increase in elasticity
- B. Decrease in pigmentation
- C. Decrease in elasticity
- D. Increase in moisture levels
Correct Answer: C
Rationale: Older adults typically experience a decrease in skin elasticity, which can contribute to various skin-related issues.
A nurse is teaching a client about the use of a metered-dose inhaler (MDI). Which instruction should the nurse include in the teaching?
- A. Inhale the medication deeply for 3-5 seconds
- B. Exhale forcefully before inhaling
- C. Shake the MDI vigorously before use
- D. Hold the mouthpiece 2.5-5 cm (1-2 in) in front of the mouth
Correct Answer: A
Rationale: Inhaling the medication deeply for 3-5 seconds and holding the breath for 10 seconds after inhalation ensures effective medication delivery to the lungs.