Nokea
The nurse is assessing a healthy middle-aged adult. Which finding should the nurse expect?
- A. Weight gain of 20 pounds in the past year
- B. Tactile fremitus is absent at the apex of the lungs
- C. Counts backward from 100 subtracting 7 each time
- D. Percussion shows heart is larger than at last checkup
Correct Answer: C
Rationale: The nurse should expect a middle-aged adult to perform mental tasks like serial 7s. A 20-pound weight gain is excessive, absent tactile fremitus suggests pneumothorax, and heart enlargement indicates a medical issue, not a normal finding.
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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 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.
While attending a health fair, the 62-year-old female is found to have many risk factors for osteoporosis. The nurse at the booth recommends that she contact her HCP about scheduling a DEXA (dual-energy x-ray absorptiometry) scan. Which risk factors influenced the nurse’s recommendation? Select all that apply.
- A. Hyperthyroidism
- B. Postmenopausal
- C. Overweight
- D. African American
- E. 62-year-old female
Correct Answer: A;B;E
Rationale: Hyperthyroidism, postmenopausal status, and being a 62-year-old female are risk factors for osteoporosis, warranting a DEXA scan. Being overweight and African American are not major risk factors.
The nurse is interviewing a family member of the hospitalized 90-year-old client to assess for common problems associated with an increased risk for falling. Which questions should the nurse ask? Select all that apply.
- A. Has your mother fallen within the past year?'
- B. Has your mother had her annual influenza vaccine?'
- C. When was the last time your mother took a pain pill?'
- D. Does your mother have any problems with urination?'
- E. Does your mother have difficulty falling asleep at night?'
Correct Answer: A;C;D;E
Rationale: Questions about past falls, pain medication, urination issues, and sleep disorders assess fall risk factors. Influenza vaccine is unrelated.
The client’s family approaches the nursing supervisor with a complaint about the NA’s inappropriate communication with their 89-year-old father. When evaluating the NA’s communication, which statements does the nurse determine most likely caused the family’s complaint? Select all that apply.
- A. Are you ready for the nurse to give you your medicine?'
- B. Would you like to go to breakfast now, Grandpa?'
- C. Would you prefer to wear the brown socks today?'
- D. Your family will be visiting today. Isn’t that nice?'
- E. Honey, this is your bath day. Are you ready to go?'
Correct Answer: B;D;E
Rationale: Grandpa,' 'Isn’t that nice?,' and 'Honey' are infantilizing or clichéd, likely causing the complaint. Other statements are appropriate.