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Med surg Older adults 3

Terms in this set (15)

1. A home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. Which of the following findings should the nurse identify as a safety risk?
A. Electrical cords are placed along the walls.
Rationale: Electrical cords along the wall are not a safety hazard and are out of the way to prevent the client from tripping on them.
B. Scatter rugs are present in the kitchen.
Rationale: Scatter rugs in the kitchen are a safety hazard. The client could trip on one of the rugs and fall due to impaired vision.
C. Handrails are present in the bathroom.
Rationale: Handrails present in the bathroom are not a safety risk and can prevent the client from falling.
D. Uses a microwave for cooking.
Rationale: Microwave ovens are a safer way of cooking than the standard stove for an individual who has impaired vision.
B. Scatter rugs are present in the kitchen
2. A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse?
A. Speak using his usual tone of voice.
Rationale: The nurse should speak in his usual tone of voice to optimize the client's ability to hear and comprehend; however, there is another action the nurse should take first.
B. Stand directly in front of the client.
Rationale: The nurse should stand directly in front of the client to optimize the client's ability to hear and comprehend; however, there is another action the nurse should take first.
C. Rephrase statements the client does not hear.
Rationale: The nurse should stand directly in front of the client to optimize her ability to hear and comprehend; however, there is another action the nurse should take first.
D. Determine if the client uses hearing aids.
Rationale: The first action the nurse should take using the nursing process is to assess the client. The nurse should find out if the client has hearing aids and whether they are in place and functioning.
D.Determine if the client uses hearing aids.
3. A nurse is teaching a client about how to use her new hearing aids. Which of the following statements should the nurse identify as an indication that the client needs further instruction?
A. "I will clean the hearing aids with alcohol wipes."
Rationale:
Alcohol use can break down the mechanism of the hearing aids. The client should follow the manufacturer's instructions, which usually include using a soft cloth to remove cerumen and other debris and never immersing them in water.
B. "I will not use hairspray if I am wearing the hearing aids."
Rationale: Hairspray residue makes hearing aids oily and greasy, which can damage them.
C. "I will change the batteries once a week."
Rationale: If the client wears the hearing aids for 10 to 12 hr a day, the batteries should last about a week. The client should keep additional batteries nearby.
D. "I will expect the hearing aids to whistle when I cup my hand over them."
Rationale: A whistling sound when the client cups her hand over an ear with a hearing aid in place means that the battery is functioning
A. "I will clean the hearing aids with alcohol wipes."
4. A nurse at an ophthalmology clinic is providing teaching to a client who has open angle glaucoma and a new prescription for timolol eye drops. Which of the following instructions should the nurse provide?
A. The medication is to be applied when the client is experiencing eye pain.
Rationale: The client needs to take the medications daily to reduce intraocular pressure and preserve remaining eyesight.
B. The medication will be used until the client's intraocular pressure returns to normal.
Rationale: Treatment for open-angle glaucoma is to continue for life. Abrupt discontinuation can worsen the client's condition.
C. The medication should be applied on a regular schedule for the rest of the client's life.
Rationale: Medications prescribed for open angle glaucoma are intended to enhance aqueous outflow, or decrease its production, or both. The client must continue the eye drops on an uninterrupted basis for life to maintain intraocular pressure at an acceptable level.
D. The medication is to be used for approximately 10 days, followed by a gradual tapering off. Rationale: Treatment for open-angle glaucoma is to continue for life.
C. The medication should be applied on a regular schedule for the rest of the client's life.
5. A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)
A. More difficulty seeing due to a greater sensitivity to glare
B. Decreased cough reflex
C. Decreased bladder capacity
D. Decreased systolic blood pressure
E. Dehydration of intervertebral disc
A,B,C,E
6. A nurse is teaching a client who has a new diagnosis of urge incontinence. Which of the following information should the nurse include in the teaching? (Select all that apply.)
