Mod 1: EAQ Chapter 18
The nurse is assessing a 25-year-old patient diagnosed with depression and anxiety disorders. Which question would the nurse ask in order to determine whether the patient is presently at risk for suicide? "Have you been feeling fatigued or lacking energy lately?" "How often do you feel afraid that something bad will happen?" "Have you had feelings of helplessness or hopelessness recently?" "Have you had thoughts of harming yourself or someone else?"
"Have you had thoughts of harming yourself or someone else?" Directly asking a patient about thoughts of harming themselves or someone else is the best way to assess risk for suicide and begin honest discussion about suicidal thoughts. Questions such as "Have you been feeling fatigued or lacking energy lately?", "How often do you feel afraid that something bad will happen?" and "Have you had feelings of helplessness or hopelessness recently?" help the nurse understand the characteristics of the patient's depression or anxiety, but are not as effective at assessing suicidal risk as directly asking about thoughts of self-harm. The nurse asks the patient about feelings of hopelessness, helplessness, and sadness to identify the factors that promote suicidal tendencies. The nurse asks about the patient's level of irritability and about feelings of fatigue or a lack of energy to assess the patient's mood fluctuations. The nurse asks about fears related to the patient's career and future in order to assess anxiety. p. 264
Which finding would the home health care nurse report to the primary health care provider while assessing a 72-year-old patient? Select all that apply. One, some, or all responses may be correct. A 3-cm (1.2 in) decrease in height since middle adulthood A 10-kg (22 lb) increase in weight over one month Dry and wrinkled skin Generalized body edema Sudden increase in urinary frequency
A 10-kg (22 lb) increase in weight over one month Generalized body edema Sudden increase in urinary frequency Any sudden changes, especially those involving fluid balance in the body, are not normal age-related findings and should be reported to the primary health care provider. A sudden increase in weight, generalized body edema, or sudden increase in urinary frequency may indicate cardiovascular, renal, or hormonal conditions and should be promptly investigated. Normal aging-related changes such as a gradual decrease in height since middle adulthood or the presence of dry and wrinkled skin are not abnormal findings and do not need to be reported. p. 256
A 25-year-old patient is admitted to the hospital for the treatment of marijuana addiction and adverse health effects of marijuana use. Which physical finding would the nurse anticipate in this patient? Select all that apply. One, some, or all responses may be correct. Anxiety and panic reactions Impulsivity and abundant energy Nausea and decreased appetite Impaired memory and learning Frequent respiratory infections
Anxiety and panic reactions Impaired memory and learning Frequent respiratory infections Marijuana is a preparation of the cannabis plant that contains tetrahydrocannabinol. Tetrahydrocannabinol causes panic reactions and impairment of memory and learning. Frequent respiratory infections may be present due to excessive inhalation of the drug. Impulsive behavior is characteristic of certain stimulant drugs, not marijuana. Nausea and decreased appetite are not typical of marijuana addiction. p. 261
Kyphosis, an age-related change in the skeletal system, leads to which finding? Decreased bone density in the vertebrae and hips Increased risk for pathologic stress fractures in the hips Changes in the configuration of the spine that affect respiratory efficiency Calcification of the bony tissues of the long bones such as in the legs and arms
Changes in the configuration of the spine that affect respiratory efficiency Kyphosis is an increased curvature of the spine that can alter the shape of the thorax and diminish the maximal inspiratory and expiratory force during respiration. Kyphosis can result from alterations in bone density, but it does not cause decreased bone density. Kyphosis does not increase the risk for pathologic stress fractures in the hips. Kyphosis is a condition of the spine, not long bones such as in the legs and arms. Test-Taking Tip: Avoid taking a wild guess at an answer. However, should you feel insecure about a question, eliminate the alternatives that you believe are definitely incorrect and reread the information given to make sure you understand the intent of the question. This approach increases your chances of randomly selecting the correct answer or getting a clearer understanding of what is being asked. Although there is no penalty for guessing on the NCLEX examination, the subsequent question will be based, to an extent, on the response you give to the question at hand; that is, if you answer a question incorrectly, the computer will adapt the next question accordingly based on your knowledge and skill performance on the examination up to that point. p. 274
