Med Surg Chapter 2 NCLEX examination

A 72-year-old client admitted to the hospital for congestive heart failure has a history of a fractured hip due to a previous fall. The client is taking oxycodone-acetaminophen (Tylox) as needed for pain secondary to a recent dental procedure. Which risk factor puts this client at greatest risk for a fall? A. Age B. Diagnosis C. History of a fall D. Narcotic use

C. History of a fall The client's recent history of falling is the single most important predictor for falls. Adults age 80 years and older and those with multiple diagnoses are at higher risk for falls. Tylox may cause mental changes, but this isn't the best answer.

Which result is frequently seen in older adults who have undiagnosed depression? A. Increased falls B. Increased need for socialization C. Spending sprees on unnecessary items D. Under-nutrition

D. Under-nutrition Older adults may respond to depression by not eating, and this can lead to under-nutrition. Many who live alone lose the incentive to prepare or eat balanced diets, especially if they do not "feel well." Falls are not typically the result of undiagnosed depression. Increased socialization is the antithesis of depression. Older adults, especially those with depression, do not typically go on spending sprees.

What is the fastest-growing subgroup of older adults? A. Young old B. Middle old C. Old old D. Elite old

C. Old old The old old, people ages 85 to 99 years, is the fastest-growing subgroup of older adults. The young old are people ages 65 to 74 years, and the middle old are people ages 75 to 84 years. The elite old are people age 100 years or older.

An older adult client who is admitted to the medical-surgical unit with a diagnosis of heart failure states to the nurse, "I am of no use to anyone. I just want to die." What does the nurse do to ensure this client's safety? A. Ask whether the client would like a visit from the hospital's spiritual staff. B. Encourage the client to rest. He or she may feel better in the morning. C. Report the client's statement to the client's family. D. Report the client's statement to the health care provider.

D. Report the client's statement to the health care provider. Older adults have the highest suicide rate of any age group. Any suicidal tendencies should be reported to the health care provider to assess the need for selective serotonin reuptake inhibitors and risk to the client. Asking the client about spiritual guidance, encouraging the client to rest, and reporting to the family do not address the safety issue at hand.

The home health aide reports that a 70-year-old client is nonadherent in taking prescribed medications. What does the nurse do to solve this problem? A. Asks what the barriers are to taking the medications B. Color-codes the labels or places dots on the bottles C. Provides a weekly pill box with daily compartments D. Provides medications with bottle caps that are easy to open

A. Asks what the barriers are to taking the medications Assessing why the client is noncompliant and overcoming those barriers are key to facilitating compliance. Using a color-coding system is a great technique, but the client's nonadherence may not be caused by failure to identify medications correctly. Use of a pill box is a good method, but the client's nonadherence may not be caused by failure to remember which medications are to be taken and when. Use of caps that are easy to open is helpful, but the client's nonadherence may not be caused by difficulty with opening medication bottles.

The RN has delegated nursing actions to experienced unlicensed assistive personnel (UAP) working in a long-term care facility. Which actions require direct supervision by the RN? (Select all that apply.) A. Assisting a 70-year-old client who has new-onset leg pain when ambulating B. Feeding an 82-year-old client who has severe joint disease in both hands C. Helping a 66-year-old client complete her personal hygiene D. Re-positioning a 69-year-old client who has recently become unconscious E. Assisting a 72-year-old client who has chronic arthritis of the knee to the restroom

A. Assisting a 70-year-old client who has new-onset leg pain when ambulating D. Re-positioning a 69-year-old client who has recently become unconscious The RN should supervise all care delegated to UAPs when there is a change in the client's condition, such as a change in the client's level of consciousness. Routine hygiene care and helping a client eat is within the UAP's scope of practice without ongoing direct supervision from the RN.

At a follow-up visit after repair of a fractured radial bone, an older adult client states, "I am not sleeping at all during the night." The client's partner reports that the client is sleeping all day. Which intervention does the nurse suggest? A. Increasing the client's daytime activities B. Placing a "Do not disturb" sign on the door at night C. Taking additional pain medication (analgesic) during the day D. Taking herbal sleep remedies to enhance the effects of prescribed medications

A. Increasing the client's daytime activities Older adult clients should try to stay awake during the day to prevent insomnia at night. Increasing activities will facilitate this goal. The client did not report interruptions, but insomnia; placing a "Do not disturb" sign on the door, although it may be effective in increasing "sleep time," does not address the client's symptom. Pain medication is best taken at night because it causes drowsiness. Encouraging herbal sleep remedies to try to enhance the effects of other medications is not an appropriate suggestion for the nurse to make.

