ADH2 FINAL misc practice q

You are the nurse planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiological changes. What phenomenon would you include in your teaching plan? Select one: A. A decrease in muscle mass and bone density B. A decrease in cognition, judgment, and memory C. The disappearance of sexual desire for both men and women D. An increase in sebaceous and sweat gland function in both men and women

A. A decrease in muscle mass and bone density Normal signs of aging include a decrease in the sense of smell, a decrease in muscle mass, a decline but not disappearance of sexual desire, and decreased sebaceous and sweat glands for both men and women. Cognitive changes are usually attributable to pathologic processes, not healthy aging.

You are the nurse caring for an elderly adult who is bedridden. What intervention would you include in the care plan that would most effectively prevent pressure ulcers? Select one: A. Post a turning schedule at the patient's bedside and ensure staff adherence. B. Slide, rather than lift, the patient when turning. C. Turn and reposition the patient a minimum of every 8 hours. D. Vigorously massage lotion into bony prominences.

A. Post a turning schedule at the patient's bedside and ensure staff adherence. A turning schedule with a signing sheet will help ensure that the patient gets turned and, thus, help prevent pressure ulcers. Turning should occur every 1 to 2 hours, not every 8 hours, for patients who are in bed for prolonged periods. The nurse should apply lotion to keep the skin moist, but should avoid vigorous massage, which could damage capillaries. When moving the patient, the nurse should lift, rather than slide, the patient to avoid shearing.

Your patient has been admitted for a liver biopsy because the physician believes the patient may have liver cancer. The family has told both you and the physician that if the patient is terminal, the family does not want the patient to know. The biopsy results are positive for an aggressive form of liver cancer and the patient asks you repeatedly what the results of the biopsy show. What strategy can you use to give ethical care to this patient? Select one: A. Promptly communicate the patient's request for information to the family and the physician. B. Obtain the results of the biopsy and provide them to the patient. C. Tell the patient that the biopsy results are not back yet in order temporarily to appease him. D. Tell the patient that only the physician knows the results of the biopsy.

A. Promptly communicate the patient's request for information to the family and the physician. Strategies nurses could consider include the following: not lying to the patient, providing all information related to nursing procedures and diagnoses, and communicating the patient's requests for information to the family and physician. Ethically, you cannot tell the patient the results of the biopsy and you cannot lie to the patient.

A physician has ordered that a medication be given "stat" for a patient who is having an anaphylactic drug reaction. At what time would the nurse administer the medication? Select one: A. immediately after the order is noted B. whenever the patient asks for it C. not until verifying it with the patient D. at the next scheduled medication time

A. immediately after the order is noted A stat order is a single order, and it is carried out immediately. This is a legal order. The nurse would not wait until the next scheduled medication time or verify the order with the patient. With a p.r.n. order, the patient receives medication when it is requested or required.

What statement by a patient would indicate that a nurse had successfully implemented a teaching/learning strategy to prevent injury in the home? Select one: A. "I will turn off the outside lights and lock the doors every night." B. "I am going to remove all those throw rugs on the floor." C. "Well, I always let the boys play in the bathtub; they love it." D. "Do you think it would be best for me to buy a gun?"

B. "I am going to remove all those throw rugs on the floor." Nurses must evaluate the effectiveness of their interventions to promote safety and prevent injury. If the expected patient outcomes have been met and evaluative criteria satisfied, the patient should be able to correctly identify real and potential unsafe environmental situations and implement safety measures in the environment.

You have been referred to the care of an extended care resident who has been diagnosed with a stage III pressure ulcer. You are teaching staff at the facility about the role of nutrition in wound healing. What would be the best meal choice for this patient? Select one: A. Eggs, hash browns, coffee, and an apple B. Steak, baked potato, spinach and strawberry salad C. Skim milk, oatmeal, and whole wheat toast D. Whole wheat macaroni with cheese

B. Steak, baked potato, spinach and strawberry salad The patient should be encouraged to eat foods high in protein, carbohydrates and vitamins A, B, and C. A meal of steak, baked potato, spinach and strawberry salad best exemplifies this dietary balance.

You are the nurse caring for an elderly patient who is being treated for community-acquired pneumonia. Since the time of admission, the patient has been disoriented and agitated to varying degrees. Appropriate referrals were made and the patient was subsequently diagnosed with dementia. What nursing diagnosis should the nurse prioritize when planning this patient's care? Select one: A. Social isolation related to dementia B. Acute confusion related to dementia C. Hopelessness related to dementia D. Risk for infection related to dementia

B. Acute confusion related to dementia Acute confusion is a priority problem in patients with dementia, and it is an immediate threat to their health and safety. Hopelessness and social isolation are plausible problems, but the patient's cognition is a priority. The patient's risk for infection is not directly influenced by dementia.

You are writing a care plan for an 85-year-old patient who has community-acquired pneumonia and you note decreased breath sounds to bilateral lung bases on auscultation. What is the most appropriate nursing diagnosis for this patient? Select one: A. Poor ventilation related to acute lung infection B. Ineffective airway clearance related to tracheobronchial secretions C. Pneumonia related to progression of disease process D. Immobility related to fatigue

B. Ineffective airway clearance related to tracheobronchial secretions Nursing diagnoses are not medical diagnoses or treatments. The most appropriate nursing diagnosis for this patient is "ineffective airway clearance related to copious tracheobronchial secretions." "Pneumonia" and "poor ventilation" are not nursing diagnoses. Immobility is likely, but is less directly related to the patient's admitting medical diagnosis and the nurse's assessment finding.

You are providing care for a patient who has a diagnosis of pneumonia attributed to Streptococcus pneumonia infection. Which of the following aspects of nursing care would constitute part of the planning phase of the nursing process? Select one: A. Auscultate chest q4h. B. Administer oral fluids q1h and PRN. C. Achieve SaO2 ≥ 92% at all times. D. Avoid overexertion at all times.

C. Achieve SaO2 ≥ 92% at all times. The planning phase entails specifying the immediate, intermediate, and long-term goals of nursing action, such as maintaining a certain level of oxygen saturation in a patient with pneumonia. Providing fluids and avoiding overexertion are parts of the implementation phase of the nursing process. Chest auscultation is an assessment.

You are providing care for an 82-year-old man whose signs and symptoms of Parkinson disease have become more severe over the past several months. The man tells you that he can no longer do as many things for himself as he used to be able to do. What factor should you recognize as impacting your patient's life most significantly? Select one: A. Age-related changes B. Neurologic deficits C. Loss of independence D. Tremors and decreased mobility

C. Loss of independence This patient's statement places a priority on his loss of independence. This is undoubtedly a result of the neurologic changes associated with his disease, but this is not the focus of his statement. This is a disease process, not an age-related physiological change.

You are the nurse caring for an elderly patient with cardiovascular disease. The patient comes to the clinic with a suspected respiratory infection and is diagnosed with pneumonia. As the nurse, what do you know about the altered responses of older adults? Select one: A. Treatments for older adults need to be more holistic than treatments used in the younger population. B. The altered responses of older adults define the nursing interactions with the patient. C. The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications. D. Older adults become hypersensitive to antibiotic treatments for infectious disease states.

C. The altered responses of older adults reinforce the need for the nurse to monitor all body systems to identify possible systemic complications. Older people may be unable to respond effectively to an acute illness, or, if a chronic health condition is present, they may be unable to sustain appropriate responses over a long period. Furthermore, their ability to respond to definitive treatment is impaired. The altered responses of older adults reinforce the need for nurses to monitor all body system functions closely, being alert to signs of impending systemic complication. Holism should be integrated into all patients' care. Altered responses in the older adult do not define the interactions between the nurse and the patient. Older adults do not become hypersensitive to antibiotic treatments for infectious disease states.

A nurse assessing a patient's wound documents the finding of purulent drainage. What is the composition of this type of drainage? Select one: A. clear, watery blood B. large numbers of red blood cells C. white blood cells, debris, bacteria D. mixture of serum and red blood cells

C. white blood cells, debris, bacteria Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. Purulent drainage is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism. Serous drainage is composed primarily of the clear, serous portion of the blood and from serous membranes. Serous drainage is clear and watery. Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serosanguineous drainage is a mixture of serum and red blood cells. It is light pink to blood tinged.

