Foundations Ex 4
The nurse makes a late entry in a clients record. Which of the following is the best example of how to document this type of situation? 1 2:45 PM ASA gr X given for temperature of 38.1 C. 2 8:30 AM Client received Percodan (1 tablet) PO an hour before going to radiology. 3 12:15 PM I gave the client morphine 10 mg IM at 11:10 AM but did not document it then. 4 8:30 PM Abdominal dressing change at 7:30 PM. No s/s of infection, and wound edges approximating well.
1 2:45 PM ASA gr X given for temperature of 38.1 C. This is the best example of a late entry. The time (2:45 PM) is indicated along with the action and an objective observation. This notation (8:30 AM) is not complete. It does not indicate why the Percodan was given. What was the clients level of pain? Where was the pain located? The nurse does not need to document about herself; only the client. In this option (12:15 PM), the nurse does not indicate why the morphine was given (clients level of pain? location of pain?). This entry (8:30 PM) is not complete. It does not state the size of the wound, type of dressing used, or the clients tolerance of the procedure.
The nurse has made an error and is documenting such on the clients record and notes. The action that the nurse should take is to: 1 Draw a straight line through the error and initial it. 2 Erase the error and write over the material in the same spot. 3 Use a dark color marker to cover the error and continue immediately after that point. 4 Footnote the error at the bottom of the page.
1 Draw a straight line through the error and initial it. If a nurse has made an error in documentation, the nurse should draw a single line through the error, write the word error above it, and sign his or her name or initials. Then record the note correctly. The nurse should not erase, apply correction fluid, or scratch out errors made while recording because charting becomes illegible. Also, entries should only be made in ink so they cannot be erased. Using a dark color marker to cover the error is not correct. It may appear as if the nurse was attempting to hide something or deface the record. Footnotes are not used in nursing documentation.
Which of the following statements made by a nurse best reflects an understanding of the negative impact of ageism regarding client care? 1 If I dont value the older client, I will never be able to provide the care they are entitled too. 2 Everyone, regardless of age or position, always deserves effective, appropriate nursing care. 3 As a society we lose so much valuable wisdom and knowledge when we devalue our older members 4 If older clients do not feel valued, they are less likely to seek the health care they need and deserve
1 If I dont value the older client, I will never be able to provide the care they are entitled too. According to experts in the field of gerontology, unopposed ageism has the potential to undermine the self-confidence of older adults, limit their access to care, and distort caregivers understanding of the uniqueness of each older adult. Health care providers must be free of such an unethical attitude so that client care will never be compromised. This is a truism that is not specific to ageism
What is the correct response for the licensed practical nurse that answers the phone to respond within the following scenario? The physician calls to leave orders late at night for one of his clients. 1 Let me get the Registered Nurse on the phone. 2 I am unable to take the order at this time. Please call in the morning. 3 Please repeat the order for me so I can make sure it is written correctly. 4 Let me have your phone number and I will have the supervisor call you back.
1 Let me get the Registered Nurse on the phone. A telephone order involves a physician stating a prescribed therapy over the phone to a registered nurse. Saying that an order is unable to be taken and to call back in the morning is not an appropriate response and not in the clients best interest. It is best to repeat any prescribed orders back to the physician, who can then verify if it is correct or clarify the order. This is not the appropriate response. A registered nurse needs to take the verbal order, but it does not have to be the nursing supervisor.
Which of the following nursing actions is most directly aimed at affording a client confidential treatment of his or her medical information while minimizing delay in accessing needed medical and nursing care? 1 Notifying the client of the institutions privacy policy 2 Denying nonessential personal access to the clients medical records 3 Acquiring the clients verbal consent to share his or her medical record with essential personnel 4 Requiring that the client sign the Health Insurance Portability and Accountability Act (HIPAA) form
1 Notifying the client of the institutions privacy policy Under new regulations, Health Insurance Portability and Accountability Act (HIPAA), in order to eliminate barriers that could delay access to care, required only that health care providers notify clients of their privacy policy and make a reasonable effort to get written acknowledgment of this notification.
To avoid legal risks and possible lack of confidentiality associated with computerized documentation, many programs currently have: 1 Periodic changes in staff passwords 2 Thumbprint ID restrictions 3 All nursing staff uses the same access code 4 Only centralized medical records use the client data
1 Periodic changes in staff passwords A good system of computerized documentation requires periodic changes in personal passwords to prevent unauthorized persons form tampering with records. Many programs do not have thumbprint identification restrictions. All nurses do not use the same access code. Each nurse should have his or her own password. Only centralized medical records using the client data is not a true statement. Authorized health care providers from any department can access and use the data.
