Nokea
The nurse is collecting information from the young adult client. Which psychosocial questions should the nurse ask during the admission assessment? Select all that apply.
- A. Do you have any pets?'
- B. How many hours of sleep do you get?'
- C. When was your last bowel movement?'
- D. How much alcohol do you drink?'
- E. Can you describe your sexual activity?'
Correct Answer: A;B;D;E
Rationale: The nurse should ask about pets (enhances mental well-being), sleep (affects coping and immunity), alcohol use (impacts health risks), and sexual activity (STI/HIV risks). Bowel movement is physiological, not psychosocial.
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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 teaches the 18-year-old diabetic client to perform self-administration of insulin. Each time the client makes even a small mistake, the client apologizes for getting it wrong- The client also profusely apologizes when making a minimal mistake in other activities. Based on Erikson’s developmental stages, the nurse concludes that the client may have an unresolved developmental task of which age period?
- A. Infancy
- B. Early childhood
- C. School-aged childhood
- D. Adolescence
Correct Answer: B
Rationale: The behavior indicates an unresolved conflict of 'autonomy versus shame and doubt' associated with the 18-month to 3-year-old age group. When parents are overly critical, the child may develop an overly critical superego, manifesting as constant apologizing for small mistakes.
The 62-year-old client is diagnosed with osteoporosis. Which medication, if taken by the client, should the nurse identify as posing a secondary risk factor for the client’s osteoporosis?
- A. Baby aspirin daily for past 4 years
- B. Escitalopram 5 mg daily for past 7 months
- C. Multivitamin for many years
- D. 10-year use of budesonide nostril spray bid
Correct Answer: D
Rationale: Long-term corticosteroid use, like budesonide, is a risk factor for osteoporosis. Aspirin, escitalopram, and multivitamins (with calcium/vitamin D) do not contribute to bone loss.
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.
The nurse is caring for the older adult client. The nurse should identify that the client is at risk for developing skin breakdown when making which observations? Select all that apply.
- A. A nursing assistant applies a perfumed lotion to the client’s skin
- B. Two nursing assistants are elevating the client’s heels off the bed
- C. A family member brings the client’s favorite custard from home
- D. The nurse applies an alcohol-based hand wash to the client’s hands
- E. The nurse is directing the client to push with the heels to move up in bed
Correct Answer: A;D;E
Rationale: Perfumed lotion, alcohol-based wash, and heel friction increase skin breakdown risk. Elevating heels and nutrition reduce risk.