Nursing Elites

1. What are the common signs and symptoms of dehydration in the elderly?

• A. Dry mouth, confusion, and decreased skin turgor
• B. Increased heart rate and muscle cramps
• C. Fever, rapid breathing, and increased urine output
• D. Increased thirst and difficulty walking

Correct answer: A

Rationale: Corrected Rationale: Dehydration in the elderly is often signaled by dry mouth, confusion, and decreased skin turgor due to reduced fluid intake. Choice A is the correct answer as these are common signs and symptoms of dehydration in the elderly.\nIncorrect Rationales: Option B (Increased heart rate and muscle cramps) are more associated with conditions like hyperthyroidism or electrolyte imbalances rather than dehydration. Option C (Fever, rapid breathing, and increased urine output) are signs of other medical conditions such as infections or diabetes insipidus. Option D (Increased thirst and difficulty walking) can be seen in various situations but are not specific signs of dehydration in the elderly.

2. What are the risk factors for developing pneumonia in older adults?

• A. Immobility and decreased lung function
• B. Poor hygiene and aspiration
• C. Use of respiratory equipment and medications
• D. Poor nutritional status and compromised immune system

Correct answer: A

Rationale: The correct answer is A: Immobility and decreased lung function. Older adults with immobility and decreased lung function are at a higher risk of developing pneumonia. Immobility can lead to decreased lung expansion and impaired clearance of secretions, predisposing to pneumonia. While poor hygiene, aspiration, use of respiratory equipment, medications, poor nutritional status, and compromised immune system can also contribute to pneumonia risk, they are not as directly associated with pneumonia in older adults as immobility and decreased lung function.

3. When providing family education for those who have a relative with Alzheimer's disease about minimizing stress, which of the following suggestions is most relevant?

• A. Allow the client to rest four to five times during the day
• B. Assess the cognitive functioning of the client regularly
• C. Provide reality orientation even if the memory loss is severe
• D. Maintain consistency in environment, routine, and caregivers

Correct answer: D

Rationale: The most relevant suggestion for minimizing stress in individuals with Alzheimer's disease is to maintain consistency in the environment, routine, and caregivers. This approach helps create a sense of familiarity and security for the individual, reducing stress and anxiety. Choice A is incorrect as it suggests allowing the client to go to bed multiple times during the day, which may disrupt their routine and lead to confusion. Choice B is incorrect as continuously testing cognitive functioning can be overwhelming and stressful for the individual. Choice C is also incorrect as providing reality orientation in cases of severe memory loss can cause frustration and confusion, ultimately increasing stress levels.

4. When collecting data from a client with posttraumatic stress disorder (PTSD), which of the following manifestations should the nurse expect?

• A. Amnesia
• B. Hypervigilance
• C. Hallucinations
• D. Severe agitation

Correct answer: B

Rationale: The correct manifestation to expect when collecting data from a client with PTSD is hypervigilance. Hypervigilance refers to increased alertness, which is a common symptom of PTSD. This heightened state of awareness is characterized by an exaggerated startle response, being easily startled, and constantly scanning the environment for potential threats. Amnesia (choice A) is not typically a primary manifestation of PTSD; it is more commonly associated with dissociative disorders. Hallucinations (choice C) involve perceiving things that are not present and are not typically a hallmark symptom of PTSD. Severe agitation (choice D) may occur in individuals with PTSD, but hypervigilance is a more specific and common manifestation associated with this disorder.

5. A nurse is providing discharge instructions to a client who has a prescription for the use of oxygen in his home. Which of the following should the nurse teach the client about using oxygen safely in his home?

• A. Family members who smoke should be at least 10 ft away from the client when oxygen is in use
• B. Nail polish should not be used near a client who is receiving oxygen
• C. A 'No Smoking' sign should be placed on the front door
• D. Cotton bedding and clothing should be replaced with items made from wool

Correct answer: C

Rationale: The correct answer is C. Placing a 'No Smoking' sign on the front door is crucial for fire safety when using oxygen at home. Choice A is incorrect as family members who smoke should not be around the client when oxygen is in use, not just at a distance. Choice B is not directly related to oxygen safety. Choice D is also irrelevant as the type of bedding and clothing material does not impact oxygen safety.

Similar Questions