Practive

10. Interventions the nurse may implement to help prevent falls include (Select all that apply.)

A.keeping the call light within reach. B.rounding on the patient every 1 to 2 hours. D.using a bed alarm if the patient is disoriented. E.teaching the patient to change positions slowly.

8. The nurse knows which patient is at the greatest risk for social isolation?

D) 73-year-old man who uses public transportation to run errands and is estranged from his children

1. A patient has been referred for polysomnography to confirm a diagnosis of sleep apnea. What symptoms would the nurse expect the patient to report?

D.Loud periodic snoring with choking on wakening

Which of the following are assessed in a fall prevention assessment of an older adult? (Select all that apply.)

Environment Physical status Functional status Medical history

. After assessing an 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 even

Instruct the patient to call for help.

4. An older man has Alzheimer's 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.

5. Which attempt by the family to prevent an older frail adult from falling causes the home health nurse concern?

Keeping the side rails up on the client's bed at night

A patient who reported "a problem sleeping" shows an understanding of good sleep hygiene when

Limiting the afternoon nap to just 30 mins

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.

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

Muscle strength

11. 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? (Select all that apply.)

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

2. 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 to use?

One half -length rail

Which factors in the patient care environment should be routinely assessed to decrease the risk of falls? (Select all that apply.)

Outdoor grounds Appropriate footwear Grabs bars in place

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

Polypharmacy

6. 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.

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

Sleep disturbances in older adults can be caused by chronic illness.

6. What is the difference between rest and sleep?

Sleep is restorative and recuperative.

12. The nurse should encourage which of the following exercises to assist with balance for a patient who is at high risk for falls

Tai Chi Walkin heel to toe

2. 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.

A nurse is admitting and orienting an older adult to the hospital unit. She discusses fall prevention and demonstrates the use of the call bell to the patient. The patient's daughter asks: "Why don't you just put up all the side rails to prevent my mother from getting out of bed by herself and falling? That should work, right?" The best response by the nurse is:

``There is no evidence that side rail use decreases falls, and in fact there is a greater risk of injury."

The community health nurse delivers a program to middle-aged adults about retirement planning and wants to them to choose the year of their retirement. Which is the most important area on which the participants should focus to ease the transition to retirement?

. Ability to maintain a stable standard of living

7. The nurse is caring for aging patients who often experience role changes and losses. The nurse knows which factor increases the patient's successful adjustment to life after retirement?

A) Having several other meaningful roles remaining

. The nurse in the long term care facility notes the patient never attends social events in the facility despite encouragement from staff. What is the best intervention for this patient?

A) Schedule time to sit with the patient

10. What information will the nurse include when teaching a patient about using a hearing aid?

A."This amplifies sound and directs it into the ear canal."

8. 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 by an 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.

9. An older woman was widowed about a year ago. What would normal expected behavior at this stage of grieving include?

B) Improved energy, interest in new activities and goals.

4. Which patient assessment data does the nurse recognize could contribute to an older adult's risk of hyperthermia?

B.Takes furosemide 40 mg daily

3. 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

10. What is the most appropriate intervention to use for an older adult who always stays in his or her room?

C) Spend one-on-one time discussing the older adult's concerns.

5. The husband is visiting his wife who is in a subacute care facility undergoing rehabilitation for physical weakness resulting from a stroke. The gerontological nurse finds the man lying in bed with his wife, caressing her.The gerontological nurse considers the developmental needs of the older adult by:

C. Closing the door and ensuring that the couple is not disturbed for as long as possible.

9. Which population group are most at risk for developing glaucoma?

a. African American

When preparing a patient teaching session on diabetic retinopathy, the nurse should include which interventions when discussing treatments for slowing the progression of the disease? (Select all that apply.)

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

3. Which disease has become known as the "great imitator?"

b. Acquired immunodeficiency syndrome (AIDS)

3. Which of the following interventions should the nurse use when communicating with a hearing-impaired older patient?

b. Always clearly identify yourself and others with you.

5. An older man who has tinnitus complains to the nurse that it is very annoying. Which should the nurse implement to alleviate the stress he is experiencing from tinnitus?

b. Assess for modifiable risk factors.

1. A patient loses her husband because of a sudden myocardial infarction, and she blames herself for not recognizing the warning signs. Which patient outcome associated with her loss should the nurse use to plan care?

b. Expresses feelings of guilt, fear, anger, or sadness

11. A 79-year-old client resides independently in the community. The visiting home health nurse finds even though it is 90 °F outside, the windows are closed, and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to

b. age-related neurosensory changes that diminish awareness of temperature changes.

4. An older man is being abused by his daughter, a single working mother of four children, with whom he lives. The nurse investigates and learns that the abuse is due to situational stress. Which of the following interventions should the nurse implement to address the short-term crisis?

c. Arrange respite care or day care for the patient.

1. Which of the following is used to treat the most common cause of impairment to an older person's hearing?

c. Ear canal irrigation

4. The nurse plans the care of an older female resident of a nursing home who has experienced a sudden deterioration in visual acuity. Which intervention should the nurse complete first?

c. Examine her mood and functional status.

7. An older nursing home resident reports that her hearing loss is getting worse. What is the first action of the nurse?

c. Examine the resident's ears for cerumen impaction.

12. Which of the following diseases affects the eyesight of an older adult by damaging the central part of the retina?

d. Macular degeneration

6. An older adult complains about experiencing dry eyes daily. Which of the following should the nurse assess to help determine the cause of the patient's complaint?

d. Prescription antihistamine use

2. A medical illustration shows a man with the blunt end of a tuning fork pressed to the center of his forehead. The man is being tested for which of the following?

d. Unilateral conductive hearing loss

13. An older patient is diagnosed with sensorineural hearing loss. The nurse knows that causes of sensorineural hearing loss include

d. age-related hearing impairment. e. excessive and loud noise.

10. An older patient asks a nurse, "I really have trouble sleeping, and my doctor does not want to prescribe a sleeping pill for me. He says they are not good for older people. I really don't understand his response. Can you help me?" The best response by the nurse is:

se is: "Sleeping medications have many adverse effects in older people and only have minimal effects in improving sleep."