Nokea
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.
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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.
A nurse is caring for an older adult who has a nonpalpable skin lesion that is less than 0.5 cm (0.2 in) in diameter. Which of the following terms should the nurse use to document this finding?
- A. Papule
- B. Vesicle
- C. Macule
- D. Nodule
Correct Answer: C
Rationale: A macule is a nonpalpable lesion smaller than 1 cm in diameter, such as a freckle.
A nurse is teaching about measures to promote sleep for a client with insomnia. What statement indicates understanding?
- A. I should reduce my fluid intake to 2 hours before bedtime
- B. I will watch TV in bed before sleeping
- C. I can take long naps during the day
- D. I should exercise right before going to bed
Correct Answer: A
Rationale: Reducing fluid intake to 2-4 hours before sleeping helps prevent interruptions during the night, promoting better sleep.
A nurse is caring for a client who reports burning around the peripheral IV site. Which finding should the nurse identify as a manifestation of infiltration?
- A. Redness at the site
- B. Warmth around the site
- C. Edema
- D. Pain at the site
Correct Answer: C
Rationale: Edema at the IV site indicates that IV solution has leaked into the extravascular tissue, which is a sign of infiltration.
A nurse is preparing a client for transfer to another unit. Which finding does the nurse include in the transfer report?
- A. Response to pain medication
- B. Review of ongoing discharge plan
- C. Recent physical changes
- D. All of the above
Correct Answer: D
Rationale: All findings are important for ensuring continuity of care in the transfer report.