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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice A reason: While wearing gloves is a standard precaution to prevent contamination and protect the nurse from potential pathogens, the gloves used for collecting a guaiac smear sample do not need to be sterile. Clean, non-sterile gloves are typically sufficient for this procedure.

Choice B reason: It is crucial to discard any samples that contain urine because urine can interfere with the results of the fecal occult blood test (FOBT). The presence of urine can cause false positives due to the peroxidase activity in urine, which can lead to unnecessary further testing.

Choice C reason: Collecting three samples from a single bowel movement is not recommended. Instead, it is advised to collect samples from three separate bowel movements to increase the likelihood of detecting intermittent bleeding, which is common in conditions like colorectal cancer.

Choice D reason: Taking the sample from the outer edge of formed stool is not the best practice. The sample should be taken from different areas of the stool to ensure a representative sample, as blood may not be uniformly distributed throughout the stool.

A. Administer prescribed corticosteroids. B. Slow infusion rate and contact the provider. C. Lower the head of the bed to semi-Fowler's. D. Change infusion to lactated Ringer's and maintain rate.

Correct Answer is B

Explanation

Choice A reason : Administering corticosteroids is not the first-line action for dyspnea related to fluid overload or other causes of respiratory distress in this context.

Choice B reason : Slowing the infusion rate is appropriate when there are signs of fluid overload, such as dyspnea and hypertension. Contacting the provider is crucial for further assessment and management, which may include diuretics or other interventions.

Choice C reason : Lowering the head of the bed to semi-Fowler's may provide some relief for dyspnea, but it does not address the potential cause, which in this case could be fluid overload.

Choice D reason : Changing the infusion to lactated Ringer's would not be appropriate if the client is experiencing symptoms of fluid overload. The type of fluid is less important than the volume and rate of administration in this scenario.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to obtain a guaiac smear sample from a client for fecal occult blood testing. Which of the following actions should the nurse plan to take?

Correct Answer is B

Explanation

A nurse is caring for a client who is receiving a 0.9% sodium chloride via IV infusion. The client has become dyspneic with a blood pressure of 140/100 mm Hg, a fluid intake of 960 mL, and an output of 300 mL in the past 12 hours. Which of the following actions should the nurse take?

Correct Answer is B

Explanation

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

A nurse is planning care for a client who is receiving targeted radiation therapy to the neck. The nurse should plan to monitor the client for which of the following as an adverse effect of this therapy?

A nurse is assessing a client who sustained major full-thickness burns to their lower legs 12 hours ago. Which of the following findings should the nurse expect?

A hospice nurse is planning care for a client who has lung cancer. Which of the following statements should the nurse make to incorporate the client's and family's cultural beliefs?

A charge nurse receives a call from the house supervisor requesting room assignments for four new clients. Based on the admission diagnoses, which of the following clients requires a private room?

A nurse is caring for a client who has been prescribed an antibiotic. The client tells the nurse, "I don't like taking medications because I don't think I need them." Which of the following responses should the nurse make?

A nurse is teaching a client who has asthma about how to use a metered-dose inhaler with a spacer. Which of the following pieces of information should the nurse include in the teaching?

A nurse is providing teaching to a client who is to start furosemide therapy for heart failure. Which of the following statements indicates that the client understands a potential adverse effect of this medication?