You are the nurse caring for a female patient who developed a pressure ulcer as a result of decreased mobility. The nurse on the shift before you has provided patient teaching about pressure ulcers and healing promotion. You assess that the patient has understood the teaching by observing what? Select one: A. Patient elevates her body parts that are susceptible to edema. B. Patient performs range-of-motion exercises. C. Patient demonstrates the technique for massaging the wound site. D. Patient avoids placing her body weight on the healing site.

D. Patient avoids placing her body weight on the healing site. The major goals of pressure ulcer treatment may include relief of pressure, improved mobility, improved sensory perception, improved tissue perfusion, improved nutritional status, minimized friction and shear forces, dry surfaces in contact with skin, and healing of pressure ulcer, if present. The other options do not demonstrate the achievement of the goal of the patient teaching.

Based on a patient's vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse's primary responsibility? Select one: A. Confront the suspected perpetrator. B. Work with the family to promote healthy conflict resolution. C. Gather evidence to corroborate the abuse. D. Report the findings to adult protective services.

D. Report the findings to adult protective services. If neglect or abuse of any kind—including physical, emotional, sexual, or financial abuse—is suspected, the local adult protective services agency must be notified. The responsibility of the nurse is to report the suspected abuse, not to prove it, confront the suspected perpetrator, or work with the family to promote resolution.

A patient tells the nurse that her doctor just told her that her new diagnosis of rheumatoid arthritis is considered to be a "chronic condition." She asks the nurse what "chronic condition" means. What would be the nurse's best response? Select one: A. "Chronic conditions are defined as health problems that require management of several months or longer." B. "Chronic conditions are medical conditions that culminate in disabilities that require hospitalization." C. "Chronic conditions are those that require short-term management in extended-care facilities." D. "Chronic conditions are diseases that come and go in a relatively predictable cycle."

A. "Chronic conditions are defined as health problems that require management of several months or longer." Chronic conditions are often defined as medical conditions or health problems with associated symptoms or disabilities that require long-term management (3 months or longer). Chronic diseases are usually managed in the home environment. They are not always cyclical or predictable.

What would a nurse instruct a patient to do after administration of a sublingual medication? Select one: A. "Try not to swallow while the pill dissolves." B. "Chew the pill so it will dissolve faster." C. "Swallow frequently to get the best benefit." D. "Take a big drink of water and swallow the pill."

A. "Try not to swallow while the pill dissolves." Sublingual and buccal medications should not be swallowed but rather held in place so that complete absorption takes place.

The nurse is caring for a 65-year-old patient who has previously been diagnosed with hypertension. Which of the following blood pressure readings represents the threshold between high-normal blood pressure and hypertension? Select one: A. 140/90 mm Hg B. 160/100 mm Hg C. 145/95 mm Hg D. 150/100 mm Hg

A. 140/90 mm Hg Hypertension is the diagnosis given when the blood pressure is greater than 140/90 mm Hg. This makes the other options incorrect.

A design firm is contracted to remodel a care facility. Which bathroom design component is most conducive to safety and quality of life for the older adult residents who will use them? Select one: A. A small independent light to remain lit in the bathroom at all times B. Bathrooms will include bathtubs rather than showers C. A single, rotating faucet installed at the sink to control water flow and temperature D. Throw rugs will be placed on the tile floors

A. A small independent light to remain lit in the bathroom at all times A small light that remains lit in a bathroom promotes safety. It is not necessary to exclude showers from all residents' rooms and clearly marked, separate hot and cold faucets should be used. Throw rugs constitute a fall risk.

Which statement should be incorporated into the restraint policy for residents of a long-term care facility? Select one: A. Alternatives should be explored before chemical and physical restraints are utilized. B. Physical restraints should only be used with verifiably agitated patients. C. Restraints should never be used. D. Restraints should only be used when one-to-one staff supervision is not possible.

A. Alternatives should be explored before chemical and physical restraints are utilized. While it is not realistic to categorically prohibit the use of restraints, it is important to first explore and exhaust all other options. Restraints exacerbate agitation and the decision to use restraints should not be driven by staffing considerations.

A home health nurse makes a home visit to a 90-year-old patient who has cardiovascular disease. During the visit the nurse observes that the patient has begun exhibiting subtle and unprecedented signs of confusion and agitation. What should the home health nurse do? Select one: A. Arrange for the patient to see his primary care physician. B. Have a family member check in on the patient in the evening. C. Refer the patient to an adult day program. D. Increase the frequency of the patient's home care.

A. Arrange for the patient to see his primary care physician. In more than half of the cases, sudden confusion and hallucinations are evident in multi-infarct dementia. This condition is also associated with cardiovascular disease. Having the patient's home care increased does not address the problem, neither does having a family member check on the patient in the evening. Referring the patient to an adult day program may be beneficial to the patient, but it does not address the acute problem the patient is having, the nurse should arrange for the patient to see his primary care physician.

What does the nurse do to verify an order for a medication listed on a medication administration record (MAR)? Select one: A. Compare it with the original physician's order. B. Look up the drug in a textbook. C. Call the pharmacist for verification. D. Ask another nurse what the drug is.

A. Compare it with the original physician's order. In many institutions, the medication order is copied onto the patient's medication record. The nurse is responsible for checking that the medication order was transcribed correctly by comparing it with the original physician's order.

A 93-year-old male patient with failure to thrive has begun exhibiting urinary incontinence. When choosing appropriate interventions, you know that various age-related factors can alter urinary elimination patterns in elderly patients. What is an example of these factors? Select one: A. Decreased muscle tone B. Decreased residual volume C. Increased bladder capacity D. Urethral stenosis

A. Decreased muscle tone Factors that alter elimination patterns in the older adult include decreased bladder capacity, decreased muscle tone, increased residual volumes, and delayed perception of elimination cues. The other noted phenomena are atypical.

A nurse has administered an intramuscular injection. What will the nurse do with the syringe and needle? Select one: A. Do not recap the needle and place it in a puncture-resistant container. B. Take off the needle and throw the syringe in the patient's trash can. C. Break off the needle, place it in the barrel, and throw it in the trash. D. Recap the needle and place it in a puncture-resistant container.

A. Do not recap the needle and place it in a puncture-resistant container. After use, needles and syringes are placed in a puncture-resistant container without being recapped. This prevents needlestick injuries, because most occur during recapping.

A 47-year-old patient who has come to the physician's office for his annual physical is being assessed by the office nurse. The nurse who is performing routine health screening for this patient should be aware that one of the first physical signs of aging is what? Select one: A. Failing eyesight, especially close vision B. Having more frequent aches and pains C. Increasing loss of muscle tone D. Accepting limitations while developing assets

A. Failing eyesight, especially close vision Failing eyesight, especially close vision, is one of the first signs of aging in middle life. More frequent aches and pains begin in the "early" late years (between ages 65 and 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs in adulthood.

A nurse is administering an intramuscular injection of a viscous medication using the appropriate-gauge needle. What does the nurse need to know about needle gauges? Select one: A. Gauges range from 18 to 30, with 18 being the largest. B. The gauge will depend on the length of the needle. C. Ask the patient what size needle is preferred. D. All needles for parenteral injection are the same gauge.

A. Gauges range from 18 to 30, with 18 being the largest. The gauge is determined by the diameter of the needle and ranges from 18 to 30. As the diameter of the needle increases, the gauge number decreases (an 18-gauge needle is, therefore, larger than a 30-gauge needle). A viscous medication requires a larger-gauge needle for injection.

Gerontologic nursing is a specialty area of nursing that provides care for the elderly in our population. What goal of care should a gerontologic nurse prioritize when working with this population? Select one: A. Helping older adults use their strengths to optimize independence B. Helping older adults determine how to reduce their use of external resources C. Helping older adults promote social integration D. Helping older adults identify the weaknesses that most limit them

A. Helping older adults use their strengths to optimize independence Gerontologic nursing is provided in acute care, skilled and assisted living, community, and home settings. The goals of care include promoting and maintaining functional status and helping older adults identify and use their strengths to achieve optimal independence. Goals of gerontologic nursing do not include helping older adults "promote social integration" or identify their weaknesses. Optimal independence does not necessarily involve reducing the use of available resources.

What intervention should be included on a plan of care to prevent pressure ulcer development in healthcare settings? Select one: A. Implement a turning schedule every 2 hours. B. Use ring cushions for heels and elbows. C. Do not turn, use pressure-relieving support surface. D. Change position at least once each shift.

