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 C

Explanation

A. Debriding agents are used to remove necrotic or non-viable tissue from a wound. While debridement can be necessary if there is evidence of necrotic tissue or eschar, the presence of thick tan exudate alone does not necessarily indicate that debridement is needed.
B. Steri-strips are used to support wound closure and can be applied to wounds with approximated edges. However, in the case of a wound healing by secondary intention (where the edges are not brought together but heal from the inside out), steri-strips are not typically used. This action is not relevant if the wound is healing by secondary intention and if there is a thick exudate present.
C. Obtaining a wound culture is important if there is a suspicion of infection, especially if there is a change in the character of the exudate, increased redness, swelling, or other signs of infection. A thick tan exudate might be indicative of an infection or could be a normal part of the healing process
D. Removing sutures in a wound that is healing by secondary intention is not appropriate as it could disrupt the healing process and potentially lead to complications. Sutures are typically removed when the wound is healing by primary intention and the edges are approximated.

A. 4+ pitting edema of both lower extremities. B. Hypoactive bowel sounds with infrequent bowel movements. C. Braden risk assessment scale rating score of ten. D. Warm, dry skin with a fever of 100.0° F (37.8° C).

Correct Answer is C

Explanation

A. Pitting edema, especially at a 4+ level, indicates significant fluid retention in the lower extremities. While this can be a concern for skin integrity and may contribute to skin breakdown due to increased pressure and reduced mobility, it is not the most direct indicator for turning schedules.
B. Hypoactive bowel sounds and infrequent bowel movements suggest gastrointestinal issues, such as constipation or reduced bowel motility. While these issues are important to address for overall client health, they do not directly impact the scheduling of turning to prevent pressure ulcers.
C. The Braden Risk Assessment Scale is a tool used to evaluate a client's risk for developing pressure ulcers. A score of 10 indicates a high risk for pressure ulcer development. This assessment directly informs the need for a more aggressive turning schedule and other preventive measures to protect skin integrity.
D. Warm, dry skin and a low-grade fever might indicate an infection or other underlying condition, but these factors are not the primary considerations for determining the turning schedule. While fever and skin temperature can be important for overall assessment and care, they do not directly impact the need for turning to prevent pressure ulcers.

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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

A surgical incision that is healing by secondary intention develops a thick tan exudate. Which action should the nurse take first?

Correct Answer is C

Explanation

In planning the turning schedule for a bedfast client, it is most important for the nurse to consider which assessment finding?

Correct Answer is C

Explanation

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?

The charge nurse is observing a new nurse administering care during new hire orientation at the hospital. Which activity by the new nurse indicates correct body movement and posture to reduce the risk for injury?

An older adult client grimaces and demonstrates guarding behavior, but denies experiencing pain when asked by the nurse to rate the pain on a numeric scale. Which action should the nurse take next?

An older client is being admitted to a rehabilitation unit from a medical-surgical unit following a left hip replacement. When reviewing the client's prescribed medications, which intervention should the nurse implement first?

Which assessment is most important for the nurse to perform prior to the application of a heating pad?

While cleansing a client's surgical incision, the nurse observes the incision as seen in the picture. How should the nurse document the appearance of the incision?