The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

The consistency of the prescribed diet.

Review of current medications.

Client's ability to chew and swallow.

The client's respiratory rate and lung sounds.

Answer and Explanation

The Correct Answer is C

A.   Knowing the consistency of the prescribed diet (e.g., pureed, mechanical soft, or regular) is important for planning the feeding process and ensuring that the diet meets the client's needs and restrictions. However, this information is secondary to assessing the client’s ability to safely chew and swallow.
B.   While reviewing current medications is important for understanding potential drug interactions, side effects, or dietary restrictions, it is not the most immediate concern before feeding. Medications can influence appetite and digestion, but the priority is ensuring the client can safely handle the food.
C.   This is the most critical information to obtain before feeding a debilitated client. Assessing the client's ability to chew and swallow helps prevent complications such as aspiration, choking, or aspiration pneumonia. The nurse should ensure that the client can safely manage the food given to them and that their swallowing mechanisms are functioning adequately.
D.   While monitoring the respiratory rate and lung sounds is important for overall health assessment, it is not the immediate priority before starting a feeding session. However, it is important to monitor for signs of aspiration during and after feeding, as compromised swallowing can lead to aspiration pneumonia.

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Correct Answer is B

Explanation

A. This option does not correspond to one of Erik Erikson's stages. Erikson's theory includes eight stages of psychosocial development, and this specific stage is not part of his framework. While depression is a relevant concern in older adults, the correct terminology and stage must be identified based on Erikson’s theory.
B. This is Erikson's eighth and final stage of psychosocial development, typically occurring in late adulthood. In this stage, individuals reflect on their lives and either achieve a sense of integrity and fulfillment or experience despair and regret. The behaviors of withdrawing from friends, crying often, and seeking increased contact with family members are consistent with feelings of despair, as individuals may struggle with reflecting on their lives and their sense of accomplishment.
C. This is Erikson's sixth stage, which occurs during young adulthood (approximately ages 18 to 40). In this stage, individuals focus on forming intimate relationships and avoiding isolation. The behaviors described are more characteristic of older adulthood rather than young adulthood, so this stage is not applicable to the client's situation.
D. This is Erikson's first stage, occurring in infancy (from birth to about 18 months). During this stage, the primary task is developing trust in caregivers and the environment. The client’s behaviors are not related to the issues of trust or mistrust from early childhood but rather reflect challenges faced in older adulthood.

A. Measure body temperature. B. Administer PRN oxygen. C. Send for chest x-ray. D. Obtain sputum for culture.

Correct Answer is B

Explanation

A. Measuring body temperature is important in assessing the client’s overall condition and identifying a fever, which is common in pneumonia. However, while it provides useful information about the client's status, it is not the most urgent action compared to interventions that could immediately impact the client’s respiratory function or confirm the diagnosis.
B. Administering PRN (as needed) oxygen is crucial if the client shows signs of hypoxia or difficulty breathing. If the client's face appears cyanotic or if they are experiencing respiratory distress, this action should be prioritized to ensure adequate oxygenation.
C. A chest x-ray is essential for diagnosing pneumonia and assessing the extent of lung involvement. However, while it is critical for diagnosis, addressing immediate respiratory needs and symptoms takes precedence.
D. Obtaining sputum for culture is important for identifying the causative organism and guiding antibiotic therapy. However, this action is less urgent than ensuring the client’s immediate respiratory needs are met and confirming the diagnosis through imaging.

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The nurse is preparing to feed a newly admitted older adult client who is debilitated, but is able to respond to most commands. Before starting to feed the client, which information is most important for the nurse to obtain?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A client is admitted with possible pneumonia. When entering the room, the nurse observes the client's face as seen in the picture. Which prescription should the nurse implement first?

Correct Answer is B

Explanation

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