N128 Week 3 - Adaptive Quizzing #3

An older adult in acute care has a risk of skin breakdown. Which intervention(s) is/are beneficial to the client? Select all that apply. One, some, or all responses may be correct. Providing thorough skin care Reducing shear forces and friction Providing beverages and snacks frequently Using a support surface base all the time Avoiding pressure with proper positioning

Providing thorough skin care Reducing shear forces and friction Avoiding pressure with proper positioning Providing an Older adult with meticulous skin care may reduce the risk of skin breakdown. Reducing shear forces and friction prevents the development of pressure injuries. Pressure can be avoided with proper positioning. Beverages and snacks are frequently provided to clients who are hospitalized due to dehydration. A supportive surface base is used based on risk factors.

Which immune function change places older clients at risk for bacterial and fungal infections? Decline in natural antibodies Reduction of neutrophil function Decrease in circulating T lymphocytes Reduction Of colony-forming B lymphocytes

Decrease in circulating T lymphocytes A decrease in circulatingT lymphocytes occurs with cell-mediated immunity, resulting in an increased risk Of bacterial and fungal infections. A client would need booster shots for Old vaccinations and immunizations when there is a decline in natural antibodies. A reduced neutrophil function may be an implication when neutrophil function is decreased. The Older adult should receive immunizations, such as flu shots, when the number of colony-forming B lymphocytes is diminished.

Which intrinsic factors may contribute to falls in older adults? Select all that apply. One, some, or all responses may be correct. Lack of exercise Impaired vision Inappropriate footwear Improper use of assistive devices Unfamiliar environment Of hospital room

Lack of exercise Impaired vision Falls in older clients may be a result of intrinsic factors and extrinsic factors. Deconditioning( lack of exercise) and impaired vision are intrinsic factors that can lead to falls. Inappropriate footwear, improper use of assistive devices such as walkers, and a lack of familiarity with the hospital room are extrinsic factors.

Which health care factors create barriers that prevent older adults from participating in health care promotion and disease prevention? Select all that apply. One, some, or all responses may be correct. Finance Activity level Transportation Personal motivation Previous health care experience

Personal motivation Previous health care experience Personal motivation and previous health care experience are factors that create barriers that prevent older adults from participating in health care promotion and disease prevention. Finances, activity levels, and transportation are non—health-related factors that create barriers for older adults.

A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, which would the nurse teach the client to do? Limit fluids at bedtime. Change positions slowly. Take the medication between meals. Assess the skin for breakdown daily.

Change positions slowly. With aging there is a decreased vasomotor response and diminished elasticity Of blood vessels, which dO not respond quickly to changes from horizontal to vertical; orthostatic hypotension may occur. Changing positions slowly allows the body to adjust, which prevents dizziness and loss of balance. Usual fluid intake patterns can be maintained. Furosemide should be taken with meals to prevent gastric irritation. It is best to take it in the morning rather than at night so that sleep is not interrupted with the need to void. There is no link between furosemide and skin breakdown.

The nurse instructs a 70-year—old client to dress warmly in cold weather. Which physical changes seen in the client necessitate this instruction? Select all that apply. One, some, or all responses may be correct. Reduced sebum production Degeneration of elastic fibers Decreased dermal blood flow Thinning of the subcutaneous layer Decreased vasomotor responsiveness

Thinning of the subcutaneous layer Decreased vasomotor responsiveness Thinning of the subcutaneous layer and decreased vasomotor responsiveness will increase the risk Of hypothermia. TO prevent hypothermia, the nurse instructs the client to wear warm clothing. Reduced sebum production can increase the size Of pores, producing comedones. Degeneration Ofelastin will decrease the skin turgor of the client but does not produce hypothermia. Decreased dermal blood flow will cause risk of dry skin, which does not require the intervention ofwarm clothing. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all Options that apply tO a given situation or client. All Options likely relate tO the situation, but only some of the options may relate My to the situation.

