GERONTOLOGIC - HESI : PN
When observing an older client with dementia for symptoms of Sundowning syndrome, it is most important that the practical nurse (PN) assesses for which finding? a. Observe for agitation at the end of the day. b. Perform a neurological and mental status examination. c. Monitor for medication side effects. d. Assess for decreased gross motor movement.
a. Observe for agitation at the end of the day. Rationale: Sundowning syndrome is a pattern of agitated behavior in the evening, believed to be associated with tiredness at the end of the day combined with fewer orienting stimuli, such as activities and interactions.
An older adult client who has Alzheimer's disease tries to slap a social worker. Which action is most appropriate for the nurse to take first? a. Ask staff members to assist with applying restraints on the client. b. Ask the client to walk away and come join others in the dining room. c. Ask the client to explain the reason he is trying to hurt the employee. d. Calmly explain it is against facility policy to hit facility personnel.
b. Ask the client to walk away and come join others in the dining room. Rationale: It is most appropriate to redirect the client's activity if the client's behavior is combative. This is usually effective in reducing the risk of harm to self or staff and should be attempted before applying restraints. When a client has Alzheimer's disease, it is futile to ask the client to explain behavior or to provide detailed information about facility policies.
The nurse is providing instructions for safely bathing older clients to a group of newly employed unlicensed assistive personnel (UAPs) in a long-term care unit. Which instruction is most crucial to provide? a. Make sure to bathe the residents according to the facility schedule. b. Check the bath water temperature carefully to prevent burn injuries. c. Ask each resident which type of bath soap the resident prefers to use. d. Ask the resident if a tub bath or shower is the preferred method.
b. Check the bath water temperature carefully to prevent burn injuries. Rationale: The most crucial aspect of bathing an older adult is to make sure the bath water is neither too hot nor too cold, as decreased peripheral sensation is common with older adults. Bathing residents according to the facility schedule would not improve safety. Asking about personal preference with bathing promotes independence, but it does not necessarily ensure safety.
An older adult client is seen in the clinic for problems with urinary frequency, urgency, and nocturia. The symptoms are an example of which condition? a. Urinary tract infection (UTI) b. Normal aging changes c. Side effect of the diuretic furosemide d. Partial obstruction of the urethra
b. Normal aging changes Rationale: Normal aging changes in the bladder are decreased capacity, increased irritability, and incomplete emptying; these changes lead to frequency, nocturia, urgency, and vulnerability to infection. The majority of UTIs in the older adult are asymptomatic. Classic signs of UTIs are fever, dysuria, and flank pain.
The nurse is preparing an older adult client for discharge following a wound infection. Which method is best for the nurse to use when evaluating the client's ability to perform a dressing change at home? a. Ask the client to describe the procedure in writing. b. Observe the client change the dressing unassisted. c. Ask the client if he feels comfortable changing the dressing. d. Ask a family member to evaluate the client's ability to change the dressing.
b. Observe the client change the dressing unassisted. Rationale: Observing the client directly will allow the nurse to determine if mastery of the skill has been attained, and provide an opportunity for further instructions if needed. Having the client describe the procedure in writing does not allow for adequate evaluation and further teaching. It is possible for the client to feel comfortable changing the dressing, and still not have adequate skills to do the procedure. Having a family member evaluate the client's skill is not appropriate.
The nurse is reinforcing education with an older adult regarding smoking cessation. The nurse recognizes teaching has been effective if the client makes which statement? a. "Stopping smoking reverses damage from emphysema." b. "Stopping smoking will not really benefit me at my age anyway." c. "Stopping smoking can also improve my heart's functioning." d. "Stopping smoking is likely impossible for people my age."
c. "Stopping smoking can also improve my heart's functioning." Rationale: Stopping smoking can improve cardiovascular functioning. Smoking cessation will not reverse damage already done by emphysema. Stopping smoking is possible at any age and will be of benefit.
The practical nurse (PN) delivers a food tray to an older adult Jewish person who has requested a kosher diet. The PN checks the tray and notes that it contains bacon, eggs, toast, oatmeal, and coffee. Which action should the PN take? a. Deliver the tray to the client. b. Ask the client if he wants this tray. c. Call the dietary department and request a new tray. d. Remove the bacon and then deliver the tray to the client.
c. Call the dietary department and request a new tray. Rationale: Pork is prohibited in a kosher diet. The practical nurse (PN) should request a new tray that follows kosher dietary guidelines for the client. Simply removing the bacon is not satisfactory, as the bacon could have come into contact with other items on the tray.
The practical nurse (PN) reinforces nutritional counseling to a group of clients with diabetes. What is the most important purpose of a diabetic diet? a. To manage adults with type 1 diabetes b. To be used during periods of high stress c. To stabilize the blood glucose level through a balanced diet d. To normalize the blood glucose level by eliminating sugar
c. To stabilize the blood glucose level through a balanced diet Rationale: The purpose of the diabetic diet is to stabilize the blood glucose level by providing balanced nutrition.
The nurse is assisting with data collection for an older adult who is taking daily aspirin to reduce the risk of a cardiovascular event. Which concern should the nurse report to the health care provider as soon as possible? a. "I feel really cold much of the time." b. "I wish my children would visit more." c. "Lately it's harder to drive a car at night." d. "My stools are sticky and are dark black."
d. "My stools are sticky and are dark black." Rationale: Dark tarry stools are an indication of gastrointestinal bleeding, an adverse effect of the daily aspirin this client is taking. There is no immediate need to contact the health care provider about the client feeling cold or wishing children would visit more. This client's inability to drive at night is a concern, and should be discussed, but gastrointestinal bleeding needs to be dealt with first.
