19. A 71-year-old immobile patient has been in his whoelchair for 2 hours. When
ID: 272366 • Letter: 1
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19. A 71-year-old immobile patient has been in his whoelchair for 2 hours. When him, the nurse observes a reddened area at the base of the buttocks. This o best be documented as a: a. Stage 2 at greater trochanter b. Stage 1 at ischial tuberosity c. Stage I on iliac crest d. Stage 0 on posterior superior iliac spine 20. Family members are caring for their elderly mother at home. Which stateent by the daughter indicates the need for further teaching a.) " I change Mom's diaper whenever it is really wet." b. "1 make sure Mom eats good meals and extra snacks." c. "We try to change Mom's position at least every two hours." d. "I try to use lotion on Mom's skin every morning and evening." 21. An elderly patient who recently has had small watery BMs, complains of rectal area and abdominal cramping. The most appropriate initial nursing action would h a. Administer an oil retention enema. b. Notify the physician of these observations. c. Digitally stimulate the rectal sphincter d. Administer the prn laxative medication. 22. An older woman reports leakage of urine during exercise, coughing, and sneezing Th characteristics are associated with: a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence 23. An elderly client residing in an community-based residential facility, CBRF, states to do lots of things." The most appropriate nursing intervention would be to: b. Select books and videos from the library to occupy his time. d. Explore the variety of activities that are now available to him. 24. The nurse would recommend the following activities as appropriate for an elderi don't know what to do except sleep. I worked hard all my life, I never had the time a. Schedule the patient to join a museum trip with the local senior center c. Refer him to occupational therapy for evaluation. a. Swimming three times per week b. Jogging every other day c. Ballroom dancing weekly d. Tai chi every day e. Walking three or four times per week f. Stretching exercise daily g. Step aerobics weekly with no serious medical problems: (Select all that apply.)Explanation / Answer
Hi Answer:
19. A 71-year-old immobile patient has been in his wheelchair for 2 hours. When repositioning him, the nurse observes a reddened area at the base of the butt lock. This observation would best document as a
Answer: Option B. stage 1 at ischial tuberosity (Injury due to pressure)
20 Family members are caring for their elderly mother at home. Which statement by the daughter indicates the need for further teaching.?
Answer: Option A. I change moms diaper whenever it is really wet
Explanation; It shows that she will change the diaper when it's completely wet but she must know that once the diaper is wet she has to change it immediately to avoid infection and rashes.
21. An elderly patient who recently has had small watery BMs, complains of pressure in the rectal area and abdominal cramping. The most appropriate initial nursing action would be.
Answer: Option D. Administer the prn laxative medication
Explanation: This medication will give relief from abdominal cramp and also relax the pressure from rectal area.
22. An older woman reports leakage of urine during exercise, coughing and sneezing. The characteristics are associated with
Answer: Option B. Stress incontinence
Explanation: Incontinence is the condition of the involuntary passing of urine or stool from bladder or bowl respectively. Stress incontinence (SI) is the most common type of incontinence suffered by women, especially older women. The cause of SI is weak muscles in the pelvic floor or a weak sphincter muscle at the neck of the bladder.
23. An elderly client residing in a community-based residential family. CBRF, states don’t know what to do except sleep. I worked hard all my life, I never had the time to do lots of things. The most appropriate nursing intervention with being to
Answer: Option D. Explore the variety of activities that are now available to him
Explanation: As patient has no medical problem means he is fit by health but sick from his thinking. He is thinking about his busy past life and regrets about ht he has no time for lots of things to do. This thinking gives him stress so to remove his stress we must engage him to explore the variety of activities which are available to him now but are not available at past.
24. The nurse would recommend the following activities as appropriate for an elder with no serious medical problems
Answer: Option B, D, and E
Explanation: These exercises will maintain good health without any muscle fatigue. Second Tai Chi improve the body strength, muscle flexibility, stress release and pain management.
The nurse is caring for a patient with a history of severe cardiac problems. The goal is to use exercise to maintain the highest level of function possible. To prevent hypertension or use of the Vassal maneuver, precautionary teaching should include direction for:
Answer: Option A and C
Explanation: As the patient has a cardiac problem and if he will do heavy exercise it will directly affect his heart. So to maintain the highest label of the function he will advise to limited exercise which will not put any pressure on the heart, second, he is advised to breathe from mouth while doing limited exercise so that there will more oxygen gave go inside the body and he didn’t get fatigue.
25. An elderly patient requests an evening snack. The most appropriate food to facilitate sleep would be
Answer: Option A. Gram crackers with banana and milk
Explanation: This combination of snack will provide all nutrition due to which person will not feel hunger and his sleep will not disturb second this food will also provide sufficient amount of energy which is necessary for vital activities.
26. List four factors that are likely to cause sleep problems in older adults
Answer: 4 major factors which cause sleep problems in older adult are: Primary sleep disorders, Medical conditions, Medications, common substances. The example of each condition is given below in sequence.
1. Sleep apnea i.e. brief disruptions breathing during sleep
27. An older client tells the nurse that she used Phenobarbital to promote sleep for 6month since her husband died. What statement indicates a knowledge deficit related to Phenobarbital?
Answer: Option A.
Explanation: Phenobarbital drug belongs to barbiturate class of drugs which are anticonvulsants/hypnotics. It works by controlling the abnormal electrical activity in the brain that occurs during a seizure. It must be used for a short time interval, not more than 2 weeks.
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