241 study guide

An older adult who is within a normal weight range asks a nurse, "I have heard that it is important to limit the amount of fats in my diet, but I don't know how much I should be taking in daily. Can you help me?" The best response by the nurse is: "Less than 10% of calories per day should come from saturated fats." "Fat intake will depend on the presence of any cardiac issues." "Someone of your age needs to limit fats." "Read food labels well and focus your diet on low-fat foods."

"Fat intake will depend on the presence of any cardiac issues."

A nurse is instructing a young adult client about healthful sleep habits. Which of the following statements should the nurse identify as an indication that the client needs further teaching? "I go to bed and get up routinely at the same time each day." "I have a small snack and take a bath before going to bed each day." "I watch television until I fall asleep at night." "I don't take naps throughout the day."

"I watch television until I fall asleep at night."

A nurse is presenting a class about fall prevention to a group of assisted-living residents. Which of the following statements by a resident best indicates an understanding of the teaching? "I should get a longer cord for my telephone." "It is a good idea to use the handrails in the bathroom." "I should place a throw rug over electrical cords." "I should use chairs without armrests."

"It is a good idea to use the handrails in the bathroom."

A nurse is caring for a client whose partner is requesting to bring the client food from home that is not allowed in the client's dietary plan. Which of the following responses should the nurse make? "You will need to discuss your concerns about your partner's diet with the provider." "Let's try to find ways to incorporate your partner's favorite food into her diet plan." "Everyone likes food from home, but it can delay your partner's recovery." "Why would you want to put your partner's health at further risk?"

"Let's try to find ways to incorporate your partner's favorite food into her diet plan."

A nurse is working with an older individual who has recently started an exercise program. The individual tells the nurse, "This exercise thing is really hard, and I absolutely hate walking on a treadmill going nowhere. I think I am going to call it quits." Which of the following responses by the nurse will be most effective in encouraging the individual to remain in the program? "I will have to report that to your physician." "What types of exercise do you enjoy doing?" . "Most older people hate exercising, but they do it anyways." "If you stop exercising, you will reverse all the good effects that the exercise accomplished."

"What types of exercise do you enjoy doing?"

A nurse is providing education for a client who has glaucoma. Which of the following statements should the nurse include in the teaching? "Use of eye drops will improve vision over time." "Glaucoma is caused by inadequate production of fluid within the eye." "Double vision is a common symptom of glaucoma." "Without treatment, glaucoma can cause blindness."

"Without treatment, glaucoma can cause blindness."

A 75-year-old female asks a nurse "I know I should be moving, but how much is the right amount of exercise for me?" The best response of the nurse is: "Since you are 75, the recommendations are 30 minutes of moderate exercise three times a week." "There are no specific recommendations for someone of your age; just keep moving." "You need to engage in 30 minutes of moderate intensity exercise at least 5 days a week." "You need to engage in at least 30 minutes of moderate intensity exercise every day of the week."

"You need to engage in 30 minutes of moderate intensity exercise at least 5 days a week."

A nurse is teaching a group of older adults about nutrition. The nurse should include which of the following amounts as an appropriate daily intake of fiber? 10 to 15 g 5 to 10 g 20 to 35 g 40 to 50 g

20 to 35 g

A nurse at a health fair is assessing the weight status of four older clients. Which of the following clients are classified as overweight? A male client who has a waist circumference of 96.52 cm (38 in) A female client who has a body mass index of 24 A female client who has a waist circumference of 101.6 cm (40 in) A male client who has a body mass index of 29

A male client who has a body mass index of 29

The nurse is performing client education related to diabetic retinopathy. Which of the following statements by the nurse is appropriate? Select all that apply. "A previous diagnosis of diabetes places you at increased risk." "You should see your eye doctor every two years for an exam." "Diabetic retinopathy is a medical emergency that requires surgery." "Glycemic control is essential in preventing this condition." "Individuals with this diagnosis experience blurry vision."

