The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

Monitor heart rate to keep within the suggested range.

Avoid exercises that impact chronic conditions.

Focus on exercises that help with balance.

Complete 30 minutes of exercise at least 3 times a week.

Answer and Explanation

The Correct Answer is B

Choice A reason: Monitoring heart rate to stay within a suggested range is correct, ensuring safe exercise intensity for older adults. This prevents overexertion, especially with cardiovascular conditions. The statement reflects understanding, as it aligns with evidence-based guidelines for safe exercise, requiring no further teaching on this point.

Choice B reason: Avoiding exercises that impact chronic conditions is overly restrictive and incorrect. Many chronic conditions, like arthritis or diabetes, benefit from tailored exercise to improve function and health. This statement suggests misunderstanding, requiring teaching to clarify that appropriate exercises can manage, not exacerbate, chronic conditions, per geriatric care guidelines.

Choice C reason: Focusing on balance exercises is appropriate for older adults to prevent falls, a major injury risk. This statement shows understanding, as balance training improves stability and safety. No further teaching is needed, as it aligns with evidence-based recommendations for exercise in aging populations to enhance mobility.

Choice D reason: Completing 30 minutes of exercise at least 3 times a week aligns with CDC guidelines for older adults, promoting cardiovascular health and strength. This statement reflects correct understanding of exercise frequency and duration, requiring no further teaching, as it supports safe, effective physical activity for health maintenance.

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Correct Answer is B

Explanation

Choice A reason: The client’s verbal assurance of continuing reflects motivation but not physiological tolerance. Activity intolerance is measured by objective signs like heart rate and respiratory response. Subjective statements may mask fatigue or distress, making this an unreliable indicator of the client’s ability to safely tolerate progressive ambulation.

Choice B reason: A normal heart rate range before and after ambulation indicates cardiovascular stability, a key marker of activity tolerance. Heart rate reflects the body’s response to physical demand. Stable rates suggest the client can handle ambulation without excessive strain, aligning with evidence-based assessment of endurance and safety in activity intolerance.

Choice C reason: Stopping frequently to talk may indicate social engagement or fatigue, not tolerance. Activity intolerance requires objective measures like heart rate or respiratory rate. Frequent stops could mask exertion or weakness, making this an ambiguous and unreliable assessment of the client’s ability to sustain ambulation safely.

Choice D reason: Progressing from a shuffling to deliberate gait suggests improved coordination but not necessarily activity tolerance. Gait quality does not directly measure cardiovascular or respiratory response to exertion. Heart rate stability is a more precise indicator of physiological tolerance, critical for assessing safety in clients with activity intolerance.

A. Auscultate breath sounds after client swallows. B. Offer small sips of water through a straw. C. Use a penlight to observe back of oral cavity. D. Place tongue blade on back half of tongue.

Correct Answer is D

Explanation

Choice A reason: Auscultating breath sounds after swallowing assesses lung function and aspiration risk but does not directly evaluate the gag reflex. The gag reflex, mediated by cranial nerves IX and X, is tested by stimulating the posterior pharynx. This method is indirect and less specific, as it relies on swallowing, which may not trigger the reflex in a weak client.

Choice B reason: Offering small sips of water tests swallowing but not the gag reflex specifically. Swallowing involves multiple cranial nerves, but the gag reflex requires direct stimulation of the posterior pharynx. In a lethargic client, this could risk aspiration, and it does not provide a clear assessment of the reflex needed for safe mouth care.

Choice C reason: Using a penlight to observe the oral cavity assesses structure but not function. The gag reflex requires tactile stimulation of the posterior pharynx to elicit a response. Visual inspection cannot confirm the reflex’s presence, which is critical to ensure safety during mouth care in a weak, lethargic client.

Choice D reason: Placing a tongue blade on the back half of the tongue directly stimulates the posterior pharynx, triggering the gag reflex if intact. This tests cranial nerves IX and X, ensuring the client can protect their airway during mouth care. In a lethargic client, this method is safe, specific, and essential to prevent aspiration, aligning with standard nursing practice.

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The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse develops an outcome statement for a male client with the nursing problem, ‘Activity intolerance.’ The plan of care includes progressive ambulation in the hallway with assistance. Which assessment best determines the client’s ability to tolerate this activity?

Correct Answer is B

Explanation

The nurse is preparing to assist a newly admitted client with personal hygiene measures. The client is lethargic and very weak. Before providing mouth care, the nurse plans to assess the client’s gag reflex. Which action should the nurse include?

Correct Answer is D

Explanation

The nurse is providing education to an older adult client about activity and exercise. Which statement made by the client indicates a need for further teaching?

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