An older adult client has developed a urinary tract infection and has antibiotics prescribed. Which instruction is most crucial to reinforce to prevent recurrence of the infection? a. You may take half of the prescribed dose once the symptoms resolve. b. Once symptoms resolve, it is not necessary to continue taking the medication. c. Gradually reduce the drug amount taken to prevent antibiotic resistance. d. Continue taking the antibiotics until the entire prescription is completed.
d. Continue taking the antibiotics until the entire prescription is completed. Rationale: In order to prevent recurrence of the infection, it is important to take all prescribed doses. Reducing the amount of drug taken could actually increase the risk of recurrence.
The practical nurse (PN) working at an assisted living facility is visiting with a client whose spouse died 8 months ago. Which behavior by the client suggests ineffective coping with the spouse's death? a. Frequently neglects to shower and shave. b. Insists on visiting the gravesite once a month. c. Joins an exercise class at the assisted living facility. d. Keeps their photo albums out and looks through them frequently.
a. Frequently neglects to shower and shave. Rationale: Ineffective coping is manifested by behaviors that may be physically or psychologically harmful to the individual. Neglecting personal hygiene is an example of ineffective coping.
The home care practical nurse (PN) assesses a client who takes digoxin. Which signs, if exhibited by the client, may lead the PN to suspect digoxin toxicity? (Select all that apply.) a. GI upset b. Tremors c. Diplopia d. Bradycardia e. Photophobia
a. GI upset c. Diplopia d. Bradycardia e. Photophobia Rationale: Signs and symptoms of digoxin toxicity include GI symptoms such as nausea, vomiting, diarrhea, and anorexia; visual disturbances such as diplopia, photophobia, yellow-green halos, and blurred vision; and heart rate abnormalities/dysrythmias such as bradycardia or tachycardia.
An older client diagnosed with congestive heart failure is taking furosemide 40 mg twice daily. The practical nurse (PN) plans to monitor this client for the development of which complication? a. Hyponatremia b. Hyperchloremia c. Hypercalcemia d. Hypophosphatemia
a. Hyponatremia Rationale: Furosemide potentiates the excretion of sodium, causing hyponatremia.
The nurse has reinforced instructions for an older adult regarding adhering to a low sodium diet. The nurse realizes further instruction is needed if the older adult selects which items from the menu? (Select all that apply.) a. Frozen broccoli b. Canned peas c. Fried donuts d. Canned vegetable soup e. Canned peaches
b. Canned peas d. Canned vegetable soup Rationale: The older adult should be educated on ways to avoid "hidden sodium" in foods such as canned foods and soups. The other menu items do not contain large amounts of sodium.
The oral temperature of a client with a urinary tract infection is 103° F. Which intervention should the practical nurse (PN) implement first? a. Instruct the client on proper hygienic practices. b. Observe the color or odor of urine. c. Recheck the temperature rectally. d. Encourage fluid intake.
d. Encourage fluid intake. Rationale: Fluids help to reduce fever as quickly and it is important to lower the temperature as soon as possible.
The practical nurse (PN) teaches the client how to administer regular and NPH insulins and requests a return demonstration from the client. Which action by the client indicates understanding of the medication instruction? a. The client drew up NPH and regular insulin in separate syringes. b. The client drew up the insulin using clean technique. c. The client drew up NPH insulin first, then the regular insulin. d. When drawing up insulin in the same syringe, the client drew up the regular insulin first then the NPH insulin.
d. When drawing up insulin in the same syringe, the client drew up the regular insulin first then the NPH insulin. Rationale: When preparing a mixture of regular and NPH insulin, the regular insulin should be drawn up first. NPH and regular insulin can be mixed. Regular insulin should be drawn up first to avoid contamination. (clear, then cloudy)
The nurse has reinforced instructions for a low-fat diet prescribed for an older adult to prevent cardiovascular disease. Which meal selection best indicates the adult understands the instructions? a. Broiled fish, green beans, and an apple b. Grilled steak, baked beans, and a salad c. Pork chops, macaroni and cheese, and grapes d. A green salad, with grilled chicken and ranch dressing
a. Broiled fish, green beans, and an apple Rationale: The best selection for an older adult client who will be eating a low-fat diet is broiled fish, green beans, and an apple. The other meal items are too high in fat.
When initially monitoring a client after a fall, which information should the practical nurse (PN) communicate immediately to the health care provider? (Select all that apply.) a. Change in the level of consciousness b. Increasing muscular weakness c. Changes in pupil size bilaterally d. Progressive nuchal rigidity e. Onset of nausea and vomiting
a. Change in the level of consciousness e. Onset of nausea and vomiting Rationale: A decrease or change in the level of consciousness is usually the first indication of neurological deterioration. Nausea and vomiting may also be present.
The practical nurse (PN) is caring for an older client diagnosed with Alzheimer dementia. Which behavior by the client should the PN be the most concerned about? a. Climbing out of bed b. Refusing to change clothes c. Wandering into other clients' rooms d. Eating food off of other clients' trays
a. Climbing out of bed Rationale: The client who is confused is at high risk for falling; thus, climbing out of bed increases the risk of injury from a fall.