Which intervention would the nurse implement with a healthy older adult client who has decreased bone density? Teaching the client to do isometric exercises Encouraging the client to do weight-bearing exercise Instructing the client to sit in supportive chairs with arms Providing moist heat such as a shower or moist compresses

Encouraging the client to do weight-bearing exercise Older adults are at risk of developing decreased bone density. Elderly clients with decreased bone density should be encouraged to do weight—bearing exercises. Teaching isometric exercises would be beneficial for a client with muscular atrophy. A client with kyphotic posture should be instructed to sit in supportive chairs with arms. Providing moist heat would be beneficial for a client with cartilage degeneration. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

Which instructions would the nurse give to an older adult with decreased perception of touch? Select all that apply. One, some, or all responses may be correct. 'Use a cane for support when walking.' ' 'Hold on to handrails while ambulating.' 'Look where your feet are placed while walking.' 'Wear shoes that give good support while walking.' 'If you are unable to change your position frequently, request assistance.'

'Hold on to handrails while ambulating.' 'Look where your feet are placed while walking.' 'Wear shoes that give good support while walking.' 'If you are unable to change your position frequently, request assistance.'

Which statement would the nurse say to an older adult, accompanied by family members, who is admitted to a long-term care facility with symptoms of neurocognitive disorder? 'You're a little disoriented now, but don't worry. You'll be all right in a few days.' 'I'm your nurse, and the staff is here to help you.' 'I will be on duty today. You're in a long-term care facility. Your family can stay about 30 minutes.' 'Let me introduce you to the staff here first. In a little while I'll get you acquainted with our unit routine.'

'I'm your nurse, and the staff is here to help you.' The nurse would say, 'I'm your nurse, and the staff is here to help you.' Familiarity with the environment and a self-introduction may help promote security and feelings of trust. Telling the client, 'You're a little disoriented now, but don't worry. You'll be all right in a few days,l provides false reassurance because Ofthe diagnosis. A self—introduction followed by orienting the client to the facility are appropriate, but telling the client that the family may stay for about 30 minutes is inappropriate. A client with neurocognitive disorder may need the family for support. For a client with neurocognitive disorder, introduction to the staff can be overwhelming and even if the nurse acquaints the client to the unit routine, it does not mean the client will remember either one the next day.

Which step listed by the nursing student indicates a need for additional training regarding communicating with older adults with hearing problems? 'Refrain from speaking extremely slowly.' 'Speak clearly by exaggerating his or her lip movements.' 'Allow the client to ask questions when necessary.' 'Ensure that the client knows that the nurse is talking.'

'Speak clearly by exaggerating his or her lip movements.' The nurse would not speak by exaggerating his or her lip movements when communicating with older adults with hearing problems. The nurse would speak clearly to facilitate understanding. The nurse would speak slowly but not extremely slowly. When communicating with the client, the nurse would allow the client to ask questions when necessary to facilitate better understanding. The nurse would ensure that the client knows that the nurse is speaking to facilitate good communication.

Which instructions would the nurse give a 60-year-old client who is at an increased risk for corneal damage? Select all that apply. One, some, or all responses may be correct. 'Use saline drops.' 'Increase humidity at home.' 'Wear prescribed lens for best vision.' 'Have corrective lenses solely for reading.'

'Use saline drops.' 'Wear prescribed lens for best vision.' 'Have corrective lenses solely for reading.' A client who has reduced tear production may have an increased risk for corneal damage and eye infection. Using saline eye drops and increasing the humidity may reduce dryness and decrease corneal damage. Flattening ofthe cornea causes blurred vision. The client should be instructed to have regular eye examinations and wear the prescribed lens to prevent corneal damage. All the rest of the instructions are associated with the pupil or lens rather than the cornea. A client whose pupils have a decreased ability to dilate has a poor capacity for acclimating to the darkness. These clients are mainly instructed to maintain good lighting to prevent an accident. A client with an inelastic lens is mainly instructed to wear corrective lenses while reading. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

A 93-year-old client in a nursing home has been eating less food during mealtimes. Which is the correct nursing intervention? Substitute a supplemental drink for the meal. Spoon-feed the client until the food is completely eaten. Allow the client a longer period of time to complete the meal. Arrange a consultation for the placement of a gastrostomy tube.

Allow the client a longer period of time to complete the meal. Older clients may display psychomotor retardation and need more time to complete the tasks associated with the activities of daily living; mealtimes should be relaxing and social. Supplemental drinks should augment meals and be offered between meals, not as a substitute for meals. Clients should be encouraged to feed themselves to remain as independent as possible; spoon-feeding may not mirror the pace Of eating preferred by the client, and forcing the client to eat all of the food may precipitate anxiety, frustration, and agitation. Placement of a gastrostomy tube is premature.

