Nokea
The nurse is performing an assessment on an older adult client. What assessment data would indicate a potential complication associated with the skin of this client?
- A. Crusting
- B. Wrinkling
- C. Thinning/loss of elasticity of skin
- D. Crusting
Correct Answer: A
Rationale: The correct answer is A: Crusting. In older adults, crusting on the skin can indicate a potential complication such as infection, dermatitis, or impaired wound healing. Crusting may result from dryness, scratching, or poor circulation. It is essential for the nurse to assess and address the underlying cause promptly to prevent further complications.
B: Wrinkling is a normal part of aging and not necessarily indicative of a complication unless it is severe and associated with other symptoms.
C: Thinning/loss of elasticity of skin is a common age-related change and may not always indicate a complication unless it is excessive.
D: Crusting is a duplicate answer.
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A case manager is likely to have how many years of nursing education?
- A. 1 to 1.5
- B. 4 to 6
- C. 2
- D. 8 or more
Correct Answer: C
Rationale: The correct answer is C: 2 years. A case manager typically requires a minimum of 2 years of nursing education to effectively coordinate care for patients. This level of education provides the necessary knowledge and skills to assess, plan, implement, and evaluate patient care.
- A: 1 to 1.5 years - Insufficient to acquire the depth of knowledge needed for case management.
- B: 4 to 6 years - Excessive for the role of a case manager, as it typically does not require a bachelor's degree.
- D: 8 or more years - Overqualified for the position of a case manager, as this level of education is beyond what is necessary for the role.
A community health nurse provides a flu prevention workshop at a senior center. Which theory of aging underpins these activities?
- A. Free radical theory
- B. Immunologic theory
- C. Oxidative stress theory
- D. Telomere theory
Correct Answer: B
Rationale: The correct answer is B: Immunologic theory. This theory of aging focuses on the decline in immune function as individuals age, making them more vulnerable to infections like the flu. The flu prevention workshop at the senior center aligns with this theory by aiming to boost seniors' immune systems to reduce their susceptibility to the flu.
A: Free radical theory attributes aging to the accumulation of damage caused by reactive oxygen species, not specifically related to immune function.
C: Oxidative stress theory is similar to the free radical theory in emphasizing the role of oxidative damage in aging, not directly related to immune function.
D: Telomere theory suggests that cellular aging is influenced by the shortening of telomeres, which is not directly related to immune function or flu prevention.
The nurse is teaching a client with COPD about proper use of an inhaler. What should the nurse emphasize?
- A. Use the inhaler only when you feel short of breath.
- B. Inhale deeply before activating the inhaler.
- C. Inhale rapidly after activating the inhaler.
- D. Use the inhaler as often as possible for maximum benefit.
Correct Answer: B
Rationale: The correct answer is B because inhaling deeply before activating the inhaler ensures proper medication delivery to the lungs. This allows the medication to reach the affected areas efficiently. Choice A is incorrect because inhalers are often used preventatively, not just when short of breath. Choice C is incorrect as inhaling rapidly may not allow the medication to be effectively deposited in the lungs. Choice D is incorrect because using the inhaler excessively can lead to overuse and potential side effects.
Which of the following assessment findings would be most suggestive of deep vein thrombosis (DVT)?
- A. Bilateral calf tenderness after walking up a flight of stairs
- B. Swelling in one leg with pitting edema
- C. Shortness of breath after activity
- D. Two plus palpable pulses
Correct Answer: B
Rationale: The correct answer is B because swelling in one leg with pitting edema is a classic sign of DVT. Pitting edema suggests fluid accumulation due to compromised venous circulation, which is common in DVT. Bilateral calf tenderness (choice A) is more indicative of muscle strain. Shortness of breath (choice C) is suggestive of a pulmonary embolism, a complication of DVT. Two plus palpable pulses (choice D) indicate good arterial circulation, not DVT.
Which nursing intervention would not help a patient with xerostomia?
- A. Using humidifiers
- B. Using mouth rinses or artificial saliva products
- C. Providing sugar free hard candies
- D. Increasing medications from once a day to twice a day
Correct Answer: D
Rationale: The correct answer is D because increasing medications would not directly address xerostomia. Xerostomia is dry mouth, often caused by decreased saliva production. Using humidifiers (A) helps increase moisture in the air, mouth rinses/artificial saliva (B) lubricate the mouth, and sugar-free hard candies (C) stimulate saliva production. Increasing medications (D) would not target the root cause of xerostomia and may even exacerbate dry mouth symptoms.