AHT1: Quizzes toward Exam 1

The most common affect or mood disorder of old age includes

depression. Depression is the most common affective or mood disorder of old age. Anxiety disorders, schizophrenia, and phobias are not a common affective or mood disorder of old age.

A nursing instructor is preparing a class on pressure ulcers. Which of the following would the instructor most likely include as a possible risk factor? Select all that apply.

• Anemia • Immobility • Increased moisture Risk factors associated with pressure ulcer development include immobility, decreased sensory perception, anemia, decreased tissue perfusion, and increased moisture.

A patient asks the nurse why his residual limb cannot be elevated on a pillow. What is the best response by the nurse?

"Elevating the leg might lead to a flexion contracture." Elevating the residual limb on a pillow may lead to a flexion contracture; this could jeopardize the patient's ability to use a prosthesis. The patient does need to turn to both sides, but might still be able to do it with his extremity elevated. Elevating the extremity would not increase the risk for compartment syndrome. The limb should not be elevated on pillows or blankets.

A nurse working in the clinic is seeing a client who has just been prescribed a new medication for hypertension. The client asks why hypertension is sometimes called the "silent killer." The nurse's correct response is which of the following?

"Hypertension often causes no symptoms." Hypertension is sometimes called the "silent killer" because people with it are often symptom free. Physical examination may reveal no abnormalities other than elevated blood pressure. People with hypertension may remain asymptomatic for many years. The usual consequences of prolonged, uncontrolled hypertension are myocardial infarction, heart failure, renal failure, strokes, and impaired vision. Pain is not usually an issue, but that is not why hypertension is called the "silent killer." Hypertension is easily diagnosed by taking a series of blood pressure readings.

A nurse is caring for an 86-year-old female patient who has become increasingly frail and unsteady on her feet. During the assessment, the patient indicates that she has fallen three times in the month, though she has not yet suffered an injury. The nurse should take action in the knowledge that this patient is at a high risk for what health problem?

A hip fracture The most common fracture resulting from a fall is a fractured hip resulting from osteoporosis and the condition or situation that produced the fall. The other listed injuries are possible, but less likely than a hip fracture.

A client spends most of his time in a wheelchair. The nurse would be especially alert for the development of pressure ulcers in which area?

Ischial tuberosity For a client who sits for prolonged periods, such as in a wheelchair, the ischial tuberosity would be highly susceptible to pressure ulcer development. Areas such as the greater trochanter and lateral malleous would be susceptible for clients lying on their side. The scapula would be considered a high risk area for clients lying on their back.

A home health nurse is teaching a client with peripheral arterial disease ways to improve circulation to the lower extremities. The nurse encourages which of the following in teaching?

Keeping the legs in a neutral or dependent position Keeping the legs in a neutral or dependent position assists in delivery of arterial blood from the heart to the lower extremities. All the other choices will aid in venous return, but will hinder arterial supply to the lower extremities.

Which of the following is a true statement regarding characteristics of chronic conditions?

Managing chronic conditions must be a collaborative process Managing chronic conditions must be a collaborative process. Many ethical issues arise in the care of people with chronic conditions. Living with chronic illness means living with uncertainty. The management of chronic conditions is becoming more costly.

A nurse is completing an assessment of a client who has just been transferred to the rehabilitation facility. During the health history, the nurse asks about the client's activities of daily living (ADLs). About which areas would the nurse gather information? Select all that apply.

• Eating • Toileting • Bathing ADLs refer to those activities related to personal care, such as bathing, using the toilet, and eating. Cleaning and cooking are independent ADLs--activities that are important for independent living.

Target organ damage from untreated/undertreated hypertension includes which of the following? Select all that apply.

• Heart failure • Retinal damage • Stroke Target organ systems include cardiac, cerebrovascular, peripheral vascular, renal, and the eye. Hyperlipidemia and diabetes are risk factors for development of hypertension.

The number of people with disabilities is expected to increase over time. What is a major contributor to this prediction?

The survival of people with severe trauma, chronic disorders, and early-onset disabilites The number of people with disabilities is expected to increase over time as people with early-onset disabilities, chronic disorders, and severe trauma survive and have normal or near-normal lifespans. There has not been a decrease in the number of people with early-onset disabilities. Acquired chronic disorders still cannot be cured. Genetic risk factors for early-onset disabilities have not decreased.

