Nokea
The nurse is caring for the 55-year-old client. Which statement by the client related to psychosocial changes should the nurse most definitely explore?
- A. I really don’t want to color my hair, even though it seems to be getting grayer every day.'
- B. I can’t see as sharp anymore. I get frustrated by the small lettering on the medicine bottles.'
- C. My husband and I have a more active sexual life now that the children are out of the house.'
- D. My house is empty; I thought I’d be happy when my children finally left, but I feel lonely.'
Correct Answer: D
Rationale: The client’s statement suggests empty nest syndrome, a psychosocial concern requiring further exploration. Graying hair is a normal physiological change, vision issues are physiological, and an active sexual life indicates a healthy relationship.
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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.
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 a group of middle-aged female nurses about middle-aged moral development applicable only to women. Which point should the nurse most specifically address?
- A. Gilligan’s moral development theory includes responsibility and caring for self and others
- B. Kohlberg’s moral development theory includes living according to universally agreed-upon principles
- C. Westerhoff’s stages of faith include putting faith into personal and social action and standing up for beliefs
- D. Fowler’s stages of spiritual development include becoming aware of truth from a variety of viewpoints
Correct Answer: A
Rationale: Gilligan’s theory, specific to women, emphasizes morality as integrity in relationships and caring for others and self, unlike Kohlberg’s justice-based theory. Westerhoff and Fowler address spiritual, not moral, development.
The nurse is caring for the 94-year-old hospitalized client of the Muslim faith who is near death. Which nursing action is most inappropriate?
- A. Spraying perfume in the client’s room
- B. Placing the client supine facing Mecca
- C. Offering grief counseling to family members
- D. Checking records for wishes of organ donation
Correct Answer: C
Rationale: Grief counseling is discouraged in Muslim faith, making it inappropriate. Perfuming, facing Mecca, and checking organ donation are culturally appropriate.
The nurse completes teaching for the 80-year-old female client. Which statement made by the client indicates further teaching is needed?
- A. Instead of using sodium seasonings, I plan to try one with herbs and lemon.'
- B. Although I find my lavender-scented hand cream relaxing, I should not use it.'
- C. I should place a towel on the floor outside my shower so I don’t slip when getting out.'
- D. Rather than relying on laxatives, I should increase my intake of fruits and vegetables.'
Correct Answer: C
Rationale: Placing a towel on the floor increases fall risk; a slip-resistant mat is needed. Nonsodium seasonings, avoiding scented lotions, and increasing roughage are correct.