An older adult client has bruises resembling handprints encircling both arms, but claims this injury was sustained when she slipped in water. The nurse also notes the client becomes very withdrawn when the son visits, and that the client is emaciated. Which action is most appropriate? a. Contact the local law enforcement agency. b. Ask the son if he was the one who injured his mother. c. Ask the client why she is attempting to cover for her son. d. Ask the older adult if she is willing to press charges against the son.
a. Contact the local law enforcement agency. Rationale: These findings correlate with elder abuse and neglect. The nurse is legally obliged to report all cases of suspected elder abuse to the appropriate law enforcement agency. It is not appropriate for the nurse to confront the son. Older adults may "cover for" their abuser due to fear of abandonment or reprisal. In many areas, the older adult does not have to press charges against the abuser, charges are filed against the abuser by the state.
The client is recently diagnosed with Parkinson disease and is to begin medication therapy. What is the purpose of the client's medication therapy? a. Decrease tremors. b. Slow disease progression. c. Cure Parkinson disease. d. Improve short-term memory.
a. Decrease tremors. Rationale: Drug therapy for Parkinson disease is used to reduce symptoms, such as tremors, to improve the client's quality of life.
An older adult client is currently being treated for a urinary tract infection (UTI). The nurse has reinforced instructions in ways to prevent future UTIs and realizes the client requires further instructions if the client makes which statements? (Select all that apply.) a. "I should drink as little fluid as possible." b. "I will be able to stop the antibiotics once I feel better." c. "I will go urinate as soon as I feel the urge to urinate." d. "I should drink lots of coffee and sodas every day." e. "If I notice blood in my urine, I should notify my health care provider."
a. "I should drink as little fluid as possible." b. "I will be able to stop the antibiotics once I feel better." d. "I should drink lots of coffee and sodas every day." Rationale: A client being treated for a UTI should drink 2 to 3 L of fluid daily if not contraindicated. Antibiotics should be taken for the prescribed course, not stopped if the symptoms reduce or go away. Caffeinated beverages can cause excessive urination. A client with a UTI should void as soon as the need is perceived and should also notify the health care provider if blood is noted in the urine.
The practical nurse (PN) prepares to administer eye drops and eye ointment to the client with a left eye infection. Which nursing intervention is the most effective for administering the medications? a. Administer the eye drops first and then the ointment. b. Administer the ointment and immediately follow with the eye drops. c. Administer the ointment, wait 5 minutes, and then administer the eye drops. d. Administer the eye drops, wait 15 minutes, and then administer the ointment.
a. Administer the eye drops first and then the ointment. Rationale: When eye drops and eye ointment are scheduled for the same time, the eye drops should be administered first, followed by the ointment 3 to 5 minutes later.
The nurse is reviewing medical records at a long-term care facility to determine if the older adult clients have received immunization for influenza. The nurse should ensure the clients receive this immunization according to which guideline? a. Annually b. Every 10 years c. After contracting influenza d. Before having major surgery
a. Annually Rationale: Older adults should receive the influenza immunization annually.
The practical nurse (PN) gives written discharge instructions to an older adult client who has undergone cataract surgery on the right eye. Which discharge instruction should the PN reinforce? a. Avoid sleeping on your right side. b. Follow up with the surgeon in 6 weeks. c. Remove the dressing when showering tonight. d. Expect to have a headache for the next 2 to 3 days.
a. Avoid sleeping on your right side. Rationale: The client should be advised about any limitations such as not sleeping on the operative side, limiting reading, no heavy lifting, and no strenuous activity. The client usually has a follow up visit with the surgeon in the first week after surgery.
The practical nurse (PN) is caring for a client who has been diagnosed with early Alzheimer disease. With which activity does the PN expect the client to experience the most difficulty? a. Balancing a checkbook b. Remembering his name c. Performing activities of daily living (ADLs) d. Recognizing friends and family members
a. Balancing a checkbook Rationale: In the early stages of Alzheimer disease, the client has difficulty with complex tasks, such as balancing a checkbook.
The practical nurse (PN) facilitates an exercise program for older adult clients with type 2 diabetes. Which are the most beneficial outcomes that the clients may experience as a result of participating in the program? (Select all that apply.) a. Improved circulation b. Decreased total cholesterol c. Reduced cardiovascular risks d. Eliminated need for a diabetic diet e. Increased insulin resistance and glucose tolerance
a. Improved circulation b. Decreased total cholesterol c. Reduced cardiovascular risks Rationale: Benefits of exercise for the diabetic client include improved circulation, decreased total cholesterol, and reduced cardiovascular risks.
The practical nurse (PN) assesses the older adult client's skin for signs of breakdown and observes that the skin is intact. What interventions by the PN will help maintain healthy skin integrity? a. Keep the client well hydrated. b. Remove adhesive tape quickly from the skin. c. Avoid creams or lotions to ensure that the skin stays dry. d. Scrub the perineum with a wet cloth after a bowel movement.
a. Keep the client well hydrated. Rationale: Keeping the client well hydrated helps prevent skin cracking and infection.
An older adult client is recovering from a myocardial infarction. The cardiologist prescribes docusate sodium with a dosage of one tablet by mouth twice a day. What therapeutic effect does this medication provide for this client? a. Maintaining soft stools to prevent straining on defecation b. Increasing cardiac blood flow by dilating the coronaries c. Replacing serum potassium lost with diuretic therapy d. Preventing the occurrence of stress ulcers in the duodenum
a. Maintaining soft stools to prevent straining on defecation Rationale: Docusate sodium is a stool softener that promotes defecation without straining or invoking the Valsalva maneuver.