When another health care professional is asked to assess a client for the purpose of suggesting treatment to the primary health care provider, this is called a: 1 Referral 2 consultation 3 transfer report 4 multidisciplinary meeting
1 Referral Referrals are the request for services by another care provider usually for the purpose of determining appropriate client care. Consultations are a form of discussion whereby one professional caregiver actually gives formal advice about the care of a client to another caregiver. The remaining options are methods of exchanging general information regarding a client.
Which of the following is an example of a problem statement used in the Problem- Intervention-Evaluation documentation method? 1 Risk for injury related to falling due to dizziness 2 client fell while walking to bathroom unassisted 3 Client continues to report periods of dizziness upon sitting up 4 educated to the purpose of dangling on the bedside before standing
1 Risk for injury related to falling due to dizziness The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention.
Which of the following is an example of a problem statement used in the Problem- Intervention-Evaluation documentation method? 1 Risk for injury related to falling due to dizziness 2 Client fell while walking to bathroom unassisted 3 Client continues to report periods of dizziness upon sitting up
1 Risk for injury related to falling due to dizziness The problem is reflected by a nursing diagnosis while the interventions are related to nursing actions directed toward minimizing or eliminating the problem. The evaluation is the clients objective or subjective response to the nursing intervention.
Regarding access to client records, the nursing faculty informs the nursing students to be prepared to: 1 Show the unit staff proper student identification 2 Sign a confidentiality agreement when on the unit to preplan 3 Review the medical record only in the presence of unit staff 4 Obtain permission from the client to access his or her medical record
1 Show the unit staff proper student identification When nurses and other health care professionals have a legitimate reason to use records for data gathering, research, or continuing education, they obtain appropriate authorization according to agency policy. Nursing students and faculty may be required to present identification indicating access to the record is authorized. The remaining options are not required if the student is properly identified and shows need to access the material.
The following statement: Upon exertion, the client is wheezing and experiencing some dyspnea, is an example of: 1 The P of PIE 2 FOCUS documentaton 3 The R in DAR documentation 4 The S in SOAP documentation
1 The P of PIE These data are examples of the P of PIE because they describe the problem. FOCUS charting does not concentrate on only problems. It is structured according to a clients concerns. The R in DAR documentation is the response of the client. This situation describes the clients problem, not the clients response. The S in SOAP documentation represents subjective data (verbalizations of the client).
2. An incident report is to be completed because the client climbed over the side rails and fell to the floor. The correct reporting of an incident involves which of the following? 1 The witnessing nurse completes the report. 2 Details of the incident are subjectively described. 3 An explanation of the possible cause for the incident is entered. 4 A notation is included in the medical record that an incident report was prepared.
1 The witnessing nurse completes the report. The nurse who witnessed the incident is the one who completes the report. Details of the incident should be objectively described. An explanation of the possible cause is not included. The sequence of events is described objectively. A notation is not included in the medical record that an incident report was written.
Which statement made by an older adult would reflect the best understanding of the nutritional requirements of individuals at this developmental stage? 1 An apple a day is my motto; always has been. 2 I eat everything, but just a little a bit of things like sweets. 3 Fiber is more important than ever to my digestive system. 4 I dont need the fat so Ive taken to drinking protein shakes.
2 I eat everything, but just a little a bit of things like sweets. Good nutrition for older adults includes a balanced diet with limited intake of refined sugars. This is not the best option because it focuses on only one aspect of nutrition. This option is not the best choice because it focuses on only one aspect of nutrition. This is not the best option because it focuses on only one aspect of nutrition.
Of the following client statements made by an older adult client which best reflects an understanding the educational materials on nutrition presented by the nurse? 1 Ill keep this literature and read it again later. 2 I love rye bread. its good to know its high in fiber 3 Nutrition and cooking has always been passions of mine. 4 Now I can see the connection between food and my health.