The nurse is reviewing the laboratory reports of a group of older adult clients. Which client has an age-related impairment of the thirst mechanism? Client A Serum sodium concentration: 167 mEq/L Client B Serum sodium concentration: 143 mEq/L Client C Serum sodium concentration: 118 mEq/L Client D Serum sodium concentration: 101 mEq/L

Client A Older adult clients are at greater risk Offluid and electrolyte imbalances such as dehydration and hypernatremia due to age—related impairment of the thirst mechanism. The normal serum sodium concentration is between 135 and 145 mEq/L. ClientA has a serum sodium concentration Of 167 mEq/L, which is higher than normal, thereby indicating hypernatremia. Client B has a serum sodium concentration of 143 mEq/L, which is a normal value. The serum sodium concentration of client C is 136 mEq/L, which is a normal value. Client D has a serum sodium concentration of 140 mEq/L, which is in the normal range.

A 68-year-old client with a new ileostomy remarks to the nurse, 'It will be difficult for my wife to care for a helpless old man. 'Which conflict according to Erikson does this comment exhibit? Initiative versus guilt Integrity versus despair Industry versus inferiority Generativity versus stagnation

Integrity versus despair According to Erikson, poor self-concept and feelings Of despair are conflicts manifested in those who are Older than 65 years Of age. The initiative versus guilt conflict is manifested in early childhood between 3 and 6 years of age. The industry versus inferiority conflict is manifested during the ages from 6 to 11 years. The generativity versus stagnation conflict is manifested during middle adulthood, 45 to 65 years Of age.

Which would the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging? Achievement of a personal philosophy Adaptation to the children leaving home Attainment of a sense of worth as a person Adjustment to life in an assisted—living facility

Attainment of a sense of worth as a person Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self—worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.

Which findings in the older adult client are associated with a urinary tract infection (UTI)? Select all that apply. One, some, or all responses may be correct. Fever Urgency Confusion Incontinence Slight rise in temperature

Confusion Incontinence Slight rise in temperature An Older adult client with a urinary tract infection (UTI) is likely to appear confused and may experience incontinence, whereas a younger client is cognitively intact and typically experiences urgency. The Older adult client may develop only a slight rise in temperature, whereas the hallmark symptoms Ofa UTI in a younger client are fever, dysuria, and urgency. Test-Taking Tip: The nurse must remember that classic symptoms of disease may not be seen in the Older client with age—related physiological changes.

The nurse is performing a male reproductive system assessment of an older adult client. The nurse expects which age-related finding? Asymmetrical testes Reduced size Of testes Absence of pubic hair Foreskin that is difficult to retract

Reduced size Of testes A reduction in the size of the testes is a characteristic of aging. The testes are symmetrical in shape and ength; any change in their symmetry denotes an abnormality. Pubic hair is normally present. For Jncircumcised males, a foreskin will be present and should be easily retractable.

Which priority factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment? Level of interest in unit activities Orientation to time, place, and person Ability to perform tasks without becoming frustrated Cognitive impairment, which will increase until adjustment to the home is accomplished

Ability to perform tasks without becoming frustrated The nurse would consider ability to perform tasks without becoming frustrated. When the client is unable to perform a task, frustration occurs and results in more disorganized behavior. Clients with disorientation and cognitive impairment may show little interest in unit activities but should be included to the best oftheir ability. However, this does not address the client's disorganized behaviors. Although orientation is important, the client's disorientation is already documented; more important is the assessment of the client's ability to function. Although cognitive impairment is important, adjusting to the nursing home may never be fully achieved.

Which nursing interventions would the nurse provide to an older client with hypertension? Select all that apply. One, some, or all responses may be correct. Provide skin care. Advise the client to limit salt intake. Teach stress management. Instruct the client to quit smoking. Advise the client to eat finger foods.

Advise the client to limit salt intake. Teach stress management. Instruct the client to quit smoking. Proper nursing interventions for an older client with hypertension include advising the client to limit salt intake, teaching stress management, and instructing the client to quit smoking. Skin care is an appropriate intervention for clients at risk of pressure injuries. The nurse would advise a client with dementia to eat finger foods such as sandwiches because these foods are easy to eat.

