Which nursing intervention is the most appropriate for managing relocation stress syndrome in an older adult in addition to supportive long-term care facility?

Encouraging the resident to unpack personal belongings and decorate the room with familiar items

Encouraging the resident to avoid social interactions until they feel more comfortable in the new environment

Restricting visitation hours to prevent overwhelming the resident with too much stimulation

Administering sedative medications to promote relaxation and reduce anxiety

Answer and Explanation

The Correct Answer is A

A.   By surrounding themselves with familiar items, such as photos, favorite objects, or comforting decor from their previous home, the resident can feel more at ease and connected to their past. This approach helps in creating a more homelike atmosphere and reducing feelings of disorientation and stress associated with the move.
B.   Isolating the resident and encouraging avoidance of social interactions can exacerbate feelings of loneliness, isolation, and anxiety. Avoiding social interactions may prolong feelings of stress and hinder adaptation to the new living situation.
C.   While it's important to manage the frequency and timing of visits to ensure the resident is not overwhelmed, outright restricting visitation hours can be counterproductive. Restricting visitation could increase feelings of isolation and loneliness, which are already common in new residents of long-term care facilities.
D.   Using sedative medications should be reserved for situations where non-pharmacological interventions have been unsuccessful and the resident's anxiety or distress is severe and persistent. Sedatives can have side effects, especially in older adults, and should not be the first-line approach for managing relocation stress syndrome.

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Correct Answer is D

Explanation

A. Petechiae are tiny, pinpoint, red or purple spots on the skin or mucous membranes, caused by bleeding under the skin. While petechiae can indicate bleeding, they are not specific to HIT and can occur due to various reasons, including low platelet count or coagulation disorders. They do not necessarily indicate thrombotic complications associated with HIT.
B. This hemoglobin level is within the normal range for adults and does not directly correlate with HIT. However, it is important to monitor hemoglobin levels in patients with HIT due to the risk of bleeding and thrombosis.
C. Bleeding gums can occur due to various reasons, including gum disease or thrombocytopenia (low platelet count). In HIT, the concern is not just bleeding but also the paradoxical risk of thrombosis despite low platelet counts. Bleeding from mucosal surfaces can indicate underlying thrombocytopenia but does not specifically highlight the thrombotic risk of HIT.
D. This symptom is concerning for deep vein thrombosis (DVT), which is a thrombotic complication associated with HIT. HIT predisposes patients to thrombosis due to the formation of antibodies against

platelet factor 4/heparin complexes, leading to platelet activation and clot formation. DVT is a serious complication that requires immediate intervention to prevent pulmonary embolism (PE).

A. Treats hyperlipidemia to reduce the risk of new plaques B. Prevents the formation of clots to reduce the risk of stroke C. Prevents vagal stimulation to reduce e risk of dysrhythmias D. Removes excess sodium to reduce the risk of hypertension

Correct Answer is C

Explanation

A. This statement refers to medications like statins (e.g., rosuvastatin, atorvastatin) which are used to lower cholesterol levels and reduce the risk of atherosclerosis progression. Docusate sodium does not treat hyperlipidemia or affect plaque formation directly.
B. This refers to anticoagulant medications (e.g., heparin, warfarin, direct oral anticoagulants) which are used to prevent clot formation and reduce the risk of thromboembolic events such as stroke. Docusate sodium does not have anticoagulant properties.
C. After a myocardial infarction (MI), especially in the early recovery phase, vagal stimulation can exacerbate bradycardia or contribute to dysrhythmias. Stool softeners like docusate sodium help prevent constipation, which can stimulate the vagus nerve during straining, potentially leading to vagally mediated dysrhythmias such as bradycardia or atrioventricular blocks.
D. Diuretics (e.g., furosemide, hydrochlorothiazide) are used to reduce fluid retention and lower blood pressure by increasing urine output. Docusate sodium does not remove excess sodium or affect blood pressure regulation.

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Which nursing intervention is the most appropriate for managing relocation stress syndrome in an older adult in addition to supportive long-term care facility?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has been diagnosed with heparin-induced thrombocytopenia (HIT). Which of the following clinical manifestations should the nurse recognize as the most concerning for a client with this condition?

Correct Answer is D

Explanation

A nurse is discussing the use of docusate sodium (Colace) with a client who is recovering from a non-ST elevation myocardial infarction (NSTEMI). What is the rationale for administering this medication during the recovery from a myocardial infarction?

Correct Answer is C

Explanation

The nurse is performing an admission assessment on a client who is being admitted for right- sided heart failure. Which statement made by the patient would be consistent with right-sided heart failure?

A client who has been diagnosed with chronic stable angina is placed on multiple medications to manage the condition. The nurse understands that the client is receiving rosuvastatin for which reason?

A nurse receives report on a client who is diagnosed with thrombotic thrombocytopenic purpura (TTP). Understanding the complications associated with this condition, which assessment is the priority for the nurse to complete for this client?

A client who is undergoing external beam radiation for prostate cancer has developed desquamation of the skin in the treatment area. Which of the following statements should the nurse plan to include for this patient? (Select all that apply.)

A client in an urgent care clinic is complaining of heart palpitations, fatigue, and shortness of breath. A 12-lead electrocardiogram (ECG) shows no discernable P-waves, and an irregular ventricular rate. The nurse should understand that this finding represents which of the following conditions?

A client presents to the emergency department with complaints of numbness and weakness which began in the feet and has progressed symmetrically in an ascending pattern through the bilateral lower extremities. The nurse understands that this pattern most closely fits which neurological disorder?