Nursing a Concept Based Approach to Learning Test Bank

Correct Answer: D

Rationale: In older adults, particularly those over 65 years of age, atypical symptoms of a myocardial infarction may occur. Abdominal pain is considered an atypical age-related warning sign because older adults may present with subtle or nonspecific symptoms, such as discomfort or pain in the abdomen, rather than the classic chest pain associated with a heart attack. This atypical presentation can lead to delays in seeking medical attention and diagnosis, which can have serious consequences for the client. Therefore, it is important for the nurse to educate older clients about the possibility of experiencing atypical symptoms, such as abdominal pain, in the context of a myocardial infarction.

Correct Answer: A

Rationale: The first action that the nurse should take when caring for a patient experiencing diarrhea is to ask the patient to describe the number and character of daily stools. This assessment is crucial in determining the severity and possible cause of the diarrhea. By understanding the frequency and consistency of the stools, the nurse can evaluate if the diarrhea is due to an infection, a reaction to medications, dietary factors, or other underlying health issues. Based on this assessment, appropriate interventions can then be implemented, which may include further diagnostic tests, fluid replacement therapy, dietary modifications, or medication administration. It is essential to gather this information first before considering other interventions such as abstaining from oral intake or using over-the-counter antidiarrheal medications.

Correct Answer: B

Rationale: For a client with peripheral vascular disease (PVD) who is at risk for Impaired Skin Integrity, keeping the skin clean and dry, and moisturizing areas of dryness is crucial. Patients with PVD often have compromised circulation to the extremities, which can lead to decreased oxygen and nutrient delivery to tissues, increasing the risk of skin breakdown and impaired wound healing. Proper skin care helps prevent skin breakdown, decreases the risk of infection, and promotes overall skin health. Keeping the skin clean and dry helps prevent skin breakdown, while moisturizing areas of dryness helps maintain skin integrity. This intervention focuses on maintaining skin health and preventing complications associated with compromised circulation in patients with PVD.

Correct Answer: A

Rationale: A. Take the medication as directed with clear water only: Alendronate should be taken with a full glass of plain water on an empty stomach in the morning at least 30 minutes before consuming any food, drink, or other medications. Avoid taking it with any other liquids besides plain water, as other beverages can interfere with the absorption of the drug.

Correct Answer: A

Rationale: Supporting a stroke client's sensorimotor needs involves encouraging independence and rehabilitation of the affected side. By encouraging the use of the nonaffected arm for self-care activities like feeding, bathing, and dressing, the nurse is promoting sensorimotor development and function in the affected arm. This intervention will help the client regain strength, coordination, and functionality in the affected arm, which is crucial for their overall recovery and independence. Encouraging the client to actively engage the affected arm promotes neuroplasticity and can improve motor function over time.