A previous diagnosis of diabetes places you at increased risk."

Primary prevention strategies for older adults include which of the following? A cardiac rehabilitation program A smoking cessation program A meal planning education program for type 2 diabetics A prostate screening program

A smoking cessation program

Dressings, bathing, toileting and feeding are examples of: IADL's cognitive markers ADL's functional markers

ADL's

Which of the following conditions is considered a medical emergency? Primary open angle glaucoma Macular degeneration Diabetic retinopathy Acute angle closure glaucoma

Acute angle closure glaucoma

The FAST tool is an assessment tool to gauge which of the following: ADL's Depression Alzheimer's Mood

Alzheimer's

During a routine physical examination, a nurse observes a 1-cm (0.4-in) lesion on a client's chest. The lesion is raised and flesh-colored with pearly white borders. The nurse should recognize that this finding is suggestive of which of the following types of skin cancer? Squamous cell carcinoma Answer Basal cell carcinoma Actinic keratosis Malignant melanoma

Basal cell carinoma

The nurse is educating an older adult client about daily fluid requirements. The nurse recognizes which of the following from the client's history as potential contraindications for increased fluid intake? Select all that apply. Congestive heart failure Stage two pressure injury Diabetes mellitus type two Laparoscopic cholecystectomy Chronic kidney disease

Congestive heart failure Chronic kidney disease

A nurse completes a cultural assessment of an older adult who is being admitted to an assisted living facility. Reasons for completing a cultural assessment include: (Select all that apply.) Knowledge of culture eliminates health care disparities. Culture impacts attitudes toward aging. All members of a culture react in the same way in similar situations. Culture guides decision-making about health, illness, and preventive care.

Culture impacts attitudes toward aging. Culture guides decision-making about health, illness, and preventive care.

An older adult asks a nurse, "I hear a lot about getting enough fruits and vegetables in my diet and eating a balanced diet. It is confusing. Can you help me understand what a balanced diet for me would be?" The nurse bases a response on which of the following? Daily intake should consist of 40% fruits and vegetables; 30% grains; and 30% protein-rich foods. Daily intake should consist of 50% fruits and vegetables; 25% grains; and 25% protein-rich foods. Daily intake should consist of 33% fruits and vegetables; 33% grains; and 33% protein-rich foods. Daily intake should consist of 25% fruits and vegetables; 25% grains; and 50% protein-rich foods.

Daily intake should consist of 50% fruits and vegetables; 25% grains; and 25% protein-rich foods.

A nurse is admitting a client who has a partial hearing loss. Which of the following is the priority action by the nurse? Stand directly in front of the client. Determine if the client uses hearing aids. Speak using his usual tone of voice. Rephrase statements the client does not hear.

Determine if the client uses hearing aids.

A nurse is educating a group of older adults on the benefits of an exercise program. The nurse includes education on when not to exercise. Which of the following should the nurse include in the education? (Select all that apply.) It is important to wait 30 minutes after a big meal before engaging in exercise. Do not exercise if a joint that you are using to exercise is red, warm, and painful. Do not exercise if your blood pressure is greater than 200 systolic and 100 diastolic. Do not exercise if your resting heart rate is over 70

Do not exercise if a joint that you are using to exercise is red, warm, and painful. Do not exercise if your blood pressure is greater than 200 systolic and 100 diastolic.

A nurse is assessing a patient's activities of daily living. The nurse will assess which of the following? (Select all that apply.) Eating Toileting Self-medication administration Bathing

Eating Toileting Bathing

The nurse is caring for a client experiencing age-related vision changes. Which of the following actions by the nurse enhances patient safety? Utilizing a tonometer to assess intraocular pressure Assisting the client in signing their informed consent form Instructing the client to surrender their driver's license Encouraging the client to wear glasses during all waking hours

Encouraging the client to wear glasses during all waking hours

A nurse is caring for a client who reports difficulty sleeping while in the hospital. Which of the following actions taken by the assistive personnel (AP) while the client is sleeping should prompt the nurse to intervene? Measures the client's vital signs routinely Closes the door to the client's room Asks a group of nurses in the hall to speak quietly Flushes the client's toilet after emptying the urinary catheter's drainage bag

Flushes the client's toilet after emptying the urinary catheter's drainage bag.

