Nokea
The nurse is teaching an older client about measures to prevent constipation. What statement made by the client indicates further teaching is needed?
- A. "I'll walk 1-2 miles everyday"
- B. "I need to decrease fiber in my diet"
- C. "I have a bowel movement everyday"
- D. "I drink 6-8 glasses of water everyday"
Correct Answer: B
Rationale: The correct answer is B because decreasing fiber in the diet can actually worsen constipation. Fiber helps promote regular bowel movements by adding bulk to the stool. Walking and staying hydrated (choices A and D) are effective strategies to prevent constipation. Having a daily bowel movement (choice C) is a positive sign of bowel health. By choosing to decrease fiber intake, the client may inadvertently reduce the effectiveness of their bowel movements, leading to constipation.
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The nurse provides opportunities for nursing home residents to read aloud to others. Which cognitive skill is this nursing intervention most likely to improve?
- A. Verbal fluency
- B. Logical analysis
- C. Object naming
- D. Visuospatial skills
Correct Answer: A
Rationale: Verbal fluency is the correct answer because reading aloud improves language skills, vocabulary, and verbal expression. It requires cognitive processes like word retrieval, organization, and articulation. Logical analysis (B) is not directly related to reading aloud. Object naming (C) focuses on identifying objects visually, not verbally. Visuospatial skills (D) involve understanding and manipulating visual information, not verbal expression. Reading aloud specifically targets verbal fluency by enhancing communication abilities and language processing.
What is the most common type of dementia in older adults?
- A. Alzheimer's disease
- B. Vascular dementia
- C. Lewy body dementia
- D. Frontotemporal dementia
Correct Answer: A
Rationale: The correct answer is A: Alzheimer's disease. It is the most common type of dementia in older adults, accounting for around 60-80% of cases. Alzheimer's is characterized by the presence of beta-amyloid plaques and tau protein tangles in the brain, leading to memory loss and cognitive decline. Vascular dementia (B) is caused by impaired blood flow to the brain, Lewy body dementia (C) is characterized by abnormal protein deposits in the brain, and Frontotemporal dementia (D) affects the frontal and temporal lobes of the brain, leading to changes in behavior and personality. However, in older adults, Alzheimer's disease is the most prevalent form of dementia due to its widespread impact on memory and cognition.
Which nursing intervention is a holistic approach to an older adult?
- A. Performs glucose testing during the weekly worship service
- B. Wheels ambulatory adults to exercise when running late
- C. Assigns female nurses to older women who are Islamic
- D. Allows older adults in a nursing home to eat meals alone
Correct Answer: C
Rationale: The correct answer is C because assigning female nurses to older women who are Islamic respects their cultural and religious beliefs, promoting holistic care. This approach considers the older adult's physical, emotional, social, and spiritual needs, aligning with the principles of holistic nursing care.
Choice A is incorrect because performing glucose testing during a weekly worship service does not necessarily address the older adult's holistic needs. Choice B is incorrect as simply wheeling ambulatory adults to exercise when running late does not encompass a holistic approach. Choice D is incorrect as allowing older adults in a nursing home to eat meals alone may neglect their social and emotional well-being.
An older patient who was just diagnosed with a terminal disease states, "All my life I attended church, but I am still worried about what will happen after death." The nurse's best response is which of the following?
- A. "The unknown may be frightening. Do you want to talk about this?"
- B. "Religious people know that God is a good God."
- C. "People that have had near-death experiences say it is peaceful."
- D. "You must feel good about attending church most of your life."
Correct Answer: A
Rationale: The correct answer is A: "The unknown may be frightening. Do you want to talk about this?" This response acknowledges the patient's fear and offers an opportunity for the patient to express their concerns. It shows empathy and encourages open communication.
Choice B is incorrect because it assumes all religious people share the same belief, which may not be the case for this patient. Choice C is incorrect as it imposes experiences of others onto the patient, which may not align with their beliefs or feelings. Choice D is incorrect as it assumes the patient's feelings without giving them a chance to express themselves.
While testing the vision of an elderly client, the nurse finds that the client has decreased ability to accommodate (presbyopia). Which clinical implication would the nurse recognize?
- A. Blurring of vision due to increased intraocular pressure
- B. Difficulty reading small print and decreased ability to focus on objects at varying distances
- C. Narrowing of field of vision-loss of peripheral vision
- D. Sensitivity to light (photophobia)
Correct Answer: B
Rationale: The correct answer is B: Difficulty reading small print and decreased ability to focus on objects at varying distances. As people age, the lens of the eye becomes less flexible, leading to presbyopia, which results in difficulty seeing close objects clearly. This explains the client's decreased ability to accommodate. This choice is correct because presbyopia specifically affects near vision, making it harder to read small print and focus on objects up close.
A: Blurring of vision due to increased intraocular pressure - This choice is incorrect because presbyopia is not related to increased intraocular pressure.
C: Narrowing of field of vision-loss of peripheral vision - This choice is incorrect because presbyopia does not affect peripheral vision; it specifically impacts near vision.
D: Sensitivity to light (photophobia) - This choice is incorrect because presbyopia does not cause sensitivity to light; it is solely related to difficulty in focusing on near objects.