An older client is apprehensive about being hospitalized for the first time. Which intervention is correct for the nurse to perform to limit the client's stress? Use the client's first name. Visit with the client frequently. Explain what the client can expect. Listen to what the client has to say.

Explain what the client can expect. Listening doesn't change anything.

Which action would the home health nurse suggest to decrease risk for injury for an older adult with peripheral arterial disease? Move into an assisted living community. Lower the thermostat setting on the hot water tank. Reduce fluid intake to less than 2500 mL/day. Limit physical activity to a short daily walk.

Lower the thermostat setting on the hot water tank. Because peripheral arterial disease may decrease the ability to feel extremes Of heat and increases risk for burn injuries, lowering the temperature of the hot water tank can reduce injury risk. There is no indication that this client needs assistance with any activities of daily living, so there is no need to move the client to an assisted living community. Reduction Offluid intake is not indicated for clients with peripheral arterial disease. Walking is encouraged because it improves blood flow and encourages collateral circulation to the legs. Test-Taking Tip: You have at least a 25% chance Of selecting the correct response in multiple-choice items. If you are uncertain about a question, eliminate the choices that you believe are wrong and then call on your knowledge, skills, and abilities to choose from the remaining responses.

Which characteristic about confusion would the nurse keep in mind when an older client with Alzheimer disease is admitted to a long-term care facility? Occurs with a transfer to new surroundings Will be unchanged despite reality orientation Is a common finding and expected with normal aging Results from brain changes that make interventions futile

Occurs with a transfer to new surroundings A change in environment and introduction of unfamiliar stimuli precipitate confusion in clients with Alzheimer disease; with appropriate intervention, confusion can be reduced. Reality orientation can reduce confusion when these clients are confronted with unfamiliar surroundings. Although confusion may be a common finding in Alzheimer disease, it is not expected with normal aging. Although brain changes do occur with Alzheimer disease, interventions can be instituted to decrease confusion. STUDY TIP: Begin studying by setting goals. Make sure they are realistic. A goal ofscoring 100% on all exams is not realistic, but scoring an 85% may be a better goal.

An 82-year-old retired schoolteacher is admitted to a nursing home. During the physical assessment, the nurse would identify which ocular problem common to persons at this client's developmental level? Tropia Myopia Hyperopia Presbyopia

Presbyopia Presbyopia is the decreased accommodative ability of the lens that occurs with aging. Tropia (eye turn) generally occurs at birth. Myopia (nearsightedness) can occur during any developmental level or be congenital. Hyperopia (farsightedness) can occur during any developmental level or be congenital.

The nurse recognizes which mental process is associated with deterioration that accompanies aging? Judgment Intelligence Creative thinking Short—term memory

Short—term memory During the aging process there is a progressive atrophy of the convolutions of the brain with a decrease in its blood supply, which may produce a tendency tO become forgetful, a reduction in short—term memory, and susceptibility to personality changes. There should belittle or no change in judgment. There is little or nO intellectual deterioration; intelligence scores show no decline. Creativity is not affected by aging; many people remain creative until very late in life.

Which interventions would the nurse implement when providing health education to an elderly client? Select all that apply. One, some, or all responses may be correct. Assess the client for pain before teaching. Take notes while talking to the client. Ensure that the client is not preoccupied or anxious. Explain one concept at a time based on the client's interest. Teach a family caregiver if the client does not respond quickly.

Assess the client for pain before teaching. Ensure that the client is not preoccupied or anxious. Explain one concept at a time based on the client's interest. The nurse must assess the client for pain and ensure that the client is physically well enough to learn. The nurse must begin teaching after determining that the client is not preoccupied or too anxious to comprehend the material. The nurse should explain one concept at a time while gauging the client's interest. The nurse would sit facing the client so that the client is able to view the nurse's expressions and lip movement. The nurse would refrain from taking down notes during the teaching because this action conveys a lack of interest. Because Older adults process information more slowly than young people, the nurse would allow the client to take some time to respond to the nurse's queries.

