A nurse is caring for a client who has an ileostomy.
Nurses' Notes
Day 1:

• Client is alert and oriented.
• ileostomy stoma is pink.
• Stoma draining moderate brown liquid stool.
• Client will not look at the stoma.
• Client states they are not interested in learning about stoma care.
• Intake: 2,200 mL over the last 24 hr
• Urine output: 1,200 ml over the last 24 hr

Day 2:

• ileostomy pouch changed. Skin surrounding the stoma is reddened and appears irritated
• initiated a request for a referral to an ostomy nurse.
• intake. 1,600 mL over the last 24 hr
• Urine output: 650 mL over the last 24 hr

The nurse is reviewing the client's medical record. Select the information that requires intervention by the nurse.

When a nurse receives a new prescription over the telephone from a client's provider, the first action the nurse should take is to write down the complete prescription. This ensures that the nurse has an accurate record of the prescription and can refer to it when administering medication or providing care.

Option a is incorrect because documenting the prescription as a telephone prescription in the medical record is important but not the first action.

Option b is incorrect because reading back the prescription to the provider is important but not the first action.

Option c is incorrect because ensuring that the provider signs the prescription is important but not the first action.

As individuals age, it is common for them to experience a decreased sense of balance. This can be attributed to age-related changes in the musculoskeletal system, sensory perception, and coordination. The inner ear, which plays a vital role in maintaining balance, undergoes natural degenerative changes over time. Additionally, age-related decline in muscle strength and flexibility can contribute to difficulties in maintaining balance. Therefore, a nurse assessing an older adult client should expect a decreased sense of balance as a common finding.

1. Nighttime urinary incontinence: While nighttime urinary incontinence can occur in some older adults, it is not a universal finding. It is important to avoid making assumptions or generalizations about older adults experiencing urinary incontinence. Each individual's urinary function can vary, and incontinence can be influenced by various factors such as overall health, bladder capacity, medication use, and underlying medical conditions.
2. Heightened sense of pain: Older adults may experience changes in pain perception due to age-related physiological changes and medical conditions. However, it is not a predictable or expected finding for all older adult clients. Pain perception can vary among individuals based on their overall health, chronic conditions, and individual pain thresholds. Therefore, while some older adults may experience heightened pain sensitivity, it is not a universal expectation.
3. Increased nighttime sleeping: Sleep patterns can change with age, and older adults may experience alterations in their sleep-wake cycles. However, increased nighttime sleeping is not a definitive finding that applies to all older adult clients. Sleep patterns can vary greatly among individuals, and some older adults may experience decreased sleep duration or disrupted sleep rather than increased nighttime sleeping.

In summary, the nurse should expect a decreased sense of balance as a common finding when assessing an older adult client. It is important to approach each individual as unique and recognize that other findings such as nighttime urinary incontinence, heightened sense of pain, or increased nighttime sleeping may or may not be present, as they can vary among older adults based on individual factors.