The nurse notes that an older adult client is wearing layers of clothing on a warm, fall day. Which of the following would be the priority assessment at this time?
A) Asking whether the client often feels cold
B) Assessing the client's developmental level
C) Reviewing the client's culture for possible influence
D) Observing the client's overall hygiene
A
You might also like to view...
The nurse received the change-of-shift report on a 74-year-old woman admitted for depression. She has aphasia from a recent stroke and communicates minimally by using pencil and paper
Her college-age grandson moved in with her to help with meals and household chores and a home health aide provides daily assistance with ADLs and medications. For the past week, she has refused to bathe, eats poorly, and has stopped writing. Which of the following statements best demonstrates that the nurse has the ability to plan holistic care for this client? 1. The client's psychobiologic health, rehabilitation, self-care potential, and discharge arrangements are interrelated. 2. Reliance on the grandson and home health aide have decreased her feelings of self-worth and caused this episode of depression. 3. The client's quality of life and prognosis are primarily related to her aphasia and inability to communicate. 4. Sudden life changes, such as a stroke, usually lead to depression in older clients.
The nurse identifies a misconception about the vaccination against human papillomavirus (HPV) when the patient says:
a. "I know I must have three doses of the vaccine." b. "Girls as young as 9 years of age may be vaccinated." c. "I am relieved that the vaccine protects me from all HPV infections." d. "I know I should continue having regular Pap smears."
The 80-year-old woman tells the home health nurse, "I can only eat cereal because I just can't make those dentures work!" What would be the most appropriate suggestion by the nurse? (Select all that apply.)
a. Take only tiny bites of food. b. Chew slowly. c. Use a dental adhesive. d. Select soft, nonsticky foods (e.g., ground meat, boiled carrots). e. Purée all food.
After an unsuccessful trial with fluphenazine (Prolixin), a patient's medication was changed to trifluoperazine (Stelazine)
Three months later the patient is still hallucinating and delusional. What is the most likely explanation for the persistent symptoms? a. Trifluoperazine (Stelazine) is a low-potency antipsychotic, and the patient might need higher doses. b. The patient has not taken trifluoperazine (Stelazine) long enough to decrease symptoms significantly. c. Delusions and hallucinations are negative symptoms of schizophrenia that do not respond to traditional antipsychotic medications. d. Both fluphenazine (Prolixin) and trifluoperazine (Stelazine) are traditional antipsychotics, and the patient does not respond well to this class of drug.