Nokea
________ is a factor that contributes to a high incidence of falls in the elderly.
- A. increased muscle mass and tone
- B. high likelihood of orthostatic hypotension upon rising quickly
- C. increasing acuity in eyesight in dim light
- D. constipation
Correct Answer: B
Rationale: The correct answer is B: high likelihood of orthostatic hypotension upon rising quickly. Orthostatic hypotension is a common issue in the elderly, causing a sudden drop in blood pressure when standing up quickly, leading to dizziness and falls. This factor directly contributes to the high incidence of falls in the elderly. Increased muscle mass and tone (A) actually reduce the risk of falls, while improving eyesight in dim light (C) would decrease the risk. Constipation (D) is not directly related to falls in the elderly.
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The nurse designs a group exercise program at a senior center. Which room should the nurse choose?
- A. Room with a hardwood floor and throw rugs
- B. Spacious room with no windows and a natural stone floor
- C. Room with a hardwood floor and large windows overlooking a garden area
- D. End room with linoleum floor and a fan for ventilation
Correct Answer: C
Rationale: The correct answer is C because a room with hardwood floor and large windows overlooking a garden area offers a safe, non-slip surface for exercise and natural light for a pleasant environment. Hardwood floors are ideal for exercise to prevent slipping, and the large windows provide a view of the garden area, which can enhance motivation and mood. The other choices are incorrect because A has throw rugs, which can cause tripping hazards, B lacks natural light and ventilation, and D has a linoleum floor which may not be as safe for exercise compared to hardwood.
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.
An older women tells the nurse that her husband seldom brushes his teeth as he did in the past. A reason why older clients stop participating in daily oral hygiene, such as brushing the teeth, include:
- A. Decreased manual dexterity and inability to hold a tooth brush
- B. Malocclusion of teeth
- C. Decrease in taste acuity
- D. Lack of dental insurance
Correct Answer: A
Rationale: The correct answer is A: Decreased manual dexterity and inability to hold a toothbrush. As people age, they may experience decreased hand strength and motor skills, making it difficult to hold and manipulate objects like a toothbrush. This can lead to a decline in oral hygiene practices. Malocclusion of teeth (B) does not directly impact the ability to brush teeth. Decrease in taste acuity (C) may affect appetite but not tooth brushing habits. Lack of dental insurance (D) is a financial barrier and may affect access to dental care, but it does not directly impact the physical ability to brush teeth.
A nurse interviewing a non–English-speaking client with an interpreter should: (Select all that apply.)
- A. Look and speak to the interpreter.
- B. Use technical terminology to ensure accuracy.
- C. Allow more time for the interview.
- D. Watch the client’s nonverbal communication.
Correct Answer: C, D, E
Rationale: The correct answers are C, D, and E. C is crucial as it allows for effective communication, D involves observing nonverbal cues, and E emphasizes the need for clear and concise language. A is incorrect as the nurse should address the client directly, not just the interpreter. B is incorrect as using technical terms may hinder understanding.
What is the most effective intervention to prevent skin breakdown in immobile older adults?
- A. Frequent use of powder to keep skin dry
- B. Application of a thick layer of moisturizer
- C. Regular repositioning and use of pressure-relieving devices
- D. Ensuring complete bed rest to limit movement
Correct Answer: C
Rationale: The correct answer is C because regular repositioning and the use of pressure-relieving devices are essential to prevent skin breakdown in immobile older adults. Repositioning helps redistribute pressure, maintaining blood flow to the skin and preventing tissue damage. Pressure-relieving devices such as cushions or special mattresses further reduce pressure on vulnerable areas. Choices A and B do not address the root cause of skin breakdown and may even exacerbate the issue. Choice D is incorrect as complete bed rest can lead to further complications like pressure ulcers. In summary, choice C is the most effective intervention as it directly targets the risk factors for skin breakdown in immobile older adults.