Geri final
10. A hospice nurse admits an older adult after the metastasis of malignant melanoma. Which of the following health problems should the nurse anticipate? A) Necrosis of extremities B) Hemoptysis C) Hyperglycemia D) Dyspnea
Ans D Dyspnea is a common accompaniment to the dying process. Hyperglycemia, hemoptysis, and tissue necrosis are less common.
4. A nurse notes a 2-mm open shallow ulcer with a red wound bed on the great toe where shoe touched the skin. Which of the following should the nurse document? A) 2-mm stage II pressure ulcer B) Stage III pressure ulcer on great toe C) 2-mm skin tear with red wound bed D) Red ulcer on the great toe 2 mm in size
Ans: A The wound described is a pressure ulcer, and Pressure Ulcer Scale for Healing (PUSH) staging should be used to document all pressure ulcers. Wound documentation should also include size of wound bed. Stage II ulcers are partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough
5. Which of the following is the most important remediable risk factor for cardiovascular disease in older adults? A) Smoking B) Stress C) Sedentary lifestyle D) Aggressive personality
Ans: A Smoking is a major risk factor for cardiovascular disease. Benefits of smoking cessation as a secondary prevention intervention begin immediately and are as effective in older adults as they are in younger people. Additional lifestyle interventions that are effective for preventing cardiovascular disease include remaining physically active, managing stress, and maintaining ideal body weight
6. A nurse in a long-term care facility is aware of the effects of age-related changes to the respiratory system. Which of the following functional consequences most likely results from age-related changes? A) Snoring and mouth breathing B) A persistent, dry cough C) Increased sensitivity to environmental allergens D) Hemoptysis on exertion
Ans: A Snoring and mouth breathing often become more prevalent with age. Hemoptysis and a persistent cough are considered pathologic at any age, and allergies do not typically worsen with age.
9. A nurse evaluates the plan of care for a client who experienced an ischemic stroke. Which of the following assessment findings should signal the nurse to the possibility that the client has developed dysphagia? A) The client complains of being excessively hungry. B) The client drinks large amounts of water with meals. C) The client pockets food in the affected cheek during meals. D) The client prefers to sit in a high Fowler's position after eating.
Ans: C Pocketed food suggests dysphagia. Sitting upright after meals prevents, rather than indicates, dysphagia and neither hunger nor high fluid intake is indicative of dysphagia
13. A nurse interviews an older adult with pulmonary disease. The client states, "I worked hard all my life in the shipyard, I provided for my family. I never smoked, why did I get this disease?" Which response by the nurse is best? A) "It is a good thing that you never smoked." B) "Pulmonary disease can happen to anyone." C) "The work in the shipyard put you at risk." D) "You feel like you are being punished..."
Ans: C Shipyard work is a job category that is associated with an increased risk of respiratory disease. Caring responses give information and are directly related to the client's issue (and smoking is not). The client does not directly imply he feels punished
15. An older adult states, "I just feel so full so fast, I can't eat any more." Which of the following responses is most appropriate? A) "All of us feel that way after a meal." B) "Make an appointment with your health care provider." C) "Slower emptying of your stomach may be the cause." D) "This happens when you have gall stones."
Ans: C Slight slowing of gastric emptying in older adults after ingestion of large meals leads to early sensations of fullness. Gallstone symptoms include pain, not fullness. An emergent visit to the health care provider is not indicated
12. A nurse assesses older adults at a pulmonary clinic. Which of the following questions might best assist identify those at risk for pulmonary disorders? A) "Do any of your children smoke?" B) "In what state did you grow up?" C) "What type of job did you have?" D) "Where do you exercise?"
Ans: C Some job categories are associated with an increased risk of respiratory disease. Children who smoke do not imply that secondhand smoke occurs. While location does correlate with the percent of smokers, it is not as helpful in identification of those with pulmonary disorders; nor is where a person exercises.
9. A nurse on an acute care unit is disturbed by the increasing incidence of pressure ulcers among older adults. Which of the following measures should the nurses on the unit prioritize in order to prevent the formation of pressure ulcers? A) Apply emollient lotions with baths B) Frequent repositioning of immobilized clients C) High-protein, high-calorie diet D) Massage bony prominences each shift
Ans: B Frequent repositioning is an important measure in prevention. Lotions should be applied; relief of pressure is the highest priority. Nurses should ensure that those at risk for pressure ulcers do receive enough calories, vitamins, and protein. Nurses do not massage bony prominences for concern of damage
2. A nurse is discussing sexual activity with older adults in a wellness clinic. Which of the following statements by an individual indicates a need for further exploration? A) "I know my diabetes can affect my sexual activity." B) "My husband has an enlarged prostate." C) "I use Premarin cream to help with vaginal dryness." D) "I will not use petroleum jelly as a lubricant."
Ans: B The husband's prostate problem can affect his sexual performance and needs further exploration. Premarin cream helps when vaginal dryness occurs because of estrogen withdrawal. Diabetes has an effect on vaginal lubrication. Petroleum jelly increases risk for infection
1. A nurse assesses an older adult's overall respiratory function. Which of the following interview questions would be most appropriate? A) "Would you be interested in finding out more about environmental smoke?" B) "Did either of your parents experience lung diseases?" C)"Have you ever worked in a job where you were exposed to dust, fumes, smoke, or other pollutants?" D) "What do you do to actively maintain your respiratory health?"
Ans: C The effects of air pollution are cumulative over many years. Thus, there is an increased impact on older adults over their lifetimes. Hazards in the workplace were unregulated before 1970. Therefore, there are older adults who have experienced cumulative and long-term effects from toxic substances
8. A nurse who works in a palliative setting is aware of the need to facilitate a "good death" for as many clients as possible. Which of the following interventions should be included? A) Discuss openly and explicitly the client's strengths and weaknesses. B) Ensure that a minimum of nursing interventions are performed. C) Empower the client and family to maintain as much control as possible. D) Emphasize spiritual needs rather than physical comfort and medical needs
Ans: C A "good death" is fostered by enabling a sense of control for the client and his or her family over a challenging situation. Nursing interventions are chosen carefully, but not necessarily minimized. A discussion of the client's strengths and weaknesses is inappropriate and spiritual needs are not mutually exclusive of comfort and appropriate biomedical interventions
12. A nurse in the ambulatory clinic assesses a 53-year-old woman who states, "last night all of the sudden I got really sick, got really hot, and started sweating; then I had chills, and my chest was pounding." Which action by the nurse is priority? A) Ask if the client had been exposed to anyone who was ill. B) Check the client's troponin and B-type natriuretic peptide (BNP) labs. C) Discuss the client's menstrual cycle with her. D) Review the client's medication history
Ans: C Asking about "anyone who was ill" is broad and generic. Illness is often spread in the prodromal phase when there are no symptoms. Troponin and BNP are indicators of cardiac functioning; women who have an MI are more likely to experience severe fatigue, not heat and chills. Hot flashes are a vasomotor symptom characterized by the sudden onset of heat, perspiration, and flushing that spreads from the head to the trunk. Symptoms last from 1 to 5 minutes and may be accompanied by chills, nausea, anxiety, palpitations, and clamminess. Medications do not relate to these symptoms
6. A gerontological nurse is aware that the aging process is accompanied by numerous, multifactorial changes that affect sexual wellness in older adults. Among women, which of the following factors is usually the primary cause of changes in sexual functioning? A) Psychosocial factors B) Environmental factors C) Hormonal factors D) Spiritual factors
Ans: C Changes in sexual functioning are influenced by many factors. In women, however, the influence of hormonal factors is often primary. Diminished estrogen levels can directly affect sexual function for older women in several ways
3. A 64-year-old man had a myocardial infarction (MI) 2 months ago. He has recovered to the point that he is able to climb up two flights of stairs, but he and his spouse have not resumed sexual relations. Which of the following responses by the nurse is most appropriate? A) "Is angina interfering with your sexual functioning?" B) "This lack of libido is caused by vasoconstriction in the genital area." C) "You are safe to have sex; you can resume sexual relations when you desire." D) "You may have a problem with retrograde ejaculation."
