Gero test III

Which of the following is a true statement about elimination in older adults?

Defecation less than once each day is not necessarily constipation.

Long-term use of external catheters can lead to which complication(s)?

Fungal skin infections Penile skin maceration Edema Phimosis

Which of the following is important to include in the initial assessment for older adults who are frail and beginning an exercise program?

Medical history and physical examination

The safest opioid analgesic choice for an older patient who has severe acute pain is which of the following?

Morphine sulfate (Morphine)

A dermatologist should promptly evaluate which one of the following skin lesions?

Multicolored raised lesion with a fuzzy border

Which of the following is a true statement about impaired skin integrity?

Muscle and fat cannot regenerate.

Which of the following patient(s) does the nurse identify as at risk for developing fungal infections?

Obesity Bedridden Incontinent

A large residual urine volume characterizes what type of incontinence?

Overflow

Which of the following is a true statement about sleep in older adults?

The time spent in bed increases, but the time spent asleep decreases.

An older woman who receives intravenous (IV) fluids is making wide gesticulations with her arms and loudly insulting the nursing staff. Which intervention should the nurse implement to maintain safe, effective nursing care initially?

Determine the patients needs.

The nurse determines the risk for a pressure ulcer in an older adult who is 6 feet tall and weighs 155 pounds. Which patient information should the nurse use in planning care to reduce this individual's risk for a pressure ulcer?

Dry mucous membranes Prealbumin level 7 mg/dl Fasting glucose 140 mg/dl Uses food stamps to get food

The nurse identifies which of the following intervention(s) in the treatment of fungal infections?

Eliminate the conditions that created the problem. Thoroughly clean and dry skin daily. Apply miconazole (Micatin) as directed.

Which option is part of a program that addresses bowel incontinence in an older adult patient?

Ensuring that a toilet or commode is readily accessible to the patient

The older adult is at a higher risk for acute psychological pain than a younger adult because older adults:

Experience more loss

An older Hispanic man states that he is not having pain, but he had knee replacement surgery 2 days ago. Which is the best pain assessment tool as recommended by the Hartford Institute for Geriatric Nursing (HIGN) from "Try This" for the nurse to apply for this man?

Faces Pain Scale-revised (FPS-R)

The nurse is caring for an older adult who has dementia. The patient has just returned from recovery after a percutaneous endoscopic gastrostomy (PEG) tube placement. Which intervention(s) should the nurse implement?

Hang the IV bag behind the patient's field of vision. Place IV tubing behind the patient. Cover the PEG tube with an abdominal binder.

What is the most important aspect of care for the nurse to maintain when assisting an older patient with urinary incontinence?

Maintaining an attitude that is respectful and positive about resolving the problem

Which of the following is a true statement about skin care for older adults?

Maintaining oral hydration may reduce the incidence of xerosis.

Exercises are prescribed for older adults as therapy to improve which one of the following qualities?

Muscle strength

The nurse expresses concern about a female nursing home resident in the team meeting. Which resident information determines the team's priority in planning her care?

Needs increasing help with personal hygiene

The nurse observes that a male patient is snoring every night. Which should the nurse assess in this patient to diagnose the potential for sleep apnea?

Number of daytime naps Headaches in the morning Irritability during the day Awakening during the night

An older adult is in the hospital because of heart failure and has become incontinent of urine. Which evidence-based resource should the nurse use to guide continence care for this patient?

Nursing Standard Practice Protocol

The nurse uses comfort measures to enhance an older adult's pharmacological pain management. Which of the following would be most helpful for the nurse to use to identify the relationships between the comfort measures, activity, and pharmacotherapy, and the older adult's pain level?

Older adult's pain diary

Which of the following statements is true about a safe, effective care environment for older adults?

Older drivers are more likely to be in a fatal motor vehicle accident than younger drivers.

The health care provider has not ordered the use of a restraint for an alert patient at high risk for falling. The nurse should implement which side rail use?

One -length rail

An older adult is vitamin deficient. Which of the following does the nurse offer to the older adult to provide the important missing vitamin for maintaining healthy skin and enhancing tissue repair?

Orange slices

Which factors in the patient care environment should be routinely assessed to decrease the risk of falls?

Outdoor grounds Appropriate footwear Grab bars in place

Which of the following statement(s) is(are) true about pain in older adults?

Pain is not a normal aging process. Opioid analgesics are often the best treatment for persistent pain.

Which of the following is(are) assessed in a fall prevention assessment of an older adult?

Physical status Environment Functional status Medical history

The nurse determines that an older adult who has chronic bronchitis is at high risk for falls, but he repeatedly tries to ambulate without assistance. Which alternative measure to restraints is contraindicated for this older adult?

Place a concave mattress on the bed.

Although intact skin effectively protects an individual, it functions within physiological limits. Which qualities of healthy skin work synergistically within these limits to absorb, cushion against, deflect, or neutralize potentially harmful forces, as well as protect against potentially harmful substances that might impair skin integrity?

