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An older adult who is a traditional Chinese man has a blood pressure of 80/54 mm Hg and refuses to remain in the bed. Which intervention should the nurse use to promote and maintain his health?
- A. Have the health care provider speak to him.
- B. Use principles of the holistic health system.
- C. Ask about his perceptions and treatment ideas.
- D. Consult with a practitioner of Chinese medicine.
Correct Answer: C
Rationale: Rationale:
C is correct as it involves understanding the patient's beliefs and preferences, crucial in culturally competent care. A would not address the patient's perspective directly. B is broad and lacks specificity. D assumes all traditional Chinese individuals seek Chinese medicine, which may not be the case.
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Mr J., an 80 yr old who has had flu like symptoms with diarrhea and has vomited 4 times in the last 24 hours is seen in the ED. Mr. J seems confused and is lethargic. The nurse notes that Mr. J has dry skin, a brown tongue, sunken cheeks and concentrated urine. This array of symptoms indicates:
- A. congestive heart failure
- B. dehydration
- C. urinary tract infection
- D. bowel obstruction
Correct Answer: B
Rationale: The correct answer is B: dehydration. Mr. J's symptoms of flu-like illness, diarrhea, vomiting, confusion, lethargy, dry skin, brown tongue, sunken cheeks, and concentrated urine are indicative of severe dehydration. Dehydration can lead to electrolyte imbalances, decreased blood volume, and impaired organ function, resulting in confusion and lethargy. Skin changes, dry mucous membranes, and concentrated urine are also classic signs of dehydration. The other choices (A, C, D) do not align with the constellation of symptoms presented by Mr. J and are less likely based on the information provided.
Which of the following is a key sign of dehydration in older adults that differs from younger populations?
- A. Dark-colored urine
- B. Increased thirst
- C. Dry mouth and skin
- D. Confusion or cognitive decline
Correct Answer: D
Rationale: The correct answer is D: Confusion or cognitive decline. In older adults, dehydration can manifest differently than in younger populations. Cognitive decline is a key sign of dehydration in older adults due to the brain being more sensitive to fluid loss. Dehydration can lead to confusion, disorientation, and impaired cognitive function in older individuals. Dark-colored urine (A) is a common sign of dehydration in all age groups. Increased thirst (B) is a general sign of dehydration but may not be as prominent in older adults due to decreased thirst sensation. Dry mouth and skin (C) are also common signs of dehydration but may not be as reliable indicators in older adults compared to cognitive changes.
All of the following except ___are risk factors for an elderly person developing pneumonia.
- A. Diarrhea
- B. Neurological disease
- C. Heart failure
- D. COPD
Correct Answer: A
Rationale: The correct answer is A: Diarrhea. Diarrhea is not a risk factor for developing pneumonia in elderly individuals. The rationale for this is that pneumonia is primarily caused by respiratory infections, not gastrointestinal issues like diarrhea. Neurological disease, heart failure, and COPD are all risk factors for pneumonia because they can weaken the immune system or impair lung function, making individuals more susceptible to respiratory infections. These conditions can lead to aspiration, impaired cough reflex, or compromised lung function, increasing the likelihood of developing pneumonia.
Providing information about diet & exercise for a healthy diabetic client is best described as which nursing activity?
- A. Promoting wellness
- B. Preventing illness
- C. Treating disease
- D. Restoring health
Correct Answer: A
Rationale: The correct answer is A: Promoting wellness. Providing information about diet and exercise for a healthy diabetic client falls under promoting wellness because it focuses on proactive measures to maintain health and prevent complications. It aims to empower the client to make healthy lifestyle choices.
B: Preventing illness is not the best description as the client is already diabetic, so the focus is on managing the condition rather than solely preventing it.
C: Treating disease is not accurate because the client is already diabetic and the goal is not to treat the disease, but rather manage it effectively.
D: Restoring health is not applicable in this scenario as the client is not in a state of compromised health that needs to be restored.
A man is terminally ill with end-stage prostate cancer. Which is the best statement about this man’s wellness?
- A. Wellness can only be achieved with aggressive medical interventions.
- B. Wellness is not a real option for this client because he is terminally ill.
- C. Wellness is defined as the absence of disease.
- D. Nursing interventions can help empower a client to achieve a higher level of wellness.
Correct Answer: D
Rationale: The correct answer is D because nursing interventions can focus on enhancing the client's quality of life, comfort, and emotional well-being even in the face of terminal illness. Nurses can provide support, educate the client and family, manage symptoms, and empower the client to find meaning and purpose in their life. This approach contributes to a higher level of wellness by addressing holistic needs beyond just medical interventions.
Incorrect choices:
A: Wellness can be achieved through various means, not just aggressive medical interventions.
B: Wellness is still achievable in terms of emotional, social, and spiritual well-being even with a terminal illness.
C: Wellness involves physical, emotional, social, and spiritual aspects beyond just the absence of disease.