A. Implement a turning schedule every 2 hours. To protect patients at risk from the adverse effects of pressure, implement turning using an every-2-hour schedule in the healthcare setting. More frequent position changes may be necessary. Never use ring cushions or "donuts."

A resident of a long-term care facility has been experiencing pain associated with sciatica, a health problem that has not previously been present. Which intervention should the nurse implement first to help control this patient's pain? Select one: A. Implement nonpharmacologic measures B. Administer fentanyl or sustained-release oxycodone C. Provide morphine or codeine D. Prepare a dose of acetaminophen

A. Implement nonpharmacologic measures Nursing guidelines for older adults with pain include exploring nonpharmacologic means to manage pain first. If nonpharmacologic measures are unsuccessful, begin with the weakest type and dose of analgesic and gradually increase so that the patient's response can be evaluated. Morphine, codeine, fentanyl, and oxycodone should be used carefully in the older patient.

Barbiturates were given to an older man with reduced kidney function, and he nearly died as a result. What was the most likely reason for this near-fatality? Select one: A. Increased biological half-life of the drug B. Increased Kidney filtration C. Increased drug dosage D. Increased reabsorption of the drugs into the blood

A. Increased biological half-life of the drug

The nurse is providing care for an older adult man whose diagnosis of dementia has recently led to urinary incontinence. When planning this patient's care, what intervention should the nurse avoid? Select one: A. Indwelling catheter B. Scheduled toileting C. External condom catheter D. Incontinence pads

A. Indwelling catheter Indwelling catheters are avoided if at all possible because of the high incidence of urinary tract infections with their use. Intermittent self-catheterization is an appropriate alternative for managing reflex incontinence, urinary retention, and overflow incontinence related to an overdistended bladder. External catheters (condom catheters) and leg bags to collect spontaneous voiding are useful for male patients with reflex or total incontinence. Incontinence pads should be used as a last resort because they only manage, rather than solve, the incontinence.

The care team has deemed the occasional use of restraints necessary in the care of a patient with Alzheimer's disease. What ethical violation is most often posed when using restraints in a long-term care setting? Select one: A. It threatens the patient's autonomy. B. It limits the patient's personal safety. C. It is not normally legal. D. It exacerbates the patient's disease process.

A. It threatens the patient's autonomy. Because safety risks are involved when using restraints on elderly confused patients, this is a common ethical problem, especially in long-term care settings. By definition, restraints limit the individual's autonomy. Restraints are not without risks, but they should not normally limit a patient's safety. Restraints will not affect the course of the patient's underlying disease process, though they may exacerbate confusion. The use of restraints is closely legislated, but they are not illegal.

A nurse is planning discharge teaching for an 80-year-old patient with mild short-term memory loss. The discharge teaching will include how to perform basic wound care for the venous ulcer on his lower leg. When planning the necessary health education for this patient, what should the nurse plan to do? Select one: A. Keep teaching periods short. B. Keep visual cues to a minimum to enhance the patient's focus. C. Provide a list of useful Web sites to supplement learning. D. Set long-term goals with the patient.

A. Keep teaching periods short. To assist the elderly patient with short-term memory loss, the nurse should keep teaching periods short, provide glare-free lighting, link new information with familiar information, use visual and auditory cues, and set short-term goals with the patient. The patient may or may not be open to the use of online resources.

What must a nurse do each time medications are administered to ensure that medication errors do not occur? Select one: A. Observe the three checks and five rights. B. Review information about classification of drugs. C. Verify the number of medications to be administered. D. Ask another nurse to double-check the medications.

A. Observe the three checks and five rights. Safety is of the utmost when preparing and administering drugs. The nurse observes the three checks and five rights each time medications are administered.

An aide tells the nurse that an older adult patient has a pulse of 105 beats/min. This pulse rate should be taken seriously because of what? Select one: A. Older adults have poor cardiac reserves B. The patient is likely taking many medications C. The patient needs to be reassured that providers care D. Older adults usually have lower than normal pulse rates

A. Older adults have poor cardiac reserves Pulses greater than 100 are abnormal and should be taken seriously. Because of their poor cardiac reserves, older adults do not tolerate these pulse rates well for long periods. The scenario does not mention the patient's medications. Pulse rates on older adults often run in the 50-60 bpm range, but not always. While patients can benefit from reassurance, this is not the primary concern in this scenario.

Which action should the emergency department staff take first for an older patient who is demonstrating extreme confusion? Select one: A. Review the drugs being taken B. Order an ECG C. Check serum electrolyte levels D. Administer a stimulant

A. Review the drugs being taken The risk of adverse reactions to drugs is so high in older people that some health care providers suggest that any symptom in an older adult be suspected as being related to a drug until proven otherwise. If the patient or an accompanying person knows what drugs are being taken and the dosages, the cause of the dysfunction may be immediately apparent. No stimulant should be given until that information is available, as it might cause an interaction with adverse results. Serum electrolyte levels and an ECG may be needed but only after the drug information is known.

After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this man's risk of future infarcts, what action should the nurse most strongly encourage? Select one: A. Rigorous control of the patient's blood pressure and serum lipid levels B. Use of mobility aids to promote independence C. Adequate nutrition and fluid intake D. Activity limitation and falls reduction efforts

A. Rigorous control of the patient's blood pressure and serum lipid levels Because vascular dementia is associated with hypertension and cardiovascular disease, risk factors (e.g., hypercholesterolemia, history of smoking, diabetes) are similar. Prevention and management are also similar. Therefore, measures to decrease blood pressure and lower cholesterol levels may prevent future infarcts. Activity limitation is unnecessary and infarcts are not prevented by nutrition or the use of mobility aids.

Mrs. Harris is an 83-year-old woman who has returned to the community following knee replacement surgery. The community health nurse recognizes that Mrs. Harris has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses? Select one: A. Risk for falls related to polypharmacy and impaired balance B. Disturbed thought processes related to adverse drug effects and hypotension C. Adult failure to thrive related to chronic disease and circulatory disturbance D. Risk for infection related to polypharmacy and hypotension

A. Risk for falls related to polypharmacy and impaired balance Polypharmacy and loss of balance are major contributors to falls in the elderly. This patient does not exhibit failure to thrive or disturbed thought processes. There is no evidence of a heightened risk of infection.

A hospitalized patient asks the nurse for "some aspirin for my headache." There is no order for aspirin for this patient. What will the nurse do? Select one: A. State that an order from the doctor is legally required and check with the doctor. B. Ask the patient's family to bring some aspirin from home. C. Ask the patient's visitors if they have any aspirin for the patient. D. Go ahead and give the patient aspirin, a common self-prescribed drug.

A. State that an order from the doctor is legally required and check with the doctor. No medication may be given to a patient without a medication order from a physician (or a nurse practitioner in some states). The nurse would tell the patient an order from the physician is required.

The nurse is caring for a patient with a nursing diagnosis of impaired skin integrity related to a stage III decubitus ulcer. What would be the most important outcome for this patient? Select one: A. The patient exhibits no signs or symptoms of infection B. The patient changes position every 2 hours C. The patient keeps the area clean and dry D. The patient knows prevention measures for decubitus

A. The patient exhibits no signs or symptoms of infection All options are appropriate outcomes for this patient, but the most important outcome is that the patient exhibits no signs or symptoms of infection.

A nurse working in long-term care is assessing residents at risk for the development of a decubitus ulcer. Which one would be most at risk? Select one: A. an 86-year-old who is bedfast B. a 92-year-old who uses a walker C. an 83-year-old who is mobile D. a 75-year-old who uses a cane

A. an 86-year-old who is bedfast Most pressure ulcers occur in older adults as a result of a combination of factors, including aging skin, chronic illness, immobility, malnutrition, fecal and urinary incontinence, and altered level of consciousness. The bedfast resident would be most at risk in this situation.

What are the two major processes involved in the inflammatory phase of wound healing? Select one: A. blood clotting is initiated, WBCs move into the wound B. collagen is remodeled, avascular scar forms C. bleeding is stimulated, epithelial cells are deposited D. granulation tissue is formed, collagen is deposited

A. blood clotting is initiated, WBCs move into the wound The inflammatory phase of wound healing begins at the time of injury and prepares the wound for healing. The two major physiologic activities are blood clotting (hemostasis) and the vascular and cellular phase of inflammation.

The admissions department at a local hospital is registering an elderly man for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this patient? Select one: A. "Advance directives are not legal documents, so you have nothing to worry about." B. "Advance directives are limited only to health care instructions and directives." C. "Your finances cannot be managed without an advance directive." D. "Advance directives are implemented when you become incapacitated, and then you will use a living will to allow the state to manage your money."

