Practice Questions from PPTs/Review

What are some expected respiratory changes in the older adult?

-can be subtle or gradual -diminished respiratory efficiency -reduced maximum inspiratory and expiratory force -lung mass decreases -smoking is the most significant factor

What are some expected changes in the genitourinary system in the older adult?

-decreased filtration rate and cell shrinkage so kidney mass decreases -slower restoration of acid-base imbalances -BPH in males -NOT urine incontinence but urge incontinence (overactive bladder, urethral dysfunction, detrusor instability, etc)

What are some expected changes in the integumentary system in the older adult?

-elastic fibers are reduced and collagen becomes stiffer -loss of resiliency with wrinkling and sagging of skin -hair pigmentation could change, and could lead to balding -subcutaneous fat diminishes; less likely to conserve body heat and could require a smaller needle for injections -epidural proliferation decreases so the dermis becomes thinner

What are some expected cardiovascular changes in the older adult?

-myocardial hypertrophy can cause decreased cardiac output -decreased elasticity of heart muscle/arteries -stroke volume isn't as responsive to demand -calcium and fat deposits can lead to hypertension and increased workload -hematopoiesis reduces which can lead to anemia -heart rate recovers SLOWER to stressors like exercise, infection, etc. -orthostatic hypotension because it tends to take longer to redistribute blood through the body in the older adult

When obtaining a health history from the newly admitted client who has chronic pain in the right knee, which pain assessment data would the nurse include? SATA a) pain history, including location, intensity, and quality of pain b) client's purposeful body movement in arranging the papers on the bedside table c) pain patter, including precipitating and alleviating factors d) vital signs, such as increased blood pressure and heart rate e) the client's family statement about increases in pain with ambulation

A and C

Which situation belongs to the first level of needs according to Maslow's hierarchy? SATA a) a client who is homeless b) a client reports feeling dizzy for 2 days c) a client reports a neighbor repeatedly beats them up d) a client reports an inability to consume food because of throat pain e) a client with a leg amputation reports they will walk one day

A, B, D

Which intervention would the nurse implement when providing health education to an elderly client? SATA a) assess the client for pain before teaching b) take notes while talking to the client c) ensure that the client is not preoccupied or anxious d) explain one concept at a time based on client's interest e) teach a family caregiver if the client does not respond quickly

A, C, D

Which is a normal finding during the regular checkup for an older adult? SATA a) loss of turgor b) urinary incontinence c) decreased night vision d) decreased mobility of ribs e) increased sensitivity to odors

A, C, D

When assessing an older adult male client, which clinical finding would the nurse expect as a response to the aging process? SATA a) slowed neurological responses b) lowered intelligence quotient c) long-term memory impairment d) forgetfulness about recent events e) reduced ability to maintain an erection

A, D, E

Which feature distinguishes nursing diagnoses from medical diagnoses? SATA a) nursing diagnoses involve the client when possible b) nursing diagnoses are based on results of diagnostic tests and procedures c) nursing diagnoses are the identification of a disease condition in the client d) nursing diagnoses involve the sorting of health problems within the nursing domain e) nursing diagnoses involve clinical judgement about the client's response to health problems

A, D, E

A patient asks the nurse why she seems to have bone changes since getting older. What is the best response by the nurse?​ A. "Bone changes from aging result from a loss of calcium"-might take Vit D supp so they can take in calcium better. Should be given together​ B. "Bone changes from aging result from a loss of magnesium"​ C. "Bone changes from aging result from a loss of vitamin A"​ D. "Bone changes from aging result from a loss of vitamin C"​

A. "Bone changes from aging result from a loss of calcium"-might take Vit D supp so they can take in calcium better. Should be given together​

A nurse is calculating body mass index (BMI) for several patients. The nurse should recognize which of the following patient BMI's as normal?​ A. 24​ B. 30​ C. 40​ D. 32​

A. 24​

The nurse takes a patient's vital signs and finds the pulse oximeter reading to be 85%. What actions by the nurse demonstrate critical thinking? (Select all that apply)​ ​ A. Compare the patient's pulse ox to the standard range​ B. Check the patient's baseline pulse ox per the patient's chart. ​ C. Call the patient's healthcare provider.​ D. Document the pulse ox in the appropriate chart page.​ E. Get the clinical instructor.​ F. Check the equipment​

A. Compare the patient's pulse ox to the standard range​ B. Check the patient's baseline pulse ox per the patient's chart. F. Check the equipment​ ​

The nurse is completing an assessment so that they can write a plan of care for a patient with benign prostatic hypertrophy (BPH). Which data should the nurse document as a subjective finding? ​ A. Complaints of inability to empty bladder​ B. Temperature of 99 degrees F and heart rate of 108​ C. Post-void residual volume of 750mL​ D. Specimen collection for culture and sensitivity

A. Complaints of inability to empty bladder​

Which action would the nurse take first when a 78-year-old client comes to the health clinic presenting with fatigue, and laboratory results indicate a hematocrit of 32% (0.32) and hemoglobin of 10.5 g/dL (105 mmol/L)?​ A. Conduct a complete nutritional assessment.​ B. Educate the patient about iron supplements.​ C. Schedule the patient to return to the clinic in 3 months for repeat labs.​ D. Explain that mild anemia is a normal age-related change.​ ​

