Combo with Older Adult Nclex questions and 1 other
A nurse is performing an assessment of a client who is scheduled for a cesarean delivery. Which assessment finding would indicate a need to contact the physician? 1.Fetal heart rate of 180 beats per minute 2.White blood cell count of 12,000 3.Maternal pulse rate of 85 beats per minute 4.Hemoglobin of 11.0 g/dL
1. A normal fetal heart rate is 120-160 beats per minute. A count of 180 beats per minute could indicate fetal distress and would warrant physician notification. By full term, a normal maternal hemoglobin range is 11-13 g/dL as a result of the hemodilution caused by an increase in plasma volume during pregnancy.
A nurse is caring for a client in labor and is monitoring the fetal heart rate patterns. The nurse notes the presence of episodic accelerations on the electronic fetal monitor tracing. Which of the following actions is most appropriate? 1.Document the findings and tell the mother that the monitor indicates fetal well-being 2.Take the mothers vital signs and tell the mother that bed rest is required to conserve oxygen. 3.Notify the physician or nurse mid-wife of the findings. 4.Reposition the mother and check the monitor for changes in the fetal tracing
1. Accelerations are transient increases in the fetal heart rate that often accompany contractions or are caused by fetal movement. Episodic accelerations are thought to be a sign of fetal-well being and adequate oxygen reserve.
When monitoring the fetal heart rate of a client in labor, the nurse identifies an elevation of 15 beats above the baseline rate of 135 beats per minute lasting for 15 seconds. This should be documented as: 1.An acceleration 2.An early elevation 3.A sonographic motion 4.A tachycardic heart rate
1. An acceleration is an abrupt elevation above the baseline of 15 beats per minute for 15 seconds; if the acceleration persists for more than 10 minutes it is considered a change in baseline rate. A tachycardic FHR is above 160 beats per minute
The breathing technique that the mother should be instructed to use as the fetus' head is crowning is: 1.Blowing 2.Slow chest 3.Shallow 4.Accelerated-decelerated
1. Blowing forcefully through the mouth controls the strong urge to push and allows for a more controlled birth of the head.
A nurse is monitoring a client in labor who is receiving Pitocin and notes that the client is experiencing hypertonic uterine contractions. List in order of priority the actions that the nurse takes. 1.Stop of Pitocin infusion 2.Perform a vaginal examination 3.Reposition the client 4.Check the client's blood pressure and heart rate 5.Administer oxygen by face mask at 8 to 10 L/min
1, 4, 2. 5, 3. If uterine hypertonicity occurs, the nurse immediately would intervene to reduce uterine activity and increase fetal oxygenation. The nurse would stop the Pitocin infusion and increase the rate of the nonadditive solution, check maternal BP for hyper or hypotension, position the woman in a side-lying position, and administer oxygen by snug face mask at 8-10 L/min. The nurse then would attempt to determine the cause of the uterine hypertonicity and perform a vaginal exam to check for prolapsed cord
A maternity nurse is caring for a client with abruptio placenta and is monitoring the client for disseminated intravascular coagulopathy. Which assessment finding is least likely to be associated with disseminated intravascular coagulation? 1.Swelling of the calf in one leg 2.Prolonged clotting times 3.Decreased platelet count 4.Petechiae, oozing from injection sites, and hematuria
1. DIC is a state of diffuse clotting in which clotting factors are consumed, leading to widespread bleeding. Platelets are decreased because they are consumed by the process; coagulation studies show no clot formation (and are thus normal to prolonged); and fibrin plugs may clog the microvasculature diffusely, rather than in an isolated area. The presence of petechiae, oozing from injection sites, and hematuria are signs associated with DIC. Swelling and pain in the calf of one leg are more likely to be associated with thrombophebitis.
A nurse is reviewing the record of a client in the labor room and notes that the nurse midwife has documented that the fetus is at -1 station. The nurse determines that the fetal presenting part is: 1.1 cm above the ischial spine 2.1 fingerbreadth below the symphysis pubis 3.1 inch below the coccyx 4.1 inch below the iliac crest
1. Station is the relationship of the presenting part to an imaginary line drawn between the ischial spines, is measured in centimeters, and is noted as a negative number above the line and a positive number below the line. At -1 station, the fetal presenting part is 1 cm above the ischial spines.
