A nurse is performing an assessment of an older adult client in an assisted living facility.
Which of the following findings is the highest priority for the nurse to address when planning care?

Unsteady gait

Report of short-term memory loss

Hearing loss

Report of frequent constipation

Answer and Explanation

The Correct Answer is A

A. An unsteady gait increases the risk of falls, which can lead to serious injuries in older adults.

A. Ensuring safety and preventing falls is a priority.

B.   Short-term memory loss is common in older adults, but it may not pose an immediate risk to safety.
C.   Hearing loss, while important, may not be an immediate safety concern unless it significantly impacts the individual's ability to communicate or hear warnings.
D.   Frequent constipation is a common concern in older adults but may not pose an immediate threat to safety. Falls prevention takes precedence in this scenario.

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Correct Answer is C

Explanation

A. Raising the index finger is not a typical response for managing gagging during NG tube insertion.

B. Bearing down during insertion is not an appropriate instruction and may increase the risk of complications.
C. Instructing the client to say "stop" if a burning sensation is felt inside the nose allows for communication and prompt action to ensure the client's comfort and safety.
D. Inhaling forcefully during insertion is not a recommended action and may interfere with the procedure.

A. Support the client in her personal decision. B. Refer the client to a counselor. C. Encourage the client not to give up. D. Suggest that the client talk with a breast cancer survivor.

Correct Answer is A

Explanation

A. Supporting the client in her personal decision respects her autonomy and right to make decisions about her own healthcare.
B. Referring the client to a counselor can be appropriate, but the primary response should be to support the client's decision.
C. Encouraging the client not to give up may not be appropriate if the client has made a well- considered decision to refuse further treatment.
D. Suggesting that the client talk with a breast cancer survivor may provide emotional support but should not be used as a means to persuade the client to undergo further treatment if she has made an informed decision to refuse.

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A nurse is performing an assessment of an older adult client in an assisted living facility. Which of the following findings is the highest priority for the nurse to address when planning care?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing to insert an NG tube for a client who requires enteral feedings. Which of the following instructions should the nurse give the client before beginning the procedure?

Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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A nurse is performing an assessment of an older adult client in an assisted living facility.
Which of the following findings is the highest priority for the nurse to address when planning care?