Nokea
The home care nurse is performing an environmental assessment in the home of an older adult. Which of the following requires immediate nursing action?
- A. Unsecured scattered rugs
- B. Operable smoke detector
- C. Prefilled medication cassette
- D. Unsecured scattered rugs
Correct Answer: A
Rationale: The correct answer is A: Unsecured scattered rugs. This requires immediate nursing action as it poses a significant fall risk for the older adult. Rugs can cause tripping hazards, leading to potential injuries. The nurse should secure or remove the rugs to ensure the safety of the patient.
Summary of other choices:
B: Operable smoke detector - While important for safety, it does not require immediate nursing action as it is already in working condition.
C: Prefilled medication cassette - This is not an immediate safety concern and can be addressed during routine medication management.
D: Unsecured scattered rugs (repeated) - This choice is the same as the correct answer, so it is incorrect.
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An older women tells the nurse that her husband seldom brushes his teeth as he did in the past. A reason why older clients stop participating in daily oral hygiene, such as brushing the teeth, include:
- A. Decreased manual dexterity and inability to hold a tooth brush
- B. Malocclusion of teeth
- C. Decrease in taste acuity
- D. Lack of dental insurance
Correct Answer: A
Rationale: The correct answer is A: Decreased manual dexterity and inability to hold a toothbrush. As people age, they may experience decreased hand strength and motor skills, making it difficult to hold and manipulate objects like a toothbrush. This can lead to a decline in oral hygiene practices. Malocclusion of teeth (B) does not directly impact the ability to brush teeth. Decrease in taste acuity (C) may affect appetite but not tooth brushing habits. Lack of dental insurance (D) is a financial barrier and may affect access to dental care, but it does not directly impact the physical ability to brush teeth.
A nurse in a long-term care facility is using the TimeSlips program with a group of cognitively impaired older adults. The nurse is using which of the following techniques?
- A. Provides a picture for all group members to look at and use to create a story
- B. Records the responses of all participants
- C. Compliments each member for his or her contribution to the story
- D. Reads the story back during the session, noting the contributions of each participant
Correct Answer: A
Rationale: The correct answer is A because the TimeSlips program involves providing a picture as a creative prompt for group members to collaboratively create a story. This technique stimulates imagination and communication in cognitively impaired individuals. Choice B is incorrect as recording responses is not specific to the TimeSlips method. Choice C is incorrect as complimenting contributions is not a core component of the TimeSlips program. Choice D is incorrect as reading back the story during the session does not align with the collaborative, creative process of TimeSlips.
The home care nurse is visiting an older female client whose husband died 6 months ago. What behavior by the client indicates ineffective coping?
- A. Neglecting personal grooming
- B. Looking at old pictures
- C. Participating in senior citizens' program
- D. Visiting her husband's grave
Correct Answer: A
Rationale: The correct answer is A because neglecting personal grooming indicates a lack of self-care, which is a common sign of ineffective coping after the loss of a loved one. This behavior suggests the client may be struggling emotionally and unable to engage in basic self-care tasks. Looking at old pictures, participating in social activities, and visiting the husband's grave are all healthy coping mechanisms that can help the client process her grief and maintain connections with her late husband.
An older adult who is a traditional Chinese man has a blood pressure of 80/54 mm Hg and refuses to remain in the bed. Which intervention should the nurse use to promote and maintain his health?
- A. Have the health care provider speak to him.
- B. Use principles of the holistic health system.
- C. Ask about his perceptions and treatment ideas.
- D. Consult with a practitioner of Chinese medicine.
Correct Answer: C
Rationale: Rationale:
C is correct as it involves understanding the patient's beliefs and preferences, crucial in culturally competent care. A would not address the patient's perspective directly. B is broad and lacks specificity. D assumes all traditional Chinese individuals seek Chinese medicine, which may not be the case.
Mr. J has been admitted to the hospital from her own home. The admitting nurse notes that the patient has severe edema in the lower extremities, no hair on the legs, and ulcerations on her feet. These signs and symptoms are most likely indications of:
- A. A diet low in protein
- B. Exposure to the cold from a lack of heat
- C. Frequent falls and injuries because of an unsteady gait
- D. Circulatory problems related to age and a chronic illness
Correct Answer: D
Rationale: The correct answer is D: Circulatory problems related to age and a chronic illness. Severe edema, hair loss on the legs, and foot ulcerations are indicative of poor circulation, often seen in conditions like peripheral artery disease. Age and chronic illnesses can contribute to circulatory issues. A diet low in protein (choice A) would not directly cause these symptoms. Exposure to cold (choice B) would not explain the specific symptoms mentioned. Frequent falls (choice C) do not align with the symptoms provided.