Nokea
Nursing interventions for the client with CHF include all of the following except_____
- A. education about daily weights, correct procedure and meaning of changes
- B. monitoring of clients as medications are introduced or titrated to therapeutic levels
- C. education about food esp. sodium levels
- D. assisting with upper endoscopy
Correct Answer: D
Rationale: The correct answer is D because assisting with upper endoscopy is not a standard nursing intervention for CHF. Nursing interventions for CHF focus on managing symptoms, medication adherence, and lifestyle modifications. Choices A, B, and C are correct as they address important aspects of CHF management such as monitoring symptoms, educating on medications, and promoting a low-sodium diet. Helping with an upper endoscopy is unrelated to the management of CHF and falls outside the scope of nursing care for this condition.
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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.
Which of the following is a common side effect of benzodiazepines in older adults?
- A. Increased alertness
- B. Increased risk of falls
- C. Improved memory
- D. Enhanced muscle strength
Correct Answer: B
Rationale: The correct answer is B: Increased risk of falls. Benzodiazepines are central nervous system depressants that can cause drowsiness, dizziness, and impaired coordination, leading to an increased risk of falls in older adults. This is due to the sedative effects of benzodiazepines, which can affect balance and motor skills. Increased alertness (choice A) is not a common side effect of benzodiazepines, as they typically have a calming and sedating effect. Improved memory (choice C) is also unlikely, as benzodiazepines are more commonly associated with memory impairment. Enhanced muscle strength (choice D) is not a known side effect of benzodiazepines, as they do not directly affect muscle strength. In summary, the correct answer is B because benzodiazepines can increase the risk of falls in older adults due to their sedative properties.
A nurse is caring for a culturally diverse patient who has missed follow-up appointments. The patient says: “You don’t understand—in my culture, we don’t do things like that.” The nurse understands which of the following about the patient’s culture?
- A. The culture does not value Western medicine.
- B. The culture has a different orientation to time than Western medicine.
- C. The culture is an interdependent culture.
- D. The culture does not believe in preventative care.
Correct Answer: B
Rationale: The correct answer is B: The culture has a different orientation to time than Western medicine. This is because the patient's statement about not following up on appointments due to cultural reasons suggests a difference in the perception and importance of time. In some cultures, time is more fluid and flexible compared to the rigid scheduling of Western medicine. This understanding helps the nurse provide culturally sensitive care.
Choices A, C, and D are incorrect:
A: The culture does not value Western medicine - This is not necessarily implied by the patient's statement about cultural differences.
C: The culture is an interdependent culture - The patient's statement does not provide direct evidence of the culture being interdependent.
D: The culture does not believe in preventative care - There is no indication in the patient's statement that the culture does not believe in preventative care.
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.
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.