A nurse is evaluating an older adult client who expresses concern about the aging process. Which of the following statements made by the client indicates a need for follow-up?
"I do my best to protect my skin from bumps and cuts. It's more fragile now."
"I guess feeling down is just part of aging."
"My hair is thinning. I'm going to go to the wig shop soon."
"I missed my eye appointment, but I rescheduled it."
The Correct Answer is B
Choice A reason: The client's effort to protect their skin due to increased fragility is a normal part of the aging process. As the skin ages, it becomes thinner and less elastic, making it more susceptible to injuries. The client's proactive approach to skin care is appropriate and does not indicate a need for follow-up.
Choice B reason: The statement "I guess feeling down is just part of aging" suggests a possible misconception about mental health and aging. While it's true that older adults may face various challenges that can affect their mood, persistent feelings of sadness or depression are not a normal part of aging and should be addressed. Mental health is as important as physical health, and feeling down can be a sign of depression, which is treatable at any age.
Choice C reason: Concerns about changes in appearance, such as hair thinning, are common as people age. The client's plan to visit a wig shop indicates they are taking steps to manage these changes and maintain their self-esteem. This does not necessarily indicate a need for follow-up unless the hair loss is sudden or accompanied by other symptoms that could suggest an underlying health issue.
Choice D reason: Missing an appointment but taking the initiative to reschedule shows that the client is actively managing their health care. Regular eye exams are important for older adults as they can help detect vision changes and conditions like glaucoma or cataracts early on. This behavior is responsible and does not indicate a need for follow-up.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason: Advising the client to avoid carbohydrates after exercise is not appropriate. Carbohydrates are necessary to replenish glycogen stores after exercise, and individuals with diabetes need to monitor their blood sugar levels to manage carbohydrate intake accordingly.
Choice B reason: Saying it is normal to feel exhausted after a morning run does not address the client's symptoms of diaphoresis, increased heart rate, and palpitations, which could be signs of hypoglycemia, a common risk for individuals with type 1 diabetes after exercise.
Choice C reason: While it's true that exercise can become easier with routine, this statement does not address the client's immediate concerns about their symptoms following exercise.
Choice D reason: Asking if the client decreased their insulin intake before exercising is an appropriate response. Individuals with type 1 diabetes need to adjust their insulin dosage to account for physical activity, which can significantly lower blood glucose levels.
Correct Answer is C
Explanation
Choice A reason: Irrigating the affected eye from the inner corner toward the outer corner is the recommended method for ocular irrigation. This technique helps to flush out the chemical agent without risking further contamination to the other eye or nasal passages.
Choice B reason: Positioning the client sitting up with their head turned toward the right side is appropriate when irrigating the left eye. This position allows gravity to assist in the flow of the irrigation solution away from the unaffected eye, reducing the risk of cross-contamination.
Choice C reason: Placing a strip of pH paper under the upper lid of the affected eye is a critical step in ocular irrigation after a chemical splash. It is used to measure the pH of the ocular surface to ensure that the pH has normalized to a range between 7.0 and 7.2 after irrigation, indicating that the chemical has been adequately flushed out.
Choice D reason: Using sterile water for ocular irrigation is not recommended because it can cause osmotic imbalances and damage to the corneal cells. Instead, normal saline or balanced salt solutions are preferred as they are isotonic and more compatible with the physiological environment of the eye.
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