A nurse keeps the top side rails of the bed of an elderly client raised. What should the
nurse explain to the client and family regarding the purpose of the side rails?
A) To assist in changing positions
B) To hold the nurse's call signal
C) To hold the TV remote control
D) To restrict client movement
A
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An S3 heart sound heard in an older adult with heart disease usually signifies
A) right atrial hypertrophy. B) ventricular failure. C) poor diastolic filling. D) a normal sound.
It is suspected that a patient who sustained multiple traumas is developing cardiac tamponade. Which nursing assessment finding would help to support this tentative diagnosis?
1. Flat neck veins despite fluid resuscitation 2. Persistent hypotension 3. Atrial fibrillation per cardiac monitor 4. Bilateral basilar crackles
The nurse is working at a state fair in the health screening booth. The nurse determines that which client demonstrates the decline in responsiveness of the immune system of an older adult?
1. A 78-year-old client with pneumonia has a temperature of 99.5°F 2. A 68-year-old client who complains of redness and itching after developing a rash from contact with poison ivy 3. An 80-year-old client who has swelling and redness around an abdominal incision from an open appendectomy 4. A 66-year-old client who has 8 mm induration at the site of a mumps skin test 72 hours earlier
A client taking protease inhibitors for HIV treatment expresses interest in adjuvant alternative nutrition therapy. The client states, "I'd like to take the supplement St. John's Wort.". The nurse replies that:
1. "This supplement has been shown to decrease the effects of protease inhibitors.". 2. "St. John's Wort has been used to promote satiety.". 3. "Take this supplement 1 hour after the protease inhibitor.". 4. "St. John's Wort neutralizes the effects of damage to cells.".