The nurse is assessing the nutritional status of an older adult client. Which statement made by the client needs to be explored further? A. "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods." B. "For protein in my diet, I like to get the fish sandwich at the fast-food drive-through at least three times a week." C. "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day." D. "With less activity and exercise in my life these days, I should reduce my total calorie intake."

B. "For protein in my diet, I like to get the fish sandwich at the fast-food drive-through at least three times a week." Fast food is a contributor to high carbohydrate and caloric intake in older adults. Because fast food is relatively inexpensive and convenient, this population tends to abuse it, thus gaining weight from unhealthy calories. Older adults do enjoy sweets and desserts because their taste acuity changes, but they still need to eat a variety of foods that are high in protein and vitamins, as well as with different textures and fiber content. Consuming fresh fruits and vegetables is characteristic of a healthy lifestyle in older adults; this practice will help keep bowel habits routine. As older adults begin to lead a more sedentary lifestyle, they should decrease their caloric intake to match a diminished basal metabolic rate.

A 70-year-old client whose spouse died the previous year says to the nurse, "Life is not fun anymore." How does the nurse respond? A. "Are you getting enough sleep? That makes me feel better!" B. "Tell me about your support network, such as friends or family." C. "How are you feeling about the death of your spouse after this length of time?" D. "Why don't you go on a vacation? A change of scenery will do you good."

B. "Tell me about your support network, such as friends or family." Establishing and maintaining relationships with others throughout life is especially important to a person's happiness. Older adults who have close, intimate, and stable relationships with others in whom they can confide are more likely to cope with crises. It is true that sleep deprivation affects coping, but this is not the best answer; this response is a closed-ended question not allowing for elaboration. The nurse providing information about "self" is also nontherapeutic. Asking about the spouse's death is leading; the source of the client's statement may have nothing to do with the spouse's death. Suggesting a vacation does not address the issue at hand. "Why" questions are typically nontherapeutic and often place clients in a defensive stance.

The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants. Which of these nursing actions does the RN delegate to a nursing assistant? A. Admitting a new client with multiple bruises over the upper thighs B. Assisting a client with chronic joint stiffness to ambulate C. Making hourly assessments on a client with delirium and dementia D. Monitoring a confused client who has been placed in a jacket restraint

B. Assisting a client with chronic joint stiffness to ambulate Nursing assistant education and scope of practice include ambulation of stable clients. The other nursing actions require broader education and scope of practice and should be done by licensed nurses. Admission of a new client who has clinical manifestations that may have been caused by abuse is the responsibility of the RN. The RN should assess the client with acute problems such as delirium and dementia. LPN/LVN education and scope of practice include monitoring, re-positioning, and toileting of clients who require restraints.

An older adult client who lives with her daughter is admitted to the hospital. During the admission assessment, the nurse notes strong body odor, several large pressure ulcers, and limb contractures. What does the nurse do first? A. Asks the daughter about the ulcers and contractures B. Contacts the hospital social worker C. Gives the client a bath D. Notifies the health care provider

B. Contacts the hospital social worker The social worker will assess the client's situation and will contact the appropriate authorities if needed. Asking the daughter sets up a potential confrontation that need not be handled by the nurse. The client should be given a bath, but this is not the first action to be taken. Notifying the health care provider will be appropriate at a later time, but is not the best action to take at this point.

A client with end-stage lung cancer and metastasis to the brain has been admitted to the medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is required to apply restraints. Which nursing intervention is required for this client? A. Checking the restraints every 1 to 2 hours B. Releasing the restraints at least every 2 hours C. Using chemical sedation instead of restraints D. Using the most restrictive devices to ensure that no falls occur

B. Releasing the restraints at least every 2 hours The Joint Commission recommends releasing restraints every 2 hours for client care such as turning, re-positioning, and toileting. The restraints must be checked every 30 to 60 minutes. Chemical sedation is also considered a restraint. The least restrictive devices should be used.

