A nurse is providing teaching to an older adult client who has kyphosis and osteoporosis. Which of the following client statements indicates an understanding of the teaching?

"I will increase daily intake of calcium and vitamin D.".

"I will schedule an electrophysiologic study.".

"I should wear a neck brace while sleeping to prevent injury.".

"I should avoid weight-bearing exercise to minimize trauma.".

Answer and Explanation

The Correct Answer is A

Choice A rationale:

The client's statement about increasing daily intake of calcium and vitamin D indicates an understanding of the teaching related to kyphosis and osteoporosis. Kyphosis is a condition where there is an abnormal curvature of the spine, leading to a hunched-back appearance, and osteoporosis is a condition characterized by weakened bones. Calcium and vitamin D are essential nutrients for maintaining bone health. Calcium is a mineral that is a major component of bones, and vitamin D helps the body absorb calcium from the diet. Adequate intake of these nutrients is crucial for preventing further bone loss and fractures in individuals with kyphosis and osteoporosis.

Choice B rationale:

The client's statement about scheduling an electrophysiologic study is unrelated to the teaching about kyphosis and osteoporosis. Electrophysiologic studies are used to evaluate the electrical activity of the heart, and they are not directly relevant to the client's bone health or the management of kyphosis and osteoporosis.

Choice C rationale:

The client's statement about wearing a neck brace while sleeping to prevent injury is incorrect and indicates a misunderstanding of the teaching. Kyphosis primarily affects the thoracic (upper/mid-back) spine and is not typically associated with wearing a neck brace. Neck braces are more commonly used for cervical spine issues.

Choice D rationale:

The client's statement about avoiding weight-bearing exercise to minimize trauma is incorrect and demonstrates a misunderstanding of the teaching. Weight-bearing exercise, such as walking and strength training, is important for maintaining bone density and muscle strength, which are critical for individuals with kyphosis and osteoporosis. Avoiding weight-bearing exercise could actually lead to further bone loss and weakness.

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Correct Answer is A

Explanation

Choice A rationale:

Unclamping the client's gastrostomy tube before connecting the syringe is the correct action. This allows the feeding to flow freely into the stomach. Clamping the tube while administering the feeding would prevent the formula from entering the stomach properly.

Choice B rationale:

Verifying the client's gastric pH to be at least 7 prior to feeding is not necessary for administering intermittent enteral feedings. Gastric pH varies widely among individuals and is not a standard requirement before every feeding.

Choice C rationale:

Pouring the client's formula into the syringe and adjusting the syringe's height to control the rate of flow is not recommended. Controlling the rate of flow in this manner is imprecise and can lead to inconsistent delivery of the formula, potentially causing discomfort or complications.

Choice D rationale:

Applying sterile gloves before accessing the client's gastrostomy tube is an important step in infection control, but it is not specifically related to administering intermittent enteral feedings. Sterile gloves are essential to prevent contamination and infection during tube maintenance and insertion, not during the feeding process itself.

A. A client who needs assistance when ambulating. B. A client who consistently has difficulty using utensils while eating. C. A client who has expressive aphasia. D. A client who consistently coughs after drinking liquids.

Correct Answer is D

Explanation

The correct answer is Choice D.

Choice A rationale: Ambulation assistance is expected in rehabilitation. It reflects motor recovery needs but does not pose an immediate safety or health risk requiring urgent referral.

Choice B rationale: Difficulty using utensils indicates fine motor deficits. While important for occupational therapy, it’s not a priority compared to airway protection concerns.

Choice C rationale: Expressive aphasia affects communication but does not compromise physical safety or airway integrity. Speech therapy is appropriate but not urgent.

Choice D rationale: Coughing after drinking signals aspiration risk. This can lead to pneumonia or airway obstruction, requiring immediate referral to speech-language pathology for swallow evaluation.

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A nurse is providing teaching to an older adult client who has kyphosis and osteoporosis. Which of the following client statements indicates an understanding of the teaching?

Nursing Test Bank

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Correct Answer is A

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Correct Answer is D

Explanation

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