When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

Provide frequent rest periods for the client.

Allow additional time to complete tasks.

Place assistive devices within reach.

Speak slowly and distinctly to the client.

Answer and Explanation

The Correct Answer is C

A.   Providing frequent rest periods is important for older adults, especially those who may be experiencing fatigue or have chronic conditions. However, this intervention, while supportive, is not always the most critical or directly related to creating a therapeutic environment in all situations.
B.   Allowing additional time for tasks is crucial for older adults who may have slower cognitive or physical processes. This approach helps reduce stress and frustration, contributing to a more supportive and therapeutic environment.
C.   Placing assistive devices within reach is essential for ensuring safety and promoting independence. It helps older adults perform tasks more easily and reduces the risk of falls or accidents. This intervention is crucial for creating a therapeutic environment as it directly impacts the client’s ability to manage their own care and environment effectively.
D.   Speaking slowly and distinctly is important for effective communication, especially if the older adult has hearing or cognitive impairments. It helps ensure that the client understands instructions and information, which is fundamental for their safety and engagement in their care.

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Correct Answer is B

Explanation

A. Applying cornstarch or other powders to moist skin can exacerbate dryness and irritation, as powders can absorb moisture but also contribute to a dry skin environment. In general, powders are not recommended for use on already dry or irritated skin, especially for older adults, as they can lead to further skin issues or contribute to fungal infections.
B. Gently applying lotion or moisturizer to the skin after bathing is the most appropriate action. Moisturizers help to rehydrate and lock in moisture, reducing the risk of dry, itchy skin. Applying lotion to damp skin (immediately after bathing) is particularly effective as it helps to seal in the moisture.
C. Adding bath oil to the bath water can be beneficial for moisturizing the skin, as it helps to create a barrier that prevents moisture loss. However, for the client’s specific request about post-bath relief, adding oil to the bath water does not address the immediate need for skin care after bathing.
D. Liquid soap can be gentler on the skin compared to bar soap, which can be drying, especially if it contains harsh ingredients. However, switching from bar soap to liquid soap is a preventive measure and does not provide immediate relief for already dry and itchy skin.

A. Provide a box of tissues for the client to use when coughing. B. Assist the client in changing into a fresh hospital gown. C. Teach the client to cover the mouth with hands when coughing. D. Obtain face masks for staff to wear upon entering the room.

Correct Answer is A

Explanation

A.Providing tissues is a helpful measure for clients to use when they need to cough or sneeze. It promotes good hygiene by allowing the client to dispose of respiratory secretions properly. However, this choice does not address the immediate concern of how the client is currently coughing and the potential for spreading infection.
B.Assisting the client with a gown change may be necessary if their current gown is soiled. However, this action does not directly address the infection control issue or the client’s method of coughing. Changing the gown is secondary to addressing proper coughing techniques and infection control.
C.Teaching clients to cover their mouth with their hands is not ideal, as it can spread germs if the hands are not washed immediately afterward. Instead, clients should be taught to cough into a tissue or their elbow (not the sleeve) to minimize the spread of germs. This is a crucial component of infection control and helps reduce the risk of transmission.
D.Providing face masks for staff is an important measure in infection control, especially if the client has a respiratory illness. However, it does not address the client's current coughing technique or teach the client how to prevent the spread of infection through their own actions.

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When establishing a therapeutic environment for an older adult client, which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The unlicensed assistive personnel (UAP) tells the nurse that an older client has requested powder applied after a tub bath to relieve itchy dry skin. Which instruction should the nurse provide to the UAP?

Correct Answer is B

Explanation

When entering a client's room, the nurse observes the client holding up an arm and coughing non-productively into the upper sleeve. Which action should the nurse take?

Correct Answer is A

Explanation

A client who has a continuous tube feeding develops a fever and reports experiencing dyspnea. Which action should the nurse implement?

An older adult woman who lives alone talks with the clinic nurse about her fears of falling at home. Which interventions should the nurse suggest? Select all that apply.

The nurse is teaching a client how to do active range of motion (ROM) exercises. To exercise the hinge joints, which action should the nurse instruct the client to perform?

During the shift change report, the nurse is told that a client has a stage 2 pressure injury. Which ulcer appearance is most likely to be observed?

When assessing a client's pain, the nurse determines the location and intensity of the pain. To gather data about the quality of the pain, which action should the nurse take?

An older adult is brought to the clinic by the oldest adult child who found the client lying on the floor at home conscious, but unable to get up by themself. The client is unable to recall what happened. Which action should the nurse take first?