AUHS Gero exam 2

9. The spouse of an elder person with a terminal illness is seen sitting in the Visitors' Lounge crying. Which question should the nurse ask to help the spouse prepare for grieving? A. "What are your thoughts about the future?" B. "can I get you anything?" C. "what can I do to help you now?" D. "Is there a reason why you aren't sitting in the room?"

A. "What are your thoughts about the future?" Rationale: At one point in time, anticipatory grief was believed to be avoided since it prevented the person and significant others from experiencing the dying process while it is occurring. Now, anticipatory grief is viewed as preparatory grief which is an opportunity to prepare psychologically for death and may help ease the grieving process. A question to ask the spouse at this time would be "What are your thoughts about the future?" This question helps the nurse determine the spouse's needs after the person dies. The other questions do not address the grieving process.

3. An older adult is concerned about the number of leg wound infections that have been occurring over the last year. What should the nurse explain about this development of these infections? A. Aging causes skin thickness to decrease, which increases the risk for skin breaks and infections B. Aging adversely affects immune function, increasing the risk for all types of infections C. The reason for skin infections occurring more frequently with aging is unknown D. Bacteria on the skin is not being adequately washed when bathing

A. Aging causes skin thickness to decrease, which increases the risk for skin breakdowns and infections Rationale: Many normal age-related changes increase risk for cellulitis. Decreased skin thickness makes the older adult more susceptible to breaks in the skin that are more likely to become infected since wound healing is often delayed. The reason for skin infections with aging is known however bacteria on the skin is not identified as a risk factor. Although aging does affect immune function, this is not identified as a risk factor for the development of skin infections with aging.

3. The nurse has accepted a position to provide care to elder person on an oncology care area. Which action should the nurse take when preparing to provide care to these patients? A. Confront personal fears about death and dying B. Review different surgical procedures used to treat cancer C. Complete continuing education on chemotherapy medications D. Study the role of radiation therapy on the treatment of cancer

A. Confront personal fears about death and dying Rationale: Nurses must be confident in their clinical skills when caring for the seriously ill and dying, and aware of the ethical, spiritual, and legal issues they may confront while providing end-of-life care. Many feel that the first step in the process is confronting personal fears about death and dying. By addressing fears, nurses are better able to help older persons and their families when they are confronted by impending death. The nurse may then be more objective in recognizing and respecting the older person's and family's values and choices that guide their decisions at the end of life. Learning more about surgery, radiation, and chemotherapy is important however recognizing personal feelings about death and dying should be completed first.

8. An older person has severe post-herpetic neuralgia. Which adjuvant medication should the nurse expect to be prescribed? A. Desipramine B. Baclofen C. Diazepam D. Gabapentin

A. Desipramine Rationale: Desipramine is a tricycle antidepressant that is helpful in the treatment of post-herpetic neuralgia. Baclofen is a muscle relaxant which may be used when muscle spasms are causing pain. Diazepam is n antianxiety medication and is not indicated in the treatment of post-herpetic neuralgia. Gabapentin is indicated for neuropathic pain conditions however post-herpetic neuralgia is not identified as benefiting from this medication.

1. The nurse is concerned that a terminally ill elder person is uncomfortable. Which action should the nurse take to help this person? A. Discuss pain control with the health care provider B. Suggest the family participate in the person's care C. Recommend transferring to a different facility D. Review the person's advance directive

A. Discuss pain control with the health care provider Rationale: There are deficiencies in the way end-of-life care is currently provided in the U.S. healthcare system. Barriers include lack of knowledge regarding pain and symptom control. The nurse should discuss this person's comfort and need for pain control with the health care provider. Reviewing the advance directive, transferring to another facility, and having the family participate in care will not necessarily improve this person's comfort level.

5. The nurse is concerned that an elder person with a terminal illness is not receiving adequate pain control. Which observation caused the nurse to make this clinical determination? A. Facial grimacing B. Asking for help moving in bed C. Lack of appetite D. Drop in blood pressure

A. Facial grimacing Rationale: The nurse should observe the person for behavioral symptoms of pain which include facial grimacing. A person nearing end-of-life may not have an appetite however this is not necessarily related to experiencing pain. A drop in blood pressure may be a sign of pending death. Asking for help to move in bed does not necessarily mean that the person is in pain. The person could be too weak to move without help.

2. An adult son is concerned because her elder parent spends nearly 10 hours each night in bed yet complains of not getting enough sleep. What could explain this person's sleep behavior? A. Frequent awakenings every night B. Electrolyte imbalance C. Late night eating D. Undiagnosed health problem

A. Frequent awakenings at night Rationale: There is an associated increase in awakenings during sleep and an increase in the total time spent in bed trying to sleep as sleep becomes less efficient. There is not enough evidence to support that an older person has difficulty sleeping because of late night eating, an electrolyte imbalance, or an undiagnosed health problem.

4. The nurse asks the health care provider to prescribe a sleep study for an older person. What behavior caused the nurse to make this request? A. Heavy snoring upon inspiration B. Elevated morning blood glucose level C. Low blood pressure during the night D. Reduction of ankle edema overnight

A. Heavy snoring upon inspiration Rationale: Snoring can signal a potentially serious condition known as sleep apnea, or temporary interruption of breathing during sleep. Sleep apnea can worsen high blood pressure. Snoring and potential sleep apnea does not affect body fluid balance or blood glucose level.

2. The nurse is concerned that an older person reports a severe amount of pain when receiving an intramuscular injection. What should the nurse consider as causing this older person's pain response? A. History of untreated pain B. Desensitization of nociceptors C. Hypochondriac behavior D. An attention-seeking response

A. History of untreated pain Rationale: With untreated pain, nociceptors become sensitive and more responsive to stimuli with a lowered pain threshold. This can lead to hyperalgesia or an increased sensitivity to pain or enhanced intensity of pain sensation. The older person may be labeled as a "hypochondriac" and further complaints of pain may be ignored. Hyperalgesia is caused by hypersensitization of nociceptors. The person's behavior is not an attention-seeking response.

3. An older person reports pain as being 7 on the Numeric Pain Rating Scale and "moderate" on the Verbal Descriptor Scale. Which action should the nurse take first? A. Identify the rating scale to use consistently with this older person B. Assess the person for pain using another rating scale C. Medicate the person according to the highest reported level of pain D. Medicate the person according to the lowest reported level of pain

A. Identify the rating scale to use consistently with this older person. Rationale: The nurse should identify an assessment tool that can be used easily by the older adult person and consistently use the same scale with each assessment; pain tools are not interchangeable and therefore do not represent comparable findings. Another rating scale should not be used. The person should not be medicated according to the lowest or highest reported level of pain. A consistent assessment must be completed first.

6. The nurse notes that an older person is prescribed tramadol for severe pain. What should the nurse instruct the person when providing this medication? A. Increase the intake of roughage and fluid to prevent constipation B. Take only as prescribed since this is a controlled substance C. Limit the amount taken to be under 3000 mg per day D. Have your blood pressure and heart rate checked regularly

A. Increase the intake of roughage and fluid to prevent constipation Rationale: Because Tramadol is centrally acting, it carries some properties of opioid analgesics, and may cause constipation. The person should be instructed to increase roughage and fluids to prevent the development of constipation while taking this medication. Acetaminophen should be limited to under 3000 mg per day. Cyclooxygenase-2 (COX-2) inhibitors are associated with increased risk of adverse cardiovascular events and many have been taken off of the market. Tramadol is not a controlled substance.

10. During a home visit the nurse learns that an older person with persistent pain has an appointment with the health care provider the following week. What should the nurse suggest so that this person is prepared to discuss the pain with the provider during the appointment? A. Keep a pain diary for a few days B. Take NSAIDS on an empty stomach C. Stop taking all pain medicine D. Increase the dosage of acetaminophen

A. Keep a pain diary for a few days Rationale: Helping the older person organize his or her thoughts about pain will help the healthcare provider appreciate the person's unique situation. A pain diary is a good place to start. The person should not stop taking all pain medication. NSAIDs should not be taken on an empty stomach. Increasing the dosage of acetaminophen could increase the person's risk of developing toxicity. It is beyond the nurse's scope of practice to prescribe medication doses or alter doses prescribed by the health care provider.

10. An elder person with a terminal illness dies in the emergency department. The patient's spouse begins to vomit upon hearing the news of the patient's death. Which response should the nurse realize that the spouse is experiencing? A. Numb shock B. Emotional turmoil C. Reorganization D. Depression

A. Numb shock Rationale: The phase of numb shock is characterized by disbelief, emotional dullness, and physical characteristics such as nausea. Emotional turmoil and depression occur during the same stage and include alarm or panic-type reactions such as crying, anger, guilt, or anorexia. Reorganization takes place later and includes the use of coping strategies.

4. While completing an assessment, the nurse notes that an older adult has a large area of ecchymosis around a 3-inch scratch on the anterior surface of the lower left leg, reported to be caused by walking into an open dresser drawer a few days ago. What should the nurse consider as the reason for the wound's appearance? A. Subcutaneous tissue atrophy with aging B. Excessive dryness of the skin C. Poor nutritional status D. Use of over-the-counter antihistamines

A. Subcutaneous tissue atrophy with aging Rationale: A skin tear is a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. Independent older adults frequently sustain skin tears on the lower legs by bumping into open dresser drawers in the home environment. Skin tears may be accompanied by dark purple ecchymosis (senile purpura) and edema because of subcutaneous tissue atrophy. The wound's appearance is not because of the person's poor nutritional status, excessive skin dryness, or the use of antihistamines.

3. During an assessment an older person explains the onset of a health problem in relationship to the date in which the spouse passed away. What should the nurse conclude about this person's response? A. The person is using a calendar date as a memory cue B. The person is grieving the death of a spouse. C. The spouse had the same health problem. D. The health problem was caused by the spouse's death

A. The person is using a calendar date as a memory cue. Rationale: One way for an older person to cope with normal age-related cognitive changes is to made associations or use memory aids. The person is recalling the onset of a health problem in relationship to the date the spouse died. This is using a calendar date as memory cue. This technique does not indicate that the spouse had the same health problem, the person is grieving the death of the spouse, or that the health problem was caused by the spouse's death.

11) A visitor to a long-term care institution witnesses an attendant psychologically abusing a client with dementia. What actions are suggestive of this type of abuse? 1. Scolding them after an incontinent incident 2. Insisting the client help them with their tuition 3. Not helping a client eat when they need assistance 4. The attendant stating "I cannot work here anymore because of you."

Answer: 1 Explanation: 1. A caregiver who scolds and ridicules a patient who is unable to care for himself or herself is committing psychological abuse by inflicting anguish and psychological pain. 2. Exploitation involves taking advantage of an older person for monetary or personal benefit. 3. Neglect occurs when there is failure to meet the older person's needs necessary for physical and emotional well-being. 4. Caregiver burnout is not a type of abuse but could cause a caregiver to abuse an older patient.

5) The nurse is assessing an older client who wakes up during the night. Which finding does the nurse identify as the greatest risk factor for disturbed sleep? 1. Client has osteoarthritis of both hips. 2. Client drinks two cups of coffee per day. 3. Client takes antidepressant medication in the morning. 4. Client leaves the television on all day and night.

Answer: 1 Explanation: 1. A common source of pain in older adults is the chronic pain resulting from osteoarthritis. It can result in chronic sleep disruption for older people. 2. Limiting caffeine intake to one to two cups of coffee per day should not interrupt sleep. If the client prefers coffee late in the day or more than two cups total during the day, the nurse assesses for caffeine tolerance and makes suggestions accordingly. 3. Some antidepressants have stimulating effects and should be taken in the morning. The nurse assesses the client for evidence of sleepiness from the antidepressant and makes suggestions accordingly. 4. Bright lights and noises can disrupt sleep. Some clients find comfort in and are used to continual TV, so this is something the nurse assesses further.

15) The hospice nurse has provided a presentation to student nurses on barriers to effective end-of-life care. Which statement made by a student indicates that additional teaching is needed? 1. "Most patients have good pain management and are comfortable when they die." 2. "Referrals to hospice or palliative care often aren't made when appropriate." 3. "When a patient is dying, there can be disagreements about the goal of their care." 4. "Healthcare professionals often have difficulty in being honest with patients when a prognosis is poor."

Answer: 1 Explanation: 1. Although not all deaths involve pain and suffering, there are deficiencies in the way end-of-life care is currently provided in the U.S. healthcare system. Barriers include lack of knowledge regarding pain and symptom control. 2. Referrals to hospice or palliative care are often not made in a timely manner or when appropriate for end-of-life care. 3. There are often disagreements about the goal when providing end-of-life care. 4. Healthcare professionals do have difficulty being honest with patients when discussing a poor prognosis.

1) An older patient has a subnormal body temperature and an infection. How does the nurse best describe this phenomenon? 1. The temperature regulating mechanism deteriorates with aging. 2. The patient's infection is improving with medication treatment. 3. The diagnosis of an infection is inaccurate and will be checked. 4. The temperature was obtained incorrectly and is inaccurate.

Answer: 1 Explanation: 1. An elevated temperature is a common sign of infection but may not be present in the frail older adult. 2. There is no information to support that the patient is receiving antipyretics that would alter the patient's body temperature. 3. The nurse should not state that the patient received an inaccurate diagnosis. This would have the family question the quality of care the patient is receiving. 4. There is no evidence to suggest that the patient's temperature was measured incorrectly.

25) After completing an assessment, the nurse reviews the older client's medications. Which finding is most concerning? 1. Client takes diphenhydramine (Benadryl) and zolpidem (Ambien) at night. 2. Client has not filled the new prescription for suvorexant (Belsomra). 3. Client reports taking zolpidem (Ambien) nightly for the past three months. 4. Client takes diazepam (Valium) during the day for anxiety as needed.

Answer: 1 Explanation: 1. Antihistamines such as diphenhydramine (Benadryl) should not be used for sleep because of their anticholinergic side effects and the potential to decrease respiratory drive. Taking this with a strong sleep aid such as zolpidem (Ambien) is not recommended or considered safe. 2. This is concerning if the client was supposed to take this medication and has not filled it due to cost, but needs the medication for sleep. 3. Sleep medications should be taken no more than four times per week and for no more than four weeks; however, this is not the most concerning finding. 4. There is a strong risk of dependence with diazepam, it is not recommended for frequent use in the older adult population, a sedative should not be taken during the day as it can disrupt night sleep, and there is a risk that this medication will be taken too close together with other sleep medications. This needs to be addressed, but is not the most concerning finding.

24) An older patient is prescribed a monoamine oxidase inhibitor (MAOI) medication. Which meal choice requires the nurse to intervene immediately? 1. Smoked salmon with salad and bleu cheese dressing 2. Grilled chicken salad on whole wheat with fresh fruit 3. Turkey sandwich with American cheese and coleslaw 4. Chicken salad on a croissant, carrot sticks, and fresh apple

Answer: 1 Explanation: 1. Because these drugs inhibit the metabolism of norepinephrine, hypertensive crisis can occur if they are administered with other drugs or food that raise blood pressure such as anticholinergics, stimulants, and foods containing tyramine including smoked meats and fish, red wine, aged cheese, beer, bologna, pepperoni, liver, raisins, and bananas. 2. None of these food items contain tyramine, which should be avoided in the patient receiving a MAOI. 3. None of these food items contain tyramine, which should be avoided in the patient receiving a MAOI. 4. None of these food items contain tyramine, which should be avoided in the patient receiving a MAOI.

1) During an interview, the nurse notes that an older patient is having mild difficulty with some words and forgets the names of people. The patient is alert, oriented to time, person, and place, and makes appropriate responses. What does the nurse determine this patient's cognitive changes to mean? 1. Normal signs of aging 2. Early symptoms of dementia 3. Indicators of depression in the elderly 4. Memory impairment that may be related to cerebral ischemia

Answer: 1 Explanation: 1. Cognitive changes vary widely in the elderly; however, older people will not suffer significant memory impairment. Many may experience mild problems with word finding and remembering names. The changes observed in this patient are normal signs of aging. 2. A problem with finding words and forgetting names is not a symptom of dementia. 3. A problem with finding words and forgetting names is not a symptom of depression. 4. A problem with finding words and forgetting names is not related to cerebral ischemia.

19) A patient with terminal cancer is experiencing the denial phase of grieving. Which statement by the patient best reflects this stage? 1. "I look at myself in the mirror and I look healthy. How can I be dying?" 2. "If I start exercising every day and taking my vitamins, I know that God will cure me." 3. "I can't stop crying. I'm sad for myself and my children." 4. "I've lived a good life and tried to be a good person."

Answer: 1 Explanation: 1. Denial is the first stage of Kübler-Ross's stages of dying. This is where the patient does not accept the diagnosis of death. 2. Bargaining is the third stage of Kübler-Ross's stages of dying. In bargaining, the patient will typically try to make deals so that he or she may live longer. 3. Depression is the fourth stage of Kübler-Ross's stages of dying. Depression involves feeling hopeless about the future. 4. Acceptance is the stage of dying in which the patient becomes at peace with the terminal illness.

14) How should the nurse explain rapid eye movement (REM) sleep to an older client? 1. Is when dreaming occurs 2. Is necessary for physical restoration 3. Involves sudden sustained muscle contractions in the extremities 4. Is accompanied by slowing of the heart rate and a fall in blood pressure

Answer: 1 Explanation: 1. Dreaming occurs during REM sleep. 2. Hormones that aid in physiological restoration are released during NREM (nonrapid eye movement) sleep. 3. In REM sleep, the limbs are temporarily paralyzed. 4. Heart rate and blood pressure both increase during REM sleep.

14) A terminally ill older client with ongoing pain is prescribed an increased dose of morphine. What is the best way for the nurse to manage this new dose? 1. Ensure the client is medicated on schedule and when needed. 2. Continue the previous dose until the client exhibits increased pain. 3. Slowly increase the current dose until the new dose is achieved. 4. Hold the next dose if the client's respiratory rate decreases.

Answer: 1 Explanation: 1. Management of pain in terminal conditions may call for higher doses of opioids, and pain should be treated aggressively to maximize comfort. 2. The previous dose is no longer an active prescription. The nurse administers medication as prescribed. The nurse would not wait until the client's pain increases. 3. An end-of-life client does not require slow narcotic dose titration. The goal is to achieve comfort quickly and efficiently. 4. Management of pain in terminal conditions is the priority, even if an unintended effect of respiratory depression occurs.

19) The nurse observes myoclonic movements in an older client receiving IV morphine sulfate for pain. What should the nurse do with this finding? 1. Contact the prescribing health care provider. 2. Continue to monitor the client for side effects. 3. Obtain a prescription for a decreased dose. 4. Request to change from IV dosing to oral dosing.

Answer: 1 Explanation: 1. Myoclonic jerking movements may be associated with high-dose opioid therapy especially morphine. An alternate opioid should be used if this occurs, and the physician needs to be contacted to change the medication order. 2. The nurse needs to do more than observe the client for more movements. This medication needs to be discontinued. 3. The morphine has built up a toxicity in the client and has to be discontinued, not reduced. 4. The morphine has built up a toxicity and this does not change in response to different forms of administration. Its use has to be discontinued.

8) An older client recovering from surgery is prescribed IV morphine sulfate 2 to 6 mg every four hours prn for pain. What approach will the nurse take to manage this client's pain? 1. Begin by administering 2 mg IV every four hours as needed. 2. Administer 4 mg of morphine every time the client requests pain relief. 3. If the 2 mg dose is not effective within 15 minutes, administer another 2 mg. 4. Offer a 6 mg dose of morphine for reports of moderate to severe pain.

Answer: 1 Explanation: 1. Older clients usually have more sensitivity to opioid analgesics, and most often these clients are started on smaller doses to avoid toxicity. The dose is then titrated upward until effective pain relief is achieved without adverse effects. 2. The nurse does not know how effective the lowest dose will be. Narcotics like morphine are started low and titrated to achieve comfort. If the 2 mg dose is not effective, the nurse offers 4 mg for the next dose. 3. A PRN dose can only be administered as prescribed. If the nurse thinks it is urgent to give the client additional pain medication before the next dose is prescribed, then the nurse places a call to the health care provider to request an additional, one time dose. 4. An older adult client may achieve adequate relief from severe pain with a 2 mg dose of morphine. The nurse must start with the lowest dose and assess pain management needs on an ongoing basis.

10) An older patient admits to feeling worthless and depressed since the death of their spouse. Which health risk is most concerning to the nurse? 1. Suicide 2. Situational depression 3. Dementia 4. Self-harm

Answer: 1 Explanation: 1. Older persons over the age of 65 have the highest suicide rates of all age groups. A major risk factor for suicide is depression. An inappropriate feeling of worthlessness is a symptom of depression. 2. Situational depression is of concern, but it is not the most concerning risk for this patient. 3. The patient is not demonstrating symptoms of dementia. 4. The patient is showing signs of depression, which may lead to the less severe risk of self-harm.

