The nurse is planning to teach a nursing assistant to use the hand-over-hand method to assist an older patient with dementia in performing mouth care. Which instruction should the nurse provide to the assistant?
1. Place a hand over the patient's hand and guide the patient to perform mouth care.
2. Use lemon and glycerin swabs to cleanse the gums around the teeth in the front.
3. Speak sternly and instruct the patient to open the mouth and brush the teeth quickly.
4. Carefully place two fingers of a gloved hand in the patient's mouth to access the back teeth.
Question 2The nurse is reviewing the care of an 89-year-old client who has a stage I decubiti on the coccyx and right heel. The nurse provides instruction to the nurse aide assigned to care for the client.
What would the nurse include in the instruction to the nurse aide?
A) keep the bed elevated 45? or higher
B) turn the client on the side to remove sheets and clothing
C) use dry dressings to the heels
D) use soap to cleanse the skin
Question 3An 82-year-old client is admitted for a hip fracture. During the postoperative recovery, the nurse notices a stage I pressure ulcer forming on the client's sacrum. To reduce the progression of this stage of ulcer, the nurse would
A) maintain the head of the bed at 45?.
B) apply a dry dressing to pressure ulcer.
C) maintain the head of the bed at 30? positioned on the right or left side.
D) apply a heat lamp to the area to increase circulation.
Question 4Which actions will the nurse include when performing a complete oral exam on an older cooperative patient?
1. Inform the patient that halitosis is considered normal.
2. Do not wear gloves while examining the tongue including the posterior surface.
3. Palpate the head and neck lymph nodes and assesses for tenderness and enlargement.
4. Tell the patient that white patches on the surface of the oral mucosa is expected with aging.
Question 5The nurse is reviewing an older patient's prescribed medications and realizes the patient is at risk for xerostomia. Which medications would increase the patient's risk for this disorder? Standard Text: Select all that apply.
1. Diuretics
2. Antibiotics
3. Antihistamines
4. Anticoagulants
5. Tricyclic antidepressants
Question 6The nurse is completing a home care visit of an 86-year-old client. The client lives alone and is independent in activities of daily living. During your visit, you notice a red mark on the arm of the client.
The client states she was unaware of the injury and it may have occurred from hot water when cooking. Your interpretation of this finding is that the client is
A) losing short-term memory.
B) experiencing friction tears of the skin.
C) at risk for further injury.
D) experiencing senile purpura in the skin.
Question 7How should the nurse respond to an older patient who does not receive regular dental examinations?
1. Losing teeth is considered a normal part of the aging process.
2. Patients who have no teeth do not need to see a dentist for regular checkups.
3. Oral malignancies seldom occur in older people so oral examinations are not necessary.
4. Regular dental examinations can improve an older person's ability to eat healthful foods.
Question 8A 75-year-old client is recovering from surgery to remove a tumor in the abdomen. When planning care for this client, the nurse would consider that the skin of an older person would require
A) increased healing time.
B) decreased healing time.
C) a need to keep the wound edges taped.
D) skin near the wound to be massaged to increase blood flow.
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