A home health nurse is performing an initial assessment on an older adult patient. Which physiologic change would the nurse anticipate as normal for an older adult? Select all that apply. One, some, or all responses may be correct. Decreased tear production Loss of skin elasticity Disorientation Loss of visual acuity Decreased blood pressure
Decreased tear production Loss of skin elasticity Loss of visual acuity The nurse should anticipate decreased tear production, loss of skin elasticity, and loss of visual acuity as normal physiologic changes in an older adult. Lacrimal glands produce less fluid, making the eyes feel dry. Skin elasticity decreases due to loss of collagen. Loss of visual acuity is due to multiple age-related changes in the eye. Disorientation is not an age-related change and is not a normal finding. Blood pressure is usually increased in older adults due to age-related stiffening of the arteries. p. 256
Which sensory change is the nurse likely to find during assessment of a75-year-old patient? Select all that apply. One, some, or all responses may be correct. Decreased visual accommodation Presbycusis Altered proprioception Decreased ability to smell Increased touch sensitivity
Decreased visual accommodation Presbycusis Altered proprioception Decreased ability to smell Aging leads to a number of physiologic and psychological changes, including changes to sensory perception. The changes in sensory perception include decreased accommodation to near/far vision (presbyopia), loss of acuity for high-frequency tones(presbycusis), decreased awareness of body positioning in space (proprioception), and decreased ability to smell. There is often a decrease, not increase, in touch sensitivity owing to decreased number of skin receptors. p. 256
The nurse observes that a patient is in a state of acute confusion, is fearful, and is experiencing memory loss. Which condition describes these findings? Delirium Depression Conduct disorder Alzheimer's disease
Delirium Delirium is a syndrome characterized by acute confusion, memory loss, disorientation, fearfulness, and excessive energy. Delirium is a serious, reversible, and treatable disorder. Depression is a mood disorder characterized by sleep problems and diminished appetite, which are also normal characteristics of the aging process. Conduct disorder is a severe psychiatric condition that occurs in children and teenagers. The defining characteristics sometimes include hostility and aggression. Alzheimer's disease is the most common form of chronic dementia. The patient may have confusion, complete loss of memory, and depression. p. 271
A 50-year-old patient tells the nurse that he has recently lost his job and his spouse has asked for a divorce. He has a flat affect and reports difficulty sleeping. For which condition would the nurse carefully assess this patient? Cardiovascular disease Depression Sexually transmitted infection Drug abuse
Depression Depression is common among middle-aged adults and has a variety of causes. Risk factors for depression include disappointments or losses at work, at school, or in family relationships and family history. The patient does not show indications of cardiovascular disease. Regular screening for sexually transmitted infections is important, but is not a priority in this patient at this time, as he does not show symptoms of sexually transmitted disease nor does he report risk factors for sexually transmitted infections such as multiple partners. Screening for drug abuse is important, but is not a priority for this patient at this time, as he shows no indication of drug use. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response. In this question, descriptions are given of the patient's affect, family history, and social triggers that can be related to psychologic illness; only one choice addresses the entire description. p. 264
A major life event such as the death of a loved one, a move to a nursing home, or a cancer diagnosis could precipitate which condition? Dementia Delirium Depression Stroke
Depression The onset of depression may be abrupt or gradual, but a common cause is a major life-altering event. Dementia is chronic and irreversible confusion caused by brain deterioration. Delirium is acute confusion triggered commonly by advancing age, pain, polypharmacy, hospitalization, surgery, infection, or physiologic or pathologic conditions. Stroke is caused by an alteration in blood flow to the brain and is not correlated to experiencing a major life-changing event. p. 263, 267, 271
Which symptom is the effect of taste bud atrophy in older adults? Increase in gum diseases Development of mouth ulcerations Altered mastication (chewing) Difficulty differentiating flavors
