When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Speak loudly and face the client.

Provide a very well lit meeting space.

Use everyday language when explaining issues.

Underline key words on the written information.

Answer and Explanation

The Correct Answer is C

A. Speak loudly and face the client:

While it's important for the nurse to speak clearly and ensure the client can see their face, speaking loudly may be perceived as patronizing or disrespectful. Many older adults may have normal hearing but prefer clear and normal volume speech.

B. Provide a very well-lit meeting space:

Ensuring adequate lighting is important for facilitating communication, especially for older adults who may have visual impairments. However, it is not as crucial as using understandable language.

C. Use everyday language when explaining issues:

This is the most important action. Using everyday language, free of medical jargon, ensures that the information is easily understood by older adult clients. Complex medical terms and terminology may be confusing or overwhelming for them, so using plain language enhances comprehension and promotes effective learning.

D. Underline key words on the written information:

This can be a helpful strategy for emphasizing important points in written materials, but it is not as critical as using everyday language when explaining concepts orally. Additionally, not all older adults may benefit from written information, as some may have visual impairments or difficulties reading. Therefore, oral communication in understandable language is paramount.

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Correct Answer is C

Explanation

A. Document the absence of the radial pulse:

While it's important to document findings accurately, it's also crucial to ensure that blood pressure measurements are obtained correctly. If the radial pulse becomes unpalpable before reaching the expected systolic pressure, further action is needed to obtain an accurate measurement.

B. Release the manometer valve immediately:

Releasing the manometer valve immediately would lead to deflating the cuff and potentially missing the opportunity to obtain an accurate blood pressure measurement. This action is not appropriate at this stage.

C. Inflate blood pressure cuff to 120 mm Hg:

When the radial pulse becomes unpalpable during cuff inflation, it indicates that the cuff pressure is above the systolic pressure. To accurately determine the systolic pressure, the cuff should be inflated to a higher pressure (usually 20-30 mm Hg above the point where the radial pulse disappears) and then slowly deflated while palpating for the return of the radial pulse.

D. Record a palpable systolic pressure of 90 mm Hg:

If the radial pulse is no longer palpable at 90 mm Hg, this suggests that the true systolic pressure is higher than 90 mm Hg. Recording a palpable systolic pressure of 90 mm Hg without further action would likely underestimate the true systolic pressure.

A. Encourage the use of incontinence briefs. B. Assist to a bedside commode 30 minutes after meals. C. Administer a glycerin suppository 15 minutes after meals. D. Insert a rectal tube at specified intervals.

Correct Answer is B

Explanation

A. Encourage the use of incontinence briefs:

While incontinence briefs may help contain fecal leakage and protect clothing and bedding, they do not address the underlying issue of fecal incontinence or assist the client in achieving continence. Additionally, relying solely on incontinence briefs may not promote independence or improve the client's quality of life.

B. Assist to a bedside commode 30 minutes after meals:

This is the most appropriate intervention for establishing a bowel training regimen. Timing the use of the bedside commode after meals takes advantage of the gastrocolic reflex, which increases bowel motility after eating. Assisting the client to the commode at specific intervals helps promote regular bowel movements and may decrease the likelihood of fecal incontinence episodes.

C. Administer a glycerin suppository 15 minutes after meals:

While glycerin suppositories can stimulate bowel movements, they are typically used for acute constipation rather than chronic fecal incontinence. Additionally, using suppositories does not address the client's emotional distress or help establish a bowel training regimen focused on promoting continence.

D. Insert a rectal tube at specified intervals:

Rectal tubes are not typically used as a first-line intervention for bowel training in clients with fecal incontinence. They may be indicated in certain situations, such as severe impaction or when other interventions have failed, but they are not appropriate for all clients and may cause discomfort and complications.

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When providing health teaching to older adult clients, which action is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is obtaining a systolic blood pressure by palpation. While inflating the cuff, the radial pulse is no longer palpable at 90 mm Hg. Which action should the nurse take?

Correct Answer is C

Explanation

A client with chronic fecal Incontinence is crying because of being embarrassed for not getting to the bathroom in time to avoid soiling the bed and clothing. When establishing a bowel training regimen, which Intervention should the nurse Implement?

Correct Answer is B

Explanation

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