An 82-year-old client is scheduled for physical therapy after a fracture of the arm. Considering the older population, the nurse recalls that mild exercise is likely to have which effect on the client's respirations? Increase to 24 breaths per minute Become progressively more difficult Decrease in rate as their depth increases Become irregular but remain within normal rates

Increase to 24 breaths per minute In an older client, respirations are expected to increase to 24 breaths per minute and are a response to the need for oxygen at the cellular level because of the increased metabolic rate associated with exercise. Respirations that become progressively more difficult should not occur with mild exercise unless the client has cardiac disease. The rate of respirations will increase with mild exercise; because of inflexibility of the chest in the older adult, the depth will increase only minimally. Irregular respirations are not an expected response to exercise; this indicates a problem. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

Which approach would the nurse use for a client with Alzheimer disease who expresses fear and anxiety upon admission to a long-term care facility? Exploring the reasons for the concerns Reassuring the client with the presence of 1 or 2 staff members Providing the client with a written schedule Of planned interactions Explaining to the client why the admission to the facility is necessary

Reassuring the client with the presence of 1 or 2 staff members The nurse would reassure the client with the presence Of 1 or 2 staff members. The client needs reassurance, because forgetfulness blocks previous explanations; the presence Of 1 or 2 staff members serves as a support system. This client will be unable to explain the reasons for the concerns because Ofthe short—term memory loss from Alzheimer disease. The client will not be able tO decode a written schedule; the client needs reassurance. This client will not remember the explanation for admission tO the facility. Test-Taking Tip: Calm yourself by closing your eyes, putting down your pencil, and relaxing. Deep—breathe for a few minutes (or as needed, ifyou feel especially tense) to relax your body and tO relieve tension.

Which action would the nurse take for an older client with Alzheimer disease who has intermittent episodes of urinary incontinence? Point out the behavior to the client. Obtain incontinence pads for the client. Take the client to the bathroom at regular intervals. Encourage the client to call for help when there is an urge to urinate.

Take the client to the bathroom at regular intervals. Taking this client to the bathroom at regular intervals will facilitate elimination needs. Clients with Alzheimer disease have difficulty recognizing and remembering to follow through on basic needs; routinely emptying the bladder may reduce episodes ofincontinence. Pointing out the behavior to the client may precipitate feelings of guilt; forgetfulness is not deliberate but instead is the result of the degenerative process of Alzheimer disease. Incontinence pads can lead to skin breakdown and do not promote elimination needs. The client may not be aware of the need to void or have the ability to control this bodily function. Test-Taking Tip: Multiple-choice questions can be challenging, because students think that they will recognize the right answer when they see it or that the right answer will somehow stand out from the other choices. This is a dangerous misconception. The more carefully the question is constructed, the more each of the choices will seem like the correct response.

The registered nurse is teaching a coworker about the care of clients who have neurological changes associated with aging. Which statement by the coworker indicates a need for further instruction? 'Clients with decreased sensory perception Of touch should be carefully monitored for infection.' 'Clients with recent memory loss should be taught by repetition and use memory aids that provide recurrent alerts.' 'Clients with slower processing time should be provided with sufficient time to respond to questions or directions.' 'Clients with decreased coordination should be instructed to hold handrails when ambulating.'

'Clients with decreased sensory perception Of touch should be carefully monitored for infection.' Decreased sensory perception is a neurological change associated with aging. Clients with this change should be instructed to reduce the risks associated with falling. The nurse would intervene to correct this misconception. All the other statements are correct and require no follow—up. Clients with an increased risk for infections due to structural deterioration of microglia should be monitored for infections. Clients with recent memory loss should be taught by repetition and by using memory aids that provide recurrent alerts to facilitate retention ofinformation. This would help the client learn new information and recall it when needed. Clients with slower processing time should be provided with sufficient time to respond to questions or directions. Allowing adequate time for processing helps differentiate normal findings from neurological deterioration. Clients with decreased coordination should be instructed to hold handrails when ambulating to provide support and prevent falls.

The nursing student counsels an older 70-year-old female client about changes caused by aging. Which statement made by the client indicates effective learning? 'I should reduce my calcium intake.' 'I should limit my Kegel exercises.' 'I should have regular breast examinations.' 'I should avoid eating protein.'

'I should have regular breast examinations.' A 70-year—old female client may need regular clinical breast examinations to detect masses or other changes that may indicate the presence of cancer. The client should take an adequate amount of calcium to prevent osteoporosis. Performing Kegel exercises strengthens pelvic muscles and reduces urinary incontinence. Protein is needed to maintain muscle mass and strength. Test-Taking Tip: An Older adult client has to be adequately educated regarding self—awareness regularly tO identify the precancerous and cancerous cells and necessary tests to be undergone.

