Question

19. A 71-year-old immobile patient has been in his wheelchair for 2 hours. When repositioning him, the nurse observes a reddened area at the base of the buttocks. This observation best be documented as a: a. Stage 2 at greater trochanter b. Stage 1 at ischial tuberosity c. Stage 1 on iliac crest d. Stage 0 on posterior superior iliac spine 20. Family members are caring for their elderly mother at home. Which statement by the daughter indicates the need for further teaching? a. "I change Mom's diaper whenever it is really wet." b. "I make sure Mom eats good meals and extra snacks." c. "We try to change Mom's position at least every two hours." d. "I try to use lotion on Mom's skin every morning and evening." 21. An elderly patient who recently has had small watery BMs, complains of pressure in the rectal area and abdominal cramping. The most appropriate initial nursing action would be to: a. Administer an oil retention enema. b. Notify the physician of these observations. c. Digitally stimulate the rectal sphincter. d. Administer the prn laxative medication. 22. An older woman reports leakage of urine during exercise, coughing, and sneezing. These characteristics are associated with: a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence 23. An elderly client residing in an community-based residential facility, CBRF, states "I just don't know what to do except sleep. I worked hard all my life, I never had the time or money to do lots of things." The most appropriate nursing intervention would be to: a. Schedule the patient to join a museum trip with the local senior center. b. Select books and videos from the library to occupy his time. c. Refer him to occupational therapy for evaluation. d. Explore the variety of activities that are now available to him. 24. The nurse would recommend the following activities as appropriate for an elderly patient with no serious medical problems: (Select all that apply.) a. Swimming three times per week b. Jogging every other day c. Ballroom dancing weekly d. Tai chi every day e. Walking three or four times per week f. Stretching exercise daily g. Step aerobics weekly

Answer 1

19.B.stage 1 at ishcial tuberosity.redness occurs in first stage presure ulcer.and ischial tuberosity is present in the base of buttocks

20.A.diaper should change in frequent intervals even it is not wet.otherwise patient get UTI

21.B.first nurse should inform the physician after getting order we can do relief methods

22.B stress incontinence occrs due to sudden action.while,presure exert on bladder causing leakage

23.D.explore the various activities which can do in his age and available these days

24.A,B,E .other activities will be difficult for old age