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A nurse provides instructions to an older adult about measures to prevent heatstroke. Which statement by the client indicates a need for further instruction?
- A. I should wear cool, light clothing in warm weather.''
- B. I need to wear a hat with a wide brim when I go outdoors.''
- C. I need to wear additional antiperspirant and deodorant in warm weather.''
- D. I should drink extra fluids during the summer.''
Correct Answer: C
Rationale: As an individual ages, the number of sweat glands decreases, resulting in reduced body odor and decreased evaporative heat loss due to less sweating. The need for antiperspirants and deodorants is reduced in older adults. Therefore, the statement 'I need to wear additional antiperspirant and deodorant in warm weather' indicates a need for further instruction. Older adults should focus on wearing cool, light clothing in warm weather to prevent overheating, wearing a hat with a wide brim when outdoors to protect from the sun's rays, and staying hydrated by drinking extra fluids during the summer. These measures are more effective in preventing heatstroke in older adults compared to using additional antiperspirants and deodorants, which are not necessary.
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When discussing birth control methods with a client, what major factor should a nurse focus on to provide the motivation needed for consistent implementation of a birth control method?
- A. Personal preference
- B. Work and home schedules
- C. Family planning goals
- D. Desire to have children in the future
Correct Answer: A
Rationale: When discussing birth control methods with a client, a nurse should focus on the client's personal preference as a major factor that will provide the motivation needed for consistent implementation of a birth control method. Personal preference plays a key role in ensuring that the chosen method aligns with the client's lifestyle and values, increasing the likelihood of adherence. While work and home schedules, family planning goals, and the desire to have children in the future can influence the choice of birth control method, they are not the primary motivating factors for consistent implementation. Personal preference is crucial as it empowers the client to select a method that suits their individual needs and preferences, ultimately leading to better compliance and effectiveness.
When an elder client asks the nurse whether he will be capable of sexual activity in old age, the best response by the nurse is:
- A. "Elder adults are psychologically and physically capable of engaging in sexual activity regardless of age-related changes."?
- B. "If you haven't been sexually active throughout your life, you will not be able to participate in sexual activity in old age."?
- C. "When intercourse isn't possible, many of your sexual needs can be met through intimacy and touch."?
- D. "You might find it takes longer for you to achieve an erection, but you can maintain it for a longer time."?
Correct Answer: A
Rationale: The best response for the nurse when an elder client asks about capability for sexual activity in old age is to provide reassurance and open communication. Choice A is the correct answer as it acknowledges that elder adults can engage in sexual activity both physically and psychologically despite age-related changes. This response encourages further discussion and addresses the client's concerns. Choices B, C, and D contain some truths but are not the most therapeutic responses. Choice B implies that past sexual activity is a prerequisite for sexual activity in old age, which is not entirely accurate as intimacy can be experienced in various ways. Choice C, while true about alternative ways to meet sexual needs, does not directly address the client's question about sexual activity. Choice D focuses on the physiological aspect of sexual function, which is important but not the most appropriate initial response to the client's query.
The nurse notes that a client in later adulthood has tremors of the hands. Based on this finding, what action should the nurse take?
- A. Ask the healthcare provider about referring the client to a neurological specialist.
- B. Obtain a prescription for a muscle relaxant.
- C. Notify the healthcare provider immediately.
- D. Document the findings.
Correct Answer: D
Rationale: When a nurse observes senile tremors, such as intentional tremor of the hands in a client in later adulthood, it is important to document the findings. Senile tremors are benign and a normal age-related occurrence. Referring the client to a neurological specialist (Choice A) is unnecessary as senile tremors do not require specialized neurological intervention. Prescribing a muscle relaxant (Choice B) is not indicated since senile tremors are benign and not typically treated with muscle relaxants. Notifying the healthcare provider immediately (Choice C) is unnecessary as senile tremors do not require urgent intervention. Therefore, the most appropriate action is to document the findings (Choice D) for the client's medical record and to establish a baseline for future assessments.
A community health nurse is providing information to a group of older clients about measures to decrease the risk of contracting influenza during peak flu season. The nurse should provide which information?
- A. Clients must stay at home and ask a neighbor or family member to run their errands.
- B. It is best to do grocery shopping and other errands early in the morning when crowds are smaller.
- C. Clients should wash their hands frequently and keep hands away from the face, especially during peak flu season.
- D. Drinking eight 8-oz glasses of fluid each day will reduce the risk of contracting influenza.
Correct Answer: C
Rationale: During peak influenza season, older clients should take measures to reduce the risk of contracting the flu. The most effective preventive measure is frequent hand hygiene and refraining from touching the face, as this reduces the transmission of the flu virus. While it is advisable to avoid crowds, the direct action of hand hygiene is more impactful. Doing errands early in the morning when crowds are smaller is a good suggestion to reduce exposure but does not address the direct transmission through hands. Drinking enough fluid daily is important for overall health but does not directly reduce the risk of contracting influenza.
How should a client's neck be positioned for palpation of the thyroid?
- A. flexed toward the side being examined
- B. hyperextended directly backward
- C. flexed away from the side being examined
- D. flexed directly forward
Correct Answer: A
Rationale: The correct way to position a client's neck for palpation of the thyroid is to have it flexed toward the side being examined. This positioning helps to better access and palpate the thyroid gland. Option B, hyperextending the neck directly backward, is incorrect as it can make palpation more difficult and uncomfortable for the client. Option C, flexing the neck away from the side being examined, is also incorrect as it may obscure the thyroid gland, making it harder to palpate. Option D, flexing the neck directly forward, is not ideal for thyroid palpation as it does not provide the best access to the gland.