A nurse is caring for an older client who has depression and is discussing activities of daily living (ADLs) with his family. The nurse should identify that the client can perform which of the following activities prior to discharge? Grocery shopping Hygiene House cleaning Driving

Hygiene Answer Rationale:The ability to maintain personal hygiene is an essential functional ability included in ADLs.

A nurse is teaching a client who has constipation. Which of the following should the nurse discuss as causes of constipation? (Select all that apply.) Ignoring the urge to defecate Ignoring the urge to defecate is correct. Anything that prevents the client from responding to the urge to defecate and disrupts regular habits can cause alterations in bowel habits, such as constipation. Increased fiber in the diet Excessive laxative use Increased activity Inadequate fluid intake Inadequate fluid intake is correct. Reduced fluid intake slows the passage of food through the intestine and can result in hardening of stool.y promotes bowel emptying.

Ignoring the urge to defecate Excessive laxative use Inadequate fluid intake

A nurse is teaching an older adult client who reports constipation. Which of the following instructions should the nurse include in the teaching? Increase dietary intake of raw vegetables Bear down hard when defecating Drink four to five glasses of water daily Limit activity

Increase dietary intake of raw vegetables

A nurse is caring for a client who is at risk for falls. Which of the following actions should the nurse take? (Select all that apply.) Assess the client every 4 hr. Keep the client's bed in the lowest position. Keep the client's room dark at night. Place a fall-risk identification band on the client's wrist

Keep the client's bed in the lowest position. Place a fall-risk identification band on the client's wrist

A nurse is caring for an older adult client who states, "I am afraid that I may fall while walking to the bathroom during the night." Which of the following actions should the nurse take? Limit the client's fluid intake in the evening. Obtain a bedside commode for the client's use. Leave a nightlight on in the client's room. Put the side rails up and tell the client to call the nurse before voiding.

Leave a nightlight on in the client's room.

A nurse is educating a client who is experiencing sleep disturbances and desires to decrease caffeine intake. Which of the following beverages should the nurse recommend? Brewed iced tea Chocolate milk Lemon-lime soda Diet cola

Lemon-lime soda

A home health nurse is making a home visit to an older patient. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the patient eliminate which of the following? (Select all that apply.) Loose carpeting on the floors Railings on the stairway Excess clutter Night-lights

Loose carpeting on the floors Excess clutter

An older patient learns that he has metastatic cancer. The patient states: "I must have angered God." This is an example of which type of belief? Biomedical Holistic Naturalistic Magico-religious

Magico-religious

A nurse is discussing culturally competent care at a nursing staff in-service. Which of the following information should the nurse include when discussing clients' cultures? Nonverbal communication is important in few cultures. Culture plays no role in determining when a client will seek medical care. Nurses should expect clients to adapt to the care provided regardless of culture. Nurses should focus on clients' cultures, rather than their ethnicity, when providing care.

Nurses should focus on clients' cultures, rather than their ethnicity, when providing care. Answer Rationale: Nurses should assess clients and make decisions regarding care based on culture, rather than based on ethnicity or race.

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence? Reflex incontinence Urge incontinence Overflow incontinence Stress incontinence

Overflow incontinence Answer Rationale:These findings are associated with overflow incontinence, which occurs when the pressure of urine in an overfull bladder overcomes sphincter control.