The registered nurse (RN) is teaching the nursing student about providing care to an older adult with dementia. Which statement made by the nursing student indicates a need for further education? 'I should serve food that is easy to eat.' 'I should assist the client with eating.' 'I should monitor weight and food intake once a month.' 'I should offer food supplements that are tasty and easy to swallow.'

'I should monitor weight and food intake once a month.' The nurse would monitor an older client's weight and food intake at least once a day because of the client's dementia. The nurse would serve food that is easy to eat and provide assistance with eating. The nurse would also Offer food supplements that are tasty and easy to swallow.

The registered nurse (RN) is teaching the nursing student about interventions for cognitively impaired older adults. Which statement made by the nursing student indicates a need for further education? 'I should encourage fluid intake.' 'I should provide conditional positive support.' 'I should promote social interaction based on abilities.' 'I should provide ongoing assistance to family caregivers.'

'I should provide conditional positive support.' When caring for cognitively impaired Older adult, the nurse would provide unconditional positive support and respect. The nurse would encourage the client to drink fluids. The nurse would promote social interactions based on abilities. The nurse would provide ongoing assistance to family caregivers, educate them in nursing care techniques, and inform them about community resources.

Which response would the nurse make to a depressed older client who has not been eating well since admission to the hospital and repeatedly states, 'No one cares'? 'We all care about you; now please eat.' 'We all care about you; you have to eat to stay alive.' 'l care about you. What are some foods you especially like?' 'l care about you. Will you please eat some of this food for me?'

'l care about you. What are some foods you especially like?' The nurse would make the statement, 'I care about you. What are some foods you especially like?' This is a direct response to the client's concern and permits some exploration of food choices. The nurse would not talk for others by saying, 'we all care about you' and would not patronize the client by saying, 'now please eat.' 'We all care about you; you have to eat to stay alive,' belittles the client's feelings. 'I care about you. Will you please eat some of this food for me?' encourages dependence on the nurse; the message is 'DO it for me, not because it is important for you.' Test-Taking Tip: Never leave a question unanswered. Even if answering is no more than an educated guess on your part, go ahead and mark an answer. You might be right, but if you leave it blank, you will certainly be wrong and lose precious points.

The registered nurse (RN) is teaching a nursing student about how to educate clients based on their developmental capacity. Which statements made by the nursing student are applicable for older adults? Select all that apply. One, some, or all responses may be correct. 'I would encourage independent learning.' '| would keep the teaching sessions short.' 'I would involve the client in any discussion or activity.' 'I would encourage learning through pictures and short stories.' 'I would teach the client psychomotor skills to maintain his or her health.'

'| would keep the teaching sessions short.' 'I would involve the client in any discussion or activity.' The nurse would keep teaching sessions short to help the older adult learn easily. Older clients should also be involved in discussions or activities to further engage them. Younger or middle—aged adults are more receptive to being encouraged to learn independently. Teaching psychomotor skills and encouraging learning via pictures and short stories are more applicable to school-aged children. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem ofthe item that are the same as or similar in nature to those in one or two ofthe options.

Which intervention would the nurse implement to ensure an older adult client's safety when demonstrating mild confusion after surgical repair of an abdominal hernia? Use a night—light in the client's room. Activate the position-sensitive bed alarm. Raise the four side rails on the client's bed. Secure a prescription for a soft vest restraint.

Activate the position-sensitive bed alarm. A positional bed alarm is a noninvasive device to protect a client who attempts to get out of bed unassisted. Staff members must immediately respond tO the alarm to ensure protection Of clients from potential injury. Although a night-light may help orient a client at night, it does not help during the daylight hours. Confused clients Often become more agitated when raising all the side rails, thus posing an increased, not a decreased, risk Of injury. Confused clients may try to climb over the side rails or try to exit from the end of the bed, placing them at risk for entrapment or a fall. A vest restraint is a measure Of last resort when all other less restrictive measures have proven to be ineffective. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options . Example: Ifthe item relates to and identifies stroke rehabilitation as itsfocus and only one of the options contains the word 'stroke' in relation to rehabilitation, you are safe in identifying this choice as the correct response.

