A nurse in the long-term care facility assesses an 86-year-old ...

[OSWALD]

A nurse in the long-term care facility assesses an 86-year-old woman who has recently become lethargic and difficult to arouse. Her vital signs are all stable and within normal limits. Her breath sounds are diminished.
 
  Which action by the nurse should be the priority?
 
  A) Call the family and give them an update.
  B) Place her on high fall risk precautions.
  C) Send her to the emergency department.
  D) Tell the aides to keep an eye on her.

Question 2

A nurse cares for an older adult in a residential care program. The client has multiple chronic conditions. The client has developed dyspnea and has lost 105 lb of body weight. Which of the following statements by the nurse is most appropriate?
 
  A) Have you ever heard of palliative care?
  B) I want to talk to you about switching our focus from cure to care.
  C) We don't think that there is anything we can change to make you better.
  D) Your breathing problems concern me.

[Swizqar]

Answer to Question 1

Ans: C
Atypical presentation is especially common in those who are older than 85 years. Changes in behavior or functioning and increased fatigue are common atypical presentations of infection (e.g., pneumonia or urinary tract infection). In addition, the expected manifestations of an infection, such as elevated temperature or specific complaints of pain or discomfort, may be absent. While the family should be made aware of the update on the condition, the care of the client is the priority. It is not appropriate to delegate this to the certified nursing assistant (CNA). Placing her on fall prevention does not address the assessment data.

Answer to Question 2

Ans: B
Unintentional weight loss, unstable medical conditions, and frequent hospitalizations indicate a need for discussion of palliative care services. The nurse uses open-ended assertive statements that teach the client. Saying we can't make you better might be helpful for a client who is unable to hear the professional the first time palliative care is introduced. The concern regarding the breathing doesn't introduce the idea of supportive care.

[OSWALD]

TYSM

[ultraflyy23]

Gracias!