Ans: C Even when no physiologic basis exists for abstaining from sexual intercourse after an MI, sexual activity is often limited or absent because of fatigue, depression, diminished sexual desire, and fears and anxiety of the person or the sexual partner. Diabetes can cause retrograde ejaculation. An MI does not cause vasoconstriction
16. A nurse at the dermatology office triages calls. Which of the following clients is the highest priority to follow up? A) A 2-year-old with diaper rash B) A 20-year-old with red sunburn on the chest and arms C) A 78-year-old with a lesion that is black, swollen, and draining liquid D) A 90-year-old with flat discolored spots on face
Ans: C In general, the following characteristics of a skin lesion warrant medical evaluation: redness, swelling, dark pigmentation, moisture or drainage, pain or discomfort, raised or irregular edges around a flat center
11. A nurse monitors a group of older adults in the long-term care facility's kitchen. Which of the following actions would cause the nurse to intervene? A) Sharing perfumed hand soap B) Using hand lotion after washing dishes C) Using hot water to rinse the dishes D) Using soap to wash the dishes
Ans: C Older adults are more susceptible to scald burns because of their diminished ability to feel dangerously hot water temperatures. Perfumed hand soap, dish washing liquid, and lotion are acceptable
8. A 79-year-old client recently experienced a syncopal (fainting) episode after standing up quickly while gardening. Which assessment is the nurse's priority? A) "Did you experience any fatigue or blurred vision?" B) "What did you doctor say about this?" C) "What medications do you take?" D) "When did you last eat a meal?"
Ans: C Risks for orthostatic hypotension include multiple medications. Orthostatic hypotension can be accompanied by symptoms such as fatigue, lightheadedness, blurred vision, and syncope upon standing or not. Whether orthostatic hypotension is symptomatic or asymptomatic, it can lead to negative functional consequences. Postprandial hypotension is not represented by this scenario. Asking what the primary health care provider said is passing the buck.
An older patient has recently been diagnosed with moderate stage AD. The nurse practitioner orders a noncompetitive receptor antagonist such as Namenda. The nurse would instruct the patient and family that this medication: a. stops the decline of the disease b. is taken over a long period of time to achieve best results c. may result in significantly higher function over time d. b and c only
B and c
In charting on a 70-year old man with a wound that appears as a shallow crater, the nurse would stage this as a: a. stage I b. stage II c. stage III d. stage IV
B. Stage II
11. A nurse in a hospital setting assesses an older adult and is unsure if the assessment data warrant notification to the authorities for elder abuse. Which action is most appropriate for the nurse at this time? A) Determine if the person has dementia. B) Discuss findings with the family. C) Follow the hospital protocol for reporting. D) Question the visitors.
C
8. An 81-year-old has been living for the past 2 years in a long-term care facility. However, financial pressures have required that the resident move in with the oldest child and spouse. Which of the following statements if made by the child's spouse should signal a potential risk for elder abuse? A) "I sure hope that we'll qualify for some home care because this seems pretty overwhelming." B) "This won't be easy for anyone. I think I might even end up having to juggle my work schedule." C) "He's used to being waited on here, but at our place he's going to have to fend for himself." D) "I'm probably going to even have to get some friends or neighbors to help out from time to time."
C
For patients who are able to rise from a seated position, what risk assessment tool may be used to evaluate strength, gait and balance, physical function, and fall risk? A) Hendrich Fall Risk Model II B) STRATIFY Risk Instrument C) Timed Get Up and Go Test D) Morse Fall Scale
C) Timed Get Up and Go Test
The nurse is asked to assist a family with finding help to care for their terminally ill grandfather who was just diagnosed with inoperable brain cancer. To which of the following programs would the nurse refer the family? a. the hospital b. respite care c. hospice d. visiting nurse association
C. Hospice
To treat dyspnea at end of life, the nurse would expect to give which of the following medications? a) Codeine b) Oxycontin c) Morphine d) Lasix
C. Morphine
A nurse is providing care to four clients with terminal cancer who are on the unit. While on rounds, the nurse assesses each client and determines that which client may be near death?
Client who has a rapid, weak pulse.
2. A nurse teaches older adults about nutrition. Which of the following statements shows the nurse that the older adult requires further teaching? A) "Alcohol intake will interfere with absorption of B-complex vitamins and vitamin C." B) "Certain 'fluid' pills can decrease the potassium level in my blood." C) "Anticholinergic medications can cause my intestines to work slower." D) "My over-the-counter beta-carotene pill is appropriate for long-term use."
Ans: D Long-term beta-carotene use can cause vitamin E deficiency. Paralytic ileus can occur with anticholinergic medication. Nutritional supplements and herbal preparations can affect nutrients. Alcohol interferes with the absorption of B-complex vitamins and vitamin C
6. A nurse assesses an older adult in the assisted living facility who has presbyphagia. Which of the following systems should the nurse auscultate? A) Abdomen for bruit B) Bowel sounds C) Heart tones D) Lung sounds
Ans: D Swallowing difficulties create a risk of aspiration. Presbyphagia is unlikely to result in assessment changes to the abdomen or heart
13. A nurse assesses an 85-year-old client and finds bruises on the arms and shins and a skin tear on the right hand. Which action is the priority for further nursing assessment? A) Consider the family as a reliable source of information. B) Determine if the person is depressed. C) Follow the protocol for reporting elder abuse. D) Review the client's medications and medical diagnoses
D
2. Which of the following is true about cognitive impairment and abuse of older adults? A) Older adults who live alone are always willing to acknowledge their impairments. B) Cognitively impaired older adults are usually able to meet minimum standards of care. C) When the older adult denies cognitive impairment, the risk for abuse declines. D) Older adults become more vulnerable to abuse because of cognitive impairment.
D
4. Which of the following statements is true about the laws of mandatory abuse reporting? A) Government agencies, not individual nurses, are responsible for reporting abuse. B) Mandatory reporting laws require reporters to know whether abuse or neglect has occurred, rather than just suspecting it has occurred. C) The use of an abuse reporting protocol replaces individual responsibility for reporting. D) A registered nurse is mandated to report abuse or neglect if it is suspected.
D
6. A nurse who works with the older population is aware that elder abuse takes many forms. Which of the following examples most clearly constitutes elder abuse? A) A paid caregiver cleans and assists with shopping for an older adult who lives alone. B) An older adult assists with child care in exchange for room and board at her niece's house. C) A daughter manages her mother's finances after the older adult granted her power of attorney. D) A daughter changes her mother's incontinence brief only after the urine has soaked through all her clothing because she wants to save money
D
A family member asks the nurse to witness the signing of a Living Will at the bedside of a mentally competent, alert, adult patient. In signing as a witness, the nurse is stating: a. the signature of this person was valid and not coerced b. the person was mentally competent to sign c. the person is terminally ill at the time d. a and b only
D
If an older adult wishes to have another person make health care decisions in his behalf should he become unable to do so himself, he should appoint: a. a living will b. a health care representative c. a durable power of attorney for healthcare d. b or c
D
If an older person wishes to have a DNR status on himself, which of the following is true? a. he needs to have the physician sign a form that states this b. he will receive less quality care than those who are not DNR status c. he should place a copy on his refrigerator at home d. a and c only
D
In describing the benefits of hospice to a dying older patient's family, the nurse correctly states that hospice care may include: a) counseling services b) medical supplies c) social services d) all of the above
D
The nurse screening for AD recognizes the diagnostic criteria to include all but which of the following? a. impaired short or long-term memory b. aphasia c. apraxia d. dysphagia
D. Dysphagia
What extrinsic factor for pressure ulcer development alters the resiliency of the epidermis to external forces by weakening the lipid layer of the stratum corneum? A) Pressure B) Shear C) Friction D) Moisture
D. Moisture
The nurse is working with clients diagnosed with cancer and their families to identify ways to deal with difficult issues. Which reason would the nurse identify as supporting why a diagnosis of malignant melanoma may be extremely difficult for clients to accept?
It is a type of skin cancer that is highly metastatic, making it more deadly.
A 78-year-old resident with a diagnosis of melanoma is experiencing anxiety related to the appearance of the large and highly visible lesion on the right cheek. Which intervention would be most appropriate for the nurse to implement to help decrease the resident's anxiety?
Resolve to interact with and touch the resident no differently than other residents.
Nonblanchable redness of the skin is characteristic of a pressure ulcer in what stage? A) Stage I B) Stage II C) Stage III D) Stage IV
Stage I
Despite the fact that the client is now receiving palliative care because of the progression of congestive heart failure (CHF), a nurse views the care that was provided for the client as a success. The nurse arrives at this conclusion most likely based on which information?
The client was able to live independently and provide self-care until very late in the progression of the disease.
A 78-year-old client has been diagnosed by his geriatrician as being in the third stage of Alzheimer's disease. Which findings would support this assessment?
The client's wife and children have recently noticed a change in memory and judgment with the client getting easily flustered in social situations.
