Nokea
The older adult client is experiencing relocation stress after being admitted to a nursing home. Which intervention is best for the nurse to implement?
- A. Ask family members to explore placing the client in another nursing home
- B. Change the client’s room every week until a compatible roommate is found
- C. Place the client’s favorite items, such as a family picture, at the client’s bedside
- D. Ask that family members avoid talking to the client about being in the nursing home
Correct Answer: C
Rationale: Familiar items like a family picture reduce relocation stress. Moving facilities, changing rooms, or avoiding discussion may increase stress.
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The nurse assesses the 75-year-old client and concludes that some findings are not age-related changes and require further follow-up. Which report by the client represents a non-age-related finding that requires additional investigation?
- A. Reports a decreased ability to see at night
- B. Reports seeing halos around lights
- C. Reports difficulty distinguishing some colors
- D. Reports diminished visual acuity
Correct Answer: B
Rationale: Seeing halos is a symptom of glaucoma, not an age-related change, requiring investigation. Night vision, color distinction, and acuity changes are normal with aging.
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 nurse is obtaining nutrition information from four 20-year-old female clients. All have a BM] of 20 to 23. Which client requires the most immediate follow-up?
- A. The client eats three nutritious meals a day with no snacks
- B. The client limits her intake to 2500 calories per day
- C. The client eats only fruits, vegetables, seeds, and nuts
- D. The client eats three 350-calorie meals per day
Correct Answer: D
Rationale: By limiting meals to 350 calories each, the client consumes only 1050 calories daily, insufficient for a sedentary female’s basic energy needs, requiring immediate follow-up. Three nutritious meals may suffice, 2500 calories is appropriate, and a vegetarian diet needs protein assessment but is less urgent.
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.
Pre-hospital admission medications for the older adult client include warfarin and atenolol. Which statement made by the client should prompt the nurse to initiate a referral to a social worker?
- A. I crush my medications and take them with applesauce because they are hard to swallow.'
- B. I stopped taking my blood pressure pill; I can’t afford it, and my blood pressure is normal.'
- C. I feel more alert after starting to take ginkgo, but I forgot to ask my doctor if it were okay.'
- D. I have my daughter set up my medications for two weeks at a time in a medication bar.'
Correct Answer: B
Rationale: Stopping medication due to cost indicates a financial concern, warranting a social worker referral. Swallowing issues, ginkgo use, and medication setup require different interventions.