A. Conduct a complete nutritional assessment.​

Assessment begins with initial patient contact. Which nursing activity is included during this component of the nursing process?​ A. Interviewing and obtaining a nursing history​ B. Choosing a nursing diagnosis​ C. Establishing expected outcomes​ D. Determining nursing actions​ ​

A. Interviewing and obtaining a nursing history​

Which of the following is an example of using critical thinking when providing genetics-related nursing care?​ A. Call the family and set up an appointment for genetic screening​ B. Assess and analyze family history data for genetic risks​ C. Obtain blood samples for genetic screening​ D. Follow up with the family after the screening appointment​ ​

B. Assess and analyze family history data for genetic risks​

What scale might the nurse use to determine a patient's risk of skin breakdown or skin injury? ​ A. Barthel Index​ B. Braden Scale​ C. The PULSES Profile​ D. The FLACC Score​

B. Braden Scale​

The nurse is completing an assessment on an older adult who fell and fractured the left hip. Which clinical indicator would the nurse identify as typical with a fractured left hip? A. Left hip is ecchymotic B. Left leg is noticeably shorter than the right C. Left leg is internally rotated D. Left hip is tender when touched

B. Left leg is noticeably shorter than the right

What would be an appropriate intervention to help prevent skin breakdown in an incontinent patient?​ A. Insert a foley catheter-don't do this preventatively, only done for a specific reason​ B. Practice meticulous hygiene measures-making sure clean and dry and happens quickly​ C. Use adult diapers for the patient-doesn't help prevent, actually holds in moisture​ D. Apply antibiotic ointment to the perineal area-not done preventatively ​ ​

B. Practice meticulous hygiene measures-making sure clean and dry and happens quickly​

A client who has recently been diagnosed with chronic heart failure is being taught by the nurse how to live successfully with the chronic condition. The client's ability to meet this goal will primarily depend on the client's ability to do which of the following?​ A. Lower the client's expectations for quality of life and level of function.​ B. Access community services to eventually cure the disease.​ C. Adapt a lifestyle to accommodate the client's symptoms.​ D. Establish good rapport with the client's primary care provider.​ ​ ​

C. Adapt a lifestyle to accommodate the client's symptoms.​

The nurse, in collaboration with the client's family, is determining priorities related to the care of the client. The nurse explains that it is important to consider the urgency of specific problems when setting priorities. What should the nurse adopt as the best framework for prioritizing client problems?​ A. Availability of hospital resources​ B. Family member statements​ C. Maslow hierarchy of needs​ D. The nurse's skill set​ ​ ​

C. Maslow hierarchy of needs​

Upon assessing an older adult client with a diagnosis of dehydration, which finding would the nurse identify as an early sign of dehydration? A. sunken eyes B. dry, flaky skin C. change in mental status D. decreased bowel sounds

C. change in mental status

Types of Disability

Cognitive: limits mental functioning-difficulties in communication, self care, social skills Developmental: occurs from birth-22years-result is impairment of physical or mental health, cognition, speech etc--an umbrella term for intellectual or physical disabilities Sensory: sight, hearing, smell, touch, taste, (think about safety implications here) Psychiatric: mental illness or impairment that limits ability to complete MAJOR life activities like learning, communicating, or working

​ A client has recently been diagnosed with type 2 diabetes. The client is clinically obese and has a sedentary lifestyle. How can the nurse best begin to help the client increase their activity level?​ A. Set up appointment times at a local fitness center for the client to attend.​ B. Have a family member ensure the client follows a suggested exercise plan.​ C. Construct an exercise program and have the client follow it.​ D. Identify barriers with the client that inhibit lifestyle changes.​ ​

D. Identify barriers with the client that inhibit lifestyle changes.​

The nurse is caring for a patient that has been in an accident. Initially, what symptoms should the nurse expect may be caused by the stress of the accident?​ A. Decreased respirations​ B. Sweating​ C. Pupil constriction​ D. Increased blood glucose

D. Increased blood glucose

Disability VS Impairment

Disability: difficulty doing a task, ADL's, etc. Impairment: loss or abnormality in body structure (including physiologic and mental function)

An assessment that refers to the motor and sensory components and circulatory functioning of a body part

Neurovascular assessment

Patients who have orthopedic surgery are at risk for these two types of Venous Thromboembolism (VTE):

PE and DVT

hypoxemia

a low level of oxygen in the blood

hypoxia

a state in which oxygen is not available in sufficient amounts at the tissue level to maintain adequate homeostasis

A complication that indicates impaired tissue perfusion is

compartment syndrome

A soft tissue injury from a blunt force is a

contusion

Secondary Injury

injury that occurs because of something else that has already occurred EX) strep might cause you to develop a throat abscess

A type of pain that occurs due to injury or dysfunction of the nerves; common in diabetics

neuropathic pain

This term refers to the realignment of the bones after a fracture

reduction