Nokea
An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful for preventing falls in this client?
- A. Keep the light on in the bathroom at night
- B. Order a wheelchair for the client
- C. Put the client on a toileting schedule
- D. Use side rails to keep the client in bed
Correct Answer: A
Rationale: Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom at night helps ensure the client can see their surroundings, reducing the risk of falls.
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A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult?
- A. Building strength and flexibility
- B. Improving exercise endurance
- C. Increasing cardiovascular capacity
- D. Enhancing balance and coordination
Correct Answer: A
Rationale: This older adult is mostly homebound. Exercise regimens for homebound clients include activities to increase functional ability for activities of daily living. Strength and flexibility exercises will help the client maintain independent living. The other options are beneficial but do not specifically address the client's functional abilities.
A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for upcoming surgery. What is the best action by the nurse?
- A. Call Adult Protective Services
- B. Discuss concerns with the health care team
- C. Assist with Adult Protective Services
- D. Have the client's family sign the consent
Correct Answer: B
Rationale: In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client's perceived incompetence, and the team can evaluate and determine the appropriate course of action.
A nurse is caring for an older adult who reports not eating well. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Ask about transportation to buy food
- B. Inquire about access to dentures
- C. Encourage the client to continue the current exercise plan
- D. Have the client complete a 3-day diet recall diary
- E. Teach the client about proper nutrition in the older population
Correct Answer: A,B,D
Rationale: Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so encouraging them to continue the current exercise plan is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client's needs, which the nurse does not yet know.
A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the home. Which statement would be most helpful to keeping the older adult safe on the steps?
- A. Have the client use a walker or cane on the steps
- B. Install contrasting color strips at the edge of each step
- C. Advise the client to avoid the steps altogether
- D. Tell the client to use a two-footed gait on the steps
Correct Answer: B
Rationale: As a person ages, they may experience a decreased sense of touch. The older adult may not be aware of where their foot is on the step. Installing contrasting color strips at the edge of each step will help increase visibility and safety for the older adult.
A nurse caring for an older adult has provided education on high-fiber foods. Which menu selection by the client demonstrates a need for further review?
- A. Barley soup
- B. Black beans
- C. White rice
- D. Whole wheat bread
Correct Answer: C
Rationale: Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products.