An older adult who has been diagnosed with COPD wants to perform self-care activities. Which instruction should the nurse include in client teaching to help achieve this goal?
Perform all activities of daily living (ADLs) and then rest
Bathe and eat slowly with periodic rest
Walk short distances without oxygen
Bathe right after eating and then rest
The Correct Answer is B
Choice A reason: Performing all activities of daily living (ADLs) and then resting is not a good instruction for the older adult who has COPD, as it can cause fatigue, shortness of breath, and anxiety. The nurse would advise the older adult to pace themselves and prioritize the most important activities, and to take breaks between tasks.
Choice B reason: Bathing and eating slowly with periodic rest is a good instruction for the older adult who has COPD, as it can help conserve energy, prevent dyspnea, and improve digestion. The nurse would advise the older adult to use a shower chair or a handheld showerhead, to avoid hot water or steam, and to use a fan or an open window for ventilation. The nurse would also advise the older adult to eat small, frequent meals, to avoid foods that cause gas or bloating, and to drink fluids between meals rather than with them.
Choice C reason: Walking short distances without oxygen is not a safe instruction for the older adult who has COPD, as it can cause hypoxia, which is a low level of oxygen in the blood. The nurse would advise the older adult to use oxygen therapy as prescribed by their doctor, and to monitor their oxygen saturation with a pulse oximeter. The nurse would also advise the older adult to exercise regularly, but to start slowly and gradually increase the intensity and duration, and to stop if they feel dizzy, chest pain, or severe breathlessness.
Choice D reason: Bathing right after eating and then resting is not a helpful instruction for the older adult who has COPD, as it can cause indigestion, reflux, or aspiration. The nurse would advise the older adult to wait at least an hour after eating before bathing, and to avoid lying down right after eating or bathing. The nurse would also advise the older adult to elevate their head with pillows when resting or sleeping, and to avoid napping during the day.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Raises all four side rails is not the best intervention, as it may not prevent the client from falling and may increase the risk of injury and entrapment. Raising all four side rails may also be considered a form of restraint, which should be avoided unless absolutely necessary.
Choice B reason: Orders a two-person assist with a transfer is not the best intervention, as it may not be appropriate for the client's level of mobility and may reduce the client's independence and self-esteem. The nurse should assess the client's ability to transfer and use the appropriate assistive device and number of staff to ensure safety and comfort.
Choice C reason: Gives the client a dry erase board is the best intervention, as it can facilitate the client's communication and expression of needs and preferences. The client may have difficulty speaking or writing due to the stroke, which can affect the language and motor areas of the brain. A dry erase board can allow the client to use simple words, symbols, or drawings to convey their messages.
Choice D reason: May need to incorporate repetition is not the best intervention, as it is not specific and may not be effective for the client's learning and retention. The nurse should use individualized and evidence-based strategies to teach the client and their family about the stroke, its effects, and the rehabilitation plan. Repetition may be one of the strategies, but not the only one.
Choice E reason: None of the above is not the correct answer, as there is one choice that is the best intervention for the nurse to implement when caring for this client.
Correct Answer is C
Explanation
Choice A reason: This is incorrect because any exertion on the part of an older adult with heart disease does not necessarily result in death. Exertion can increase the oxygen demand of the heart and cause angina, or chest pain, but it can also be beneficial for the cardiovascular health and fitness of the older adult, if done within the limits of their tolerance and under medical supervision.
Choice B reason: This is incorrect because myocardial infarction is not the same as heart attack, cardiac arrest, or coronary thrombosis, although they are related terms. Myocardial infarction is the medical term for the death of a part of the heart muscle due to lack of blood supply. Heart attack is the common term for myocardial infarction. Cardiac arrest is the sudden loss of heart function, which can be caused by myocardial infarction or other factors. Coronary thrombosis is the formation of a blood clot in a coronary artery, which can lead to myocardial infarction.
Choice C reason: This is correct because both excessive undernutrition and overnutrition can contribute to heart disease. Undernutrition can cause malnutrition, anemia, and low immunity, which can increase the risk of infections and inflammation that can damage the heart. Overnutrition can cause obesity, diabetes, and high cholesterol, which can increase the risk of atherosclerosis and hypertension that can impair the blood flow to the heart.
Choice D reason: This is incorrect because a person with diabetes should have their blood pressure checked regularly, but this is not a statement about heart disease in Kenya. Diabetes is a risk factor for heart disease, as it can damage the blood vessels and nerves that control the heart. However, this statement is applicable to any person with diabetes, regardless of their location.
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