The nurse is caring for an older person from a different culture than her own. What is her best approach to providing holistic care to this patient? a. provide care as she would to all other patients b. learn more about the person's culture c. talk to family members about the person's medical condition d. ask other nurses what they do to care for this person
b. learn more about the person's culture
A large stage 4 pressure ulcer that occur in the nursing home on a resident who was admitted with intact skin one week prior is most likely a sign of: a. direct physical abuse b. an albumin of 4.5 c. inadequate nursing care d. being give the wrong tube feeding
c. inadequate nursing care
The emergency room nurse is evaluating a 90-year old male that she suspects may have been abused by a caregiver. Which of the following data most supports her suspicion? a. the man has a skin tear on his hand b. the man has a small bruise on his outer leg c. the man has a numerous large bruises of different colors on various parts of his body d. the man's explanation of his bruises fits the appearance of the injury
c. the man has a numerous large bruises of different colors on various parts of his body
Nursing interventions to prevent pressure ulcers include all of the following except: a. use lift devices for transferring or moving patient in bed b. assess each patient for risk c. turn all patients every two hours d. use pressure relieving devices for patients at risk
c. turn all patients every two hours
Which of the following is least likely a risk factor associated with those who abuse the elderly? a. history of mental illness b . overwhelmed c. poor self-image d. female
d. female
Which of the following best describes a characteristic of the earliest phase of Alzheimer's disease? a. impaired speech b. personality changes c. total dependence upon others for care d. progressive forgetfulness
d. progressive forgetfulness
Depending on the physical health of the individual, pressure ulcers can develop within what time from of the insult? A) 1-24 hours B) 24-48 hours C) 48-72 hours D) 72-96 hours
1-24 hours
1. An 80-year-old is seen in the emergency department for a fall. The client has bruises on the upper arms and appears depressed. The client is accompanied by a grandchild, who is unkempt, glassy-eyed, and whose breath smells of alcohol. Which of the following should be a priority with the nurse? A) Assess whether the older adult is safe in the home environment. B) Determine whether legal interventions are appropriate. C) Assess the client's degree of frailty and chronic health problems. D) Determine the mental capacity of the older adult.
A
3. A neighbor notices an 81-year-old getting water from someone's outside faucet. The neighbor notices that this person's ankles are very swollen and there is an open wound on her left leg. The older adult says, "I stopped taking my pills because the water department turned off my water and I can't use the bathroom. My daughter did not pay the water bill, and she never has time to take me to the doctor so my legs can be checked." The neighbor calls adult protective services. Which of the following interventions is the priority when the nurse visits for an evaluation and does not find any immediate danger? A) The competency of the older adult in making decisions needs to be determined. B) The daughter needs to be picked up by the police on a neglect charge. C) The older adult needs to be involuntarily committed to a long-term care facility. D) An involuntary legal intervention needs to be initiated immediately.
A
9. A wound care nurse is assessing a 76-year-old client. The client has intimated to the nurse that her son sometimes "flies off the handle and gets rough with me." Which response made by the nurse is the best response? A) "When you say 'gets rough,' what does that look like?" B) "What do you think usually provokes this to happens?" C) "I'm going to have to phone adult protective services right now." D) "Why do you think that there is that response with anger or frustration?"
A
7. A nurse is participating in a health fair that is being sponsored by a local seniors' center, discussing healthy skin and aging. Which of the following teaching points should the nurse emphasize? A) "You should limit your sun exposure to a small amount each day and keep your skin protected from direct sunlight for the remainder." B) "Many drugs can have an effect on your skin, so it's important to avoid most over-the-counter medications." C) "The health of your skin is primarily determined by your genes, so all you can do is try to maintain your overall level of health." D) "Even if you find it difficult to do, it's important to bathe once a day."
Ans: A Current recommendations emphasize the importance of a balanced approach that encourages small amounts of sun exposure each day for adequate vitamin D synthesis, but not so much that would lead to increased skin cancer risk. Many medications affect the skin, but it would be inappropriate for the nurse to recommend that older adults refrain from all over-the-counter medications. Genetic factors influence integumentary health, but this does not mean that other risk factors are irrelevant or nonmodifiable. It is unnecessary for most older adults to bathe every day
13. A community nurse develops wellness outcomes for those at highest risk for poor management of cardiovascular disease. Which of the following populations should the nurse target? A) African American woman B) Hindu men C) Immigrant Indian population D) Mentally ill persons
Ans: A Poor people, women, and African Americans have more health disparities based on risk factors and poor health management. American Indians and Alaskan natives have the highest prevalence by population. Religion is not a diversity factor, nor is mental illness.
2. A 65-year-old client with a long-standing history of chronic obstructive pulmonary disease (COPD) was placed recently on Coumadin after experiencing atrial fibrillation. Upon discharge from the hospital, which of the following statements by the client indicates a need for further teaching? A) "I will continue to use smokeless tobacco since it's a lot better than smoking." B)"I will avoid using over-the-counter antihistamines since they can dry my mucosal secretions." C)"I will watch my intake of dark green leafy vegetables since they may impact the effects of Coumadin." D)"I will not take any herbal preparations without my health care provider's knowledge."
Ans: A Smokeless tobacco is associated with mouth cancer, gingivitis, and tooth loss and may be carcinogenic to the pancreas. The other noted actions are appropriate to the maintenance of health.
10. A nurse admits a 90-year-old client to the hospital with a diagnosis of failure to thrive. Which of the following laboratory data should the nurse expect? A) Low albumin and red blood cells B) Elevated white blood cells (WBCs) and low potassium C) Low platelets and low prothrombin time (PT) D) Elevated calcium and magnesium
Ans: A Anemia and low serum albumin levels are consistent with malnutrition. Elevated WBCs, calcium, and magnesium and low platelets and PT are not characteristic of malnutrition
15. While discussing sexual behavior at a sex and aging seminar, one older adult states, "No condoms for me, I can't get pregnant!" Which of the following responses is most appropriate? A) "Condoms protect you from sexually transmitted diseases including HIV." B) "How freeing to not have to be concerned about unwanted pregnancies anymore." C) "The youth of society have so much to be concerned with, what with AIDS killing people." D) "Your generation is soon going to have the largest population of HIVinfected persons."
Ans: A Condoms are an important protection for sexually active adults who are sexual with anyone other than a long-term monogamous partner. Condoms protect from many sexually transmitted diseases. Acquired immunodeficiency syndrome is considered a chronic disease. Eleven percent of new human immunodeficiency virus (HIV) infections occur in adults aged 50 years, and by 2015, 50% of HIV-infected individuals will be 50 and older. This is true, but doesn't answer the question.
14. A nurse at a rehabilitation unit assesses an 86-year-old woman with a BMI of 30 and a history of heart failure, whose oral intake is declining. Which of the following risk factors is related to this older adult's decline in appetite? A) Diuretics B) Exercise C) Female gender D) Obesity
Ans: A Diuretics decrease saliva, olfactory function, and gustatory functioning. Women have better olfactory and gustatory function than men; exercise increases appetite. Obesity is unrelated
14. A nurse assesses an older adult for dietary habits. Which of the following statements by the client should the nurse identify as a positive dietary habit for cardiovascular functioning? A) "I avoid meat, and eat nuts instead." B) "I don't eat vegetables." C) "I drink 4 glasses of wine a day." D) "I limit my salt to 3,500 grams per day."
Ans: A Heart-healthy diets include high intake of nuts, fish, fruits, vegetables, and fiber-rich whole grains, less than 1,500 mg of sodium a day, and fruits and vegetables that are rich in essential nutrients, including antioxidants. Excessive use of alcoholic beverages increases the risk
4. A nurse completes assessment of an older adult. Which of the following physical assessment findings is within normal limits? A) Kyphosis and increased anteroposterior diameter of the chest B) Increased intensity of lung sounds C) Decreased resonance on percussion D) Decreased adventitious sounds in lower lungs
Ans: A Minor differences in assessment findings for healthy older adults include shortened thorax, chest wall stiffness, increased anteroposterior diameter of the chest, and forward-leaning posture because of kyphosis
1. A nurse teaches an older adult about changes to nutritional requirements. Which of the following meal choices would give evidence that the older adult understands the teaching? A) Baked chicken, carrots, and angel food cake B) Green salad, mashed potatoes, and an oatmeal cookie C) Vegetable beef soup, crackers, and Jell-O D) Baked pork chop, green beans, and sherbet
Ans: A Older adults need increased intake of foods with a high nutritional value and a concomitant decrease in the intake of foods containing little or no nutrients.
