A frail, elderly client is admitted to the unit with a diagnosis of pneumonia.
Which finding is most important for the registered nurse (RN) to report to the
healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting - B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate
oxygenation and perfusion in this frail elderly client. (A), (C) and (D) are all
common with pneumonia, but the most important finding is confusion and
evidence of dehydration, which require treatment for this frail elderly client.
A frail elderly couple asks the registered nurse (RN) if they have to watch
their salt intake because food does not taste as good as it used to so they
have to season most foods. What information should the RN offer the
couple?
A. Boredom may influence how the taste of food is perceived, and different
seasonings can stimulate taste.
B. With age, an increase in sodium intake is needed to compensate for a
decrease in renal function.
C. Short-term memory loss and confusion may be the reason they want to
over-season their food.
D. Taste buds often are dull due to atrophy so older clients should use other
seasonings instead of salt. - D. Taste buds are often dull due to atrophy so
older clients should use other seasonings instead of salt.
Rationale: Taste buds atrophy with normal aging, which influences an older
client's sensitivity to taste and is often compensated for the use of stronger
tasting seasonings. (A), (B), and (C) are not normal aging processes related to
taste.
,After taking a 10-day course of an antibiotic that was ineffective, a frail,
elderly client with chronic obstructive pulmonary disease (COPD) is admitted
for pneumonia. The client has a long history of smoking and still smokes a
pack of cigarettes a day. Which finding should the registered nurse (RN)
report to the healthcare provider?
A. Barrel chest with increased chest diameter
B. Crackles and pulse oximetry level of 88%
C. Low hemoglobin and hematocrit levels
D. Arterial blood gases indicating respiratory acidosis - B. Crackles and
pulse oximetry level of 88%
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B)
can impact adequate oxygenation, which should be reported to the HCP. (A)
occurs due to chronic hyperinflation of the lungs and is common in clients
with COPD. Anemia (C) is frequently identified in clients with COPD, and
respiratory acidosis (D) due to CO2 retention contributes to a lower blood
pH.
An older female client recently moved to an assisted living facility. The
family explains to the registered nurse (RN) that the client is unmanageable
and always confused, disoriented and depressed. The client asks the RN
repeatedly, "Where am I?". How should the RN respond?
A. Explain that she is in a new home called an assisted living community
B. Question the client about her perception of where she might be now.
C. Distract the client with a scenario that she is on an outing with her family.
D. Reassure the client not to worry because she will meet new friends. - A.
Explain that she is in a new home called an assisted living community.
Rationale: Reality re-orientation (A) is the best response for a client who is
confused because the response is consistent and true. (B, C, and D) do not
provide the client with feedback that is reality based.
A new resident in an assisted living facility is an older client who is
experiencing short- term memory loss and confusion. Which activity should
the registered nurse (RN) schedule the client to do during the day?
, A. Arts and crafts
B. Current events discussion group
C. Group sing-along
D. Daily exercise group - D. Daily exercise group
Rationale: A daily exercise group (D) allows the client to mirror the leader
and minimizes the client's stress to remember. (A), (C), and a current events
discussion group (B) are thought-provoking activities that require attention
to detail and short-term memory to participate in the group activity which
may be stressful and frustrating to the resident who has difficulty
remembering sequence of the details.
The hospice nurse is completing a focused assessment of an older female
client with end stage Alzheimer's disease, who recently fractured her hip.
What technique should the registered nurse (RN) use to determine the
client's pain?
A. Use the FACE pain scale
B. Ask the client to rate pain on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating habits - C. Observe for facial
grimacing
Rationale: Observing for facial grimacing (C) is the best method for evaluating
pain for a client who cannot communicate due to Alzheimer disease. (A) and
(B) may not be understood by a client with end-stage Alzheimer's disease. (D)
is not a helpful tool for pain assessment.
An older male client arrives at the clinic for an annual physical examination.
While the nurse assesses the client, the client states that he is having
intimacy problems with his wife. Which information should the nurse provide
to elicit more information from the client?
A. Query client to clarify the client's idea of an intimacy problem.
B. Discuss benign prostatic hypertrophy (BPH) and ejaculation.
C. Explore the frequency that he experiences erectile dysfunction (ED)
D. Determine if the client's wife is young enough to get pregnant - A.
Query client to clarify the client's idea of an intimacy problem.
