Which nonpharmacologic pain treatment should the nurse avoid using in an older adult who shows signs of confusion?

Music

Aromatherapy

Heat application

Distraction

Guided Imagery

Answer and Explanation

The Correct Answer is E

A. Music can be a soothing nonpharmacologic method to reduce pain and may help with relaxation, even for confused patients, as it typically doesn’t require cognitive engagement.
B. Aromatherapy is generally safe and may offer calming effects for older adults without relying heavily on cognitive processing.
C. Heat application is a physical pain relief method, and as long as safety precautions are taken, it can be used effectively in confused patients.
D. Distraction can be a beneficial technique for pain relief and is often effective without requiring cognitive engagement.
E. Guided Imagery should be avoided in confused older adults, as it relies on the patient's ability to follow instructions and visualize mental images, which can be challenging and potentially frustrating for someone with cognitive impairment.

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Correct Answer is C

Explanation

A. A respiratory rate of 20 is within the normal range for adults (12-20 breaths per minute), especially in someone experiencing dyspnea.
B. Vesicular sounds in the lung periphery are normal findings, particularly in healthy lung areas.
C. A capillary refill time of 5 seconds indicates poor perfusion and could suggest systemic issues or hypoxia, which is concerning in a patient with dyspnea.
D. An anteroposterior (AP) diameter of 1:2 is normal; a barrel chest might indicate chronic respiratory conditions but is not an immediate concern in this context.
E. Equal chest expansion is a normal finding and indicates effective respiratory mechanics.

A. Edema B. Shortness of breath C. Increase in appetite D. Extreme weight loss E. Jugular vein distended (enlarged)

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

Explanation

A. Edema is a common finding in heart failure due to fluid retention.
B. Shortness of breath occurs due to fluid accumulation in the lungs, common in heart failure.
C. Increased appetite is not typical in heart failure; decreased appetite is more common.
D. Weight gain due to fluid retention is more common in heart failure, rather than extreme weight loss.
E. Jugular vein distention is a classic sign of right-sided heart failure due to increased central venous pressure.

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Which nonpharmacologic pain treatment should the nurse avoid using in an older adult who shows signs of confusion?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is on the medical/surgical floor is getting a new admission. The client is being admitted for shortness of breath (dyspnea). Which assessment finding would be of concern?

Correct Answer is C

Explanation

The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

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

Explanation

The nurse wants to prevent venous thrombus (DVT) formation in a client after surgery. What action should the nurse delegate to the certified nursing assistant/patient care assistant to help prevent DVT formation in the client?

The nurse is reviewing the risk factors for a blood clot in a vein. Which of these situations can put a client at higher risk for developing a blood clot in a vein? Select all that apply.

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The nurse is asked to describe what the heart sound S1 represents. What would be the correct response by the nurse?

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When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?

Which statement by the nurse indicates the correct order of steps to take when performing a focused assessment of the respiratory system?