What is the most effective intervention to prevent skin breakdown in immobile older adults?

Questions 44

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basic geriatric nursing 8th edition test bank Questions

Question 1 of 9

What is the most effective intervention to prevent skin breakdown in immobile older adults?

Correct Answer: C

Rationale: The correct answer is C because regular repositioning and the use of pressure-relieving devices are essential to prevent skin breakdown in immobile older adults. Repositioning helps redistribute pressure, maintaining blood flow to the skin and preventing tissue damage. Pressure-relieving devices such as cushions or special mattresses further reduce pressure on vulnerable areas. Choices A and B do not address the root cause of skin breakdown and may even exacerbate the issue. Choice D is incorrect as complete bed rest can lead to further complications like pressure ulcers. In summary, choice C is the most effective intervention as it directly targets the risk factors for skin breakdown in immobile older adults.

Question 2 of 9

What is the most effective intervention to prevent skin breakdown in immobile older adults?

Correct Answer: C

Rationale: The correct answer is C because regular repositioning and the use of pressure-relieving devices are essential to prevent skin breakdown in immobile older adults. Repositioning helps redistribute pressure, maintaining blood flow to the skin and preventing tissue damage. Pressure-relieving devices such as cushions or special mattresses further reduce pressure on vulnerable areas. Choices A and B do not address the root cause of skin breakdown and may even exacerbate the issue. Choice D is incorrect as complete bed rest can lead to further complications like pressure ulcers. In summary, choice C is the most effective intervention as it directly targets the risk factors for skin breakdown in immobile older adults.

Question 3 of 9

Mr J., an 80 yr old who has had flu like symptoms with diarrhea and has vomited 4 times in the last 24 hours is seen in the ED. Mr. J seems confused and is lethargic. The nurse notes that Mr. J has dry skin, a brown tongue, sunken cheeks and concentrated urine. This array of symptoms indicates:

Correct Answer: B

Rationale: The correct answer is B: dehydration. Mr. J's symptoms of flu-like illness, diarrhea, vomiting, confusion, lethargy, dry skin, brown tongue, sunken cheeks, and concentrated urine are indicative of severe dehydration. Dehydration can lead to electrolyte imbalances, decreased blood volume, and impaired organ function, resulting in confusion and lethargy. Skin changes, dry mucous membranes, and concentrated urine are also classic signs of dehydration. The other choices (A, C, D) do not align with the constellation of symptoms presented by Mr. J and are less likely based on the information provided.

Question 4 of 9

The gerontological nurse collaborates with the wound care team about an older patient who has an ulcer. How is this nurse demonstrating leadership in the care of older people?

Correct Answer: C

Rationale: The correct answer is C: Coordinating members of the health care team. This demonstrates leadership as the nurse is taking charge of organizing and communicating with various healthcare professionals to ensure the best care for the older patient. By collaborating with the wound care team, the nurse shows effective coordination and communication skills, which are crucial in managing complex cases in older adults. Assessing older adults effectively (choice A) is important but does not specifically address leadership in coordinating care. Facilitating access to eldercare programs (choice B) is important but does not directly demonstrate leadership in coordinating care. Empowering older adults to manage chronic illness (choice D) is important for patient education but does not directly show leadership in coordinating the healthcare team.

Question 5 of 9

Which common cognitive impairment is often mistaken for normal aging in older adults?

Correct Answer: A

Rationale: The correct answer is A: Mild cognitive impairment (MCI). MCI is often mistaken for normal aging because it involves subtle changes in memory and thinking abilities that are beyond what is expected for age but not severe enough to be classified as dementia. Individuals with MCI may experience forgetfulness or difficulty with complex tasks, which can be misconstrued as typical age-related changes. Alzheimer's disease (B), dementia with Lewy bodies (C), and vascular dementia (D) are all forms of dementia characterized by more significant cognitive decline and functional impairment compared to MCI, making them less likely to be confused with normal aging.

Question 6 of 9

An older women tells the nurse that her husband seldom brushes his teeth as he did in the past. A reason why older clients stop participating in daily oral hygiene, such as brushing the teeth, include:

Correct Answer: A

Rationale: The correct answer is A: Decreased manual dexterity and inability to hold a toothbrush. As people age, they may experience decreased hand strength and motor skills, making it difficult to hold and manipulate objects like a toothbrush. This can lead to a decline in oral hygiene practices. Malocclusion of teeth (B) does not directly impact the ability to brush teeth. Decrease in taste acuity (C) may affect appetite but not tooth brushing habits. Lack of dental insurance (D) is a financial barrier and may affect access to dental care, but it does not directly impact the physical ability to brush teeth.

Question 7 of 9

An older adult who is a traditional Chinese man has a blood pressure of 80/54 mm Hg and refuses to remain in the bed. Which intervention should the nurse use to promote and maintain his health?

Correct Answer: C

Rationale: Rationale: C is correct as it involves understanding the patient's beliefs and preferences, crucial in culturally competent care. A would not address the patient's perspective directly. B is broad and lacks specificity. D assumes all traditional Chinese individuals seek Chinese medicine, which may not be the case.

Question 8 of 9

Which of the following medications should be avoided in older adults due to the increased risk of falls?

Correct Answer: B

Rationale: The correct answer is B: Benzodiazepines. Benzodiazepines are central nervous system depressants that can cause drowsiness, dizziness, and confusion, increasing the risk of falls in older adults. They can also impair balance and coordination. Older adults are more sensitive to these effects due to age-related changes in metabolism and increased risk of cognitive impairment. Beta-blockers (A), statins (C), and antihypertensives (D) are generally safe in older adults and do not directly increase the risk of falls. Beta-blockers can sometimes cause dizziness but are more commonly associated with bradycardia. Statins are used to lower cholesterol levels and do not affect fall risk. Antihypertensives help lower blood pressure and can actually reduce the risk of falls by preventing conditions like orthostatic hypotension.

Question 9 of 9

Mr. J has been admitted to the hospital from her own home. The admitting nurse notes that the patient has severe edema in the lower extremities, no hair on the legs, and ulcerations on her feet. These signs and symptoms are most likely indications of:

Correct Answer: D

Rationale: The correct answer is D: Circulatory problems related to age and a chronic illness. Severe edema, hair loss on the legs, and foot ulcerations are indicative of poor circulation, often seen in conditions like peripheral artery disease. Age and chronic illnesses can contribute to circulatory issues. A diet low in protein (choice A) would not directly cause these symptoms. Exposure to cold (choice B) would not explain the specific symptoms mentioned. Frequent falls (choice C) do not align with the symptoms provided.

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