Nokea
The experienced nurse is observing the new nurse recommend screening tests to the 80-year-old female client. Which recommendation made by the new nurse should the experienced nurse correct?
- A. Hearing screen annually
- B. Colonoscopy every 10 years
- C. Pneumococcal vaccine annually
- D. Mammogram every 1 to 2 years
Correct Answer: C
Rationale: Pneumococcal vaccine is given at 65 and every 10 years, not annually. Hearing screens, colonoscopies, and mammograms are correctly recommended.
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The 83-year-old tells the nurse, 'I’m not taking my medication because it’s too expensive and I really don’t need it anymore.' Before responding to the client, the nurse should consider that the most common reason for older clients to discontinue their medications is which of the following?
- A. Information about the medications is insufficient
- B. Medications alter the taste of foods that they enjoy
- C. Fear they will live longer than their resources will last
- D. They want the attention from others when they are sick
Correct Answer: C
Rationale: Fear of outliving resources is a common reason older adults stop medications, reflecting financial concerns. Lack of information, taste changes, and seeking attention are less common.
The nurse observes the NA providing a stuffed animal to the hospitalized older adult client who is experiencing delirium. Which action by the nurse is most appropriate?
- A. Reprimand the NA for treating the client like a child
- B. Remove the stuffed animal before anyone else sees it
- C. Report the NA’s action to the unit’s nurse manager
- D. Thank the NA for providing it for the client’s fidgeting
Correct Answer: D
Rationale: A stuffed animal can occupy a delirious client’s hands, preventing line removal, and may be comforting. Thanking the NA is appropriate; other actions are unnecessary or punitive.
The 18 year-old tells the clinic nurse, 'Thinking about college is stressing me out. I am used to getting A’s and B’s.' Which statement should the nurse reserve until a follow-up visit with the client?
- A. Expressing your feelings of anxiety to a friend or nurse helps you cope emotionally.'
- B. I will check with the provider about prescribing paroxetine hydrochloride.'
- C. Exercise increases the release of endorphins and can enhance your sense of well-being.'
- D. If you like drawing or painting, register for an art class during your first semester in college.'
Correct Answer: B
Rationale: The nurse should reserve suggesting an antidepressant until other interventions have been tried. Paroxetine influences neurotransmitters related to anxiety, but non-pharmacological coping strategies like expressing feelings, exercise, and art therapy should be prioritized initially.
The home health nurse is caring for the middle-aged client who is disabled due to a recent accident. The client has few interests, spends most days watching TV, and has become estranged from the family. Which of Erikson’s developmental stages should the nurse conclude that the client is not meeting?
- A. Industry versus inferiority
- B. Initiative versus guilt
- C. Generativity versus stagnation
- D. Intimacy versus isolation
Correct Answer: C
Rationale: The client’s isolation and lack of interests indicate stagnation, failing to meet generativity versus stagnation, the central task of middle adulthood. Other stages apply to younger age groups.
The nurse plans to teach the client progressive muscle relaxation. Prioritize the steps that the nurse should teach to correctly perform progressive muscle relaxation.
- A. Relax the feet, imagining the tension flowing out with each exhalation
- B. Lie down in a quiet place where you are undisturbed
- C. Contract the muscles of your feet first as you inhale and hold the contraction briefly
- D. Relax your body, allowing it to feel heavy
- E. Lie still for a few minutes after the contraction and relaxation of all muscles
- F. Imagine the tension flowing out with each breath you take
- G. Move up the body, contracting then relaxing each muscle
Correct Answer: B;D;F;C;A;G;E
Rationale: Steps: 1) Lie in a quiet place to focus; 2) Relax body to feel heavy; 3) Imagine tension flowing out with breaths; 4) Contract feet muscles; 5) Relax feet; 6) Move up body; 7) Lie still to monitor relaxation.