The nurse is talking to a group of active senior citizens about making healthy lifestyle choices. Which suggestion is most important in promoting health and safety? A. "Continue to eat healthy foods, especially protein." B. "Seek counseling for depression, because it is not a normal part of aging." C. "Stop driving when your vision, motor skills, and confidence begin to diminish." D. "Walk 30 minutes three to five times a week."

C. "Stop driving when your vision, motor skills, and confidence begin to diminish." Motor vehicle crashes are the most common cause of injury-related death for those between 65 and 74 years of age. To promote health and safety, driving should be discontinued when vision, reflexes, or confidence begin to suffer. Eating healthy foods and exercise promote health but not safety. Encouraging good mental health promotes well-being but not safety.

The nurse is completing a hospital admission assessment on an 86-year-old client with renal impairment. The client's daughter gives the nurse a long list of drugs that the client is taking at home, both prescription and over-the-counter. What does the nurse do next? A. Calls the pharmacy to verify that the drugs do not interact adversely B. Calls the health care provider to verify the drug list C. Copies the list to the assessment data form D. Ensures that all of the drugs have been ordered for the client's hospital stay

C. Copies the list to the assessment data form Copying the list to the assessment data form should be done first. Then, the health care provider should be notified of all drugs, which may or may not be ordered during the client's stay, depending on the client's diagnosis. Calling the pharmacy and calling the provider are not the priority for admission. The client may not require all the medications during the hospital stay.

The son of an older adult client states that he has noticed progressive periods of forgetfulness in his father over the past year. After noting the son's comments and assessing the client, which cognitive problem does the nurse suspect the client may have? A. Alzheimer's disease B. Delirium C. Dementia D. Depression

C. Dementia Dementia is a broad term used for a syndrome that involves a slowly progressive cognitive decline. It is sometimes referred to as chronic confusion. Alzheimer's disease is a form of dementia, but Alzheimer's disease is not quickly diagnosed. Further cognitive and medical/neurologic testing would be needed to establish this diagnosis, which would not be done by a nurse. Delirium is an acute state of confusion, which differs from dementia in that it is usually short term and reversible within 3 weeks. It is often seen in older adults when they are in an unfamiliar setting. Depression is broadly defined as a mood disorder that can have cognitive, affective, and physical manifestations.

The nurse is conducting a medication assessment on an older adult client who is being admitted to a long-term care facility for rehabilitation following a hip replacement. With Beers Criteria used as a resource, which drug poses a potential risk for this client? A. Acetaminophen (Tylenol) B. Celecoxib (Celebrex) C. Digoxin (Lanoxin) D. Mesalamine (Asacol)

C. Digoxin (Lanoxin) Digoxin is listed in the Beers Criteria as a drug that leads to toxicity and drug interaction problems. Clients receiving this medication are at greater risk for serious side effects and interactions. Acetaminophen, celecoxib, and mesalamine are not listed in the Beers Criteria as drugs that lead to toxicity and drug interaction problems.

The nurse is teaching a class of older adults about ways to promote their cognitive health. Which collaborative interventions will be most helpful for them? (Select all that apply.) A. Allowing for increased rest and relaxation time B. Having solitary times to reminisce about life experiences C. Joining a peer group with a common learning goal D. Learning a new skill E. Meditating for 30 minutes every day F. Starting a new physical activity

C. Joining a peer group with a common learning goal E. Meditating for 30 minutes every day F. Starting a new physical activity Cognitive health problems (depression, delirium, and dementia) can be offset by social engagement, learning a new skill, and physical activity. Increased rest time, meditation, and increased solitude may be helpful for other aspects of aging but do not benefit the older adult's cognitive capabilities.

The nurse is assessing an older adult client's alcohol use. Which client statement warrants a follow-up collection of more data? A. "I am a 'teetotaler'; I never drink anything alcoholic." B. "I had three glasses of champagne at my granddaughter's wedding last month." C. "I like to have a glass of wine every once in a while." D. "I usually drink two vodkas to help me get to sleep each night."