B. "Advance directives are limited only to health care instructions and directives." An advance directive is a formal, legally endorsed document that provides instructions for care (living will) or names a proxy decision maker (durable power of attorney for health care) and covers only issues related specifically to health care, not financial issues. They do not address financial issues. Advance directives are implemented when a patient becomes incapacitated, but financial issues are addressed with a durable power of attorney for finances, or financial power of attorney.

A nurse is teaching an older adult at home about taking newly prescribed medications. Which of the following would be included? Select one: A. "Don't worry if the label comes off; just look at the shapes." B. "I have written the names of your drugs with times to take them." C. "You won't forget a medication if you count them every day." D. "You can identify your medications by their color."

B. "I have written the names of your drugs with times to take them." Teach patients the names of drugs rather than distinguishing drugs by color. Manufacturers may vary the color of generic drugs, and the visual changes associated with aging may make it more difficult to identify medications by color. Medications should not be identified by counting or by shapes.

Despite the wishes of her family and the recommendations of the care team, a 70-year-old client with a diagnosis of congestive heart failure, but who is otherwise healthy, wants to have a no-code order in place. Which of the following statements by the care team most clearly prioritizes the patient's autonomy? Select one: A. "If this is what is best for everyone then we need to go ahead with the order." B. "If that's what she wants, then ultimately we're obliged to respect her wishes." C. "Provided it can be demonstrated that she has a potentially poor prognosis, we should certainly consider doing this." D. "It's best that social work get involved at this point to reconcile the family's and the patient's wishes."

B. "If that's what she wants, then ultimately we're obliged to respect her wishes." Answer D most clearly prioritizes the patient's individual freedom, preference, and rights in this case, and these considerations would override the family's or the care team's conflicting interests.

Nurse M is employed in an assisted living facility and is privy to many of the changes that accompany the aging process. An older female resident of the facility has expressed a fear that her decreased mobility will make her increasingly dependent on her daughter. How can the nurse best respond to the resident's concerns? Select one: A. "This is a normal part of the aging process and you don't necessarily need to fear it." B. "Many older adults have similar concerns. We can work together to keep you independent as long as possible." C. "There are treatments and drugs that we can explore which might prevent this from happening." D. "I'm sure this is very stressful for you, but it's fortunate that you are not experiencing severe pain or illness."

B. "Many older adults have similar concerns. We can work together to keep you independent as long as possible." Answer C validates the client's concerns and expresses the possibility of addressing the issue without downplaying it or providing unrealistic promises. Answer A provides an unrealistic promise of prevention, while answers B and D downplay the severity and significance of the client's concerns.

Which of the following diagnostic and assessment findings from among the patients on a geriatric medical unit most warrants further investigation? Select one: A. A 78-year-old male's stomach pH is increased. B. A 78-year-old man has recently developed urinary incontinence. C. An 81-year-old woman's glomerular filtration rate (GFR) is low D. A 71-year-old male client's echocardiogram reveals slight left ventricular hypertrophy.

B. A 78-year-old man has recently developed urinary incontinence.

A nurse is caring for an 86-year-old female patient who has become increasingly frail and unsteady on her feet. During the assessment, the patient indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this patient is at a high risk for what health problem? Select one: A. Pelvic dysplasia B. A hip fracture C. Tearing of a meniscus or bursa D. A femoral fracture

B. A hip fracture The most common fracture resulting from a fall is a fractured hip resulting from osteoporosis and the condition or situation that produced the fall. The other listed injuries are possible, but less likely than a hip fracture.

A patient admitted with right leg thrombophlebitis is to be discharged from an acute-care facility. Following treatment with a heparin infusion, the nurse notes that the patient's leg is pain-free, without redness or edema. Which step of the nursing process does this reflect? Select one: A. Diagnosis B. Evaluation C. Analysis D. Implementation

B. Evaluation The nursing actions described constitute evaluation of the expected outcomes. The findings show that the expected outcomes have been achieved. Analysis consists of considering assessment information to derive the appropriate nursing diagnosis. Implementation is the phase of the nursing process where the nurse puts the care plan into action. This nurse's actions do not constitute diagnosis.

An adult patient has requested a "do not resuscitate" (DNR) order in light of his recent diagnosis with late stage pancreatic cancer. The patient's son and daughter-in-law are strongly opposed to the patient's request. What is the primary responsibility of the nurse in this situation? Select one: A. Contact a social worker or mediator to intervene. B. Honor the request of the patient. C. Perform a "slow code" until a decision is made. D. Temporarily withhold nursing care until the physician talks to the family.

B. Honor the request of the patient. The nurse must honor the patient's wishes and continue to provide required nursing care. Discussing the matter with the physician may lead to further communication with the family, during which the family may reconsider their decision. It is not normally appropriate for the nurse to seek the assistance of a social worker or mediator. A "slow code" is considered unethical.

An elderly patient has come in to the clinic for her twice-yearly physical. The patient tells the nurse that she is generally enjoying good health, but that she has been having occasional episodes of constipation over the past 6 months. What intervention should the nurse first suggest? Select one: A. Increase carbohydrate intake and reduce protein intake. B. Increase daily intake of water. C. Take herbal laxatives, such as senna, each night at bedtime. D. Reduce the amount of stress she currently experiences.

B. Increase daily intake of water. Constipation is a common problem in older adults and increasing fluid intake is an appropriate early intervention. This should likely be attempted prior to recommending senna or other laxatives. Stress reduction is unlikely to wholly resolve the problem and there is no need to increase carbohydrate intake and reduce protein intake.

Older people have many altered reactions to disease that are based on age-related physiological changes. When the nurse observes physical indicators of illness in the older population, that nurse must remember which of the following principles? Select one: A. The same physiological processes that indicate serious health care problems in a younger population indicate mild disease states in the elderly. B. Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults. C. Potential life-threatening problems in the older adult population are not as serious as they are in a middle-aged population. D. Middle-aged people do not react to disease states the same as a younger population does.

B. Indicators that are useful and reliable in younger populations cannot be relied on as indications of potential life-threatening problems in older adults. Physical indicators of illness that are useful and reliable in young and middle-aged people cannot be relied on for the diagnosis of potential life-threatening problems in older adults. Option A is incorrect because a potentially life-threatening problem in an older person is more serious than it would be in a middle-aged person because the older adult does not have the physical resources of the middle-aged person. Physical indicators of serious health care problems in a young or middle-aged population do not indicate disease states that are considered "mild" in the elderly population. It is true that middle-aged people do not react to disease states the same as a younger population, but this option does not answer the question.

Nurses provide many interventions to prevent falls in healthcare settings. Which of the following would be an appropriate fall-prevention intervention? Select one: A. Keep bed in the high position. B. Lock wheels on beds and wheelchairs. C. Apply restraints to all confused patients. D. Keep side rails up at all times.

B. Lock wheels on beds and wheelchairs. Locking wheels on beds and wheelchairs prevents them from rolling and precipitating a fall. Beds should be kept in low positions with the side rails down in most situations; restraints should be applied only as a last resort.

Gerontological nursing will become an increasingly important profession, compared with in the past, because: Select one: A. A greater number of people are surviving the previously hazardous period of infancy B. More people are spending a longer time span in old age C. More people will be presenting with the same health care challenges D. More elderly are living in increasingly squalid living conditions

B. More people are spending a longer time span in old age More people are achieving and spending longer periods of time in old age than ever before in history. Declines in living conditions, increased prevalence and incidence of the same health problems, and higher survival rates during infancy do not account for the increased importance of gerontological nursing.

A nurse has begun creating a patient's plan of care shortly after the patient's admission. It is important that the wording of the chosen nursing diagnoses falls within the taxonomy of nursing. Which organization is responsible for developing the taxonomy of a nursing diagnosis? Select one: A. Joint Commission B. NANDA C. National League for Nursing (NLN) D. American Nurses Association (ANA)

B. NANDA NANDA International is the official organization responsible for developing the taxonomy of nursing diagnoses and formulating nursing diagnoses acceptable for study. The ANA, NLN, and Joint Commission are not charged with the task of developing the taxonomy of nursing diagnoses.

