When administering drug therapy to a male geriatric patient, the nurse must stay especially alert for adverse effects. Which factor makes geriatric patients to adverse drug effects?
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Solution
Aging-related physiological changes account for the increased frequency of adverse drug reactions in geriatric patients. Renal and hepatic changes cause drugs to clear more slowly in these patients. With increasing age, neurons are lost and blood flow to the GI tract decreases.
Before administering the evening dose of a prescribed medication, the nurse on the evening shift finds an unlabeled, filled syringe in the patient’s medication drawer. What should the nurse in charge do?
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Solution
As a safety precaution, the nurse should discard an unlabeled syringe that contains medication. The other options are considered unsafe because they promote error.
A female patient who speaks a little English has emergency gallbladder surgery, during discharge preparation, which nursing action would best help this patient understand wound care instruction?
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Solution
Demonstrating by the nurse with a return demonstration by the patient ensures that the patient can perform wound care correctly. Patients may claim to understand discharge instruction when they do not. An interpreter of family member may communicate verbal or written instructions inaccurately.
The nurse in charge is transferring a patient from the bed to a chair. Which action does the nurse take during this patient transfer?
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Solution
After placing the patient in high Fowler’s position and moving the patient to the side of the bed, the nurse helps the patient sit on the edge of the bed and dangle the legs; the nurse then faces the patient and places the chair next to and facing the head of the bed.
A female patient with a terminal illness is in denial. Indicators of denial include:
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Solution
Shock and dismay are early signs of denial-the first stage of grief. The other options are associated with depression—a later stage of grief.
Which of the following planes divides the body longitudinally into anterior and posterior regions?
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Solution
Frontal or coronal plane runs longitudinally at a right angle to a sagittal plane dividing the body in anterior and posterior regions. A sagittal plane runs longitudinally dividing the body into right and left regions; if exactly midline, it is called a midsagittal plane. A transverse plane runs horizontally at a right angle to the vertical axis, dividing the structure into superior and inferior regions.
A male patient has a soft wrist-safety device. Which assessment finding should the nurse consider abnormal?
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Solution
A safety device on the wrist may impair circulation and restrict blood supply to body tissues. Therefore, the nurse should assess the patient for signs of impaired circulation, such as cool, pale fingers. A palpable radial or lunar pulse and pink nail beds are normal findings.
The nurse is assessing a postoperative adult patient. Which of the following should the nurse document as subjective data?
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Solution
Subjective data come directly from the patient and usually are recorded as direct quotations that reflect the patient’s opinions or feelings about a situation. Vital signs, laboratory test result, and ECG waveforms are examples of objective data.
When examining a patient with abdominal pain the nurse in charge should assess:
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Solution
The nurse should systematically assess all areas of the abdomen, if time and the patient’s condition permit, concluding with the symptomatic area. Otherwise, the nurse may elicit pain in the symptomatic area, causing the muscles in other areas to tighten. This would interfere with further assessment.
Nurse Clarisse is teaching a patient about a newly prescribed drug. What could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications?
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Solution
Sensory deficits could cause a geriatric patient to have difficulty retaining knowledge about prescribed medications. Decreased plasma drug levels do not alter the patient’s knowledge about the drug. A lack of family support may affect compliance, not knowledge retention. Toilette syndrome is unrelated to knowledge retention.