An older adult is admitted for a respiratory infection and is found to have very dry skin with several areas exhibiting some cracking. What question is most important for the nurse to ask the patient?
a. "Are you able to reach your feet when you bathe?"
b. "Would you like me to give you a back massage?"
c. "Do you get chilled easily when you bathe?"
d. "How often do you usually bathe?"
D
Older adults have skin that is dry and can easily become cracked. Bathing too often can cause this problem. This is the most important question to ask based on the assessment data. The other options do not relate to assessing the patient's skin.
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Which nursing intervention has priority when assisting a patient who has been transported to the hospital admissions unit by police for wandering barefoot and naked on the street in freezing weather?
a. Establishing trust in the one-to-one, nurse-patient relationship b. Performing a rapid multidisciplinary physical assessment c. Contacting family for permission to treat the patient d. Determining why the patient removed all clothing
The self-concept of the older adult is influenced by the amount and degree of change experienced in his or her _____________________________. (Select all that apply.)
a. financial security. b. social life. c. physical health. d. mobility. e. independence.
A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assist the client to the chair for meals and to the bathroom. b. Encourage the client to use the spirometer every 4 hours. c. Ensure the client wears TED hose or sequential compression devices. d. Have the client rate pain on a 0-to-10 scale and report to the nurse. e. Take and record a full set of vital signs per hospital protocol.
The nurse is caring for a 49-year-old patient, who has been receiving bethanechol (Duvoid) for 1 week. The patient develops progressive muscle weakness and respiratory difficulty. Edrophonium is ordered and injected and the patient's symptoms worsen
How would the nurse interpret this response? A) Myasthenic crisis B) Cholinergic crisis C) Anaphylactic reaction D) Pulmonary edema