Nokea
Pre-hospital admission medications for the older adult client include warfarin and atenolol. Which statement made by the client should prompt the nurse to initiate a referral to a social worker?
- A. I crush my medications and take them with applesauce because they are hard to swallow.'
- B. I stopped taking my blood pressure pill; I can’t afford it, and my blood pressure is normal.'
- C. I feel more alert after starting to take ginkgo, but I forgot to ask my doctor if it were okay.'
- D. I have my daughter set up my medications for two weeks at a time in a medication bar.'
Correct Answer: B
Rationale: Stopping medication due to cost indicates a financial concern, warranting a social worker referral. Swallowing issues, ginkgo use, and medication setup require different interventions.
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The nurse is completing an assessment on the 19 year - old female who participates in strenuous physical activities many hours daily. Which nursing assessment is most important?
- A. Check for the presence of lordosis
- B. Look for signs of an eating disorder
- C. Examine muscles for increased mass
- D. Ask about excessive bleeding with menses
Correct Answer: B
Rationale: Females who participate in strenuous physical activities are at risk for eating disorders. Strenuous activity does not cause lordosis, increased muscle mass is expected, and delayed menses, not excessive bleeding, is a concern with strenuous activity.
The nurse is assessing the 50-year-old female client who is hospitalized. The nurse should assess the client for which physical changes associated with aging? Select all that apply.
- A. Increased sweat gland activity
- B. Decreased ability to read smaller print
- C. Weight loss due to hypermetabolism
- D. Increased sebaceous gland activity
- E. Absence of a menstrual cycle
Correct Answer: B;E
Rationale: Visual acuity declines, affecting near vision, and menopause causes absence of menstruation in middle-aged women. Sweat and sebaceous gland activity decrease, and weight gain, not loss, occurs due to slower metabolism.
The nurse has limited time to teach the middle-aged adult client. The nurse should initially plan to take which action?
- A. Provide brochures and handouts that the client can discuss with family members
- B. Make a referral to outpatient resources for the client to receive the needed teaching
- C. Establish the highest-priority learning needs and teach with each client or family contact
- D. Answer the client’s questions and leave the extensive teaching for the nurse on the next shift
Correct Answer: C
Rationale: Prioritizing learning needs ensures important teaching is completed efficiently during limited time. Brochures alone, referrals, or deferring teaching are less effective initially.
The nurse is obtaining nutrition information from four 20-year-old female clients. All have a BM] of 20 to 23. Which client requires the most immediate follow-up?
- A. The client eats three nutritious meals a day with no snacks
- B. The client limits her intake to 2500 calories per day
- C. The client eats only fruits, vegetables, seeds, and nuts
- D. The client eats three 350-calorie meals per day
Correct Answer: D
Rationale: By limiting meals to 350 calories each, the client consumes only 1050 calories daily, insufficient for a sedentary female’s basic energy needs, requiring immediate follow-up. Three nutritious meals may suffice, 2500 calories is appropriate, and a vegetarian diet needs protein assessment but is less urgent.
The nurse overhears a person say, 'I’m having a senior moment because I forgot.' How should the nurse interpret this statement?
- A. This phrase is a comical statement without age bias and is acceptable to others
- B. This phrase is a stereotypical reference to older adults that can be termed ageism
- C. This phrase admits that the older adult’s ability to learn new information is limited
- D. This phrase recognizes that all older adults have short- and long-term memory issues
Correct Answer: B
Rationale: The phrase is a stereotypical reference to older adults, perpetuating ageism. It’s not comical, doesn’t imply learning limits, and not all older adults have memory issues.