The nurse is caring for an older adult patient who has a history of depression. Which comment by the patient indicates an immediate need for further assessment?
a. "I am so old; all my friends have died."
b. "I am useless now; there is no reason to be alive."
c. "I am looking forward to seeing my husband in heaven someday."
d. "I retire in 6 months, and it will be all downhill from there."
____
ANS: B
Comments by any older adult referring to hopelessness or desire to die must be explored to assess suicide risk. A and D may require further assessment but are not as hopeless as B. C is a positive comment.
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A college student is being treated for Chlamydia. What should the nurse teach this student to decrease the risk of transmitting another sexually transmitted infection?
A) Unprotected sex is acceptable if you know the partner well. B) Latex condoms should be used for all sexual activity. C) Birth control pills will help to decrease the risk of pregnancy and STDs. D) Condoms should be used with petroleum jelly.
Which actions should the nurse take to ensure effective sleep for older clients in a long-term care facility? Select all that apply.
1. Use nightlights during the night. 2. Establish consistent nighttime routines. 3. Schedule routine care in the early evening hours. 4. Put clients to bed immediately after the evening meal. 5. Reduce noise and light disruption throughout the night.
Which statement is true regarding the lymphatic system?
1) The lymphatic system is able to pump lymph independently of the cardiovascular system. 2) The lymphatic system pumps blood through the cardiovascular system. 3) The lymphatic system carries oxygen to the major organs. 4) The lymphatic system carries unoxygenated blood back to the heart.
A home health nurse was making an initial visit to an elderly man. As the nurse began the assessment, the wife gave all of the information requested. What does the nurse need to do next?
A. Because the nurse has all the needed information, appropriate interventions must be agreed upon with the family. B. Having the information, the nurse should now decide upon appropriate nursing diagnoses. C. The next step is to assess the environment of the wider community. D. The nurse needs to confirm information with the client because the nurse has heard only the wife's perspective.