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. Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B. While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C. This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D. While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

A. Apply a debriding agent. B. Apply steri-strips. C. Obtain a wound culture. D. Remove every other suture.

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.

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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 nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Correct Answer is C

Explanation

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

After an IV antibiotic is started, the nurse determines that the medication is not prescribed for the client and stops the infusion. Which action should the nurse implement next?

Prior to receiving a 120 mL hypertonic enema, an ambulatory female client tells the nurse that she does not believe that she can walk all the way to the bathroom without expelling the enema. Which intervention is best for the nurse to implement?

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?

Which breakfast selection indicates that the client understands the nurse's instructions about the dietary management of osteoporosis?

While changing the dressing of a client who is immobile, the nurse observes a red and swollen wound with a moderate amount of yellow and green drainage and a foul odor. Before reporting this finding to the healthcare provider, the nurse should note which of the client's laboratory values?

The nurse finds a confused client wandering in the hallway during the night. Which actions should the nurse implement? Select all that apply.