Nokea
The nurse identifies the presence of age-associated memory impairment in the older adult who states
- A. I just can't seem to remember the name of my granddaughter.
- B. I make out lists to help me remember what I need to do but I can't seem to use them.
- C. I forgot that I went to the grocery store this morning and didn't realize it until I went again this afternoon.
- D. I forget movie stars' names more often now but I can remember them later after the conversation is off.
Correct Answer: C
Rationale: Age-associated memory impairment typically involves short-term memory lapses rather than complete forgetting. Forgetting actions like visiting the grocery store earlier in the day aligns with this type of impairment.
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Which chief complaint is NOT desirable for recording on the client’s chart?
- A. CC: “cough and temperature elevation,” 2 days duration
- B. CC: “passing black stools,” 1 day duration
- C. CC: “substernal pain,” 2 hours duration
- D. Reason for contact: “physical examination for college”
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Chief complaints should be symptoms or concerns related to the client's health issues.
2. "Physical examination for college" is not a specific symptom or health concern.
3. Chief complaints guide healthcare providers in assessing and treating the client.
4. Recording irrelevant chief complaints can lead to confusion in diagnosis and treatment.
Summary of Incorrect Choices:
A: Describes specific symptoms, suitable for recording.
B: Describes a specific symptom (black stools), suitable for recording.
C: Describes a specific symptom (substernal pain), suitable for recording.
Which of the following comments should be given first consideration?
- A. There was a lot of blood and we used three bandages
- B. He pulled the stick out, just now, because it was hurting him
- C. The stick was really dirty and covered with mud
- D. He's a diabetic, so he needs attention right away
Correct Answer: B
Rationale: Pulling out the stick could have caused internal injury, making this the most urgent concern.
Why should the nurse closely monitor older adults when they are receiving IV therapy?
- A. Because their defense mechanisms are less efficient.
- B. Because they are prone to fluid overload.
- C. Because they are prone to increased renal efficiency.
- D. Because they have inadequate intake of dietary fiber.
Correct Answer: B
Rationale: The correct answer is B because older adults are more susceptible to fluid overload due to decreased kidney function and other physiological changes.
Why should the nurse closely monitor a client to ensure that the venous access device remains in the vein during a transfusion?
- A. It minimizes the risk of phlebitis.
- B. It minimizes the risk of pulmonary embolism.
- C. It minimizes the risk of circulatory overload.
- D. It minimizes the risk of localized edema.
Correct Answer: B
Rationale: The correct answer is B because dislodged catheters can lead to emboli formation.
What should a nurse include in the teaching plan for clients who have a potential for hypovolemia?
- A. Avoid alcohol and caffeine
- B. Increase intake of dried peas and beans
- C. Increase intake of milk and dairy products
- D. Avoid table salt or food containing sodium
Correct Answer: A
Rationale: Alcohol and caffeine are diuretics, increasing fluid loss and worsening hypovolemi Avoiding them helps maintain fluid balance.