The nurse is obtaining a healthy history from a client with blood pressure of 146/88 mm Hg. The client states that lifestyle changes have not been effective in lowering the blood pressure. Which medication classification does the nurse anticipate first?

Thiazide diuretic Clients with hypertension, unable to be lowered by lifestyle changes, usually are placed on a thiazide diuretic initially. However, most people with hypertension will need two or more antihypertensive medications to reduce their blood pressure.

A nurse is assessing a patient brought to the emergency room by his daughter. Which statement by the daughter would most likely lead the nurse to suspect that the patient may have an infection?

"All of a sudden he seemed to become confused." Due to age-related changes in the nervous system, a sudden onset of confusion may be the first symptom of an infection. Feeling dizzy on arising suggests orthostatic hypotension. A temperature of 97.6 degrees F may or may not suggest an infection. Typically older adults do not experience a traditional fever. Complaints of being tired could indicate numerous conditions.

The initial sign of skin pressure is erythema, which normally resolves in less than

1 hour. The initial sign of pressure is erythema caused by reactive hyperemia that normally resolves in less than 1 hour. All of the other timeframes are incorrect.

A patient is being discharged home with a venous stasis ulcer on the right lower leg. Which topic will the nurse include in patient teaching prior to discharge?

Application of graduated compression stockings Graduated compression stockings usually are prescribed for patients with venous insufficiency. The amount of pressure gradient is determined by the amount and severity of venous disease. Graduated compression stockings are designed to apply 100% of the prescribed pressure gradient at the ankle and pressure that decreases as the stocking approaches the thigh, reducing the caliber of the superficial veins in the leg and increasing flow in the deep veins. These stockings may be knee high, thigh high, or pantyhose.

A home health nurse makes a home visit to a 90-year-old patient who has cardiovascular disease. During the visit the nurse observes that the patient has begun exhibiting subtle and unprecedented signs of confusion and agitation. What should the home health nurse do?

Arrange for the patient to see his primary care physician. In more than half of the cases, sudden confusion and hallucinations are evident in multi-infarct dementia. This condition is also associated with cardiovascular disease. Having the patient's home care increased does not address the problem, neither does having a family member check on the patient in the evening. Referring the patient to an adult day program may be beneficial to the patient, but it does not address the acute problem the patient is having, the nurse should arrange for the patient to see his primary care physician.

The nurse is working in a long-term care facility. When assessing her patients, what body system dysfunction should the nurse look for as the leading cause of morbidity and mortality in the older adult population?

Cardiovascular Most deaths in the United States occur in people 65 years of age and older; 48% of these are caused by heart disease and cancer

A health care team is involved in caring for a client with advanced Alzheimer's disease. During a team conference, a newly hired nurse indicates that she has never cared for a client with advanced Alzheimer's disease. Which key point about the disease should the charge nurse include when teaching this nurse?

Clients with Alzheimer's disease are at high risk for injury because of their impaired memory and poor judgment. The charge nurse should inform the new nurse that clients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. Maintaining a safe environment takes top priority. Families are an important part of the client care team; however, they shouldn't be relied upon to deliver care. Family members may take turns sitting with the hospitalized client to help maintain client safety. All procedures should be explained in simple terms that the client can understand. Medications should be administered as ordered; however, they don't typically improve symptoms. Instead, they slow disease progression.

Which of the following statements describes accurate information related to chronic illness?

Most people with chronic conditions do not consider themselves sick or ill. Although some people take on a sick role identity, most people with chronic conditions do not consider themselves sick or ill and try to live as normal a life as is possible. Research has demonstrated that some people with chronic conditions may take on a sick role identity, but they are not the majority. Chronic conditions may be due to illness, genetic factors, or injury. Many chronic conditions require therapeutic regimens to keep them under control.

An elderly client who lives in a retirement community is having a mild depressive episode over the past few weeks. The nurse intervenes by recommending

Participation in a social activity For the elderly client experiencing mild depression, nonpharmacologic measures can be effective. These measures include increasing interpersonal interactions; an example is participating in a social activity. Other nonpharmacologic measures are bright lighting and exercise. Watching television limits interpersonal interactions. Decreasing walking would also decrease exercise. Antidepressants are indicated for major depression.