Which finding is most important for the registered nurse (RN) to report to the
healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting - B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate
oxygenation and perfusion in this frail elderly client. (A), (C) and (D) are all
common with pneumonia, but the most important finding is confusion and
evidence of dehydration, which require treatment for this frail elderly client.
A frail elderly couple asks the registered nurse (RN) if they have to watch
their salt intake because food does not taste as good as it used to so they
have to season most foods. What information should the RN offer the
couple?
A. Boredom may influence how the taste of food is perceived, and different
seasonings can stimulate taste.
B. With age, an increase in sodium intake is needed to compensate for a
decrease in renal function.
C. Short-term memory loss and confusion may be the reason they want to
over-season their food.
D. Taste buds often are dull due to atrophy so older clients should use other
seasonings instead of salt. - D. Taste buds are often dull due to atrophy so
older clients should use other seasonings instead of salt.
Rationale: Taste buds atrophy with normal aging, which influences an older
client's sensitivity to taste and is often compensated for the use of stronger
tasting seasonings. (A), (B), and (C) are not normal aging processes related to
taste.
,After taking a 10-day course of an antibiotic that was ineffective, a frail,
elderly client with chronic obstructive pulmonary disease (COPD) is admitted
for pneumonia. The client has a long history of smoking and still smokes a
pack of cigarettes a day. Which finding should the registered nurse (RN)
report to the healthcare provider?
A. Barrel chest with increased chest diameter
B. Crackles and pulse oximetry level of 88%
C. Low hemoglobin and hematocrit levels
D. Arterial blood gases indicating respiratory acidosis - B. Crackles and
pulse oximetry level of 88%
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B)
can impact adequate oxygenation, which should be reported to the HCP. (A)
occurs due to chronic hyperinflation of the lungs and is common in clients
with COPD. Anemia (C) is frequently identified in clients with COPD, and
respiratory acidosis (D) due to CO2 retention contributes to a lower blood
pH.
An older female client recently moved to an assisted living facility. The
family explains to the registered nurse (RN) that the client is unmanageable
and always confused, disoriented and depressed. The client asks the RN
repeatedly, "Where am I?". How should the RN respond?
A. Explain that she is in a new home called an assisted living community
B. Question the client about her perception of where she might be now.
C. Distract the client with a scenario that she is on an outing with her family.
D. Reassure the client not to worry because she will meet new friends. - A.
Explain that she is in a new home called an assisted living community.
Rationale: Reality re-orientation (A) is the best response for a client who is
confused because the response is consistent and true. (B, C, and D) do not
provide the client with feedback that is reality based.
A new resident in an assisted living facility is an older client who is
experiencing short- term memory loss and confusion. Which activity should
the registered nurse (RN) schedule the client to do during the day?
, A. Arts and crafts
B. Current events discussion group
C. Group sing-along
D. Daily exercise group - D. Daily exercise group
Rationale: A daily exercise group (D) allows the client to mirror the leader
and minimizes the client's stress to remember. (A), (C), and a current events
discussion group (B) are thought-provoking activities that require attention
to detail and short-term memory to participate in the group activity which
may be stressful and frustrating to the resident who has difficulty
remembering sequence of the details.
The hospice nurse is completing a focused assessment of an older female
client with end stage Alzheimer's disease, who recently fractured her hip.
What technique should the registered nurse (RN) use to determine the
client's pain?
A. Use the FACE pain scale
B. Ask the client to rate pain on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating habits - C. Observe for facial
grimacing
Rationale: Observing for facial grimacing (C) is the best method for evaluating
pain for a client who cannot communicate due to Alzheimer disease. (A) and
(B) may not be understood by a client with end-stage Alzheimer's disease. (D)
is not a helpful tool for pain assessment.
An older male client arrives at the clinic for an annual physical examination.
While the nurse assesses the client, the client states that he is having
intimacy problems with his wife. Which information should the nurse provide
to elicit more information from the client?
A. Query client to clarify the client's idea of an intimacy problem.
B. Discuss benign prostatic hypertrophy (BPH) and ejaculation.
C. Explore the frequency that he experiences erectile dysfunction (ED)
D. Determine if the client's wife is young enough to get pregnant - A.
Query client to clarify the client's idea of an intimacy problem.