1.A nurse is caring for a client in labor. The nurse determines that the client is beginning in the 2nd stage of labor when which of the following assessments is noted? A.The client begins to expel clear vaginal fluid B.The contractions are regular C.The membranes have ruptured D.The cervix is dilated completely
1.4. The second stage of labor begins when the cervix is dilated completely and ends with the birth of the neonate.
A nurse is caring for a client in the second stage of labor. The client is experiencing uterine contractions every 2 minutes and cries out in pain with each contraction. The nurse recognizes this behavior as: 1.Exhaustion 2.Fear of losing control 3.Involuntary grunting 4.Valsalva's maneuver
2. Pains, helplessness, panicking, and fear of losing control are possible behaviors in the 2nd stage of labor.
A nurse is caring for a client in labor who is receiving Pitocin by IV infusion to stimulate uterine contractions. Which assessment finding would indicate to the nurse that the infusion needs to be discontinued? 1.Three contractions occurring within a 10-minute period 2.A fetal heart rate of 90 beats per minute 3.Adequate resting tone of the uterus palpated between contractions 4.Increased urinary output
2. A normal fetal heart rate is 120-160 BPM. Bradycardia or late or variable decelerations indicate fetal distress and the need to discontinue to pitocin. The goal of labor augmentation is to achieve three good-quality contractions in a 10-minute period.
A client arrives at a birthing center in active labor. Her membranes are still intact, and the nurse-midwife prepares to perform an amniotomy. A nurse who is assisting the nurse-midwife explains to the client that after this procedure, she will most likely have: 1.Less pressure on her cervix 2.Increased efficiency of contractions 3.Decreased number of contractions 4.The need for increased maternal blood pressure monitoring
2. Amniotomy can be used to induce labor when the condition of the cervix is favorable (ripe) or to augment labor if the process begins to slow. Rupturing of membranes allows the fetal head to contact the cervix more directly and may increase the efficiency of contractions.
One reason for medication problems in the elderly is that 1. Regular use of laxatives increases absorption of medications 2. Decreased renal function slows excretion of drugs 3. Enhanced sense of taste of medications 4. Increased perception of pain from injections
2. Decreased renal function slows excretion of drugs
An ultrasound is performed on a client at term gestation that is experiencing moderate vaginal bleeding. The results of the ultrasound indicate that an abruptio placenta is present. Based on these findings, the nurse would prepare the client for: 1.Complete bed rest for the remainder of the pregnancy 2.Delivery of the fetus 3.Strict monitoring of intake and output 4.The need for weekly monitoring of coagulation studies until the time of delivery
2. The goal of management in abruptio placentae is to control the hemorrhage and deliver the fetus as soon as possible. Delivery is the treatment of choice if the fetus is at term gestation or if the bleeding is moderate to severe and the mother or fetus is in jeopardy.
During the period of induction of labor, a client should be observed carefully for signs of: 1.Severe pain 2.Uterine tetany 3.Hypoglycemia 4.Umbilical cord prolapse
2. Uterine tetany could result from the use of oxytocin to induce labor. Because oxytocin promotes powerful uterine contractions, uterine tetany may occur. The oxytocin infusion must be stopped to prevent uterine rupture and fetal compromise.
A nurse is monitoring a client in labor. The nurse suspects umbilical cord compression if which of the following is noted on the external monitor tracing during a contraction? 1.Early decelerations 2.Variable decelerations 3.Late decelerations 4.Short-term variability
2. Variable decelerations occur if the umbilical cord becomes compressed, thus reducing blood flow between the placenta and the fetus. Early decelerations result from pressure on the fetal head during a contraction. Late decelerations are an ominous pattern in labor because it suggests uteroplacental insufficiency during a contraction. Short-term variability refers to the beat-to-beat range in the fetal heart rate.
When examining the fetal monitor strip after rupture of the membranes in a laboring client, the nurse notes variable decelerations in the fetal heart rate. The nurse should: 1.Stop the oxytocin infusion 2.Change the client's position 3.Prepare for immediate delivery 4.Take the client's blood pressure
2. Variable decelerations usually are seen as a result of cord compression; a change of position will relieve pressure on the cord.
The most common affective or mood disorder of old age is 1. dementia. 2. depression. 3. delirium. 4. Alzheimer's.
2. depression.
A client who is gravida 1, para 0 is admitted in labor. Her cervix is 100% effaced, and she is dilated to 3 cm. Her fetus is at +1 station. The nurse is aware that the fetus' head is: 1.Not yet engaged 2.Entering the pelvic inlet 3.Below the ischial spines 4.Visible at the vaginal opening
3. A station of +1 indicates that the fetal head is 1 cm below the ischial spines.
After doing Leopold's maneuvers, the nurse determines that the fetus is in the ROP position. To best auscultate the fetal heart tones, the Doppler is placed: 1.Above the umbilicus at the midline 2.Above the umbilicus on the left side 3.Below the umbilicus on the right side 4.Below the umbilicus near the left groin
3. Fetal heart tones are best auscultated through the fetal back; because the position is ROP (right occiput presenting), the back would be below the umbilicus and on the right side.