23) The nurse is planning care for an older patient with pneumonia and a stage II pressure ulcer. Which nursing diagnosis would have the greatest priority for this patient's care? 1. Acute Pain related to destruction of tissue 2. Knowledge Deficit related to care of skin disorder 3. Risk for Infection related to impaired skin integrity 4. Potential for Infection related to impaired skin integrity

Answer: 1 Explanation: 1. Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned. 2. All of the diagnoses are appropriate and have importance. Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned. 3. All of the diagnoses are appropriate and have importance. Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned. 4. All of the diagnoses are appropriate and have importance. Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned.

5) The nurse is caring for an older client with chronic pain caused by arthritis and uterine cancer. What is the best approach for the nurse to take when managing this client's pain? 1. Administering the pain medication around the clock 2. Administering the medication when the client requests it 3. Consulting the physician to order intravenous pain medication 4. Administering the medication sparingly to avoid narcotic addiction

Answer: 1 Explanation: 1. Pain medication is best when it is administered around the clock. 2. Needless suffering occurs when waiting for the client to request something for pain. 3. Oral medications are the least invasive and may provide sufficient relief; therefore, they should be tried first. 4. Needless suffering occurs when the medication is used sparingly. Older people are less likely to become addicted to narcotics.

11) The nurse provides a seminar on the impact of the sun on the skin with a group of older community members. Which statement indicates the older clients understood the education? 1. "It is important to wear sunscreen all the time." 2. "The sun should be avoided at all times." 3. "African Americans can not experience sun damage." 4. "The melanocytes in the subcutaneous tissue protect the skin from sun damage."

Answer: 1 Explanation: 1. Sunscreen is important to wear during all daytime hours. This statement indicates that additional teaching is not necessary. 2. The sun should be avoided only between the peak hours of 10 a.m. and 4 p.m. This statement does indicate that additional teaching is necessary. 3. African Americans can experience sun damage despite the dark skin tones. This statement does indicate that additional teaching is necessary. 4. Melanocytes are located in the epidermal skin layers and not the subcutaneous tissue. This statement indicates that additional teaching is necessary.

21) The nurse is caring for an older patient with a stage II pressure ulcer. The nurse suspects this stage of wound will likely need to be cleaned with: 1. Saline 2. Dakin's solution 3. Povidone-iodine 4. Hydrogen peroxide

Answer: 1 Explanation: 1. The safest, most cost effective and most common cleansing agent for wounds is isotonic saline. 2. Topical antiseptics such as Dakin's solution should not be used on a wound because it has been found to be toxic to the wound fibroblasts and macrophages. 3. Topical antiseptics such as povidone-iodine should not be used on a wound because it has been found to be toxic to the wound fibroblasts and macrophages. 4. Topical antiseptics such as hydrogen peroxide should not be used on a wound because it has been found to be toxic to the wound fibroblasts and macrophages.

3) The nurse administers a narcotic for pain to a terminal patient with end-stage pulmonary disease and dementia. After one hour, the patient exhibits facial grimacing and restlessness. How should the nurse interpret these assessment findings? 1. The patient has continuing pain. 2. The patient is experiencing a sleep disorder. 3. The patient requires comfort measures. 4. The patient assessment is is within normal limits.

Answer: 1 Explanation: 1. When an older adult is unable to speak or self-report the level of pain, the nurse should carefully observe the patient for behavioral symptoms of pain that may include restlessness and grimacing. 2. Restlessness may indicate a sleep difficulty but grimacing occurs with pain, not insomnia. 3. Comfort measures can augment medication for pain; however, this patient is demonstrating signs of acute pain. 4. The patient is restless and grimacing, which are behavioral symptoms of pain that is not normal and needs to be addressed.

3) The home-care nurse determines that their patient is at risk for further injury due to normal aging sensation loss when they state the following: 1. "I have this large red mark on my arm and I think it occurred yesterday from cooking." 2. "I can't remember what I ate for lunch yesterday." 3. "I got a small cut on my arm from a zipper when I was getting dressed yesterday." 4. "I have some discolorations on my arm, but they have been there for months."

Answer: 1 Explanation: 1. With normal aging there is a gradual decline in both touch and pressure sensations, causing the older adult to be at risk for injury such as burns and pressure sores. 2. There is no indication that the patient has memory loss. 3. A skin tear is a dramatic separation of the dermis. 4. Bruised or discolored skin would be seen in senile purpura.

2) An older patient is recovering from abdominal surgery. Which interventions will the nurse consider when planning care for this patient? 1. The wound should be kept covered with an antimicrobial dressing. 2. The wound dressing should be changed daily and kept dry. 3. There is a need to keep the wound edges taped. 4. Skin near the wound needs to be massaged to increase blood flow.

Answer: 1 Explanation: 1. Wounds may have a high bacterial burden and may benefit from antimicrobial wound dressings containing silver, iodine, or polyhexamethylene (PHMB). 2. A dry wound surface impairs epithelial migration and leads to tissue injury and necrosis. 3. Taping the wound edges would cause damage to the skin. Taping should be limited. 4. Massaging the skin would cause further damage to the skin and delicate, new-skin growth

5) An older patient is concerned about remembering to take prescribed medications. What strategies should the nurse recommend to this patient? Select all that apply. 1. Rely on habit to take the medication. 2. Use an assistive device such as a pillbox. 3. Suggest a family member provide the medication. 4. Discuss moving to an assisted living facility for safety. 5. Discuss reducing the number of medications with the physician.

Answer: 1, 2 Explanation: 1. Reliance on habit helps to reduce the chances of forgetting vital information, such as taking prescribed medications. 2. Using assistive devices such as pillboxes helps to reduce the chances of forgetting vital information, such as taking prescribed medications. 3. Suggesting that a family member provide the medication would be an unnecessary burden to the family. 4. There is no reason for the patient to be transferred to an assisted living facility. 5. Consulting the healthcare provider to alter the drug schedule may be necessary but would be considered after other strategies have been tried.

10) The nurse is preparing to cleanse an older patient's pressure injury. Which techniques should the nurse use to perform this action? Select all that apply. 1. Pour saline over the wound using a saline-filled syringe. 2. Apply saline-soaked gauze over the wound. 3. Apply hydrogen peroxide over the wound. 4. Place gauze pads soaked with Dakin's solution on the wound. 5. Apply dry gauze pads over the wound and saturate with sterile water.

Answer: 1, 2 Explanation: 1. Wound cleansing can be done by pouring saline over the wound. 2. Wound cleansing can be done by applying saline-soaked gauzes over the wound to clean the debris from the wound bed. 3. Topical antiseptics such as povidone-iodine, acetic acid, hydrogen peroxide, and Dakin's solution should be used with extreme caution in a wound because these products have been found to be toxic to fibroblasts and macrophages. 4. Dakin's solution should not be used long-term for wounds since they have been found to cause damage to fibroblasts. 5. Applying dry gauze pads over the wound and saturating with sterile water is not a recommended approach to cleanse a wound.

14) The nurse educator is preparing an educational program about psychiatric issues in older patients. Which symptoms should be included in instruction? Select all that apply. 1. Flat affect 2. Thoughts of suicide 3. Social withdrawal and isolation 4. Delusions and hallucinations 5. Difficulty in performing ADLs

Answer: 1, 2, 3, 4 Explanation: 1. A psychiatric symptom that should be investigated and not written off as a normal change of aging includes problems with emotional expression such as a flat affect. 2. A psychiatric symptom that should be investigated and not written off as a normal change of aging includes suicide. 3. A psychiatric symptom that should be investigated and not written off as a normal change of aging includes social withdrawal and isolation. 4. A psychiatric symptom that should be investigated and not written off as a normal change of aging includes delusions and hallucinations. 5. Difficulty in performing ADLs does not necessarily indicate a psychiatric issue

2) An 85-year-old client is admitted to the emergency room with a fractured arm and bruises on the chest and back. The nurse should assess? Select all that apply 1. Hygiene 2. Marital status 3. Their caretaker 4. History of falls 5. Financial status

Answer: 1, 2, 3, 4 Explanation: 1. Caregivers failure to provide an older adult with life's necessities such as medication, food, and shelter is neglect. 2. Two-thirds of abusers are adult children or spouses. 3. Caregivers are often abusers of elderly individuals as well. 4. Because some frail older individuals are prone to underlying conditions that give rise to trauma, such as instability of gait and poor vision resulting in falls, it may be difficult for clinicians to differentiate accidental from willful injuries. 5. Unexplained monetary expenditures and the lack of money for personal items are evidence of financial exploitation, but there is no evidence in this scenario.

7) An elderly, Asian patient is admitted for suicide precautions. After performing an assessment, the nurse identifies a history of multiple, unsuccessful suicide attempts in the past three years. Which factor(s) may have contributed to the delay in treatment? Select all that apply. 1. Ageism 2. Poverty 3. Cultural bias 4. Discrimination 5. Birth order

Answer: 1, 2, 3, 4 Explanation: 1. Minority elders are at increased risk for mental health problems because of ageism and a negative stereotype toward older adults. 2. One factor that contributes to poor mental health in minority elders is poverty. 3. Minority elders are at risk for mental health problems because of cultural bias. 4. One factor that contributes to poor mental health in minority elders is discrimination. 5. Although a predictor of personality traits, birth order does not increase the risk for delayed mental health treatment.

12) What should the nurse instruct an older patient to do to cope with age-associated cognitive changes? Select all that apply. 1. Read daily 2. Write "notes to self" 3. Play computer games 4. Learn memory enhancement techniques 5. Avoid group conversations

Answer: 1, 2, 3, 4 Explanation: 1. One way to cope with age-associated cognitive changes is to read daily in order to keep the mind challenged and mentally active. 2. One way to cope with age-associated cognitive changes is to write "notes to self." 3. One way to cope with age-associated cognitive changes is to play computer games. 4. One way to cope with age-associated cognitive changes is to learn memory enhancement techniques. 5. The patient should be encouraged to socialize to maintain social relationships and support.

15) The nurse is concerned that an older patient has a problem related to regular alcohol consumption. What did the nurse assess in this patient? Select all that apply. 1. Anxiety 2. Malnutrition 3. Social isolation 4. Bruises from falling 5. Dependence on family members

Answer: 1, 2, 3, 4 Explanation: 1. Problems related to excessive or regular alcohol consumption include anxiety. 2. Problems related to excessive or regular alcohol consumption include malnutrition or failure to prepare and eat an adequate diet. 3. Problems related to excessive or regular alcohol consumption include social isolation because of avoiding people who do not drink or are judgmental. 4. Problems related to excessive or regular alcohol consumption include recurrent bruises from falls. 5. Problems related to excessive or regular alcohol consumption do not include dependence on family members.

18) The family of an older patient who is terminally ill wants to know if the patient can have a massage to help with the pain. How should the nurse respond to the family? Select all that apply. 1. "It might reduce the patient's anxiety." 2. "It might help reduce the patient's pain." 3. "It might help the patient breathe better." 4. "It could help improve the patient's mood." 5. "It could cause the patient more discomfort."

Answer: 1, 2, 3, 4 Explanation: 1. The use of complementary and alternative medicine at the end of life is associated with reduction in anxiety. 2. The use of complementary and alternative medicine at the end of life is associated with reduction in pain. 3. The use of complementary and alternative medicine at the end of life is associated with reduction in breathlessness. 4. The use of complementary and alternative medicine at the end of life is associated with an improvement in mood. 5. The use of complementary and alternative medicine at the end of life is not associated with more discomfort but rather has been known to reduce pain.

18) The daughter of an older patient is researching viable skilled facilities to have the patient admitted. Institutional abuse information on facilities is difficult to find. What are some reasons for this? Select all that apply. 1. Residents fear retribution. 2. Managers fear adverse publicity. 3. Staff members fear losing their jobs. 4. Billing department members fear not getting paid for services. 5. Family members fear needing to find a new agency for the patient.

Answer: 1, 2, 3, 5 Explanation: 1. A federal report revealed large delays in the reporting of incidents of elder mistreatment in nursing homes. One reason for this delay is that residents may fear retribution if they report the abuse. 2. A federal report revealed large delays in the reporting of incidents of elder mistreatment in nursing homes. One reason for this delay is that the managers of the facilities may fear adverse publicity about the abuse. 3. A federal report revealed large delays in the reporting of incidents of elder mistreatment in nursing homes. One reason for this delay is that staff members may fear losing their jobs if they report abuse of residents. 4. A federal report revealed large delays in the reporting of incidents of elder mistreatment in nursing homes. Billing or payment issues are not reasons why incidents of elder abuse in nursing homes are not being reported. 5. A federal report revealed large delays in the reporting of incidents of elder mistreatment in nursing homes. One reason for this delay is that families may fear needing to find a new agency for the patient.

2) The nurse is caring for an older patient who is terminally ill and in the end stages of life. Which actions by the patient would the nurse anticipate? Select all that apply. 1. Asking an estranged brother to make a hospital visit. 2. Assigning a family member as executor of their estate. 3. Discussing pain management with their physician. 4. Voicing concerns of leaving behind loved ones after death. 5. Increasing the hours for private duty aid to assist with personal care needs.

Answer: 1, 2, 3, 5 Explanation: 1. Common fears and concerns of the dying include not wanting to die alone. 2. Financial and estate planning concerns are common with those terminally ill. 3. Common fears and concerns of the dying include hoping for a peaceful death. 4. Common fears of the dying do not include leaving loved ones behind. 5. Common fears and concerns include becoming a burden to others during end of life.

17) The nurse is preparing a presentation on grief. What information should be included regarding factors that can affect duration and the course of grieving? Select all that apply. 1. Centrality of loss 2. Suicide of an adult child 3. Death of a child who lived next door 4. Cultural and ethnic influences 5. Survivor's religious or spiritual belief system

Answer: 1, 2, 3, 5 Explanation: 1. Factors that can affect the duration and course of grieving include the centrality of the loss. 2. Factors that can affect the duration and course of grieving include the relationship of those involved in a suicide. 3. Factors that can affect the duration and course of grieving include the relationship of those involved. 4. Factors that can affect the duration and course of grieving do not include cultural and ethnic influences. 5. Factors that can affect the duration and course of grieving include the survivor's religious or spiritual belief system.

5) The nurse is planning oral hygiene for an older patient with a terminal illness who has an intact swallowing reflex. Which interventions would be appropriate for this patient? Select all that apply. 1. Offer ice chips frequently. 2. Provide care with soft swabs. 3. Apply petroleum jelly to the lips. 4. Brush the teeth three times a day. 5. Avoid using alcohol-based solutions

Answer: 1, 2, 3, 5 Explanation: 1. Ice chips to relieve the feeling of dryness may be offered as long as the swallowing reflex is present. 2. Oral care with soft swabs should be provided several times a day and whenever the mouth has a foul odor or appears uncomfortable for the patient. 3. Soothing ointments or petroleum jelly may be applied to the lips to prevent painful cracking or drying. 4. The patient's oral hygiene should be provided with soft oral swabs or moistened cloths. A toothbrush would be too harsh for the patient's delicate oral tissues. 5. Alcohol-based products can be irritating and drying and their use is discouraged.

24) An older client has taken paroxetine hydrochloride (Paxil) for depression for one month. When discussing the medication, which client statements are most concerning? Select all that apply. 1. "I feel tired after taking this medication." 2. "I have not had trouble with driving my vehicle." 3. "I take all my medications with breakfast except Paxil." 4. "I take the Paxil before eating my evening meal." 5. "I cannot take this medication with my other medications."

Answer: 1, 4, 5 Explanation: 1. Paroxetine hydrochloride (Paxil) is a stimulating antidepressant and will not make the client feel tired after taking it. 2. This medication is stimulating so it should not affect the client's ability to drive. 3. This medication should be taken with breakfast so it does not interfere with sleep. It can be taken with the other medication doses. 4. This medication should be taken with breakfast. If taken with dinner, it can interfere with sleep since it is a stimulating antidepressant. 5. There is no evidence to suggest that paroxetine hydrochloride (Paxil) cannot be taken with other prescribed medications.

13) Which actions should the nurse take to ensure effective sleep for older clients in a long-term care facility? Select all that apply. 1. Use nightlights during the night. 2. Establish consistent nighttime routines. 3. Schedule routine care in the early evening hours. 4. Put clients to bed immediately after the evening meal. 5. Reduce noise and light disruption throughout the night.

Answer: 1, 2, 3, 5 Explanation: 1. Interventions to ensure effective sleep for older clients in a long-term care facility include using nightlights during the night. 2. Interventions to ensure effective sleep for older clients in a long-term care facility include establishing consistent nighttime routines. 3. Interventions to ensure effective sleep for older clients in a long-term care facility include scheduling routine care in the early evening hours. 4. Interventions to ensure effective sleep for older clients in a long-term care facility include not putting clients to bed immediately after supper. Try to provide restful evening activities like music or group readings so that gastrointestinal problems such as gastroesophageal reflux disease are avoided. 5. Interventions to ensure effective sleep for older clients in a long-term care facility include reducing noise and light disruption throughout the night.

4) An older patient is recovering from surgery to repair a fractured hip. What interventions will the nurse use to prevent the development of a pressure ulcer in this patient? Select all that apply. 1. Avoid sitting unless for meals. 2. Use pillows to protect the skin. 3. Reposition the patient every 2 hours. 4. Keep the skin dry with frequent bathing. 5. Encourage independent position changes

Answer: 1, 2, 3, 5 Explanation: 1. Interventions to prevent pressure ulcer formation include avoiding the sitting position unless it is for meals. 2. Interventions to prevent pressure ulcer formation include using pillows to protect the skin. 3. Interventions to prevent pressure ulcer formation include repositioning the patient every 2 hours. 4. Frequent bathing could dry out the skin and encourage the formation of ulcers, wounds, and skin tears. 5. Interventions to prevent pressure ulcer formation include encouraging the patient to make independent position changes. Even small shifts redistribute the body weight and improve perfusion of the tissue.

9) An older client is diagnosed with sleep apnea. Which interventions can the nurse add to the client's care plan to address this health problem? Select all that apply. 1. Discussing smoking cessation techniques 2. Encouraging the client to sleep on the side 3. Instructing to avoid alcohol before going to sleep 4. Suggesting sleeping in an upright position in a chair 5. Consulting with a dietitian to discuss meal planning for weight reduction

Answer: 1, 2, 3, 5 Explanation: 1. Treatment for sleep apnea may include teaching the client to avoid smoking since this has been known to aggravate sleep apnea. 2. Treatment for sleep apnea may include encouraging the client to sleep on the side to keep the airway open. 3. Treatment for sleep apnea may include teaching the client to avoid alcohol before going to sleep since this has been known to aggravate sleep apnea. 4. Sleeping upright in a chair is not a recommended treatment for sleep apnea. This might be appropriate for the client with severe heart failure. 5. Treatment for sleep apnea may include weight reduction for obesity since this has been known to aggravate sleep apnea.

1) An older patient with terminal cancer is considering hospice care but is concerned that Medicare will stop payments if the care is provided for longer than 6 months. What can the nurse respond to this patient? Select all that apply. 1. Medicare does not limit the hospice benefit. 2. Medicare regulations discourage a longer use of the benefit. 3. Hospice costs more than traditional hospital or long-term care. 4. Patient may enroll when the life expectancy is 6 months or less. 5. Hospice supports the family for 6 months after the patient's death.

Answer: 1, 2, 4 Explanation: 1. Medicare law does not limit the hospice benefit. 2. Medicare regulations often discourage a patient from using hospice for longer than 6 months. 3. Hospice costs less than traditional hospital or long-term care. 4. Patients may enroll when their physician judges their life expectancy to be 6 months or less. 5. Hospice supports all family members during the illness and supports the family for 1 year after the death.

8) The nurse is teaching an older client about an overnight sleep study to diagnose sleep apnea. What will the nurse include when teaching this client? Select all that apply. 1. Oxygen saturation level will be measured. 2. An electrocardiogram will be used to measure heart activity. 3. Pins will be inserted into leg muscles to measure tone and tension. 4. An electromyogram will be done to measure face and leg movements. 5. An electroencephalogram will be done to measure brain wave activity.

Answer: 1, 2, 4, 5 Explanation: 1. During an overnight sleep study, the client's oxygen saturation level will be measured. 2. During an overnight sleep study, an electrocardiogram will be used to measure heart activity. 3. During an overnight sleep study, pins are not inserted into leg muscles to measure tone and tension. 4. During an overnight sleep study, an electromyogram will be done to measure face and leg movements. 5. During an overnight sleep study, an electroencephalogram will be done to measure brain wave activity.