14. A nurse plans care for a frail older adult in long-term care. Which of the following interventions should be included in the plan of care to reduce the risk of respiratory infections? A) Oral care B) Oxygen administration C) Pulmonary function testing D) Tracheal suctioning
Ans: A Poor oral care in long-term care residents increases the risk for pneumonia. Tracheal suctioning should be limited to those who are intubated. Neither testing nor oxygen would decrease risk of pneumonia
9. Which of the following older adult clients is most likely to have physiologic barriers to sexual wellness? A) One who has chronic obstructive pulmonary disease and a recent MI B) One who has early stages of lung cancer and who is being treated for hypothyroidism C) One who had an ostomy created several years ago as treatment for colon cancer D) One who recently recovered from urinary tract infection that progressed to urosepsis
Ans: A Chronic obstructive pulmonary disease and coronary heart disease are associated with sexual dysfunction. The other noted health problems are not associated with physiologic barriers to sexual health and function. Early stages of lung cancer symptoms include cough, which potentially produces bloody sputum, not shortness of air. The ostomy may psychologically impact a client, but not physiologically. Recovered urinary tract infection/urosepsis would not specifically cause a physiologic barrier.
13. A nurse monitors older adults at an assisted living facility for pressure ulcers. Which of the following older adult is at highest risk for a pressure ulcer? A) The obese older adult with continuous positive airway pressure (CPAP) mask B) The frail older adult with a hearing aid C) The older adult undergoing therapy for a weak hand D) The older adult preparing to walk a half marathon
Ans: A Medical devices that are commonly associated with increased risk for pressure ulcers include masks, orthotics, tubing, immobilizers, stockings or boots, nasogastric tubes, cervical collars or braces, and tracheostomy tubes and ties. People who are unable to move around independently are at high risk for pressure ulcers, not those who move and participate in physical activities
4. A nurse cares for an older adult who is nonresponsive and surrounded by family. Which of the following statements by the nurse is most appropriate? A) "I am here for you, how can I be helpful?" B) "I know just how you feel, my mother died last month." C) "I'll leave you alone so that you can grieve in private." D) "She was a really nice lady; she did a good job raising you."
Ans: A Nurses can help people who are dying and their caregivers express their needs by using open, honest, direct, and empathetic communication. Nurses use ongoing assessment to meet the needs of their clients. The statements by the nurse should center on the client and not the nurse. Presence is an appropriate intervention; the nurse should not assume that they desire to be alone
2. Which of the following statements by an older adult indicates the need for further teaching related to cholesterol reduction? A) "I will decrease my intake of food high in polyunsaturated fatty acids." B) "I will increase my intake of soybeans, walnuts, and canola oil." C) "I will eat fish four times a week." D) "I will limit my intake of trans fatty acids and saturated fat."
Ans: A Nutritional interventions for cholesterol reduction limit foods containing saturated fats and trans fatty acids and increase foods that are high in polyunsaturated fatty acids
11. An emergency room nurse cares for the family of a 70-year-old African American woman who died unexpectedly. In the waiting room, upon hearing of the death, two family members kneel to the floor moaning and do not respond. Which intervention by the nurse is most appropriate at this time? A) Allow the family to grieve in this manner directing others away. B) Assess these family members' vital signs and neurologic status. C) Bring these family members to the body of their loved one. D) Call an emergency response team to care for these family members.
Ans: A Recognize that this "falling out" is a culturally based response and not an emergency medical condition; provide support. There is no need to assess these clients for emergency assistance. Bringing all of the family members is appropriate when the family is ready (note: family members may also "fall out" then too)
8. A 78-year-old home health client has admitted to his nurse that his level of sexual activity with his wife has declined in recent months and become wholly absent over the past several weeks. The client has implied that this is due to a lack of performance, rather than lack of desire, on his part. What assessment should the nurse prioritize in light of this revelation? A) Client's medication regimen B) Client's musculoskeletal system and active range of motion C) Client's cognitive status and level of consciousness D) Client's cardiovascular status
Ans: A Sexual wellness and sexual performance are affected by multiple factors. However, the effects of medications are highly significant and likely supersede potential changes in strength, cognition, or cardiovascular status
1. A client is unresponsive, the skin is usually dry, confined to bed, with limited mobility and contractures, and the nutrition is less than adequate. Using the Braden score, which score will be assigned to this client's risk for pressure ulcers? A) 8, very high risk B) 8, at risk C) 18, high risk D) 18, moderate risk
Ans: A The nurse uses the Braden score to determine the plan of care. The lower the Braden score, the greater the risk. Scores of 9 or less are considered to be at very high risk, and additional pressure relieving surface and treatment of nutrition are important for this client
7. A nurse in an intensive care unit prepares to perform postmortem care on an older Jewish client. Family members are at his bedside. Which of the following actions by the nurse is appropriate? A) Allow the family to remain with the client. B) Liaise with the hospital chaplain to visit the family in the chapel. C) Address the man's oldest son when discussing the client's cares. D) Determine which family member(s) will be staying at the bedside during the cares
Ans: A With the Jewish faith, the dying person should not be left alone. Ask the closest relative specifically about postmortem practices. The other noted interventions are not particular to the Jewish culture
4. Which of the following considerations should a nurse prioritize when assessing an older adult who has arrhythmias? A) Assess the client for adverse medication reactions. B) Check the client's electrolytes immediately. C) Make an assessment in relation to the client's medical history. D) Perform auscultation before collecting the client's history
Ans: C Murmurs and arrhythmias may be caused by cardiac diseases, electrolyte imbalances, or adverse medication effects. It is important to make an assessment of underlying causes in relation to the client's medical history
12. A nurse working for human services visits a long-term care facility. Which resident assessment finding indicates poor quality care? A) BMI of 29 B) Indentured mouth C) Serum albumin of 3.5 D) Unintentional weight loss
Ans: D Healthy adult BMI is between 18 and 25 and may extend to 30 for older adults. Dentures are a common finding in older adults. Normal serum albumin is 3.5 to 5; unintentional weight loss is an indicator of quality of care provided by the facility
6. A nurse cares for a 100-year-old man in hospice. The client contemplates his perspectives regarding end-of-life care. Which of the following historical perspectives most likely represent how this client's life experiences have had a formative influence on his views on death and dying? (Select all that apply.) A) I never thought that I would be this old. B) My brother died in a work-related accident. C) I outlived my children and my two wives. D) My family shouldn't have to take care of me. E) I lost an infant to small pox.
Ans: A, B, C, E Concepts related to death, dying, and end of life have changed since the early 1900s. At that time, death was a common occurrence in infants, children, youth, and young adults. Communicable diseases were common. Families provided care. Accidental deaths were common, and death was accepted as an inevitable and normal part of life
15. A nurse provides education to an 82-year-old woman with postprandial hypotension. Which of the following interventions should be included? (Select all that apply.) A) Avoid sitting still for prolonged periods. B) Drink eight glasses of non-caffeinated beverages daily. C) Eat regularly scheduled meals with breakfast as the largest. D) Engage in regular, but not excessive, exercise. E) Limit alcohol consumption to one drink per evening.
