ATI GENERONTOLOGY EXAM A+ GUARANTEED

The nurse is teaching a newly hired assistive Personnel about her role in helping older adult clients with activities of daily living ADLs. the nurse should explain that which of the following is the most common factor for theFX a client's performance of adl's? A- social withdrawal B- chronic physical disability C- emotional impairment D- cognitive dysfunction Answer- b Physical disability is the most common reason older adult clients have difficulty performing ADLs. Self-care deficit, the nursing diagnosis that describes the inability of the client to perform self-care activities necessary for optimum health and function,is associated with several physical etiologic factors: activity intolerance, pain, neuromuscular impairment, sensory-perceptual impairment, musculoskeletal impairment, and cognitive impairment. A- Although some older adult clients might become socially withdrawn due to depression, physical debilitation, or lack of transportation, it should not affect theirability to perform ADLs. C- Emotional stability does not decrease in older adult clients as a consequence ofthe aging process. While depression is common in older adult clients, it is often associated with a serious or disabling medical diagnosis, physical impairment, or asa side effect of medications. Clients who are depressed might, as a result of their mood disorder, be reluctant to perform their ADLs and need assistance or encouragement. D- Cognition does not decrease in older adults as a consequence of the aging process. Even clients who have dementia and other neurologic disorders might stillbe able to learn and perform tasks, such as ADLs, or adjust to new situations or routines. The nurse is planning care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client?A- The clients skip will remain intact during hospitalization B- the client will verbalize one new word each week C- the client will begin to help turn himself in bed, indicating improve Mobility D- the clients airway will remain clear, as evidenced by clear breath sounds Answer- d The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicatea threat to life and is the nurse’s priority concern. When applying the ABC priority- setting framework, airway is always the highest priority because the airway must beclear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effort isessential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority- setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carryingoxygen to them. The priority nursing action is to promote pulmonary hygiene as evidenced by clear breath sounds. A- Prevention of skin breakdown following a stroke is an important goal; however,there is another goal that is the priority. B- Relearning speech is important for communication skills following a stroke;however, there is another goal that is the priority. C- Following a stroke, one goal of rehabilitation is to encourage self-help. Activitygoals are important; however, there is another goal that is the priority. The nurse is developing a plan of care for a client who had a recent stroke andhas a history of gastroesophageal reflux disease GERD. For which of the following disorders should the nurse plan to monitor this client? A- Duodenal Ulcer Disease B- aspiration pneumonia C- viral pneumonia D- esophageal varices Answer- b GERD results in reflux of gastric secretions from the stomach into the lower esophagus. When regurgitation occurs, the client is at high risk for pneumonia. Pneumonia occurs due to aspiration of gastric contents into the airway. This client is at increased risk for dysphagia due to the stroke and history of GERD; therefore, thenurse should monitor closely for aspiration pneumonia. A- The acidity of stomach contents that reflux back into the esophagus results in aninflamed esophagus, not duodenum, which is a section of the small intestine. With duodenal ulcer disease, there are ulcers in the duodenum, usually associated with stress, COPD, pancreatic disease, and chronic renal failure. C- The cause of viral pneumonia is an inhaled virus that settles in the lungs. GERDdoes not increase the risk of viral pneumonia. D- Esophageal varices occur in clients who have portal hypertension, usually due tohepatic cirrhosis.