A maternity nurse is preparing to care for a pregnant client in labor who will be delivering twins. The nurse monitors the fetal heart rates by placing the external fetal monitor: 1.Over the fetus that is most anterior to the mothers abdomen 2.Over the fetus that is most posterior to the mothers abdomen 3.So that each fetal heart rate is monitored separately 4.So that one fetus is monitored for a 15-minute period followed by a 15 minute fetal monitoring period for the second fetus
3. In a client with a multi-fetal pregnancy, each fetal heart rate is monitored separately.
A nurse is assessing a pregnant client in the 2nd trimester of pregnancy who was admitted to the maternity unit with a suspected diagnosis of abruptio placentae. Which of the following assessment findings would the nurse expect to note if this condition is present? 1.Absence of abdominal pain 2.A soft abdomen 3.Uterine tenderness/pain 4.Painless, bright red vaginal bleeding
3. In abruptio placentae, acute abdominal pain is present. Uterine tenderness and pain accompanies placental abruption, especially with a central abruption and trapped blood behind the placenta. The abdomen will feel hard and boardlike on palpation as the blood penetrates the myometrium and causes uterine irritability. Observation of the fetal monitoring often reveals increased uterine resting tone, caused by failure of the uterus to relax in attempt to constrict blood vessels and control bleeding.
A maternity nurse is preparing for the admission of a client in the 3rd trimester of pregnancy that is experiencing vaginal bleeding and has a suspected diagnosis of placenta previa. The nurse reviews the physician's orders and would question which order? 1.Prepare the client for an ultrasound 2.Obtain equipment for external electronic fetal heart monitoring 3.Obtain equipment for a manual pelvic examination 4.Prepare to draw a Hgb and Hct blood sample
3. Manual pelvic examinations are contraindicated when vaginal bleeding is apparent in the 3rd trimester until a diagnosis is made and placental previa is ruled out. Digital examination of the cervix can lead to maternal and fetal hemorrhage. A diagnosis of placenta previa is made by ultrasound. The H/H levels are monitored, and external electronic fetal heart rate monitoring is initiated. External fetal monitoring is crucial in evaluating the fetus that is at risk for severe hypoxia
A nurse is developing a plan of care for a client experiencing dystocia and includes several nursing interventions in the plan of care. The nurse prioritizes the plan of care and selects which of the following nursing interventions as the highest priority? 1.Keeping the significant other informed of the progress of the labor 2.Providing comfort measures 3.Monitoring fetal heart rate 4.Changing the client's position frequently
3. The priority is to monitor the fetal heart rate.
A nurse is assigned to care for a client with hypotonic uterine dysfunction and signs of a slowing labor. The nurse is reviewing the physician's orders and would expect to note which of the following prescribed treatments for this condition? 1.Medication that will provide sedation 2.Increased hydration 3.Oxytocin (Pitocin) infusion 4.Administration of a tocolytic medication
3. Therapeutic management for hypotonic uterine dysfunction includes oxytocin augmentation and amniotomy to stimulate a labor that slows.
The physician asks the nurse the frequency of a laboring client's contractions. The nurse assesses the client's contractions by timing from the beginning of one contraction: 1.Until the time it is completely over 2.To the end of a second contraction 3.To the beginning of the next contraction 4.Until the time that the uterus becomes very firm
3. This is the way to determine the frequency of the contractions
The nurse observes the client's amniotic fluid and decides that it appears normal, because it is: 1.Clear and dark amber in color 2.Milky, greenish yellow, containing shreds of mucus 3.Clear, almost colorless, and containing little white specks 4.Cloudy, greenish-yellow, and containing little white specks
3. by 36 weeks' gestation, normal amniotic fluid is colorless with small particles of vernix caseosa present.
Which medication prevents the breakdown of a brain chemical important for memory and thinking and may slow the progress of Alzheimer's disease. 1. memantine (Namenda) 2. ozazepam (Serax) 3. donepezil (Aricept) 4. citalopram (Celexa)
3. donepezil (Aricept)
A nurse in the postpartum unit is caring for a client who has just delivered a newborn infant following a pregnancy with placenta previa. The nurse reviews the plan of care and prepares to monitor the client for which of the following risks associated with placenta previa? 1.Disseminated intravascular coagulation 2.Chronic hypertension 3.Infection 4.Hemorrhage
4. Because the placenta is implanted in the lower uterine segment, which does not contain the same intertwining musculature as the fundus of the uterus, this site is more prone to bleeding.
A nurse is monitoring a client in active labor and notes that the client is having contractions every 3 minutes that last 45 seconds. The nurse notes that the fetal heart rate between contractions is 100 BPM. Which of the following nursing actions is most appropriate? 1.Encourage the client's coach to continue to encourage breathing exercises 2.Encourage the client to continue pushing with each contraction 3.Continue monitoring the fetal heart rate 4.Notify the physician or nurse mid-wife
4. A normal fetal heart rate is 120-160 beats per minute. Fetal bradycardia between contractions may indicate the need for immediate medical management, and the physician or nurse mid-wife needs to be notified.
A laboring client complains of low back pain. The nurse replies that this pain occurs most when the position of the fetus is: 1.Breech 2.Transverse 3.Occiput anterior 4.Occiput posterior
4. A persistent occiput-posterior position causes intense back pain because of fetal compression of the sacral nerves. Occiput anterior is the most common fetal position and does not cause back pain.
