Nokea
The nurse is admitting the older adult client to a nursing home. Which is the nurse’s best approach when obtaining information during the admission interview?
- A. Direct questions to the family member accompanying the client
- B. Speak clearly and slowly to the client using high-pitched vocal tones
- C. Take the client and family members to a private room without distractions
- D. Speak to the client loudly about familiar topics before asking questions
Correct Answer: C
Rationale: A private, distraction-free room respects confidentiality and aids focus. Directing questions to family, high-pitched tones, or loud familiar topics are inappropriate.
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A 72-year-old woman reports she is sexually active. It is most important for the nurse to follow up by asking which question?
- A. Can you tell me more about your sexual partners?'
- B. Have you tried artificial water-based lubricants?'
- C. Are any medications having any drying effects?'
- D. Do you need to use different sexual positions?'
Correct Answer: A
Rationale: Assessing sexual partners is critical due to rising STI/HIV rates in older adults. Lubricants, medication effects, and positions are secondary to infection risk.
After performing an assessment and determining that there are no other causes, the nurse concludes that the older adult’s recent hearing loss in one ear may be from cerumen accumulation from age-related changes. The nurse’s conclusion was based on which age-related changes that contribute to the cerumen accumulation?
- A. Reduced sweat gland activity; thinning and drying of the skin lining the ear canal
- B. Ossicular bone calcification; longer and thicker hair growth in the ear canal
- C. Degenerative structural changes of the eardrum preventing cerumen passage
- D. Over activity of the sweat glands contributing to the development of presbycusis
Correct Answer: A
Rationale: Reduced sweat gland activity and thinning/drying of the ear canal skin cause cerumen buildup, affecting sound perception. Ossicular calcification, eardrum changes, and presbycusis are unrelated.
The nurse is caring for the older adult client. The nurse should identify that the client is at risk for developing skin breakdown when making which observations? Select all that apply.
- A. A nursing assistant applies a perfumed lotion to the client’s skin
- B. Two nursing assistants are elevating the client’s heels off the bed
- C. A family member brings the client’s favorite custard from home
- D. The nurse applies an alcohol-based hand wash to the client’s hands
- E. The nurse is directing the client to push with the heels to move up in bed
Correct Answer: A;D;E
Rationale: Perfumed lotion, alcohol-based wash, and heel friction increase skin breakdown risk. Elevating heels and nutrition reduce risk.
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.
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.