The nurse is reviewing the care plan of an 89 yr old client who has been admitted for prostate surgery. The client is on medication for hypertension and had a recent fall at home prior to admission. The nurse would include which assessment in the care plan?

Correct Answer: B

Rationale: The correct answer is B. Checking postural blood pressures is essential to assess for orthostatic hypotension in an elderly client with a history of falls and hypertension medication. Orthostatic hypotension can lead to falls, so monitoring postural B/Ps is crucial. Checking B/P every 2 hours (choice A) is not necessary and could cause unnecessary discomfort to the client. Checking serum sodium levels (choice C) and serum creatinine levels (choice D) are not directly related to the client's risk factors for falls post-prostate surgery.

Correct Answer: A

Rationale: Holistic nursing is the correct answer because it considers the physical, emotional, social, and spiritual aspects of an individual's life in the care plan. It emphasizes treating the whole person rather than just the symptoms. Healthy People 2020 focuses on improving the overall health of the population. Maslow's hierarchy of needs prioritizes basic human needs. Orem's self-care requirements focus on the individual's ability to care for themselves. Holistic nursing is the only approach that integrates and balances all aspects of an individual's life into the care plan, making it the most comprehensive and patient-centered approach.

Correct Answer: B

Rationale: The correct answer is B: Fewer taste buds. As people age, they tend to have fewer taste buds, leading to a decreased ability to taste food. This can result in a loss of interest in eating, which may contribute to anorexia and weight loss. Excessive saliva (A) does not directly contribute to anorexia or weight loss. Wearing dentures (C) may affect chewing but is not a major factor in anorexia. Softened tooth enamel (D) is more related to dental health rather than appetite and weight loss.

Correct Answer: B

Rationale: The correct answer is B because baby boomers were exposed to unhealthy lifestyle choices and environments in their formative years, contributing to the prevalence of chronic conditions. This is supported by research showing that environmental factors, such as diet and exposure to toxins, play a significant role in the development of chronic illnesses. Additionally, unhealthy habits established in youth can have long-term effects on health. Choice A is incorrect because higher physical activity rates during youth would typically lead to better health outcomes, not increased chronic conditions. Choice C is incorrect as better access to preventive healthcare services would likely reduce chronic conditions, not increase them. Choice D is incorrect because education about nutrition and wellness would typically lead to healthier lifestyle choices and lower rates of chronic conditions.

Correct Answer: B

Rationale: The correct answer is B: Providing palliative care focused on symptom management and comfort. This is the most appropriate intervention for an older adult with advanced heart failure as it prioritizes quality of life by focusing on alleviating symptoms and ensuring comfort. High-dose diuretics (choice A) may lead to electrolyte imbalances and worsen the patient's condition. Initiating aggressive cardiac surgery (choice C) may be too risky and invasive for an older adult with advanced heart failure. Enforcing strict bed rest (choice D) can lead to deconditioning and muscle wasting, further compromising the patient's quality of life.

Correct Answer: C

Rationale: The correct answer is C because consistent routines and environmental modifications have been shown to be the most effective approach in reducing agitation and aggression in older adults with dementia. This approach focuses on providing structure and familiarity, which can help decrease confusion and anxiety in individuals with dementia. Physical restraints (A) are not recommended as they can lead to further agitation and pose risks of injury. Increased sedation with antipsychotics (B) should be used as a last resort due to potential side effects and risks. Ignoring the behavior (D) is not appropriate as it can exacerbate the situation and lead to further distress for the individual.

Correct Answer: C

Rationale: The correct answer is C: Certified gerontological nurse. This nurse has specialized knowledge and training in caring for elderly patients, aligning with the nursing home's focus on eldercare standards. Certification demonstrates expertise in gerontological nursing. A: A nurse from a certified college may not necessarily have specialized training in gerontological nursing. B: Experience is valuable, but without specific gerontological training, the nurse may lack the specialized skills required for eldercare. D: A gerontological nurse practitioner has advanced training, but for direct patient care in a nursing home setting, a certified gerontological nurse may be a better fit.

Correct Answer: B

Rationale: The correct answer is B because using large size fonts on written material is important for elderly individuals in assisted living facilities who may have visual impairments. This accommodation ensures that the residents can easily read and understand the information being presented. This is crucial for effective communication and engagement in the educational program. A: While using simple language is generally beneficial, the primary concern for this specific population is visual accessibility rather than language complexity. C: Providing the program in a quiet area is important for minimizing distractions, but it is not as critical as ensuring the residents can read the material. D: While building on prior knowledge is a good practice in teaching, it is secondary to ensuring that the information is visually accessible to the residents.

Correct Answer: B

Rationale: The correct answer is B: Provide step-by-step verbal cues to assist the client. This intervention is appropriate for an older adult with dementia as it offers structured support while still promoting independence. Verbal cues can help guide the client through the self-care tasks, maintaining their dignity and autonomy. Option A is incorrect as full independence may be overwhelming and unsafe. Option C is inappropriate and neglectful. Option D may be too demanding for someone with dementia. Verbal cues strike a balance between support and autonomy, making it the best intervention in this scenario.