A nurse in the delivery room is assisting with the delivery of a newborn infant. After the delivery of the newborn, the nurse assists in delivering the placenta. Which observation would indicate that the placenta has separated from the uterine wall and is ready for delivery? 1.The umbilical cord shortens in length and changes in color 2.A soft and boggy uterus 3.Maternal complaints of severe uterine cramping 4.Changes in the shape of the uterus
4. Signs of placental separation include lengthening of the umbilical cord, a sudden gush of dark blood from the introitus (vagina), a firmly contracted uterus, and the uterus changing from a discoid (like a disk) to a globular (like a globe) shape. The client may experience vaginal fullness, but not severe uterine cramping. I am going to look more into this answer. According to our book on page 584, this is not one of our options.
The leading cause of injury and preventable source of mortality and morbidity in older adults is 1. presbycusis. 2. car accidents. 3. pneumonia. 4. falls.
4. falls.
A long-term care facility sponsors a discussion group on the administration of medications. The participants have a number of questions concerning their medications. The nurse responds most appropriately by saying: A. "Don't worry about the medication's name if you can identify it by its color and shape." B. "Unless you have severe side affects, don't worry about the minor changes in the way you feel." C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you." D. "Remember that the hepatic system is primarily responsible for the pharmacotherapeutics of your medications."
C. "Feel free to ask your physician why you are receiving the medications that are prescribed for you." Rationale: The nurse should encourage the older adult to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. The older adult should be taught the names of all drugs being taken, when and how to take them, and the desirable and undesirable effects of the drugs.
The nurse is setting up an education session with an 85-year-old patient who will be going home on anticoagulant therapy. Which strategy would reflect consideration of aging changes that may exist with this patient? A. Show a colorful video about anticoagulation therapy. B. Present all the information in one session just before discharge. C. Give the patient pamphlets about the medications to read at home. D. Develop large-print handouts that reflect the verbal information presented.
D. Develop large-print handouts that reflect the verbal information presented. Rationale: Option D addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Option A does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand.
The nurse defines ageism most accurately as: A. The undervaluing of individuals based on their age. B. Perception of a person's worth based on productivity C. Biases directed towards individuals considered aged D. Discrimination based on an individual's increasing age
D. Discrimination based on an individual's increasing age
Which of the following interventions should be taken to help an older client to prevent osteoporosis? A. Decrease dietary calcium intake. B. Increase sedentary lifestyles C. Increase dietary protein intake. D. Encourage regular exercise.
D. Encourage regular exercise. Rationale: Key word in question is prevent Weight-bearing exercises helps to fight off degeneration of bone in osteoporosis
What is the best resource (of those listed below) for identifying information regarding an older adult's current functional ability? A. Psychological tests and related exams B. Diagnostic x-rays and lab tests C. Family members who visit occasionally and call weekly D. Neighbor who visits daily and helps the person to the store weekly.
D. Neighbor who visits daily and helps the person to the store weekly.
Of the following options, which is the greatest barrier to providing quality health care to the older-adult client? A. Poor client compliance resulting from generalized diminished capacity B. Inadequate health insurance coverage for the group as a whole C. Insufficient research to provide a basis for effective geriatric health care D. Preconceived assumptions regarding the lifestyles and attitudes of this group
D. Preconceived assumptions regarding the lifestyles and attitudes of this group
A 70-year-old client asks the nurse to explain to her about hypertension. An appropriate response by the nurse as to why older clients often have hypertension is due to: A. Myocardial muscle damage B. Reduction in physical activity C. Ingestion of foods high in sodium D. Accumulation of plaque on arterial walls
D. Accumulation of plaque on arterial walls
A client is admitted to the birthing suite in early active labor. The priority nursing intervention on admission of this client would be: 1.Auscultating the fetal heart 2.Taking an obstetric history 3.Asking the client when she last ate 4.Ascertaining whether the membranes were ruptured
1. Determining the fetal well-being supersedes all other measures. If the FHR is absent or persistently decelerating, immediate intervention is required.
A nurse in the labor room is performing a vaginal assessment on a pregnant client in labor. The nurse notes the presence of the umbilical cord protruding from the vagina. Which of the following would be the initial nursing action? 1.Place the client in Trendelenburg's position 2.Call the delivery room to notify the staff that the client will be transported immediately 3.Gently push the cord into the vagina 4.Find the closest telephone and stat page the physician
1. When cord prolapse occurs, prompt actions are taken to relieve cord compression and increase fetal oxygenation. The mother should be positioned with the hips higher than the head to shift the fetal presenting part toward the diaphragm. The nurse should push the call light to summon help, and other staff members should call the physician and notify the delivery room. No attempt should be made to replace the cord. The examiner, however, may place a gloved hand into the vagina and hold the presenting part off of the umbilical cord. Oxygen at 8 to 10 L/min by face mask is delivered to the mother to increase fetal oxygenation.