A. "Your provider might prescribe anticholinergic medications."
B. "You should limit fluids in the evening."
C. "You should restrict your intake of caffeine."
D. "You might require intermittent urinary catheterization."
E. "You might require an anterior vaginal repair."
A,B,C
7. A nurse in a long-term care facility is caring for an older adult client who has dementia and begins to have frequent episodes of urinary incontinence. After the provider determines no medical cause for the client's incontinence, which of the following interventions should the nurse initiate to manage this behavior?
A. Remind the client to tell the nurse when he has to urinate.
Rationale: It is unlikely that a client who has dementia will remember to tell the nurse when he needs to urinate.
B. Use adult diapers to prevent frequent clothing changes.
Rationale: Adult diapers might contain the urine, but they will not help to manage the behavioral aspects of incontinence.
C. Take the client to the bathroom every 2 hr.
Rationale:
By assisting the client to the bathroom every 2 hr, the staff establishes a regular pattern of toileting, and the client learns to trust that the staff places value on his bladder-training needs. He also learns a physical pattern that promotes bladder control.
D. Request a prescription for an indwelling urinary catheter.
Rationale: Because of the complications invasive procedures like catheterization can cause, the nurse should consider them a last resort.
C. Take the client to the bathroom every 2 hr.
8. A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?
A. Stress incontinence
Rationale: Stress incontinence is associated with a loss of urine with physical exertion.
B. Urge incontinence
Rationale: Urge incontinence is associated with a strong desire to urinate.
C. Overflow incontinence
Rationale: These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.
D. Reflex incontinence
Rationale: Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.
C. Overflow incontinence
9. A nurse is assessing an older adult client who reports a sudden onset of urinary incontinence. The nurse should recognize which of the following conditions can cause incontinence in the older adult client?
A. Nephrosclerosis
Rationale: Nephrosclerosis is a degenerative kidney disorder that can cause kidney ischemia and fibrosis.
B. Uremia
Rationale: Uremia can cause nausea, vomiting, and fatigue.
C. Diverticulitis
Rationale: Diverticulitis can cause abdominal pain and nausea, and can lead to peritonitis.
D. Cystitis
Rationale: A sudden onset of urinary incontinence or increased confusion can indicate the presence of a urinary tract infection or bacterial cystitis in the older adult client.
D. Cystitis
10.A nurse in a long-term care facility is observing an assistant personnel (AP) changing the linen for a client who has fecal incontinence. Which of the following actions indicates that the AP understands the principles of infection control?
A. Shakes the soiled linen to remove any toilet paper remnants
Rationale: The AP should never shake soiled linen because the air currents that action creates can spread pathogens.
B. Places the soiled linen on the floor before bagging it
Rationale: The AP should never place soiled linens on the floor because that action spreads pathogens and forces the AP to handle the contaminated linen twice.
C. Holds the soiled linen against her body while carrying it to the linen bag
Rationale: The AP should hold the linen away from her body to prevent spreading pathogens to her clothing.
D. Places clean linen that touched the floor in the soiled linen bag
Rationale: Linen that touches the floor or the AP drops requires laundering.
D. Places clean linen that touched the floor in the soiled linen bag
11.A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?
A. Apply a moisture barrier ointment to the client's skin.
Rationale: Skin that remains in contact with urine for prolonged periods is at risk for maceration and breakdown. After cleansing and drying the client's skin, the nurse should apply a moisture barrier ointment to prevent further contact of the skin with urine.
B. Clean the client's skin and perineum with hot water after each episode of incontinence.
Rationale: The nurse should wash the client's skin with mild soap and warm water and pat it dry gently. Hot water can be irritating and can dry the skin.
C. Check the client's skin every 8 hr for signs of breakdown.
Rationale: Clients who are incontinent are at a high risk for skin breakdown. Examining the skin at least every 2 hr and providing hygiene are two initial defenses against skin breakdown.
