Which method elicits the most accurate information during a physical assessment of an older adult?
A. use reliable assessment tools for older adults
B. Review the past medical record for medications
C. Ask the client to recount one's health history
D. Obtain the client's information from a caregiver
Answer: A. use reliable assessment tools for older adults
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The family of an 85-year-old client expresses concern regarding the gradual decline in cognitive functioning of their family member. What mental health condition does this sug-gest?
A. Depression B. Psychosis C. Dementia D. Delirium
When the nurse is attempting to manipulate the burn client's environment to diminish stress in order to promote wound healing, which of the following is not appropriate for a burn client?
1. Keeping the room cool 2. Pain medication 3. Closing the curtains 4. Noise control
The nurse auscultates the FHR and determines a rate of 112 beats/min. Which action is appropriate?
1. Inform the maternal client that the rate is normal. 2. Reassess the FHR in 5 minutes because the rate is low. 3. Report the FHR to the doctor immediately. 4. Turn the maternal client on her side and administer oxygen.
The parents of an infant with gastroesophageal reflux (GER) ask the nurse about the advisability of the side-lying or supine position for prevention of sudden infant death syndrome (SIDS) for their infant. The nurse's best response would be:
a. "Yes, prevention of SIDS is extremely important and the side-lying or supine position is currently recommended." b. "Currently the prone or head-elevated prone position is recommended for GER, and with the elimination of puffy bedding from the crib you can decrease chances of SIDS." c. "The side-lying or supine position will work just fine as long as you elevate the head of the bed so that the infant is sleeping nearly sitting up." d. "SIDS is something you cannot really protect against for certain, so get some baby monitors and let your baby seek whatever position is most comfortable."