2 I love rye bread. its good to know its high in fiber The correct option shows the client making a connection between a type of food, its nutritional value, and its impact on personal health
Which of the following statements made by a nurse most reflects a need for additional instruction on areas of client care requiring nursing documentation? 1 The fact that the client refused the prescribed antidepressant medication was noted in his chart. 2 I provided a detailed description of the dressing change in the clients chart in order to show it was done as prescribed. 3 The clients wife told me he often develops a rash when he comes into contact with scented soaps, so I noted that in his chart. 4 I had a long conversation with the client concerning his fears about his upcoming surgery and I mentioned his concerns in my nursing note.
2 I provided a detailed description of the dressing change in the clients chart in order to show it was done as prescribed. Common charting mistakes that can result in malpractice include the following: (1) failing to record pertinent health or drug information; (2) failing to record nursing actions; (3) failing to record that medications have been given; (4) failing to record drug reactions or changes in clients condition; (5) writing illegible or incomplete records; and (6) failing to document a discontinued medication. Detailed descriptions of procedures are not included in the nursing notes.
The client developed a slight hematoma on his left forearm. The nurse labels the problem as an infiltrated intravenous (IV) line. The nurse elevates the forearm. The client states, My arm feels better. What is documented as the R in FOCUS charting? 1 Infiltrated IV line 2 My arm feels better 3 Elevation of left forearm 4 Slight hematoma on left forearm
2 My arm feels better The R in FOCUS charting is the clients response. In this case, the nurse would document, My arm feels better.
Which of the following is evaluated as a legally appropriate notation? 1 Dr. Green made an error in the amount of medication to administer 2 Verbalized sharp, stabbing pain along the left side of chest. 3 Nurse Williams spoke with the client about the surgery. 4 Client upset about the PT
2 Verbalized sharp, stabbing pain along the left side of chest. Entries should be concise, factual, and accurate. Verbalized sharp, stabbing pain along the left side of chest is an example of an objective description of a clients behavior. The nurse should not document physician made error. Instead, the nurse could chart that Dr. Green was called to clarify order for medication administration. The nurse should chart only for himself or herself. In this case, nurse Williams should write the charting entry. Only objective descriptions of the clients behavior should be recorded. For example: Client states, I dont want physical therapy! I want to go home!
Which statement made by an older adult would reflect the best understanding of the nutritional guidelines for this age-group? 1. I can prepare grilled chicken at least 10 different, delicious ways. 2. When I entertain, I serve healthy foods like veggies and low- fat dip. 3. I know I need to eat nutritiously, and I have certainly been doing better. 4. I take seriously the suggestions my health team gives me on healthy eating.
2. When I entertain, I serve healthy foods like veggies and low-fat dip. This option shows an understanding of healthy eating as well as a commitment to incorporating this knowledge into everyday living. While this is a good option, it is not as encompassing regarding knowledge and commitment as other options. This option leaves some doubt as to how committed the client really is to nutritional eating. While this is a good option, it is not as encompassing regarding knowledge and commitment as other options.
Which of the following nursing notations shows the best understanding regarding the need to document only objective client assessment data? 1 Client was angry because breakfast was not to her liking. Client is depressed; was observed crying while alone in room. 2 Client is depressed, was observed crying while alone in room 3 Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists. 4 Client was verbally abusive to staff when approached concerning clients continued attempts to smoke in the bathroom.
3 Client expressed pain as an 8 out of 10, was diaphoretic, guarding her abdomen and clenching her fists. Do not write personal opinions. Document observable, measurable client-oriented data only. Recording that the client is depressed based on the observation of tears is not objective and so is not acceptable. While one option does report only observable, measurable behavior, the remaining options, while noting observed client behavior, do fail to objectively describe the noted client behavior.
he professional nurse realizes there is both a legal and an ethical obligation to keep client information obtained through examination, observation, conversation, or treatment: 1 Secured 2 Accessible 3 Confidential 4 Documented
3 Confidential Nurses are legally and ethically obligated to keep information about clients confidential. Nurses may not discuss a clients examination, observation, conversation, or treatment with other clients or staff not involved in the clients care. The other options are primarily directed towards written records and are not ethically oriented.
The nurse realizes that the incorrect spelling of terms in the medical record most importantly: 1 Shows a lack of competency 2 Displays little attention to detail 3 Contributes to serious treatment errors 4 Negatively affects the accuracy of the documentation
3 Contributes to serious treatment errors Spelling errors can result in serious treatment errors; for example, the names of certain medications such as digitoxin and digoxin or morphine and Numorphan are similar. Misspelling such terms can result in medication errors that may cause serious harm to a client. The other options are correct but do not have the seriousness of client care errors.