The nurse prevents and treats pressure ulcers in the at-risk population of immobile elders. Which of the following interventions will best treat a stage 1 pressure ulcer? Select one: A. Thoroughly clean and irrigate the lesion. B. Off-load the area under pressure. C. Cover with a hydrogel sheet like Vigilon. D. Clean with normal saline three times a day.

B. Off-load the area under pressure. With hyperemia the redness of the skin can disappear quickly if pressure is removed. Vigilon is a high moisture content dressing appropriate for open lesion. The skin should be kept clean and dry using lotions to keep the skin soft.

A terminally ill patient you are caring for is complaining of pain. The physician has ordered a large dose of intravenous opioids by continuous infusion. You know that one of the adverse effects of this medicine is respiratory depression. When you assess your patient's respiratory status, you find that the rate has decreased from 16 breaths per minute to 10 breaths per minute. What action should you take? Select one: A. Stimulate the patient in order to increase respiratory rate. B. Report the decreased respiratory rate to the physician. C. Allow the patient to rest comfortably. D. Decrease the rate of IV infusion.

B. Report the decreased respiratory rate to the physician. End-of life issues that often involve ethical dilemmas include pain control, "do not resuscitate" orders, life-support measures, and administration of food and fluids. The risk of respiratory depression is not the intent of the action of pain control. Respiratory depression should not be used as an excuse to withhold pain medication for a terminally ill patient. The patient's respiratory status should be carefully monitored and any changes should be reported to the physician.

When administering a proton pump inhibitor to a patient with gastroesophageal reflux disease (GERD), the nurse notes that the patient has great difficulty swallowing the enteric-coated pill. What should the nurse do when administering this medication to the patient in the future? Select one: A. Provide an herbal alternative that also reduces stomach acid production B. Reposition the patient and provide more fluid when giving the pill C. Crush the pill and mix with applesauce D. Split the pill in two parts and give each separately

B. Reposition the patient and provide more fluid when giving the pill Since enteric-coated pills should not be crushed or split, the nurse's best alternative is to reposition the patient and provide more fluid to aid with swallowing. It would be inappropriate to provide a nonpharmacologic alternative to the prescribed medication.

The child of a nursing home resident complains to the nurse that his mother is required to get out of bed and do simple morning exercises when she would rather sleep. Which of the following rationales is the most appropriate for the nurse to state to the relative? Select one: A. The exercise is needed for preventing pressure ulcers. B. The exercise is needed for promoting circulation. C. The nurse's aide can make the bed more easily. D. The exercise is needed for psychological health.

B. The exercise is needed for promoting circulation. All of these choices are valid reasons for asking a patient to get out of bed, but A is the best one. Without exercise, the resident is likely to develop varicose veins and stasis ulcers. A bed-ridden patient can be turned to prevent pressure ulcers, and making the bed is possible, though more difficult, while the patient is in it. Psychological health is aided by exercise, but that can be promoted in other ways (such as getting enough sleep) as well.

The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility. When planning relevant assessments, the nurse should prioritize inspection of what area? Select one: A. The patient's elbows B. The patient's heels C. The patient's knees D. The soles of the patient's feet

B. The patient's heels Full inspection of the patient's skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.

The nurse is caring for an older patient with a fractured hip. Which pain control goal would be the most realistic for the patient? Select one: A. The patient will experience relief from pain. B. The patient's self-report of pain will remain below 5 out of 10 while hospitalized. C. Scheduled and breakthrough analgesia will be administered as needed. D. The patient will state that being in a state of comfort.

B. The patient's self-report of pain will remain below 5 out of 10 while hospitalized. The goal that the patient's self-report of pain will remain below 5 out of 10 while hospitalized is realistic, specific, and achievable. The patient experiencing relief from pain is not specific. The goal that the patient will state being in a state of comfort is neither realistic nor measurable. Providing analgesia is a nursing goal.

A nurse is administering a liquid medication to an infant. Where will the nurse place the medication to prevent aspiration? Select one: A. under the tongue B. between the gum and the cheek C. on the front of the tongue D. in front of the teeth and gums

B. between the gum and the cheek A dropper is used to give infants or very young children liquid medications while holding them in a sitting or semisitting position. The medication is placed between the gum and the cheek to prevent aspiration.

An elderly woman in a long-term care facility has fallen and sustained several injuries. Which of her injuries would be the most serious fall-related injury? Select one: A. lacerated lip B. fractured hip C. fractured ulna D. thigh contusion

B. fractured hip Falls can occur at any age, but a large percentage of elderly adults in long-term settings suffer a fall. Hip fractures are among the most serious fall-related injuries.

When patients are pulled up in bed rather than lifted, they are at increased risk for the development of a decubitus ulcer. What is the name given to the factor responsible for this risk? Select one: A. ischemia B. shearing force C. friction D. necrosis of tissue

B. shearing force A shearing force results when one layer of tissue slides over another layer. Patients who are pulled rather than lifted when being moved up in bed or from bed to chair to stretcher are at risk for injury from shearing forces.

An older patient with a history of arthritis has fallen after an episode of dizziness. Laboratory data reveal anemia and stool positive for occult blood. Which assessment question is the most appropriate for the patient's health situation? Select one: A. "What herbal remedies or supplements do you use regularly?" B. "Do you take any medication for high blood pressure?" C. "Do you take aspirin for the treatment of pain or inflammation?" D. "Does your family doctor ask you to get regularly scheduled blood work?"

C. "Do you take aspirin for the treatment of pain or inflammation?" Anemia and stool positive for occult blood could indicate the presence of gastrointestinal (GI) bleeding. Since aspirin is commonly implicated in episodes of GI bleeding this question would be the best to ask the patient at this time. The other questions may or may not relate to the patient's condition and are less likely to be related to anemia and blood in the stool.

Which of the following social changes is increasing the number and complexity of ethical dilemmas that nurses face? Select one: A. Diminished fiscal constraints B. Expansion of the hospice movement C. Greater numbers of older adults D. Outdated medical technologies

C. Greater numbers of older adults Nurses face more ethical dilemmas as a result of new medical technologies and increased fiscal constraints. The complexity is increased by larger numbers of older adults to serve. The expansion of hospice care helps nurses deal with ethical dilemmas.

An elderly woman diagnosed with osteoarthritis has been referred for care. The patient has difficulty ambulating because of chronic pain. When creating a nursing care plan, what intervention may the nurse use to best promote the patient's mobility? Select one: A. Encourage the patient to push through the pain in order to gain further mobility. B. Motivate the patient to walk in the afternoon rather than the morning. C. Administer an analgesic as ordered to facilitate the patient's mobility. D. Have another person with osteoarthritis visit the patient.

C. Administer an analgesic as ordered to facilitate the patient's mobility. At times, mobility is restricted because of pain, paralysis, loss of muscle strength, systemic disease, an immobilizing device (e.g., cast, brace), or prescribed limits to promote healing. If mobility is restricted because of pain, providing pain management through the administration of an analgesic will increase the patient's level of comfort during ambulation and allow the patient to ambulate. Motivating the patent or having another person with the same diagnosis visit is not an intervention that will help with mobility. The patient should not be encouraged to "push through the pain."

A recent nursing graduate is aware of the differences between nursing actions that are independent and nursing actions that are interdependent. A nurse performs an interdependent nursing intervention when performing which of the following actions? Select one: A. Providing mouth care to a patient who is unconscious following a cerebrovascular accident B. Auscultating a patient's apical heart rate during an admission assessment C. Administering an IV bolus of normal saline to a patient with hypotension D. Providing discharge teaching to a postsurgical patient about the rationale for a course of oral antibiotics

C. Administering an IV bolus of normal saline to a patient with hypotension Although many nursing actions are independent, others are interdependent, such as carrying out prescribed treatments, administering medications and therapies, and collaborating with other health care team members to accomplish specific, expected outcomes and to monitor and manage potential complications. Irrigating a wound, administering pain medication, and administering IV fluids are interdependent nursing actions and require a physician's order. An independent nursing action occurs when the nurse assesses a patient's heart rate, provides discharge education, or provides mouth care.

An elderly patient is brought to the emergency department with a fractured tibia. The patient appears malnourished, and the nurse is concerned about the patient's healing process related to insufficient protein levels. What laboratory finding would the floor nurse prioritize when assessing for protein deficiency? Select one: A. Cortisol B. Hemoglobin C. Albumin D. Bilirubin

C. Albumin Serum albumin is a sensitive indicator of protein deficiency. Albumin levels of less than 3 g/mL are indicative of hypoalbuminemia. Altered hemoglobin levels, cortisol levels, and bilirubin levels are not indicators of protein deficiency.