Which intrinsic factor is associated with the fall of an older adult? Wet floors Poor lighting Lack of exercise Inappropriate footwear

Lack of exercise Intrinsic risk factors associated with the fall of an older adult may include a lack of exercise or deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

The home health care nurse visits an older adult couple living independently. The wife cares for the husband, who has dementia. Which interventions would the nurse implement for them? Select all that apply. One, some, or all responses may be correct. Assess the wife for caregiver burden. Arrange hospice care for the husband. Make health care decisions for the couple. Assess the husband for signs of physical abuse. Identify social support within the community.

Assess the wife for caregiver burden. Assess the husband for signs of physical abuse. Identify social support within the community. An Older caregiver should be assessed for caregiver burden. Anxiety, depression, relationship tension, or health changes are indicators of caregiver burden. The nurse would assess the client for any unexplained bruises or skin trauma; these are signs of physical abuse. These findings must be reported to the state protective agencies. The nurse would also help the couple identify social support within the community. Terminally iII clients who need pain management require hospice care. The nurse need not arrange hospice care for a client with dementia. The nurse would not make health care decisions for the client. The client and spouse should be consulted in all health care decisions. Test-Taking Tip: Read the question carefully before looking at the answers: (1) determine what the question is really asking and look for key words; (2) read each answer thoroughly and see if it completely covers the material asked by the question; and (3) narrow the choices by immediately eliminating answers you know are incorrect.

While assessing the skin of an older adult, the nurse finds redundant flesh around the eyes. Which changes in the skin are responsible for this condition? Select all that apply. One, some, or all responses may be correct. Decrease in muscle laxity Increase in capillary fragility Decrease Of subcutaneous fat Decrease Of extracellular water Increase in focal melanocytes in the basal layer

Decrease in muscle laxity Decrease Of subcutaneous fat Redundant flesh around the eyes is due to a decrease in muscle laxity and a decrease Of subcutaneous fat. Bruising is due to an increase in capillary fragility. Dry, flaking skin with possible signs of excoriation is due to a decrease of extracellular water. Solar lentigines on the face and backs of the hands are due to an increase in focal melanocytes in the basal layer.

Which important points would the nurse keep in mind when caring for an older adult to promote health? Select all that apply. One, some, or all responses may be correct. Focus on achieving the highest level Of health and absence of disease. Encourage regular physical activity and the use Of stress—management strategies. Encourage the client to accept help for carrying out activities of daily living (ADLs). Consider the client's social environment, and strengthen social support to promote health. Assess the client for fear of falling, and provide support by making environmental changes.

Encourage regular physical activity and the use Of stress—management strategies. Consider the client's social environment, and strengthen social support to promote health. Assess the client for fear of falling, and provide support by making environmental changes. The nurse would encourage the client to include physical activity regularly and to use stress—management strategies to promote a healthy lifestyle. The nurse would consider the client's social environment and strengthen social support to promote health. Because a fear of falling is a significant risk related to older adults, the nurse would assess the client for fear and provide support by making environmental changes. The nurse would not focus on the absence of a disease, but on achieving the highest level of health in the presence of disease. The nurse would encourage older adults to perform activities of daily living on their own to promote health.

Which are extrinsic factors responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct. Impaired vision Cognitive impairment Environmental hazards Inappropriate footwear Improper use of assistive devices

Environmental hazards Inappropriate footwear Improper use of assistive devices Environmental hazards, inappropriate footwear, and improper use of assistive devices are extrinsic factors that are responsible for falls in Older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in Older adults.

Which change in the joint may result in joint pain for older adults? Dehydration of discs Loss of muscle mass Decreased elasticity in the ligaments Increased cartilage erosion

Increased cartilage erosion Joint pain in an older adult is due to increased cartilage erosion. A loss in height and shortening of the trunk is due to a loss of water from the discs. A decrease in muscle cells causes a decrease in muscle strength. An increased rigidity in the neck, shoulders, back, hips, and knees is due to a loss of elasticity in the ligaments.

The nurse is assessing an older adult during a regular checkup. Which finding(s) during the assessment is/are normal? Select all that apply. One, some, or all responses may be correct. Loss of turgor Urinary incontinence Decreased night vision Decreased mobility of ribs Increased sensitivity to odors

Loss of turgor Decreased night vision Decreased mobility of ribs In Older adults, the skin loses its turgor or elasticity, and there is fat loss in the extremities. Visual acuity declines with age; therefore decreased night vision is a normal finding in Older adults. Decreased mobility of the ribs is found in older adults due to calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In Older adults, diminished sensitivity to odor, not increased sensitivity, is often found.

