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The nursing assessment of an older female elicits information that the client is diagnosed with
raynaud's phenomenon. Which exposure should the nurse instruct the client to avoid?
A) alcohol consumption
B) warm climates
C) cold climates
D) active exercise
ANS: c) cold climates
FEEDBACK: can cause prolonged painful vasoconstriction of the peripheral extremities
(especially hands) in client's with raynaud's phenomenon.
A family member brings their aging father to the clinic because he has been alert and oriented
during the day but agitated and disoriented in the evening. The registered nurse (rn) reviews
the client's list of current medications with the client and family. Which action taken by the rn is
most important?
A) medication review with family caregivers is the pn's responsibility
B) multiple medications can contribute to sundowner like symptoms
C) medication recall is the best way to evaluate the client's memory
D) reviewing medication actions is a component of effective client care
ANS: b) multiple medications can contribute to sundowner like symptoms
, FEEDBACK: older clients may see a variety of healthcare providers which can increase the
change of polypharmacy that compounds the workload of metabolic pathways that may be less
efficient due to the aging process. Multiple medication interactions may contribute to
sundowner like symptoms.
An older client with chronic kidney disease (ckd) has an arteriovenous fistula (av) in the left
forearm for hemodialysis. After palpating the av fistula, which finding is an indication that the av
fistula is functioning properly?
A) enlarged veins
B) redness around the site
C) decreased pulses below the fistula
D) marked ecchymotic areas
ANS: a) enlarged veins
FEEDBACK: the mixing of arterial and venous blood in an av fistula causes the veins to enlarge,
which facilitate cannulation for hemodialysis
The home health registered nurse (rn) is changing an older client's wet to dry dressing. Which
observation should the rn evaluate as a therapeutic response with the removal of the dry
dressing?
A) debridement and removal of slough and eschar
B) drainage of purulent exudate from the wound
C) moist skin edges around the wound field