Nursing: Medical-Surgical Revew

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Which method elicits the most accurate information during a physical assessment of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health history
D. Obtain the client's information from a caregiver

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A. use reliable assessment tools for older adults

Specific assessment tools (D) for an older adult, such as Older Adult Resource Services Center Instrument, mini-mental assessment, fall risk, depression, or skin breakdown risk, consider age-related physiologic and psychosocial changes related to aging and provide the most accurate and complete information. A and B are subjective and may vary in reliability based on the client's memory and caregiver's current involvement. Although C is a good resource to identify polypharmacy, a written record may not be available or currently accurate.

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A client who has just tested positive for HIV does not appear to hear what the nurse is saying during post-test counseling. Which information should the nurse offer to facilitate the client's adjustment to HIV infection?
A. teach the client about the medications that are available for treatment
B. discuss retesting to verify the results, which will ensure continuing contact
C. identify the need to test others who have had risky contact with the client
D. inform the client how to protect sexual and needle-sharing partners

B. discuss retesting to verify results, which will ensure continuing contact

encouraging retesting supports hope and gives the client time to cope with the diagnosis. Although post-test counseling should include education about A, B, and C, retesting encourages the client to maintain medical follow-up and management.

The nurse is caring for a client with HIV infection who develops Mycobacterium avium complex (MAC). what is the most significant desired outcome for this client?
A. free from injury of drug side effects
B. maintenance of intact perineal skin
c. adequate oxygenation
D. return to pre-illness weight

D. return to pre-illness weight

MAC is an opportunistic infection that presents as a TB like pulmonary process. MAC is a major contributing factor to the development of wasting syndrome, so the most significant desired outcome is the client's return to a pre-illness weight. drug schedules and side effects remain a life-long management problem. Client outcomes for adequate oxygenation are often dependent on management of anemia, maintenance of activities without fatigue, and supplemental oxygen to prevent hypoxia. Skin integrity is dependent upon resolution of diarrhea, which is not as significant as optimal nutrition.

A client who had abdominal surgery two days ago has prescriptions for intravenous morphine sulfate 4 mg every 2 hours and a clear liquid diet. the client complains of feeling distended and has sharp, cramping gas pains. What nursing intervention should be implemented?
A. assist the client to ambulate in the hall
B. obtain a prescription for a laxative
C. administer the prescribed morphine sulfate
D. withhold all oral fluid and food

a. assist the client to ambulate in the hall

Post-operative abdominal distention is caused by decreased peristalsis as a result of handling the intestine during surgery, limited dietary intake before and after surgery, and anesthetic and analgesic agents. Peristalsis is stimulated and distention minimized by implementing early and frequent ambulation. Based on the client's status, laxatives or withholding dietary progression are not indicated at this time. although pain management should be implemented, another analgesic prescription may be needed because morphine reduces intestinal motility and contributes to the client's gas pains.

A client with Meniere's disease is incapacitated by vertigo and is lying in bed grasping the side rails and staring at the television. Which nursing intervention should the nurse implement?
A. keep the head of the bed elevated 30 degrees
B. turn off the television and darken the room
c. encourage fluids to 3000 mL per day
D. change the client's position every two hours

B. turn off the television and darken the room

to decrease the client's vertigo during an acute attack of Meniere's disease, any visual stimuli or rotational movement, such as sudden head movements or position changes, should be minimized. Turning off the television and darkening the room minimize fluorescent lights, flickering television lights, and distracting sound. The other are ineffective in managing the client's symptoms.