Nokea
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.
You may also like to solve these questions
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.
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.
What is the primary role of the gerontological nurse when providing end-of-life care for a terminally ill older adult?
- A. To offer aggressive curative treatments to extend life
- B. To focus on pain management and comfort care, ensuring dignity
- C. To administer sedatives to prevent distress
- D. To encourage family members to make all decisions for the patient
Correct Answer: B
Rationale: The correct answer, B, is the primary role of the gerontological nurse when providing end-of-life care for a terminally ill older adult. This choice emphasizes the importance of pain management, comfort care, and preserving the patient's dignity. The nurse's focus should be on enhancing the quality of life and ensuring the patient's comfort rather than pursuing aggressive curative treatments (A). Administering sedatives (C) should be based on individual needs and preferences, not as a blanket approach. While family involvement is crucial, the nurse should still advocate for the patient's autonomy and preferences, rather than solely relying on family decisions (D).
A retirement community is divided into different communities with different activities available for the residents. There is one community for individuals ages 65 to 74 years, one for individuals ages 75 to 85 years, and one for individuals older than age 85 years. This is consistent with which theory of aging?
- A. Role theory
- B. Disengagement theory
- C. Age-stratification theory
- D. Social exchange theory
Correct Answer: C
Rationale: The correct answer is C: Age-stratification theory. This theory suggests that age is a powerful determinant of social organization. In the given scenario, the retirement community is structured based on age groups, indicating stratification by age. This separation aligns with the concept of age-based social hierarchies and differing opportunities and resources based on age.
Choice A (Role theory) focuses on how individuals adapt to social roles as they age, which is not directly reflected in the scenario. Choice B (Disengagement theory) posits that aging individuals withdraw from societal roles, which is not evident in the active engagement of residents in different age-specific communities. Choice D (Social exchange theory) emphasizes the relationships individuals form based on rewards and costs, which is not the primary focus in the scenario compared to the age-based stratification.
The gerontological nurse collaborates with the wound care team about an older patient who has an ulcer. How is this nurse demonstrating leadership in the care of older people?
- A. Assessing older adults effectively
- B. Facilitating access to eldercare programs
- C. Coordinating members of the health care team
- D. Empowering older adults to manage chronic illness
Correct Answer: C
Rationale: The correct answer is C: Coordinating members of the health care team. This demonstrates leadership as the nurse is taking charge of organizing and communicating with various healthcare professionals to ensure the best care for the older patient. By collaborating with the wound care team, the nurse shows effective coordination and communication skills, which are crucial in managing complex cases in older adults. Assessing older adults effectively (choice A) is important but does not specifically address leadership in coordinating care. Facilitating access to eldercare programs (choice B) is important but does not directly demonstrate leadership in coordinating care. Empowering older adults to manage chronic illness (choice D) is important for patient education but does not directly show leadership in coordinating the healthcare team.