A nurse will conduct an influenza vaccination campaign at an extended care facility. The nurse will be administering intramuscular (IM) doses of the vaccine. Of what age-related change should the nurse be aware when planning the appropriate administration of this drug? Select one: A. An older patient has a higher risk of bleeding after an IM injection than a younger patient. B. An older patient has more subcutaneous tissue and less durable skin than a younger patient. C. An older patient has less subcutaneous tissue and less muscle mass than a younger patient. D. An older patient has more superficial and tortuous nerve distribution than a younger patient.

C. An older patient has less subcutaneous tissue and less muscle mass than a younger patient. When administering IM injections, the nurse should remember that in an older patient, subcutaneous fat diminishes, particularly in the extremities. Muscle mass also decreases. There are no significant differences in nerve distribution or bleeding risk.

An older individual is touring an assisted living facility with his family in order to find a place to live after the death of his spouse and issues with mobility. Which characteristic of the facility is most in need of modification? Select one: A. Aromatherapy is used in the facility to provide a pleasant scent environment B. The temperature of common areas is kept between 75°F and 77°F C. Area rugs are placed in front of each sink in residents' washrooms to ensure warmth D. There is more tile than carpet throughout the facility and carpets are glued to the floor

C. Area rugs are placed in front of each sink in residents' washrooms to ensure warmth Area rugs constitute a fall risk and should not be used. The temperature, the use of aromatherapy, and the prioritization of tile over carpet are all conducive to a safe and pleasant environment.

When administering a medication to a client, the nurse needs to identify the client. Which of the following methods of identification should the nurse perform? Select one: A. Check the client's ID bracelet and scan the bar code. B. Check the client's name on the medication administration record. C. Ask the the client's full name and date of birth. D. Check the client's name with a family member

C. Ask the the client's full name and date of birth.

Which of following statements most accurately captures the role of chronic illness in the lives of older adults? Select one: A. While chronic diseases used to be the leading cause of death, this is no longer the case. B. More older adults die from acute illnesses than from chronic diseases. C. Chronic illnesses constitute the leading cause of death for older adults. D. While cancer rates have fallen, other chronic diseases remain a common cause of death.

C. Chronic illnesses constitute the leading cause of death for older adults. Chronic illnesses constitute the leading cause of death for older adults, exceeding those attributed to acute illnesses. The presence of heart disease as a cause of death has decreased in recent years, while at the same time cancer has become more prevalent.

The nursing instructor is explaining critical thinking to a class of first-semester nursing students. When promoting critical thinking skills in these students, the instructor should encourage them to do which of the following actions? Select one: A. Weigh each of the potential negative outcomes in a situation. B. Disregard input from people who do not have to make the particular decision. C. Examine and analyze all available information. D. Set aside all prejudices and personal experiences when making decisions.

C. Examine and analyze all available information.

A nurse is teaching medication safety to a group of healthy older adults at a community center. The nurse explains that due to the high frequency of food-drug interactions, the clients should avoid taking their medications with which of the following? Select one: A. Orange juice B. Milk C. Grapefruit juice D. Carbonated beverages

C. Grapefruit juice

A nurse is administering an oral medication to an older adult client. The client states, "The pill I always take is green. I don't take an orange pill." Which of the following nursing responses is appropriate? Select one: A. Let me explain the purpose of the medication." B. This is the medication that your doctor wants you to take." C. I will check your medication orders again." D. Sometimes the same pill comes in a different color."

C. I will check your medication orders again."

An elderly female patient who is bedridden is admitted to the unit because of a pressure ulcer that can no longer be treated in a community setting. During your assessment of the patient, you find that the ulcer extends into the muscle and bone. At what stage would document this ulcer? Select one: A. I B. II C. IV D. III

C. IV Stage III and IV pressure ulcers are characterized by extensive tissue damage. In addition to the interventions listed for stage I, these advanced draining, necrotic pressure ulcers must be cleaned (débrided) to create an area that will heal. Stage IV is an ulcer that extends to underlying muscle and bone. Stage III is an ulcer that extends into the subcutaneous tissue. With this type of ulcer, necrosis of tissue and infection may develop. Stage I is an area of erythema that does not blanch with pressure. Stage II involves a break in the skin that may drain.

A patient has recently been diagnosed with type 2 diabetes. The patient is clinically obese and has a sedentary lifestyle. How can the nurse best begin to help the patient increase his activity level? Select one: A. Have a family member ensure the patient follows a suggested exercise plan. B. Construct an exercise program and have the patient follow it. C. Identify barriers with the patient that inhibit his lifestyle change. D. Set up appointment times at a local fitness center for the patient to attend.

C. Identify barriers with the patient that inhibit his lifestyle change. Nurses cannot expect that sedentary patients are going to develop a sudden passion for exercise and that they will easily rearrange their day to accommodate time-consuming exercise plans. The patient may not be ready or willing to accept this lifestyle change. This is why it is important that the nurse and patient identify barriers to change.

A group of residents in a skilled nursing facility are sitting outside in the garden enjoying a hot summer day. What primary concern does the nurse recognize for these residents? Select one: A. Lack of motivation to get out of the sun B. Effects of certain medications on body temperature C. Lack of thirst perception D. Lack of energy and related depression

C. Lack of thirst perception Thirst perception declines with age, and so older persons are less aware of their fluid needs. This can be dangerous in hot weather. Natural sunlight would help with energy and depression. The residents may need assistance to get out of the sun. The effects of medications on body temperature may or may not be a concern since it would depend upon the resident and the medications being taken.

Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should nurses identify? Select one or more: A. Chronic Disease diagnosis B. C. Medication effects D. Overdependence on assistive devices E. Ineffective coping mechanisms

C. Medication effects Causes of falls are multifactorial. Both extrinsic factors, such as changes in the environment or poor lighting, and intrinsic factors, such as physical illness, neurologic changes, or sensory impairment, play a role. Mobility difficulties, medication effects, foot problems or unsafe footwear, postural hypotension, visual problems, and tripping hazards are common, treatable causes. Overdependence on assistive devices and ineffective use of coping strategies have not been shown to be factors in the rate of falls in the elderly population.

Which of the following statements is true of the older adult population? Select one: A. Most older adults live in nursing homes. B. Older adults are not interested in sex. C. Old age begins at 65 years of age. D. Incontinence is not a part of aging.

C. Old age begins at 65 years of age. D. Incontinence is not a part of aging. Although a common myth of aging is that bladder problems are common, in actuality incontinence is not a normal part of aging and requires medical attention.

A nurse assesses an area of pale white skin over a patient's coccyx. After turning the patient on her side, the skin becomes red and feels warm. What should the nurse do about these assessments? Select one: A. Immediately report to the physician that the patient has a pressure ulcer. B. Implement nursing interventions for Altered Skin Integrity. C. Recognize that this is ischemia, followed by reactive hyperemia. D. Document the presence of a pressure ulcer and develop a care plan.

C. Recognize that this is ischemia, followed by reactive hyperemia. Blanching of skin over an area under pressure results from ischemia. When pressure is relieved, reactive hyperemia follows and the skin is red and feels warm. Reactive hyperemia is not a stage I pressure ulcer.

While conducting a health assessment with an older adult, the nurse notices it takes the person longer to answer questions than is usual with younger patients. What should the nurse do? Select one: A. Realize that the patient has some dementia. B. Stop asking questions so as not to confuse the patient. C. Slow the pace and allow extra time for answers. D. Ask a family member to answer the questions.

C. Slow the pace and allow extra time for answers. Cognition does not change appreciably with aging. It is normal for the older adult to take longer to respond and react. The nurse should slow the pace of care and allow older patients extra time to answer questions or complete activities.

During a morning assessment the nurse notes that the oral temperature of an older patient is 96°F (35.6°C). What guide will the nurse use to make decisions about this assessment finding? Select one: A. Older adults are at increased risk for hyperthermia B. Older adults often lose body heat in response to infection C. The normal body temperature of older adults is often lower than that of younger people D. Low temperature constitutes a risk to cardiac health

C. The normal body temperature of older adults is often lower than that of younger people

While caring for an elderly man, the nurse observes that his skin is dry and wrinkled, his hair is gray, and he needs glasses to read. Based on these observations, what would the nurse conclude? Select one: A. The observations are not typically found in older adults. B. Extra teaching will be necessary to prevent complications. C. These are normal physiologic changes of aging. D. These are abnormal observations and must be reported.