The nurse is preparing an educational program for members of the local senior center. Which of the following topics would present the greatest learning challenge for this developmental group? 1 Exercising arthritic joints 2. Tips for living with GERD 3 Importance of the human touch 4. Principles of heart healthy eating
3 Importance of the human touch Of the available topics, Importance of the human touch is possibly the most abstract in nature. Older adults are lifelong learners, but concrete rather than abstract material appears to be a better choice for the learning style of most older adults
Which of the following nursing statements regarding the release of a clients medical record to another institution requires immediate follow-up by the nurses manager? 1 Im pretty sure this will require the clients permission. 2 Are you sure of the exact policy? Do you know what I should do? 3 The client agreed to the consultation, so Ill have the chart sent over. 4 I think the client will need to give a verbal consent before it can be sent.
3 The client agreed to the consultation, so Ill have the chart sent over. Each institution has policies to control the manner for sharing records. In most situations, clients are required to give written permission for release of medical information. The other options have the nurse asking for help or expressing doubt about the proper protocol for the release of the records; these would be appropriate statements and the manager should provide the correct information.
When presenting information to the older adult, the client will be most likely to engage with the nurse in the learning process if: 1 Client feedback is encouraged and valued 2 physical disabilities are accommodated for 3 The topic or information is valued by the learner 4 New knowledge is connected to knowledge already processed
3 The topic or information is valued by the learner The older adult learner will be more interested and willing to participate actively in the learning if they have been given the opportunity to determine the values of the information to them personally.
Which is the most appropriate notation for a use to use according to the guidelines that should be followed when documenting client care? 1 1230 Clients vital signs taken. 2 0700 Client drank adequate amount of fluids. 3 0900 Demerol given for lower abdominal pain. 4 0830 Increased IV fluid rate to 100 mL/hr according to protocol.
4 0830 Increased IV fluid rate to 100 mL/hr according to protocol. Information within a recorded entry needs to be complete, containing appropriate and essential information. This notation (0830) provides the time and action taken by the nurse including the reason for doing so. This entry (1230) does not indicate what the vital signs were. This entry (0700) does not provide the specific amount the client drank. Stating adequate is subjective, not objective. This notation (0900) does not have the client describe his or her pain or rate it according to a pain scale for comparison later. It also does not indicate whether the clients pain was in the lower left or lower right quadrant, or both.
The new staff nurse is having her documentation evaluated by the charge nurse. On review of her charting, the charge nurse notes that there is evidence of appropriate documentation when the new staff nurse: 1 Uses a pencil to make the entries 2 Uses correction fluid to correct written errors 3 Identifies an error made by the attending physician 4 Dates and signs all of the entries made in the record
4 Dates and signs all of the entries made in the record Each entry should begin with the time and end with the signature and title of the person recording the entry. All entries should be recorded legibly and in black ink because pencil can be erased. The nurse should never erase entries, never use correction fluid, or never use a pencil. The use of correction fluid could make the charting become illegible and it may appear as if the nurse were attempting to hide something or to deface the record. If the physician made an error, the nurse should not document it in the clients chart. It should be documented in an incident report.
To locate the recording of a nurses description of the teaching provided to the client on performance of self-medication administration, one would look in a(n): 1 Kardex 2 Incident report 3 Nursing history form 4 Discharge summary form
4 Discharge summary form A nurses description of the teaching provided to the client on performance of self-medication administration is recorded in the discharge summary form. A Kardex is a written form that contains basic client information. A Kardex contains an activity and treatment section and a nursing care plan section that organizes information for quick reference as nurses give change- of-shift report. It does not include a description of teaching that was provided to the client. An incident report is any event that is not consistent with the routine operation of a health care unit or routine care of a client (e.g., a client falls). A nursing history form guides the nurse through a complete assessment to identify relevant nursing diagnoses or problems. It provides baseline data about the client.
The nurse defines ageism most accurately as: 1 The undervaluing of individuals based on their age. 2 Perception of a persons worth based on productivity 3 Biases directed towards individuals considered aged 4 Discrimination based on an individuals increasing age
4 Discrimination based on an individuals increasing age The correct option best describes ageism since it identifies discrimination towards a person based solely on the persons age. Devaluing is one aspect of ageism but this option failed to identify discrimination as the goal. While perception of a persons worth is a criteria used to judge, it is not the most complete description of the term. Bias and discrimination are the outcomes of ageism.
Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem? 1 His surgery corrected the mobility problem, so I draw a line through it and dated it. 2 The clients problem list has several resolved problems on it; should I take them off? 3 The client no longer has anxiety issues so I highlighted that problem on his problem list. 4 He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list.
4 He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list. New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number. Erasure is not an acceptable method of showing that a problem has been resolved.
Related to Problem Oriented Medical Record (POMR) documentation, which of the following statements made by a nurse reflects the greatest need for additional instruction on the proper management of a resolved client problem? 1 His surgery corrected the mobility problem, so I drew a line through it and dated it. 2 The clients problem list has several resolved problems on it; should I take them off? 3 The client no longer has anxiety issues so I highlighted that problem on his problem list. 4 He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list.
4 He doesnt experience any dizziness now that we have his medication regulated, so Ive erased that from his problem list. New problems are added as they are identified. When a problem has been resolved, record the date and highlight it or draw a line through the problem and its number.
Which of the following statements made by an older adult regarding sexuality would be of greatest concern for the nurse? 1 Will this new medication affect my libido? 2 what can i do to help with vaginal dryness? 3 I really miss the intimacy my husband and I shared. 4 Its so nice not to have to worry about an unwanted pregnancy.
4 Its so nice not to have to worry about an unwanted pregnancy. This option infers that the client is sexually active and not using protection because there is no longer a possibility of conception. Information about the prevention of sexually transmitted diseases should be included when appropriate because there is a growing number of older adults contracting STDs. Many older adults use prescription medications that depress sexual activity, such as antihypertensives, antidepressants, sedatives, or hypnotics. This question requires further education but the statement does not arouse concern regarding the clients safe sex practices. Physiological changes may have an adverse influence on sexual activity. The older woman may experience vaginal dryness. This question requires further education, but the statement does not arouse concern regarding the clients safe sex practices. It is a common misconception that older adults are not interested in sex. This statement would require further discussion to assess the degree of distress the situation is causing the client, but the statement does not arouse concern regarding the clients safe sex practices.
The nursing faculty recognizes the correct way to instruct the nursing students to acknowledge their charting in a clients medical record is: 1 James Thicket, NS, WVU 2 J Jones, NS, Montclair Shores College 3 N.H, SN, Bellfield City Community College 4 Linda Mozden, SN, Fairmont State U
4 Linda Mozden, SN, Fairmont State U A nursing student enters full name, student nurse abbreviation (e.g., SN or NS), and educational institution, such as David Jones, SN (student nurse), CMTC (Central Maine Technical College).
Of the following options, which is the greatest barrier to providing quality health care to the older-adult client? 1 Poor client compliance resulting from generalized diminished capacity 2 Inadequate health insurance coverage for the group as a whole 3 Insufficient research to provide a basis for effective geriatric health care 4 Preconceived assumptions regarding the lifestyles and attitudes of this group
4 Preconceived assumptions regarding the lifestyles and attitudes of this group Despite ongoing research in the field of gerontology, myths and stereotypes about older adults persist. These include false ideas about the physical and psychosocial characteristics and lifestyles of older adults. However, when health care providers hold negative stereotypes about aging, those stereotypes negatively affect the quality of the care. While there may be poor compliance related to diminished physical and cognitive capacity, it is not the primary barrier to effective care of this developmental group. While there are numbers of the older-adult population who are underinsured, it is not the primary barrier to effective care of this developmental group. A lack of research regarding the unique needs of this age-group is not the primary barrier to providing effective care.
Which of the following nursing statements reflects the best understanding of the role of documentation and the Medicare reimbursement policy? 1 Medicare reviews client charts to determine care given. 2 Good charting results in good Medicare reimbursement. 3 Our nursing salaries are paid for by the Medicare reimbursement funds. 4 The hospital is reimbursed for the nursing care documented in the client chart.
4 The hospital is reimbursed for the nursing care documented in the client chart. Under the prospective payment system, Medicare reimburses hospitals a set dollar amount for each diagnosis-related group (DRG). Everything that is done for a client must be documented in the medical record for the health care institution to recover its costs.
