A nurse is caring for an older adult client who is postoperative following a total hip arthroplasty. The nurse is preparing to change the client's surgical dressing. Which of the following actions should the nurse take to demonstrate sensitivity to age-related changes?
Ask the client to help with the dressing change
Wait for the client to approach the nurse for assistance
Use paper tape for securing the new dressing
Apply the dressing loosely over the incision
The Correct Answer is D
d. Apply the dressing loosely over the incision.
Explanation:
The correct answer is d. Apply the dressing loosely over the incision.
When caring for an older adult client, it is important for the nurse to be sensitive to age-related changes and promote their comfort and well-being. Applying the dressing loosely over the incision allows for beter circulation and ventilation, which can help prevent complications such as skin breakdown and infection.
Option a is not the correct answer. Asking the client to help with the dressing change may not be appropriate, as postoperative clients, especially older adults, may have limited mobility or dexterity. It is the nurse's responsibility to provide the necessary care and support during the dressing change.
Option b is not the correct answer. Waiting for the client to approach the nurse for assistance may lead to delays in care and could potentially compromise the client's healing process. The nurse should proactively assess the client's needs and provide appropriate care.
Option c is not the correct answer. Using paper tape for securing the new dressing does not specifically address sensitivity to age-related changes. While paper tape may be gentle on the skin, it is not the primary consideration in this situation.
By applying the dressing loosely over the incision, the nurse demonstrates sensitivity to age-related changes and promotes the client's comfort and optimal healing. This approach takes into account the potential for decreased skin elasticity and fragility in older adults, allowing for proper circulation and reducing the risk of complications.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
a. "Many people have colostomies and they live full lives."
Explanation:
The correct answer is a. "Many people have colostomies and they live full lives."
When a client expresses concerns or distress regarding their colostomy and not wanting others to see the colostomy bag, it is essential for the nurse to provide support and reassurance. Responding by acknowledging that many people live full lives with colostomies helps normalize the experience and offers hope to the client.
Option b, "Would it help to speak to someone else who has a colostomy?" may be a helpful suggestion, but it should not be the initial response. First, it is important to provide immediate reassurance and support to the client before exploring additional resources or contacts.
Option c, "Why don't you want people to see the colostomy bag?" may be seen as invasive and may put the client on the spot, potentially making them feel uncomfortable or defensive. It is important to create a safe and non-judgmental environment for the client.
Option d, "The colostomy is probably only temporary," assumes information about the client's specific situation that may not be accurate. It is important to avoid making assumptions about the duration or permanence of the colostomy unless the client has shared that information. Providing false reassurances can negatively impact the client's trust and emotional well-being.
By responding with the statement that many people live full lives with colostomies, the nurse offers support, normalizes the client's experience, and promotes a positive outlook for the client's future.
Correct Answer is C
Explanation
c. Periorbital edema.
Explanation: Acute glomerulonephritis is an inflammatory condition affecting the glomeruli of the kidneys. It is commonly characterized by periorbital edema, which is swelling around the eyes. This occurs due to fluid retention and impaired kidney function. Other common manifestations of acute glomerulonephritis include hypertension (increased blood pressure), dark or tea-colored urine (hematuria), decreased urine output, and signs of fluid overload such as edema in the hands, feet, and face.
Option a, decreased blood pressure, is not typically seen in acute glomerulonephritis. Instead, hypertension is a common finding due to fluid retention and increased blood volume.
Option b, pale yellow urine, is not expected in acute glomerulonephritis. Instead, urine may appear dark or
tea-colored due to the presence of blood (hematuria).
Option d, increased urination, is not a characteristic finding in acute glomerulonephritis. Instead, there is often a decrease in urine output or oliguria.
It is important to note that individual presentations may vary, and the nurse should consider the complete clinical picture and the child's specific symptoms when assessing for acute glomerulonephritis.
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