Difficulty differentiating flavors Taste bud atrophy causes difficulty differentiating tastes and flavors, particularly salty and sweet. Taste bud atrophy does not cause an increase in gum diseases, development of mouth ulcerations, or altered mastication. Test-Taking Tip: The most reliable way to ensure that you select the correct response to a multiple-choice (single-answer) question is to recall it. Depend on your learning and memory to furnish the answer to the question. To do this, read the stem and then stop! Do not look at the response options yet. Try to recall what you know and, based on this, what you would give as the answer. After you have taken a few seconds to do this, look at all of the choices and select the one that most closely matches the answer you recalled. Maximize your chance of correctly answering each question by considering all the choices before making your final decision. pp. 256-257
The idea that authority figures should be respected simply because of their authority base exemplifies which cognitive concept? Dualistic thinking Relativist thinking Fluid intelligence Crystallized intelligence
Dualistic thinking This example is typical of dualistic thinking, in which information, values, and authority are divided into right and wrong, good and bad, and "we" and "they". In dualistic thinking, truth is compared against abstract standards, and authority figures are respected simply because of their authority base. Relativist thinking involves recognizing that there are multiple conflicting versions of "truth" that represent legitimate alternatives. Fluid intelligence is defined as basic information-processing skills. Crystallized intelligence refers to skills that depend on accumulated knowledge and experience. p. 258
Which developmental stage of Erikson's stages of growth and development will the nurse utilize when planning care for a 75-year-old patient? Intimacy versus isolation Autonomy versus shame and doubt Generativity versus self-absorption Ego integrity versus despair
Ego integrity versus despair Erikson's developmental stage of ego integrity versus despair (late 60s to death) is focused on reflecting on life and its meaning and providing a legacy for the next generation. Intimacy versus isolation is a young adult development task occurring between the ages of 21 and 39. Autonomy versus shame and doubt is a young child developmental task occurring between the ages of 18 months and 3 years. Generativity versus self-absorption is a middle-aged adult developmental task occurring between the ages of 40 to 65. p. 271
Which statement explains the change in sexuality experienced by many people in older adulthood? The need to express passion and affection subsides. Sexual preferences change. Sexual activity shifts from a focus on companionship to procreation. Frequency and opportunities for sexual activity decline.
Frequency and opportunities for sexual activity decline. As a result of reduced energy, a physical limitation in themselves or their partner, or loss of a partner, frequency and opportunities for sexual activity often decline. The need to express passion and affection does not disappear with age. Sexual preferences generally do not change with age. Sexual activity in older adulthood commonly shifts from procreation in the younger years to companionship and intimate communication in the older years. Test-Taking Tip: Key words or phrases in the stem of the question such as first, primary, early, or best are important. More than one choice may be correct, but you are asked to choose the best explanation in this question. p. 272
According to Erikson, which stage of cognitive development involves the potential for self-centered and narcissistic behavior characterized by the loss of interest in being productive at work? Integrity versus despair Intimacy versus isolation Identity versus role confusion Generativity versus stagnation
Generativity versus stagnation Generativity versus stagnation occurs during middle adulthood. Generativity can be attained through successful execution of life activities, rearing children, and reevaluation. Failure to develop generativity during middle adulthood leads to stagnation. The patient becomes self-centered, narcissistic, and detached from his or her children. Integrity versus despair is Erikson's final stage of cognitive development, characterized by a sense of wholeness and satisfaction from life or the belief that poor choices were made during life. Intimacy versus isolation occurs during young adulthood, during which the individual may develop intimate and trusting relationships or display a tendency toward isolation and limited relationships. Identity versus role confusion occurs in adolescence, during which the individual develops a sense of identity. p. 266