Pliability Strength Durability

The nurse completes an admission assessment on an older adult patient. The nurse identifies which factor that may contribute to sleep problems?

Polypharmacy

Which of the following pain sensation(s) is(are) associated with neuropathic pain?

Postamputation

Which type of pain tends to occur persistently along a well-defined path in a region of the body?

Postherpetic pain

The nurse wants to use exercise according to the recommendations of the American Geriatrics Society (AGS) for an older woman who lost her balance and fell. Which nursing intervention is suitable for this older adult according to the AGS?

Provide information on group exercises for balance training.

The nurse assesses a male resident in a nursing home for urinary incontinence and determines that he is unaware of the problem. Which recommendation should the nurse implement?

Provide regular toileting

An older woman tells the nurse practitioner that she fears her family will place her in a nursing home because she developed stress incontinence. Which recommendation should the nurse implement?

Recommend exercises to strengthen the pelvic floor.

The nurse can place an older adult into one of four patient rooms. Which is the most suitable room for an older adult?

Room with orange carpeting and soft lighting

The nurse wants to begin helping a resident who is overweight and has urinary incontinence with healthy bladder behavior skills. Which intervention should the nurse implement?

Schedule voiding at 2- to 4-hour intervals.

The nurse is discharging an older woman who uses a walker from rehabilitative care. Which observation does the nurse use to determine whether the patient is prepared for discharge?

She takes the walker to the elevator.

Which of the following is an important consideration about the skin of an older adult person

Skin becomes more vulnerable to damage.

Which of the following is a true statement about sleeping in older adults?

Sleep disturbances in the older adult can be caused by cardiovascular disease, arthritis, or diabetes.

What is the difference between rest and sleep?

Sleep is restorative and recuperative.

A nurse will be conducting an educational session on preventing skin cancer at a local senior citizens center. Which should the nurse include in the session?

Squamous cell cancer may appear similar to a wart.

Which of the following statements is true about analgesic medications for older adults?

Stool softeners and laxatives should be used with opioids

An older man who had a gastric resection states that he wants to ambulate but the osteoarthritis (OA) in his knees causes too much pain. Which intervention should the nurse implement to increase the amount of walking this man can perform?

Suggest taking pain medication before walking

The older adult residents of an assisted-living facility are preparing for a 14-day trip to Europe. Which is the most important exercise for the nurse to recommend for the group?

Swim laps in the pool for 10 minutes continuously.

Which of the following should the nurse recommend for a moderate-intensity exercise for older adults who are ambulatory and in good health?

Swim laps in the pool for 20 minutes.

The nurse should encourage which of the following exercise(s) to assist with balance for a patient who is at high risk for falls?

Tai chi Walking heel to toe

An older man was oriented and responded appropriately in the hospital, but he is now disoriented and confused in his home after discharge. Which of the following issues is the first that the home nurse should examine to determine whether an environmental issue is contributing to the patient's condition at home?

Temperature of household

Which one of the following is a true statement about mobility and safety for older adults?

Lowering the bed and fluorescent tapes are interventions to increase safety.

Which of the following is a true statement about assistive devices to aid older adults with impaired mobility?

A cane is most useful for unilateral disabilities but not bilateral problems.

The nurse is caring for a patient who has recently had an indwelling catheter placed. The nurse should assess the patient for:

A change in mental status

The nurse is conducting an admission assessment on an older adult and notes a small lesion with a multicolor appearance. Which assessment approach should the nurse use?

ABCD (asymmetry, border, color, diameter) rule

Each of the following is a nonpharmacological intervention for pain except which one?

Acupuncture treatments

An older adult admitted for back surgery asks for opioid pain medication. The nurse knows the patient asks for pain medication 15 minutes before it is due. Which recommendation should the nurse implement?

Administer the pain medication as requested by the patient.

The overall temperature in your gerontological unit is 62° F during the evening shift. In documenting this concern to the administration, which factor is the most important for the health and well-being of older adults?

An ambient temperature of 62° F is unsuitable for older people because they have impaired thermoregulation.

Which signs and symptoms are characteristic of a urinary tract infection (UTI) in an older adult?

Anorexia Turbid urine

The nurse understands that stress incontinence occurs:

As a result of increased intraabdominal pressure

The nurse admits an older man who had abdominal surgery. Admission vital signs are heart rate (pulse) (P), 73 beats per minute (bpm); respiration rate (R), 20 breaths per minute; blood pressure (BP), 136/84 mm Hg. He is receiving intravenous (IV) fluids but has not requested pain medication since surgery. Seven hours later, his vital signs are P, 98 bpm; R, 26 breaths per minute; and BP, 164/90 mm Hg; and he denies pain. Which intervention should the nurse implement?

Ask if he has about discomfort at the surgical site or any other location.

The nurse at an assisted-living facility uses the Exercise and Screening for You (EASY) tool to plan an exercise program for a female resident who is in good health except that her height has decreased ½ inch. Which exercise safety tip from EASY calls for the nurse to assess the resident before planning care?

Avoid stretches that cause you to bend at the waist.