A nurse is admitting a pregnant client to the labor room and attaches an external electronic fetal monitor to the client's abdomen. After attachment of the monitor, the initial nursing assessment is which of the following? 1.Identifying the types of accelerations 2.Assessing the baseline fetal heart rate 3.Determining the frequency of the contractions 4.Determining the intensity of the contractions
2. Assessing the baseline fetal heart rate is important so that abnormal variations of the baseline rate will be identified if they occur. Options 1 and 3 are important to assess, but not as the first priority.
A nurse is beginning to care for a client in labor. The physician has prescribed an IV infusion of Pitocin. The nurse ensures that which of the following is implemented before initiating the infusion? 1.Placing the client on complete bed rest 2.Continuous electronic fetal monitoring 3.An IV infusion of antibiotics 4.Placing a code cart at the client's bedside
2. Continuous electronic fetal monitoring should be implemented during an IV infusion of Pitocin.
You are caring for a 78 year-old female cardiac patient. In preconference, your clinical instructor asks you what is an age-related change in the cardiac system of the older adult? Your best response would be Student Response Value Correct Answer Feedback 1. Decreased blood pressure 2. Decreased cardiac output 3. Increase ability to respond to stress 4. Increased heart recovery rate
2. Decreased cardiac output
Your patient assigned to you has pneumonia. You are reviewing the age-related changed involved with the older adult. Select all age-related changes of the respiratory system that apply. 1. Decreased in residual lung volume 2. Decreased gas exchange 3. Decreased cough efficiency 4. Increased gas exchange
2. Decreased gas exchange 3. Decreased cough efficiency
A nurse explains the purpose of effleurage to a client in early labor. The nurse tells the client that effleurage is: 1.A form of biofeedback to enhance bearing down efforts during delivery 2.Light stroking of the abdomen to facilitate relaxation during labor and provide tactile stimulation to the fetus 3.The application of pressure to the sacrum to relieve a backache 4.Performed to stimulate uterine activity by contracting a specific muscle group while other parts of the body rest
2. Effleurage is a specific type of cutaneous stimulation involving light stroking of the abdomen and is used before transition to promote relaxation and relieve mild to moderate pain. Effleurage provides tactile stimulation to the fetus.
A nurse in a labor room is assisting with the vaginal delivery of a newborn infant. The nurse would monitor the client closely for the risk of uterine rupture if which of the following occurred? 1.Hypotonic contractions 2.Forceps delivery 3.Schultz delivery 4.Weak bearing down efforts
2. Excessive fundal pressure, forceps delivery, violent bearing down efforts, tumultuous labor, and shoulder dystocia can place a woman at risk for traumatic uterine rupture. Hypotonic contractions and weak bearing down efforts do not alone add to the risk of rupture because they do not add to the stress on the uterine wall.
A nurse in the labor room is preparing to care for a client with hypertonic uterine dysfunction. The nurse is told that the client is experiencing uncoordinated contractions that are erratic in their frequency, duration, and intensity. The priority nursing intervention would be to: 1.Monitor the Pitocin infusion closely 2.Provide pain relief measures 3.Prepare the client for an amniotomy 4.Promote ambulation every 30 minutes
2. Management of hypertonic labor depends on the cause. Relief of pain is the primary intervention to promote a normal labor pattern.
A nurse in the labor room is caring for a client in the active phases of labor. The nurse is assessing the fetal patterns and notes a late deceleration on the monitor strip. The most appropriate nursing action is to: 1.Place the mother in the supine position 2.Document the findings and continue to monitor the fetal patterns 3.Administer oxygen via face mask 4.Increase the rate of pitocin IV infusion
3. Late decelerations are due to uteroplacental insufficiency as the result of decreased blood flow and oxygen to the fetus during the uterine contractions. This causes hypoxemia; therefore oxygen is necessary. The supine position is avoided because it decreases uterine blood flow to the fetus. The client should be turned to her side to displace pressure of the gravid uterus on the inferior vena cava. An intravenous pitocin infusion is discontinued when a late deceleration is noted.
At 38 weeks' gestation, a client is having late decelerations. The fetal pulse oximeter shows 75% to 85%. The nurse should: 1.Discontinue the catheter, if the reading is not above 80% 2.Discontinue the catheter, if the reading does not go below 30% 3.Advance the catheter until the reading is above 90% and continue monitoring 4.Reposition the catheter, recheck the reading, and if it is 55%, keep monitoring
4. Adjusting the catheter would be indicated. Normal fetal pulse oximetry should be between 30% and 70%. 75% to 85% would indicate maternal readings.
A pregnant client is admitted to the labor room. An assessment is performed, and the nurse notes that the client's hemoglobin and hematocrit levels are low, indicating anemia. The nurse determines that the client is at risk for which of the following? 1.A loud mouth 2.Low self-esteem 3.Hemorrhage 4.Postpartum infections
4. Anemic women have a greater likelihood of cardiac decompensation during labor, postpartum infection, and poor wound healing. Anemia does not specifically present a risk for hemorrhage. Having a loud mouth is only related to the person typing up this test.