Ans: A, B, D, E Health promotion measures specific to postprandial hypotension include the following: minimize the risk for postprandial hypotension by taking antihypertensive medications (if prescribed) 1 hour after meals rather than before meals; eat small, low-carbohydrate meals; avoid alcohol consumption; and avoid strenuous exercise, especially for 2 hours after meals
15. A nurse assesses older adults at risk for pressure ulcers. Which of the following assessment tools should the nurse use to identify those who might benefit from interventions? (Select all that apply.) A) Braden Scale B) Norton Scale C) PUSH Scale D) Reverse staging E) Waterloo Scale
Ans: A, B, E Braden Scale has been recommended for identifying older adults who are at risk for the development of pressure ulcers. The Norton and Waterloo scales are also commonly used, with reviews of studies indicating that all three of these scales can help identify clients at risk for pressure ulcers. PUSH is a staging system, which rates current pressure ulcers, and reverse staging is not a recommended practice
8. One of the functional consequences of age-related changes to the skin is an increased susceptibility to injury. Which of the following factors contributes to this susceptibility? (Select all that apply.) A) Decreased sensation of cutaneous pain and discomfort B) Changes in vitamin D synthesis C) Increased healing time for skin wounds D) Decreased resistance to shearing forces E) Changes in skin pigmentation
Ans: A, C, D A muted pain response, increased healing time, and decreased resistance to shearing all contribute to older adults' susceptibility to injury. Changes in vitamin D may occur with age, but these changes do not constitute a risk for injury. Similarly, changes in pigmentation are not a significant risk factor for injury
10. A 72-year-old man's diagnostic testing and physical examination have resulted in a diagnosis of COPD. Which symptomatology is unexpected and will require follow-up? (Select all that apply.) A) Hemoptysis and orthostatic hypotension B) Chest pain and shortness of breath C) Cough and dyspnea D) Apneic spells and fatigue E) Wheezing and clubbing
Ans: A, D The most common manifestations of COPD are cough, dyspnea, wheezing, and increased sputum production. Hemoptysis and orthostatic hypotension are unexpected and require follow-up, as do apneic spells and fatigue. Chest pain and shortness of breath signal cardiac dysfunction and require immediate attention
13. A nurse plans care for a client who states that food is no longer appealing. The nurse notes a dry mouth and teeth in poor condition. Which interventions should the nurse include in the plan of care? (Select all that apply.) A) Eight-ounce bottle of water between each meal B) Hard toothbrush C) Ice cold water at bedside D) Meals in the common room E) Oral care before each meal
Ans: A, D, E Social isolation can lead to lack of appetite. Saliva-producing activities before each meal and 60 to 80 ounces of water a day are recommended to treat dry mouth. Iced drinks are less palatable to the older adult with poor oral condition. A soft electric toothbrush is recommended
4. Which of the following processes should a nurse address first when assessing sexual function in older adults? A) Identify risk factors that may interfere with the older adult's sexual functioning. B) Assess own personal attitudes toward sexuality and aging. C) Obtain permission from the individual to initiate a discussion on sexual relations. D) Provide detailed information about sexual function to the older adult.
Ans: B A personal attitude assessment about sexuality and aging is a nurse's prerequisite to discussing sexual function with older adults. The next step would be to obtain permission from the individual to initiate discussion about sexual relations
4. A nurse plans the diet for an older adult with congestive heart failure. Which of these nursing interventions would be most successful to encourage optimal nutrition? A) Encourage calorie supplements. B) Provide 55% of calories from complex carbohydrates. C) Teach older adults to sit upright for 2 hours after a meal. D) Use moderate to large amounts of flavor enhancers
Ans: B Dietary guidelines for older adults recommend a daily intake of five to nine servings of fruits and vegetables; 55% of calories need to come from complex carbohydrates. Older adults need fewer calories with increased quality of nutrients in their nutritional requirements. Older adults with presbyesophagus must sit upright for 30 minutes to 1 hour after eating. Flavor enhancers (except lemon) contain sodium and need to be used in small amounts for older adults who have a diminished sense of taste.
12. A nurse manager of an intensive care unit develops plans to improve end-of-life care for clients in the unit. Which of the following actions is the priority? A) Create a script for nurses to use when discussing hospice and palliative care. B) Guide staff to improve communication with families about end-of-life decision making. C) Increase communication between professionals about end-of life decision making. D) Survey clients and families about their end-of-life needs.
Ans: B In recent years, nurses and other health care professionals raised concerns about the need to improve end-of-life care in hospitals. Much of this concern is associated with poor communication between professionals and families about end-of-life decision making. Creating a script can help with that specific need, but the clients continue to experience pain, indignity, social isolation, and uncomfortable symptoms related to ineffective and unwanted life-sustaining treatments, particularly in intensive care units. Interprofessional communication will also help; the priority is between staff and families.
5. An older adult client on a palliative care unit divulges to his nurse that he fears being in pain during the dying process. How can the nurse best respond to the client's admission? A) "It sounds like you're understandably anxious about this. How can I help you to relax?" B) "A lot of clients do have pain at the end, and we will do all we can to control it for you." C) "We will do all we can to address it, and you'll be able to have a peaceful passing." D) "Pain during the dying process actually is not nearly as common as many people believe."
Ans: B Acknowledging that a lot of clients do have pain at the end and that staff will do all they can to control it both acknowledges the client's specific concern and provides a realistic response that the pain will be treated as effectively as possible, but does not guarantee a pain-free dying process. Acknowledging the anxiety and offering relaxation assistance do not address the specific concern about pain. Stating that the client will have a peaceful passing makes a promise that is not possible to guarantee. Pain is a common accompaniment to the dying process
11. A nurse discusses common illnesses at the local health fair. The older adult asks, "Why do all my friends seem to get pneumonia? We never did when we were younger." Which of the following interventions should the nurse include in the teaching? A) Examinations by health care provider B) Hand hygiene C) Jogging/running D) Yearly pneumovax
Ans: B Age-related alterations of the immune functions are a major contributing factor in the prevalence of lung diseases among older adults. Examinations are helpful in early identification of some lung diseases but not preventative regarding communicable diseases such as pneumonia. Pneumovax is not required yearly
9. A community health nurse is to create initiatives to foster the health of older adults in the community. Which of the following health promotion activities has the greatest potential to promote the respiratory health of older adult participants? A) A lung cancer screening program B) A smoking cessation program C) A tuberculosis screening program D) A bronchitis immunization program
Ans: B As with younger adults, smoking cessation confers a multitude of health benefits, especially with regard to respiratory and cardiovascular health. Lung cancer screening and tuberculosis screening are less likely to benefit large numbers of participants. Bronchitis is not a health problem that is amenable to immunization
7. The nurses who provide care in a long-term care setting are aware of the high prevalence and risks of cardiovascular disease among the older adults who live at the facility. Which of the following measures is most likely to prevent heart disease among older adults? A) Advocating for organic dietary choices for residents B) Establishing an exercise program C) Teaching about the relationships between family history and heart disease D) Teaching residents to reduce their stress levels
Ans: B Inactivity is among the most salient risk factors for heart disease, exceeding the effects of stress. Knowledge about the role of family history is unlikely to lower individuals' risks of heart disease. An organic diet is not necessary to prevent heart disease
1. Which of the following individuals is likely at the highest risk for orthostatic hypotension? A) A 75-year-old woman who uses a walker B) An 80-year-old man who strains to void when using the bedside commode C) A 60-year-old who has a long leg cast on his right leg D) An 80-year-old woman who is taking Premarin
Ans: B Orthostatic hypotension rises significantly after the age of 75. A risk factor for orthostatic hypotension is doing a Valsalva maneuver while voiding.
6. Older adults experience a number of changes in the structure or function of their cardiovascular system. Which of the following changes is considered to be a normal, age-related change? A) Veins become thinner and more elastic. B) Regulation of blood pressure and heart rate becomes less efficient. C) Heart valves become atrophied and regurgitation occurs. D) Heart rate becomes slower and ejection fraction increases
Ans: B Overall regulation of blood pressure and heart rate becomes less responsive and less efficient with age. Veins become thicker and stiffer. Heart rate does not typically slow with age and valvular regurgitation is considered a pathologic condition at any age
3. A 70-year-old client with urosepsis is admitted to a nursing unit. The labs include elevated sodium, blood urea nitrogen, hematocrit, and albumin. Which of the following nursing diagnoses is priority for this client? A) Constipation B) Fluid volume deficit C) Imbalanced nutrition: less than body requirements D) Impaired tissue perfusion
Ans: B The appropriate nursing diagnosis is fluid volume deficit. Blood values that may be altered in dehydration include elevations in sodium, hematocrit, creatinine, osmolality, and blood urea nitrogen. While the client may develop constipation, it is not the priority at this time. Albumin will be decreased with poor nutrition but increased with dehydration. An elevation in these labs does not implicate impaired tissue perfusion
11. A nurse assesses older adults at a senior center. One older adult, age 78, has a body mass index (BMI) of 15. Which response by the nurse is appropriate? A) "You are too skinny." B) "Have you been losing weight?" C) "Have you tried to lose this extra weight?" D) "Congratulations your BMI is great."
