Correct Answer: D

Rationale: The correct answer is D, EKG and serial enzymes for determination of an MI. In this scenario, the patient's symptoms of nausea and sudden onset shortness of breath raise concern for a possible myocardial infarction (MI). Conducting an EKG and serial enzymes helps in diagnosing an MI by assessing for cardiac ischemia or injury. Upper endoscopy (choice
A) is not indicated for these symptoms. A CT of the head (choice
B) is unnecessary as the symptoms are suggestive of a cardiac issue, not a neurological one. Liver function studies (choice
C) do not align with the presenting symptoms and are not a priority in this acute setting. Conducting an EKG and serial enzymes is the most appropriate initial workup to assess for a possible MI in this elderly patient with concerning symptoms.

Correct Answer: C

Rationale: The correct answer is C: Urinary tract infections (UTIs). UTIs are a common cause of delirium in hospitalized older adults due to their impact on the central nervous system. UTIs can lead to systemic inflammation and affect cognitive function, resulting in delirium. Other choices like medication side effects, sleep deprivation, and electrolyte imbalances can contribute to delirium but are not as common or direct as UTIs in this population.

Correct Answer: A

Rationale: The correct answer is A because a high-intensity lamp can provide better lighting for reading, addressing the difficulty the patient experiences in the evening. This intervention can improve visibility and reduce strain on the eyes. Option B is incorrect as arcus senilis is a common age-related condition but not a direct cause of difficulty reading. Option C is incorrect as simply increasing the power of fluorescent lights may not address specific visual needs for reading. Option D is incorrect as examining the retinas may not directly address the patient's difficulty in reading and is not the most appropriate initial intervention.

Correct Answer: A

Rationale: The correct answer is A: Regular repositioning every 2 hours. Repositioning helps to relieve pressure on vulnerable areas, improving blood flow and preventing tissue damage. This intervention is evidence-based and recommended in pressure ulcer prevention guidelines. Administering pain medications before repositioning (
B) does not address the root cause of pressure ulcers. Encouraging excessive hydration (
C) may have other health benefits but does not directly prevent pressure ulcers. Using restrictive bandages (
D) can actually increase pressure and worsen the risk of pressure ulcers.

Correct Answer: D

Rationale: The correct answer is D because promoting independence without assistance to all clients may not always maintain safety for the elderly. Elderly individuals may require some level of assistance for certain activities to prevent falls or other safety risks. Providing assistance when needed is crucial for ensuring their safety.

A: Modifying the environment to reduce obstacles and barriers to ambulation helps prevent falls.
B: Consistent checks of ambulation abilities ensure early detection of any decline in mobility.
C: Orienting to new surroundings and repeating as needed helps prevent confusion and disorientation.