8) After an assessment the nurse is concerned that an older patient is at risk for pressure ulcer development because of the current nutritional status. What nutritional factors did the nurse assess in the patient? Select all that apply. 1. Diagnosis of dehydration 2. Hemoglobin level 9 mg/dL 3. Treatment for chronic renal failure 4. Serum albumin level below normal 5. Loss of 20 pounds over the last 3 months

Answer: 1, 2, 4, 5 Explanation: 1. Nutritional factors associated with pressure ulcer development include dehydration. 2. A hemoglobin level of 9 mg/dL indicates anemia, which is a nutritional factor associated with pressure ulcer development. 3. Chronic renal failure is not specifically associated with the development of pressure ulcer formation. 4. Nutritional factors associated with pressure ulcer development include a decreased serum albumin level. 5. Nutritional factors associated with pressure ulcer development include decreased body weight.

15) An older patient has been brought into the emergency department with injuries caused by suspected physical abuse. Which tools would the nurse use to assess this patient's injuries? Select all that apply. 1. Indicators of abuse screen 2. AMA assessment protocol 3. Adult protective services report 4. Brief abuse screen for the elderly 5. Hwalek-Sengstock elder abuse screening test

Answer: 1, 2, 4, 5 Explanation: 1. The indicators of abuse screen is a 29-item set of indicators for use by social service agency practitioners to identify elder mistreatment. 2. The AMA assessment protocol is a checklist used if abuse is suspected. 3. Adult protective services do not use a specific format. Intake forms are used to document calls of suspected elder mistreatment from public hotlines and state agencies. 4. The brief abuse screen for the elderly asks five standard questions that focus on abuse. 5. The Hwalek-Sengstock elder abuse screening test is one 15-item assessment screen for detecting suspected elder abuse and neglect.

11) The nurse is planning care for an older patient who is dying. Which interventions will assist the patient to die with dignity? Select all that apply. 1. Maintain cleanliness and patient's personal hygiene. 2. Provide pain management and control symptoms. 3. Make decisions for the patient and family. 4. Coordinate goals of treatment with the patient's values. 5. Communicate patient needs to the healthcare team.

Answer: 1, 2, 4, 5 Explanation: 1. The nurse who maintains the patient's personal care, grooming, hygiene, and cleanliness will help the patient die comfortably and with dignity. 2. The nurse who helps the patient die comfortably with controlled pain will promote a comfortable death. 3. Making decisions for the patient and family will not help the patient die comfortably and with dignity. The nurse must implement the decisions of the patient and family to ensure a comfortable death with dignity. 4. The nurse who helps the patient die comfortably and with dignity will clarify the goals of treatment and the patient's values. 5. The nurse who helps the patient die comfortably and with dignity will communicate the patient's needs and goals to members of the patient's healthcare team.

6) The nurse is concerned that an older client with dementia is receiving psychotropic medications for sleep. Which assessment findings best indicate the client is experiencing side effects? Select all that apply. 1. Feeling lightheaded upon standing 2. Unable to have bowel movement for four days 3. Hearing a conversation though no one is present 4. Inability to stay awake while completing a puzzle 5. Attempting to swallow one bite multiple times

Answer: 1, 2, 4, 5 Explanation: 1. Typical side effects of hypnotic drugs include dizziness. 2. Typical side effects of hypnotic drugs include constipation. 3. Typical side effects of hypnotic drugs do not include hallucinations. 4. The older person who routinely takes hypnotic drugs for sleep will have a change in the architecture of the sleep cycle and may experience daytime lethargy. 5. Typical side effects of hypnotic drugs include problems with swallowing.

20) An older client newly diagnosed with arthritis wants to know what else can be done to help with the pain. What should the nurse instruct this client? Select all that apply. 1. Maintain a healthy weight. 2. Avoid positions that increase or cause pain. 3. Reduce intake of red meat and processed grains. 4. Alcohol should not be used for any reason. 5. Perform daily gentle exercise like walking.

Answer: 1, 2, 5 Explanation: 1. Weight control reduces pain, especially in older clients. 2. Recognizing what avoidable positions cause pain will help reduce the amount of pain from the arthritis. 3. There is no evidence to suggest that red meat and processed grains contribute to the pain of arthritis. 4. There is no evidence to suggest that alcohol should be avoided in the client with arthritis. Alcohol should not be taken with narcotic doses. 5. Regular exercise strengthens muscles that support painful joints and may help speed recovery, prevent injury, and reduce disability.

23) An older patient experiencing cancer pain is prescribed intravenous pain medication. What actions will the nurse take when administering this medication? Select all that apply. 1. Assess the effectiveness of the pain medication after each administration. 2. Use the appropriate fluid delivery system when administering intravenously. 3. Offer oral medications for breakthrough pain management. 4. Withhold pain medication until the pain becomes intolerable. 5. Ensure the intravenous site does not become infected or infiltrated.

Answer: 1, 2, 5 Explanation: 1. When administering pain medication, the effectiveness of the medication should be assessed by the nurse approximately 30—60 minutes after administration. 2. When administering pain medication using the intravenous route, use the appropriate fluid delivery system. 3. Oral medications are not used for breakthrough pain. Intravenous medications will most likely be provided for breakthrough pain when the patient is receiving intravenous pain medication. It will take too long for the pain medication to be effective through the oral route. 4. Pain medication should be provided to keep the patient comfortable and not have the patient endure unnecessary duress. 5. When administering pain medication using the intravenous route, the nurse needs to ensure that the site does not become infected or infiltrated.

19) The nurse is performing a skin assessment on an older African American patient. Which findings would be considered normal for this patient? Select all that apply. 1. Xerosis 2. Many small, dark papules on the face 3. Hard, smooth purple area on the upper arm 4. Multiple skin tears with clear fluid drainage 5. Freckle-like pigmentation of the tongue borders

Answer: 1, 2, 5 Explanation: 1. Xerosis or dry skin occurs more frequently as a person ages. 2. Many small dark papules on the face are dermatosis papulosa nigra, a type of Seborrheic keratoses that only occurs in African Americans. 3. A hard, smooth purple area on the upper arm is erythema in the dark-skinned patient and is not a normal skin finding. 4. Multiple skin tears with clear fluid drainage is not a normal skin finding for the African American patient. 5. Dark-skinned people may have freckle-like pigmentations of the tongue borders which is a normal finding.

12) An older client undergoing chemotherapy for cancer asks the nurse about using massage for pain relief. How does the nurse best respond? Select all that apply. 1. "We will have to discuss this with your oncologist." 2. "Wait until the chemotherapy is completed." 3. "Massage has many benefits, including relief of pain." 4. "The tumor was removed, so a massage is safe." 5. "Reiki is a good alternative to massage therapy."

Answer: 1, 3 Explanation: 1. Massage is generally safe in people with cancer, but the oncologist must be consulted. Massage is contraindicated in clients with low platelet counts, which can be caused by chemotherapy. 2. This response dismisses the client's question. The client may not have to wait. Sometimes the health care provider will approve light massage. 3. Massage does relieve pain and increase general feelings of well-being. 4. Massage over an area of tumor is contraindicated; however, the location of the tumor is not the only consideration. 5. Suggesting Reiki does not address the client's question about massage therapy. If massage is contraindicated, the nurse, client, and provider can discuss Reiki, which uses light touch to promote healing.

24) An older patient comes to the emergency room with a black eye and is diagnosed with a broken right arm. What nursing assessment findings are indicative of potential physical abuse? 1. The patient is 65 years old and has no history of falls. 2. The client states "I fell on a shovel while clearing snow from a walkway." 3. The patient is confused about how they broke their arm and cannot recount events. 4. The patient is African American and states "I have broken many bones in my lifetime."

Answer: 2 Explanation: 1. One characteristic of older abuse victims is an age over 75 years. 2. One sign of elder mistreatment includes diagnostic testing results inconsistent with the history given. 3. There is no evidence to suggest that the patient is confused. 4. One characteristic of older abuse victims is Caucasian race.

13) An older patient complains about increasing dry skin. What should the nurse explain to the patient about this skin problem? Select all that apply. 1. There is a reduction in sebum production as the body ages. 2. There is a decrease in the number of sweat glands in the body with aging. 3. There is a change in the keratinization and lipid content in the stratum corneum. 4. There is an increase in body core temperature with aging, resulting in skin drying. 5. There is a change in the structure of the skin cell because of years of using alcohol-based soaps.

Answer: 1, 3 Explanation: 1. Sebum is an oily substance that keeps hair supple and lubricates the skin. Sebum protects the skin from water loss and provides protection against infection. Sebaceous glands increase in size with age, but the amount of sebum produced is decreased. This would explain why the older patient is experiencing increasingly dry skin. 2. The number of sweat glands does decrease with aging but does not have a role in the reduction of the production of sebum. 3. Changes in the keratinization process and lipid content in the stratum corneum cause the flaking appearance and dry sensation of the skin. 4. Changes in body temperature do not impact the dryness of the older patient's skin. 5. The older patient's complaint of increasingly dry skin is not because of years of using alcohol-based soaps.

11) The daughter of an elderly patient expresses concern about a change in the patient's mental health. Which is most likely due to normal cognitive changes? Select all that apply. 1. Decline in the ability to draw 2. Decrease in size of vocabulary 3. Difficulty filtering out irrelevant information 4. Difficulty switching attention from one person to another 5. Increased need to repeat information to the patient

Answer: 1, 3, 4, 5 Explanation: 1. A decline in visuospatial task ability such as drawing declines with aging. 2. Vocabulary improves with age. 3. The ability to filter out irrelevant information declines with age. 4. The ability to switch attention between people declines with age. 5. Information-processing speed declines with age, necessitating the need to repeat information to the patient several times.

25) Which actions would the nurse take to prevent skin tears on an older patient with friable skin? Select all that apply. 1. Avoid harsh soaps. 2. Apply silk tape over dressings. 3. Ensure an adequate fluid intake. 4. Use a lift sheet to reposition in bed. 5. Apply skin-moisturizing cream to arms and legs twice a day.

Answer: 1, 3, 4, 5 Explanation: 1. An intervention to prevent skin tears is to avoid harsh soaps. 2. An intervention to prevent skin tears is to use paper tape and not silk tape to affix dressings. 3. An intervention to prevent skin tears is to ensure an adequate fluid intake. 4. An intervention to prevent skin tears is to use a lift sheet to reposition the patient in bed. 5. An intervention to prevent skin tears is to apply skin-moisturizing cream to the arms and legs twice a day.

11) An older client is prescribed topical capsaicin for joint pain. What should the nurse instruct the client about the use of this medication? Select all that apply. 1. Avoid getting the medication in the eyes. 2. This medication will react with other medications. 3. It will cause a burning sensation when first applied. 4. Do not permit the medication to touch an open wound. 5. The burning sensation will decrease with subsequent uses.

Answer: 1, 3, 4, 5 Explanation: 1. The client should be instructed to avoid getting capsaicin in the eyes as this will cause burning. 2. This medication does not react with other medications. 3. The client should be instructed that this medication will cause a burning sensation when first applied. 4. The client should be instructed to avoid getting capsaicin in an open wound since it will cause burning. 5. The client should be instructed that the burning sensation from capsaicin will decrease when applied frequently.

10) An older client with sleep apnea is prescribed continuous positive airway pressure (CPAP). What will the nurse explain to the client about this treatment? Select all that apply. 1. Continuous pressure keeps the airway open to enhance breathing. 2. This is considered an oral airway to keep the tongue in place. 3. The machine is noisy and will keep the client awake. 4. Noninvasive treatment is administered through a nasal mask. 5. The face mask is uncomfortable but important to well-being.

Answer: 1, 4, 5 Explanation: 1. Continuous positive airway pressure works by applying pressure to the airway in order to keep the airway open during sleep. 2. CPAP does not involve the insertion of any airways. The pressure from the machine forces air beyond the relaxed airway. 3. The CPAP machine does not make much more noise than a fan. 4. CPAP is a noninvasive treatment that is administered through a nasal mask. 5. The face mask has been known to be uncomfortable, but the mask can be fitted to the client to increase comfort. There is about a 50 percent rate of compliance with CPAP use, but it is essential to reduce complications such as increased stroke risk and effects such as daytime sleepiness.

25) The daughter of an older patient who is a resident of a nursing home suspects the patient is a victim of abuse. What should the nurse suggest that the daughter do about this situation? Select all that apply. 1. Visit the facility at varied times. 2. Do nothing until evidence is obtained. 3. Realize that the patient can be confused. 4. Participate in the resident's council. 5. Actively participate in care plan meetings.

Answer: 1, 4, 5 Explanation: 1. For the older adult living in long-term care facilities, the California Advocates for Nursing Home Reform recommend that family should visit the facility at varied times. 2. The nurse should not recommend that the daughter do nothing about the situation until evidence is obtained. The older patient could be drastically harmed. 3. There is no evidence that the older patient is confused. The nurse should not make this recommendation to the daughter. 4. For the older adult living in long-term care facilities, the California Advocates for Nursing Home Reform recommend that the family participate in the resident's council. 5. For the older adult living in long-term care facilities, the California Advocates for Nursing Home Reform recommend that the family actively participate in care plan meetings for the older patient.

4) An older client is having difficulty sleeping. What can the nurse instruct the client to help improve the client's sleep? Select all that apply. 1. Do not nap during the day. 2. Take a walk an hour before going to sleep. 3. Have a glass of wine before going to sleep. 4. Avoid reading or watching television in bed. 5. If unable to sleep, get up and go to another room.

Answer: 1, 4, 5 Explanation: 1. One action to improve sleep is to avoid napping during the day. 2. Activity should be restricted to 3 hours before going to sleep. 3. Alcohol has been found to disrupt sleep and should be avoided. 4. The bed should be used for sex or sleep and not for reading or watching television. 5. One action to improve sleep is to get up and go to another room if unable to sleep.

12) An older patient is being abused by family members in the home and asks about adult protective services. What should the nurse explain about these services? 1. They are an organization that prosecutes those persons who abuse the elderly. 2. They provide services to protect older people who may be abused or neglected. 3. They provide a way to permanently keep the older patient separated from the abuser. 4. They place older patients who cannot adequately care for themselves in nursing homes.

Answer: 2 Explanation: 1. Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited. APS do not punish persons who abuse the elderly. 2. Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited. 3. Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited. APS do not permanently keep the older patient separated from the abuser. 4. Adult protective services (APS) programs are social services organized to protect vulnerable older adults who may be abused, neglected, or exploited. APS do not place older patients in nursing homes.

14) An older patient recently diagnosed with skin cancer does not understand why the disease developed since sunbathing has always been avoided. How should the nurse respond to this patient? 1. "Can you tell me more about your feelings?" 2. "Sun exposure can happen from driving a car." 3. "We frequently never find out why cancer strikes." 4. "This is unusual, as skin cancer normally only occurs in sunbathers."

Answer: 2 Explanation: 1. Asking the patient to explain feelings does not answer the patient's question. This is an inappropriate response for the nurse to make. 2. Sun exposure can occur from routine activities such as driving or riding in a car. 3. Stating that we frequently never find out why cancer strikes does not answer the patient's question. This is an inappropriate response for the nurse to make. 4. Stating that skin cancer normally only occurs in sunbathers is an inaccurate response. Skin cancer can occur after sun exposure, regardless how the sun exposure occurs.

24) An older patient has a stage III pressure ulcer. Which treatment would the nurse expect the physician to order for the patient's wound? 1. Cadexomer 2. Silver sulfadiazine 3. Nanocrystalline silver 4. Topical antibiotic cream

Answer: 2 Explanation: 1. Cadexomer iodine dressings provide a slow-release form of iodine. These dressings have effective antibacterial action and do not harm granulation tissue. The patient's wound is not healing and would not have granulation tissue. 2. Silver sulfadiazine is the topical antimicrobial of choice for the non-healing ulcer. 3. Nanocrystalline silver dressings have been found to be effective against gram-negative, gram-positive, and anaerobic organisms. 4. Topical antibiotics are not recommended for pressure ulcers. Reasons include inadequate penetration if the wound is deep, development of antibiotic resistance, hypersensitivity reactions, and local irritation.

20) The nurse is caring for a patient who is terminally ill and can no longer speak. Which best indicates that this patient is in pain? 1. Skin is cool and moist to touch. 2. Facial grimacing with moaning when turned 3. Cyanotic feet and lower legs 4. Cheyne-Stokes respiratory pattern

Answer: 2 Explanation: 1. Cool moist skin may be present in a dying patient but is not a symptom of unrelieved pain. 2. Moaning while being turned and grimacing may indicate pain. 3. Cyanotic feet and lower legs may be present in a dying patient but is not a symptom of unrelieved pain. 4. Cheyne-Stokes respiratory pattern may be present in a dying patient but is not a symptom of unrelieved pain.

2) An older adult client has a history of osteoarthritis. The nurse cares for the client in the postoperative period after a below-the-knee amputation for complications of peripheral vascular disease. Which finding most concerns the nurse? 1. The client has a history of depression and anxiety, treated with a selective serotonin reuptake inhibitor. 2. The client takes acetaminophen (Tylenol) instead of prescribed pain medication as needed for osteoarthritis. 3. The client's spouse visits the hospital occasionally, usually to assist with the morning meal and bathing. 4. The client is irritable, reports moderate generalized pain, and states that he cannot "put a number on it."

Answer: 2 Explanation: 1. Depression and anxiety can worsen with undertreated, persistent pain. The fact the client is already being treated for this is a positive finding. 2. A history of undertreated, chronic pain is often related to musculoskeletal disorders. The client has not been taking medications that might have helped the pain. This can result in hyperalgesia, an increased sensitivity to pain that leads to an exaggerated pain response. 3. Ideally, the client would have more continuous in-hospital support, but the client does have a support person. The spouse may be busy with work, family, or other responsibilities. 4. Older clients sometimes are vague with pain reports, particularly when there are multiple pain sources, such as chronic musculoskeletal pain and acute surgical pain. It is not uncommon for someone in moderate to severe pain to demonstrate frustration with, or refusal to use, the pain scale.

24) An older patient who is dying is unable to fully close the eyes. What can the nurse do to protect the patient's eyes from irritation? 1. Apply eye guards. 2. Apply artificial tears. 3. Tape the eyes closed. 4. Reduce the room lighting.

Answer: 2 Explanation: 1. Eye guards are not used to protect the eyes of a dying patient from drying out. 2. As death approaches and the patient becomes increasingly sedated, the blink reflex decreases resulting in dry eyes. Opened or half-opened eyelids dry and become irritated. Frequent eye care is provided to promote comfort when this occurs. Artificial tears may be used to prevent drying of the eyes. 3. Taping the eyes closed is not an intervention to protect the eyes of a dying patient from drying out. 4. Reducing the lighting in the room is not an intervention to protect the eyes of a dying patient from drying out.

20) An older patient has a Braden Scale pressure ulcer risk score of 18. What interventions would be indicated by the nurse? 1. Provide routine skin care with soap and water daily. 2. Inspect skin when repositioning, toileting, and assisting with ADLs. 3. Avoid the use of pillows and foam slabs between bony prominences. 4. Provide routine activities, score is not concerning.

Answer: 2 Explanation: 1. Keep the skin clean and dry. Avoid overuse of soap which can be drying. 2. Evaluate and manage incontinence. A bowel- and bladder-management program should be in place. If soiling occurs, skin should be cleansed as soon as possible using a pH balanced skin cleanser. Underpads that absorb moisture and present a quick-drying surface to the skin should be used. 3. Use pillows or wedges to prevent the skin from touching the bed on trochanter, heels, and ankles. 4. The score is not inconclusive and it does show a risk for pressure ulcer development.

8) A nursing manager is assessing a nursing home over concerns regarding institutional mistreatment of older patients. Which situation would warrant further concern over this issue? 1. A client refuses to take her morning shower. 2. A client screams at a patient care technician. 3. A client denies taking his morning medication. 4. A client curses out another nursing home patient.

Answer: 2 Explanation: 1. Patients have a right to choose when they want to shower; this is not indicative of abuse. 2. Patient aggressiveness has been found to be a predictor of physical and psychological abuse by staff members. 3. Patients may not remember if they have taken their medications; this is not indicative of abuse. 4. Patients may not socialize and get along with all other patients; this is not indicative of abuse.

3) The discharge nurse is teaching insulin administration to an older patient. Which teaching strategy would be best? 1. Provide written materials to reinforce the verbal instructions. 2. Encourage repetitive exercises to review new information until it is understood. 3. Allow longer teaching times to compensate for a slower learning pace. 4. Provide instruction to relatives so the patient will not be overwhelmed with new information.

Answer: 2 Explanation: 1. Short-term memory, or primary memory, remains relatively stable when aging. 2. Normal age-related changes include a slowing of information processing, which results in the need for repetition of information. 3. Another age-related change includes the inability to maintain sustained attention. Long teaching sessions would not be appropriate. 4. Assuming the older patient cannot learn new information is a false belief of the aging process.

12) An older client is being prescribed medication to help with sleep. What is most important for the nurse to teach a group of orienting nurses caring for geriatric clients? 1. Lorazepam is the best benzodiazepine to use for sleep. 2. Medications for sleep disorders should be used for less than one month. 3. Some medications are not safe for an older client, regardless of dose. 4. A dose of an antidepressant medication is helpful for sleep.