The nurse is preparing the information that will be provided to the staff on the next shift. Which of the following should the nurse include in the inter-shift report to nursing colleagues? 1 Audit of client care procedures 2 The clients diagnostic-related group 3 All routine care procedures required by the client 4 instructions given to the client in a teaching plan
4 instructions given to the client in a teaching plan A change-of-shift report should include instructions given in a teaching plan and the clients response. This should not include detailed content unless staff members ask for clarification. The nurse should relay to staff significant changes in the way therapies are given, but should not describe basic steps of a procedure. The clients diagnosis-related group is not essential background information to be shared in an inter-shift report. The nurse should not review all routine care procedures or tasks.
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 Im 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 Im less likely to forget them. There may be a concern regarding drug interactions if all the medications are taken at the same time. The nurse should have a discussion with the client to determine if this practice is appropriate. This option shows the clients willingness to deal with this issue effectively and safely. This option shows an appropriate intervention for keeping the pills out of sunlight. This option shows an appropriate intervention for dealing with multiple medication schedules.
Which of the following nursing questions is best directed towards the assessment of a normal finding regarding physiological changes in an older-adult client? a. any difficulty driving at night? b. are you experiencing any loss of libido? c. do you see yourself as becoming forgetful? d. have you had your cholesterol tested lately?
a. any difficulty driving at night? A common physiological change in the older-adult client is an increased sensitivity to glare, which makes night driving difficult. Decreased sexual drive is not a normal physiological change of aging. Memory loss is not a normal physiological change of aging. Hyperlipidemia is not a normal physiological change of aging, nor should it be monitored only by the older adult.
The nurse is presenting an information session on nutritional guidelines at a senior living center. Which of the following foods meets the recommended nutritional guidelines for older adults? a. grilled chicken b. hamburger and french fries c. hot dog with dill pickle relish d, baked potato with cheese and bacon bits
a. grilled chicken Grilled chicken would be a good source of protein that is also low in fat. A hamburger and french fries are high in fat content and calories, making them a less desirable food choice. A hot dog with pickle relish is high in fat and sodium. Good nutrition for the older adult includes a limited intake of fat and salt. A baked potato with cheese and bacon bits is higher in calories and fat. A plain baked potato would be a healthier food choice.
To assist older adults to meet their needs for sexuality, the nurse should recognize that the greatest impact on the sexuality of older adults is: a. therapeutic medications may alter sexual function b. secxual interest declines and then fades completely with age c. physiological changes do not adversely influence sexual activity d. prevention of sexually transmitted diseases is no longer an issue
a. therapeutic medications may alter sexual function Many older adults use prescription medications that depress sexual activity, such as antihypertensives, antidepressants, sedatives, or hypnotics. Some drugs increase libido in older adults. For example, phenothiazines increase sexual desire in women, and levodopa has a similar effect in men. It is a common misconception that older adults are not interested in sex. The older adults libido does not decrease, although frequency of sexual activity may decline. Physiological changes may have an adverse influence on sexual activity. The older man may experience decreased firmness in his erection, a decreased need for ejaculation with orgasm, or a longer recovery period between episodes of intercourse. The older woman may experience vaginal dryness. Information about the prevention of sexually transmitted diseases should be included when appropriate.
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.
b. I can't help worrying about becoming forgetful Although some forgetfulness is accepted, memory loss is not a normal physiological change of aging. This expressed fear requires further education by the nurse so as to help eliminate the clients concerns. A common physiological change in the older-adult client is an increased sensitivity to glare, which makes night driving difficult. A common physiological change in the older-adult client is an alteration in visual acuity, which would require regular vision check-ups. Hyperlipidemia is a concern regarding cardiac health and should be considered by the older adult.
Which of the following statements made by a 75-year-old client shows the best understanding of how the aging process affects the musculoskeletal system? a. I drink milk and eat cheese to get my calcium. b. I walk 1 mile every day to strengthen my bones c. I wear sensible shoes so I wont sprain an ankle d. At my age I might never fully recover from a hip fracture.
b. I walk 1 mile every day to strengthen my bones Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Walking regularly shows that this client has an understanding of and the disciple to work on health promotion habits for a healthy musculoskeletal system. While this option shows an understanding regarding osteoporosis and the need for calcium, it is not the best option because it focuses on only one aspect of musculoskeletal health. This option focuses only on safety measures, and so it is not the best option. While this option shows an understanding regarding the seriousness of a hip fracture for someone of older age, it is not the best option because it focuses on only one aspect of musculoskeletal health.
