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An older client who was recently admitted to the sub-acute setting after having a knee replacement, is very anxious and refuses to get out of bed, stating that it is too painful. Which intervention will the nurse implement?

Allow the client to remain in bed but share that getting up will be required at least twice a day starting the next morning.

Use the Hoyer lift to get her out of bed so that the knee will not experience much movement and so there will be little pain.

Share with the client that it is important to get out of bed and that there is pain medication available if it does hurt.

Offer pain medication, administer the medication, and wait 30 minutes before getting her out of bed.

Answer and Explanation

The Correct Answer is D

Choice A reason: Allowing the client to remain in bed but sharing that getting up will be required at least twice a day starting the next morning is not an effective intervention, as it does not address the client's current pain or anxiety, and may increase the client's resistance or fear of mobilization.

Choice B reason: Using the Hoyer lift to get her out of bed so that the knee will not experience much movement and so there will be little pain is not an appropriate intervention, as it does not respect the client's autonomy or preference, and may cause more pain or injury to the knee or other joints.

Choice C reason: Sharing with the client that it is important to get out of bed and that there is pain medication available if it does hurt is not a sufficient intervention, as it does not provide the client with adequate pain relief or reassurance, and may imply that the client's pain is not taken seriously or validated.

Choice D reason: Offering pain medication, administering the medication, and waiting 30 minutes before getting her out of bed is the best intervention, as it provides the client with effective pain management, reduces the client's anxiety, and facilitates the client's mobilization and recovery.

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Correct Answer is C

Explanation

Choice A reason: Histoplasmosis is a fungal infection that affects the lungs, but it is not a chronic condition and does not cause airflow obstruction. It is not included in the diagnosis of COPD.

Choice B reason: Bacterial pneumonia is a bacterial infection that causes inflammation and fluid accumulation in the lungs, but it is not a chronic condition and does not cause permanent damage to the airways. It is not included in the diagnosis of COPD.

Choice C reason: Bronchial asthma is a chronic condition that causes inflammation and narrowing of the airways, resulting in difficulty breathing, wheezing, coughing, and chest tightness. It is one of the main conditions that make up COPD, along with chronic bronchitis and emphysema.

Choice D reason: Mycobacterium tuberculosis is a bacterial infection that causes tuberculosis, a serious disease that affects the lungs and other organs. It is not a chronic condition and does not cause airflow obstruction. It is not included in the diagnosis of COPD.

A. Skin turgor at the sternum B. Orthostasis C. Sunken eyes D. Decreased urine output

Correct Answer is ["A","B"]

Explanation

Choice A reason: This assessment is reliable in the older adult because the skin turgor at the sternum is less affected by age-related changes in skin elasticity and hydration than other sites, such as the forearm or the hand. The skin turgor at the sternum can indicate the fluid status of the older adult, as well as the presence of dehydration or edema.

Choice B reason: This assessment is reliable in the older adult because orthostasis, or a drop in blood pressure when changing positions, is a common condition in this population. Orthostasis can be caused by various factors, such as medications, dehydration, anemia, or autonomic dysfunction. Orthostasis can increase the risk of falls, dizziness, syncope, or cardiovascular complications in the older adult.

Choice C reason: This assessment is not reliable in the older adult because sunken eyes are not a specific sign of dehydration in this population. Sunken eyes can be a normal age-related change in the facial structure, or a result of other factors, such as weight loss, malnutrition, or chronic illness. Sunken eyes can also be influenced by the lighting, the angle of observation, or the presence of glasses or contact lenses.

Choice D reason: This assessment is not reliable in the older adult because decreased urine output is not a sensitive indicator of dehydration in this population. Decreased urine output can be influenced by various factors, such as renal function, fluid intake, medications, or environmental conditions. Decreased urine output can also be a sign of other conditions, such as urinary tract infection, urinary retention, or renal failure.

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An older client who was recently admitted to the sub-acute setting after having a knee replacement, is very anxious and refuses to get out of bed, stating that it is too painful. Which intervention will the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which condition is included in the diagnosis of chronic obstructive pulmonary disease (COPD)?

Correct Answer is C

Explanation

Which of the following assessment(s) is/are considered reliable in the older adult? (Select all that apply.)

Correct Answer is ["A","B"]

Explanation

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