Nokea
The nurse is caring for the 87-year-old hospitalized client. The nurse should assess for which age-related changes to best protect the client from friction injury?
- A. Increased tissue vascularity
- B. Increase in subcutaneous tissue
- C. Increased rate of cellular replacement
- D. Loss of skin thickness and elasticity
Correct Answer: D
Rationale: Loss of skin thickness and elasticity increases friction injury risk due to a thinner epidermis and reduced strength. Vascularity, subcutaneous tissue, and cellular replacement decrease with aging.
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The nurse is caring for the 50-year-old client who reports having difficulty falling asleep. Which recommendations should the nurse make to this client? Select all that apply.
- A. Drink a glass of wine or a beer before bedtime
- B. Avoid exercising 2 to 3 hours before bedtime
- C. Go to bed at the same time each night
- D. Watch television in bed just before bedtime
- E. Avoid eating large or spicy meals in the evening
Correct Answer: B;C;E
Rationale: Avoiding exercise near bedtime, maintaining a consistent bedtime, and avoiding large/spicy meals promote sleep. Alcohol and TV in bed can disrupt sleep.
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.
The nurse is assessing the chest of the normally healthy adult male client without chest abnormalities. Which chest curvature illustrated should the nurse expect to observe?
- A. Illustration A
- B. Illustration B
- C. Illustration C
- D. Illustration D
Correct Answer: C
Rationale: The normal adult chest has an anteroposterior-to-lateral ratio of approximately 1:2 and a costal angle less than 90 degrees. Illustration A is pectus excavatum, B is pectus carinatum, and D is barrel chest associated with COPD.
The nurse is assessing the 88-year-old client. Which finding should the nurse associate with the normal aging process?
- A. Arm muscle strength 4 on a 0 to 5 scale
- B. Multiple fractures to the thoracic spine
- C. Ulnar deviation of the left hand fingers
- D. Slight pain in the right and left heel
Correct Answer: A
Rationale: Muscle strength of 4/5 is normal with aging. Fractures, ulnar deviation (rheumatoid arthritis), and heel pain (bone spurs) are not normal aging changes.
The nurse is caring for the middle-aged client. Which client behavior should indicate to the nurse that the client may have difficulty achieving Erikson’s developmental stage of generativity?
- A. Talks about accomplishments that made the workplace a better place
- B. Volunteers at the local nursing home reading to residents one day a week
- C. Focuses conversation on self and displays disinterest in the activities of others
- D. Shows pictures of the client’s grandchildren and the client at various sports events
Correct Answer: C
Rationale: Self-focus and disinterest in others suggest self-absorption and stagnation, indicating difficulty with generativity. Workplace accomplishments, volunteering, and involvement with grandchildren demonstrate generativity.