C. These are normal physiologic changes of aging. Dry wrinkled skin, gray hair, and needing glasses to read are all commonly occurring and normal physiologic changes of aging. They are not abnormal and do not lead to complications.

An elderly patient has presented to the clinic with a new diagnosis of osteoarthritis. The patient's daughter is accompanying him and you have explained why the incidence of chronic diseases tends to increase with age. What rationale for this phenomenon should you describe? Select one: A. Chronic illnesses are diagnosed more often in older adults because they have more contact with the health care system. B. Older adults often have less support and care from their family, resulting in illness. C. With age, biologic changes reduce the efficiency of body systems. D. There is an increased morbidity of peers in this age group, and this leads to the older adult's desire to also assume the "sick role."

C. With age, biologic changes reduce the efficiency of body systems. Causes of the increasing number of people with chronic conditions include the following: longer lifespans because of advances in technology and pharmacology, improved nutrition, safer working conditions, and greater access (for some people) to health care. Also, biologic conditions change in the aged population. These changes reduce the efficiency of the body's systems. Older adults usually have more support and care from their family members. Assuming the "sick role" can be a desire in any age group, not just the elderly.

A nurse teaches adults preventive measures to avoid problems of middle adult years. Which of the following are the major health problems during the middle adult years? Select one: A. upper respiratory infections, fractures B. communicable diseases, dementia C. cardiovascular disease, cancer D. sexually transmitted diseases, drug abuse

C. cardiovascular disease, cancer The major health problems of the middle adult years are cardiovascular and pulmonary diseases, cancer, rheumatoid arthritis, diabetes mellitus, obesity, alcoholism, and depression. The risk for these health problems often depends on a combination of lifestyle factors and aging.

Mrs. Ash, an 88-year-old woman who lives alone, has deficits in vision and hearing. Her blood pressure medicine is making her dizzy. What response to these health problems would the home health nurse identify? Select one: A. altered consciousness B. risk for impaired judgment C. risk for accidental injury D. decreased social interaction

C. risk for accidental injury The older adult is at increased risk for accidental injury because of changes in vision and hearing, loss of muscle mass and strength, slower reflexes and reaction time, and decreased sensory ability. The effects of chronic illness and medications may also make the older adult more prone to accidents.

Which anatomic site is recommended for intramuscular injections for adults? Select one: A. subcutaneous fat B. vastus lateralis C. ventrogluteal muscles D. epidermis of inner forearm

C. ventrogluteal muscles The ventrogluteal site involves the gluteus medius and gluteus minimus muscles in the hip area. This site is recommended for adults because there are no large nerves or blood vessels, it is removed from bone tissue, it is clean, and the patient may lie on the back, abdomen, or side for the injection.

A nurse recommends to an older patient's family to place a seat alongside the bathtub to enable the older adult bather to rest while drying off. What is the best explanation for the nurse's recommendation? Select one: A. Most elderly have an age-related problem discriminating hazards. B. Nonslip surfaces are essential for tubs and shower floors. C. The elderly use the bathroom often and can benefit from the rest. D. A drop in blood pressure may follow bathing.

D. A drop in blood pressure may follow bathing. A drop in blood pressure may follow bathing; sitting down after bathing lessens the risk of the elderly bather falling because of low blood pressure. Nonslip surfaces inside tubs and shower stalls are important, but this choice is not a reason for having a seat outside the tub. It is not true that the elderly use the bathroom often and can benefit from the rest. It is also not true that most elderly have an age-related problem with discriminating hazards.

The nurse is on a task force to reduce the incidence of falls among residents of a long-term care facility. Which measure should the nurse recommend to prevent the most falls? Select one: A. The use of diffuse, natural lighting on the unit B. Psychosocial interventions aimed at reducing individuals' fear of falling C. Use of physical restraints on new patients who have delirium or dementia. D. A fall history and fall risk assessment of each patient on admission

D. A fall history and fall risk assessment of each patient on admission A thorough history and fall risk assessment is central to any fall reduction initiative. This would supersede the use of diffuse lighting, though this type of lighting is appropriate. Interventions aimed at reducing the fear of falling will not necessarily reduce falls, and the liberal use of restraints is inappropriate.

A gerontologic nurse practitioner provides primary care for a large number of older adults who are living with various forms of cardiovascular disease. This nurse is well aware that heart disease is the leading cause of death in the aged. What is an age-related physiological change that contributes to this trend? Select one: A. Resting heart rate decreases with age. B. Atrial-septal defects develop with age. C. Systolic blood pressure decreases. D. Heart muscle and arteries lose their elasticity.

D. Heart muscle and arteries lose their elasticity. The leading cause of death for patients over the age of 65 years is cardiovascular disease. With age, heart muscle and arteries lose their elasticity, resulting in a reduced stroke volume. As a person ages, systolic blood pressure does not decrease, resting heart rate does not decrease, and the aged are not less likely to adopt a healthy lifestyle.

A gerontologic nurse is making an effort to address some of the misconceptions about older adults that exist among health care providers. The nurse has made the point that most people aged 75 years remains functionally independent. The nurse should attribute this trend to what factor? Select one: A. Changes in the medical treatment of hypertension and hyperlipidemia B. Early detection of disease and increased advocacy by older adults C. Genetic changes that have resulted in increased resiliency to acute infection D. Application of health-promotion and disease-prevention activities

D. Application of health-promotion and disease-prevention activities Even among people 75 years of age and over, most remain functionally independent, and the proportion of older Americans with limitations in activities is declining. These declines in limitations reflect recent trends in health-promotion and disease-prevention activities, such as improved nutrition, decreased smoking, increased exercise, and early detection and treatment of risk factors such as hypertension and elevated serum cholesterol levels. This phenomenon is not attributed to genetics, medical treatment, or increased advocacy.

The nurse caring for older patients in an acute care facility is aware of the changes in drug metabolism that can occur in older adults. Which statement explains the most important factor that affects pharmacokinetics in older patients? Select one: A. Changes in gastrointestinal (GI) motility increase the absorption time for many drugs. B. Preexisting chronic conditions complicate the distribution and metabolism of drugs. C. Drug distribution is unpredictable due to metabolic and body-composition factors. D. Decreased renal and liver function contributes to an increased half-life for many drugs.

D. Decreased renal and liver function contributes to an increased half-life for many drugs. Changes in renal and liver function contribute significantly to the changes in pharmacokinetics that are common in older adults. While changes in GI motility, drug distribution, and preexisting conditions may be true for many patients, these factors are inconsistent.

A gerontologic nurse has observed that patients often fail to adhere to a therapeutic regimen. What strategy should the nurse adopt to best assist an older adult in adhering to a therapeutic regimen involving wound care? Select one: A. Provide a detailed pamphlet on a dressing change. B. Delegate the dressing change to a trusted family member. C. Verbally instruct the patient how to change a dressing and check for comprehension. D. Demonstrate a dressing change and allow the patient to practice.

D. Demonstrate a dressing change and allow the patient to practice. The nurse must consider that older adults may have deficits in the ability to draw inferences, apply information, or understand major teaching points. Demonstration and practice are essential in meeting their learning needs. The other options are incorrect because the elderly may have problems reading and/or understanding a written pamphlet or verbal instructions. Having a family member change the dressing when the patient is capable of doing it impedes self-care and independence.

A gerontologic nurse is basing the therapeutic programs at a long-term care facility on Miller's Functional Consequences Theory. To actualize this theory of aging, the nurse should prioritize what task? Select one: A. Helping older adults accept the inevitability of death B. Attempting to control age-related physiological changes C. Lowering expectations for recovery from acute and chronic illnesses D. Differentiating between age-related changes and modifiable risk factors

D. Differentiating between age-related changes and modifiable risk factors The Functional Consequences Theory requires the nurse to differentiate between normal, irreversible age-related changes and modifiable risk factors. This theory does not emphasize lowering expectations, controlling age-related changes, or helping adults accept the inevitability of death.

A gerontologic nurse is overseeing the care that is provided in a large, long-term care facility. The nurse is educating staff about the significant threat posed by influenza in older, frail adults. What action should the nurse prioritize to reduce the incidence and prevalence of influenza in the facility? Select one: A. Make arrangements for residents to limit social interaction during winter months. B. Teach staff how to administer prophylactic antiviral medications effectively. C. Ensure that residents receive a high-calorie, high-protein diet during the winter. D. Ensure that residents receive influenza vaccinations in the fall of each year.

