An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?

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Question 1 of 5

An 80 year-old nursing home resident has a temperature of 101.6 degrees Fahrenheit rectally. This is a sudden change in an otherwise healthy client. Which should the nurse assess first?

Correct Answer: C

Rationale: Sudden fever in the elderly can indicate delirium; assessing alertness first evaluates for acute neurological changes.

Question 2 of 5

The nurse is providing diet instruction to the parents of a child with cystic fibrosis. The nurse would emphasize that the diet should be high

Correct Answer: C

Rationale: CF requires high-calorie, high-protein diets with unrestricted fat to offset malabsorption.

Question 3 of 5

In order to be effective in administering cardiopulmonary resuscitation to a 5 year-old, the nurse must

Correct Answer: B

Rationale: For a 5-year-old, 1 breath every 5 compressions (30:2 ratio) aligns with pediatric CPR guidelines.

Question 4 of 5

The nurse notes an abrupt onset of confusion in an elderly patient. Which of the following recently-ordered medications would most likely contribute to this change?

Correct Answer: C

Rationale: Antihistamines often cause confusion in the elderly due to anticholinergic effects.

Question 5 of 5

A parent tells the nurse that their 6 year-old child who normally enjoys school, has not been doing well since the grandmother died 2 months ago. Which statement most accurately describes thoughts on death and dying at this age?

Correct Answer: B

Rationale: By age 6, children typically understand death as permanent and irreversible.

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