The most common psychogenic disorder among elderly person is:
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Solution
Option A: Depression typically begins before the onset of old age and usually is caused by psychosocial, genetic, or biochemical factors.
Options B, C, and D: Sleep disturbances, inability to concentrate and decreased appetite are symptoms of depression, the most common psychogenic disorder among elderly persons. Other symptoms include diminished memory, apathy, disinterest in appearance, withdrawal, and irritability.
The most common injury among elderly persons is:
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Solution
Option D: Hip fracture, the most common injury among elderly persons, usually results from osteoporosis.
Options A, B, and C: The other answers are diseases that can occur in the elderly from physiologic changes.
Examples of patients suffering from impaired awareness include all of the following except:
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Solution
Option C: A patient who cannot care for himself at home does not necessarily have impaired awareness; he may simply have some degree of immobility.
Studies have shown that about 40% of patients fall out of bed despite the use of side rails; this has led to which of the following conclusions?
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Solution
Option D: Since about 40% of patients fall out of bed despite the use of side rails, side rails cannot be said to prevent falls; however, they do serve as a reminder that the patient should not get out of bed.
Options A, B, and C: The other answers are incorrect interpretations of the statistical data.
Which of the following nursing interventions promotes patient safety?
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Solution
Option D: Assisting a patient with ambulation and transfer from a bed to a chair allows the nurse to evaluate the patient’s ability to carry out these functions safely. Demonstrating the signal system and providing an opportunity for a return demonstration ensures that the patient knows how to operate the equipment and encourages him to call for assistance when needed. Checking the patient’s identification band verifies the patient’s identity and prevents identification mistakes in drug administration.
After 1 week of hospitalization, Mr. Gray develops hypokalemia. Which of the following is the most significant symptom of his disorder?
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Solution
Option C: Presenting symptoms of hypokalemia ( a serum potassium level below 3.5 mEq/liter) include muscle weakness, chronic fatigue, and cardiac dysrhythmias. The combined effects of inadequate food intake and prolonged diarrhea can deplete the potassium stores of a patient with GI problems.
A prescribed amount of oxygen s needed for a patient with COPD to prevent:
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Solution
Option D: Delivery of more than 2 liters of oxygen per minute to a patient with chronic obstructive pulmonary disease (COPD), who is usually in a state of compensated respiratory acidosis (retaining carbon dioxide (CO2)), can inhibit the hypoxic stimulus for respiration.
Option A: An increased partial pressure of carbon dioxide in arterial blood (PACO2) would not initially result in cardiac arrest.
Options B and C: Circulatory overload and respiratory excitement have no relevance to the question.
An additional Vitamin C is required during all of the following periods except:
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Solution
Option B: Additional Vitamin C is needed in growth periods, such as infancy and childhood, and during pregnancy to supply demands for fetal growth and maternal tissues. Other conditions requiring extra vitamin C include wound healing, fever, infection and stress.
Mrs. Lim begins to cry as the nurse discusses hair loss. The best response would be:
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Solution
Option D: “I know this will be difficult” acknowledges the problem and suggests a resolution to it.
Option A: “Don’t worry..” offers some relief but doesn’t recognize the patient’s feelings.
Option B: “..I didn’t get to the bad news yet” would be inappropriate at any time.
Option C: “Your hair is really pretty” offers no consolation or alternatives to the patient.
A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate nursing diagnosis would be:
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Solution
Option A: Thick, tenacious secretions, a dry, hacking cough, orthopnea, and shortness of breath are signs of ineffective airway clearance.
Option B: Ineffective airway clearance related to dry, hacking cough is incorrect because the cough is not the reason for the ineffective airway clearance.
Option C: Ineffective individual coping related to COPD is wrong because the etiology for a nursing diagnosis should not be a medical diagnosis (COPD) and because no data indicate that the patient is coping ineffectively.
Option D: Pain related to immobilization of affected leg would be an appropriate nursing diagnosis for a patient with a leg fracture.