The nurse is assisting with planning care for a group of older adult clients who are interested in disease prevention with immunizations. Which advice is best for the nurse to provide to this group? a. Make sure you get the influenza vaccine every year. b. Make sure you get the pneumonia vaccine every year. c. Make sure you get the tetanus/diphtheria/pertussis vaccine every year. d. If you did not get chicken pox as a child, get the shingles vaccine every year.
a. Make sure you get the influenza vaccine every year. Rationale: All adults, but especially older adults, need an influenza vaccine (flu shot) yearly. The other vaccines are important for older adults, but are not required yearly.
An 83-year-old client diagnosed with type 2 diabetes mellitus has been admitted to home health care for an ulcer on the heel of the left foot. Which changes in the foot should the practical nurse (PN) expect to find? (Select all that apply.) a. Pedal pulses will be weak or absent in the left foot. b. The client states that the left foot is usually warm. c. Flexion and extension of the left foot will be limited. d. Capillary refill of the client's left toes is longer than 2 seconds. e. The client denies any pain in the left foot.
a. Pedal pulses will be weak or absent in the left foot. e. The client denies any pain in the left foot. Rationale: Symptoms associated with decreased blood supply are weak or absent pedal and tibial pulses. The client denying any pain is a common complication with type 2 diabetes in the elderly.
The home health practical nurse (PN) visits the home of an older client. The PN assesses the environment for fall hazards. Which suggestions made by the PN may prevent the client from falling? (Select all that apply.) a. Use night lights. b. Wax the floors frequently. c. Place a nonskid mat in the shower. d. Keep a throw rug on the kitchen floor. e. Keep walkways clear inside and outside.
a. Use night lights. c. Place a nonskid mat in the shower. e. Keep walkways clear inside and outside. Rationale: Falls in the home can be prevented by ensuring adequate lighting, including night light use, placing nonskid mats in showers and tubs, and keeping all walkways clear, both inside and outside.
The nurse is meeting with a group of older adults to encourage the adults to incorporate exercise into their healthy lifestyle. Which type of exercise should the nurse encourage this group to undertake? a. Walking on a daily basis b. Jogging, but only weekly c. Sprinting, but only on weekends d. Exercise is rarely recommended for older adults
a. Walking on a daily basis Rationale: Exercise for older adults should be regular and low impact. Daily walking fits this criterion. Weekly or weekend only exercise is not frequent enough. Most health older adults can perform some type of increased activity.
An older adult has undergone a prostatectomy due to prostate cancer. He asks the nurse "Will the operation change my love life? I am widowed, but I have been dating someone seriously." How should the nurse respond to this question? a. "Your new friend will likely not be interested in a sexual relationship." b. "What concerns do you have about sexuality in your new relationship?" c. "You should wait until after you have healed to think about your relationship." d. "You should have asked your family their opinion about dating someone new."
b. "What concerns do you have about sexuality in your new relationship?" Rationale: Using the steps of the nursing process, and the keys to effective communication, use data collection to determine the client's concerns first. It is ageist to state that the older adult is not interested in sexual relations. Telling the client not to think about his new relationship is inappropriate, because the client voiced a concern that should be addressed. It is inappropriate to discuss the family's concerns when the client has not mentioned them.
The nurse is assisting with data collection regarding an older adult's risk for development of neurological system changes. The presence of which risk factors should the nurse discuss with the health care provider? a. A history of concussion injury in a sibling b. A history of substance abuse as an adult c. A long history of personality disorders d. A history of anoxic brain injury in a parent
b. A history of substance abuse as an adult Rationale: A history of substance abuse as an adult is a risk factor for development of neurological system changes. A history of concussion or anoxic brain injury in a family member is not a risk factor for an individual. Personality disorders do not cause neurological system changes.
A client has had cataract surgery. What is the most important postsurgery instruction that the practical nurse (PN) should implement? a. Increase dietary intake of vitamin E. b. Avoid bending at the waist. c. Instruct the client to look for halos around objects. d. Advise the client that there will be significant changes in vision.
b. Avoid bending at the waist. Rationale: The client needs to avoid heavy lifting, straining, and bending to prevent intraocular pressure in the eye.
An older adult residing at the long-term care facility developed pneumonia, was subsequently hospitalized, and died. The nurse participating on the nursing quality assurance review committee is most likely to note that which was the most likely early symptom the resident displayed? a. A cough productive of thick yellow sputum b. Confusion reported by the resident's family c. Respiratory stridor and expiratory wheezing d. Hyperthermia, hypoxia, and then hypercapnia
b. Confusion reported by the resident's family Rationale: Confusion is frequently an early symptom of respiratory infection in the older adult, and is caused by hypoxia. The immune response is delayed in the older adult, and sputum and fever are not formed as quickly. Respiratory distress, stridor, and wheezing would be very late symptoms of this disease.
An older client is admitted to the hospital with abdominal pain and watery, incontinent diarrhea following a course of antibiotic therapy. Stool cultures show the presence of Clostridium difficile. What information is most important for the practical nurse (PN) to tell the unlicensed assistive personnel (UAP) about caring for this client? a. Hands should be washed with hand sanitizer. b. Follow isolation precautions while caring for the client. c. Clean all solid surfaces with hospital-approved cleaning products. d. Make sure that only visitors don gowns and gloves before entering client's room.
b. Follow isolation precautions while caring for the client. Rationale: A priority goal for the client with infectious diarrhea due to C. difficile is infection control precautions and the prevention of nosocomial transmission. Everyone who enters the room should wear gown and gloves.
