The nurse is obtaining a health history on an 87-year-old woman. Which of the following areas of questioning would be most useful at this time?
a. Obstetric history
b. Childhood illnesses
c. General health for the past 20 years
d. Current health promotion activities
ANS: D
It is important for the nurse to recognize positive health measures, such as what the person has been doing to help him or herself stay well and to live to an older age. The other responses are not pertinent to a patient of this age.
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A hospitalized patient with impaired vision must get a picture in his or her mind of the hospital room and its contents in order to mobilize independently and safely. What must the nurse monitor in the patient's room?
A) That a commode is always available at the bedside B) That all furniture remains in the same position C) That visitors do not leave items on the bedside table D) That the patient's slippers stay under the bed
The nurse is planning interventions to prevent the onset of urinary retention in a postpartum patient. Why are these interventions needed?
A) Frequent partial voiding never relieves the bladder pressure. B) Catheterization at the time of delivery reduces bladder tonicity. C) Mild dehydration causes a concentrated urine volume in the bladder. D) Decreased bladder sensation results from edema because of pressure of birth.
The nurse has an order to administer an intramuscular (IM) immunization to a 2-month-old child. Which site is considered the best choice for this injection?
a. Deltoid b. Dorsogluteal c. Ventrogluteal d. Vastus lateralis
What is the best way to assess psychological status in an older adult?
a. Direct observation b. Input from family members c. Subjective findings d. Review of nursing notes