A patient who was admitted to the hospital with a diagnosis of thrombophlebitis 1 day ago suddenly develops complaints of chest pain and shortness of breath and is visibly anxious. The nurse immediately assesses the patient for other signs and symptoms of which of the following problems?

Pulmonary embolism Pulmonary embolism is a potentially life-threatening disorder typically caused by blood clots in the lungs. This disorder poses a particular threat to people with cardiovascular disease. Blood clots that form in the deep veins of the legs and embolize to the lungs can cause a pulmonary infarction where emboli mechanically obstruct the pulmonary vessels, cutting off the blood supply to sections of the lung. Clinical indicators of pulmonary embolism can vary but typically include dyspnea, pleuritic chest pain, and tachypnea.

Which intervention should the nurse implement, when caring for the client who complains of phantom limb pain two months after amputation?

Reassure the client that phantom pain is common. The nurse acknowledges the client's complaints of pain.

Based on a patient's vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurse's primary responsibility?

Report the findings to adult protective services. If neglect or abuse of any kind—including physical, emotional, sexual, or financial abuse—is suspected, the local adult protective services agency must be notified. The responsibility of the nurse is to report the suspected abuse, not to prove it, confront the suspected perpetrator, or work with the family to promote resolution.

The nurse is assessing a patient's pressure ulcer and notes a full-thickness wound that extends into the subcutaneous tissue. Necrosis and infection are present. The nurse documents this ulcer as which stage?

Stage III A stage III ulcer is a full-thickness wound that extends into the subcutaneous tissue with necrosis and infection. A stage I ulcer is characterized by an area of erythema that does not blanch with pressure. A stage II ulcer is a partial-thickness wound characterized by a break in the skin with edema and some drainage. A stage IV ulcer is a full-thickness wound that extends to the underlying muscle and bone with deep pockets of infection and necrosis.

Which of the following is a factor that alters urinary elimination patterns in the older adult?

Decreased muscle tone Older adults typically have decreased muscle tone related to urinary elimination. Increased residual volume, decreased bladder capacity, and sedentary lifestyle are other factors that alter urinary elimination patterns in the older adult.

When changing the dressing on a pressure ulcer, a nurse notes necrotic tissue on the edges of the wound. Which action should the nurse anticipate that the physician will order?

Debridement Necrotic tissue prevents wound healing and must be removed. This is accomplished by debridement. Incision and drainage, culture, or irrigation won't remove necrotic tissue. Incision and drainage drain a wound abscess. A wound culture indentifies organisms growing in the wound and helps the physician determine appropriate therapy. If the wound is infected, the physician may order irrigation — usually with an antibiotic solution — to treat the infection and clean the wound.

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?

Dyspnea on exertion Left-sided heart failure produces hypoxemia as a result of reduced cardiac output of arterial blood and respiratory symptoms. Many clients notice unusual fatigue with activity. Some find exertional dyspnea to be the first symptom. An increase in urinary output may be seen later as fluid accumulates. Hypotension would be a later sign of decompensating heart failure as well as tachycardia.

The nurse is evaluating the serum albumin of a patient newly admitted on the rehabilitation unit. The nurse determines that the serum albumin is low, indicating that the patients level of which of the following is deficient?

Protein Serum albumin is a sensitive indicator of protein deficiency. Serum albumin is not an indicator of potassium, calcium, or phosphorous deficiency.

Which of the following is a nurse's role in providing home care for a patient with Alzheimer's disease?

Provide emotional and physical support Home health care nurses provide emotional support and intervene if family caregivers become overburdened. The nurse also instructs the family about physical care, the disease process, and treatment. Administering IV and oxygen or supporting patients with household errands is not a relevant role for a home nurse.

A hospitalized client with heart failure puts on the call light and makes the following statement: "I've become very short of breath, and I've been coughing up this pink frothy sputum." The nurse immediately suspects which of the following complications?

Pulmonary edema When the left ventricle fails, blood backs up into the pulmonary system. Large quantities of frothy sputum, which is sometimes blood-tinged, may be produced, indicating severe pulmonary congestion or pulmonary edema.