Using the Resident Assessment Instrument (RAI), the nurse ...

[Brittanyd9008]

Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger for a male nursing home resident who requires an indwelling urinary catheter from the Minimum Data Set (MDS). Which should the nurse do next?
 
  a. Develop an individualized care plan.
  b. Assign suitable nursing interventions.
  c. Use the Resident Assessment Protocols.
  d. Institute agency approved catheter care.

Question 2

An older man in a cardiac rehabilitation exercise class refuses to participate in the cool-down phase of the activity; consequently, 2 minutes later, he passes out but quickly regains conscious-ness.
 
  Which instruction does the nurse include in patient teaching to reinforce the importance of cooling down after exercising to this man? a. Cardiac output diminishes with age.
  b. Mobility capacity decreases with age.
  c. Baroreceptor function diminishes with age.
  d. Sensory perception diminishes with age.

[chereeb]

Answer to Question 1

C

Feedback
A Incorrect. The nurse develops the care plan after completing the RAPs.
B Incorrect. The nurse assigns suitable nursing interventions to the plan of care.
C Correct. The nurse uses the Resident Assessment Protocols (RAP) to assess triggers identified from the MDS. To help the resident achieve optimal func-tional status by determining his strengths, needs, and preferences, RAPs provide an organized framework used by the health care team for additional assessment of the trigger.
D Incorrect. The nurse uses agency-approved policies to provide care as assigned in the plan of care.

Answer to Question 2

C
During exercise, the body shunts blood to the skeletal muscles to supply enough oxygen to meet the increased metabolic demands of the muscles. If the exercise is suddenly withdrawn, however, the blood temporarily pools in the skeletal muscles, and the older adult loses consciousness from transient hypotension. Baroreceptor responsiveness declines with age; therefore the body does not respond as readily to the need for changes in blood pressure. The cool-down period compen-sates for this effect.
An acute problem such as losing consciousness as a result of decreased cardiac output should appear during the real exercise. The man is mobile enough to participate in the exercise program. Gradual sensory alteration does not account for the acute episode.