Answer: 2 Explanation: 1. Shorter-acting benzodiazepines such as lorazepam are suggested to be the better choice for older adults because these drugs have the best effects and fewer safety concerns. 2. Benzodiazepine therapy is recommended for short-term use not to exceed 2 weeks. Sleep disorder treatment should be limited to 3-4 weeks. 3. It is important to avoid using the benzodiazepines with longer half-lives such as diazepam since this drug is associated with a high abuse potential, daytime sedation and falls, and memory impairment. The health care provider should manage the client's regimen accordingly. 4. Low doses of tricyclic antidepressants are used for sleep disorders, too. Not all antidepressants have a sleep-inducing effect, though.

25) The nurse is planning care for an older patient diagnosed with major depression who states that voices are telling the patient to kill himself. Which nursing diagnosis would be a priority for this patient? 1. Social isolation 2. Risk for suicide 3. Disturbed sleep pattern 4. Altered sensory perception

Answer: 2 Explanation: 1. Social isolation might be causing the patient to hear voices; however, this would not be the priority diagnosis at this time. 2. The patient is hearing voices that are telling him to kill himself. This patient is at risk for suicide. 3. The patient may or may not have disturbed sleep. This is not the priority diagnosis for the patient at this time. 4. Even though the patient is hearing voices, which would be an alteration in sensory perception, the voices are telling the patient to kill himself. This is not the priority diagnosis for the patient at this time.

25) An older client with chronic low back pain asks the nurse if there is anything else besides taking pain medication that the client can do to help with the discomfort. What recommendation can the nurse safely make to the client? 1. Purchase a Tai Chi home exercise program. 2. A yoga class might be helpful to relieve pain. 3. Acupuncture will correct any source of back pain. 4. Take over-the-counter chondroitin or glucosamine.

Answer: 2 Explanation: 1. Tai Chi improves musculoskeletal pain. The client with back pain should attend a class so that modifications can be made safely. 2. Yoga can reduce functional disability, pain, and depression in people with low back pain. Attending a class helps ensure that the proper physical modifications are made to reduce risk of injury. 3. Acupuncture is good for many types of pain, but it is not a guaranteed correction for any back pain the client is experiencing. 4. The nurse should not suggest a supplement, but refer the client to the health care provider to address this possibility.

3) An older client living at home with cancer reports having to take twice as much pain medication over the last 24 hours. What should the nurse do with this information? 1. Double the current dose of narcotic pain medication. 2. Discuss options to prevent and treat breakthrough pain. 3. Use non-pharmacological methods for pain relief instead of pain medication. 4. Advocate for a medication change because the client has opioid tolerance.

Answer: 2 Explanation: 1. The client may be experiencing breakthrough pain and a different pain management approach may be needed. Titrating the medication dose upward is a reasonable option, but doubling the dose is too drastic and can lead to adverse effects. 2. If the client experiences breakthrough pain on a consistent basis, the nurse should notify the client's provider so that the dose of the long-acting, sustained-release preparation can be increased to more effectively control the pain. Immediate-release doses are also used to better manage breakthrough pain. 3. Alternative methods of pain relief may or may not be effective with breakthrough pain. The nurse could implement these in conjunction with, but not instead of, better pharmacological pain management. 4. There is no evidence to suggest that the client has opioid tolerance. Opioid tolerance does not occur over the period of one day, but rather takes a days, weeks, or months to create a problem.

4) An older patient dying from a terminal illness reports that the last dose of pain medication provided barely reduced the level of pain. What should the nurse do to help this patient? 1. Give the patient pain medication every hour. 2. Contact the physician for an adjustment in pain medication. 3. Provide the pain medication at the next scheduled dose time. 4. Give the patient another dose of the medication even though it is before the scheduled time.

Answer: 2 Explanation: 1. The nurse cannot prescribe the dose or frequency of pain medication and cannot give the patient pain medication every hour if it is not prescribed at this frequency. 2. Dying patients may need more pain medication than the normal range for the prescribed drug. Organic changes are occurring rapidly within the body and systems are shutting down, decreasing the absorption levels of drugs. 3. Delaying medication would cause unnecessary suffering for the patient. 4. Altering the administration schedule is outside of the scope of the professional practice role of nursing.

17) An older patient requests a small, inflated donut to sit on to relieve pressure. What response by the nurse is appropriate? 1. "Ok, it will definitely help with relieving pressure." 2. "Using the donut can cause skin breakdown." 3. "I will need to obtain an order from the physician for you." 4. "I will give it to your wife and you can use this at home."

Answer: 2 Explanation: 1. The use of the device should be avoided because it applies pressure and results in tissue hypoxia. 2. The use of a donut applies pressure and results in tissue anoxia. The patient may indeed feel that pressure is lessened, but this is due to the loss of sensation. The use of the devices should be avoided. 3. The use of the device should be avoided because it applies pressure and results in tissue hypoxia. 4. The nurse should instruct the patient that the use of the device should be avoided because it applies pressure and results in tissue hypoxia. The patient should not use the device at home.

20) The nurse assesses a client before bedtime. The spouse at bedside jokes about the client's snoring. Which assessment finding most concerns the nurse? 1. The client reports unrefreshing sleep. 2. Blood pressure 168/98 mmHg. 3. Choking sounds during sleep. 4. Oxygen saturation 88 percent during sleep.

Answer: 2 Explanation: 1. This report indicates to the nurse that the client likely has sleep apnea, rather than just snoring. 2. Sleep apnea results in hypertension. This blood pressure reading could indicate the client is experiencing adverse physiological effects from sleep apnea. 3. Sounds of choking during sleep occur when the client struggles to breathe during sleep due to apnea. This finding supports the nurse's suspicion that the client has sleep apnea. 4. A decreased oxygen saturation during sleep helps confirm the nurse's suspicion that the client has sleep apnea, particularly if the oxygen saturation returns to normal when the client is woken. This reading is not of most concern.

7) The nurse is caring for an older patient who has a healed, sacral pressure ulcer. What would the nurse include in teaching about this new tissue growth? 1. "Your sacral area will heal faster if reinjured." 2. "Your skin will break down faster if your sacrum is reinjured." 3. "You may have a loss of feeling in the old, pressure ulcer area." 4. "You are more at risk for infection in the sacral area."

Answer: 2 Explanation: 1. This site will not heal faster if reinjured. The wound will never reach the pre-wound strength. 2. Skin will break down faster in areas that were previously injured. Scarred wounds never reach prewound strength. 3. Sensation does return to the skin of a pressure ulcer. 4. Intact skin does not increase the risk for infection.

14) Which nursing assessment findings would support a nursing diagnosis of caregiver role strain? 1. An older client has multiple wounds on both arms in various stages of healing. 2. An older client is hard of hearing and has difficulty completing ADL's; he lives with his son. 3. An older client states, "I really am becoming a burden on my family; they don't love me anymore." 4. An older client is accompanied to a physician's office visit with an adult daughter who he lives with. She refuses to take him to bingo every week.

Answer: 2 Explanation: 1. This supports a diagnosis of risk for ineffective protection. 2. Caregiver role strain is the priority since the son needs to help the older patient who is hard of hearing and has difficulty completing activities of daily living. The son may become stressed with having to help the older patient as well as himself with care needs. 3. This supports a diagnosis of situational low self-esteem. 4. This supports a diagnosis of social isolation.

21) An emergency room nurse is caring for an older patient brought in by a neighbor. The neighbor states that the patient lives with a son who "drinks a lot." What does the nurse assess that suggests elder neglect? Select all that apply. 1. Thick, yellow fingernails 2. Dry, cracked lips and tongue 3. Pressure ulcer on the sacrum 4. Small skin tears to the right elbow 5. Cracked, dry skin on the lower legs bilaterally

Answer: 2, 3 Explanation: 1. Thick, yellow fingernails could be an expected finding in an older patient and not indicative of neglect. 2. Common signs and symptoms of neglect include dehydration, which would be manifested as dry, cracked lips and tongue. 3. A pressure ulcer on the sacrum is a manifestation of caregiver neglect. 4. Small skin tears to the right elbow do not necessarily indicate caregiver neglect and could have occurred during routine activities in the home. 5. Cracked dry skin on both lower legs does not necessarily indicate caregiver neglect. This could be an expected finding in an older patient.

16) The home healthcare nurse is preparing an educational program for other healthcare providers regarding elder abuse. What information should the nurse include? Select all that apply. 1. The typical abuser is the spouse. 2. The typical abuser is the adult child. 3. The typical elder who is abused is a woman. 4. The majority of abuse occurs in the home setting. 5. The majority of abuse occurs in the long-term care setting.

Answer: 2, 3, 4 Explanation: 1. Spouses account for only 11.3% of abuse. 2. Adult children account for 32.6% of abuse. 3. The typical older person who is abused is a Caucasian woman. 4. The vast majority of abuse and neglect occurs in the domestic setting. 5. Although institutional abuse can occur, the vast majority of abuse occurs in the home setting.

9) An older client with a history of constipation is prescribed an opioid analgesic for postoperative pain. What should the nurse include in this client's plan of care to avoid the pain management complication of constipation? Select all that apply. 1. Mix psyllium in 4 ounces of water. 2. Provide stool softeners as prescribed. 3. Monitor for adequate daily fluid intake. 4. Increase ingestion of fresh fruit each day. 5. Offer senna tea each evening before sleep.

Answer: 2, 3, 4, 5 Explanation: 1. A prophylactic bowel regimen must be initiated when opioid analgesics are utilized. Bulking agents such as psyllium should be avoided to prevent fecal impaction. 2. A prophylactic bowel regimen must be initiated when opioid analgesics are utilized. Stool softeners should be provided as prescribed. 3. A prophylactic bowel regimen must be initiated when opioid analgesics are utilized. The client should be encouraged to increase the oral fluid intake. 4. A prophylactic bowel regimen must be initiated when opioid analgesics are utilized. Fruits may also be helpful to prevent constipation. 5. A prophylactic bowel regimen must be initiated when opioid analgesics are utilized. Senna tea may also be helpful to prevent constipation.

21) The hospice nurse is discussing the addition of adjuvant medication to help an older patient with cancer pain. Which types of medications would the considered as adjuvant for this type of pain? Select all that apply. 1. Antiemetics 2. Corticosteroids 3. Antidepressants 4. Anticonvulsants 5. Muscle relaxants

Answer: 2, 3, 4, 5 Explanation: 1. A wide array of nonopioid medications from several pharmacological classes has been shown to improve pain control when used concomitantly with pain medications. Their use may enhance the effectiveness of other classes of drugs, improving the treatment of pain at lower doses and decreasing the risk of side effects. Medications in this class do not include antiemetics. 2. A wide array of nonopioid medications from several pharmacological classes has been shown to improve pain control when used concomitantly with pain medications. Their use may enhance the effectiveness of other classes of drugs, improving the treatment of pain at lower doses and decreasing the risk of side effects. Medications in this class include corticosteroids. 3. A wide array of nonopioid medications from several pharmacological classes has been shown to improve pain control when used concomitantly with pain medications. Their use may enhance the effectiveness of other classes of drugs, improving the treatment of pain at lower doses and decreasing the risk of side effects. Medications in this class include antidepressants. 4. A wide array of nonopioid medications from several pharmacological classes has been shown to improve pain control when used concomitantly with pain medications. Their use may enhance the effectiveness of other classes of drugs, improving the treatment of pain at lower doses and decreasing the risk of side effects. Medications in this class include anticonvulsants. 5. A wide array of nonopioid medications from several pharmacological classes has been shown to improve pain control when used concomitantly with pain medications. Their use may enhance the effectiveness of other classes of drugs, improving the treatment of pain at lower doses and decreasing the risk of side effects. Medications in this class include muscle relaxants.

9) The nurse is assessing an older patient exhibiting signs of paranoia. Which is known to increase the risk of developing of this disorder? Select all that apply. 1. Food allergies 2. Hearing loss 3. Dementia 4. Social isolation 5. Cognitive impairment

Answer: 2, 3, 4, 5 Explanation: 1. Food allergies are not known risk factors for paranoia. 2. Hearing loss is a risk factors for the development of paranoia. 3. Risk factors for the development of paranoia include dementia. 4. Social isolation is a risk factor for the development of paranoia. 5. Risk factors for the development of paranoia include cognitive impairment.

17) An older client with chronic pain is newly prescribed transdermal fentanyl. What will the nurse do when providing this medication? Select all that apply. 1. Teach the client to avoid other narcotics after 72 hours with the patch. 2. Start with the lowest possible dose of the medication patch. 3. Anticipate and treat side effects such as nausea or constipation. 4. Apply the patch to clean, dry, hairless skin in a fatty area. 5. Administer other pain medications the first day the patch is used.

Answer: 2, 3, 4, 5 Explanation: 1. The client does not need to exercise caution if using fentanyl with other narcotics, but clients often need two or more simultaneous narcotics to achieve adequate pain relief, particularly if breakthrough pain is an issue. 2. The lowest possible dose should be used when starting transdermal fentanyl, even if previous narcotics have been used. It can be titrated up every few days until the desired effect is reached. 3. Side effects should be anticipated and managed aggressively for any narcotic. 4. The nurse should apply the transdermal fentanyl patch to clean, dry, hairless skin. The medication absorbs best in an area with subcutaneous tissue, such as the abdomen. 5. Since the peak effects of the first dose of transdermal fentanyl take 24 hours, the client should be covered with oral pain medications the first day of application.

7) An older client with a speech deficit from a previous stroke is admitted for a repair of a hip fracture. Which techniques will the nurse use to assess this client's pain level? Select all that apply. 1. Ask to describe the level of pain. 2. Observe for tense body posturing. 3. Listen for sounds such as groaning. 4. Notice changes in appetite or sleep. 5. Observe facial expressions such as grimacing.

Answer: 2, 3, 4, 5 Explanation: 1. The client is unable to speak, so verbally asking the client to describe the level of pain will not provide the nurse with any information about the client's current level of pain. 2. Tense body posturing is a pain behavior that the client who is unable to speak might demonstrate. 3. Sounds such as groaning are pain behaviors that the client who is unable to speak might demonstrate. 4. Changes in appetite or sleep are pain behaviors that the client who is unable to speak might demonstrate. 5. Grimacing is a pain behavior that the client who is unable to speak might demonstrate.

3) Which findings most concern the nurse that a client is experiencing sleep apnea? Select all that apply. 1. Frequent daily headaches 2. Sleeping with three pillows 3. Daytime sleepiness 4. Restless legs during long drives 5. Reports of choking when waking from sleep

Answer: 2, 3, 5 Explanation: 1. Morning headaches, rather than headaches at any point in the day, are associated with sleep apnea. 2. A client who sleeps with multiple pillows needs evaluation to rule out conditions such as sleep apnea. Propping the head or torso up with pillows reduces sleep interruptions from the impaired airway that occurs with apnea. 3. Excessive daytime sleepiness is a manifestation of sleep apnea. 4. Restless legs can be associated with many conditions. Falling asleep while driving is associated with sleep apnea. 5. Complaints of choking when waking from sleep is a manifestation of sleep apnea.

5) What instruction should the nurse provide to a nursing assistant who is assigned to care for an older patient with a stage I pressure injury on the right heel? 1. Apply a dry dressing to the site. 2. Apply a donut under the right heal. 3. Cleanse the area with tepid water. 4. Keep the head of the bed elevated.

Answer: 3 Explanation: 1. A dry dressing is not indicated for this type of pressure ulcer. 2. Mechanical devices can exacerbate pressure ulcers and should not be used. 3. The area at risk for pressure sore development should be washed gently with tepid water, and minimal soap. Soap removes natural oils from the skin, and cleaning the soap off may cause additional friction damage. 4. Elevating the head of the bed increases pressure on the sacrum and lower extremities which could cause the pressure ulcer to become worse.

4) Which patients seen by a nurse working in the emergency department identify a situation that suggests a case of elder mistreatment? 1. A 77-year-old patient who fell at home 2. A 73-year-old patient found to be anemic after vomiting blood 3. An 86-year-old patient who has three dime-size burned areas on the upper inner thigh 4. An 85-year-old patient who has several small areas of bruising on the back of the hands

Answer: 3 Explanation: 1. A patient with a broken bone that is consistent with an injury event and seeks medical attention promptly is not generally suspect for elder abuse. 2. The patient with active bleeding would be expected to have anemia. 3. The patient who has skin burns suggestive of cigarette burns in an area normally covered by clothing is suggestive of abuse. 4. Bruising is common in elderly patients, especially those taking medication that affects the blood, who have thin skin and is especially common in the hands, which is an area that is easily bumped.

18) During an assessment, the nurse learns that an older patient feels his heart race during times of stress. How would the nurse best describe this event? 1. "Your body is reacting with a fight-or-flight response which is normal." 2. "Your body is releasing a chemical to make your heart stronger because it is weak." 3. "This is not a normal response, and further testing will be required." 4. "This is an emergency and will require immediate hospitalization."

Answer: 3 Explanation: 1. The fight-or-flight response stimulates epinephrine release and increases pulse, blood pressure, blood glucose, and muscle tension. 2. Epinephrine is released but does not make the heart stronger. 3. This is not a normal response. 4. This is not an emergency that requires immediate hospitalization.

23) An older client prescribed an oral time-release pain medication is having difficulty swallowing the dose. What should the nurse do to help this client? 1. Teach the client to crush the medication and put it in applesauce. 2. Offer alternatives to pharmacological therapy, including massage. 3. Consult with the health care provider to have the medication route changed. 4. Assess the client for continued need of pain medication doses.

Answer: 3 Explanation: 1. A time-released medication cannot be chewed or crushed because it destroys the controlled-release properties and causes rapid absorption of the entire dose, resulting in a possible overdose. 2. Alternative therapies can be used with analgesics, but the client on extended-release medication is not a good candidate to use massage or similar therapies as a primary pain relief method. 3. The nurse should discuss the client's inability to swallow the medication with the physician so that an alternative route can be determined. 4. The client on extended-release analgesic is not likely to have decreased pain management needs.

2) An older patient wakes up from sleep, confused, and insists a family member is in the other room. What information within the patient's medical record should the nurse consider as a source of the patient's confusion? 1. The patient is elderly. 2. The patient's spouse recently died. 3. The patient received pain medication. 4. The patient has a history of cardiac disease.

Answer: 3 Explanation: 1. Age does not cause confusion. 2. The loss of a loved one may cause depression but is not identified as a reason for confusion. 3. Certain medications like sleeping pills, tranquilizers, and some pain medications can cause symptoms similar to dementia. 4. Cardiac disease alone is not known to cause confusion.

22) An older client does not understand why an alcoholic drink cannot be provided before going to sleep in the evening. What should the nurse explain to the client? 1. Alcohol has an initially depressant effect. 2. Alcohol can increase the time needed to fall asleep. 3. Alcohol is disruptive of the second half of the sleep cycle. 4. Alcohol can enable an individual to sleep through the entire night.

Answer: 3 Explanation: 1. Alcohol has an initial stimulating effect. 2. Alcohol reduces the amount of time needed to fall asleep. 3. Alcohol use at bedtime is associated with disruption during the second portion of the sleep cycle. 4. Since alcohol disrupts the second portion of the sleep cycle, it does not enable an individual to sleep through the entire night.

9) Which older patient is at greatest risk for mistreatment in the home? 1. An older patient who is retired from owning a business and lives with an adult married son 2. An older patient with a history of coronary bypass surgery, is active, and lives with his spouse 3. An older patient with severe osteoarthritis who lives with his daughter who has a son with cerebral palsy 4. An older patient with well-controlled diabetes and heart disease who lives alone, his wife died a year ago

Answer: 3 Explanation: 1. An older patient who is retired from owning a business and living with an adult married son is not at risk for mistreatment in the home. 2. Risk factors for elder mistreatment include being female, over the age of 75, having a dependent functional status, having a poor social network, poverty, minority, cognitive impairment, and having less than an 8th-grade education. An older patient with a history of coronary bypass surgery and lives with the spouse is not at risk for mistreatment in the home. 3. Risk factors for elder mistreatment include being female, over the age of 75, having a dependent functional status, having a poor social network, poverty, minority, cognitive impairment, and having less than an 8th-grade education. An older patient with severe osteoarthritis and macular degeneration who lives with his daughter who has a son with a health problem is at the greatest risk for mistreatment in the home. 4. Risk factors for elder mistreatment include being female, over the age of 75, having a dependent functional status, having a poor social network, poverty, minority, cognitive impairment, and having less than an 8th-grade education. An older patient who has a chronic illness and lives alone is not at risk for mistreatment in the home.

