A nurse is assessing an older adult client. Which of the following statements indicates that the client is at a risk for being socially isolated?
"People have to speak louder for me to hear when they visit."
"I only babysit my grandchildren twice each month."
"My hearing aid is lost, so I don't go to church like I used to do."
"My adult child takes me to the grocery store every other week."
The Correct Answer is C
A. Hearing difficulties can be a challenge but do not necessarily indicate social isolation unless they lead to withdrawal from activities.
B. Babysitting twice a month still allows for social interaction and does not suggest isolation.
C. Not attending church due to a lost hearing aid suggests withdrawal from social activities, which increases the risk of social isolation.
D. Having a family member assist with grocery shopping indicates some level of social interaction and support, reducing the risk of isolation.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. I will turn the car seat forward facing when my baby is 1 year old. This is incorrect because the American Academy of Pediatrics recommends keeping infants in a rear-facing car seat until at least 2 years of age or until they reach the maximum height and weight limit specified by the car seat manufacturer.
B. I will place the retainer clip on my baby's upper abdomen. This is incorrect because the retainer clip should be positioned at armpit level to properly secure the straps and protect the baby in case of a collision.
C. I will position the shoulder harness straps 3 inches above my baby's shoulders. This is incorrect because for a rear-facing car seat, the shoulder harness straps should be positioned at or just below the infant’s shoulders, not above.
D. I will position my baby at a 45-degree angle in the car seat. This is correct because positioning the baby at a 45-degree angle helps maintain an open airway and prevents airway obstruction due to the head falling forward.
Correct Answer is C
Explanation
A. Reinserting the protruding intestinal tissue is inappropriate and can cause further injury or infection. The nurse should keep the tissue moist and protected until surgical intervention.
B. Placing the client in Trendelenburg position is incorrect because it does not reduce tension on the wound. Instead, the client should be placed in a low Fowler's position with knees slightly flexed to reduce strain.
C. Covering the wound with a sterile saline-soaked dressing is the priority action to keep the tissue moist and prevent further contamination or damage until the provider can intervene.
D. Monitoring vital signs every 30 minutes is important but not the priority action. The nurse should immediately cover the wound first, then monitor for signs of shock or infection.
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