A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up?

"I do my best to protect my skin from bumps and cuts. It's more fragile now."

"I guess feeling down is just part of aging."

"My hair is thinning. I'm going to go to the wig shop soon."

"I missed my eye appointment, but I rescheduled it."

Answer and Explanation

The Correct Answer is B

Choice A reason: The client's effort to protect their skin due to increased fragility is a normal part of the aging process. As the skin ages, it becomes thinner and less elastic, making it more susceptible to injuries. The client's proactive approach to skin care is appropriate and does not indicate a need for follow-up.

Choice B reason: The statement "I guess feeling down is just part of aging" suggests a possible misconception about mental health and aging. While it's true that older adults may face various challenges that can affect their mood, persistent feelings of sadness or depression are not a normal part of aging and should be addressed. Mental health is as important as physical health, and feeling down can be a sign of depression, which is treatable at any age.

Choice C reason: Concerns about changes in appearance, such as hair thinning, are common as people age. The client's plan to visit a wig shop indicates they are taking steps to manage these changes and maintain their self-esteem. This does not necessarily indicate a need for follow-up unless the hair loss is sudden or accompanied by other symptoms that could suggest an underlying health issue.

Choice D reason: Missing an appointment but taking the initiative to reschedule shows that the client is actively managing their health care. Regular eye exams are important for older adults as they can help detect vision changes and conditions like glaucoma or cataracts early on. This behavior is responsible and does not indicate a need for follow-up.

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Correct Answer is A

Explanation

Choice A reason: Placing the client's bed at the lowest height is a safety intervention that minimizes the risk of injury from falls, which is particularly important for clients with dementia who may have impaired mobility or judgment. Lowering the bed height can reduce the severity of an injury if a fall does occur. Additionally, it can facilitate easier access for the client to get in and out of bed with less assistance.

Choice B reason: Requesting a prescription for a nightly sedative is not typically recommended as a first-line intervention for clients with dementia. Sedatives can increase the risk of confusion, falls, and can worsen cognitive impairment in the elderly. Non-pharmacological approaches are preferred for managing sleep disturbances in dementia patients.

Choice C reason: Assisting the client with toileting at least once every 4 hours is an important intervention to maintain hygiene and comfort, as well as to prevent urinary tract infections and skin breakdown. However, the frequency of toileting assistance should be individualized based on the client's needs and level of incontinence.

Choice D reason: Turning off all lights in the client's room at night is not advisable as some clients with dementia may experience increased confusion or agitation in complete darkness. A nightlight or low-level lighting can provide a safer environment and help to orient the client during nighttime hours.

A. Muscle twitching B. Client report of nausea C. Serosanguineous drainage D. Client report of incisional pain

Correct Answer is A

Explanation

Choice A reason : Muscle twitching can be indicative of hypocalcemia, a common and serious complication following a complete thyroidectomy due to potential damage or removal of the parathyroid glands. Hypocalcemia requires immediate intervention to prevent more severe symptoms such as tetany or cardiac complications.

Choice B reason : While nausea is a common postoperative symptom, it is not typically as urgent as signs of hypocalcemia. However, persistent nausea should still be addressed as it can affect the client's comfort and nutritional intake.

Choice C reason : Serosanguineous drainage is expected to some extent after surgery, but if it is excessive or changes in character, it may indicate hemorrhage or infection, which would then become a priority.

Choice D reason : Incisional pain is also expected postoperatively. While pain management is important for recovery, it is not as immediately concerning as potential hypocalcemia unless the pain is severe or uncontrolled, suggesting complications.

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A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up?

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