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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.
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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 reviewing the medical history of a client who is listed for surgery. Which of the following findings places the client at risk for a complication of incisional hematoma forming?
- A. The client is underweight
- B. The client takes anticoagulant medications
- C. The client has urinary incontinence
- D. The client has peripheral vascular disease
Correct Answer: B
Rationale: The correct answer is B: The client takes anticoagulant medications. Anticoagulant medications inhibit blood clotting, increasing the risk of bleeding and hematoma formation at the surgical site. This poses a significant complication during and after surgery. Other choices are incorrect because being underweight (A), having urinary incontinence (C), and having peripheral vascular disease (D) do not directly increase the risk of incisional hematoma formation.
A nurse is receiving report on a group of clients. Using the ABCDE priority framework which of the following clients should the nurse see first?
- A. A client who has early dementia and awoke confused to their location this morning
- B. A client who is scheduled for discharge and has a 38.4 C (101.1 F) temperature this morning
- C. A client who has pneumonia and has developed wheezing
- D. A client who is postoperative and has a urine output of 50 mL for the past 3 h
Correct Answer: C
Rationale: The correct answer is C because the client with pneumonia developing wheezing is experiencing a potential airway obstruction, impacting their breathing (airway). In the ABCDE priority framework, airway comes first to ensure adequate oxygenation. Choice A may indicate confusion but does not pose an immediate threat to life. Choice B has a fever, but unless there are other concerning symptoms, it does not require immediate attention. Choice D has decreased urine output, indicating a potential issue with circulation or kidneys, but it is not immediately life-threatening. Therefore, C takes precedence due to the potential airway compromise.
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.
A nurse is caring for a client who has a cloudy, opaque area over the lens of one eye. The nurse should identify that this is a manifestation of which of the following visual impairments?
- A. Cataracts
- B. Diabetic retinopathy
- C. Macular degeneration
- D. Glaucoma
Correct Answer: A
Rationale: The correct answer is A: Cataracts. Cataracts cause a cloudy, opaque area over the lens of the eye, leading to blurred vision. This occurs due to the clouding of the lens from protein buildup. Diabetic retinopathy, choice B, involves damage to blood vessels in the retina due to diabetes. Macular degeneration, choice C, affects the central part of the retina leading to distortion or loss of central vision. Glaucoma, choice D, is characterized by increased pressure within the eye damaging the optic nerve. In this scenario, the cloudy, opaque area over the lens specifically points towards cataracts, making it the correct choice.