A nurse is caring for a client who has herpes zoster. Which of the following findings should the nurse expect? Multiple furuncles located on the client's back Painful lesions following a nerve pathway Patches scattered across the torso Different-sized papules in the genital area

Painful lesions following a nerve pathway

The nurse recognizes which of the following as the most effective intervention in prevention of aspiration pneumonia? Assistance with ambulation twice per day Placement of a gastric tube for feedings Assistance with ambulation twice per day Performance of oral care four times per day

Performance of oral care four times per day

A nurse is teaching a class on health promotion and illness prevention. The nurse should include that which of the following is an example of secondary prevention? Providing a community program on stress reduction Teaching foot care to a client who has diabetes Answer Rationale:Tertiary preventive care focuses on creating a better quality of life and decreasing physical deterioration. Referring a client who has had a mastectomy to a support group Performing monthly breast self-examinations

Performing monthly breast self-examinations

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? Reposition the client every 4 hr. Massage bony prominences to promote circulation Provide the client with a diet high in protein. Apply cornstarch to keep the skin dry.

Provide the client with a diet high in protein. Inadequate intake of protein, iron, vitamins, and calories increase the risk for skin breakdown.

A community health nurse is reviewing the levels of disease prevention. Which of the following activities is an example of tertiary prevention? Providing treatment for clients who have chronic obstructive pulmonary disease Administering influenza immunizations at a local health fair Performing screening for sexually transmitted infections Testing new nurses for exposure to tuberculosis.

Providing treatment for clients who have chronic obstructive pulmonary disease

The nurses recognizes which wound characteristics as hallmarks of a full-thickness tissue injury (stage 3 or 4 pressure injury)? Select all that apply. Purulent drainage Slough Nonblanchable erythema Granulation tissue Serous drainage

Purulent drainage Slough Granulation tissue Serous drainage

The nurse is caring for an older adult client who presents with a recent history of diarrhea and poor oral intake. The nurse recognizes which of the following as a reliable indicator of dehydration? Select all that apply. Rapid pulse Dry mouth Low urine output Poor skin turgor

Rapid pulse Dry mouth Low urine output

A nurse is developing a plan of care for a client who has a stage 2 sacral pressure injury. Which of the following interventions should the nurse include in the plan? Select all that apply. Massage reddened areas with dressing changes. Reposition the client at least every two hours Clean the wound with hydrogen peroxide solution. Consult with a dietician to increase sources of protein in the client's diet Promote good perineal hygiene and perform hourly checks and/or bathroom breaks

Reposition the client at least every two hours Consult with a dietician to increase sources of protein in the client's diet Promote good perineal hygiene and perform hourly checks and/or bathroom breaks

Which technique is most effective when communicating with a client who is positioned in bed? Sitting in a chair at the bedside facing the client When communicating with individuals in a bed or wheelchair, position yourself at their level and directly face them rather than talking over a side rail or standing above them. Standing at the foot of the bed Standing near the client's head on his or her dominant side Sitting in a chair at the foot of the bed

Sitting in a chair at the bedside facing the client When communicating with individuals in a bed or wheelchair, position yourself at their level and directly face them rather than talking over a side rail or standing above them.

A nurse is assessing an older client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer? Exposed bone Subcutaneous tissue Partial-thickness skin loss. Blood filled blisters

Subcutaneous tissue Answer Rationale:Manifestations of a stage 3 pressure ulcer can include full-thickness skin loss with subcutaneous tissue.

A nurse is assessing a family as a system. Which of the following factors should the nurse include when assessing sociocultural context? The family's religious practices The roles of family members The sense of self among individual family members The future goals of the family

The family's religious practices Answer Rationale:This is appropriate when assessing the sociocultural context of the family.

The nurse is caring for a client with mixed urinary incontinence. The nurse recognizes which of the following as an appropriate first-line intervention for incontinence management? Transportation Mobility Socioeconomic status Chronic disease Endurance

Transportation Mobility Socioeconomic status Chronic disease Endurance

The LEARN model is a framework for cross-cultural communication True False

True

A nurse is assisting an older adult client who is sedentary plan a new exercise regimen. Which of the following activities should the nurse recommend? Tennis Walking Jumping rope Running

Walking

A nurse in the ambulatory care setting is preparing to do an interview with a non-English-speaking client. The nurse secures an interpreter. In order to have the most effective interview, the nurse should do which of the following? (Select all that apply.) Use technical terminology to ensure accuracy. Watch the client's nonverbal communication. Look and speak to the interpreter. Have the interpreter check whether the client understands the communication.

