Exam 1 Older Adult
a nurse is taking a health history of a client who reports occasionally taking several over-the-counter medications, including an h2 receptor antagonist (h2ra). which of the following outcomes indicates the h2ra is therapeutic? a. relief of heartburn b. cessation of diarrhea c. passage of flatus d. absence of constipation
a
an older adult client has developed pneumonia. what initial assessment finding would most concern the nurse? a. confusion or delirium b. high grade fever and severe chills c. hemoptysis and dyspnea d. pleuritic chest pain and cough
a
a nurse is administering timolol eye drops to a client who has glaucoma. which of the following actions should the nurse take? a. apply pressure to the bridge of the nose after administration b. wipe the eye from the outer canthus to the inner canthus before instillation c. drop prescribed amount of medication into the conjunctival sac d. protect the distal portion of the eyedropper using clean technique
c
a nurse is planning care for a client who has dementia. which of the following interventions should the nurse include in the plan of care? a. provide a cognitively stimulating environment b. rotate staff to prevent caregiver role strain c. limit the client's choices for daily activities d. use confrontation to manage negative behavior
c (decreases the client's level of anxiety)
a nurse is assessing a client who has parkinson's disease. which of the following manifestations should the nurse expect? a. pruritus b. hypertension c. bradykinesia d. xerostomia
c (difficulty moving)
a nurse is caring for a client who has dementia. the client is agitated and is having difficulty staying in his chair. which of the following actions should the nurse take first? a. apply a vest restraint on the client b. place the client in bed with the two side rails raised c. place a seat alarm in the client's chair d. administer lorazepam the client
c (the nurse should first use the LEAST restrictive intervention)
a charge nurse is conducting a staff education in-service about depressive disorders. which of the following should the nurse identify as a risk factor for depression? a. being married b. pregnancy c. male gender d. chronic illness
d
a community health nurse is providing teaching to the family of a client who has primary dementia. which of the following manifestations should the nurse tell the family to expect? a. decreased auditory and visual acuity b. decreased display of emotions c. personality traits that are opposite of original traits d. forgetfulness gradually progressing to disorientation
d
a nurse is providing teaching to the family of a client who has parkinson's disease. which of the following info should the nurse include in the teaching? a. provide client supervision b. limit client physical activity c. speak loudly to the client. d. leave the television on continuously
a
a nurse is teaching the family of a client who has Alz disease about donepezil. which of the following info should the nurse include in the teaching? a. syncope episodes may occur when taking this med b. this med may cause tachycardia c. you should administer the med each morning d. you will need to monitor for constipation
a (pt is at risk for falling)
a home health nurse is assessing an older adult client in the home who has decreased vision due to a history of glaucoma. which of the following findings should the nurse identify as a safety risk? a. electrical cords are placed along the walls b. scatter rugs are present in the kitchen c. handrails are present in the bathroom d. uses a microwave for cooking
b
a nurse is caring for a client following cataract surgery. which of the following comments from the client should the nurse report to the client's provider a. my eye really itches, but im trying not to rub it b. i need something for the pain in my eye. i cant stand it c. its hard to see with a patch on one eye. im afraid of falling d. the bright light in this room is really bothering me
b
a nurse is caring for a group of older adult clients. which of the following manifestations indicates one of the clients is experiencing delirium? a. a client wants to know the current time while there is a clock on the wall b. a client attempts to climb out of bed and repeatedly states she must get home c. a client requests extra blankets when the thermostat in the room indicates 25.6 degrees C (78 degrees F) d. a client refuses to get out of bed and has no motivation to attend to daily hygiene
b
a nurse is providing teaching for a client who has a recent diagnosis of depression. which of the following should the nurse identify as a primary risk factor for this disorder? a. recent history of stressful, positive life events b. past history of childhood trauma c. being an old child d. having elevated levels of serotonin
b
a nurse is providing teaching to a client with gastroesophageal reflux. which of the following statements by the client indicates a need for further teaching a. i should elevate the head of my bed while sleeping b. i drink no more than 4 cups of coffee a day c. i take my time when i an eating d. i avoid foods and drinks made with chocolate
b
an older adult diagnosed with dementia wanders the halls of the locked nursing unit during the day. to ensure the client's safety while walking in the halls, what should the nurse do? a. administer PRN haloperidol to decrease the need to walk b. assess the client's gait for steadiness c. restrain the client in a geriatric chair d. administer PRN lorazepam to provide sedation
b
the client is to undergo a series of diagnostic tests to determine if the client's cognitive impairment is treatable. which state can lead to nonreversible cognitive impairment? a. cerebral abscess b. alz disease c. delirium d. electrolyte imbalance
b
a nurse is modifying the diet of a client who has Parkinson's disease and is prescribed selegiline, an MAOI. which of the following foods should the nurse eliminate? a. fresh fish b. cheddar cheese c. cherries d. chicken
b (contains tyramine, which can cause a hypertensive crisis)
a nurse in an ophthalmology clinic is interviewing a client who was referred by his primary care provider for suspicion of cataracts. the nurse should expect the client to report a. loss of central vision b. having a loss of peripheral vision c. seeing bright flashes of light and floaters d. having a decreased ability to perceive colors
d
a nurse is caring for a client who has been diagnosed with delirium. which statement about delirium is true? a. it's characterized by an acute onset and lasts about 1 month b. it's characterized by a slowly evolving onset and lasts about 1 week c. it's characterized by a slowly evolving onset and lasts about 1 month d. it's characterized by an acute onset and lasts hours to a number of days
d
a nurse is planning care for a client 1 day postoperative following a detached retinal repair. which of the following instructions should the nurse include in the plan? a. encourage coughing, and deep-breathing b. allow the client to ambulate c. remove the eye patch during the day d. avoid reading and writing
d