A client who resides in a long-term care facility has a seizure disorder that has been managed with phenobarbital for several years. Lately, the client has become more difficult to arouse. What intervention should the PN implement? a. Carefully monitor the client's intake and output. b. Hold the medication and notify the health care provider. c. Continue to monitor the client closely for the next 24 hours. d. Determine the amount of medication the client has taken.
b. Hold the medication and notify the health care provider. Rationale: The client is exhibiting signs of antiepileptic drug toxicity (AED), and a serum phenobarbital level needs to be obtained to determine if the client is experiencing drug toxicity.
The practical nurse (PN) educates the client diagnosed with Parkinson about levodopa-carbidopa. Which instruction about this medication should the PN include in the client's discharge teaching plan? a. Notify the health care provider immediately if the urine turns bright orange. b. Notify health care provider if tremors worsen. c. Take levodopa-carbidopa with a high-protein meal. d. Client may discontinue medication if side effects occur.
b. Notify health care provider if tremors worsen. Rationale: The client should call the health care provider if tremors become worse because the dose may need to be adjusted. A bright orange color to the urine is harmless.
An older client is discharged from the hospital with a prescription for digoxin 0.25 mg daily. Which instruction should the practical nurse (PN) include in this client's discharge teaching plan? a. Take the medication in the morning before rising. b. Take and record radial pulse rate daily. c. Expect some vision changes due to the medication. d. Increase intake of foods rich in vitamin K.
b. Take and record radial pulse rate daily. Rationale: Monitoring pulse rate is very important when taking digoxin. The client should be further instructed to report pulse rates below 60 or greater than 110 beats/min and to withhold the dosage until consulting with the health care provider.
The older adult client diagnosed with a pulmonary embolus is taking warfarin 5 mg daily. The practical nurse (PN) notes that the most recent international normalized ratio (INR) value is 5.0. Which intervention should the practical nurse (PN) anticipate? a. The provider will increase the dose of warfarin. b. The provider will decrease the dose of warfarin. c. The provider will not change the warfarin order. d. The provider will add heparin to the client's medications.
b. The provider will decrease the dose of warfarin. Rationale: Warfarin is an anticoagulant, and the INR measures the clotting time of the blood. The therapeutic range for INR is 2 to 4.5, depending on the client's disease process. An INR above the recommended range means that the warfarin should be reduced to prevent bleeding.
An older adult had right hip replacement surgery several days ago and is being prepared for discharge home with relatives. The nurse has reinforced instructions to prevent hip displacement. Which client statement indicates the client needs further instruction? a. "I will ask my son to get a raised toilet seat for the bathroom." b. "I will need to keep a pillow between my legs when I'm in bed." c. "I will need to remember to sleep only on my right side now." d. "I should not cross my right leg over my left leg when I sit."
c. "I will need to remember to sleep only on my right side now." Rationale: The client should not sleep on the right side after surgery. The other options are all actions to take following hip surgery to prevent hip dislocation.
An older adult client has been diagnosed with lung cancer and will begin receiving hospice services. The nurse expects to see which aspects included in the plan of care? (Select all that apply.) a. Encouraging the client and family to remain hopeful that a cure will be found b. Encouraging the client to continue with chemotherapy and radiation to treat cancer c. Administering medications to relieve symptoms of nausea, vomiting, and diarrhea d. Encouraging the client to continue with spiritual practices that provide comfort e. Waiting until the pain becomes severe to administer narcotics to prevent dependence
c. Administering medications to relieve symptoms of nausea, vomiting, and diarrhea d. Encouraging the client to continue with spiritual practices that provide comfort Rationale: The plan of care for a client who is terminally ill and receiving hospice services includes symptom management for distressful symptoms that interfere with the quality of life. The client is also encouraged to use spiritual practices that provide comfort. Hospice care focuses on care, rather than cure and it is nontherapeutic to encourage the client and family to hope for a cure or to continue futile therapy. Pain management is emphasized, without concern of drug dependence.
The practical nurse (PN) educates the older client about a new hearing aid. Which instruction is the most important for the PN to give the client about the care of the new hearing aid? a. Instruct client to keep extra batteries on hand. b. Tell client to clean it with a toothpick or pipe cleaner. c. Inform client to remove it before bathing. d. Turn it off and remove the battery when not in use.
c. Inform client to remove it before bathing. Rationale: Hearing aids should not be used in and around water; therefore, the client should remove his hearing aid for bathing.
A male client is seen in the clinic for benign prostatic hypertrophy (BPH). Which intervention is essential for the practical nurse (PN) to include in the client's visit? a. Reeducate the client about limiting fluid intake. b. Reassure the client that his BPH is a non-life-threatening condition. c. Assess the client for urinary hesitancy and weak or split urinary stream. d. Inform the client that there may be a genetic predisposition for male family members.
c. Assess the client for urinary hesitancy and weak or split urinary stream. Rationale: These symptoms may indicate progression of BPH to partial obstruction of the urethra, a medical emergency, and need to be reported to the health care provider. Fluids should be encouraged, not limited; hydration needs to be maintained.
