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A nurse is assessing an older adult client. Which of the following statements indicates that the client is at a risk for being socially isolated?

A.

"People have to speak louder for me to hear when they visit."

B.

"I only babysit my grandchildren twice each month."

C.

"My hearing aid is lost, so I don't go to church like I used to do."

D.

"My adult child takes me to the grocery store every other week."

Answer and Explanation

The Correct Answer is C

A. Hearing difficulties can be a challenge but do not necessarily indicate social isolation unless they lead to withdrawal from activities.
B. Babysitting twice a month still allows for social interaction and does not suggest isolation.
C. Not attending church due to a lost hearing aid suggests withdrawal from social activities, which increases the risk of social isolation.
D. Having a family member assist with grocery shopping indicates some level of social interaction and support, reducing the risk of isolation.


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Related Questions

Correct Answer is D

Explanation

A. Strain the client's urine. This is incorrect because straining urine is necessary for clients with radioactive seeds placed in the bladder, but not for prostate cancer brachytherapy, where the seeds typically remain in place.
B. Limit each of the client's visitors to 2 hr per day. This is incorrect because visitors should be limited to short durations, but the exact time is typically restricted to 30 minutes per visit rather than a total of 2 hours per day.
C. Attach a dosimeter to the client's gown. This is incorrect because a dosimeter should be worn by healthcare staff, not attached to the client. It helps monitor radiation exposure for staff members.
D. Instruct visitors to stay 1 m (3.3 feet) away from the client. This is correct because maintaining a safe distance from the client helps minimize radiation exposure for visitors. Visitors should also limit their time near the client and avoid close contact.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Anticipated Interventions:

  • Initiate an IV infusion of lactated Ringer's
  • Place the client in a left lateral position
  • Maintain continuous monitoring of the FHR

Contraindicated Intervention:

  • Monitor blood pressure every hour

Rationale:

  • Initiate an IV infusion of lactated Ringer’s: Hydration is important for labor progression and maternal hemodynamic stability, especially considering the client has a history of chronic hypertension and gestational diabetes.
  • Place the client in a left lateral position: This improves uteroplacental perfusion, helping to optimize fetal oxygenation.
  • Maintain continuous monitoring of the FHR: The presence of meconium-stained amniotic fluid and an elevated FHR (165/min) suggests potential fetal distress, warranting continuous fetal monitoring.
  • Monitor blood pressure every hour (Contraindicated): The client has chronic hypertension and gestational diabetes, both of which increase the risk for complications like preeclampsia and fetal distress. More frequent BP monitoring (e.g., every 15-30 minutes) is necessary to detect any abnormalities early.

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