Ans: B The nurse uses therapeutic communication to assess the weight loss. Unintentional weight loss is considered a significant indicator of poor nutrition. Healthy adult BMI is between 18 and 25 and may extend to 30 for older adults
3. A 70-year-old client smoked for 30 years and has a history of COPD. The spouse assists with cooking, cleaning, and transportation. The spouse has become ill, and they now receive assistance from a home health nurse. Which of the following interventions should be the priority? A) Assisting the clients to perform instrumental activities of daily living (IADLs) B) Determining a plan for providing meals C) Setting up medications for the clients D) Smoking cessation plan
Ans: B The nurse's role is not to perform the IADLs, but to plan for the IADLs including meals, cleaning, and transportation. There is no indication that the clients need their medications set up, smoking cession is important, but basic needs come first
1. A 65-year-old woman is speaking to her nurse at the primary care clinic. She states that it is very painful for her when she has sexual relations. She asks the nurse what she could do to alleviate the pain. Which of the following suggestions could the nurse make to the woman? A) Decrease the incidence of sexual relations. B) Use a water-soluble lubricant or estrogen cream. C) While engaging in intercourse, have your partner thrust his penis upward. D) Use a polyisoprene (non-latex) condom for intercourse
Ans: B With age, there is a thinning of the vaginal mucosa, which creates dryness and predisposes women to irritation and inflammation so using a water-soluble lubricant or estrogen cream may be helpful. The male partner should thrust downward instead of upward during sexual intercourse. Decreasing the incidence of sexual relations may lead to a "use it or lose it" principle. Use of a condom, latex or polyisoprene, will not decrease vaginal wall irritation.
14. A nurse assesses residents of the acute care facility for pressure ulcers. Which older adult should the nurse monitor closely for pressure ulcers? A) The Asian with multiple nevi on extremities B) The Ethiopian former store clerk C) The fair-skinned Caucasian woman D) The wrinkled face Hispanic ranch worker
Ans: B Persons with darkly pigmented skin have a higher incidence of serious pressure ulcers. Nevi, sun exposure, and fail skin are related to cancer, not pressure ulcers
2. A nurse cares for an 87-year-old client from India who has noted Hinduism as religious preference on admission records. This client is transferred to the hospice unit. Which of the following actions by the nurse best shows caring? A) Ask the family to tell you about Hinduism. B) Assess the client's spiritual needs. C) Notify the family's pastor. D) Pray with the client and family.
Ans: B Spiritual assessment should take place on admission and throughout the client's time in palliative care. Spiritual care is within the scope of nursing, and prayer would be appropriate if it were chosen based on a sound assessment of the client's needs and belief system. Nurses should be prepared to refer to whatever spiritual leader the client expresses a desire to speak with. Now is not the time to query, it is the time to listen.
3. A nurse explores resources available to assist a client. Which of the following older adults meets the eligibility requirements for hospice care? A) A client who is immobilized and unable to afford specialized nursing care B) A client who has experienced a stroke and been given 3 months to live C) A client with cancer who is living with uncontrolled persistent pain D) A client with acquired immunodeficiency syndrome who lacks family support to provide needed care
Ans: B The eligibility requirements for hospice care include physician referral and a life expectancy of less than 6 months. Financial need, high pain levels, and lack of family support are not explicit qualifiers for hospice care
An older adult is dying of cancer, and a hospice nurse comes to the home every day to oversee the client's care and comfort. Which intervention would be most important for the nurse to provide?
Assuring support
To the embarrassment of his family, an 81-year-old male client on the subacute unit of a hospital has made repeated, sexually inappropriate statements to female staff members. The client's family is adamant that such behavior is uncharacteristic. Which action would the nurse implement first?
Attempt to identify the underlying cause of the client's behavior.
10. An older adult who appears to be between 85 and 95 has been brought to the emergency department by emergency medical services after being found wandering in the street. The older adult is filthy, confused, and exhibits numerous bruises to the face and neck as well as signs of malnutrition and dehydration. What problem should the nurses prioritize for assessment and intervention? A) Hygiene B) Malnutrition C) Dehydration D) Potential elder abuse
B
12. A nurse educates an older adult recently diagnosed with hypertension. Which of the following teaching points should the nurse include? (Select all that apply.) A) Avoid home blood pressure monitoring. B) Increase the daily intake of grains to 8 ounces per day. C) Read labels and limit sodium to 1,500 g/day. D) Walk daily for 30 minutes a day 5 of the 7 days. E) If your blood pressure is higher than 130/80 notify the primary health care provider.
Ans: B, C, D About 30 to 45 minutes of exercise, such as brisk walking, at least five times weekly is recommended for all people with hypertension. The following nutritional interventions are recommended for all people with hypertension: sodium intake limited to 1.5 g daily; avoidance of processed foods; daily intake of 7 to 8 servings of grains and grain products and 8 to 10 servings of fruits and vegetables. A person's blood pressure should be measured at least three times before making any decisions about treatment with a goal of systolic blood pressure of <130/80 mm Hg. Home blood pressure monitoring is recommended for initial and ongoing assessment.
13. A nurse reviews the medications of a 58-year-old man who has erectile dysfunction. Which of the following prescribed medications can interfere with sexual functioning? (Select all that apply.) A) Acetylsalicylic acid (aspirin) B) Metoprolol (Lopressor) C) Clopidogrel (Plavix) D) Lisinopril (Prinivil) E) Ezetimibe (Zetia)
Ans: B, D Metoprolol and lisinopril interfere with libido and can cause erectile dysfunction in men. Acetylsalicylic acid, clopidogrel, and ezetimibe do not. Of note, these medications indicate cardiovascular disease which is strongly associated with sexual dysfunction
14. A nurse administrator incorporates older adults' sexuality into the policies of a long-term care facility. Which of the following should be included in this plan? (Select all that apply.) A) Allow public masturbation. B) Ask permission to enter a room. C) House spouses separately. D) Knock on door before entering. E) Redirect inappropriate sexual behaviors.
Ans: B, D, E Masturbation is normal, but not appropriate for public places, assuring that the clients' rooms are their own personal space and assuring privacy while in those rooms are important to sexuality. Sexual behaviors that impinge on others' comfort should be redirected. Components of sexuality that are especially important for older adults include kissing, hugging, intimacy, fantasy, masturbation, oral sex, loving words, physical closeness, and expressions of affection
5. A nurse plans interventions in a skilled nursing facility to prevent lower respiratory infections. Which of the following nursing interventions should be included in the plan? (Select all that apply.) A) Encourage annual pneumonia vaccinations. B) Encourage annual influenza vaccinations. C) Encourage annual chest radiographs to detect tuberculosis. D) Encourage influenza vaccinations every 5 years. E) Encourage hand hygiene for residents and staff.
Ans: B, E Influenza vaccinations should be given yearly to older adults. The Centers for Disease Control and Prevention (CDC) recommends a one-time booster dose of the pneumonia vaccination for all people 65 years of age or older if they received an initial pneumonia vaccination 5 or more years earlier or were younger than 65 years of age when they first received the pneumonia vaccine. Chest radiographs will not prevent lower respiratory infections. Hand hygiene is essential in prevention of infections
11. A 52-year-old woman discusses her menstrual cycles with the nurse. The client states that she still has menses, but that she "never knows when they might begin or end." Which of the following is the most appropriate response by the nurse? A) "It sounds like you are frustrated with this change; it is a difficult part of life." B) "Reproduction is no longer possible so that is one thing less to worry about." C) "We can't say how long this perimenopausal phase might last." D) "You are in the postmenopausal cycle and should expect further changes."
Ans: C Perimenopause refers to the several years before menopause when women begin experiencing changes in menstrual cycles. The client doesn't express frustration, nor does she sound like she is "worrying" about reproduction (which still could happen, even with low probability). Menopause typically occurs around the age of 49 to 51 years and postmenopause begins 12 months after last period
15. A nurse admits an older adult from a long term care facility into the hospital for respiratory infection. Which diagnostic testing should the nurse anticipate? A) Electrocardiogram B) Lung cancer screening C) Mantoux testing D) Pulmonary function testing
Ans: C Feedback: Residents of long-term care are at risk for tuberculosis. While cancer and cardiac and lung function testing may occur, testing for tuberculosis should be done to screen for this contagious disease to protect others.
9. A nurse who works on a geriatric long-term care unit is aware that many of the older adult clients on the unit have a documented history of orthostatic hypotension. What measure should the nurse prioritize in order to ensure the safety of such clients? A) Mobilize clients within 2 hours of eating a meal. B) Have clients take several deep breaths before standing to their feet. C) Have clients sit on the edge of their beds for a minute or two before ambulating. D) Encourage clients to use a bedpan or incontinence brief to prevent falls while ambulating to the bathroom.
Ans: C Feedback: Sitting at the edge of the bed before standing can significantly reduce the risk of falls in individuals with orthostatic hypotension. It is inappropriate to have clients use bedpans or briefs for the sole reason of preventing falls. Mobilizing after meals and deep breathing do not appreciably address orthostatic hypotension.