Patient education for a healthy 24-year-old focuses primarily on which topic? Stroke prevention Bone density maintenance Health promotion Chronic disease management
Health promotion Although young adults generally have a minimum of major health problems, lifestyles such as tobacco or alcohol abuse, risky sexual activity, obesity, and lack of physical activity put them at risk for health problems. Patient education for young adults focuses on health-promotion activities such as establishing healthy lifestyle choices and obtaining regular health checkups and screenings. Stroke prevention and bone density maintenance are higher priority education topics for older adults than young adults. Chronic disease management would be an important patient education topic for a young adult coping with a chronic disease, not a healthy young adult. p. 258
The nurse is caring for a 78-year-old patient who is terminally ill and needs end-of-life care. Which type of care would alleviate pain and other symptoms? Hospice care Adult day care Critical care Adult foster care
Hospice care Hospice care is provided to patients during the final days of life to provide the best quality of life by reducing the pain and other symptoms. Adult day care is provided to older adults whose caregivers are unable to provide care or look after them during the day while at work. Critical care is provided to patients with sudden life-threatening illnesses. Adult foster care is provided to independent older adults who may need some assistance safely performing certain tasks. STUDY TIP: Hospice care is appropriate when a cure is not possible. Its focus on providing comfort gives it the nickname "comfort care." Think of the phrase "comfort of your own home" to recall that hospice is comfort care. p. 272
Which symptom characterizes presbycusis? Impairment in the ability to hear high-pitched sounds Difficulty in distinguishing between dark colors such as blue and black Difficulty in vision when moving from bright to dark environments Decline in the ability of the eyes to accommodate from near to far vision
Impairment in the ability to hear high-pitched sounds Common age-related change in auditory acuity is called presbycusis . Presbycusis affects the ability to hear high-pitched sounds and sibilant consonants such as s, sh, and ch. Difficulty in distinguishing between dark colors such as blue and black occurs due to changes in color vision and discoloration of the lens. Difficulty in vision when moving from bright to dark environments occurs due to a reduction in the ability to adapt to abrupt changes from dark to light areas. Decline in the ability of the eyes to accommodate from near to far vision is known as presbyopia. p. 256
Which sign and symptom does the nurse expect in a patient under the influence of cocaine? Select all that apply. One, some, or all responses may be correct. Decreased metabolism Impulsive behavior Increased heart rate Impaired coordination Decreased respiratory rate
Impulsive behavior Increased heart rate Impaired coordination Cocaine is a stimulant; therefore a patient under the influence of cocaine would exhibit impulsive behavior, an increased heart rate, and impaired coordination. Cocaine use increases, rather than decreases, metabolism. A decreased respiratory rate would not be expected in a patient under the influence of a stimulant such as cocaine. Test-Taking Tip: As long as you saw the "Select all that apply" direction, you know this question has at least two correct answers. If you know just one of them, look for another answer that would be grouped with the one that you know. In this case, you are looking for at least two choices related to stimulants. It is a tremendous advantage to know that there are at least two correct choices. Be sure to check for the "Select all that apply" phrase before submitting your answer! p. 261
Which drug is categorized as a stimulant? Select all that apply. One, some, or all responses may be correct. Nicotine Barbiturates Amphetamines Benzodiazepines Lysergic acid diethylamide (LSD)
Nicotine Amphetamines Nicotine and amphetamines are stimulants. Nicotine is a potent parasympathomimetic alkaloid and a stimulant drug. It is currently widely used to help people quit smoking. Amphetamines are a potent stimulant used in the treatment of attention deficit hyperactivity disorder. Barbiturates and benzodiazepines are depressants, not stimulants. Barbiturates are used for sedative, hypnotic, tranquilizing, or anticonvulsant effects. Benzodiazepines are used for sedative and antianxiety effects. LSD is a schedule I hallucinogen with no recognized medical use. STUDY TIP: You may be wondering why you need to know about stimulants at this point. Recognizing the signs of addiction will be an important step in your training. Begin now to group drugs—legal and illegal—into classes to learn their effects. Learn which drugs are stimulants, depressants, and hallucinogens. Recognizing drug classes will enhance your understanding and may save a life! p. 261