A nurse assists in the vaginal delivery of a newborn infant. After the delivery, the nurse observes the umbilical cord lengthen and a spurt of blood from the vagina. The nurse documents these observations as signs of: 1.Hematoma 2.Placenta previa 3.Uterine atony 4.Placental separation
4. As the placenta separates, it settles downward into the lower uterine segment. The umbilical cord lengthens, and a sudden trickle or spurt of blood appears.
. A nurse is caring for a client in labor and prepares to auscultate the fetal heart rate by using a Doppler ultrasound device. The nurse most accurately determines that the fetal heart sounds are heard by: 1.Noting if the heart rate is greater than 140 BPM 2.Placing the diaphragm of the Doppler on the mother abdomen 3.Performing Leopold's maneuvers first to determine the location of the fetal heart 4.Palpating the maternal radial pulse while listening to the fetal heart rate
4. The nurse simultaneously should palpate the maternal radial or carotid pulse and auscultate the fetal heart rate to differentiate the two. If the fetal and maternal heart rates are similar, the nurse may mistake the maternal heart rate for the fetal heart rate. Leopold's maneuvers may help the examiner locate the position of the fetus but will not ensure a distinction between the two rates.
A client in labor is transported to the delivery room and is prepared for a cesarean delivery. The client is transferred to the delivery room table, and the nurse places the client in the: 1.Trendelenburg's position with the legs in stirrups 2.Semi-Fowler position with a pillow under the knees 3.Prone position with the legs separated and elevated 4.Supine position with a wedge under the right hip
4. Vena cava and descending aorta compression by the pregnant uterus impedes blood return from the lower trunk and extremities. This leads to decreasing cardiac return, cardiac output, and blood flow to the uterus and the fetus. The best position to prevent this would be side-lying with the uterus displaced off of abdominal vessels. Positioning for abdominal surgery necessitates a supine position; however, a wedge placed under the right hip provides displacement of the uterus.
Which of the following client statements regarding self-medication administration by an older-adult client requires follow-up teaching by the nurse? A. "I take all the pills ordered once a day at bedtime, so I'm less likely to forget them." B. "I have one pill that needs cut in half. I am going to ask the pharmacist to do that for me." C. "The pharmacist said to keep my pills away from the sunlight, so I put them inside the kitchen cabinet." D. "My daughter comes over each morning and puts my pills into a container that sorts them by the time they are due."
A. "I take all the pills ordered once a day at bedtime, so I'm less likely to forget them."
A nurse is caring for an older adult client preparing for discharge to a nursing center after having hip surgery. Which of the following nursing responses is most therapeutic with a client's concern that she, will never go back home? A. "What makes you think that this transfer to the nursing center will be permanent?" B. "The reason for this transfer is only to support you while you continue to recuperate." C. "The decision to stay in the nursing center is yours to make. When you want to leave no one will stop you." D. "The nursing center is a lovely place with a wonderful staff of caring people. Just give it a chance. You may like it."
A. "What makes you think that this transfer to the nursing center will be permanent?"
While bathing an elderly client who has limited abilities for self-care, the nurse notices several patches of dry skin on the clients heels, elbows, and coccyx. The nurse cleans and dries all the areas well and applies a moisturizing lotion. The most appropriate immediate follow-up by the nurse to ensure appropriate nursing care for this clients skin is to: A. Revise the client's care plan to show the need for the application of moisturizing lotion B. Assume personal responsibility to apply the moisturizing lotion daily to the client's skin C. Encourage the client to tell whomever bathes her to apply the moisturizing lotion to her areas of dry skin D. Inform the staff that the client's skin is showing signs of breakdown and moisturizing lotion needs to be applied daily
A. Revise the client's care plan to show the need for the application of moisturizing lotion
The nurse works with elderly clients in a wellness screening clinic on a weekly basis. Which of the following statements made by the nurse is the most therapeutic regarding their mobility? A. "Your shoulder pain is normal for your age." B. "Continue to exercise your joints regularly to your tolerance level." C. "Why don't you begin walking 3 to 4 miles a day, and we'll evaluate how you feel next week." D. "Don't worry about taking that combination of medications since your doctor has prescribed them."
B. "Continue to exercise your joints regularly to your tolerance level."
Which of the following responses by an older-adult client is most reflective of a need for further education by the nurse regarding the physiological changes associated with the older adult? A. "I call a cab if I want to go out after dark." B. "I can't help worrying about becoming forgetful." C. "I have my eyes checked regularly. Can't afford to fall." D. "I really enjoy eating good vanilla ice cream, but I have cut way down." 0%
B. "I can't help worrying about becoming forgetful."
Which of the following statements, made by the daughter of an older adult client concerning bringing her mother home to live with her family, presents the greatest concern for the nurse? A. "If this doesn't work out, she can always go to live with my sister." B. "I don't think she will react very well to me making decisions for her." C. "I'm afraid that mom will be depressed and miss her home." D. "My children will just have to adjust to having their grandmother with us."
