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The nurse is caring for a 67-year-old client with postherpetic neuralgia who has a new prescription for amitriptyline. Which of the following actions would be a priority for the nurse to take?
- A. Schedule frequent rest periods for the client.
- B. Encourage the client to increase the intake of fluids.
- C. Instruct the client to stand up slowly from a sitting position.
- D. Remind the client to wear sunglasses when spending time outdoors.
Correct Answer: C
Rationale: Amitriptyline can cause orthostatic hypotension, making slow position changes a priority to prevent falls.
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The nurse is caring for a 2 month-old infant with a congenital heart defect. Which of the following is a priority nursing action?
- A. Provide small feedings every 3 hours
- B. Maintain intravenous fluids
- C. Add strained cereal to the diet
- D. Change to reduced calorie formula
Correct Answer: A
Rationale: Infants with congenital heart defects are at increased risk for developing congestive heart failure. Infants with congestive heart failure have an increased metabolic rate and require additional calories to grow. At the same time, however, rest and conservation of energy for eating is important. Feedings should be smaller and every 3 hours rather than the usual 4 hour schedule.
A 2 year-old child has recently been diagnosed with cystic fibrosis. The nurse is teaching the parents about home care for the child. Which of the following information is appropriate for the nurse to include?
- A. Allow the child to continue normal activities
- B. Schedule frequent rest periods
- C. Limit exposure to other children
- D. Restrict activities to inside the house
Correct Answer: A
Rationale: Allow the child to continue normal activities. Physical activity supports autonomy and mucus secretion in cystic fibrosis.
The daughter of an 80-year-old client recently diagnosed with Alzheimer disease (AD) says to the nurse, 'I guess I can anticipate getting this disease myself at some point.' What is an appropriate response by the nurse?
- A. Engaging in regular exercise decreases the risk of AD.
- B. Having a family history of AD is not a risk factor.
- C. Try not to worry about this now as you can't do anything to prevent AD.
- D. You should avoid aluminum cans and cookware to prevent AD.
Correct Answer: A
Rationale: Regular exercise is associated with a reduced risk of Alzheimer disease. Family history is a risk factor, and aluminum is not a proven cause.
The home health nurse is caring for a 75-year-old client with dementia and suspects that the client may be experiencing elder mistreatment. Which of the following findings would be consistent with elder mistreatment? Select all that apply.
- A. disorientation to time and place
- B. stage 2 pressure injury on the sacrum
- C. 15-lb (6.8-kg) weight loss over the past 4 weeks
- D. eyeglasses are broken and have been unusable for 2 months
- E. prescription medications are expired and have not been refilled
Correct Answer: B,C,D,E
Rationale: Pressure injuries, significant weight loss, broken eyeglasses, and expired medications suggest neglect or mistreatment. Disorientation is expected in dementia.
The practical nurse (PN) is collaborating with the registered nurse to conduct a developmental assessment of a 9-month-old client during a well-child visit. Which statement by the infant's parent should cause the PN concern?
- A. Our child needs help to grasp and bring teething toys to the mouth.
- B. Our child says 'mamama' to our dog.
- C. Our child screams when approached by unfamiliar people.
- D. Our child uses both hands for support to be able to sit upright.
Correct Answer: A
Rationale: By 9 months, infants should independently grasp objects. This indicates a potential fine motor delay requiring further evaluation.