The nurse is caring for an older adult who is at high risk for skin breakdown. Which is the best method for the nurse to determine if the plan of care for this client is effective? a. Reviewing the documentation of the client's turn schedule b. Turning the client at least every 2 hours around the clock c. Assessing the client's skin for pressure ulcers every shift d. Completing a nutritional assessment to determine protein needs
c. Assessing the client's skin for pressure ulcers every shift Rationale: The best way to determine if the plan of care to prevent skin breakdown is effective is to actually assess the client's skin. Reviewing documentation and completing a nutritional assessment will not likely give a complete picture. Turning the client every 2 hours is an intervention, not a method of evaluating the effectiveness of care.
The nurse at a long-term care facility is working with a group of unlicensed assistive personnel (UAPs) and is asking the UAPs to provide oral care to the residents. The nurse should explain this is important to provide for which vital reasons? (Select all that apply.) a. Inspecting agencies review medical records for compliance b. Frequent oral care reduces halitosis, or bad breath, in older adults c. Dental caries, or cavities, can occur in older adults resulting in teeth loss d. Dry mouth in older adults may cause a decreased appetite, resulting in poor nutrition e. If multiple teeth are missing, the older adult has difficulty eating fresh vegetables
c. Dental caries, or cavities, can occur in older adults resulting in teeth loss d. Dry mouth in older adults may cause a decreased appetite, resulting in poor nutrition e. If multiple teeth are missing, the older adult has difficulty eating fresh vegetables Rationale: It is important to ensure that older adults receive adequate oral care, because cavities, dry mouth, and missing teeth can lead to teeth loss. This can cause severe nutritional problems due to the inability to chew meats, fresh fruits and vegetables, and other essential food items. While it is true that inspecting agencies often review medical records, this is not the most crucial reason to provide this care. Halitosis can be caused by poor oral hygiene, but this is also not the most crucial reason to provide care.
An older adult in a long-term care setting approaches the nurse and states "I have not had a bowel movement today, and I usually have a bowel movement every day." Which action should the nurse take first? a. Encourage the older adult to walk around. b. Ask the older adult to drink additional fluids. c. Determine any changes in the older adult's routine. d. Ask the health care provider for a laxative prescription.
c. Determine any changes in the older adult's routine. Rationale: Recall the steps of the nursing process: data collection is the first step. First determine if there has been any change in the older adult's routine that could have caused the change in bowel activity. Until data collection has been completed, it is fruitless to suggest alterations in the care of the client.
The practical nurse (PN) emphasizes ways to prevent constipation to the older adult client. Which instruction should the PN reinforce in the client's discharge teaching plan? a. Avoid caffeinated beverages. b. Take a stool softener once a week. c. Drink several glasses of water throughout the day. d. Make sure to chew food completely before swallowing.
c. Drink several glasses of water throughout the day. Rationale: Adequate hydration is an important measure for preventing constipation.
An older adult client is recovering from a hip fracture. The health care provider has prescribed home health care nursing upon discharge. Which statement describes the primary goal for the client? a. Return the client to his or her previous lifestyle. b. Avoid dependency on medication therapy. c. Establish self-care and independence. d. Maintain a friendly relationship with family members.
c. Establish self-care and independence. Rationale: Loss of independence is a significant issue with the aging population and is one of the most important issues for the home health practical nurse (PN) to establish with the client. Establishing the client's individual goals is the primary concern of the home health care PN.
When talking with a family member about prevention of falls, which recommendations should the practical nurse (PN) include in the discussion? (Select all that apply.) a. Review a history of falls. b. Contact a medical alert company. c. Get vision and hearing examinations. d. Recommend that the client join a tai chi group. e. Move the client to an assisted living community.
c. Get vision and hearing examinations. d. Recommend that the client join a tai chi group. Rationale: Vision and hearing impairment are risk factors for falls. Correction of any impairment will help prevent falls; tai chi has been identified as the most beneficial strength and balance exercise program to reduce falls. A previous history of falls is predictive of further falls, so prevention strategies could be recommended but this is not a recommendation for preventing falls.
An older client who has a history of a hip fracture was admitted to the hospital for congestive heart failure. The client is taking codeine-acetaminophen as needed for pain. Which risk factor puts this client at greatest risk for a fall? a. Age b. Diagnosis c. History of falls d. Narcotic use
c. History of falls Rationale: Older clients with previous hip fractures have a higher morbidity/mortality rate and are at a greater risk for additional falls, so the client's history of falls would be important information to know while planning care for the client.
An older adult client diagnosed with Alzheimer disease has been receiving donepezil for the past 6 weeks. Which change would indicate that the medication has been effective? a. Increased muscle strength and tone b. Fewer episodes of urinary incontinence c. Increased ability to solve simple problems d. Increased feelings of well-being
c. Increased ability to solve simple problems Rationale: Donepezil is used to improve cognitive functioning in those suffering from Alzheimer disease. Improvement in cognitive functioning is most clearly assessed when the client exhibits increased memory, attention, reasoning, and problem solving.
The hospitalized client with end-stage renal disease has expressed verbal and written wishes not to be resuscitated. Which action should the practical nurse (PN) take? a. Bring the crash cart into the room. b. Ask the client to validate end-of-life wishes. c. Keep the client as comfortable as possible. d. Ask the family if they want the client resuscitated.
c. Keep the client as comfortable as possible. Rationale: Clients have the right to make decisions regarding their care, up to and including resuscitative measures. The practical PN must respect the client's wishes by keeping him comfortable.