B. "I don't think she will react very well to me making decisions for her."
Which of the following statements made by a nurse reflects the best understanding of the health value of conducting a blood pressure (BP) screening at a senior citizens centers health fair? A. "This is a high risk group, so assessing BP allows us to identify clients at risk and send them for treatment." B. "Older adults enjoy health fairs, so it's a good place to screen substantial numbers of clients for hypertension." C. "Hypertension doesn't present symptoms early on, so screening elder adults is a wonderful preventive measure." D. "Blood pressure problems are common among this group, so it's a good way to monitor the effectiveness of their medications."
B. "Older adults enjoy health fairs, so it's a good place to screen substantial numbers of clients for hypertension."
Which of the following statements made by a family member of a client recently diagnosed with early stages of Alzheimer's disease is most reflective of an understanding of this disease process? A. "Dad has always been a fighter; he'll fight this too. He won't give up." B. "We have an appointment with his care provider to see about medication therapy." C. "Good thing we found out about this early so we can prevent this from getting worse." D. "We have a made arrangements to discuss nursing home placement for dad."
B. "We have an appointment with his care provider to see about medication therapy."
When caring for an older adult patient, the nurse uses the following interventions to accommodate visual changes with age: A. Eye glasses in the bedside table. B. Adequate lighting and uncluttered walkways. C. Draw drapes in room to prevent glare. D. Keep bedside rails down.
B. Adequate lighting and uncluttered walkways.
An assisted living facility has provided its clients with an educational program on safe administration of prescribed medications. Which statement made by an older-adult client reflects the best understanding of safe self-administration of medications? A. "I don't seem to have problems with side effects, but I'll let my doctor know if something happens." B. "I'm lucky since my daughter is really good about keeping up with my medications." C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something." D. "It shouldn't be too hard to keep it straight since I don't have any really serious health issues."
C. "I'll be sure to read the inserts and ask the pharmacist if I don't understand something."
In performing a physical assessment for an older adult, the nurse anticipates finding which of the following normal physiological changes of aging? A. Increased perspiration B. Increased airway resistance C. Increased salivary secretions D. Increased pitch discrimination
B. Increased airway resistance Rational: Normal physiological changes of aging include increased airway resistance in the older adult. The older adult would be expected to have decreased perspiration and drier skin as they experience glandular atrophy (oil, moisture, sweat glands) in the integumentary system. The older adult would be expected to have a decrease in saliva. A normal physiological change of the older adult related to hearing is a loss of acuity for high-frequency tones (presbycusis).
A client has been recently diagnosed with Alzheimer's disease. When teaching the family about the prognosis, the nurse must explain that: A. Diet and exercise can slow the process considerably B. It usually progresses gradually with a deterioration of function C. Many individuals can be cured if the diagnosis is made early D. Few clients live more than 3 years after the diagnosis
B. It usually progresses gradually with a deterioration of function
A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.) A. Falls asleep in the examination room B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healing
B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healing
Of the following, which describes dementia? A. Quick onset, irreversible B. Slow onset, chronic C. Acute onset, reversible D. Progressive, terminal
B. Slow onset, chronic
Which information obtained by the home health nurse when making a visit to an 88-year-old with mild forgetfulness is of the most concern? A. The patient's son uses a marked pillbox to set up the patient's medications weekly. B. The patient has lost 10 pounds (4.5 kg) during the last month. C. The patient is cared for by a daughter during the day and stays with a son at night. D. The patient tells the nurse that a close friend recently died.
B. The patient has lost 10 pounds (4.5 kg) during the last month. Rationale: A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse.
When caring for the older adult, it is important to: Student Response Value Correct Answer Feedback A. Repeat oneself often because older adults are forgetful. B. Treat the client as an individual with a unique history of his or her own. C. Be aware that older adults are no longer interested in sex. D. Disregard the older adult's experiences because older people are too old-fashioned to be of value today.
B. Treat the client as an individual with a unique history of his or her own.
When administering a mental status examination to a patient with delirium, the nurse should A. give the examination when the patient is well-rested. B. choose a place without distracting environmental stimuli. C. reorient the patient as needed during the examination. D. medicate the patient first to reduce anxiety.
B. choose a place without distracting environmental stimuli.
A nurse caring for older adults in an assistive living facility recognizes that a clients quality of life needs are best determined by: A. Excellent physical, social, and emotional nursing assessments B. A working knowledge of this age-group's developmental needs C. A therapeutic nurse-client relationship that facilitates communication D. The client's need for complete physical, emotional, and cognitive care
C. A therapeutic nurse-client relationship that facilitates communication
The three common conditions affecting cognition in the older adults are: A. Stroke, MI, Cancer B. Cancer, Alzheimer's disease, Stroke C. Delirium, Depression, Dementia D. Blindness, Hearing loss, Stroke
C. Delirium, Depression, Dementia
When a fall results in injury and hospitalization, a cycle of disuse may occur over time. When establishing a care plan for the patient and family to prevent this, it is important to remember disuse is most likely a result of: A. Decreasing muscle strength. B. Decreased joint mobility. C. Fear of repeated falls. D. Changes in sensory perception.