Which living arrangement is typically designed to support the needs of an older adult dependent on others for all aspects of daily care? Assisted living facility Nursing home Palliative care Adult foster home
Nursing home Nursing homes and long-term care facilities provide care for individuals who can no longer care for themselves, often due to memory or mobility impairment. Assisted living facilities provide assistance for semi-independent older adults who may need assistance with some activities of daily living. Palliative care and hospice care are designed to meet the needs of individuals coping with chronic debilitating illnesses; hospice care specializes in providing end-of-life care. Adult foster homes typically serve older adults who can mostly or completely care for themselves but require supervision for safety reasons. p. 272
Which characteristic describes most older adults? Select all that apply. One, some, or all responses may be correct. Productive Involved in family and community Pessimistic Unable to care for themselves Able to make important decisions
Productive Involved in family and community Able to make important decisions The nurse should avoid generalizing and stereotyping the older adult. Most older adults are productive, involved in family and community, and are able to make important decisions. Some older adults are pessimistic, and some are unable to care for themselves, but most are hopeful and competent and thrive on independence. p. 270
Which outcome correlates with this patient-focused teaching plan? Prevent cardiovascular disease Reduce the risk of cancer Prevent sexually transmitted diseases (STDs) Reduce the risk of myocardial infarction
Reduce the risk of cancer Reducing the risk of cancer best correlates with this teaching plan. A teaching plan to educate a patient about cardiovascular disease may contain some of the same key topics as this plan, but would not include avoidance of sun, x-rays, and pollutants. A teaching plan to prevent STDs would focus on STD prevention of transmission, signs and symptoms, and screening. A teaching plan to reduce the risk of myocardial infarction may contain some of the same key topics as this plan, but would not include avoidance of sun, x-rays, and pollutants. p. 267
Middle-aged adults caring for both children and aging parents are frequently referred to as which generation? Millennial Sandwich X Y
Sandwich The sandwich generation refers to middle-aged adults who are the caretakers of both the older and younger generations of their family. The millennial generation, sometimes referred to as Generation Y, is defined as individuals born between approximately 1981 and 1996, regardless of who they care for. Generation X is defined as individuals born approximately mid-1960s to early 1980s, regardless of who they care for. Generation Y is also referred to as the millennial generation, and is defined as individuals born between approximately 1981 and 1996. p. 269
Which physiologic change is associated with normal aging? Select all that apply. One, some, or all responses may be correct. Stiffer heart and blood vessels Increased muscle mass Decreased number of brain nerve cells Increased lung elasticity Enlarged kidneys
Stiffer heart and blood vessels Decreased number of brain nerve cells Normative physiologic changes associated with aging include stiffer heart and blood vessels and decreased number of nerve cells in the brain. Increased muscle mass is not observed as a normal age-related change. With age, lung elasticity decreases rather than increases. Enlarged kidneys are not a normal age-related change; with age, the kidneys become smaller because the number of cells decreases. p. 256
Which lifestyle factor would the nurse encourage to promote well-being in a group of middle-aged adults? Select all that apply. One, some, or all responses may be correct. Stress management Exercise Positive self-image Competitive social relationships Mastery of a single role
Stress management Exercise Positive self-image Lifestyle factors which promote well-being in midlife include effective stress management, exercise and good health, and positive self-image. Competitive social relationships are more likely to be a source of stress and friction than a source of well-being. Mastery of a single role does not provide balance and depth to an individual's life; mastery of multiple roles promotes well-being in midlife. p. 267
The nurse is teaching an older adult patient and family members about oral anticoagulant therapy before discharge. Which intervention by the nurse increases the patient's safe use of the medication? Recommend increased intake of foods rich in vitamin K. Teach the signs of bleeding or hemorrhage. Describe the pharmaceutical action of anticoagulant therapy. Instruct how to self-inject the medication.
