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. Administering diuretics in the evening may increase the client's need to urinate and disrupt sleep.

B. Using overhead lighting when checking equipment may disrupt the client's sleep and should be avoided.

C. Keeping the door to the client's room closed can reduce noise and disturbances from the hallway, promoting a more restful sleep environment.

D. Providing snug-fitting nightwear may be uncomfortable and restrict movement during sleep.

A. Tell the nurse that permission from the risk manager is required to view the client's record. B. Contact facility security to remove the nurse from the unit. C. Complete an incident report about the breach of confidentiality. D. Remind the nurse that only staff caring for the client may access the client's record.

Correct Answer is D

Explanation

Rationale:

A. Telling the nurse that permission from the risk manager is required to view the client's record is not accurate and may not address the situation appropriately.

B. Contacting facility security to remove the nurse from the unit is not necessary and may not address the situation appropriately.

C. Completing an incident report about the breach of confidentiality may be appropriate later if the situation escalates or if there is no resolution after speaking to the nurse. However, the immediate step is to address the breach directly.

D. Reminding the nurse that only staff caring for the client may access the client's record is the correct action. The nurse should remind the colleague that access to a client's medical record is restricted to those directly involved in their care. This respects patient confidentiality and complies with legal and ethical guidelines.

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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?

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