C. Fear of repeated falls.
When performing a comprehensive geriatric assessment of an older adult, focus of the nursing assessment is on the patient's: A. Physical signs of aging. B. Immunological function. C. Functional abilities. D. Chronic illness.
C. Functional abilities.
A patient is taking delayed-release omeprazole (Prilosec) capsules for the treatment of gastroesophageal reflux disease (GERD). Which statement will the nurse include in the teaching plan about this medication? A. "Take this medication once a day after breakfast." B. "You will only have to be on this medication for 2 weeks for a life long treatment of the reflux disease." C. "The medication may be dissolved in a liquid for better absorption." D. "The entire capsule should be taken whole, not crushed, chewed, or opened."
D. "The entire capsule should be taken whole, not crushed, chewed, or opened."
In reviewing changes in the older adult, the nurse recognizes that which of the following statements related to cognitive functioning in the older client is true? A. Delirium is usually easily distinguished from irreversible dementia. B. Therapeutic drug intoxication is a common cause of senile dementia. C. Reversible systemic disorders are often implicated as a cause of delirium. D. Cognitive deterioration is an inevitable outcome of the human aging process.
C. Reversible systemic disorders are often implicated as a cause of delirium. Rationale: Delirium is a potentially reversible cognitive impairment that is often due to a physiological cause such as an electrolyte imbalance, cerebral anoxia, hypoglycemia, medications, tumors, cerebrovascular infection, or hemorrhage.
Which of the following statements made by an older-adult client poses the greatest concern for the nurse conducting an assessment regarding the clients adjustment to the aging process? A. "I use to enjoy dancing and jogging so much, but now I have arthritis in my knees so that it's hard to even walk." B. "I've given my grandchildren money for college so they can live a better life than I had." C. "Growing old certainly presents all sorts of challenges. I wish I knew then what I know now." D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."
D. "As I age I've found its harder to do the things I love doing, but I guess it will all be over soon enough."
The primary reason an older adult client is more likely to develop a pressure ulcer on the elbow as compared to a middle-age adult is: A. A reduced skin elasticity is common in the older adult B. The attachment between the epidermis and dermis is weaker C. The older client has less subcutaneous padding on the elbows D. Older adults have a poor diet that increases risk for pressure ulcers
C. The older client has less subcutaneous padding on the elbows
There are factors that influence the musculoskeletal system associated with aging. The nurse recognizes that with age: A. Men have the greatest incidence of osteoporosis B. Muscle fibers increase in size and become tighter C. Weight-bearing exercise reduces the loss of bone mass D. Muscle strength does not diminish as much as muscle mass
C. Weight-bearing exercise reduces the loss of bone mass
An overall, general assessment of an older adult patient is best performed in which setting? A. During a meal. B. During assessment of vital signs. C. While assisting a patient with a bath. D. When assisting a patient during a walk.
C. While assisting a patient with a bath.
When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should A. use a standardized geriatric nursing care plan. B. plan for likely long-term-care transfer to allow additional time for recovery. C. consider the preadmission functional abilities when setting patient goals. D. minimize activity level during hospitalization.
C. consider the preadmission functional abilities when setting patient goals. Rationale: The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan is unlikely to address individual patient needs and strengths. A patients need for discharge to a long-term-care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.
Which of the following statements accurately reflects data that the nurse should use in planning care to meet the needs of the older adult? A. 50% of older adults have two chronic health problems. B. Cancer is the most common cause of death among older adults. C. Nutritional needs for both younger and older adults are essentially the same. D. Adults older than 65 years of age are the greatest users of prescription medications.
D. Adults older than 65 years of age are the greatest users of prescription medications. Rationale: Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults
The nurse is aware that the majority of older adults: A. Live alone B. Live in institutional settings C. Are unable to care for themselves D. Are actively involved in their community
D. Are actively involved in their community
The nurse, preparing to discharge an 81-year-old client from the hospital, recognizes that the majority of older adults: A. Require institutional care B. Have no social or family support C. Are unable to afford any medical treatment D. Are capable of taking charge of their own lives
D. Are capable of taking charge of their own lives
The nurse is planning client education for an older adult being prepared for discharge home after hospitalization for a cardiac problem. Which nursing action addresses the most commonly determined need for this age-group? A. Suggest that he purchase an emergency in-home alert system. B. Arrange for the client to receive meals delivered to his home daily. C. Encourage the client to use a compartmentalized pill storage container for his daily medications. D. Provide only written document describing the medications the client is currently prescribed.
Encourage the client to use a compartmentalized pill storage container for his daily medications.