The nurse assesses the quality of which of the following patient characteristics when applying the Get-Up-and-Go test from the Hendrich II Fall Risk Model?

Balance

A nurse will be conducting an education session at the local senior citizens center on the importance of physical activity. Which activities should the nurse include as an example of moderate-intensity aerobic activity?

Biking, and Dancing

Which conditions are likely to cause an older adult chronic pain?

Bone metastasis Compression fracture Postherpetic neuralgia

Compared with acute pain, which of the following statements is true of persistent pain?

Can bring about long term changes in lifestyle.

Residents of a nursing home taking which of the following medication(s) are at risk for sleep disturbances as an adverse effect of the medication?

Celecoxib (Celebrex) Diltiazem (Cardizem) Venlafaxine (Effexor) Ipratropium (Atrovent) Oxycodone (Oxycontin)

The nurse evaluates the urinalysis (UA) of a female patient with an indwelling urinary catheter. The UA report shows gross contamination of the urine. Rank the nursing interventions in order, beginning with the first intervention the nurse should implement.

Check the duration of catheterization. Provide urinary catheter care. Provide perineal hygiene. Obtain a urine specimen from a sterile port.

The nurse monitors for which clinical indicator when the older adult complains of pruritus?

Coarse skin

An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse's priority for preventive care?

Constipation

Which infection-control practice should the nurse implement when caring for an older adult who has active herpes zoster?

Cover ruptured skin lesions with a nonabsorbent dressing.

An older adult woman complains of foot pain from a corn. After assessing her feet, which intervention should the nurse implement to alleviate her discomfort safely?

Cut out an oval corn pad to make a U shape.

The nurse plans care to prevent a dangerous thermal environment for an older man who lives in a northern climate of the United States. Which patient assessment data does the nurse recognize that can contribute to his risk of hypothermia?

Has a history of a cerebrovascular accident (CVA) Has a history of diabetes mellitus Builds miniature cars for a hobby Gets heat from a boiler in the cellar

An older woman had hip replacement surgery 1 day ago, and the nurse thinks that the woman also has dementia. Which patient assessment does the nurse use to determine whether this woman is experiencing pain?

Holds abdomen tightly.

The nurse plans care to protect the skin covering an older adult's greater trochanter. Which of the following interventions is the nurse's priority when the older adult is positioned on the side?

Implement a turning schedule.

An older woman maintains an active lifestyle playing various games with friends. She reports to the nurse that she experiences wakefulness during the night and an inability to fall asleep after waking up at night. Which intervention should the nurse implement to improve the quality of this woman's sleep?

Inquire about her nightly sleep rituals

During the night, an older woman complains to the nurse that she has not slept more than 2 hours since admission to the hospital. Which intervention should the nurse implement to increase the duration of this woman's sleep?

Inquire about her sleep habits used at home.

The nurse administers an opioid analgesic to an older male postoperative patient in the surgical unit. Which is the most important intervention for the nurse to implement before leaving the patient's room?

Instruct him to ask for help before getting up.

The nurse cares for an older man who has a malignant melanoma. Which intervention should the nurse implement for this man to prevent a recurrence or advancement of this condition in the future?

Instruct him to wear sun-protective clothing and a hat at all times.

After assessing the older man in his bed, the nurse determines that he is at high risk for falls. The nurse leaves the room to get a fall risk sign and returns to find him on the floor pleading for help. Which of the following was the most important intervention the nurse should have implemented to prevent this event?

Instruct the patient to call for help.

An older man has Alzheimer disease, and his wife says he is up and wandering around the house at night. Which intervention should the nurse implement to increase the man's duration of sleep?

Instruct the wife to increase his daily physical activity.

Which topical agent is safe to apply?

Light mineral oil to moisten skin after bathing

Which pain sensation is associated with nociceptive pain?

Tissue inflammation

Which action should be included in all bladder-retraining programs?

Toileting at bedtime Toileting at bedtime should be incorporated for all patients. This intervention decreases the amount of urine in the bladder during the night. Incontinence pads are not encouraged during the retraining process. Toileting is not automatically scheduled every hour but is based on the individual's needs. The volume of scheduled fluid intake is also based on the individual's needs.

A nursing home resident who has type 1 diabetes mellitus is gradually requiring more and more insulin on an as-needed (PRN) basis to treat hyperglycemia. Which of the following should the nurse assess to plan care for improving this individual's glucose metabolism?

Trends over time in activity level

Continuous indwelling catheter use is indicated for which condition(s)

Urethral obstruction Urinary retention Severely impaired skin integrity

Which nursing intervention is most likely to prevent the creation of an environment conducive to fungal growth?

Use mild skin cleansing agents and blot dry.

An older patient complains of dry skin and asks for advice. Which advice should the nurse offer for improving dry skin?

Use tepid bath water.

The nurse will be educating a group of senior citizens on adaptations for safer driving. Which adaptation(s) should the nurse include?

Wide rear-view mirrors Pedal extensions Global positioning system (GPS) devices