Teach the signs of bleeding or hemorrhage. Teaching the patient and family the signs of bleeding or hemorrhage increases safety because the patient and family can self-monitor for the most risky adverse effect of anticoagulants: bleeding complications. The intake of vitamin K does affect the patient's blood coagulation time and is a consideration with anticoagulant medication, but the nurse should not advise increasing vitamin K intake, but rather recommend maintaining a consistent intake of vitamin K so as not to increase the risk of either bleeding or clotting. Describing the pharmaceutical action of the medication will not increase the safety of its use by the patient. Because this is an oral medication, teaching self-injection is not necessary. Test-Taking Tip: It is not helpful to panic when the correct answer is not easily known. Were you able to eliminate two choices? If you are unsure of the answer in a multiple-choice, single-response question like this one, start by eliminating the choices you know are incorrect. If you can eliminate two of the four, it allows you to focus on picking from just two possibilities, which increases your chances of being correct. p. 273
Which changes related to drug metabolism occur with age? Drugs are metabolized more quickly in older adults. The liver metabolizes drugs less efficiently with age. Metabolism of drugs is not affected by age. Drugs are metabolized into different compounds in older adults, resulting in unexpected adverse medication outcomes.
The liver metabolizes drugs less efficiently with age. With age, liver enzymes that help the body process and remove drugs work less efficiently. Drugs are metabolized more slowly, not more quickly, in older adults. Metabolism of drugs is slowed with age. With age, drug metabolism is generally slowed, but the process does not result in different compounds. Adverse medication outcomes in older adults are commonly a result of polypharmacy or reduced clearance rate of drugs due to slowed drug metabolism. p. 256
The nurse is assessing a 60-year-old male patient. Which finding would the nurse consider a normal sign of aging? Select all that apply. One, some, or all responses may be correct. Reported inability to achieve an erection Thin, wrinkled skin with decreased elasticity Chronic confusion and forgetfulness Feelings of helplessness and hopelessness Dry eyes and difficulty focusing on close objects
Thin, wrinkled skin with decreased elasticity Dry eyes and difficulty focusing on close objects Thin, inelastic, and wrinkled skin is a normal physical change associated with aging. Skin changes are due to the loss of additional fat and muscle mass. Dry eyes and difficulty focusing on close objects are normal physical changes of the eyes, and are due to decreased lacrimal fluid production and increased density of the lens. Reported inability to achieve an erection is an abnormal finding not associated with normal aging. In older men, penile erection and orgasm may be diminished by reduced blood flow to the penis, but erectile dysfunction is not a normal age-related change. Confusion and forgetfulness suggest disease or dementia and are not normal age-related changes. Feelings of hopelessness and helplessness are not normal findings at any age and require immediate medical attention. STUDY TIP: Signs of depression (feelings of helplessness and hopelessness) and dementia (chronic confusion and forgetfulness) are not signs of normal aging! To help you remember this, think of your favorite older adult friend, actor, or comedian and consider how cheerful they are and how well they function. p. 257
Which assessment finding reported by the home health care nurse about an 80-year-old adult is abnormal and needs further medical evaluation? Unintentional sudden weight loss Ongoing difficulty seeing objects in dim light Thin, rough, and blotchy skin since age 70 Chronic difficulty hearing high-pitched sounds
Unintentional sudden weight loss Sudden, unintentional, significant weight loss is an abnormal finding at any age and should be evaluated. Difficulty seeing in dim light is a normal age-related finding. Thin, rough, and blotchy skin is a normal age-related finding. Difficulty hearing high-pitched sounds is a normal age-related finding. p. 256
Which assessment finding is a hallmark of delirium? Select all that apply. One, some, or all responses may be correct. Unaltered sensory perception Calm demeanor Waxing-waning confusion Unconsciousness Decreased attention span
Waxing-waning confusion Decreased attention span The clinical hallmarks of delirium, or acute confusion, are intermittent (waxing-waning) confusion and a decreased attention span. Sensory perception alterations such as hallucinations and delusions are commonly observed in delirium. Excessive energy and fearfulness, rather than calm demeanor, are observed in delirium. Unconsciousness is not a finding associated with delirium. STUDY TIP: Bring to your test prep a positive attitude about yourself, your nursing knowledge, and your test-taking abilities. A positive attitude is achieved through self-confidence gained by effective study. This means (a) answering questions (assessment),(b) organizing study time (planning), (c) reading and further study (implementation),and (d) answering questions (evaluation). p. 271
