Nokea
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.
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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 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.
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 is interviewing an 80-year-old client who has urinary incontinence. The client is taking furosemide. When asked about daily fluid intake, the client states, 'I drink 2 glasses of water, 1 glass of milk, and a half glass of juice. I don’t drink coffee or tea.' Which responses by the nurse are appropriate? Select all that apply.
- A. Your fluid intake should be 6 to 8 glasses of water, plus other fluids.'
- B. Your fluid intake is adequate and may help to reduce your incontinence.'
- C. Caffeine increases urination; it is good that you avoid drinking coffee.'
- D. Your fluid intake is limited; this increases your risk for dehydration.'
- E. Your fluid intake is sufficient to maintain a fluid and electrolyte balance.'
Correct Answer: A;C;D
Rationale: The client’s 3.5 glasses of fluid are inadequate, increasing dehydration risk, especially with furosemide. Older adults need 6-8 glasses of water plus other fluids, and avoiding caffeine reduces diuresis. Inadequate fluid may worsen incontinence.
The home health nurse suspects elder mistreatment of the 93-year-old client by the live-in caregiver. Which findings support the nurse’s conclusion? Select all that apply.
- A. Client has urine burns
- B. Client has wrist bruises
- C. Client states there have been some unexplained financial expenditures
- D. Client is more talkative than during previous home visits
- E. Smell of alcohol noted on live-in caregiver’s breath
Correct Answer: A;B;C;E
Rationale: Urine burns (neglect), wrist bruises (physical abuse), unexplained expenditures (financial abuse), and caregiver alcohol use (abuser characteristic) support mistreatment. Increased talkativeness suggests comfort, not abuse.