9) An older patient is not breathing well and has cold, mottled skin. The patient has a living will and requests comfort measures only. What should the nurse do to care for this patient? 1. Ask the family what they want to be done for the patient. 2. Contact the physician for orders to control the patient's breathing. 3. Provide personal hygiene and skin care as outlined in the care plan. 4. Withhold pain medication, hygiene, and nutrition until the patient dies

Answer: 3 Explanation: 1. Asking the family what they want to be done for the patient will go against the patient's written wishes and is inappropriate. 2. Contacting the physician to intervene to control respiration is considered adding extraordinary measures and is inappropriate, as it is going against the patient's written wishes when a living will is present and in force. 3. Comfort measures only indicate that the patient does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide patient comfort is intensified and maintained through the end stages of the patient's life. 4. Comfort measures only indicate that the patient does not want extraordinary measures to sustain life. This does not mean that nursing care ceases but that nursing care to provide patient comfort is intensified and maintained through the end stages of the patient's life.

8) While providing postmortem care to a patient who has died the patient elicits a respiratory sound when turned. What should the nurse do? 1. Check for a pulse. 2. Reposition the airway. 3. Continue with the postmortem care. 4. Report to the physician the patient is still breathing.

Answer: 3 Explanation: 1. Checking for a pulse is not necessary in a deceased patient. 2. Repositioning the airway is not necessary in a deceased patient. 3. When the body is moved or the extremities repositioned, the body may produce respiratory-type sounds or the chest may appear to rise and fall. This can be alarming, but is only the sound of air leaving the lungs. 4. Contacting the physician is not necessary because the sound is a normal finding.

17) The home care nurse is performing wound care on a newly widowed patient whose adult daughter died six months ago. Which statement by the patient is most concerning to the nurse? 1. "I've been so lonely. At least you come to visit me." 2. "I pass the time by writing my life's story in a journal." 3. "I have no regrets. I've lived a good, long life." 4. "I don't know why God took both my wife and daughter from me so soon."

Answer: 3 Explanation: 1. Normal grief is an experience of sadness and loss. 2. The grieving process may be lessened by activities that attempt to keep memories alive of the deceased such as journaling or creating a memory book. 3. The patient's statement indicates that they are having a difficult time with coping and grief. This statement indicates that the patient may have thoughts of suicide. 4. Questioning God is a common expression of grief as one moves through the grieving process.

15) An older client with muscle wasting, renal disease, and advanced cancer pain asks for stronger pain medication than immediate-release oral morphine. What is the most important consideration when recommending a pain medication change to the health care provider for this client? 1. If the narcotic dose is increased, constipation is more likely. 2. Sleeping through meals is more likely when narcotic doses are increased. 3. Extended-release oral morphine should be considered for this client. 4. A Fentanyl transdermal patch provides excellent relief for cancer-related pain.

Answer: 3 Explanation: 1. Constipation does increase with increased narcotic amounts. This is a side effect that can be aggressively prevented and is not a reason to undertreat pain. 2. First, the client may become relieved enough to enjoy eating; sleeping through meals is not guaranteed with narcotic doses. Second, the client with muscle wasting likely has very far progressed disease and malnutrition will be difficult to correct in the presence of pain, wasting, and renal failure whether pain is controlled or not. 3. Morphine is a commonly used and versatile opioid for the treatment of moderate to severe pain. Short- and long-acting formulations exist, and the drug can be delivered via many routes including oral form. The amount of immediate-release medication used can help determine the dose of extended-release morphine to prescribe. 4. Fentanyl patches work well to provide sustained pain control. However, this is not the next option for this client. A client who has lost a great deal of weight, such as occurs with muscle wasting, may not have enough tissue to correctly absorb the medication transdermally.

22) The nurse is caring for a patient who has been the victim of elder abuse by her son. Which assessment finding would support the situational violence theory of elder mistreatment? 1. The son is having a hard time staying employed. 2. The son went off to live at a boarding school for many years as a child. 3. The son witnessed several young boys being beat up in the neighborhood. 4. The son has lost his girlfriend and friends due to having to care for his mother full time.

Answer: 3 Explanation: 1. Employment status of the son is not a part of the situational violence theory of elder mistreatment. Employment may play a role in the characteristics of the abuser. 2. The situational violence theory does not address how children are raised and educated. 3. The situational violence theory does not address a situation of violence that the son may have witnessed while growing up. This could be explained by the learning theory of violence. 4. The situational violence theory suggests that elder mistreatment is thought to be a result of the caregiver becoming overwhelmed by the care the patient requires.

17) The home care nurse is preparing to visit an older female patient who lives in her son's home. The medical record indicates that the client has a high socioeconomic status. It also indicates that the son is Hispanic and is slightly cognitively impaired. Which risk factors for elder abuse would be most concerning? 1. Male gender 2. Hispanic race 3. Impaired cognitive status 4. High socioeconomic status

Answer: 3 Explanation: 1. Females are at a higher risk for elder abuse than males. 2. Those of the Caucasian race are at a higher risk for elder abuse than other races. 3. Cognitive impairment is a risk factor for elder abuse. 4. Poverty, and not a high socioeconomic status, is a risk factor for elder abuse.

8) An elderly patient is admitted for abdominal pain. The nurse assesses withdrawal, somatic complaints, and continued, unrelieved pain. What nursing action is indicated? 1. Request an anti-anxiety medication 2. Contact the family to intervene 3. Assess for signs and symptoms of depression 4. Obtain an order for stronger pain medication

Answer: 3 Explanation: 1. Further assessment is required to determine patient's current needs. 2. The family may be ineffective in meeting the patient's psychological needs. 3. The major signs of depression in the older person include multiple somatic complaints and reports of persistent chronic pain. 4. Obtaining different pain medication would not treat potential psychological problems.

15) The nurse is preparing discharge instructions for an older patient. If the patient is prescribed Ibuprofen, what should the nurse specifically educate the patient about? Select correct answer. 1. The nurse should teach the patient that they may experience a pimply rash on their arms. 2. The nurse should teach the patient that they may experience blue pigmentation. 3. The nurse should teach the patient to avoid extended sun exposure. 4. The nurse should teach the patient that he/she may be at risk for skin melanomas.

Answer: 3 Explanation: 1. Ibuprofen carries a risk of skin disorders, but they are not a pimply rash in appearance. 2. Ibuprofen does not cause blue pigmentation. 3. Ibuprofen is a medication that causes skin sensitivity and sensitivity to the sun. 4. Ibuprofen does not increase their risk of skin melanomas.

13) The health status of an older patient with liver disease is rapidly deteriorating. There is no documentation on the medical record regarding the patient's care wishes. What should the nurse do to ensure the patient receives care that is desired at the end of life? 1. Ask social services to provide an advance directive for the patient to complete. 2. Talk with the patient regarding what the patient wants after the hospitalization ends. 3. Call a meeting with the patient, family, and primary care physician to discuss care goals. 4. Discuss the patient's dire situation with the family and find out what their wishes might be.

Answer: 3 Explanation: 1. If unsure of a patient's wishes for care at the end of life, a team meeting with the key decision makers such as the patient, family, and primary care physician should be held. The nurse should not ask for an advance directive unless the patient desires to complete one. 2. If unsure of a patient's wishes for care at the end of life, a team meeting with the key decision makers such as the patient, family, and primary care physician should be held. Talking with the patient about what the patient wants after the hospitalization ends may or may not address the issue that the patient is dying. 3. If unsure of a patient's wishes for care at the end of life, a team meeting with the key decision makers such as the patient, family, and primary care physician should be held. This ongoing open discussion about goals of care will help the patient and the family receive the best possible care at the end of life. 4. If unsure of a patient's wishes for care at the end of life, a team meeting with the key decision makers such as the patient, family, and primary care physician should be held. Discussing the patient's dire situation with the family should be conducted by the physician. Care needs should be focused on the patient and not want the family desires.

20) The home care nurse asks an older patient's caregiver to complete a questionnaire regarding caregiver strain. The caregiver states, "You are here to see my mom. Why do you need information about me?" Which is the most appropriate response by the nurse? 1. "We need to make sure you don't abuse your mother." 2. "It's just something that the insurance companies make us fill out." 3. "We need to gather information about how you are dealing with caring for your mother." 4. "We fill out this paperwork for all caregivers; we have to assess your psychological well-being."

Answer: 3 Explanation: 1. It has been documented that fewer older adults report mistreatment by family members, which may be a protective act. Caregivers of older adults should be assessed at each primary care visit for caregiver stress, substance abuse, and a history of psychopathology. The Modified Caregiver Strain Index has been recommended by the Hartford Institute of Geriatric Nursing as the best practice in the nursing care of older adults. This instrument is a valid and reliable screening tool and can identify caregivers in need of support. Responding that it ensures that the caregiver is not abusing the patient is not a therapeutic response. 2. It has been documented that fewer older adults report mistreatment by family members, which may be a protective act. Caregivers of older adults should be assessed at each primary care visit for caregiver stress, substance abuse, and a history of psychopathology. The Modified Caregiver Strain Index has been recommended by the Hartford Institute of Geriatric Nursing as the best practice in the nursing care of older adults. This instrument is a valid and reliable screening tool and can identify caregivers in need of support. Responding that it is something that insurance companies expect is incorrect information. 3. It has been documented that fewer older adults report mistreatment by family members, which may be a protective act. Caregivers of older adults should be assessed at each primary care visit for caregiver stress, substance abuse, and a history of psychopathology. The Modified Caregiver Strain Index has been recommended by the Hartford Institute of Geriatric Nursing as the best practice in the nursing care of older adults. This instrument is a valid and reliable screening tool and can identify caregivers in need of support. 4. It has been documented that fewer older adults report mistreatment by family members, which may be a protective act. Caregivers of older adults should be assessed at each primary care visit for caregiver stress, substance abuse, and a history of psychopathology. The Modified Caregiver Strain Index has been recommended by the Hartford Institute of Geriatric Nursing as the best practice in the nursing care of older adults. This instrument is a valid and reliable screening tool and can identify caregivers in need of support. The nurse should not state that the reason is to complete paperwork.

19) An older client with difficulty sleeping wants to use an herbal remedy to help getting to sleep since problems with hay fever and nasal congestion are interfering with "drifting off" at night. Which herbal remedy should the nurse caution the client to avoid? 1. Lemon balm 2. A glass of warm milk 3. A cup of chamomile tea 4. A small turkey sandwich

Answer: 3 Explanation: 1. Lemon balm is a natural remedy to induce sleep and could be used by this client. 2. Warm milk is a natural remedy to induce sleep and could be used by this client. 3. The use of chamomile products is contraindicated with allergies to ragweed. The client has hay fever and seasonal allergies, which may be associated with ragweed. 4. A turkey sandwich is a natural remedy to induce sleep and could be used by this client.

11) An older client who is hospitalized has been having difficulty sleeping since admission and is prescribed a low dose of zolpidem (Ambien). Why is the nurse most concerned about administering this medication? 1. It is not a natural option like melatonin. 2. It is associated with daytime hangover and sleepiness. 3. The client is documented as being on fall precautions. 4. The client takes diphenhydramine (Benadryl) for allergies.

Answer: 3 Explanation: 1. Melatonin is a hormone that is naturally produced by the pineal gland in the human. Melatonin is sold in pharmacies and health food stores and has been effective in improving sleep in some people. 2. With any sleep-inducing medication, daytime sleepiness is a potential. This can be reduced or eliminated by taking the drug earlier in the evening. 3. Ambien is not recommended for use at all in older adults due to risks such as delirium, falls, and fractures. This drug does not work well for this age group. 4. Zolpidem should not be used with diphenhydramine (Benadryl). Diphenhydramine is an antihistamine and is not recommended as a medication for sleep because of anticholinergic side effects and the potential to adversely affect respiratory function.

18) An older client receiving intravenous morphine sulfate is experiencing nausea and vomiting. What action should the nurse take at this time? 1. Provide the client with meperidine for pain as prescribed. 2. Suspend the use of morphine and use a different opioid analgesic. 3. Provide a prescribed antiemetic for a few days and gradually taper it. 4. Discuss using nonopioid analgesics since the client cannot tolerate them.

Answer: 3 Explanation: 1. Meperidine is not a recommended medication for pain control in the older client because of harmful metabolites. 2. The client needs to develop tolerance to the morphine. Another opioid analgesic may produce the same side effects of nausea and vomiting. 3. Opioid analgesics are associated with nausea and vomiting. The use of an antiemetic can be implemented for a short period and then withdrawn. The client will then be able to tolerate the opioid. 4. The client's level of pain is severe in that intravenous morphine is being used. Nonopioid analgesics may not help control this client's pain.

17) An older client in a long-term care facility does not sleep much at night and prefers to stay up late reading. The client takes "power naps" during the day. How should the nurse respond to this client's plan to acquire adequate sleep? 1. "Daytime napping is a positive method to restore the missed sleep time at night." 2. "You do not need the same quantity of sleep as younger adults." 3. "If you feel like you are getting enough rest at night, a daytime nap is acceptable." 4. "There is no problem as long as the total number of hours slept per 24-hour period is at least 8."

Answer: 3 Explanation: 1. Naps do not replace the needed rest lost at night. Longer sleep cycles are essential. However, if the client prefers napping, is not experiencing cognitive issues, and is overall satisfied with the quality of nighttime sleep, the nurse does not have to address this further. 2. Older people do need similar amounts of sleep as younger adults. Older adults often do sleep less due to individual differences, medical conditions, or increased incidence of insomnia, but the physiological sleep requirements are the same. 3. Napping during the day may make it more difficult to get to sleep at night. If the client feels rested and comfortable with their sleep pattern, the nurse should support this rather than making the client conform to typical nighttime sleep patterns. 4. The goal of adequate sleep is not that the client achieves a certain number of hours. Some clients will do well with less and some require more hours of sleep. The outcome of good sleep is positive cognitive functioning.

7) An older patient is experiencing exploitation. The nurse recognizes this when the client states: 1. "My son, who I live with, only helps me bathe once a week." 2. "Sometimes, my daughter, gets frustrated with me and hits me." 3. "My neighbor will not drive me to the grocery store unless I buy their groceries too." 4. "My daughter said she will stay and take care of me, but goes out every night with her friends."

Answer: 3 Explanation: 1. Neglect involves failure to provide adequate care or services for an older adult. 2. Abuse is any action or inaction harming or endangering the welfare of an older adult. 3. Elder mistreatment by exploitation involves the abuser taking advantage of the older person for monetary or personal benefit. This is the case in which the older patient is being coerced to buy the neighbor's groceries. 4. Abandonment is the desertion or willful forsaking of an older person.

7) The nurse is most concerned about which assessment finding in an older client with sleep apnea? 1. The client's body mass index is 48.7. 2. The client takes a sleeping medication at night. 3. The client has a family history of sudden death. 4. The client has added pillows for sleep at night.

Answer: 3 Explanation: 1. Obesity is associated with sleep apnea. Obesity does make sleep apnea much worse. 2. Persons with sleep apnea seldom achieve deep sleep because of frequent brief awakenings to end the apneic episodes. Sedative-hypnotics are often prescribed for sleep and are contraindicated in the client with sleep apnea due to inability to arouse when needed during apneic episodes. 3. The person with sleep apnea is subject to episodes of hypoxemia, which increases the risk for sudden death and stroke. A family history of sudden death often indicates familial cardiovascular disease leading to death. This indicates the client is at high risk from complications of unmanaged sleep apnea. 4. In sleep apnea, the muscles in the throat, soft palate, and tongue relax during the night and cause airway obstruction. As the condition worsens, the client will sit more upright during sleep to deal with apneic episodes and feelings of choking in the night.

22) The nurse is treating a skin tear on an older patient's lower leg. Which dietary selection contains ingredients that will be most favorable to wound healing for this patient? 1. Cereal, milk, and toast 2. Bacon, toast, and coffee 3. Eggs, toast, and orange juice 4. Ham slices, milk, and applesauce

Answer: 3 Explanation: 1. Protein and vitamin C are needed for tissue healing. Cereal, milk, and toast do not contain the most amounts of healing foods for the patient. 2. Protein and vitamin C are needed for tissue healing. Bacon, toast, and coffee do not contain the most amounts of healing foods for the patient. 3. Protein and vitamin C are needed for tissue healing. Eggs and orange juice contain the most amounts of healing foods for the patient. 4. Protein and vitamin C are needed for tissue healing. Ham slices, milk, and applesauce do not contain the most amounts of healing foods for the patient.

10) An older patient is experiencing self-neglect. A nurse recognizes this after the client states: 1. "My son sometimes calls me stupid and annoying." 2. "Those bruises are from my grandson; he gets frustrated with me sometimes." 3. "Yes, my clothes are a bit dirty, but I live alone and I haven't done laundry in a while." 4. "My nephew had to borrow quite a bit of money, leaving me not enough to buy medication this month."

Answer: 3 Explanation: 1. Psychological abuse involves the infliction of anguish or emotional abuse. 2. Physical abuse is the intentional infliction of physical injury or pain. 3. Self-neglect occurs when mentally competent patients engage in behaviors that threaten their own safety and well-being. Failure to maintain proper hygiene practices falls into this category of elder mistreatment. 4. Financial exploitation is taking advantage of an older person for monetary or personal benefit.

20) The nurse working in a long-term care facility is coordinating a screening for depression. Which is the primary benefit of this event? 1. Educates family about signs of depression 2. Allows family to lower their expectations of their loved one 3. Identifies symptoms of depression often associated with chronic illness and pain 4. Allows early intervention with antidepressant medication

Answer: 3 Explanation: 1. Screening an older patient for depression allows for earlier identification and treatment. Education to the family would follow. 2. Screening older patients for depression is not done to lower expectations from older patients' family members. This action helps to identify those patients who need intervention to treat depression. 3. Depression is the mental health problem of greatest frequency and magnitude in the older population. The risk of depression in the older person increases with other illnesses and when ability to function becomes limited. Symptoms of depression are often associated with chronic illness and pain. 4. Depression in older adults is often undetected and untreated. Non-pharmacological approaches are the first line of care for depression.

1) During a home visit of an elderly married patient, the nurse observes listlessness, dry and cracked skin, and skin irritation on both inner thighs; what type of neglect should the nurse be concerned with? 1. Self-neglect 2. Sexual abuse 3. Caregiver neglect 4. Financial exploitation

Answer: 3 Explanation: 1. Signs and Symptoms of self-neglect include dehydration, malnutrition, unattended or untreated health problems, listlessness, decubitus ulcers, urine burns, and history of being left alone. Often, the older adult is suspicious and refuses to accept offers of outside help. 2. Signs and Symptoms of sexual abuse include genital bruising, rectal bleeding, and unexplained sexually transmitted diseases. 3. Listlessness, dry/cracked skin, and skin irritation on both inner thighs could indicate urine burns, which is a manifestation of caregiver neglect. 4. The unexplained inability to pay bills or purchase necessary items such as food, shelter, and medication is indicative of financial exploitation.

6) An older patient with cardiac disease has frequent sleep problems and insomnia. How would the nurse describe these manifestations? 1. Abnormal sleep disturbances due to chest pain 2. Predictive signs of respiratory disease 3. Negative symptoms of stress and anxiety 4. Expected manifestations of cardiac disease

Answer: 3 Explanation: 1. Sleep problems due to chest pain are not normal signs for older patients. 2. There is no information to suggest that sleep problems and insomnia are predictive signs of respiratory disease. 3. Symptoms that indicate an older person may be suffering negative effects of stress include sleep problems and insomnia. 4. There is no information to suggest that sleep problems and insomnia are expected manifestations of cardiac disease.

22) An older client with arthritis pain asks the nurse what can be taken to help with the mild discomfort. How should the nurse respond to this client? 1. "How would you rate this pain on a scale of 0-10?" 2. "Non pharmacological methods are best for mild pain." 3. "Acetaminophen or ibuprofen are good choices for mild pain." 4. "If you have a history of stomach ulcers, you can't take anything."

Answer: 3 Explanation: 1. The client has already stated that the pain is mild. The client has asked what medication is useful for mild discomfort. 2. The client specifically asked about medication. The nurse can offer additional suggestions, but would not dismiss the client's question. 3. Acetaminophen (Tylenol) is a good choice for mild to moderate pain caused by osteoarthritis. The client should check with the healthcare provider about the dose if taking it for more than a few days. 4. Clients with stomach ulcers can achieve adequate pharmacological pain relief with guidance from the health care provider.

12) A new nurse is caring for an older patient who is nearing death. What is the nurse's best action before caring for this patient? 1. Confirm the patient's Do Not Resuscitate status. 2. Review the facility's policy on post-mortem care. 3. Reflect and examine personal feelings and fears about death. 4. Contact the funeral home to notify of impending death.

Answer: 3 Explanation: 1. The nurse does need to be aware of the patient's code status but this is not the first thing that the nurse needs to do prior to caring for the patient. 2. The nurse does need to be aware of the facility's policy on post-mortem care but this is not the priority action. 3. Nurses must be confident in their clinical skills when caring for the dying, and aware of the ethical, spiritual, and legal issues they may confront while providing end-of-life care. Many feel that the first step in the process is confronting their own personal fears about death and dying. By addressing their own fears, nurses are better able to help patients and families when they are confronted by impending death. The nurse may then be more objective in recognizing and respecting the patient's and family's values and choices that guide their decisions at the end of life. 4. Funeral arrangements do not need to be made prior to the patient's death and notification to the funeral home is not made until death has occurred.

