HA Exam 3

After assessing the older client 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? a. Instruct the client to use call bell for help. b. Call for someone to bring the sign. c. Provide a urinal and drinking water. d. Ensure he can reach his personal items.

a. Instruct the client to use call bell for help.

An older aphasic client has severe osteoarthritis, bilateral contractures of the lower extremities, and a stage IV pressure ulcer. The nurse practitioner prescribes analgesic medications to be administered around-the-clock, with as-needed doses to be administered as appropriate. What observation by the nurse would indicate that the pain regimen is effective? (Select all that apply.) a. "Client ate 80% of breakfast, 70% of lunch and 100% of dinner." b. "Client winces only when turned and repositioned." c. "Client slept during dressing change." d. "Client cooperative during AM care." e. "Client slept throughout the night."

a. "Client ate 80% of breakfast, 70% of lunch and 100% of dinner." c. "Client slept during dressing change." d. "Client cooperative during AM care." e. "Client slept throughout the night."

The nurse admits an older adult 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? a. Ask if he has about discomfort at the surgical site or any other location. b. Administer an opioid medication by IV route. c. Check the surgical dressing for bleeding. c. Report the vital signs to the health care provider.

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

When preparing a client's teaching session on diabetic retinopathy, the nurse should include which intervention(s) when discussing treatments for slowing the progression of the disease? (Select all that apply.) a. Laser therapy b. Lens transplant surgery c. Glucose control d. Blood pressure control e. Cornea transplant

a. Laser therapy c. Glucose control d. Blood pressure control

Which of the following diseases affects the eyesight of an older adult by damaging the central part of the retina? a. Macular degeneration b. Glaucoma c. Cataract d. Presbyopia

a. Macular degeneration

Which of the following statements is the most suitable for establishing goals when teaching an older adult with a chronic illness about potential changes in the health maintenance regimen? a. Management of the client's chronic disease rests on the client and the caregiver; therefore, the goals should be collaboratively set. b. The client will be able to make needed changes in his or her life if the nurse provides accurate, written instructions. c. The client's values, culture, and beliefs will have little to do with the types of changes he or she will be able to make. c. Psychological functioning is usually impaired only to a small extent in a client with a chronic illness.

a. Management of the client's chronic disease rests on the client and the caregiver; therefore, the goals should be collaboratively set.

Which factor(s) is(are) modifiable health risk behaviors for chronic illness? (Select all that apply.) a. Physical activity b. Poor nutrition c. Prescription medication use d. Tobacco use

a. Physical activity b. Poor nutrition d. Tobacco use

Persons with normal age-related sensory changes are likely to have the most difficulty distinguishing which of the following? a. Spoken pairs of phrases like "she's praised" and "fees raised" b. "Go" and "to" in lowercase letters in fine print c. Spoken word pairs like "cupful" and "capful" d. Orange towel hanging on a beige wall

a. Spoken pairs of phrases like "she's praised" and "fees raised"

A home health nurse is making a home visit to an older adult client. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the client eliminate which of the following? (Select all that apply.) a. excess clutter b. loose carpeting on floor c. The use of a cane d. Night lights e. Railings on the stairway

a. excess clutter b. loose carpeting on floor

Which of the following client(s) does the nurse identify as at risk for developing fungal infections? (Select all that apply.) a. obesity b. bedridden c. incontinent d. multiple sclerosis e. impaired mental status

a. obesity b. bedridden c. incontinent

An older client is diagnosed with sensorineural hearing loss. The nurse knows that causes of sensorineural hearing loss include: (Select all that apply.) a. Cerumen impaction b. Age related hearing impairment c. Infections of the external and middle ear d. Tumors of the middle ear e. Exposure to excessive and loud noise

b. Age related hearing impairment e. Exposure to excessive and loud noise

The daughter of an older adult client states the following to a nurse: "I am so concerned that my dad is still driving. He is dangerous! He has had a couple of accidents and I am worried that he is going to kill himself, or worse, somebody else. What can I do?" The nurse recommends which of the following interventions to help deal with this situation? (Select all that apply.) a. Ask the client's physician to write a prescription for the person to stop driving. b. Arrange for alternate transportation for the person. c. Confiscate the keys to the car. d. Report the person to the division of motor vehicles for license suspension. e. Hold a family meeting with the person to discuss the situation and come to a mutual agreement of the problem.

b. Arrange for alternate transportation for the person. e. Hold a family meeting with the person to discuss the situation and come to a mutual agreement of the problem.

A home care nurse in an area of the country that is prone to tornadoes routinely discusses disaster preparedness with older adult clients. What is the primary rationale for this intervention? a. Most older adults have insurance to help them recover from material losses due to a natural disaster. b. Older adults are less likely to seek formal and informal help when affected by natural disasters. c. The older adult is more likely to live in a communal environment which provides assistance in times of natural disasters. d. Federal and private assistance agencies generally provide older adults with priority attention in time of natural disasters.

b. Older adults are less likely to seek formal and informal help when affected by natural disasters.

The nurse observes that a male client is snoring every night. Which should the nurse assess in this client to diagnose the potential for sleep apnea? (Select all that apply.) a. rituals for sleeping b. numbers of daytime naps c. awakening during the night d. irritability during the day e. change in appetite f. headaches in the morning

b. numbers of daytime naps c. awakening during the night d. irritability during the day f. headaches in the morning

Which of the following is an important consideration about the skin of an older adult person? a. skin becomes darker in unexposed areas b. skin becomes more vulnerable to sun damage c. sweat gland activity increases d. generous amounts of soap should be used for cleaning

b. skin becomes more vulnerable to sun damage

Which of the following is true statement about sleep in older adults? a. rapid eye movement (REM) sleep becomes more unevenly distributed with age b. the time spent in bed increases, the time spent asleep decreases c. the amount of leg movement during sleep remains stead throughout life d. the amount of stage III sleep increases steadily throughout life

b. the time spent in bed increases, the time spent asleep decreases

The relationship between acute illness and chronic illness is represented by which comparison? a. A hospital staff nurse is to a nurse practitioner. b. Health insurance is to Medicare for older adults. c. An emergency department is to a nursing home. d. In-client surgical care is to out-client medical care.

c. An emergency department is to a nursing home.

Which one of the following is a true statement about mobility and safety for older adults? a. The get-up-and-go test provides a measure of a patient's energy and initiative. b. Use of restraints on older patients helps prevent injuries from falls. c. Falls that do not cause physical injury are not significant. d. About 50% to 70% of falls in hospitals occur while transferring between bed/chair.

d. About 50% to 70% of falls in hospitals occur while transferring between bed/chair.

An older adult experiencing tinnitus reports to the nurse that it is very annoying. Which should the nurse implement to alleviate the stress he is experiencing from tinnitus? a. Irrigate the bilateral Eustachian tubes. b. Propose a hearing aid and a masker. c. Use white noise to override the tinnitus. d. Assess for modifiable risk factors.

d. Assess for modifiable risk factors.

The partner of an older adult man diagnosed with Alzheimer disease reports that he is up and wandering around the house at night. Which intervention should the nurse implement to increase the man's duration of sleep? a. Collaborate with the health care provider to administer a hypnotic medication. b. Teach the wife how to apply a vest restraint during sleep. c. Help the wife plan daily periods for napping and activity. d. Instruct the partner to increase his daily physical activity.

d. Instruct the partner to increase his daily physical activity.