A nurse is conducting a psychosocial assessment of an older adult client who has recently retired from work.

Which of the following questions should the nurse ask?

(Select all that apply.).

How do you feel about your retirement?.

What are some of the activities that you enjoy doing?.

How often do you interact with your family and friends?.

What are some of the sources of stress or conflict in your life?

How do you cope with your physical or mental health issues?.

Answer and Explanation

Correct Answer : A,B,C,D,E

The correct answer is A, B, C, D, and E.

All of these questions are relevant for conducting a psychosocial assessment of an older adult client who has recently retired from work. A psychosocial assessment is a process for learning about a client’s problems and needs, so that together you can create therapy goals and a plan for recovery. The information-gathering process should allow you to learn more about the client as a person, beyond just a diagnosis.

• Choice A is correct because it explores how the client feels about their retirement, which can be a major life transition that affects their identity, self-esteem, and sense of purpose.

• Choice B is correct because it assesses the client’s interests and hobbies, which can provide sources of enjoyment, stimulation, and meaning in their life.

• Choice C is correct because it evaluates the client’s social support network, which can influence their mental health, well-being, and coping skills.

• Choice D is correct because it identifies the client’s stressors and challenges, which can affect their mood, functioning, and quality of life.

• Choice E is correct because it examines the client’s physical and mental health issues, which can impact their ability to perform daily activities, manage their emotions, and adhere to treatment plans.

A comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of older people. The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors, as well as physical and mental health. Ideally, a regular examination of older patients incorporates many aspects of the comprehensive geriatric assessment, making the two approaches very similar.

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Correct Answer is C

Explanation

The correct answer is C.

Check for bladder distention or fecal impaction.

Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.

It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury.It leads to severe hypertension and is a medical emergency.

Bladder or bowel distension are the most common triggers of autonomic dysreflexia.

Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.

This can help to eliminate the stimulus and lower the blood pressure.

Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.

The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder.Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.

Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure.It may also increase the risk of orthostatic hypotension once the stimulus is removed.However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.

Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia.There is no evidence that body temperature is elevated or contributes to the hypertension in this condition.A cooling blanket may also cause vasoconstriction and worsen the hypertension.

Normal ranges for blood pressure vary depending on age, sex, and other factors.

However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.

Normal ranges for heart rate also vary depending on age, activity level, and other factors.

However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.

References:.

A. Avoid drinking grapefruit juice while taking this medication. B. Brush your teeth gently with a soft-bristled toothbrush C. Wear a medical alert bracelet or necklace at all times. D. Stop taking this medication if you develop a rash or fever. E. Have your blood levels checked regularly as directed by your provider.

Correct Answer is ["B","C","E"]

Explanation

The correct answer is B, C, and E.

Phenytoin (Dilantin) is an anticonvulsant medication that is used to control seizures.

It can have several side effects, some of which are serious and require medical attention.

Here are some explanations for each choice:.

A. Avoid drinking grapefruit juice while taking this medication.

This iswrongbecause grapefruit juice does not interact with phenytoin.However, grapefruit juice can affect the levels of other medications, such as statins, calcium channel blockers, and some antidepressants.

B. Brush your teeth gently with a soft-bristled toothbrush.This isrightbecause phenytoin can causegingival hyperplasia, which is an overgrowth of the gums that can lead to bleeding, infection, and difficulty chewing.

To prevent this, patients should practice good oral hygiene, avoid alcohol and tobacco, and see a dentist regularly.

A. Avoid drinking grapefruit juice while taking this medication B.

Brush your teeth gently with a soft-bristled toothbrush C.

Wear a medical alert bracelet or necklace at all times D.

Stop taking this medication if you develop a rash or fever E.

Have your blood levels checked regularly as directed by your provider

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A nurse is conducting a psychosocial assessment of an older adult client who has recently retired from work. Which of the following questions should the nurse ask? (Select all that apply.).

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who has had a spinal cord injury at level C5-C6 as a result of an automobile accident. The patient suddenly develops severe hypertension, throbbing headache, blurred vision, and bradycardia. What is the priority nursing intervention?

Correct Answer is C

Explanation

A nurse is providing discharge teaching for a patient who had a seizure disorder and is prescribed phenytoin (Dilantin). Which of the following instructions should the nurse include? (Select all that apply.).

Correct Answer is ["B","C","E"]

Explanation

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A nurse is conducting a psychosocial assessment of an older adult client who has recently retired from work.

Which of the following questions should the nurse ask?

(Select all that apply.).