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During an assessment, an older adult client's son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?
- A. Bradycardia
- B. Night sweats
- C. Confusion
- D. Narrowed pulse pressure
Correct Answer: C
Rationale: Step 1: Pneumonia in older adults often presents with atypical symptoms.
Step 2: Confusion is a common manifestation due to decreased oxygen levels.
Step 3: Respiratory illness can lead to hypoxia, causing confusion.
Step 4: Bradycardia, night sweats, and narrowed pulse pressure are not typical manifestations of pneumonia in older adults.
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A 47-year-old client is admitted for colon surgery. Intravenous antibiotics are started two hours prior to surgery even though the client has no known infection. The reason for giving antibiotics prior to surgery is to:
- A. provide a cathartic action within the colon.
- B. reduce the risk of wound infection from anaerobic bacteria.
- C. relieve anxiety.
- D. reduce the risk of intraoperative fever.
Correct Answer: B
Rationale: Cathartics, not antibiotics, promote the evacuation of intestinal contents. The client undergoing intestinal surgery is at an increased risk for infection from large numbers of anaerobic bacteria that inhabit the intestines. Administering antibiotics prophylactically can reduce the client's risk for infection. Antibiotics are indicated in the treatment of infections and have no effect on emotions. Antibiotics would have an effect on an infection which causes a temperature elevation, but they would not directly affect the temperature elevation.
An 88-year-old woman is brought to the health clinic for the first time by her 64-year-old daughter. During the initial comprehensive nursing assessment of the patient, what should the nurse do?
- A. Ask the daughter whether the patient has any urgent needs or problems.
- B. Interview the patient and daughter together so that pertinent information can be confirmed.
- C. Obtain a health history using a functional health pattern and assess activities of daily living (ADLs) and mental status.
- D. Refer the patient for an interdisciplinary comprehensive geriatric assessment because at her age she will have multiple needs.
Correct Answer: C
Rationale: Assessing ADLs, mental status, and obtaining a thorough health history ensures comprehensive understanding of the patient's needs.
During seizure activity which observation is the priority to enhance further direction of treatment?
- A. Observe the sequence or types of movement.
- B. Note the time from beginning to end.
- C. Identify the pattern of breathing.
- D. Determine if loss of bowel or bladder control occurs.
Correct Answer: B
Rationale: Timing seizures is crucial for determining appropriate interventions.
What outcome criterion would be most appropriate based on Mr. Stout’s nursing diagnosis of sleep pattern disturbance?
- A. Demonstrate abdominal and pursed-lip breathing
- B. Explain rationale for use of sleeping medication
- C. Explain basic pathology of chronic bronchitis
- D. List food and fluid requirements and plans for meeting them
Correct Answer: A
Rationale: Breathing techniques improve oxygenation and reduce nocturnal awakenings.
A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?
- A. Perform suctioning for up to four passes.
- B. Apply suction to the catheter when advancing it into the trachea.
- C. Preoxygenate the client with 100% oxygen for up to 3 min.
- D. Limit each suction pass to 25 seconds.
Correct Answer: C
Rationale: Correct Answer: C
Rationale:
1. Preoxygenating the client with 100% oxygen for up to 3 minutes helps prevent hypoxia during suctioning.
2. COPD patients are at higher risk for hypoxia due to impaired gas exchange.
3. Preoxygenation helps maintain oxygen saturation levels and reduces the risk of complications.
4. This action supports safe and effective nasotracheal suctioning in clients with COPD and an artificial airway.
Summary:
- Option A: Performing suctioning for up to four passes can increase the risk of hypoxia and mucosal damage.
- Option B: Applying suction to the catheter during advancement can cause trauma and increase the risk of infection.
- Option D: Limiting each suction pass to 25 seconds may not provide adequate time for effective suctioning in clients with COPD and artificial airways.