Watch the client's nonverbal communication. Have the interpreter check whether the client understands the communication.

A client who reported "a problem sleeping" shows an understanding of good sleep hygiene by: seldom eating a bedtime snack. engaging in computer games as a pre-bed activity. avoiding daytime napping. doing 10 pushups before bed to encourage a "pleasant tiredness."

avoiding daytime napping.

The shared and learned beliefs, expectations, and behavior of a group of people are defined as: social mores ethnicity culture acculturation

culture

A paper on culture and illness would be likely to include the statement that: Ethnic groups always share common geographic origin and religion. Ethnicity involves recognized traditions, symbols, and literature. Most members of an ethnic group exhibit identical cultural traits. Culture is the same as ethnicity.

ethnicity involves recognized traditions, symbols, and literature.

Two common tools used with the elderly is FANSCAPES and Fulmer's SPICES? True False

false

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 having a decreased ability to perceive colors. having a loss of peripheral vision. loss of central vision. seeing bright flashes of light and floaters.

having a decreased ability to perceive colors.

A nurse is teaching a client about nutritional requirements necessary to promote wound healing. Which of the following nutrients should the nurse include in the teaching? Vitamin D Protein Vitamin B1 Calcium

protein

Assessment of the "Older Adult" is: requires special communication techniques More complex does not include a review of systems very short and simple

requires special communication techniques More complex

Adult multidimensional cognitive health and structure can be described as: (select all that apply) short term recall memory increases with age remote or long term memory allows the older adult to maintain social connectedness Answer immediate recall the ability to permit functional recovery from illness or injury

short term recall remote or long term memory allows the older adult to maintain social connectedness Answer immediate recall the ability to permit functional recovery from illness or injury

When conducting an admissions interview with an older client, the nurse observes that the client pauses for a period of time before responding to the questions. The nurse responds to this client based on the assumption that the client is: reluctant to share information with someone with whom he or she has no relationship. exhibiting signs of mild cognitive impairment. sorting through his or her vast life experiences in order to answer appropriately. nervous and having difficulty concentrating on the questions.

sorting through his or her vast life experiences in order to answer appropriately.

Ageism is: stereotyping not common in the US prevalent in the US is a benefit to the older adult can affect healthcare professional as fewer are choosing to study gerontology

stereotyping prevalent in the US can affect healthcare professional as fewer are choosing to study gerontology

Health literacy is defined as: the capacity to read and write in order to access health care. The capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. The capacity to read and execute health care documents. The capacity to read basic health information in order to make appropriate health decisions.

the capacity to obtain, process, and understand basic health information needed to make appropriate health decisions. Health literacy involves more than basic reading and writing skills. It involves the ability to obtain, process, and understand health information in order to make health care decisions.

Balance and Fall Prevention is the most important to decrease injury related deaths in hospitals? True False

true

Comprehensive Geriatric Assessment (OASISCI) is aimed at preventing hospitalizations and ensuring safety at home? True False

true

In caring for older adults, it is important to listen to "life stories"? True False

true

In promoting healthy aging communications is the most vital "service" we can offer and is the "heart of nursing". True False

true

It is important to use evidence based tools that have been researched well for an adequate functional assessment? True False

true

The goal of assessment is always to assist the person to move along the wellness continuum. True False

true

Elderspeak can be: using short simple sentences repeating what has been said using pet names such as "honey" or sweetie" using limited vocabulary talking to them using usual terms and not talking down to them

using short simple sentences repeating what has been said using pet names such as "honey" or sweetie" using limited vocabulary