Author Question: The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. ... (Read 65 times)

mynx · **on:** Jul 22, 2018

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?

a. Inform the patient of the importance of finishing the entire dose of antibiotics.
b. Encourage the patient to stay up-to-date on all vaccinations.
c. Schedule patient to get annual tuberculosis skin testing.
d. Create an exercise routine to run 45 minutes every day.

Question 2

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately?

a. Ventricular tachycardia
b. Atrial fibrillation
c. Sinus rhythm
d. Paroxysmal supraventricular tachycardia

djpooyouma · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

ANS: B
A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up-to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method.

Answer to Question 2

ANS: A
Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously.