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A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

Determining the client's mobility

Explaining the roles of the RN, licensed practical nurse, and assistive personnel

Introducing health care team members to the client

Understanding the client's routine for his own care at home

Answer and Explanation

The Correct Answer is D

A. Determining the client's mobility

Important for safety and fall prevention, but not the first priority during care planning.

B. Explaining the roles of the RN, licensed practical nurse, and assistive personnel

This is part of orientation and education but does not help in personalized care planning.

C. Introducing health care team members to the client

While courteous and important for building rapport, it’s not the first step in individualized care planning.

D. Understanding the client's routine for his own care at home

This helps in personalizing the care plan to maintain the client’s independence and preferences, especially for older adults in long-term care.

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Correct Answer is ["A","B","C","D"]

Explanation

A. Loss of calcium from bone matrix

Immobility causes bone demineralization, increasing the risk for osteoporosis and fractures.

B. Stasis of respiratory secretions

Lack of movement decreases chest expansion, leading to retained secretions and risk of pneumonia or atelectasis.

C. Increased cardiac workload

Immobilization leads to venous stasis and reduced venous return, increasing cardiac workload and risk of thromboembolism.

D. Decreased circulation from pressure

Prolonged pressure leads to reduced perfusion, increasing risk for pressure ulcers.

E. Increased mental activity

Immobilization often results in decreased mental stimulation, potentially leading to depression or confusion, especially in older adults.

A. dry and dirty. B. moist and pink. C. moist and white D. dry and greenish.

Correct Answer is A

Explanation

A. Dry and dirty

Skin under a cast is typically dry, flaky, and appears dirty due to the accumulation of dead skin cells and lack of exposure to air and water.

B. Moist and pink

Moist and pink skin suggests healthy, well-hydrated tissue, which is not typical after cast removal.

C. Moist and white

Moist and white skin may indicate maceration, which can occur under wet dressings, not a dry cast.

D. Dry and greenish

Green discoloration is not a normal finding and may suggest infection, which is not expected under a dry cast unless there were complications.

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A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the nurse take first when assisting with planning the client's care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse designs care for the immobilized patient to help combat the major dangers of immobilization, which include: Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

A patient who fractured a leg several weeks ago is scheduled for cast removal after he returns home. The nurse should explain to the patient to expect the skin underneath the cast to appear:

Correct Answer is A

Explanation

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