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A nurse is taking the health history of an 85-year-old client. Which of the following physical findings is consistent with normal aging?
- A. Increase in subcutaneous fat.
- B. Diminished cough reflex.
- C. Long-term memory loss.
- D. Myopia.
Correct Answer: B
Rationale: The correct answer is 'Diminished cough reflex.' Diminished cough reflex is a physical finding consistent with normal aging in older adults, which can increase the risk of aspiration and atelectasis. An increase in subcutaneous fat actually raises the risk of pressure ulcers. While long-term memory is typically preserved in aging unless affected by dementia, short-term memory often declines. Myopia (near-sightedness) is common in younger individuals, but presbyopia (far-sightedness) is more common with aging. Additionally, individuals with myopia may experience an improvement in vision as they age.
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The nurse is caring for a 44-year-old client diagnosed with hypoparathyroidism. Which electrolyte imbalance is closely associated with hypoparathyroidism?
- A. Hypocalcemia.
- B. Hyponatremia.
- C. Hyperkalemia.
- D. Hypophosphatemia.
Correct Answer: A.
Rationale: The correct answer is Hypocalcemia. In hypoparathyroidism, where the parathyroid glands are not producing sufficient parathyroid hormone, calcium levels become inadequate. This leads to hypocalcemia, characterized by symptoms such as muscle spasms, anxiety, seizures, hypotension, and congestive heart failure. Hyponatremia and hyperkalemia are not typically associated with hypoparathyroidism. While hyperphosphatemia can be seen in hypoparathyroidism due to decreasing calcium levels, the question specifically asks about the primary electrolyte imbalance closely related to hypoparathyroidism, which is hypocalcemia.
Which of the following microorganisms is easily transmitted from client to client on the hands of healthcare workers?
- A. mycobacterium tuberculosis
- B. clostridium tetani
- C. staphylococcus aureus
- D. human immunodeficiency virus
Correct Answer: C
Rationale: The correct answer is staphylococcus aureus. Staphylococcus aureus microorganisms are ubiquitous and easily transmitted by healthcare workers who fail to conduct routine hand washing between clients. Staphylococcus aureus can reside on the skin and be transferred from one client to another if proper hand hygiene is not practiced. Mycobacterium tuberculosis is mainly transmitted through the airborne route, clostridium tetani is usually acquired through exposure to soil or dirt contaminated with tetanus spores, and human immunodeficiency virus is not easily transmitted through casual contact or on the hands of healthcare workers.
The client seeks advice from the nurse regarding issues with flatus due to colostomy. Which food should the nurse recommend?
- A. High-fiber foods, such as bran.
- B. Cruciferous vegetables, such as cabbage, broccoli, and kale.
- C. Carbonated beverages.
- D. Yogurt.
Correct Answer: D
Rationale: The correct answer is yogurt. Yogurt can help reduce gas formation in clients with a colostomy. High-fiber foods like bran can stimulate peristalsis and increase flatulence, which is not helpful in this situation. Cruciferous vegetables, such as cabbage, broccoli, and kale, and beans tend to increase gas formation. Carbonated beverages, along with smoking, chewing gum, and drinking fluids with a straw, can also increase gas formation. Therefore, the nurse should recommend yogurt to help alleviate the client's issues with flatus.
A client is being taught about self-administration of Haldol 15 mg po hs. For which side effect/s should the client seek medical attention?
- A. Shortness of breath and fatigue
- B. Restlessness and muscle spasms
- C. Dry mouth
- D. Diarrhea
Correct Answer: B
Rationale: The correct answer is restlessness and muscle spasms. Haldol, an antipsychotic medication, can cause extrapyramidal side effects such as muscle spasms and restlessness. These side effects can be serious and should prompt the client to seek medical attention. Shortness of breath, fatigue, dry mouth, and diarrhea are not commonly associated with Haldol use, making choices A, C, and D incorrect.
When discussing the child's wishes for future care, it is important for the nurse to first identify what the child knows about the disease and his prognosis. Factors such as the perceived severity of the illness will be significant in planning for end-of-life care. If the child does not understand the disease process or prognosis, the plan of care would not be effective or realistic. In addition, asking a child about desired interventions in the event of cardiac or respiratory arrest would not be an appropriate initial area of questioning. If the child does not understand the disease process, these questions may seem frightening or threatening. While exploring the child's belief about death would be important, it would not be the initial area of discussion and should be guided by the child rather than the nurse.
- A. What the child knows about the disease and his prognosis.
- B. How the child would like to handle the plan of care.
- C. What interventions the child would like in the event of cardiac or respiratory arrest.
- D. What the child believes about death.
Correct Answer: A
Rationale: When discussing the child's wishes for future care, it is essential to first determine what the child understands about the disease and his prognosis. This information is crucial for planning appropriate end-of-life care. If the child lacks comprehension of the illness and its prognosis, any care plan discussed would be ineffective and unrealistic. Inquiring about desired interventions during cardiac or respiratory arrest is not the initial step, as it may cause distress if the child lacks understanding. While exploring the child's beliefs about death is significant, it should not be the primary focus initially and should be approached based on the child's readiness, not the nurse's agenda. Therefore, the correct first step is to assess what the child knows about the disease and his prognosis.