Which statement is true about older adults and type 2 diabetes? Older adults seldom develop ketoacidosis. Older adults secrete no endogenous insulin. Older adults have a lower risk of complications. Older adults develop a sudden onset of symptoms.

Older adults seldom develop ketoacidosis. Lipolysis is not a common response to meeting the metabolic needs of those with type 2 diabetes; therefore, ketones are not present in large enough amounts to cause ketoacidosis. Adults with type 2 diabetes do secrete endogenous insulin, but secretion is slow and in smaller than adequate amounts. The incidence Of chronic complications depends on the level Of glucose control, not developmental level. The onset of type 2 diabetes is usually gradual, whereas in type 1 diabetes, it is sudden and dramatic. Test-Taking Tip: The night before the examination, you may wish to review some key concepts that you believe need additional time, but then relax and get a good night's sleep. Remember to set your alarm, allowing yourself plenty of time to dress comfortably (preferably in layers, depending on the weather), have a good breakfast, and arrive at the testing site at least 15 to 30 minutes early.

Which important step(s) would the community nurse take when dealing with older adults with a confusional states problem? Select all that apply. One, some, or all responses may be correct. Provide a protective environment. Monitor blood pressure and weight. Recommend applicable community resources. Demonstrate proper hygiene to the primary caretaker. Educate about polypharmacy and drug—drug and drug-food interactions.

Provide a protective environment. Recommend applicable community resources. Demonstrate proper hygiene to the primary caretaker. When dealing with Older adults with a confusional states problem, the nurse would ideally provide a protective environment for the client. In addition, the nurse would recommend applicable community resources like adult day care, home care aides, and homemaker services. When dealing with community—dwelling older adults with a confusional states problem, the nurse would assist with adequate personal hygiene, nutrition, and hydration. When dealing with the community—dwelling Older adults with a hypertension problem, the nurse would monitor blood pressure and weight. When dealing with the community—dwelling older adults with a medication use and abuse problem, the nurse would educate about polypharmacy and drug—drug and drug-food interactions. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

When teaching about aging, the nurse explains that older adults usually have which characteristic? Inflexible attitudes Periods of confusion Slower reaction times Some senile dementia

Slower reaction times A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most Older adults do not have organic mental disease. Test-Taking Tip: Answer every question. A question without an answer is always a wrong answer, so go ahead and guess.

Which priority parameter would the nurse assess when caring for an older adult client with a neurocognitive disorder who demonstrates disorientation and numerous unmanageable behaviors? Orientation to time, place, and person Ability to perform daily activities without assistance from others Stressors that appear to precipitate the client's disruptive behavior Cognitive impairments until complete adjustments are accomplished

Stressors that appear to precipitate the client's disruptive behavior The nurse's priority assessment would be to assess for stressors that appear to precipitate the client's disruptive behavior. Additional information must be collected to determine what may be precipitating the disruptive behavior. Clients with cognitive impairment may have difficulty controlling behaviors and may need the environment to provide the structure needed to act appropriately. The client's disorientation is documented, so orientation to time, place, and person is not the priority. The client's ability to perform daily activities is important, but it is not the priority. Although cognitive impairments are important, the phrase 'until complete adjustments are accomplished' makes this a low priority. The client may never achieve complete adjustment to the facility.

Which nursing action(s) may help in the effective assessment of older clients? Select all that apply. One, some, or all responses may be correct. The nurse makes eye contact with the client. The nurse leans backward during the interaction. The nurse smiles at the client during the interaction. The nurse shrugs her shoulders in response to a client's question. The nurse asks the client tO express details as quickly as possible.

The nurse makes eye contact with the client. The nurse smiles at the client during the interaction. The nurse would make eye contact while interacting with the client. It shows that the nurse is interested in hearing client issues. The nurse shows positivity and good humor with a smile during an interaction. The nurse would lean forward while interacting with the client; this shows attention and interest. The nurse would answer questions verbally, not simply with body language. Older adults may need time to think and answer; therefore the nurse would allow pauses and time while asking client to explain anything.