Answer to Question 1
D
Aspiration occurs when food, fluid, or medication intended for GI administration inadvertently enters the respiratory tract. To minimize aspiration risk, allow the patient, if capable, to self-administer medication. Patients should also hold their own cup to control how quickly they take in fluid. Liquids should be thickened to reduce the risk of aspiration. Patients at risk for aspiration should not be given straws because use of a straw decreases the control the patient has over volume intake.
Answer to Question 2
B
Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case. Older adults tent to have lower temperatures, so the nurse needs to assess for slight elevations. A temperature of 97.6 F is within normal limits.
Patient Teaching
NANDA international nursing diagnosis 1
Nursing care plan anxiety
Vapocoolant spray application while passively stretching the paracervical muscles. Take care to prot
An example of a medical history sheet to list patient problems.
Action Potential Summary