18) The daughter of an older patient sees a reddened area on the patient's coccyx and wants to massage the area to improve circulation. What response by the nurse is indicated? 1. "I will record these findings in the medical record." 2. "I will need to obtain an order from the physician to perform a massage." 3. "Massaging the area twice a day would help circulation." 4. "It is best to hydrate the skin with a moisturizer."

Answer: 3 Explanation: 1. The nurse needs to do more than state that this finding will be recorded in the patient's medical record. 2. A massage does not require a physician's order. 3. The presence of redness may indicate the presence of a stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted. 4. Keep the skin clean and dry and hydrate the skin with a moisturizer.

23) The nurse is concerned that an older client who lives with her son is at risk for psychopathology abuse. What assessment findings are consistent with this theory? 1. The son tends to yell at her if she does not fully assist him with her bathing. 2. The son does not allow her to go to any of her quilting group classes. 3. The son witnessed his mother endure frequent beatings from his father. 4. The son who she lives with drinks 10-12 beers every night of the week.

Answer: 3 Explanation: 1. The situational theory of elder abuse believes that as the care burden increases, the caregiver's capacity to meet the needs of the older adult may be strained. 2. The isolation theory of elder abuse believes that mistreatment is prompted by a dwindling social network. 3. In the transgenerational theory of elder abuse, elder mistreatment is thought to be a part of a family violence continuum, which may begin with child abuse and end with elder mistreatment. 4. In the psychopathological theory of elder abuse, caregivers who have preexisting conditions may have impaired capacity to give appropriate care, such as a caregiver with alcohol dependency may not be able to exercise appropriate judgment in caregiving of an older adult, which can ultimately lead to abuse or neglect.

12) The nurse is caring for an older patient diagnosed with melanoma of the nail. What might the nurse find during the physical assessment? Select correct answer. 1. Decreased skin thickness around the nail beds. 2. A sore, rough, scaly, reddened papule around the nails. 3. A longitudinal pigmented band. 4. Indurated scaly plaques, papules, or nodules near the nail bed

Answer: 3 Explanation: 1. This is a normal age related finding. 2. Erythematous actinic keratosis appears as a sore, rough, scaly, reddened papule or plaque and is not indicative of melanoma of the nail. 3. A longitudinal pigmented band is indicative of melanoma of the nail. 4. Squamous cell carcinoma of the skin originates in the higher levels of the epidermis. It appears as flesh-colored to erythematous, indurated scaly plaques, papules, or nodules and may have ulceration or erosions in the center

23) During a routine physical examination, an older client reports having problems falling asleep at night despite engaging in vigorous activities to become tired in the evening. How should the nurse respond to the client? 1. "You should vary your routine each day." 2. "You should time activities to end within an hour of bedtime." 3. "Exercise should be done before the evening meal." 4. "Concentrate exercise toward the morning hours."

Answer: 3 Explanation: 1. Varying the routine is a positive idea but does not meet the problems presented by the client. 2. Exercise close to bedtime can cause difficulty falling asleep. 3. Exercise should not be done closer than three hours to bedtime. 4. The client may not prefer morning exercise. Exercise later in the day is fine, as long as it is not near bedtime.

13) An older client, experiencing severe pain from diabetic neuropathy, is having minimal pain relief from opioid analgesics. Which adjuvant medications should the nurse ask the healthcare provider to consider helping this client's pain? Select all that apply. 1. Calcitonin 2. Muscle relaxants 3. Topical analgesics 4. Tricyclic antidepressant 5. Antianxiety medications

Answer: 3, 4 Explanation: 1. Calcitonin is helpful to assist with bone pain. It is not indicated to help with the pain of diabetic neuropathy. 2. Muscle relaxants help when there is a muscle component to the pain. This does not occur with diabetic neuropathy. 3. Topical analgesics are helpful for the pain of diabetic neuropathy. 4. Tricyclic antidepressants are helpful for the pain of diabetic neuropathy. 5. Antianxiety medications are helpful when the client is anxious or has muscle spasms. They are not indicated for diabetic neuropathy.

3) An older patient is accompanied by an adult daughter who is the patient's primary caregiver for a routine clinic visit. During the examination, what would indicate caregiver role strain in the daughter? 1. She expresses concerns over medication usage. 2. She is reading a magazine during the vital sign assessment. 3. She is on the phone with her husband discussing evening plans for dinner. 4. She does not ask any questions during the physical assessment done by the nurse.

Answer: 4 Explanation: 1. Caregivers of older adults should be assessed at each primary care visit for caregiver stress. If she is involved and asking questions, she is likely managing well. 2. Caregivers of older adults should be assessed at each primary care visit for caregiver stress. If she is reading a magazine during vital signs, it may not be indicative of role strain. 3. Caregivers of older adults should be assessed at each primary care visit for caregiver stress. If she is on the phone arranging dinner, she is likely managing well. 4. Caregivers of older adults should be assessed at each primary care visit for caregiver stress. If she is not asking any questions and acting disinterested during the assessment, she may be experiencing caregiver role strain.

16) An older patient with terminal cancer asks the nurse to explain palliative care. How should the nurse respond to this patient? Select all that apply. 1. "It is the same as hospice care." 2. "It is always provided in the home." 3. "It can be provided along with life-prolonging care." 4. "It is helpful for chronic health problems for which there is no cure." 5. "It improves the quality of life while facing a life-threatening illness."

Answer: 3, 4, 5 Explanation: 1. Palliative care is not the same as hospice care. Palliative care is focused on the relief of suffering in an attempt to achieve the best possible quality of life for patients with serious illness and their families. Hospice care is focused on support and care for the patient in the last phase of an incurable disease so that the patient may live life as fully and comfortably as possible. 2. Palliative care can take place across all care settings. 3. Regardless of the stage of the disease or the need for curative therapies, palliative care is appropriate for patients with life-limiting, serious illness. It can be delivered concurrently with life-prolonging care or as the main focus of care. 4. Although palliative care can be delivered to patients of any age, it is especially appropriate when provided to older people who have progressive chronic illnesses. 5. Palliative care is an approach that improves the quality of life of patients and their families facing the problem associated with life-threatening illnesses.

22) The nurse is planning an educational session on suicide in the older patient population. What information should the nurse include in this presentation? Select all that apply. 1. An older patient does not have the physical strength to commit suicide. 2. A patient should never be questioned about suicide intent. 3. Suicide rates are the highest in people age 65 and older. 4. An older person who contemplates suicide is more likely to complete the act than a younger person. 5. Many older adults who commit suicide had visited their primary care physician within the previous month.

Answer: 3, 4, 5 Explanation: 1. Suicide can occur by methods that do not require physical strength to perform. 2. Suicide intent is part of the nursing assessment for depression. 3. Older persons age 65 and over have the highest suicide rates of all age groups. 4. An older person who contemplates suicide is more likely to complete the act than a younger person because older people often employ lethal methods when attempting suicide, experience greater social isolation, and generally have poorer recuperative capacity, which makes them less likely to recover from a suicide attempt. 5. Approximately 70 percent of older adults who commit suicide had visited their primary care physician within the previous month.

6) An older client asks why sustained-release pain medication cannot be chewed. How should the nurse respond to this client? Select all that apply. 1. Chewing deactivates the medication. 2. The medication is damaging to the teeth and gums. 3. Chewing destroys their controlled-release properties. 4. The saliva in the mouth breaks the medication down and makes it toxic. 5. Chewing causes a rapid absorption of the entire dose and a possible overdose.

Answer: 3, 5 Explanation: 1. Chewing sustained-release preparations of analgesics destroys their controlled-release properties and causes rapid absorption of the entire dose, resulting in possible overdose. Chewing does not deactivate the medication. 2. Chewing sustained-release preparations of analgesics destroys their controlled-release properties and causes rapid absorption of the entire dose, resulting in possible overdose. The medication is not damaging to the teeth and gums. 3. Chewing sustained-release preparations of analgesics destroys their controlled-release properties. 4. Chewing sustained-release preparations of analgesics destroys their controlled-release properties and causes rapid absorption of the entire dose, resulting in possible overdose. The saliva in the mouth does not make the medication toxic. 5. Chewing sustained-release preparations of analgesics causes rapid absorption of the entire dose, resulting in possible overdose.

21) The nurse is planning care for an older client who reports interrupted sleep. Which assessment findings most concern the nurse? Select all that apply. 1. Frequent nighttime urination 2. History of kidney stones 3. Morning headaches 4. Early morning awakening 5. Feeling unable to empty bladder

Answer: 3, 5 Explanation: 1. Older people may be awakened from sleep because of the need to urinate. Common age-related alterations in urinary tract function include nocturia. This is not concerning, but should be assessed further. 2. Kidney stones are not a common age-related alteration in urinary tract function. 3. Reports of morning headaches often indicate sleep apnea, which causes frequent sleep interruptions and can be medically treated. 4. Early morning awakening can be a sign of insomnia, but sometimes it is just the person's habit or preference. This is not concerning, but should be assessed further. 5. Older people may be awakened from sleep because of the need to urinate. Common age-related alterations in urinary tract function include benign prostatic hypertrophy or slight bladder prolapse. These problems can be medically treated.

5) The nurse suspects that an older patient has been physically abused. What must be included in the medical workup for this patient? 1. Pelvic examination 2. Toxicological screening 3. Complete blood count and blood chemistries 4. Complete visual examination with clothing removed

Answer: 4 Explanation: 1. A pelvic examination is indicated for suspected sexual abuse. 2. Toxicological screening is indicated for suspected drug abuse. 3. Complete blood count and blood chemistries would be indicated if concerns included neglect reflected by malnutrition and dehydration. 4. If you suspect elder mistreatment or abuse, a complete visual examination of the older person without clothing is necessary. Abusers may strike where clothing hides the resulting bruises. You can protect privacy by assessing the older person's body one area at a time from head to toe.

21) The nurse is assessing an older patient in a long-term care facility. Which observation best indicates the need for depression screening? 1. Slight decline in memory 2. Increase in socialization 3. Increased energy and participation 4. Persistent sadness

Answer: 4 Explanation: 1. A slight decline in memory is not unexpected in an older patient. 2. Increased socialization is not a sign of depression. 3. Increases in energy and participation are not signs of depression. 4. Persistent sadness is a sign of depression.

16) The nurse notes a small, indurated, scaled spot on the upper chest of an older patient. The nurse would suspect the physician to diagnose this condition as: 1. Actinic keratosis 2. Basal cell carcinoma 3. Malignant melanoma 4. Squamous cell carcinoma

Answer: 4 Explanation: 1. Actinic keratosis is a precancerous condition. The lesion appears as a sore, rough, scaly plaque. 2. Basal cell carcinoma presents as a small fleshy bump. 3. Malignant melanoma manifests as black, brown, or multicolored nodules or plaques. 4. Squamous cell carcinoma most often appears as a flesh-colored, erythematous, indurated scaly plaque.

21) An older client recovering from surgery refuses pain medication because of the fear of becoming addicted. What action should the nurse take at this time? 1. Contact the physician. 2. Administer the medication when the client is sleeping. 3. Withhold the analgesic medication and continue to observe the client. 4. Determine what methods of pain management are acceptable to the client.

Answer: 4 Explanation: 1. Contacting the physician is premature and the client is not in danger. 2. Administration of the medication that had been refused would be a violation of the client's rights. 3. The nurse needs to do more than observe the client. 4. The risk of addiction in the elderly is rare. Additionally, the risk of addiction is limited when managing acute pain. The client is in pain. Management of the pain is the priority. Determining what the client will consider using is important. During the review of acceptable pain management interventions, the lines of communication will remain open and the client may reconsider the decision.

1) The nurse is caring for an older client who is experiencing sleep deprivation due to a prolonged stay in intensive care. Which manifestation is the nurse most likely to observe in this client? 1. Constant fatigue 2. Gustatory hallucinations 3. Increased activity 4. Need for repeated instructions

Answer: 4 Explanation: 1. Daytime fatigue is more likely in the client with sleep deprivation. 2. The client who is deprived of sleep may experience visual or auditory hallucinations. 3. The client may be more irritable, but this doesn't translate to increased activity. Smell-related hallucinations are less likely. 4. Learning and memory are severely impaired in the client with a lack of sleep, particularly in ICU-associated delirium.

10) The family of an older patient with a terminal illness has been aware of the patient's pending death and is present when the patient dies. The family's reaction to the patient's death was very emotional and demonstrated a state of disbelief. How should the nurse interpret this family's behavior? 1. Irrational behavior 2. Expression of anger 3. Maladaptive coping of the family 4. Normal shock when experiencing the loss of a loved one

Answer: 4 Explanation: 1. Even if the family is expecting the death, the actual notification may be shocking to the family and needs to be handled gently and with empathy. This is not irrational behavior. 2. Even if the family is expecting the death, the actual notification may be shocking to the family and needs to be handled gently and with empathy. This is not an expression of anger. 3. Even if the family is expecting the death, the actual notification may be shocking to the family and needs to be handled gently and with empathy. This is not maladaptive coping of the family. 4. Even if the family is expecting the death, the actual notification may be shocking to the family and needs to be handled gently and with empathy. There is disbelief that death has occurred and may be marked by shock, emotional dullness, and restless behavior that may include stupor and withdrawal. It may include physical characteristics such as nausea or insomnia.

23) Which statement made by an older patient best indicates to the nurse that the patient might be contemplating suicide? 1. "I wish I could stop all of this pain." 2. "I'll beat this cancer even if it kills me." 3. "I'll get through this one day at a time." 4. "I'm no use to anyone. I might as well be dead."

Answer: 4 Explanation: 1. Expressing a desire to have pain end does not indicate that an older patient is contemplating suicide. 2. This statement reflects determination and is not expressing suicidal intentions. 3. This statement reflects facing illness and is not expressing suicidal intentions. 4. The statement that reflects uselessness and being dead is one that should be analyzed for suicidal intentions.

2) An older client reports insomnia. What is the best suggestion the nurse can offer this client? 1. "Taking a nap during the day might help you catch up." 2. "During the week, wake up at the same time every day." 3. "Drink a little liquor or wine just prior to bedtime." 4. "Stay busy during the daytime with social and physical activities."

Answer: 4 Explanation: 1. Generally, the amount of sleep needed is about the same for the youth, middle-aged, and older adult. Though naps work well for some people, it often has the effect of preventing good nighttime sleep. 2. Good sleep patterns include waking and going to sleep at the same time every day, including the weekends. 3. Alcohol can help someone get to sleep, but usually has the effect of disrupting the length of sleep. 4. Staying active helps improve positive energy, makes a clear difference between daytime and nighttime, reduces depression, exposes the person to more daylight usually, and generally helps establish a better daily rhythm.

22) An older patient who is dying has complained of ongoing pain for several days. What is the best way for this patient's pain to be treated at the end of life? 1. Give immediate-release medications routinely. 2. Refrain from administering pain medication at end of life. 3. Administer maximum doses of long and short-acting pain medication routinely. 4. Give long-acting medications routinely and immediate-release doses with breakthrough pain.

Answer: 4 Explanation: 1. Immediate-release agents are excellent prn medications and should only be used to control breakthrough pain. 2. Pain management is an important role of the nurse during end of life. Pain medication should not be withheld if the patient is in pain and pain medication is ordered. 3. Immediate-release agents are excellent prn medications. Long-acting agents are used for consistent pain. However, the patient's pain should be assessed and monitored, with the appropriate dosages given accordingly. 4. Long-acting drugs or sustained-release formulations are ideal because they provide consistent pain relief. Immediate-release agents are excellent prn medications and should only be used to control breakthrough pain.

15) The nurse is implementing sleep restriction therapy with an older client. What intervention will be performed to support this plan of treatment? 1. Structuring client naps to occur midmorning and midafternoon 2. Putting on the television in the room after getting the client ready for sleep 3. Teaching the client to watch the second hand move on the clock while waiting to fall asleep 4. Planning to wake the client up at the same time each morning regardless of the sleep obtained

Answer: 4 Explanation: 1. In sleep restriction therapy, naps are to be avoided. 2. In sleep restriction therapy, the bed is for sex or sleep and not for watching television. 3. In sleep restriction therapy, clients are instructed to not watch the clock. 4. In sleep restriction therapy, the client is to be woken up from sleep at the same time every morning, regardless of the amount of sleep obtained the previous night.

16) An older client lives in an assisted living facility and is seen reading in the lounge area most nights. Which issue causes the greatest concern for the nurse caring for this client? 1. The client may have significant underlying problems. 2. The client is averaging five hours of sleep every 24 hours. 3. The client occasionally expresses the desire for more sleep. 4. The client is forgetful, irritable, and frequently lethargic.

Answer: 4 Explanation: 1. Insomnia can be the result of a primary psychological or physiological issues, but this is not always the reason for nighttime wakefulness. The nurse would assess for pain, depression, and other difficulties. 2. Most people do require roughly eight hours of sleep each night or desire a daytime nap; however, some people prefer and function well on less sleep. 3. The nurse is concerned about and addresses the client's expressed desire to obtain more sleep. An as-needed dose of a sleeping medication should be requested in response to this report. 4. Insomnia is defined as an inability to fall asleep or stay asleep on most nights and lasting for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience problems with concentration and function. The client who exhibits cognitive symptoms is not getting enough rest.

16) An older client receiving a low dose of oral morphine for chronic pain feels sleepy when taking the medication. What should the nurse explain to the client about this analgesic? 1. "Lowering the dose may reduce these feelings." 2. "Unfortunately you will need to change medications." 3. "Feeling sleepy is an unfortunate problem with morphine." 4. "Once you develop a tolerance to the medications, this will improve."

Answer: 4 Explanation: 1. Lowering the dosage will not meet the ultimate goal, which is pain control. 2. Suggesting a medication change is not within the scope of the nurse's responsibility. 3. Telling the client this is an unfortunate result of the medication does little to meet the client's needs for information and is not the best action by the nurse. 4. Opioid analgesic use is associated with mild sedation initially. Once tolerance develops, the drowsiness should be lessened.

18) An older client has been reading about the use of melatonin for sleep. Which statement best indicates to the nurse that the client understands instruction about taking this supplement? 1. "Melatonin is a hormone my body makes on its own without intervention." 2. "Nausea is the worst side effect associated with melatonin." 3. "Older adults have reduced levels of melatonin and need a supplement." 4. "A melatonin dose should be taken a few hours before bedtime."

Answer: 4 Explanation: 1. Melatonin is a natural hormone produced in the pineal gland. Melatonin is produced by the body, but occasionally in insufficient quantities. There are also sleep aids, like ramelteon, that increase the availability of melatonin in the body. 2. Nausea is a side effect of melatonin. Other side effects include dizziness and drowsiness. The older client who experiences dizziness is at risk for falls and might discontinue melatonin use. 3. Older people often do have reduced levels of melatonin. Many older adults do not take and do not need a melatonin supplement. 4. Melatonin needs 3-5 hours to work for inducing sleep.

13) The son of an older patient is concerned about the patient's ongoing forgetfulness and asks the nurse to explain what could be wrong with the patient. How should the nurse respond to the son? 1. "Memory difficulties are hard for family members to deal with." 2. "My parents are the same age as yours, and they can't remember anything." 3. "Forgetfulness is common in older adults. It's nothing you need to worry about." 4. "Memory difficulties can be due to underlying issues including anxiety, chronic pain, or depression."

Answer: 4 Explanation: 1. Memory difficulties are difficult for family members to deal with, but this is not the most appropriate statement at this time. The nurse is discounting the son's feelings. 2. The nurse is showing sympathy with the statement about the parents but is not addressing the son's feelings. 3. Forgetfulness is common in older adults, but this statement is not therapeutic. 4. Cognitive changes can be due to anxiety, chronic pain, depression, or Alzheimer's disease.

14) Hospice care has been ordered in the home for an older patient who is terminally ill. What is the hospice nurse's priority assessment? 1. Assess the patient's need to be admitted to the hospital. 2. Assess the patient's financial ability to pay for hospice service. 3. Assess the patient's funeral and burial arrangements. 4. Assess the patient's needs to be comfortable at home.

Answer: 4 Explanation: 1. Most Americans express a preference to die in their own homes. The hospice nurse should not discuss that the patient be admitted to a hospital. 2. There is no charge for hospice services. 3. Patients may chose to participate in their funeral arrangements and burial details but this is not the priority assessment. 4. Most Americans express a preference to die in their own homes. The hospice nurse should find out what the patient needs to be comfortable at home during death.