D. Request a prescription for the insertion of an indwelling urinary catheter.
Rationale: Although it is true that clients who have a urinary catheter in place have less risk for skin breakdown due to incontinence, this is an invasive procedure that poses significant risks. The catheterization of the bladder can introduce bacteria into the bladder, creating a risk for bacteremia, a life-threatening bacterial infection of the blood.
A. Apply a moisture barrier ointment to the client's skin.
12.A nurse is providing instructions about bowel cleansing with polyethylene glycol-electrolyte solution (PEG) for a client who is going to have a colonoscopy. Which of the following information should the nurse include?
A. "To prevent dehydration, drink an additional liter of fluid during preparation time." Rationale: Dehydration does not occur with PEG. No additional fluid intake is necessary.
B. "Expect bowel movements to begin 3 hr following completion of solution." Rationale: Bowel movements begin about 1 hr following the first dose.
C. "Abdominal bloating might occur."
Rationale: While PEG is well-tolerated, adverse effects include nausea, bloating, and abdominal discomfort.
D. "Drink 400 mL every hour until bowel movements are clear."
Rationale: The client should ingest the full solution by drinking 250 mL to 300 mL every 10 minutes over 2 to 3 hr.
C. "Abdominal bloating might occur."
13.A nurse is administering a tap water enema to a client who is constipated. During the administration of the enema, the client states he is having abdominal cramps. Which of the following actions should the nurse take to relieve the client's discomfort?
A. Lower the height of the solution container.
Rationale: If nausea or cramping occurs, the flow of water should momentarily be slowed or stopped by lowering the device or clamping the tubing. This allows the intestinal spasm to pass while leaving the catheter in place. The nurse should then continue administering the enema at a slower rate once the cramping has passed.
B. Encourage the client to bear down.
Rationale: Bearing down will cause early release of the fluid, decreasing the effectiveness of the enema.
C. Allow the client to expel some fluid before continuing.
Rationale: Allowing the client to expel solution too early in the procedure will decrease the effectiveness of the enema.
D. Stop the enema and document that the client did not tolerate the procedure.
Rationale: Cramping is a normal response to an enema. There are actions the nurse can take to decrease the cramping.
A. Lower the height of the solution container.
14.A nurse is providing instructions for a 52-year-old client who is scheduled for a colonoscopy. The client reports that he has not had the procedure before and is very anxious about feeling pain during the procedure. Which of the following responses by the nurse is appropriate?
A. "Don't worry; most clients dislike the prep more than the procedure itself."
Rationale:
This response is an example of unwarranted or false reassurance. It does not encourage the client to explain his feelings.
B. "Before the examination, your provider will give you a sedative that will make you sleepy."
Rationale: This therapeutic response appropriately addresses the client's concerns. The client is seeking information and this response provides the client with accurate information. It can also lead to further discussion about the procedure.
C. "I know you're anxious, but this procedure is recommended for people your age."
Rationale: This statement is true. Routine screening for polyps and colon cancer is recommended starting at age 50; however, the nurse is changing the subject and this does not encourage the client to explain his feelings.
D. "After you have signed the consent form, we can talk more about this."
Rationale: The nurse should ensure that the client understands and agrees to the procedure before the client signs the consent form.
B. "Before the examination, your provider will give you a sedative that will make you sleepy."
15.A nurse is preparing to administer a soap suds enema to a client who has constipation. As the nurse explains the procedure, the client states, "The doctor didn't tell me I was supposed to receive an enema." Which of the following nursing actions is appropriate at this time?
A. Check the client's medical record for the provider's prescription.
Rationale: The nurse should use the client's medical record to verify the provider prescribed an enema for the client.
B. Explain to the client that the provider prescribed the procedure.
Rationale: This option ignores the client's concern about whether or not an enema is prescribed.
C. Assure the client that enemas are commonly prescribed for constipation.
Rationale: This option ignores the client's concern about whether or not an enema is prescribed.
D. Inform the charge nurse that the client refused the enema.
Rationale: The client did not refuse the enema; therefore, this action is not appropriate.
A. Check the client's medical record for the provider's prescription.
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