Based on an understanding of the cognitive changes that normally occur with aging. what would the nurse expect a newly hospitalized older adult to do?
Interrupt with frequent questions
Answer slowly and be confused
Withdraw from strangers
Take longer to respond and react
The Correct Answer is D
A) Interrupt with frequent questions: While older adults may have questions, they typically do not interrupt frequently. This behavior is more indicative of anxiety or agitation rather than a cognitive change associated with aging.
B) Answer slowly and be confused: While some older adults may exhibit slower responses, confusion is not a normal cognitive change associated with aging. Confusion may suggest underlying issues such as delirium or dementia, rather than typical age-related cognitive changes.
C) Withdraw from strangers: Social withdrawal can occur in some older adults, but it is not a universal expectation. Many older adults remain engaged and sociable, and withdrawal is more commonly associated with mental health issues rather than cognitive changes.
D) Take longer to respond and react: It is common for older adults to take longer to process information and respond due to normal cognitive slowing. This may reflect changes in processing speed rather than a decline in cognitive function, and it is an expected part of aging.
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Correct Answer is C
Explanation
A) Listen for another minute just to be sure: While it is important to confirm findings, simply listening for another minute may not provide enough time to accurately assess bowel sounds, as they can be infrequent or absent in certain conditions.
B) Contact the physician as this is a surgical emergency: Not hearing bowel sounds for a minute is not immediately indicative of a surgical emergency. It’s essential to gather more information before escalating the situation.
C) Auscultate for another 4 minutes: This is the appropriate action, as the nurse should auscultate for a total of 5 minutes (1 minute initially and then 4 more minutes) to adequately assess bowel sounds. This duration allows for the detection of normal, hypoactive, or absent bowel sounds, which can provide critical information about the client’s gastrointestinal function.
D) Listen posteriorly for enhanced bowel sounds: While listening from different positions may sometimes help, the standard practice is to listen for an appropriate duration before changing techniques. Auscultating for a longer period is more clinically relevant in this scenario.
Correct Answer is C
Explanation
A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.
B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."
C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.
D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.