Nokea
The client’s family approaches the nursing supervisor with a complaint about the NA’s inappropriate communication with their 89-year-old father. When evaluating the NA’s communication, which statements does the nurse determine most likely caused the family’s complaint? Select all that apply.
- A. Are you ready for the nurse to give you your medicine?'
- B. Would you like to go to breakfast now, Grandpa?'
- C. Would you prefer to wear the brown socks today?'
- D. Your family will be visiting today. Isn’t that nice?'
- E. Honey, this is your bath day. Are you ready to go?'
Correct Answer: B;D;E
Rationale: Grandpa,' 'Isn’t that nice?,' and 'Honey' are infantilizing or clichéd, likely causing the complaint. Other statements are appropriate.
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The 70-year-old client, hospitalized with chest pain, has been functioning independently at home. During the night, the client is found wandering in the hallway and states, 'I can’t find my kitchen. I need a glass of milk.' What is the nurse’s best interpretation of the client’s behavior?
- A. The client most likely had a stroke
- B. The stress of being in unfamiliar surroundings has caused the client’s confusion
- C. The decline in mental status, especially at night, is a normal part of aging
- D. This is an insidious change, and it likely means the client has early dementia
Correct Answer: B
Rationale: Stress from unfamiliar surroundings can cause confusion in older adults. No stroke symptoms are noted, mental decline isn’t normal aging, and the change is abrupt, not insidious.
The 66-year-old client recently retired after working 30 years as a bank manager. Which statement to the nurse during a clinic visit best suggests that the client is achieving the developmental stage of 'integrity versus despair'?
- A. Now that I have some free time, I want to treat my wife to a trip to Hawaii.'
- B. I seem to be staying in bed longer and longer each day. There isn’t a reason to get up now.'
- C. I am noticing the little aches and pains more; before I was just too busy to notice them.'
- D. I get calls a few times a week for advice; my coworkers still value my suggestions.'
Correct Answer: D
Rationale: Integrity versus despair involves accepting one’s life’s worth. Valued advice from coworkers indicates positive resolution. A trip reflects generativity, staying in bed suggests despair, and aches are unrelated.
The nurse is assessing a healthy middle-aged adult. Which finding should the nurse expect?
- A. Weight gain of 20 pounds in the past year
- B. Tactile fremitus is absent at the apex of the lungs
- C. Counts backward from 100 subtracting 7 each time
- D. Percussion shows heart is larger than at last checkup
Correct Answer: C
Rationale: The nurse should expect a middle-aged adult to perform mental tasks like serial 7s. A 20-pound weight gain is excessive, absent tactile fremitus suggests pneumothorax, and heart enlargement indicates a medical issue, not a normal finding.
The nurse is caring for the 50-year-old client who reports having difficulty falling asleep. Which recommendations should the nurse make to this client? Select all that apply.
- A. Drink a glass of wine or a beer before bedtime
- B. Avoid exercising 2 to 3 hours before bedtime
- C. Go to bed at the same time each night
- D. Watch television in bed just before bedtime
- E. Avoid eating large or spicy meals in the evening
Correct Answer: B;C;E
Rationale: Avoiding exercise near bedtime, maintaining a consistent bedtime, and avoiding large/spicy meals promote sleep. Alcohol and TV in bed can disrupt sleep.
The nurse is assessing the older adult. Which tool should the nurse select to identify the client’s needs and care deficits?
- A. Katz Index of Activities of Daily Living
- B. Maslow’s Hierarchy of Needs
- C. Mini Mental State Exam (MMSE)
- D. Erikson’s Developmental Tasks
Correct Answer: A
Rationale: The Katz Index assesses functional ability in daily activities, identifying care deficits. Maslow’s is a general needs theory, MMSE assesses cognition, and Erikson’s is developmental.