14. A home health nurse visits a client who has a history of alcoholism and dementia. The client's words are incoherent, and the client's clothes are filthy. The client is unsteady and leaning to the right, and the room in the rooming house is in disarray. The only word that the nurse can clearly identify is "no." Which action by the nurse is most appropriate at this time? A) Ask the neighbors what has been happening. B) Call emergency services for transport to a hospital. C) Leave and return later. D) Search the room for empty bottles.
B
12. A nurse evaluates the healing of a full-thickness skin tear on a 92-year-old resident of a long term care facility. Which of the following would support the continuation of the current treatment plan? A) The wound with redness surrounding at 12 days B) The wound draining serosanguinous drainage at 14 days C) The wound showing 50% healing at 16 days D) Pain at the wound site at 19 days
Ans: C Feedback: About 50% healing at 16 days is acceptable. Full-thickness skin tears take an average of 21 days to healing in older adults. The treatment plan needs to be changed if there is redness (at 12 days), pain (at 19 days), or draining plasma (at 14 days).
10. A nurse in a long-term care facility teaches aides to assist several older adults with bathing each day. Which of the following interventions should the nurse include in the teaching? A) Apply perfumed products after bathing to promote hygiene and self esteem. B) Cleanse groin with isopropyl alcohol to eliminate potential pathogens. C) Dry skin thoroughly; particularly between the toes and other areas where skin touches. D) Use water that is warm to hot (100°F to 105°F) to prevent hypothermia.
Ans: C Feedback: Skin need to be dried thoroughly but gently, particularly between the toes and other areas where skin touches. Perfumed products and alcohol should be avoided. Water temperatures for bathing should be about 90°F to 100°F.
11. A nurse identifies clients who are at risk for modifiable risk factors for cardiovascular disease. Which of the following clients should the nurse prioritize as having modifiable cardiovascular functional consequences? A) A 54-year-old admitted to the hospital with hepatitis A B) A 72-year-old after her second myocardial infarction. C) A 86-year-old obese woman who has type 2 diabetes D) A 94-year-old with a strong family history of myocardial infarctions at an early age
Ans: C Modifiable risk factors include obesity, and control of blood glucose levels. Hepatitis A is not a risk factor. Prior myocardial infarction and strong family history are not modifiable. However, those clients are at risk and other risk factors in their life may need to be modified.
7. Mr. Thomas and Mrs. Young are residents of a long-term care facility who are both physically frail but cognitively healthy. Last night, the nurse at the facility discovered Mr. Thomas and Mrs. Young in bed together in Mr. Thomas' room and engaging in foreplay. How should care providers best respond to these residents' new sexual relationship? A) Ensure that each resident's family members are aware of this development. B) Teach Mr. Thomas and Mrs. Young about sexual health promotion. C) Accommodate the residents' relationship and provide them with appropriate privacy. D) Have each resident assessed to ensure that the relationship is medically safe and appropriate.
Ans: C Sexual relationships between competent and consenting residents in institutional settings should be accommodated by care providers. It is likely unnecessary to directly involve family members. Education and medical assessment are likely unnecessary and may be inappropriate.
8. A nurse manager of the long-term care facility develops plans to reduce nutritional deficits. Which of the following interventions is appropriate to include in the plan? A) Encourage residents to eat in their rooms to minimize distractions. B) Offer four to five small meals a day rather than three larger meals. C) Promote oral care for residents multiple times each day. D) Provide incentives for residents to eat all the food on their trays.
Ans: C Adequate oral care is important in the promotion of adequate food intake, because it enhances chewing, eating, and swallowing. Eating alone is associated with lower caloric intake. Offering incentives may be construed as coercive or patronizing. Frequent, small meals may be necessitated by certain medical conditions, but this is not a recognized strategy for the promotion of nutrition among a larger group of older adults
7. A nurse counsels an older adult regarding nutritional requirements. Which of the following teaching points is priority when discussing age-related changes in nutritional requirements? A) "If possible, try to eliminate animal fats from your diet." B) "You should try to eat less meat and proteins than you did when you were younger." C) "Overall, you don't need to take in as many calories as you used to." D) "As an older adult, you don't need to eat as many starches and complex carbohydrates."
Ans: C Caloric requirements for older adults are significantly less than those for younger adults. It is unnecessary to wholly eliminate animal fats from the diet, and protein intake should remain same as for younger adults. Complex carbohydrates should constitute the majority of caloric intake
7. A nurse admits an 81-year-old man to the hospital with aspiration pneumonia. Which of the following risk factors should the nurse predict that the client has in his history? A) Cigarette smoking B) Lung cancer C) Dysphagia D) Sleep apnea
Ans: C Dysphagia creates a serious risk for aspiration pneumonia. Smoking, cancer, and sleep apnea do not have a direct correlation with aspiration pneumonia
8. A 78-year-old client has been brought to the emergency department from home with a sudden change in mental status accompanied by significant weakness. For which condition should the health care providers assess? A) Alzheimer disease B) Lung cancer C) Pneumonia D) Tuberculosis
Ans: C In older adults, pneumonia often has a presentation that differs from that of younger adults. Rather than presenting with a cough, chills, dyspnea, elevated temperature, and elevated white blood cell count, older adults are more likely to have subtler and nonspecific disease manifestations such as fatigue and change in mental status. Alzheimer disease has an insidious onset. Lung cancer and tuberculosis are not characterized by cognitive deficits
3. The nurse assesses the fluid volume status of a 72-year-old client who takes Lasix (furosemide) and Pacerone (amiodarone). Which of the following is the most reliable method for assessing this client's skin turgor? A) Ask the client to open the mouth and examine the oral mucous membranes for dryness. B) Examine the skin on the lower legs and look for dry, scaly, or rough skin. C) Gently pinch the skin on the abdomen to see how long it takes to return to normal. D) Squeeze the skin on back of hand to see if it remains pinched or is slow to return to normal.
Ans: C Skin turgor should be checked over protected areas, such as the sternum or abdomen. The use of diuretics can exacerbate xerosis that older adults may have. Diuretics and amiodarone increase the risk for photosensitivity
2. A nurse teaches older adults about skin care and aging. Which of the following would be appropriate to include in this teaching? (Select all that apply.) A) Avoid sunscreens with a sun protection factor (SPF) higher than 14. B) Gently apply rubbing alcohol to keratosis growths to remove them. C) Include adequate amounts of fluid and vitamins in the daily diet. D) Use firm rubbing motions when drying your skin. E) Use emollient moisturizing lotions after bathing. F) When bathing or showering, use a mild, unscented soap.
Ans: C, E, F Older adults need an adequate intake of calories, nutrients, and hydration. Older adults should use a gentle, patting motion when drying their skin ensuring dry skin between toes. Older adults need to use a sunscreen with an SPF of 15 or higher even on overcast days and apply the emollient moisturizing lotion after bathing (not oils during bathing).
10. A nurse who provides care in a nursing home occasionally encounters colleagues' prejudices and misperceptions around the sexual wellness of residents. Which of the following statements reflects an appropriate view of sexual health in older adults? A) "I think it's just so cute when residents think that they're dating each other." B) "We need to make sure that residents get the teaching they need before we allow a sexual relationship." C) "Older adults need companionship and comfort much more than they need sex." D) "Let's do all we can to facilitate competent residents' sexual relationships."
Ans: D Among competent older adults, autonomy around sexual relationships should be protected and fostered. It is untrue that older adults have little need for sex and it is inappropriate for a nurse to prohibit a relationship pending education. Referring to older adults' relationships as "cute" is patronizing and inappropriate
10. A 70-year-old client has been a regular cigarette smoker since late teens and has made several attempts to quit over the years. When the nurse encourages the client to again try to quit, the client responds, "At this point in my life, I think it's probably too late." How should the nurse best respond to the client's statement? A) "You'll be able to avoid having a future heart attack if you quit smoking now." B) "Three months after your quit, you'll have the same risk of heart disease as a lifetime nonsmoker." C) "In a way that's true, but you would feel much better about yourself if you managed to quit." D) "Actually, you'll start to enjoy some health benefits almost as soon as you quit."
Ans: D Benefits of smoking cessation exist at any age. Complete elimination of smoking-related health threats does not disappear after only 3 months, however. Smoking cessation is not a guarantee against future MI
5. A nurse teaches a health education class for older adults about constipation. Which of the following points should the nurse stress? A) Older adults who do not have a daily bowel movement should use a laxative. B) Older adults should limit their intake of high fiber foods because of a risk of lactose intolerance. C) If older adults need a medication to promote bowel regularity, a laxative or enema should be given. D) If older adults need a medication to promote bowel regularity, a bulk-forming agent is needed daily
Ans: D Feedback: A bulk-forming agent is least likely to have detrimental effects; providing fluid intake is adequate, if a medication is needed to promote regular bowel elimination. If at all possible, older adults should avoid laxatives. Older adults should include several portions of high-fiber foods in their daily diet.
