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A maleclientis seenin theclinic for benignprostatichypertrophy(BPH). Which interventionis essential for the
practical nurse (PN) to include in the client's visit?
a. Reeducatetheclientaboutlimiting fluid intake.
b. Reassuretheclientthathis BPH is a non-life-threateningcondition.
c. Assesstheclientfor urinary hesitancyand weakor split urinarystream.
d. Inform theclientthattheremay bea geneticpredispositionfor malefamilymembers.-
ANSWER ****c. Assesstheclientfor urinaryhesitancyand weakor split urinarystream.
These symptoms may indicate progression of BPH to partial obstruction
of the urethra, a medicalemergency,and
needto bereportedto thehealthcareprovider.Fluids shouldbeencouraged,not limited; hydration needs to be
maintained.
An older adult client has been diagnosed with third
-degree heart block and the health care provider recommends
a pacemakerbeimplantedtomorrow.Prior to thesurgery,thenurseexpectstheclient's plan of care to emphasize
which aspect?
a. Instructionto avoidmicrowaves
b. Preparingfor bloodtransfusion
c. Administrationof anticoagulants
d. Preventinginjury relatedto falling - ANSWER ****d. Preventinginjury relatedto falling
A client with a dysrhythmia is at risk for fall injury due to syncope caused by a reduction in output.
cardiacThe
client'splan of careshouldemphasizewaysto keeptheclientsafe,such as assistingtheclientwith ambulation.The
clientwill not needto avoidmicrowavesand bloodtransfusionsarenot
commonwithpacemakerinsertion.Anticoagulantsarenotnecessarilyassociatedwithpacemaker
insertionor with third-degreeheartblock.
The hospitalizedclientwith end-stagerenaldiseasehasexpressedverbaland writtenwishesnot to be resuscitated.
Which action should the practical nurse (PN) take?
a. Bring thecrashcartinto theroom.
b. Ask theclientto validateend-of-life wishes.
c. Keep theclientas comfortableas possible.
,d. Ask thefamily if theywanttheclientresuscitated.- ANSWER ****c. Keeptheclientas comfortable as
possible.
Clients havetheright to makedecisionsregardingtheircare,up to and including resuscitativemeasures. The
practical PN must respect the client's wishes by keeping him comfortable.
An olderadulthasundergonea prostatectomydueto prostatecancer.He asksthenurse"Will the
operationchangemy lovelife? I am widowed,butI havebeendatingsomeoneseriously."How should the nurse
respond to this question?
a. "Your newfriendwill likely not beinterestedin a sexualrelationship."
b. "Whatconcernsdo you haveaboutsexualityin your newrelationship?"
c. "You shouldwaituntil afteryou havehealedto think aboutyour relationship."
d. "You shouldhaveaskedyour familytheiropinionaboutdatingsomeonenew."- ANSWER ****b. "What
concerns do you have about sexuality in your new relationship?"
Using thestepsof thenursingprocess,and thekeysto effectivecommunication,usedatacollectionto determine
the client'sconcernsfirst. It is ageistto statethattheolderadultis not interestedin sexualrelations.Telling the
clientnot to thinkabouthis newrelationshipis inappropriate,becausetheclient
voiceda concernthatshouldbeaddressed.It is inappropriateto discussthefamily'sconcernswhenthe
clienthasnot mentionedthem .
An older adult client has bruises resembling handprints encircling both arms, but claims this injury was sustained
whensheslippedin water.The nursealsonotestheclientbecomesverywithdrawnwhenthe son visits, and that
the client is emaciated. Which action is most appropriate?
a. Contactthelocallawenforcementagency.
b. Ask theson if he wastheonewho injuredhis mother.
c. Ask theclientwhy sheis attemptingto coverfor her son.
d. Ask theolderadultif sheis willing to presschargesagainsttheson. - ANSWER ****a. Contactthe local
law enforcement agency.
These findings correlate with elder abuse and neglect. The nurse is legally obliged to report allsuspected
cases of
elderabuseto theappropriatelaw enforcementagency.It is not appropriatefor thenurseto confront the son.
,Older adults may "cover for" their abuser due to fear of abandonment or reprisal. In
, many areas,theolderadultdoesnot haveto presschargesagainsttheabuser,chargesarefiledagainstthe abuser
by the state.
The practicalnurse(PN) deliversa foodtrayto an olderadultJewishpersonwhohasrequesteda kosher diet. The
PN checks the tray and notes that it contains bacon, eggs, toast, oatmeal, and coffee. Which action should the PN
take?
a. Deliver thetrayto theclient.
b. Ask theclientif he wantsthis tray.
c. Call thedietarydepartmentand requesta newtray.
d. Removethebaconand thendeliverthetray to theclient.- ANSWER ****c. Call thedietary
department and request a new tray.
Pork is prohibitedin a kosherdiet.The practicalnurse(PN) shouldrequesta newtraythatfollowskosher dietary
guidelines for the client. Simply removing the bacon is not satisfactory, as thecould
baconhavecome into contact
with other items on the tray.
The nurseis assistingwithplanningcarefor a groupof olderadultclientswhoareinterestedin disease prevention
with immunizations. Which advice is best for the nurse to provide to this group?
a. Makesureyou gettheinfluenzavaccineeveryyear.
b. Makesureyou getthepneumoniavaccineeveryyear.
c. Makesureyou getthetetanus/diphtheria/pertussis
vaccineeveryyear.
d. If you did not getchickenpox as a child, gettheshinglesvaccineeveryyear.- ANSWER ****a. Make sure
you get the influenza vaccine every year.
All adults,butespeciallyolderadults,needan influenzavaccine(flu shot)yearly.The othervaccinesare
importantfor olderadults,butarenot requiredyearly.
An olderclientwhoresidesin a long-termcarefacilityis hearing-impaired.How shouldthepractical nurse (PN)
modify interventions for this client?
a. Turn off theclient'stelevisionand speakveryloudly.
b. Communicatein writingwheneverit is possible.
c. Speakveryslowlywhileexaggeratingeachword.
d. Facetheclientand speakin a normaltoneof voice.- ANSWER ****d. Facetheclientand speakin a normal
tone of voice.