A frail, aged customer is admitted to the unit with a diagnosis of pneumonia. Which finding is
most essential for the registered nurse (RN) to file to the healthcare issuer?
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 on this frail elderly customer. (A), (C) and (D) are all common with pneumonia,
however the maximum important locating is confusion and evidence of dehydration, which
require remedy for this frail elderly patron.
A frail elderly couple asks the registered nurse (RN) if they must watch their salt intake
because food does now not taste as proper because it used to in order that they must
season maximum foods. What records should the RN offer the couple?
A. Boredom may additionally affect how the flavor of meals is perceived, and specific
seasonings can stimulate taste.
B. With age, an growth in sodium intake is needed to catch up on a decrease in renal
function.
C. Short-time period reminiscence loss and confusion may be the motive they want to
over-season their food.
D. Taste buds regularly are dull due to atrophy so older customers ought to use other
seasonings in preference to salt. - ANSD. Taste buds are frequently stupid because of
atrophy so older customers need to use other seasonings in preference to salt.
Rationale: Taste buds atrophy with ordinary getting old, which affects an older purchaser's
sensitivity to flavor and is regularly compensated for using stronger tasting seasonings. (A),
(B), and (C) aren't normal aging strategies associated with flavor.
After taking a ten-day course of an antibiotic that became useless, a frail, aged client with
continual obstructive pulmonary ailment (COPD) is admitted for pneumonia. The customer
has a long records of smoking and nevertheless smokes a p.C. Of cigarettes an afternoon.
Which finding should the registered nurse (RN) document to the healthcare issuer?
A. Barrel chest with multiplied chest diameter
B. Crackles and pulse oximetry degree of 88%
C. Low hemoglobin and hematocrit ranges
D. Arterial blood gases indicating respiration acidosis - ANSB. Crackles and pulse oximetry
stage of 88%
,Rationale: With pneumonia, crackles within the lungs and occasional O2 saturation (B) can
impact good enough oxygenation, which must be reported to the HCP. (A) happens due to
chronic hyperinflation of the lungs and is common in clients with COPD. Anemia (C) is
regularly recognized in customers with COPD, and breathing acidosis (D) due to CO2
retention contributes to a decrease blood pH.
An older female purchaser currently moved to an assisted residing facility. The family
explains to the registered nurse (RN) that the purchaser is unmanageable and constantly
stressed, disoriented and depressed. The purchaser asks the RN again and again, "Where
am I?". How have to the RN reply?
A. Explain that she is in a new domestic referred to as an assisted living community
B. Question the patron about her perception of in which she might be now.
C. Distract the purchaser with a scenario that she is on an trip together with her circle of
relatives.
D. Reassure the patron not to worry because she will meet new pals. - ANSA. Explain that
she is in a brand new home known as an assisted residing community.
Rationale: Reality re-orientation (A) is the pleasant reaction for a consumer who's careworn
because the response is steady and proper. (B, C, and D) do no longer provide the patron
with remarks that is reality primarily based.
A new resident in an assisted living facility is an older customer who is experiencing
quick-time period memory loss and confusion. Which interest ought to the registered nurse
(RN) agenda the purchaser to do throughout the day?
A. Arts and crafts
B. Current events discussion organization
C. Group sing-along
D. Daily exercise organization - ANSD. Daily exercise organization
Rationale: A every day exercising institution (D) lets in the purchaser to mirror the leader and
minimizes the patron's strain to consider. (A), (C), and a current activities dialogue institution
(B) are idea-scary activities that require interest to detail and quick-term reminiscence to
participate within the group activity which may be stressful and frustrating to the resident
who has problem remembering sequence of the info.
The hospice nurse is completing a targeted evaluation of an older female client with stop
stage Alzheimer's disease, who lately fractured her hip. What technique need to the
registered nurse (RN) use to determine the customer's pain?
A. Use the FACE pain scale
B. Ask the patron to charge ache on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating behavior - ANSC. Observe for facial grimacing
Rationale: Observing for facial grimacing (C) is the nice technique for evaluating pain for a
customer who can not talk due to Alzheimer ailment. (A) and (B) may not be understood with
the aid of a consumer with stop-degree Alzheimer's ailment. (D) isn't always a useful tool for
ache evaluation.
, An older male client arrives at the sanatorium for an annual bodily exam. While the nurse
assesses the consumer, the customer states that he is having intimacy troubles with his wife.
Which records have to the nurse offer to elicit extra facts from the consumer?
A. Query consumer to make clear the purchaser's idea of an intimacy problem.
B. Discuss benign prostatic hypertrophy (BPH) and ejaculation.
C. Explore the frequency that he stories erectile disorder (ED)
D. Determine if the consumer's wife is young enough to get pregnant - ANSA. Query
purchaser to make clear the purchaser's concept of an intimacy problem.
Rationale: Clarification of the client's difficulty is needed to accurately address the particular
problem about intimacy issues (A). (B), (C), and (D) are details that the purchaser must
present, not the RN.
The registered nurse (RN) is worrying for an older woman client with a 20 year history of
rheumatoid arthritis (RA), who is admitted for carpel tunnel launch. Which locating related to
RA should the RN record?
A. Asymmetrical joint deformity
B. Small joint involvement in arms
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 distinctive OA from RA.
The registered nurse (RN) is re-implementing discharge commands with the family of an
older patron who became recently admitted for an intestinal obstruction. Which
announcement shows that the own family is familiar with the instructions?
A. Increase protein and carbohydrates within the day by day weight loss plan
B. Limit activity to mattress relaxation for the primary week and boom mobility incrementally
each week
C. Report belly distention, constipation or every other nausea and vomiting to the healthcare
provider
D. Drink drinks 2 hours after meals in preference to all through meals - ANSC. Report belly
distention, constipation, or any nausea and vomiting to the healthcare provider.
Rationale: (C) are symptoms that occur with intestinal obstruction and need to be addressed
immediately. (A, B, and D) are not indicated for a patron who has been discharged for
intestinal obstruction.
An older customer 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 ache - ANSC. Establish telemetry tracking.
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