1) An older client with a history of severe arthritis has not received pain medication for over 18 hours. The client is currently complaining of severe pain in both legs. What will the nurse attribute as being the reason for the client's increase in pain? 1. Dependency on narcotics 2. Over-exaggeration of the amount of pain 3. Need for alternative measures for pain relief 4. Untreated pain resulting in lower pain threshold

Answer: 4 Explanation: 1. Narcotic dependency in the older adult is unlikely. 2. Pain is whatever the client says it is. The nurse cannot assume that the client is over-exaggerating the amount of pain being experienced. 3. Alternative measures may be helpful, but something else is needed to help the client with severe pain. 4. With untreated pain, the nociceptors become sensitive and more responsive to stimuli resulting in a lowered pain threshold. This client experienced a long period of time between administrations of pain medication, and this causes an increase in the pain experienced.

10) The nurse explores nonpharmacological approaches with an older client with chronic osteoarthritis pain. What is the best action for the nurse to teach to the client? 1. Weight control should eliminate osteoarthritis-related knee pain. 2. Avoid activities that increase osteoarthritis-related discomfort. 3. When pain medications are taken regularly, other pain interventions are not needed. 4. Daily swimming is a useful adjunct to prescribed pain medication.

Answer: 4 Explanation: 1. Nonpharmacological approaches are more effective when used with pharmacological therapy. Though weight loss or control can help with pain, it is not an expectation that this is the only intervention required. 2. Avoiding activities that increase pain is not always possible or advisable. The client should limit exposure to uncomfortable activities or positions. 3. Pharmacological interventions work better when used with non pharmacological interventions. 4. Greater reductions in pain are seen when pharmacological and nonpharmacological techniques are combined.

16) An older patient's spouse passed away 4 years ago; however, the patient still sets a place at the dinner table for the spouse and has never removed any clothing or other personal items from the home. What does the nurse suspect the patient is experiencing? 1. Normal grief 2. Hopelessness 3. Survivor guilt 4. Pathological grief

Answer: 4 Explanation: 1. Normal grief is that which lasts within a 2-year time frame. 2. Hopelessness is when the patient sees no hope in life. This is not what the patient is experiencing. 3. Survivor guilt is associated with a traumatic event where a person survives when another loved one does not. 4. Grief persisting longer than 2 years is considered pathological in the United States.

7) An older patient with heart and end-stage renal failure is hearing things and seeing things that others do not. How does the nurse best describe this finding? 1. Deteriorating sense of vision and hearing 2. Late-onset mental illness 3. Overdose of narcotic medication 4. Visual and auditory hallucinations at the end of life

Answer: 4 Explanation: 1. Respiratory, neurological, and cardiac changes are more likely to indicate impending death. Senses may become more heightened during the dying process. 2. Visual and auditory hallucinations in the terminally ill patient do not indicate a mental illness. 3. Visual and auditory hallucinations in the terminally ill patient do not occur because of an overdose of narcotic medication. A change in respiratory status would indicate an overdose of narcotic medication. 4. Terminal delirium presents as confusion, restlessness, and/or agitation, with or without day—night reversal. Visual, auditory, and olfactory hallucinations may occur during this time. It is important for the nurse to understand that this condition is irreversible.

4) An older client takes meperidine daily for arthritic pain. Which finding is most concerning? 1. The client has a low glomerular filtration rate. 2. The client is arousable only to touch and voice. 3. The client has a history of a seizure disorder. 4. The client reports headaches, dizziness, and ataxia.

Answer: 4 Explanation: 1. The client with decreased kidney function is at risk for accumulating toxic metabolites more easily, leading to complications. This potential risk is less concerning than current assessment findings. 2. Good pain management can sometimes result in a client who is sleepy. As long as the respiratory rate and depth is adequate and the client is arousable, there is no serious concern. 3. The metabolite buildup from meperidine can result in seizures, but the client's history of seizures represents a potential increased seizure risk rather than a current concerning finding. 4. Meperidine is not recommended for treatment of persistent pain in older persons because it tends to cause accumulations of toxic metabolites that can cause delirium, ataxia, and dizziness.

13) When documenting suspected abuse of an older patient, it is important that the nurse document: 1. The nurse's subjective data and opinion. 2. The nurse's suspicion and personal conclusions. 3. Photographic evidence provided by the family and friends. 4. Objective data of the older patient's reaction when the suspected abuser is present.

Answer: 4 Explanation: 1. The nurse should present the facts objectively and not include personal conclusions or other incidents not related to the case. 2. The nurse's suspicion and personal conclusions of abuse should not be shared in the report to adult protective services. 3. Photographic documentation is especially helpful in cases where there is observable evidence, but photos brought by family members are not proof. 4. Older adults who appear fearful when in the presence of a suspected abuser will need careful assessment as this may be a warning sign of mistreatment. Physical indicators of elder mistreatment that are clearly described will assist interdisciplinary members with diagnosis as well as with planning goals of patient care.

6) The family of an older patient dying of liver cancer is concerned that the patient will not eat or drink. The patient is alert and oriented, and expresses no desire to eat. What nursing action would be best? 1. Request an order from the physician for a feeding tube. 2. Obtain a dietary consult for feeding supplements. 3. Encourage the family to bring in home-cooked food. 4. Comply with the patient's wishes despite the family's concern.

Answer: 4 Explanation: 1. The patient's wishes should be respected. The nurse should educate the family and reassure them that anorexia may result in ketosis that can lead to a peaceful state of mind and decreased pain. 2. The patient's wishes should be respected and a request for a dietician consultation does not support those wishes. 3. The patient's wishes should be respected and family should refrain from bringing food into the hospital for the patient. 4. Anorexia and dehydration are common and normal with a patient with a terminal illness. The patient's wishes should be respected.

19) The nurse is caring for an older patient who has been the victim of elder abuse by his adult son. Which assessment finding would support the transgenerational violence theory of elder mistreatment? 1. The son drinks 6—8 beers every night of the week. 2. The son watched his father consistently beating his mother. 3. The son has given up his full-time job to care for his father. 4. The son suffered physical beatings frequently when he was a child.

Answer: 4 Explanation: 1. The son being an alcoholic is an example of the psychopathology theory of abuse. 2. The son witnessing the father beating the mother is an example of the learned theory of abuse. 3. The care of the patient overwhelming the son is an example of the psychopathology theory of abuse. 4. The transgenerational violence theory suggests that elder mistreatment is thought to be part of the family violence continuum. It begins with child abuse and ends with elder abuse.

25) A newly licensed nurse is preparing to provide postmortem care for the first time and asks for help. What is the staff nurse's best response? 1. "Postmortem care is something that a nurse must learn to do. Take out all tubes and clean the body." 2. "Family members rarely ask to see the body so just clean the deceased from the shoulders and up." 3. "You can delegate this to the nursing assistant since it is within their scope of care." 4. "Providing postmortem care shows respect and dignity to the patient. But I can understand that you are nervous."

Answer: 4 Explanation: 1. The staff nurse should not make an insensitive comment. This does not demonstrate respect for the recently deceased patient. 2. Families do care about the body of their deceased loved one. This comment is inappropriate for the staff nurse to make. 3. Postmortem care is not delegated to nursing assistants. 4. Postmortem care needs to be done promptly, quietly, efficiently, and with dignity, so that it is communicated to the family that the deceased was valued and respected.

19) While organizing a walking program at an assisted living facility, one resident asks why older people should exercise. Which is the nurse's best response? 1. "You aren't too old to exercise." 2. "Older people often forget to exercise." 3. "Your doctor has ordered it." 4. "Exercise can reduce stress and improve physical health."

Answer: 4 Explanation: 1. The statement "You aren't too old to exercise" does not answer the resident's question. 2. Memory problems are not a normal part of aging. 3. Having a doctor's order does not answer why exercise is beneficial. 4. Exercise can help to break the cycle of long-term negative effects of stress and reduce the harmful effects of elevated cortisol levels caused by stress.

6) The nurse is concerned that specific families in a community are at increased risk for transgenerational violence. Which family situation exemplifies the transgenerational theory of violence? 1. Family with a daughter who has severe arthritis and finds it increasingly difficult to deal with her forgetful, frail mother 2. Family with a daughter who abuses alcohol whose father was a chronic alcoholic and is currently suffering from cirrhosis 3. Family with a daughter who is working two jobs with significant debts and cares for her father, who is becoming more confused and dependent 4. Family with a son who, as a teenager and young adult, had serious arguments with both of his parents, who were emotionally and sexually abusive to him

Answer: 4 Explanation: 1. The theory of psychopathology of the abuser refers to caregivers who have preexisting conditions that impair their abilities to provide proper care, as in the case of an adult child with severe arthritis. 2. The theory of psychopathology of the abuser refers to caregivers who have preexisting conditions that impair their abilities to provide proper care, as in the case of an adult child who has an ongoing alcohol abuse problem. 3. Situational theory or caregiver stress involves care burdens that outweigh the caregiver's abilities to deliver care. Examples of caregiver stress are severe financial or time constraints paired with the older adult requirements for more physical care or supervision. 4. The theory of transgenerational violence involves a continuum of family violence. A child grows up in a home where there is a contentious family relationship and some form of abuse is the norm. Then, the child who was abused grows up and later becomes aggressive and abusive to the elderly parent.

6) The nurse is assessing an older patient's stage III pressure ulcer. What would be indicative of proper wound healing? 1. An increase in wound depth 2. Large amount of undermining 3. Presence of leathery black tissue 4. Beefy red and moist, grainy appearance

Answer: 4 Explanation: 1. The wound increasing depth is indicative of improper healing. 2. The wound's undermining does not indicate an improvement in healing. 3. Eschar is a sign of delayed wound healing. 4. Healing of a decubitus fills from the wound bottom so the depth decreases before the wound width decreases. The beefy red and grainy appearance is evidence of granulation tissue as the capillary bed builds. These are all indicators of good wound healing.

24) The spouse of an older client asks that the client be given pills and to tell the client that they are for pain. How should the nurse respond to the spouse's request? 1. "I have to tell the client what each pill is for." 2. "I will explain to the client that pain is normal with aging." 3. "Let's speak with the health care provider about this request." 4. "Administering a placebo pill is not ethical."

Answer: 4 Explanation: 1. This is a true statement, but does not address the spouse's question. 2. Pain is not a normal part of the aging process, and this does not address the spouse's request. 3. The consideration of lying to the client is inappropriate. 4. The use of placebos is not ethical in clinical practice for management of pain. Placebos should be limited to research protocols, where clients have given informed consent and are aware that they may receive an inert medication as part of the research protocol.

4) The nurse is admitting an older patient who requires a cane for ambulation, bilateral hearing aids, and monthly vitamin B12 injections. The daughter of the patient tells the nurse that the patient no longer remembers how to use a toothbrush or turn on the television set. Which information requires further assessment? 1. Vitamin deficiency 2. Loss of hearing 3. Assistive device for ambulation 4. Cognitive change

Answer: 4 Explanation: 1. Vitamin deficiency is being currently treated with medication and does not require further, immediate assessment. 2. Hearing loss is compensated with hearing aid devices and does not require further, immediate assessment. 3. Using a cane for ambulation compensates for unstable ambulation and does not require further, immediate assessment. 4. Normal, healthy older persons who forget what an item is used for or how to use it should be referred for further evaluation and treatment.

9) The nurse is teaching assisted living center residents about over-the-counter skin preparations. Which should be used with caution in an older patient? Select all that apply. 1. Sunblock SPF 50 2. Super-fatted soaps 3. Emollients that keep the skin moist 4. Steroid-based ointments and creams 5. Topical lotion with an antihistamine

Answer: 4, 5 Explanation: 1. Sunblock is appropriate to protect for UV exposure to the sun. 2. Super-fatted soaps are appropriate treatments for dry skin. 3. Emollients are an appropriate treatment for dry skin. 4. Older adults have a high rate of adverse reactions to corticosteroids, which are frequently prescribed for skin problems. Older adults should be reminded not to buy over-the-counter preparations of this drug without specific instructions from the primary care provider. If this medication is prescribed, directions should be strictly followed and any unusual symptoms reported promptly. 5. Older adults have a high rate of adverse reactions to antihistamines, which are frequently prescribed for skin problems. Older adults should be reminded not to buy over-the-counter preparations of this drug without specific instructions from the primary care provider. If this medication is prescribed, directions should be strictly followed and any unusual symptoms reported promptly.

10. An older person is prescribed escitalopram to help with feelings of depression. What information in the person's medical history supports the selection of this medication? A. Orthostatic lymphedema B. Benign prostatic hypertrophy C. Osteoarthritis D. Diverticulitis

B. Benign Prostatic Hypertrophy Rationale: Some geriatricians prefer to use the selective serotonin reuptake inhibitors (SSRIs) as first-line drugs for many older persons, especially those benign prostatic hypertrophy. Escitalopram is an SSRI and would be appropriate for this person. There is not a specific antidepressant medication identified in the person with a history of diverticulitis, osteoarthritis, or orthostatic lymphedema.

5. An older adult has visibly darker and more weathered skin over the face, arms, and lower legs. What should the nurse suspect as the reason for this skin change pattern? A. Vitamin deficiency B. Photoaging C. Low fat diet D. Dehydration

B. Photoaging Rationale: The older adult who has spent a lot of time outdoors, either for work or leisure, may have long-term UVR damage known as photoaging, the damage that is done to the skin from lifelong exposure to UV radiation. These changes occur on exposed areas such as the face, neck, arms, and hands and include freckling, loss of elasticity, damaged blood vessels, and a general coarse and weathered appearance. This skin change is not caused by dehydration, a low-fat diet, or a vitamin deficiency.

8. The nurse notes that an older person is prescribed a total-protein level. Which physical assessment finding would support this laboratory test being used as an indication of elder mistreatment? A. Body wounds and bruises at various stages of healing B. Inability to remember recent events C. Shortness of breath with ambulation and mild exertion D. Weak hand grasps

B. Body wounds and bruises at various stages of healing Rationale: Wounds and bruises at various stages of healing could indicate repeated episodes of elder physical mistreatment. Weak hand grasps could be an expected change based upon the person's age. Loss of short-term memory is a sign of cognitive impairment and does not indicate elder mistreatment. Shortness of breath with ambulation could indicate chronic lung disease, bleeding, chronic renal failure, or anemia caused by poor nutritional status.

5. The nurse prepares to assess for the presence of pain in the older person with dementia. What should the nurse include when using the Pain Assessment In Advanced Dementia scale to assess this older person? A. Heart rate B. consolability C. Pupil response D. Blood pressure

B. Consolability Rationale: The Pain Assessment IN Advanced Dementia scale assesses five areas: breathing, negative vocalization, facial expression, body language, and consolability. Heart rate, pupil response, and blood pressure are not assessed to determine the presence of pain using this pain scale.

6. An elder person with a terminal illness expresses sadness about dying before seeing children graduate from high school and feels this part of the process is the most painful to experience. What should the nurse do first to help with this person's psychological pain? A. Encourage the person to think of something else B. Discuss this person's needs with the interdisciplinary team C. Suggest the person spend more time with the children now D. Offer analgesics to support physical comfort needs

B. Discuss this person's needs with the interdisciplinary team Rationale: The concept of "total pain" must be taken into consideration when assessing for and managing pain at the end of life. Total pain recognizes that pain at the end of life is more than just physical suffering; it also includes associated emotional, social, and spiritual suffering. To enhance quality of life, an interdisciplinary team approach is necessary so that these domains are adequately assessed and relief of all types of pain may be provided. After the team meets, a suggestion might be for the person to spend more time with the children now. Thinking of something else does not address this person's pain. The person is experiencing psychological pain and not physical pain.

9. An older person reports epigastric distress after taking a complementary and alternative therapy supplement for arthritis pain. Which substance should the nurse suspect as the reason for this discomfort? A. Topical Capsaisin B. Glucosamine/ chondroitin C. St. John's Wart D. Lavender oil

B. Glucosamine/ Chondroitin Rationale: Glucosamine/chondroitin is used in patients with osteoarthritis and may provide pain relief to those with moderate to severe pain. There is a risk for mild gastrointestinal side effects including epigastric discomfort and heartburn. Lavender and St. John's wort are not identified as herbal remedies for pain management. Topical capsaisin causes a burning sensation when first applied, though this subsides when applied frequently.

7. An older person reports lying in bed for hours, waiting to fall sleep. What should the nurse suggest to this person? A. Take a walk B. Go to another room C. Turn on the television D. Stay in bed

B. Go to another room Rationale: If unable to sleep, the person should be encouraged to go to another room until feeling sleepy. Staying in bed waiting to fall sleep causes frustration. Exercise should not be done within 3 hours before bedtime. Watching television in bed could be stimulating and further delay the onset of sleep.

7. During a home visit the older person reminds the nurse to lock the door and keep the blinds closed because the neighbors are outside talking about the older person. What should the nurse include when assessing this person? A. Blood pressure B. Hearing function C. Heart rhythm D. Blood glucose level

B. Hearing function Rationale: Hearing loss may place older persons at risk for developing paranoia because they may misinterpret the casual conversation of others and believe they are the focus of the conversation. The onset of paranoia is not associated with an irregular heart rhythm, blood pressure level, or blood glucose level.

7. An older person seeks medical attention for a facial laceration that reportedly occurred by hitting the face on the door of an open kitchen cabinet. Which information in the person's medical record will hinder the nurse's ability to discern if the injury is caused by elder mistreatment? A. Lives with adult daughter and three grandchildren B. Mild cognitive changes associated with Alzheimer's disease C. Cares for an aging spouse with chronic health problems D. Pays for a home-health aide who performs household chores

B. Mild cognitive changes associated with Alzheimer's disease. Rationale: Older adults with cognitive impairment are a challenge. Their self-reporting may be questioned for accuracy or they may be unable to express the mistreatment situation due to amnesia, aphasia, agnosia, or apraxia which commonly occur with dementia. It is often difficult to determine whether the older adult's worsening physical condition is a result of the natural progression of illness or mistreatment on the part of a caregiver. Because some frail older individuals are prone to underlying conditions that give rise to trauma, such as instability of gait and poor vision resulting in falls, it may be difficult for clinicians to differentiate accidental from willful injuries. Living with family, being a caregiver, and paying for help in the home does not impact the nurse's ability to discern if the injury is caused by elder mistreatment.

1. The nurse arrives for a home visit and suspects that the older person is experiencing financial exploitation. Which observation caused the nurse to make this clinical decision? A. Streaks of stool running down the person's legs B. No electricity in the home C. Dry, cracked lips D. Rat droppings on the kitchen floor

B. No electricity in the home Rationale: Signs and symptoms of financial exploitation includes an unexplained inability to pay bills or purchase necessity items such as food, shelter, and medications. The lack of electricity would indicate this type of abuse. Dry cracked lips and stool streaks down the legs would indicate either neglect or self-neglect. Rat droppings would indicate neglect.

9. The administrator is preparing for a site visit of the skilled-nursing facility. Which action indicates that the organization is prepared to address any issues of elder mistreatment to the proper authorities? A. Contact name and telephone number for the local and state Center for Aging B. Policy and process to report elder mistreatment placed in a folder posted in the nurse's station C. Documentation when the most recent staff inservice on fire safety occurred D. Names and numbers of all organization administrators placed near the unit telephones

B. Policy and process to report elder mistreatment placed in a folder in the nurse's station. Rationale: Evidence that the organization is prepared to address issues of elder mistreatment include having the organization's policy and procedure on elder mistreatment along with the telephone number and reporting process in a location for all staff to have access. Elder mistreatment is not reported to the Center for Aging. Fire safety is not the same as elder mistreatment. Access to administrator telephone numbers is not helpful when needing to report elder abuse.

1. An older person reports constant discomfort in the lower back. Which physiological event is causing this older person to experience pain? A. Pain signal modulation altered in the limbic system B. Repetitive stimulation in the dorsal horn C. Malfunctioning nociceptors in the peripheral nervous system D. Noxious stimuli are transmitted to the thalamus

B. Repetitive stimulation in the dorsal horn Rationale: Persistent pain is associated with repetitive stimulation in the dorsal horn and this continued stimulation can sensitize neurons so that lesser stimuli can cause pain. Noxious stimuli are transmitted to the central areas of the brain via the dorsal horn of the spinal cord. The pain signal is modulated at multiple points in the transmission process. Nociceptors, or pain receptors, are nerve endings in the peripheral nervous system that respond to stimuli that threaten or produce damage to the organism.

2. An elder person with metastatic cancer is unaware of care options and believes the health care provider will prescribe the best treatment to achieve a cure. Which approach should the nurse take before identifying goals for care? A. Assess the person for pain and medicate as prescribed B. Schedule a team meeting with the elder person, family, and care provider C. Encourage the person to return home to be in a comfortable environment D. Recommend hospice discuss care approaches with the person

B. Schedule a team meeting with the elder person, family, and care provider Rationale: If unsure of a person's wishes for care at the end of life, the nurse should call a team meeting with the key decision makers such as the older person, family members, and the primary care physician. Ongoing open discussion about goals of care will help the older adult and the family receive the best possible care at the end of life. The nurse should do more than medicate the person for pain. The person's needs, and desires are unknown at this time. A meeting with the key individuals would help identify the role of hospice and if the person would be more comfortable in the home environment.