When caring for a client on digoxin therapy, the practical nurse (PN) knows to be alert for digoxin toxicity. Which finding would predispose this client to developing digoxin toxicity? a. Low serum magnesium level b. High serum magnesium level c. Low serum potassium level d. High serum potassium level
c. Low serum potassium level Rationale: Hypokalemia predisposes the client on digoxin to digitalis toxicity, usually presenting as abdominal pain, anorexia, nausea, vomiting, visual disturbances, bradycardia, and atrioventricular (AV) dissociation. Assessment of the serum potassium level with prompt correction of hypokalemia is an important intervention for the client taking digoxin.
A 90-year-old client is brought to the emergency room by a niece who visits him twice a week. The client lives independently, has several hobbies, and interacts well with his friends and relatives. Last night, the client suddenly became agitated, and started hallucinating. Urinalysis and complete blood count reveal a urinary tract infection. The niece asks "Is my uncle developing dementia?" Which answer is most appropriate to provide? a. Unfortunately, these are early signs of dementia. b. It is unfortunate he did not get treatment for dementia earlier. c. Since the symptoms began so rapidly, it is not likely dementia. d. The hallucinations he is having indicate he may have dementia.
c. Since the symptoms began so rapidly, it is not likely dementia. Rationale: Acute delirium, rather than dementia, is more likely because delirium is associated with an abrupt onset and a systemic illness. In this case the client has only had symptoms since last night and has been diagnosed with a urinary tract infection. Once the infection has been treated successfully, it is likely the client will return to his usual state. Dementia is characterized by a slower onset of symptoms. It is nontherapeutic to tell a client's family member he should have been treated earlier.
The practical nurse (PN) performs a skin assessment on an older adult client who is on bed rest. The PN notes a circular area of nonblanchable erythema on the coccyx. Which type of skin condition does this indicate? a. Fungal rash b. First-degree burn c. Stage 1 pressure ulcer d. Stage 2 pressure ulcer
c. Stage 1 pressure ulcer Rationale: An area of nonblanchable erythema over a bony prominence caused by pressure is a stage 1 pressure ulcer.
An older client at a long-term care facility is to be monitored for early signs of pneumonia. The practical nurse's (PN) observation of the client will most likely show which early sign(s)/symptom(s)? (Select all that apply.) a. Fever b. Abnormal breath sounds c. Tachycardia d. Confusion e. Tachypnea
c. Tachycardia d. Confusion e. Tachypnea Rationale: The onset of pneumonia in the older adult may be signaled by general deterioration, confusion, increased heart rate, or increased respiratory rate. Fever and abnormal breath sounds occur later with the older adult.
An older adult client is being treated for toxicity related to medication use. When reviewing the client's medical records, the nurse is most likely to find which factor is correlated with this problem? a. The client has forgotten to take several doses of medication. b. The client's white blood cell count has steadily increased. c. The client's liver function has decreased since last year. d. The client has gained 40 pounds (18.2 kg) over 3 years.
c. The client's liver function has decreased since last year. Rationale: With aging, liver function decreases, affecting drug metabolism and detoxification. Forgetting to take doses of medication would not cause drug toxicity; excessive doses could cause toxicity. Elevated white blood cell counts and weight gain would not likely cause drug toxicity.
The daughter of a client diagnosed with Alzheimer disease reports to the practical nurse (PN) that her mother has recently lost her appetite and refuses to eat. The client was recently prescribed rivastigmine tartrate. What instructions are important for the PN to provide to the client's daughter? a. Taking the medication before meals will help stimulate her interest in eating b. Appetite generally increases once the medication has reached therapeutic levels c. The prescriber should be notified if there is weight loss or an increased loss of appetite d. Anorexia indicates toxic drug levels and requires immediate assessment by the prescriber
c. The prescriber should be notified if there is weight loss or an increased loss of appetite Rationale: Rivastigmine tartrate, used to treat the dementia of Alzheimer disease, often causes gastrointestinal side effects, which should be reported to the prescriber before significant malnutrition and fluid volume deficit occur.
The client has end-stage Alzheimer disease and is admitted into hospice care. Which focus does the nurse expect to note in the plan of care? a. To provide maximum treatment to keep the client alive b. To focus on caring interventions and symptom management c. To allow the client to die with as much comfort and dignity as possible d. To rehabilitate the patient by offering physical and occupational therapies
c. To allow the client to die with as much comfort and dignity as possible Rationale: The philosophy of hospice care is to allow the client in the end stages of life to die with dignity and to be as comfortable as possible. Clients on hospice care are not provided lifesaving measures; the goal of palliative care is to allow clients to have a peaceful death focusing on caring interventions and symptom management.
The practical nurse (PN) is caring for a client who is having an exacerbation of congestive heart failure (CHF). The PN should place the client in which position? a. Trendelenburg position b. Lateral lying, with the legs slightly bent c. Upright, with the legs in a dependent position d. Semi-Fowler, with the legs elevated above the heart
c. Upright, with the legs in a dependent position Rationale: Clients with congestive heart failure or pulmonary edema should be positioned upright, preferably with the legs dangling over the side of the bed, to decrease venous return and lung congestion.
The nurse has reinforced education regarding safety aspects for antihypertensive medication with an older adult. Which statement by the client best indicates learning has been effective? a. "I should rest in bed most of the day when I take this medication." b. "I will be sure to keep this medication out of the reach of children." c. "I will need to make sure that I take this medication with some food." d. "I will make sure that I stand up slowly if I have been sitting down."
d. "I will make sure that I stand up slowly if I have been sitting down." Rationale: Older adults are particularly likely to develop orthostatic hypotension after taking medications to treat hypertension. It is not necessary for the older adult to stay in bed while taking this medication. Some medications should be taken with food, others on an empty stomach. Each medication should be individually researched. While it is important to prevent children from consuming medications intended for the older adult, the focus of this question is the safety of the older adult.