9. A 79-year-old experienced a severe stroke several days ago. The client's spouse has been told by the care team that he is unlikely to survive more than a few days and that aggressive treatment would likely be futile. The nurse has just entered the client's room to find the spouse softly crying at the bedside, and makes no attempt to acknowledge the nurse's presence. What is the nurse's most therapeutic response to the client's wife? A) "Do you feel like he was able to live a full life?" B) "Did you feel like you were able to discuss his treatment options thoroughly?" C) "What is it that makes you the saddest about your husband's situation?" D) "I am here; should I leave you alone for now?"
Ans: D In light of the fact that the wife is grieving quietly and has not acknowledged the nurse's presence, it is likely appropriate to offer to leave her alone. Alluding to treatment options, a "full life," or particularly sad aspects of the situation is inappropriate
4. A quality care nurse assesses the care given by a hospice. Which of the following statements by the client best reflects dignified end-of-life care? A) "I'm glad that my family is making all the decisions; it's too much for me." B) "I'm not ready to die yet; I've got a few more in me." C) "It is fine sharing a room; I like the company." D) "They listened to me and stopped the therapy."
Ans: D Some characteristics of dignified care include being involved in decision making, having privacy and a safe environment, being listened to and having needs and wishes respected, and feeling peaceful and ready to die
16. An older adult develops diarrhea. Which of the following is the priority intervention for the nurse? A) Assess for pancreatitis. B) Determine the last bowel movement. C) Review meal preparation techniques with the client. D) Review the client's medication list.
Ans: D A number of medications can cause diarrhea in the older adult (e.g., Cimetidine, laxatives, antibiotics, cardiovascular drugs, and cholinesterase inhibitors). Additionally, Clostridium difficile and its related diarrhea are related to antibiotic usage
3. An older adult is admitted to the emergency department with dyspnea and a sudden change in level of consciousness. The nurse should assess first for which of the following disorders? A) Myocarditis B) Aortic aneurysm C) Cor pulmonale D) Myocardial infarction
Ans: D Compared with younger adults, older adults experiencing a myocardial infarction are more likely to have dyspnea or neurologic symptoms, rather than chest discomfort. Older adults with angina and acute myocardial infarction are more likely to have subtle and unusual manifestations
5. Which of the following functional consequences of skin changes will impact the nursing care of older adults? A) Older adults have an increased incidence of moles requiring intervention. B) There is a decreased incidence of skin cancer in older adults because of an increase in melanocytes. C) In older adults, tactile sensitivity increases and there is an intense response to cutaneous stimulation. D) Collagen changes interfere with tensile strength of older adults' skin, causing the skin to be less resilient
Ans: D There is less tensile strength of the skin because of collagen changes, which predisposes the older adult to abrasive and tearing skin damage. There is a decreased incidence of moles after 40 years of age. There is an increased incidence of skin cancer in older adults, and decreased melanocytes is one factor that impacts this. Tactile stimulation decreases, and there is a less intense response to cutaneous stimulation
5. A nurse is conducting a health education class for older adults with arthritis that will address relevant issues of sexual function. Which of the following statements indicates that the nurse's teaching has been successful? A) "I will decrease the amount of time spent in foreplay before engaging in sexual intercourse." B) "I will avoid taking a warm bath before engaging in sexual activity." C) "I will avoid experimenting with different positions during sexual relations." D) "I will use a vibrator since my ability to massage is limited."
Ans: D People with arthritis will want to increase foreplay. Warm baths will decrease stiffness. People with arthritis should experiment with sexual positions for comfort and support. A vibrator may help if the ability to massage is limited for the person with arthritis
6. A gerontological nurse is aware of the changes in the structure and function of the skin and accessory glands that occur with aging. Which of the following changes is a normal accompaniment to the aging process? A) Thickening of collagen in the dermal layers of the skin B) Cessation of eccrine and apocrine sweat gland function C) Increase in the number of melanocytes in the epidermis D) Decrease in the vascular bed of the dermis
Ans: D The dermal vascular bed decreases by about one-third with increased age; this contributes to the atrophy and fibrosis of hair bulbs and sweat and sebaceous glands. However, sweat glands do not wholly stop functioning. Collagen tends to thin rather than thicken, and the number of melanocytes in the epidermis decreases.
1. A nurse on a geriatric medical care unit consults hospice for a client. Which of the following nursing interventions should the nurse anticipate after the client begins hospice care? A) Administering chemotherapy to a client with a diagnosis of pancreatic cancer B) Assessing the deep tendon reflexes of a client with neurologic impairment C) Infusing total parenteral nutrition to a client with dysphagia D) Providing an opioid analgesic to a client with bone metastases
Ans: D The focus of hospice care is on the relief of suffering rather than cure of disease. Relief of suffering often encompasses providing pain relief to clients. Active curative treatments, such as chemotherapy, and parenteral feeding often are forgone. Health assessments that do not assess the client's comfort, such as the assessment of deep tendon reflexes, are not the priority of palliative/hospice care
13. A quality control nurse for a large group of long-term care facilities assesses the quality of care at the end of life for the residents. Which of the following measures indicate quality care? (Select all that apply.) A) Increase in the number of deaths in the hospital B) Increase in the number of residents who refuse treatments at the end of life C) Increase in the percent of residents with advanced dementia D) Increase in the use of hospice services E) Increasing number of staff trained in palliative care
Ans: D, E Studies confirm the need for staff education related to symptom management and other aspects of palliative care. Two measures of quality care at the end of life for nursing home residents are use of hospice services and avoiding death in the hospital. There are a large number of residents with advanced dementia (the desire is that more of these become clients of hospice)
5. A 30-year-old grandchild lives with and provides care for the 75-year-old grandparent. The grandparent has congestive heart failure, hypothyroidism, and chronic pain from a compression fracture and osteoporosis. The grandchild supervises the older adult's medications. The home health nurse notes that the older adult has extra diuretic pills and that the pain medications for a month have been used and cannot be refilled for 2 more weeks. The older adult tells the nurse: "Those pain pills don't work, my back is always hurting." The nurse notes that the older adult's ankles are very swollen. Which of the following things should the nurse do first? A) Call adult protective services and ask for an immediate evaluation. B) Assess the grandchild's understanding of her grandmother's needs. C) Take the grandmother to the emergency department immediately. D) Tell the older adult that her grandchild is probably taking her pain medications.
B
7. A nurse who provides care in a clinic comes into contact with numerous older adults, many of whom have bruises of various sizes and stages on their body. What pattern of bruising is most suggestive of possible abuse? A) Significant bruising on the shin region of a client's leg B) Bruising on both ears and both sides of the neck C) Bruising on the back of a client's hands D) Bruising on both of a client's elbows
B
Poor nutrition and subsequent skin breakdown is associated with which of the following lab results? a. Serum albumin of 3.0 b. Serum transferrin of 250 c. Cholesterol of 200 d. none of the above
a. Serum albumin of 3.0
The nurse is caring for a healthy older patient who tells her that he is going to die and wishes no heroic measures to be taken. There are no advance directives on the chart. The nurse leaves the room and returns minutes later to find the patient with no pulse and not breathing. What should the nurse do? a. call a code or 911 and begin CPR b. quickly write and sign advance directives c. leave the room and close the door d. call the doctor before beginning CPR
a. call a code or 911 and begin CPR
Clinically, Lewy body dementia (LBD) can be distinguished from Alzheimer's disease (AD) by: a. motor symptoms in the early stage of LBD b. visual halluincations in late LBC c. fluctuating mental status as a feature of AD but not LBD d. response of motor symptoms to dopaminergic agents
a. motor symptoms in the early stage of LBD
The Up and Go Test is useful for assessment because it: a. provides a quick measure of physical, especially walking, ability b. gives a precise indication of physical strength c. provide a statistically accurate number associated with grip strength d. gives an idea of cognitive function
a. provides a quick measure of physical, especially walking, ability
When an elderly person is adequately physically cared for in the home by adult children, but socially isolated and expresses no purpose or will to live, this is a sign of: a. psychological or emotional neglect b. psychological or emotional abuse c. direct physical abuse d. physical neglect
a. psychological or emotional neglect
In caring for a person with middle to late stage or moderately severe Alzheimer's disease, which of the following concerns takes priority? a. safety b. socialization c. body-image d. coping
safety
