Before assessing an older adult patient, the nurse reviews the age-related changes in the ear. (See accompanying box.) After the assessment, the nurse recognizes which priority concern related to the finding of vestibular degeneration?
1. skin breakdown
2. fall prevention
3. nausea
4. low night vision
Correct Answer: 2
Degeneration and atrophy of inner ear structures involved in balance and equilibrium, such as the vestibule, increase the risk for falls. Skin breakdown and nausea are not consequences of age-related changes that may occur in the ear. Reduced night vision is an age-related change in the eyes.
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A nurse is teaching a group of patients about weight management options. Which statement by the patient indicates a need for further teaching?
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The nurse observes a client's escalating anger. The client begins to pace the hall and shouts, "You all better watch out. I'm going to hurt anyone who gets in my way." Which should be the priority nursing intervention?
A. Calmly tell the client, "Staff will help you to control your impulse to hurt others." B. Remove other clients from the area and maintain milieu safety. C. Gather a show of force by contacting security for assistance. D. Calmly tell the client, "You will need to be medicated and secluded."
A parent has used permethrin (Nix) twice to treat head lice in a child. Two weeks after the last treatment, head lice are again found in the child's hair. The parent asks the nurse what to do
The nurse will recommend asking the child's provider about which therapy? a. Applying lindane 1% shampoo b. Cutting the child's hair c. Ordering permethrin 5% (Elimite) d. Using benzyl alcohol (Ulesfia)