Nokea
Nurse is counseling older adult who describes having difficulty with several issues. Which problem should nurse identify as priority for more assessment & intervention?
- A. I spent my whole life dreaming about retirement, & now I wish I had my job back
- B. It's been so stressful for me to have to depend on my son to help around the house
- C. I just heard my friend Al died. That's the 3rd one in 3 months
- D. I'm struggling with helping out in my community. I just don't know what I can do
Correct Answer: D
Rationale: The correct answer is D. The priority issue for assessment & intervention is the older adult struggling with helping out in the community. This indicates a potential loss of purpose and meaning in life, which can negatively impact mental health. It may also suggest decreased social engagement, which is crucial for overall well-being in older adults. This issue requires immediate attention to prevent further decline in mental health and overall quality of life.
A: While feeling regret about retirement is important, it does not pose an immediate risk to the individual's well-being.
B: Depending on family for help is common in older age but does not indicate an urgent need for intervention.
C: Grieving the loss of friends is significant, but it may not be the priority issue for immediate intervention.
E, F, G: Choices are not provided, but they would likely be incorrect as they are not the priority issue for assessment & intervention.
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A nurse reviews an immobilized patient's laboratory results and discovers hypercalcemia. Which condition will the nurse monitor for most closely in this patient?
- A. Hypostatic pneumonia
- B. Renal calculi
- C. Pressure ulcers
- D. Thrombus formation
Correct Answer: B
Rationale: The correct answer is B: Renal calculi. Hypercalcemia can lead to the formation of kidney stones (renal calculi) due to increased levels of calcium in the blood being excreted by the kidneys. The nurse should monitor for signs and symptoms of renal colic, such as severe flank pain, hematuria, and urinary urgency.
Incorrect choices:
A: Hypostatic pneumonia - Hypercalcemia does not directly lead to pneumonia.
C: Pressure ulcers - Hypercalcemia does not increase the risk of pressure ulcers.
D: Thrombus formation - While hypercalcemia can predispose to blood clot formation, it is not the most closely monitored condition in this scenario.
Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale:
1. Crib gyms can pose a suffocation risk for infants, so removing it shows understanding of safety.
2. Soft mattresses increase the risk of Sudden Infant Death Syndrome.
3. Fluffy pillows pose suffocation hazard; infants should sleep on a firm, flat surface.
4. Child-safety gates should not fold like accordions as they can trap fingers.
Summary:
B and C pose suffocation risks. D is incorrect as accordion-style gates can be hazardous. A demonstrates understanding of infant safety by removing the crib gym.
A nurse delegating ambulation of a client who had knee arthroplasty 5 days ago to an AP. Which of the following information should the nurse share with the AP?
- A. The roommate is up independently
- B. Client ambulates with slippers over antiembolic stockings
- C. Client uses front-wheeled walker when ambulating
- D. Client had pain medication 30 min ago
- E. Client is allergic to codeine
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. The nurse should share that the client ambulates with slippers over antiembolic stockings (B) to ensure proper footwear and prevent falls. Sharing that the client uses a front-wheeled walker when ambulating (C) is vital for safety and stability. Informing the AP that the client had pain medication 30 minutes ago (D) is crucial to prevent overexertion and ensure appropriate monitoring for side effects. Choice A is incorrect because the roommate's independence is not relevant to the client's ambulation. Choice E is also incorrect as the client's allergy to codeine is not directly related to ambulation delegation.
Nurse is admitting older adult who lost 4.5 kg since last admission 6 months ago. Which questions should nurse ask to investigate source of weight loss? (Select all that apply.)
- A. Do you eat alone or with someone?
- B. Do you watch TV while eating your meals?
- C. Have you started any new meds in past 6 months?
- D. What foods have you eaten in past 24 hours?
- E. Are you on a fixed income?
Correct Answer: A,C,D,E
Rationale: The correct answers are A, C, D, and E.
A: Asking if the person eats alone or with someone helps to assess social factors influencing eating habits, such as loneliness or lack of social interaction affecting appetite.
C: Inquiring about new medications can reveal potential side effects like appetite changes, nausea, or malabsorption leading to weight loss.
D: Knowing the foods consumed in the past 24 hours helps identify dietary patterns that may contribute to weight loss, such as poor nutrition or reduced intake.
E: Asking about a fixed income can uncover financial constraints affecting food choices and access to nutritious meals, potentially leading to weight loss.
Summary:
B: Watching TV while eating is not directly related to weight loss causes.
F and G: Not provided in the question, so no basis to consider them as relevant questions for investigating weight loss.
Nurse providing discharge instructions to client with a prescription for oxygen use at home. What should the nurse teach about using oxygen safely? (Select all that apply)
- A. Family members who smoke must be at least 10 ft from client when oxygen is on
- B. Nail polish shouldn't be used near client receiving oxygen
- C. A 'No Smoking' sign should be placed on front door
- D. Cotton bedding/clothing should be replaced with items made from wool
- E. Fire extinguisher should be readily available in home
Correct Answer: B,C,E
Rationale: Correct Answer: B, C, E
Rationale:
B: Nail polish shouldn't be used near client receiving oxygen to prevent flammability risk as it contains volatile chemicals that can ignite.
C: A 'No Smoking' sign should be placed on the front door to remind visitors and family members to not smoke near oxygen, reducing fire risk.
E: Fire extinguisher should be readily available in the home to quickly address any potential fires related to oxygen use, ensuring safety.
Summary:
A: Keeping family members who smoke at least 10 ft away is important, but not the most critical safety measure.
D: Replacing cotton with wool clothing does not directly impact oxygen safety.
F & G: No information provided.