Nursing Elites

1. Which of these nursing diagnoses of 4 elderly clients would place 1 client at the greatest risk for falls?

• A. Sensory perceptual alterations related to decreased vision
• B. Alteration in mobility related to fatigue
• C. Impaired gas exchange related to retained secretions
• D. Altered patterns of urinary elimination related to nocturia

Correct answer: D

Rationale: The correct answer is D: Altered patterns of urinary elimination related to nocturia. Nocturia increases the risk of falls in elderly clients due to frequent nighttime trips to the bathroom. Choice A is incorrect because while decreased vision can contribute to falls, nocturia poses a more direct risk. Choice B is incorrect as fatigue may affect mobility but is not as directly linked to falls as nocturia. Choice C is incorrect as impaired gas exchange is not typically associated with an increased risk of falls.

2. A client is recovering from a hip replacement and is taking Tylenol #3 every 3 hours for pain. In checking the client, which finding suggests a side effect of the analgesic?

• A. Bruising at the operative site
• B. Elevated heart rate
• C. Decreased platelet count
• D. No bowel movement for 3 days

Correct answer: D

Rationale: The correct answer is D. Constipation is a common side effect of Tylenol #3, which contains codeine. Codeine can slow down bowel movements, leading to constipation. Monitoring for constipation and implementing management strategies is crucial. Choices A, B, and C are incorrect because bruising at the operative site, elevated heart rate, and decreased platelet count are not commonly associated side effects of Tylenol #3.

3. The nurse is about to assess a 6-month-old child with nonorganic failure-to-thrive (NOFTT). Upon entering the room, the nurse would expect the baby to be

• A. Irritable and 'colicky' with no attempts to pull to standing
• B. Alert, laughing, and playing with a rattle, sitting with support
• C. Skin color dusky with poor skin turgor over the abdomen
• D. Pale, thin arms and legs, uninterested in surroundings

Correct answer: D

Rationale: A baby with nonorganic failure-to-thrive often appears pale, thin, and uninterested in their surroundings. Choice A is incorrect as 'irritable and colicky with no attempts to pull to standing' is more indicative of other conditions like colic. Choice B is incorrect as a baby with nonorganic failure-to-thrive is unlikely to be alert, laughing, and playing, as they would typically present with signs of failure to thrive. Choice C is incorrect as dusky skin color and poor skin turgor are not typical findings in a baby with nonorganic failure-to-thrive.

4. What should a client with diarrhea avoid consuming?

• A. Orange juice
• B. Tuna
• C. Eggs
• D. Macaroni

Correct answer: A

Rationale: A client with diarrhea should avoid consuming orange juice. Orange juice is high in sugar content, which can worsen diarrhea symptoms by drawing water into the intestines, potentially leading to further dehydration and discomfort. Tuna, eggs, and macaroni are generally well-tolerated and do not exacerbate diarrhea symptoms, making them more suitable food choices for individuals experiencing diarrhea.

5. The nurse is teaching an 87-year-old client methods for maintaining regular bowel movements. The nurse would caution the client to AVOID

• A. Glycerin suppositories
• B. Fiber supplements
• C. Laxatives
• D. Stool softeners

Correct answer: C

Rationale: The correct answer is C: Laxatives. Laxatives can be harsh on elderly clients, leading to dependence and potential side effects. While fiber supplements (B) and stool softeners (D) are generally safe options to promote regular bowel movements, laxatives should be used cautiously in older adults due to their potential risks. Glycerin suppositories (A) can also be a safe and effective option for managing constipation in the elderly, but laxatives should be avoided unless deemed necessary by a healthcare provider.

Similar Questions