Which of the following is a normal change observed in an elderly individual?

Correct Answer: C

Rationale: The correct answer is C, frequent urination. As people age, they may experience physiological changes that can lead to an increased frequency of urination. This is due to a decrease in bladder capacity and increased bladder irritability, which are normal age-related changes. On the contrary, the sense of taste (Choice A) and appetite (Choice B) often decrease with age, not increase. As for Choice D, the lens of the eye actually thickens with age, not thins, leading to conditions like presbyopia. Therefore, Choices A, B, and D are incorrect.

Correct Answer: D

Rationale: The correct answer is 'D: Advanced age of the client.' Age can be a significant obstacle in communication due to factors such as hearing loss, cognitive decline, or memory issues, which all can hamper effective communication. Choices A, B, and C, while they may present challenges in communication, are not directly related to age and its influence on communication, making them incorrect. The issues presented by not using universally accepted abbreviations, incorrect grammar, and poor handwriting can be resolved through clarification, education, or the use of alternative communication methods, unlike the difficulties that can arise from advanced age.

Correct Answer: C

Rationale: The correct answer is C. While it is true that Mrs. Guevarra is delegating tasks to the nurse-aide, she does not necessarily have to directly supervise or evaluate the aide. She still retains the overall accountability for the care of the client, but direct supervision of the aide is not a requirement for delegation. Choice A is incorrect because the primary purpose of delegation is not instruction. Choice B is also incorrect because although Mrs. Guevarra is delegating tasks, she still retains accountability for those tasks. Finally, choice D is incorrect because the ability to perform the task being delegated is not a requirement for the delegator; the delegatee should have the necessary skills and knowledge to perform the delegated tasks.

Correct Answer: C

Rationale: Given Miss CEE's state of major depression and her expressed feelings of worthlessness ('Nobody wants me'), the nurse would most likely expect her to be placed on suicide precaution. This means that measures would be taken to ensure her safety and to prevent her from harming herself. While medications like neuroleptics (Choice A) and anxiolytics (Choice D) might be employed as part of her overall treatment, these medicines are primarily used for conditions like psychosis and anxiety respectively, not specifically for depression or suicidal ideation. A special diet (Choice B) may be part of a comprehensive treatment plan, but it is not as immediate or as directly related to her current emotional and psychological state as suicide precaution is.

Correct Answer: A

Rationale: A registered nurse is responsible for a group of patients from their admission to their discharge. This responsibility encompasses assessing patient needs, formulating care plans, administering medications, monitoring patient progress, and coordinating with other members of the healthcare team. Choice B is not entirely accurate because, even though nurses often work with nursing aides, the nurses themselves hold the ultimate responsibility for the overall care of the patient. Choices C and D are incorrect as they depict an incomplete and inaccurate representation of a nurse's role, which extends beyond administrative duties and equipment maintenance to primarily focus on direct patient care.

Correct Answer: D

Rationale: A pulse oximeter is used to detect the oxygen saturation levels in arterial blood before the onset of hypoxemia symptoms. This device provides essential information about the effectiveness of oxygen transportation to the body's tissues. Choice A is incorrect because a pulse oximeter does not directly measure hemoglobin levels nor determine the need for a blood transfusion. Choice B is incorrect because a pulse oximeter is designed specifically to assess oxygen saturation, not tissue perfusion. Choice C is incorrect because a pulse oximeter is not used to measure the efficacy of anti-hypertensive medications, but rather to monitor oxygen levels in the blood.

Correct Answer: B

Rationale: Decreasing the intake of refined carbohydrates is the most effective dietary modification for a client with type 2 diabetes who aims to improve their glycemic control. Refined carbohydrates can cause sudden spikes in blood sugar levels, making diabetes management more difficult. Increasing the intake of saturated fats (Choice A) is not advisable as it can negatively impact heart health. Completely avoiding all fruits (Choice C) is unnecessary because most fruits have a low glycemic index and provide essential nutrients. Increasing the intake of sugary snacks (Choice D) will deteriorate glycemic control due to their high sugar content.

Correct Answer: D

Rationale: A written nursing care plan fundamentally serves to facilitate the development of a nursing diagnosis. This procedure involves analyzing patient data and identifying health problems that nurses can address independently. This analysis then aids in determining the most appropriate nursing interventions for the identified health issues. Although evaluating the achievement of nursing care goals is an important aspect, it is not the primary function of a nursing care plan. Similarly, while delivering quality nursing care is crucial, it is a broader concept that includes many other facets beyond just the initial nursing diagnosis and interventions.

Correct Answer: D

Rationale: Broccoli is high in vitamin K, which can affect the effectiveness of warfarin. Warfarin is an anticoagulant medication that functions by reducing the activity of vitamin K in the body. When one consumes broccoli, which is rich in vitamin K, it could counteract the anticoagulant effect of warfarin, thereby interfering with its effectiveness. On the other hand, cauliflower, zucchini, and green beans do not have significant levels of vitamin K and hence, are not known to impact the effectiveness of warfarin.