D. "I usually drink two vodkas to help me get to sleep each night." The recommended alcohol intake (National Institute on Alcohol Abuse and Alcoholism) for people over 65 years of age is one drink daily or seven drinks weekly. The practice of drinking two vodkas daily exceeds those recommendations and needs to be followed up by the nurse. Although it is impossible to determine whether someone who abstains from alcohol is an alcoholic, many people choose not to drink any alcohol at all. Unless evidence is available to dispute, the client who is a "teetotaler" should be believed. An occasional drink of an alcoholic beverage is within the range of normal consumption for older adults. Unless other alcohol was reported, and is used more routinely, the level of consumption for the other clients should cause no alarm on a routine assessment.

The RN is arriving for night duty at an acute care hospital. Which client does the RN assess first? A. A 65-year-old who is scheduled for surgery the next day B. A 68-year-old who has chronic protein-calorie malnutrition C. A 70-year-old who has a history of gout and is reporting joint pain D. A 72-year-old who was admitted to the unit with postoperative delirium

D. A 72-year-old who was admitted to the unit with postoperative delirium Clients with delirium are at risk for injury because associated agitation and/or combativeness may lead to behaviors such as climbing out of bed or pulling at invasive catheters. The other clients should be assessed as soon as possible, but scheduled surgery, malnutrition, and a diagnosis of gout with joint pain do not indicate any acute risk for complications.

The nurse is teaching a class of unlicensed assistive personnel (UAP) about turning and re-positioning clients in a long-term care setting. Which client requires extreme caution and is at greatest risk for a skin tear? A. A 38-year-old client with paraplegia resulting from a motor vehicle accident B. A 70-year-old client with a recent total hip replacement receiving rehabilitation care C. An 80-year-old client with a recent stroke and left-sided paralysis D. An 85-year-old client with breathing problems receiving daily doses of prednisone

D. An 85-year-old client with breathing problems receiving daily doses of prednisone UAPs need to use extreme caution when handling members of the old old age group and clients who are on long-term steroid therapy. These groups are most prone to skin tears. This client has both of these high-risk indicators. Although the client with paraplegia has limited mobility, no other factors place the client at high risk for a skin tear. Most total hip repairs have short periods of immobility, with minimal skin breakdown potential; no specific risk factors are evident in this client's history. Although the client with a recent stroke is at risk for skin breakdown because of age and immobility, fewer risk factors are present than in the older client on steroid therapy.

An 80-year-old client is being relocated from a home setting to a long-term care facility. Which nursing intervention best minimizes the effects of relocation stress syndrome? A. Explaining all procedures and routines to the client's family before they occur B. Keeping the room clear of personal belongings to reduce the risk of falling C. Providing the client with limited decision making to avoid stressful situations D. Re-orienting the client frequently to his or her new location

D. Re-orienting the client frequently to his or her new location Re-orienting the client to the new location helps minimize relocation stress syndrome effects. All procedures and routines should be explained to the client as well as the family. Familiar and special personal belongings are helpful to keep at the client's bedside to minimize the effects of relocation stress syndrome. The client should be provided opportunities to assist in decision making, which helps the client feel more in control.

The RN manager of a skilled nursing facility wants to assign a staff member to assess the nutritional needs of an emaciated client with pressure ulcers. Which of these team members is appropriate? A. The LPN/LVN treatment nurse responsible for the client's wound care B. The LPN/LVN medication nurse for this client C. The nursing assistant caring for this client for the past 2 weeks D. The RN team leader responsible for care planning

D. The RN team leader responsible for care planning The RN is responsible for the assessment and planning components of the client care plan. The LPN/LVNs and nursing assistant also have important roles in implementation of the client's care, but do not have the education or scope of practice needed for assessment and care planning.

Which older adult client's living situation typically presents highest risk for abuse? A. At home alone B. At home with a spouse C. In a long-term care facility D. With adult daughter and grandchildren

D. With adult daughter and grandchildren Older adults are often abused by a family member who becomes frustrated or distraught over the burden of caring for the older adult. Prolonged caregiving by a family member is a new and unexpected role for adult children, most often women (as in this case), and is highly stressful. The client living at home alone may suffer from self-neglect, but not from neglect and abuse by another person. Although it is possible that the client living at home with a spouse or in a long-term care facility may suffer from abuse, this is not as common as with clients who live with children and grandchildren.