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.
You may also like to solve these questions
When the office nurse completes height measurement for the 72-year-old female, the client says that she lost half an inch. Which explanation by the nurse is most accurate?
- A. As we age, we lose muscle mass.'
- B. Bone loss is due to lack of exercise.'
- C. As we age, we lose knee and hip cartilage.'
- D. The vertebral column shortens with aging.'
Correct Answer: D
Rationale: Aging causes vertebral column shortening due to water and bone density loss, leading to height reduction. Muscle mass, exercise, and cartilage loss don’t primarily affect height.
The nurse is reviewing a laboratory report for a 61-year-old client. Which finding is most important for the nurse to address with the HCP?
- A. Total cholesterol 180 mg/dL; was 140 at age 50
- B. Erythrocyte sedimentation rate (ESR) increased
- C. Alkaline phosphatase increased
- D. AST, ALT, and serum bilirubin increased
Correct Answer: D
Rationale: Elevated liver function tests (AST, ALT, bilirubin) are not age-related and suggest liver pathology, requiring immediate HCP notification. Cholesterol, ESR, and alkaline phosphatase increases are normal with aging.
The nurse is teaching newly hired NAs in a long term care facility. What information about skin care for older adults should the nurse emphasize?
- A. Avoid skin products purchased for the resident by family that contain alcohol
- B. Apply perfumed skin lots after the resident’s bath when the skin is still moist
- C. When taking residents outdoors, apply sunscreen with a sun protection factor of 8
- D. Apply a strong detergent to clothing with food stains before sending to laundry
Correct Answer: A
Rationale: Avoiding alcohol-containing products prevents skin drying in older adults with fragile skin. Perfumed lotions, low SPF, and strong detergents increase irritation 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.
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.