Which of the following statements made by a family member of a client recently diagnosed with Alzheimers disease is most reflective of an understanding of this disease process? a. dad has always been a fighter; hell 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 steps can be taken to keep it from getting worse. d. It usually progresses gradually so we are hoping it will be a while before his memory is gone.
b. We have an appointment with his care provider to see about medication therapy Medications can slow the process of Alzheimers disease considerably when prescribed appropriately. There is no cure for Alzheimers disease. This option suggests that the family member still clings to the hope that there is a cure. Alzheimers disease usually progresses gradually with a deterioration in function, but medications can be given to slow the progression of symptoms, not halt them. Although Alzheimers disease usually progresses gradually with a deterioration in function with some clients living years after the diagnosis of Alzheimers disease, this option does not reflect the best understanding because no mention of management is made.
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 3-4 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 Clients in the older adult age group should be advised to exercise their joints regularly to their level of tolerance. Shoulder pain is not a normal finding in the older adult. It may indicate a condition such as arthritis. Exercise programs should begin conservatively and progress slowly. Periodic and thorough review of all medications being used is important to restrict the number of medications used to the fewest necessary. Concurrent use of medications increases the risk for adverse reactions.
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 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 nurse is performing a physical examination on an older-adult client in an assisted living facility. On completion of the examination, the nurse compares the results to findings expected for individuals in this age-group. An expected finding for this client is: a. increased tactile responsiveness b. increased sensitivity to visual glare c. increased hearing acuity for higher tones d. increased thoracic expansion during ventilation
b. increased sensitivity to visual glare A common physiological change in the older-adult client is an increased sensitivity to glare. Increased tactile responsiveness would not be an expected finding in the older-adult client. An expected physiological change in the older adult-client is a loss of hearing acuity for high- frequency tones (presbycusis). The older adult has decreased thoracic expansion during ventilation because of musculoskeletal changes.
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 dont seem to have problems with side edffects, but ill let my doctor know if something happens b. Im lucky since my daughter is really good about keeping up with my medications. c. Ill be sure to read the inserts and ask the pharmacist if I dont understand something. d. It shouldnt be too hard to keep it straight since I dont have any really serious health issues.
c. Ill be sure to read the inserts and ask the pharmacist if I dont understand something. This option reflects an understanding of the importance to understand the various aspects of the medication and its effects on the client. The older adult should be encouraged to question the physician and/or pharmacist about all prescribed drugs and over-the-counter drugs. Although this option reflects an understanding of potential risk for side effects, it is not the best option because it focuses on only one aspect of self-medication. This option appears to have the client delegating responsibility to the daughter. This option appears to have the client minimizing the importance of informed self-administration.
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 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 meds d. provide a written document describing the meds the client is currently prescribed.
c. encourage the client to use a compartmentalized pill storage container for his daily med Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults. A system that allows the client to sort his medication for daily dosage would help minimize the risk of overdosing as well as missing ordered medications. While this option addresses the risk of injury in the home, it does not address the greatest need experienced by this age-groupthe risk of overmedication or undermedication of prescribed drugs. While this option does address the clients nutritional needs, it does not address the greatest need experienced by this age-groupthe risk of over- or under- medication of prescribed drugs. Although this option does address the clients need to monitor the medications he is prescribed, it does not address the greatest need experienced by this age- groupthe risk of overmedication or undermedication of prescribed drugs on a daily basis.
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 medications name if you can identify it by its color and shape b. unless you have sever side effects, don't worry about the minor changes in the way you feel c. feel free to as your physician why you are receiving the medications that are prescribed for you d. remember the the hepatic system is primarily responsible for the pharmacotherapeutics of your medications
c. feel free to as your physician why you are receiving the medications that are prescribed for you 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 should teach the client how to avoid adverse side effects and to report them to their care provider if they occur. If the client is disturbed by minor side effects, it could be an indication of beginning drug toxicity. Another possibility is that the client may become noncompliant with their medication because they dislike how the side effects make them feel. The hepatic system is not the only system responsible for the pharmacotherapeutics of medication. Older adults are at risk for adverse reactions because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Changes in the GI system may affect absorption, distribution may be affected by changes in body composition and by reduced serum albumin levels, and changes in kidney functioning may impair excretion.
