A frail, elderly customer is admitted to the unit with a prognosis of pneumonia. Which
locating is maximum important for the registered nurse (RN) to document to the healthcare
company?
A. Fever and chills
B. Confusion and dehydration
C. Crackles within the lung fields
D. Nausea and vomiting - ANSB. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and
perfusion in this frail aged client. (A), (C) and (D) are all commonplace with pneumonia,
however the maximum vital locating is confusion and evidence of dehydration, which require
remedy for this frail aged customer.
A frail aged couple asks the registered nurse (RN) in the event that they must watch their
salt intake due to the fact food does now not taste as precise because it used to so that they
must season maximum ingredients. What records have to the RN provide the couple?
A. Boredom might also impact how the taste of meals is perceived, and distinct seasonings
can stimulate flavor.
B. With age, an boom in sodium consumption is wanted to make amends for a decrease in
renal function.
C. Short-term memory loss and confusion can be the reason they want to over-season their
food.
D. Taste buds often are dull because of atrophy so older customers should use different
seasonings instead of salt. - ANSD. Taste buds are regularly stupid because of atrophy so
older clients should use different seasonings in preference to salt.
Rationale: Taste buds atrophy with everyday ageing, which affects an older patron's
sensitivity to taste and is frequently compensated for the use of more potent tasting
seasonings. (A), (B), and (C) are not normal aging strategies related to flavor.
After taking a ten-day direction of an antibiotic that was ineffective, a frail, aged client with
persistent obstructive pulmonary ailment (COPD) is admitted for pneumonia. The purchaser
has an extended history of smoking and still smokes a % of cigarettes an afternoon. Which
locating have to the registered nurse (RN) document to the healthcare provider?
A. Barrel chest with extended chest diameter
B. Crackles and pulse oximetry stage of 88%
C. Low hemoglobin and hematocrit stages
D. Arterial blood gases indicating breathing acidosis - ANSB. Crackles and pulse oximetry
stage of 88%
,Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact good
enough oxygenation, which must be pronounced to the HCP. (A) takes place because of
persistent hyperinflation of the lungs and is not unusual in clients with COPD. Anemia (C) is
frequently recognized in customers with COPD, and respiratory acidosis (D) because of CO2
retention contributes to a lower blood pH.
An older girl customer lately moved to an assisted residing facility. The circle of relatives
explains to the registered nurse (RN) that the consumer is unmanageable and continually
harassed, disoriented and depressed. The patron asks the RN time and again, "Where am
I?". How must the RN respond?
A. Explain that she is in a new domestic called an assisted dwelling network
B. Question the consumer approximately her perception of in which she might be now.
C. Distract the purchaser with a state of affairs that she is on an day trip together with her
circle of relatives.
D. Reassure the patron now not to fear because she can meet new friends. - ANSA. Explain
that she is in a new home referred to as an assisted residing network.
Rationale: Reality re-orientation (A) is the best reaction for a patron who's burdened because
the reaction is consistent and proper. (B, C, and D) do no longer provide the consumer with
feedback this is reality primarily based.
A new resident in an assisted dwelling facility is an older customer who is experiencing
short-term reminiscence loss and confusion. Which activity need to the registered nurse
(RN) time table the customer to do for the duration of the day?
A. Arts and crafts
B. Current activities discussion organization
C. Group sing-along
D. Daily exercising organization - ANSD. Daily workout organization
Rationale: A every day exercise institution (D) permits the purchaser to reflect the leader and
minimizes the consumer's pressure to do not forget. (A), (C), and a present day occasions
discussion group (B) are notion-upsetting activities that require attention to detail and
brief-term memory to take part inside the organization hobby which may be demanding and
frustrating to the resident who has problem remembering series of the information.
The hospice nurse is finishing a targeted assessment of an older female patron with cease
degree Alzheimer's sickness, who lately fractured her hip. What technique have to the
registered nurse (RN) use to determine the client's ache?
A. Use the FACE pain scale
B. Ask the consumer to charge pain on a scale of one to ten
C. Observe for facial grimacing
D. Review documentation of new ingesting conduct - ANSC. Observe for facial grimacing
Rationale: Observing for facial grimacing (C) is the first-class technique for evaluating pain
for a customer who cannot speak because of Alzheimer sickness. (A) and (B) might not be
understood by way of a client with end-level Alzheimer's ailment. (D) isn't always a beneficial
tool for ache assessment.
, An older male purchaser arrives at the health center for an annual physical exam. While the
nurse assesses the purchaser, the patron states that he's having intimacy troubles together
with his wife. Which data must the nurse provide to elicit extra records from the patron?
A. Query customer to clarify the client's concept of an intimacy trouble.
B. Discuss benign prostatic hypertrophy (BPH) and ejaculation.
C. Explore the frequency that he reports erectile dysfunction (ED)
D. Determine if the purchaser's wife is young sufficient to get pregnant - ANSA. Query
customer to clarify the purchaser's concept of an intimacy problem.
Rationale: Clarification of the patron's problem is needed to accurately address the precise
concern about intimacy troubles (A). (B), (C), and (D) are info that the client should gift, now
not the RN.
The registered nurse (RN) is worrying for an older girl client with a 20 12 months records of
rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which locating related to
RA must the RN record?
A. Asymmetrical joint deformity
B. Small joint involvement in palms
C. Crepitation or grating sensation in joints
D. Weight bearing joint involvement - ANSB. Small joint involvement in fingers.
Rationale: Small joint involvement (B) is commonplace in rheumatoid arthritis. (A), (C) and
(D) are findings that different OA from RA.
The registered nurse (RN) is re-implementing discharge commands with the circle of
relatives of an older client who changed into these days admitted for an intestinal
obstruction. Which declaration suggests that the own family is familiar with the commands?
A. Increase protein and carbohydrates within the every day food plan
B. Limit interest to mattress relaxation for the first week and increase mobility incrementally
every week
C. Report belly distention, constipation or every other nausea and vomiting to the healthcare
provider
D. Drink beverages 2 hours after food in place of throughout food - ANSC. Report stomach
distention, constipation, or any nausea and vomiting to the healthcare company.
Rationale: (C) are symptoms that arise with intestinal obstruction and need to be addressed
right now. (A, B, and D) aren't indicated for a customer who has been discharged for
intestinal obstruction.
An older consumer is transferred to a telemetry unit after placement of a pacemaker. What
action ought to the registered nurse (RN) take first?
A. View incision website
B. Obtain a blood pressure
C. Establish telemetry monitoring
D. Evaluate purchaser for pain - ANSC. Establish telemetry tracking.
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