A nurse is reinforcing teaching with a group of older adult clients about preventing hypothermia in the winter.Which of the following information should the nurse include in the teaching?

Set the indoor temperature at 17°C (64°F).

Eat low-carbohydrate meals and snacks.

Cover the head when sleeping at night.

Wear a single layer of warm clothing.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Setting the indoor temperature at 17°C (64°F) is too low for older adults, increasing their risk for hypothermia. A higher indoor temperature is recommended for safety.

Choice B rationale

Low-carbohydrate diets are not ideal in preventing hypothermia. Carbohydrates are essential for energy production and thermoregulation, especially in colder weather.

Choice C rationale

Covering the head is critical as significant heat loss occurs through the head. This practice helps conserve body heat during colder temperatures.

Choice D rationale

Wearing a single layer is insufficient for retaining body heat in winter. Layering clothing provides insulation by trapping warm air, which helps prevent hypothermia. .

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Correct Answer is A

Explanation

Choice A rationale

Alzheimer's disease affects cognitive function, making it difficult for clients to process and remember complex instructions. Limiting instructions to two steps at a time reduces cognitive overload and enhances the client's ability to follow directions. This approach is supported by evidence-based guidelines for managing Alzheimer's, which emphasize simplifying tasks to match the individual's functional capabilities.

Choice B rationale

Encouraging independence in activities of daily living (ADLs) may lead to frustration and increased agitation in clients with Alzheimer's. As cognitive decline progresses, the client often lacks the ability to independently complete ADLs, requiring structured assistance to prevent anxiety and promote safety.

Choice C rationale

Using socialization as a distractor during agitation is not effective because it may overstimulate the client, worsening the agitation. Alzheimer's clients are often sensitive to changes in environment and increased activity, necessitating calm and consistent approaches during episodes of distress.

Choice D rationale

Varying staff providing care disrupts consistency and routine, which are crucial for clients with Alzheimer's. Familiar caregivers help foster trust and reduce confusion, aligning with care practices that prioritize stability and minimize anxiety caused by frequent changes in personnel.

A. Bulging of the eyes. B. Sunken appearance of the eyes. C. Swelling of the eyelids. D. Redness and watering of the eyes.

Correct Answer is A

Explanation

Choice A rationale

Exophthalmos is characterized by abnormal protrusion or bulging of the eyes due to retro-orbital tissue swelling and inflammation associated with Graves’ disease. This condition is a hallmark symptom of Graves’ ophthalmopathy.

Choice B rationale

Sunken eyes are not indicative of exophthalmos and are typically associated with dehydration or aging, rather than retro-orbital tissue changes as seen in Graves’ disease.

Choice C rationale

Eyelid swelling might occur in various conditions, such as allergies or infections, but it does not specifically point to exophthalmos or Graves’ disease-related complications.

Choice D rationale

Redness and watering of the eyes are non-specific symptoms that could occur in conjunctivitis or dry eye syndrome but do not define exophthalmos uniquely.

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A nurse is reinforcing teaching with a group of older adult clients about preventing hypothermia in the winter.Which of the following information should the nurse include in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is contributing to the plan of care for a client who has Alzheimer's disease.Which of the following interventions should the nurse include in the plan?

Correct Answer is A

Explanation

A nurse is collecting data from a client who has Graves' disease.Which of the following signs should the nurse identify as an indication that the client is experiencing exophthalmos?

Correct Answer is A

Explanation

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