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 This is a true statement. Approximately two thirds of older adults use prescription and nonprescription drugs with one third of all prescriptions being written for older adults. Approximately 90% of adults older than 65 have at least one chronic health condition. Approximately 70% of older adults have multiple chronic conditions with arthritis, hypertension, heart disease, vision impairment, and diabetes mellitus being the most common in noninstitutionalized older adults. Heart disease is the leading cause of death in older adults. Nutritional needs of older adults are affected by their levels of activity and by clinical conditions.
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 Older adults who exercise regularly do not lose as much bone and muscle mass or muscle tone as those who are inactive. Postmenopausal women have a greater problem with osteoporosis than older men. Muscle fibers are reduced in size with aging. Muscle strength diminishes in proportion to the decline in muscle mass.
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 its hard to even walk. b. Ive 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 Ive found its harder to do the things I love doing, but I guess it will all be over soon enough.
d. As I age Ive found its harder to do the things I love doing, but I guess it will all be over soon enough. This option should give the nurse concern over the clients possible depression because there are indications of possible suicide. This option does reflect regret over the inability to do the things previously enjoyed and the presence of a painful condition, but it does not present the seriousness of other available options. This option does reflect regret regarding life situations, but it does not present the seriousness of other available options. This option does reflect regret over the perceived changes, but it does not present the seriousness of other available options.
A 70-year-old client asks the nurse to explain her hypertension as she is to have her blood pressure checked each shift. An appropriate response by the nurse as to why older clients often experience hypertension is because of: 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 Although hypertension is not a normal physiological change of aging, older adults often experience hypertension because of vascular changes and accumulation of plaque on arterial walls, both of which reduce contractility. Vascular changes include thickening of vessel walls, narrowing of vessel lumen, and loss of vessel elasticity. Myocardial damage is not the reason for older adults commonly experiencing hypertension. Hypertension is not caused by a reduction in physical activity. Older adults with hypertension should be counseled on limiting fat and salt in their diet. However, ingestion of processed foods high in salt is not the reason why older clients often experience hypertension.
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 majority of adults are indeed active within their community. The majority of older adults live with a spouse or have other living arrangements such as living with a family member. Most older adults live in noninstitutional settings. Most older adults are able to care for themselves.
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 majority of older adults are interested in their health and are capable of taking charge of their lives. Most older adults do not require institutional care. The majority of older adults have social or family support. Most older adults live with a spouse or have other living arrangements, such as living with a family member. Most older adults receive Social Security benefits and are able to afford medical treatment.
In the assessment of older-adult clients, it is often difficult to discriminate between delirium and dementia. Delirium is characterized by: a. a slow progression b. lasting months to years c. a normal state of alertness d. occurrences at twilight or darkness
d. occurrences at twilight or darkness Delirium is characterized by short, diurnal fluctuations in symptoms and is worse at night, in darkness, and on awakening. Delirium has an abrupt onset. Dementia has a slow progression. Delirium lasts hours to less than 1 month, seldom longer. Dementia may last months to years. Delirium is characterized by fluctuating alertness; the client may be lethargic or hypervigilant. Alertness is generally normal with dementia.
The nurse is presenting an information session on nutritional guidelines at a senior living center. Incorporated into the discussion are the recommendations for nutritional intake for individuals of this age-group, which include a reduction in: a. fiber b. protein c. vitamin a d. refined sugar
d. refined sugar Good nutrition for older adults includes a limited intake of refined sugars. Fiber should not be reduced as it has benefits of aiding bowel elimination and lowering cholesterol. Protein should not be reduced. Protein intake may be lower than recommended if older adults have reduced financial resources or limited access to grocery stores. Difficulty chewing meat may also limit protein intake. Vitamin A does not need to be reduced in the older adult. Vitamin intake may be less than recommended if shopping for fresh fruits and vegetables is difficult.
Which of the following behaviors shows the greatest risk to an older adult as they attempt to minimize the effects of the aging process? a. increased cosmetic use b. refusing to share their actual ages c. spending less time d. refusing assistance with certain activities
d. refusing assistance with certain activities Some older adults may deny functional declines associated with aging and refuse to ask for assistance with tasks that place their safety at great risk. Some older adults find it difficult to accept themselves as aging and attempt to conceal physical evidence of aging with cosmetics. Older adults who find it difficult to accept themselves as aging may understate their age when asked. Spending more time with other older adults is indicative of the older adults acceptance of personal aging. Those who find it difficult to accept themselves as aging may avoid activities designed to benefit older adults, such as senior citizens centers and senior health promotion activities.