A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

The client verbalizes regret about never marrying.

The client has poorly fitting dentures.

The client has no living family.

The client is sedentary throughout most of the day.

Answer and Explanation

The Correct Answer is D

Rationale:

A. While the client's feelings about never marrying are important, they do not represent an immediate health risk or safety concern.

B. Poorly fitting dentures can affect the client's quality of life and ability to eat, but they do not represent an immediate health risk or safety concern.

C. While having no living family can be a social concern, it does not represent an immediate health risk or safety concern.

D. The client being sedentary throughout most of the day is a risk factor for numerous health problems, including cardiovascular disease, obesity, and decreased mobility. It is also a modifiable risk factor that can be addressed to improve the client's health and quality of life. Encouraging the client to engage in regular physical activity is a priority.

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Correct Answer is C

Explanation

Rationale:

A. Postponing the procedure could put the client at risk if the appendicitis worsens.

B. Obtaining consent from the client may not be possible due to the client's developmental disability.

C. Preparing the client for surgery with implied consent is appropriate when the client is unable to provide consent and the procedure is urgent.

D. Requesting that the provider sign the consent form is not appropriate because the provider cannot provide consent on behalf of the client.

A. Provide oral care to the client once every 8 hr. B. Reposition the client once every 4 hr. C. Place the head of the client's bed flat. D. Use a fan to circulate air in the client's room.

Correct Answer is B

Explanation

Rationale for A: Providing oral care once every 8 hours is not directly related to relieving dyspnea. Oral care addresses comfort related to dry mouth, but it doesn't improve breathing difficulties.

Rationale for B: Repositioning the client every 4 hours can help alleviate dyspnea by improving lung expansion and preventing pooling of secretions. It also helps in reducing pressure injuries, promoting comfort, and preventing complications.

Rationale for C: Placing the head of the bed flat can exacerbate dyspnea by hindering lung expansion. It is recommended to elevate the head of the bed to improve air exchange and breathing.

Rationale for D: While using a fan can help with the sensation of breathlessness, repositioning every 4 hours is a more direct action to support ventilation and reduce dyspnea.

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A nurse is collecting data from an older adult client who lives alone. Which of the following findings should the nurse identify as the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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