D. Ensure that residents receive influenza vaccinations in the fall of each year. The influenza and the pneumococcal vaccinations lower the risks of hospitalization and death in elderly people. The influenza vaccine, which is prepared yearly to adjust for the specific immunologic characteristics of the influenza viruses at that time, should be administered annually in autumn. Prophylactic antiviral medications are not used. Limiting social interaction is not required in most instances. Nutrition enhances immune response, but this is not specific to influenza prevention.

In response to a patient's complaint of pain, the nurse administered a PRN dose of hydromorphone (Dilaudid). In what phase of the nursing process will the nurse determine whether this medication has had the desired effect? Select one: A. Data collection B. Analysis C. Assessment D. Evaluation

D. Evaluation Evaluation, the final step of the nursing process, allows the nurse to determine the patient's response to nursing interventions and the extent to which the objectives have been achieved.

The nurse educates the staff of a residential home about an upcoming influenza season. Which of the following should the nurse include in the presentation? Select one: A. Antibiotics are an effective treatment for influenza. B. Infection control practices increase the risks of transmission of influenza. C. The influenza vaccination is not recommended for persons over the age of 64. D. Hand hygiene is one of the most important ways to prevent the spread of infections.

D. Hand hygiene is one of the most important ways to prevent the spread of infections. Health care providers should adhere to strict infection control practices and practice hand hygiene at key points in time to disrupt the transmission of microorganisms. A yearly influenza vaccination is recommended to reduce its occurrence.

Nurse H is providing care in the hospital for a 71-year-old male patient who is in the late stages of cancer and who has painful bone metastases. The client is non-responsive but groans and grimaces intermittently. Nurse H is drawing up a breakthrough dose of morphine for the patient, but Nurse R cautions that, "sure, that will address his pain, but it could depress his respiratory drive and actually kill him at this stage." Which of the following ethical principles is Nurse R prioritizing? Select one: A. Justice B. Fidelity C. Beneficence D. Nonmaleficence

D. Nonmaleficence Nurse R's emphasis on preventing harm to the patient, even during an act that may be motivated by altruism, is characteristic of the principle of nonmaleficence.

Gerontological nursing is a complex specialty. Which of the following contributes most to this fact? Select one: A. Elderly people are generally compromised in their health status B. Complications after surgery or illness result in death in most cases C. Care for the elderly costs more than care for younger patients D. Numerous health conditions can overlap in the elderly

D. Numerous health conditions can overlap in the elderly Most elderly people are well, and their care is no more expensive than that of any other person. Death is not the most frequent outcome of illness or surgery. Multiple health conditions often coexist, making it difficult for health care professionals to sort out cause-and-effect relationships in symptoms, diagnoses, and treatments.

A patient with end-stage lung cancer has been admitted to hospice care. The hospice team is meeting with the patient and her family to establish goals for care. What is likely to be a first priority in goal setting for the patient? Select one: A. Promotion of spirituality B. Maintenance of activities of daily living C. Social interaction D. Pain control

D. Pain control Once the phase of illness has been identified for a specific patient, along with the specific medical problems and related social and psychological problems, the nurse helps prioritize problems and establish the goals of care. Identification of goals must be a collaborative effort, with the patient, family, and nurse working together, and the goals must be consistent with the abilities, desires, motivations, and resources of those involved. Pain control is essential for patients who have a terminal illness. If pain control is not achieved, all activities of daily living are unattainable. This is thus a priority in planning care over the other listed goals.

A nurse is caring for a client who is receiving nifedipine (Procardia). The nurse checks the client's blood pressure before administering medication and reports 98/58. Which of the following actions should the nurse take first? Select one: A. Notify the client's provider of the result. B. Instruct the client to get up from the sitting position slowly. C. Document the client's blood pressure. D. Recheck the client's blood pressure.

D. Recheck the client's blood pressure.

The nurse is preparing to conduct an admission assessment on a 76-year-old man. What would be important to do before interviewing this patient? Select one: A. Make sure the door is not blocked B. Speak in a louder than normal voice C. Turn up the patient's hearing aid D. Reduce or eliminate background noise

D. Reduce or eliminate background noise It is essential to reduce or eliminate background noise as much as possible when carrying on conversations. This includes turning off the television or radio in the patient's room and closing the door to reduce sounds of telephones, beepers, alarms, or pagers. Before beginning the interview, it would not be necessary to make sure the door is not blocked or to speak in a louder than normal voice. The scenario does not say that the patient is using a hearing aid.

You are caring for a patient with a history of chronic angina. The patient tells you that after breakfast he usually takes a shower and shaves. It is at this time, the patient says, that he tends to experience chest pain. What might you counsel the patient to do to decrease the likelihood of angina in the morning? Select one: A. Shower once a week and shave prior to breakfast. B. Skip breakfast and eat an early lunch. C. Take a nitro tab prior to breakfast. D. Shower in the evening and shave before breakfast.

D. Shower in the evening and shave before breakfast. If the nurse determines that one of the situations most likely to precipitate angina is to shower and shave after breakfast, the nurse might counsel the patient to break these activities into different times during the day. Skipping breakfast and eating an early lunch would not decrease the likelihood of angina in the morning. Taking a nitro tablet before breakfast is inappropriate because the event requiring the medication has not yet occurred. Also, suggesting that the patient shower once a week and shave prior to breakfast is an incorrect suggestion because showering and shaving can both be done every day if they are spread out over the course of the day.

The nurse assists in the surgical removal of eschar from a trochanter pressure ulcer revealing the bone and tendons. The nurse correctly stages this ulcer as what stage? Select one: A. Stage 2 B. Stage 3 C. Stage 1 D. Stage 4

D. Stage 4 With stage 4 the subcutaneous tissue is lost, exposing muscle, bone, or both. Eschar must be removed to fully stage and treat a pressure ulcer.

The nurse is caring for an older adult patient who is receiving rehabilitation following an ischemic stroke. A review of the patient's electronic health record reveals that the patient usually defers her self-care to family members or members of the care team. What should the nurse include as an initial goal when planning this patient's subsequent care? Select one: A. The patient will participate in a life skills program. B. The nurse will delegate the patient's care to a nursing assistant. C. The patient's family will collaboratively manage the patient's care. D. The patient will demonstrate independent self-care.

D. The patient will demonstrate independent self-care. An appropriate patient goal will focus on the patient demonstrating independent self-care. The rehabilitation process helps patients achieve an acceptable quality of life with dignity, self-respect, and independence. The other options are incorrect because an appropriate goal would not be for the family to manage the patient's care, the patient's care would not be delegated to a nursing assistant, and participating in a social program is not an appropriate initial goal.

A nurse is assessing a patient with a stage IV pressure ulcer. What assessment of the ulcer would be expected? Select one: A. blister formation B. skin pallor C. eschar formation D. full-thickness skin loss

D. full-thickness skin loss A stage IV pressure ulcer is characterized by the extensive destruction associated with full-thickness skin loss.

A home care nurse makes the following assessments of a wound: increased drainage and pain, increased body temperature, red and swollen wound, and purulent wound drainage. What wound complication do these assessments indicate? Select one: A. fistula B. dehiscence C. evisceration D. infection

D. infection Symptoms of infection usually become apparent within 2 to 7 days after an injury or surgery; often the patient is at home. Symptoms include purulent drainage; increased drainage; pain, redness, and swelling around the wound; increased body temperature; and increased WBCs.

A nurse is administering a medication to a patient for acute pain. Of the various routes for drug administration, which would be chosen because it is absorbed more rapidly? Select one: A. oral-coated medications B. topical skin medications C. liquid oral medications D. injected medications

D. injected medications Injected medications are usually absorbed more rapidly than oral or topical medications.

A nurse is administering a medication that is formulated as enteric-coated tablets. What is the rationale for not crushing or chewing enteric-coated tablets? Select one: A. to facilitate absorption in the stomach B. to prevent absorption in the esophagus C. to prevent absorption in the mouth D. to prevent gastric irritation

D. to prevent gastric irritation Enteric-coated tablets are covered with a hard surface to impede absorption until the tablet has left the stomach. Enteric-coated tablets should not be chewed or crushed because the active ingredient of the drug is irritating to the gastric mucosa.