Lagniappe
The nurse cautions that although activity and exercise during the day are an effective sleep aid, activity and exercise should be avoided within _____ before bedtime.
2 hours
When planning care for a client at risk for pressure sores, the nurse recognizes that the most important nursing responsibility is:
Prevention
The nurse tells the older adult that a food with the double action of providing fiber and being a natural laxative is:
Prunes
The admitting nurse gives the new long-term care facility patient an assessment that utilizes both the Norton Risk Assessment Scale and the Braden Scale for Predicting Pressure Sore Risk. These scores indicates the resident’s risk for:
Developing a pressure ulcer
The nurse uses special caution when performing a rectal digital examination on a patient with:
Cardiac disease
When brushing the teeth of an unconscious client, the most appropriate position is:
Side lying
The nurse explains that older adults often experience a disturbed sleep-wake cycle because of hormonal changes, which include a(n) _____ level.
Decrease in melatonin
When the patient tells the home health nurse that he has begun to take psyllium (Metamucil), the nurse cautions him that to avoid fecal impaction with this drug, he should:
Increase his fluid intake
In which pressure ulcer stage is the patient likely to feel no pain?
Stage IV
The nurse would be especially observant for the indication of constipation in the patient who is taking what medication?
Iron supplements
The nurse plans to help reduce episodes of bowel incontinence by a proactive program of:
establishing a toileting schedule
When the older adult complains of the bruises on his extremities, the nurse explains that these colorful marks of increasing age are the result of:
Fragility of capillary walls
A common sign of fecal impaction may include:
Oozing of small amounts of liquid stool
To prevent pressure ulcers in the bedridden patient, the most effective intervention would be to:
Change the patient’s position every 2 hours
When the male patient who has been on long-term antibiotic therapy inquires what may have caused his thrush, the nurse’s most informative response would be that the yeast infection occurred because:
Long-term antibiotic therapy has destroyed the normal flora of his mouth
The home health nurse suggests that the patient perform a frequent series of Kegel exercises to reduce incontinence by:
Strengthening the pelvic floor muscles and urinary sphincter
The nurse clarifies that the continuous positive airway pressure (CPAP) machine decreases the incidence of episodes of sleep apnea by:
Keeping alveoli from collapsing
When mobility decreases with age, elderly patients often display signs and symptoms of:
Isolation
To reduce pressure ulcers in a bedridden patient, the nurse places the patient in what position?.
In a 30 degree lateral position, with body rotated 30 degrees with gluteus bearing the weight
Which of the following would be considered a risk factor for Deficient Fluid Volume?
Diuretic meds or Diarrhea or Vomiting
The phenomenon of sleep walking is most likely to occur in the sleep stage of:
Stage 4 NREM
Activity, performed regularly, has several benefits for older adults. Psychological benefits include:
Improved self-esteem
Functional incontinence in older adults may be due to a poor relationship with:
The environment
Of the following, which is the earliest sign indicating a risk for skin breakdown on the patient’s skin?
Very pale or reddened area of skin
While in the supine position for a bed bath, an elderly client c/o SOB. The best FIRST action is to:
Raise HOB