1. During a home visit, the nurse learns that an older adult spends no time out of doors because of a fear of developing skin cancer. Which action should the nurse take to help maintain this person's health status? A. Discuss the importance of performing weightbearing exercises everyday B. Suggest the healthcare provider measure the person's vitamin D level C. Recommend attending events for senior citizens scheduled in the evenings D. Change the time for the next home visit to occur in the evening

B. Suggest the healthcare provider measure the person's vitamin D level Rationale: Since the person spends no time out of doors, the nurse should recommend that the primary care provider check the vitamin D blood level to ensure adequate calcium absorption. This person needs teaching on ways to prevent the development of skin cancer. There is no reason for the person to avoid going out of doors because of this fear. Changing the time for the next home care visit is not necessary. Recommending the person attend events that are scheduled in the evenings is encouraging this person's fear of the sun. Weight-bearing exercises are suggested to reduce the risk of osteoporosis which would be known only after learning the person's vitamin D level.

10. An older person is disappointed that melatonin is not working because of early awakening during the night. What should the nurse recommend to this person? A. Take Valerian in combination B. Use an extended-release format C. Drink orange juice before going to bed D. Take two doses of the herb

B. Use an extended-release format Rationale: Melatonin is effective for some older people with sleep disturbances due to decreased levels of melatonin. Doses of 0.5 to 3 mg have been suggested for sleep. It should be taken approximately 3-5 hours before bedtime. Because melatonin has a short half-life (about 40 minutes), a controlled-release formulation is recommended to maintain sleep throughout the entire sleep cycle. The nurse should not recommend adding another herbal remedy to help with sleep. The nurse should not recommend a dose that is greater than the recommended amount. Drinking orange juice before bed is not identified as an effective sleep aid.

9. An older patient has a Baden Scale score of 15. What should the nurse add to this patient's plan of care? A. massage reddened skin areas B. wash skin with tepid water C. restrict oral protein intake D. restrict vitamin C and Zinc intake

B. wash skin with tepid water Rationale: Skin care considerations to prevent pressure injuries in older adults at risk include washing the skin with tepid water, with a pH balanced skin cleanser. Protein is required for wound healing. Reddened areas should not be massaged. Nutritional supplements such as vitamin C and zinc promote skin healing.

5. The nurse suspects that an older person is experiencing an increase in stress. Which finding caused the nurse to make this clinical determination? A. Urinary frequency during the night. B. Weight loss of 2 kg over 1 month C. Increased blood pressure D. Mild lower-extremity edema

C. Increased blood pressure Rationale: Stressors are highly individual. The event that one older person perceives as challenging may be stressful for another. Stressors may be physical, emotional, biological, or developmental. Symptoms that indicate the older person may be suffering negative effects of stress include a new onset of hypertension. Edema, weight loss, and urinary frequency are not identified as symptoms of stress in an older person.

2. An older person plays Scrabble with family members several times a week. What should the nurse expect when assessing this person? A. Tolerance for physical changes B. Improvement in short-term memory C. Intact cognitive functioning D. Adequate coping skills

C. Intact cognitive functioning Rationale: The use of word games such as Scrabble help an aging person maintain cognitive functioning. This type of activity does not indicate that the person has adequate coping skills or tolerance for physical changes. Word games are not used to improve short-term memory however changes in this type of memory are considered a normal age-related change.

2. The nurse reviews with an older adult the reasons they may experience dry skin during the winter months. Which statement indicates that this person understands ways to prevent this skin change from occurring? A. "I should continue to take showers with hot water." B. "A heavy towel that is dragged over my skin is the best way to dry it." C. "Mild soap and warm water is better for me to use." D. "I will continue to drink about 410-ounce glasses of fluid each day."

C. " Mild soap and warm water is better for me to use" Rationale: Xerosis or dry skin occurs more frequently as a person ages. Ways to prevent this skin change include overuse of harsh soaps and personal care products, frequent bathing with hot water, dehydration, and vigorous towel drying. Using mild soap indicates the person understands how to prevent this skin change from occurring.

4. The charge nurse is concerned that nursing-assistive personnel (NAP) in a skilled facility are prone to neglecting the needs of the residents. What statement did the nurse hear one of the NAP make to come to this conclusion? A. "Your daughter will be here at 10 am. How about a shower now to get ready?" B. "Everyone's in the rec room watching the movie! Don't you want to see it too?" C. "Maybe I'll bring you some water, if you behave." D. "I'll be back in a few minutes to take you to the dining room."

C. "Maybe I'll bring you some water, if you behave" Rationale: Threatening to withhold water unless the person "behaves" can be a precursor to neglect. The NAP should be counseled because of this statement. Returning in a few minutes, helping a person get ready for family, and asking about watching a movie are not indications that the residents are experiencing neglect.

9. An older person takes lorazepam every evening to help with sleep. Which observation indicates that the person is experiencing an adverse effect of this medication? A. Played cards during recreation hour B. Poor appetite during the dinner hour C. Daily napping in the afternoon D. Watched the baseball game after dinner

C. Daily napping in the afternoon Rationale: Even though lorazepam is a short-acting benzodiazepine, there is still a risk for dependence or adverse effects which include daytime drowsiness. This medication does not affect appetite. Engaging in activities during the day indicates the medication is effective as this person is alert during the day.

4. The nurse asks the health care provider for a prescription for pain medication for an older person with an altered level of consciousness. What did the nurse observe that indicates that this person is experiencing pain? A. Smiling when covered with a blanket B. Opening eyes with painful stimuli C. Grimacing when repositioned in bed D. Curling the fingers when pulse is assessed

C. Grimacing when repositioned in bed Rationale: A nonverbal indication of pain is facial grimacing. Opening the eyes would be an expected response with painful stimuli. Smiling and curling the fingers are not identified as nonverbal responses to pain.

6. The nurse notes several older persons with family caregivers are waiting to see the healthcare provider for a scheduled appointment. For which person will the nurse make completing the Elder Assessment Instrument a priority? A. Person asking the family caregiver if they can go to the store after the appointment B. Person talking with family caregiver about a magazine article C. Person sitting with head down, hair uncombed, shoes untied D. Person watching the television while the family caregiver makes a telephone call

C. Person sitting with head down, hair uncombed, shoes untied. Rationale: An older adult appearing disheveled with poor hygiene should be evaluated for potential neglect if there is a responsible caregiver who may be having trouble meeting the caregiving needs of the older person. Talking, asking questions, and watching television are not indications that the older person might be experiencing neglect.

8. An older person reports reading a few a book before turning off the light and going to sleep. How should the nurse document this person's sleep ritual? A. Uses reading to calm down after exercise B. Prefers to read instead of watching television C. Reading occurs during the transition period D. Reading interrupts the onset of sleep

C. Reading occurs during the transition period Rationale: The hour before the older person goes to bed should be considered a "transition" hour in which the daytime cares and activities begin to shut down and the body and mind begin to prepare for the onset of sleep. Bedtime rituals such as performing progressive relaxation exercises, listening to nature tapes, praying, reading a few pages of a novel, or other relaxing activities may assist the older person who is anxious at bedtime to sleep. Reading is not interrupting sleep. The person should not be exercising before going to sleep. Reading is not being done to stay awake.

4. The nurse educator prepares a teaching session on end-of-life care for a group of new nurses working in the Cancer Center. For which reason should the educator ask the nurses to consider their own lives, "at what age do I think I will be when I die?" A. Determine what items should be left to family members B. Strategize approaches to ensure advance directives are followed as written C. Recognize that death in old age is a natural end to the cycle of life D. Encourage planning for resources to receive adequate care in old age

C. Recognize that death in old age is a natural end to the cycle of life. Rationale: Personal assessment about death and dying is essential for the nurse to help persons who are approaching end-of-life. Asking the question "at which age do I think I will be when I die" helps the nurse recognize that death in old age is a natural end to the cycle of life. This question is not asked to help with estate planning or to ensure advance directives are followed as written.

5. The manager of a skilled facility is concerned that residents are not receiving required care and are experiencing neglect. Which information caused the manager to make this assumption? A. All residents prescribed the annual influenza vaccination B. Family members visiting more frequently C. Pressure ulcer healing rate at 10% D. Resident sitting in urine-saturated clothing for hours

C. Resident sitting in urine-saturated clothing for hours Rationale: A resident made to wear and sit in urine-saturated clothing for hours is a form of neglect. Pressure ulcer healing may be delayed in a skilled facility because of the age of the resident, health problems, and nutritional status. Frequency of family visits is not an indication of possible neglect. Long-term care facilities take action to prevent an outbreak of a seasonal infection and will provide the annual influenza vaccination to all residents.

1. An older person asks to have the room door closed during the night because they are a very light sleeper. What should the nurse consider as being the reason why the person is a light sleeper? A. Insufficient amount of exercise during the day B. Body is spending too much time in deep sleep C. Stimulation of the reticular activation system D. Chronic or recurrent health problems

C. Stimulation of the reticular activation system Rationale: Sensory inputs such as loud noises and bright lights can stimulate the reticular activating system and cause an older person to awaken. The amount of time spent in deeper levels of sleep diminishes with aging. A chronic health problem is not identified as the reason for being a light sleeper. Exercise does help regulate the sleep-wake cycle however this is not identified as a reason for the older person to be a light sleeper.

6. The nurse notes that an older person has a score of 7 on the Pittsburgh Sleep Quality Index (PSQI). What does this information indicate to the nurse? A. The person experiences sleep latency B. The person is a good sleeper C. The person is a poor sleeper D. The person has good sleep duration

C. The person is a poor sleeper Rationale: The Pittsburgh Sleep Quality Index (PSQI) is an effective instrument for measuring the quality and patterns of sleep in the older adult. It differentiates "poor" from "good" sleep by measuring seven domains: subjective sleep quality, sleep latency, sleep duration, habitual sleep efficiency, sleep disturbances, use of sleeping medication, and daytime dysfunction during the past month. A global sum of 5 or greater indicates a poor sleeper. Since the person's individual scores are not provided, it is unknown if the person has good sleep duration or experiences sleep latency.

2. The nurse suspects that an older person is at risk for elder mistreatment. Which finding supports the nurse's conclusion? A. Volunteers at the library B. Lives with adult children C. The person is female D. Retired school teacher

C. The person is female Rationale: Risk factors that increase the possibility of elder mistreatment include begin of the female gender. Employment, volunteer status, or living arrangements do not increase the risk of elder mistreatment.

8. The nurse notes that an older adult has a large area of skin atrophy on the left forearm. What should the nurse consider as the reason for this skin change? A. Topical antibiotics B. Systemic antibiotics C. Topical steroids D. Silver nitrate dressings

C. Topical steroids Rationale: Often corticosteroids are prescribed as topical treatment for dermatological problems in older people. These creams should be applied sparingly in thin layers to maximize therapeutic outcome and minimize the risk of side effects. Hydrocortisone 1% or 2.5% is a low-potency topical corticosteroid that can be applied for short-term treatment of inflamed dry skin. Long-term use may cause cutaneous side effects like skin atrophy. This skin change is not associated with topical or systemic antibiotics, or silver nitrate dressings.

7. The family providing care at home to an elder person nearing end-of-life is concerned that the patient is dehydrated because of dry cracked lips. What should the nurse recommend to this family? A. Encourage sips of fluid every hour B. Provide hard candy C. Apply petroleum jelly to the lips D. Swab the mouth with a mouth wash solution

C. apply petroleum Jelly to the lips Rationale: Soothing ointments or petroleum jelly may be applied to the lips to prevent painful cracking or drying. Hard candy and sips of fluid should only be provided if the person can swallow. But since this is unknown, this is not the best recommendation. Mouthwash solutions contain alcohol and may be drying to the oral mucosa. This should not be recommended to the family to do.

5. An adult daughter thinks her elder parent has a kidney problem because of the need to void so many times during the night. What should the nurse respond to this family member? A. "I will ask the healthcare provider to change the diuretic to help with sleeping through the night." B. "It happens with a bladder infection, which I will report to the health care provider." C. "Kidney stones or other disorders can cause this to happen. We should do testing." D. "Normal kidney and bladder-aging changes increase the need to void during the night."

D. "Normal kidney and bladder-aging changes increase the need to void during the night." Rationale: Older people may be awakened from sleep because of the need to urinate. Common age-related alterations in urinary tract function result from changes in the renal and hormonal systems that control urine production and from decreases in the reservoir capacity of the bladder. With aging, nighttime urine flow rates may equal or exceed daytime rates. Voiding frequency, nocturia, and urinary urgency have been shown to increase with age. Night time voiding does not indicate kidney stones or a bladder infection. Increased urine production is an expected effect of a diuretic.

6. The nurse plans to teach an older adult on the hazards of sun exposure to the skin. Which finding caused the nurse to implement this teaching? A. Edematous lower extremities with areas of ecchymosis B. Rough, dry skin over the arms and legs C. Generally red, rough, itchy skin D. A sore, rough, scaly, reddened patch on the face

D. A sore, rough, Scaly, reddened patch on the face Rationale: The most common precancerous lesion is actinic keratosis, also known as solar keratosis and senile keratosis. Erythematous actinic keratosis is the most common type and appears as a sore, rough, scaly, reddened papule or plaque. The most common sites for all types of actinic keratoses are sun-exposed areas such as the back of the hands, forearm, face, V of the neck, nose, tips of the ears, and bald scalp. Red rough itchy skin and rough dry skin over the arms and legs may be caused by too frequent bathing, dehydration, or vigorous towel drying. Edematous lower extremities with areas of ecchymosis might be the result of a skin tear or another health problem.

7. An older adult has a stage 3 pressure injury over the sacral region. Which diagnosis should the nurse use to guide care? A. Altered skin integrity B. Risk for altered skin integrity C. Risk for infection D. Altered tissue integrity

D. Altered tissue integrity Rationale: Because a stage 3 pressure injury is full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia, Tissue integrity, impaired, is the most appropriate diagnosis for the person. There is insufficient information to determine the person's risk for infection. Skin integrity, impaired, and Skin integrity, high risk for impaired, describes situations in which the individual is at risk for or experiences damage to the epidermal and dermal tissue only.

8. An elder person with a terminal illness has died. Which action should the nurse take when providing postmortem care? A. Place dentures in a safe location B. Place in a side-lying position C. Elevate the head on several pillows D. Apply a clean sheet over the body

D. Apply a clean sheet over the body Rationale: When providing postmortem care, the nurse should place the body supine, with the head and shoulders elevated on one pillow. Dentures should be inserted into the mouth. A clean sheet should be placed over the body.

10. During a home visit the nurse notes that an older person, who lives alone, is being visited by an adult son who is asking their parent for money. After the son leaves, what should the nurse do to ensure for this person's safety? A. Provide a list of caregiver-support groups B. Recommend that the person be admitted to a care facility immediately C. Discuss identifying a guardian with an attorney D. Devise a safety plan with the person

D. Devise a safety plan with the person Rationale: For older adults who possess capacity to make their own decisions and remain in their home living environment, an individualized safety plan should be developed in which emergency phone numbers, location of a safe place to go (if needed), a list of essential items to be taken if a quick exit is required, and consideration of transportation needs. This person is an elders at risk and careful monitoring and follow up is required. Caregiver support groups would be appropriate if the adult son is living with the person. Guardianship and hospital respite care would be appropriate if the adult person is being abused and needs to be removed from the home for safety.

9. The nurse notes that an older person, who lives alone, demonstrates a flat affect and sadness during the winter months. What should the nurse consider to help this person with symptoms of depression? A. Work on a hobby B. Attend a support group C. Antidepressant medication D. Engage in light therapy

D. Engage in light therapy Rationale: Light therapy has been shown to be effective for older persons diagnosed with seasonal affective disorder, a cyclic depression that occurs when hours of daylight are short, usually in the fall and early spring. This person is demonstrating signs of seasonal affective disorder since it occurs during the months when there is less sunlight. Hobbies, support groups, and antidepressant medication are not identified as interventions for seasonal affective disorder.

3. The nurse documents that the family caregiver of an older person should be assessed for stress during every home visit. What caused the nurse to make this notation in the older person's medical record? A. Unread newspapers on the kitchen table B. The sink is full of dirty dishes C. Person sitting quietly watching television D. Family caregiver complaining about the volume of laundry

D. Family caregiver complaining about the volume of laundry Rationale: Caregiver stress is a significant risk factor and many caregivers cannot balance their own needs with the needs of the dependent older adult. These feelings can lead to resentment and possibly abusive or neglectful behavior. Complaining about laundry could be an indication that the family caregiver may be experiencing stress. There is no indication that unwashed breakfast dishes, unread newspapers, or the person's behavior support family caregiver stress.

1. An older person has difficulty remembering activities completed the day before yet can relate in detail people who attended a birthday party several decades ago. What should this finding indicate to the nurse? A. Early dementia B. Symptom of a stroke C. Untreated Delirium D. Normal changes

D. Normal Changes Rationale: One cognitive change that is identified as being a normal age-related change is a loss of short term member but intact long term memory. This finding does not indicate early dementia, untreated delirium, or symptoms of a stroke.

3. The nurse completes an assessment with an older person. Which health problem causes the nurse to focus on this person's sleep pattern? A. Psoriasis B. Glaucoma C. Chronic tinnitus D. Osteoarthritis

D. Osteoarthritis Rationale: A common source of pain in older adults is the chronic pain resulting from osteoarthritis. Because osteoarthritis of the hip and knee is so common in aging, it can result in chronic sleep disruption for large numbers of older people. Further, older adults who experience chronic pain may also limit daytime activities, resulting in physical inactivity, deconditioning or loss of physical strength and function, and further disruption of the sleep-activity cycle. Psoriasis, glaucoma, and chronic tinnitus are not identified as health problems that affect sleep in an older person.

7. The nurse reviews prescriptions written for an older person. Which medication should the nurse question before administering the medication? A. Methadone B. Fentanyl C. Morphine D. Propoxyphene

D. Propoxyphene Rationale: Propoxyphene, a drug with efficacy similar to aspirin or acetaminophen, carries the risk for potentially serious or even fatal heart arrhythmias. And, there is the burden of serious side effects (delirium, ataxia, and dizziness) caused by the accumulation of toxic metabolites. Fentanyl is another commonly used opioid. The transdermal formulation has become more widely used for the management of persistent pain in older adults. Morphine is a commonly used and versatile opioid for the treatment of moderate to severe pain and is the "gold standard" to which all other opiates are compared. Methadone should be initiated and titrated cautiously, and only prescribed by clinicians experienced in its use.

8. An older person states that activities that used to be joyful are now viewed as a nuisance and is experiencing persistent feelings of sadness for several weeks. Which medication should the nurse suspect as the cause of this person's symptoms? A. Gabapentin B. Furosemide C. Acetaminophen D. Ranitidine

D. Ranitidine Rationale: Depressive symptoms can be side effects of medications the older person is taking for a physical problem. One such medication is ranitidine, an anti-ulcer medication. Furosemide, gabapentin, and acetaminophen are not identified as medications that can contribute to the development of depression in an older person.

10. An older patient's plan of care includes frequent position changes, application of skin lotion, and assistance with ambulation three times a day. Which goal was used when selecting these interventions? A. Explain the importance of activity and exercise B. Demonstrate safety with ambulation C. Pressure injury will demonstrate signs of healing D. Skin integrity will remain intact

D. Skin integrity will remain intact Rationale: Nursing care of the older person should focus on the prevention of pressure injuries since research has shown that most pressure injuries can be prevented. Actions to prevent this injury includes frequent position changes, use of protective skin products, and increased activity. These interventions do not focus on safety or activity and exercise. Since these interventions do not address wound care, it is unlikely that this person has a pressure injury.

6. An older person's daughter is getting divorced and plans to move herself and two toddlers in with the older person. What should the nurse suggest when the older person expresses anxiety over this change in living situation? A. Recommend an alternative living arrangement for the daughter B. Ask if the older person has considered moving to an adult-living community C. Encourage to charge the daughter rent D. Suggest stress-reduction techniques and exercise

D. Suggest stress-reduction techniques and exercise Rationale: A suggestion to help an older person with stress is to encourage or suggest stress-reduction techniques such as yoga or medication. Charging the daughter rent assumes the person's stress is related to finances. Recommending alternative living arrangements for the daughter or the person are not identified as methods to help the older person cope with stress.

4. The spouse of an older person is concerned because of an acute change in ability to remember how to get dressed in the morning. What should the nurse consider as causing the change in cognitive functioning? A. sleep deprivation B. Undiagnosed infection C. Insufficient nutritional intake D. Worsening Alzheimer's disease

D. Worsening Alzheimer's disease Rationale: Severe changes and sudden loss of cognitive function are usually symptoms of a physical or mental illness such as Alzheimer's disease, stroke, or serious depression. An acute change in remembering how to perform a routine task is not associated with sleep deprivation, infection, or nutritional intake in an older person.