The client complains of nausea and vomiting about 1 hour after taking the morning dose of an oral antidiabetic agent, glyburide. What is the priority nursing intervention? a. Administer an additional dose of glyburide. b. Take the client's blood glucose levels and administer insulin subcutaneously. c. Check the blood glucose level and monitor for signs of hyperglycemia. d. Closely monitor the blood glucose level and watch for signs of hypoglycemia.
d. Closely monitor the blood glucose level and watch for signs of hypoglycemia. Rationale: When a client who has taken an oral antidiabetic agent vomits, the practical nurse (PN) should monitor the blood glucose level and watch for signs of hypoglycemia.
The practical nurse (PN) reinforces the instructions to the client after a hip replacement. Which client action indicates the need for further education? a. Lying on the unaffected side b. Flexing and extending the feet c. Ambulating with physical therapy d. Crossing the feet while lying in bed
d. Crossing the feet while lying in bed Rationale: Maintaining the knee and hip in proper alignment and avoiding internal or external rotation can prevent hip displacement. Crossing the legs at the feet will cause the hip to rotate internally.
An older client is admitted to the hospital after experiencing confusion, nausea and vomiting, and headache for several days. The client's pulse rate is 43 beats/min. The practical nurse (PN) is most concerned about the client's history related to what medication? a. Warfarin b. Ibuprofen c. Nitroglycerin d. Digoxin
d. Digoxin Rationale: Older adult persons are particularly susceptible to the buildup of cardiac glycosides such as digoxin which leads to a toxic level within their systems. Toxicity can cause anorexia, nausea, vomiting, diarrhea, headache, and fatigue.
An older client who resides in a long-term care facility is hearing-impaired. How should the practical nurse (PN) modify interventions for this client? a. Turn off the client's television and speak very loudly. b. Communicate in writing whenever it is possible. c. Speak very slowly while exaggerating each word. d. Face the client and speak in a normal tone of voice.
d. Face the client and speak in a normal tone of voice. Rationale: A hearing-impaired client frequently relies on lip reading and body language to determine what is being said, so face the client and speak in a normal tone of voice. (low-pitch voice)
An older client verbalizes to the practical nurse (PN) that he feels a lack of control over his life. The family member who came with the client states that his father has been exhibiting increased passive behavior and an unwillingness to participate in family functions. What word best describes this client's behavior? a. Anxiety b. Fear c. Altered self-esteem d. Powerlessness
d. Powerlessness Rationale: The behaviors that the client is exhibiting are most characteristic of powerlessness and could affect the client's safety.
An older adult client has been diagnosed with third-degree heart block and the health care provider recommends a pacemaker be implanted tomorrow. Prior to the surgery, the nurse expects the client's plan of care to emphasize which aspect? a. Instruction to avoid microwaves b. Preparing for blood transfusion c. Administration of anticoagulants d. Preventing injury related to falling
d. Preventing injury related to falling Rationale: A client with a dysrhythmia is at risk for fall injury due to syncope caused by a reduction in cardiac output. The client's plan of care should emphasize ways to keep the client safe, such as assisting the client with ambulation. The client will not need to avoid microwaves and blood transfusions are not common with pacemaker insertion. Anticoagulants are not necessarily associated with pacemaker insertion or with third-degree heart block.
An older adult client tells the nurse "I do not understand how I could have a sexually transmitted disease! My partner seems like such a nice, clean person." Which explanation should the nurse provide? a. Most people in your age are not interested in sexual relationships. b. You should have discussed this with your family before you started dating. c. Maybe you should go back to just holding hands and hugging on dates. d. Sexually transmitted diseases are possible to have at any age of your life.
d. Sexually transmitted diseases are possible to have at any age of your life. Rationale: Sexually transmitted diseases are possible at any age. It is inappropriate, untrue, and ageist to comment that older adults are not interested in sexual relations. It is very judgmental for the nurse to suggest the older adult should have sought their family's input or that the older adult should stop having sexual relations.
An older client is receiving hospice care and the spouse and family have expressed several concerns. Which concern expressed by the family should the practical nurses (PN) address first? a. The spouse asks about the side effects of the client's pain medication. b. The client's family requests referrals for support groups to help with the grieving process. c. The spouse reports that the client finally slept for more than 2 hours last night. d. The client's spouse wants to know when it is time to call 9-1-1.
d. The client's spouse wants to know when it is time to call 9-1-1. Rationale: This statement by the client's spouse about calling 9-1-1 shows that further education is needed about hospice and the end-of-life process.
An older client diagnosed with benign prostatic hypertrophy (BPH) asks the practical nurse (PN) what will happen if he decides not to have it treated. Which information given by the PN is most accurate regarding BPH? a. Prostatitis results from untreated BPH. b. Painful kidney stones will develop if you do not treat BPH. c. If left untreated, BPH will develop into a severe bladder infection. d. Untreated BPH causes urinary reflux and possibly hydronephrosis.
d. Untreated BPH causes urinary reflux and possibly hydronephrosis. Rationale: Untreated BPH leads to urinary reflux and possibly hydronephrosis because of increased pressure in the bladder.
