EAQ Exam 1
The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? A. Ulnar drift B. Heberden nodes C. Swan-neck deformity D. Boutonnière deformity
B.
A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply A. Hips B. Knees C. Ankles D. Shoulders E. Metacarpals
A., B.
Which intrinsic factors may contribute to falls in older adults? Select all that apply. A. Deconditioning B. Impaired vision C. Inappropriate foot wear D. Improper use of assistive devices E. Unfamiliar environment of hospital room
A., B.
A nurse is caring for an older client with hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select All that apply A. Dry cerumen B. Tears in the tympanic membrane C. Difficulty in hearing high-pitched voices D. Decrease of hair in auditory canal E. Overgrowth of the epithelial lining
A., C.
A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? A. Relieving muscle spasm and pain B. Preventing contractures from developing C. Keeping the client from turning and moving in bed D. Maintaining the limb in a position of external rotation
A.
What musculoskeletal system change is associated in older adult clients? A. Decrease in height B. Decreased neck rigidity C. Increase in fine-motor dexterity D. Increased range of motion
A.
What interventions should the nurse follow when giving health education to an elderly client? Select all that apply. A. Assess the client for pain before teaching B. Take down notes while talking to the client C. Ensure the client is not preoccupied or anxious D. Teach one concept at a time, according to the client's interest E. Teach a family caregiver if the client does not respond quickly
A., C., D.
An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in response to this client's question? Select all that apply A. "Ask your healthcare provider how and when you should be taking your medications." B. "Stop taking a prescribed medication if you are not feeling better in a few days." C. "Discard medications into the toilet that have exceeded the expiration date on the bottle." D. "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy." E. "Inform your healthcare provider of the over-the-counter drugs, recreational drugs, and amount of alcohol you ingest."
A., D., E.
A nursing student is listing points to remember about wellness promotion in older adults. Which points mentioned by the nursing student need correction? Select all that apply. A. "It is essential to prevent injuries in older adults when promoting wellness." B. "It is essential to focus on curing diseases or other illnesses completely in older adults to promote wellness." C. "It is essential to assess the level of fear of falling and provide support accordingly when caring for older adults." D. "It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." E. "It is necessary to consider the older adult's social environment and ensure that he or she lives in social isolation to prevent stress."
B., D., E.
What important points should the nurse keep in mind when caring for an older adult to promote health? Select all that apply. A. Focus on achieving the highest level of health and absence of disease B. Encourage regular physical activity and the use of stress-management strategies C. Encourage the client to accept help for carrying out activities of ADLs D. Consider the client's social environment and strengthen social support to promote health E. Assess the client for fear of falling and provide support by making environmental changes
B., D., E.
Which principles are appropriate for promoting older adult learning? Select all that apply. A. Emphasize abstract material B. Use past experiences while teaching C. Teach by presenting multiple examples at a time D. Keep the environmental distractions to a minimum E. Use audio, visual, and tactile cues to enhance learning
B., D., E.
Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. A. Difficulty in swallowing B. Increased sensitivity to heat C. Increased sensitivity to glare D. Diminished sensation of pain E. Heightened response to stimuli .
C., D.
The nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective? A. "I can drink beer on this, but not wine" B. "I need to limit my intake of acetaminophen to 650 mg per day" C. "I should take an emetic if I accidentally overdose on the acetaminophen" D. "I have to be careful about which over the counter cold preparations I take when I have a cold"
D.
Which client would the nurse consider to have the highest risk of pneumonia? Client 1: 16 y/o with a poor nutritional status that has received the pneumococcal vaccine within the last 3 months. Client 2: 28 y/o that uses tobacco that has received the pneumococcal vaccine 2 years ago. Client 3: 45 y/o that consumes alcohol regularly and has received the pneumococcal vaccine within the past year. Client 4: 67 y/o with chronic lung disease that received the pneumococcal vaccine more than 5 years ago. A. Client 1 B. Client 2 C. Client 3 D. Client 4
D.
An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? A. Providing psychotherapy to the client B. Teaching strategies to overcome depression C. Encouraging the client to walk for 30 minutes D. Requesting that the physician change the drug
D.
A nurse is educating an older adult for the purpose of promoting wellness. What instruction should the nurse give the client to reduce the risk of disability? A. "Engage in physical activities to stay fit." B. "Don't exhaust yourself by engaging in physical activities." C. Pay no heed to your financial problems if you want to stay healthy." D. "Stay away from people so as to prevent anxiety and stress disorders."
A.
What is the main reason a nurse raises three of the four side rails of the bed of an 83 year old client who had surgery for a fractured hip? A. As a safety measure because of the client's age B. Because clients older than 60 years of age should use side rails C. To be used as handholds to facilitate the client's ability to move in bed D. Because all older adults are disoriented for several days after anesthesia
A.
While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has COPD? A. Barrel chest B. Cyanosis C. Hyperventilation D. Lordosis
A.
A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply. A. Loss of turgor B. Urinary incontinence C. Decreased night vision D. Decreased mobility of ribs E. Increased sensitivity to odors
A., C., D.
An older adult fell at home and fractured the left hip. Which response should the emergency department nurse identify as a typical clinical indicator associated with a fractured hip? A. Affected hip is ecchymotic B. Left leg is noticeably shorter than the right C. Left extremity is internally rotated D. Affected hip is tender to touch
B.
The nurse is providing home to care to an older adult client with decreased bone density. Which nursing intervention will be most beneficial for the client? A. Teaching isometric exercises B. Encouraging the client to do weight-bearing exercises C. Instructing the client to sit in supportive chairs with arms D. Providing moist heat, such as shower or moist compresses
B.
When two nurses are getting an older adult out of bed, the client reports feeling lightheaded. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? A.Slide slowly to the floor to prevent a fall and injury. B. Sit on the edge of the bed while they hold the client upright. C. Bend forward because this will increase blood flow to the brain. D. Lie down quickly so the legs can be raised above the heart level.
B.
Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? A. Carelessness B. Fragility of bone C. Sedentary existence D. Rheumatoid disease
B.
A nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply A. Scaly skin B. Tenting of skin C. Transparent skin D. Increased wrinkles E. Pigmented lesion
B., C., D, E.
A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply. A. Suggest that the client have annual Papanicolaou (pap) smears and mammograms B. Promote dietary modifications by using varied techniques C. Assess the client's current lifestyle and promote lifestyle changes D. Monitor the client's blood pressure and weight and establish blood pressure screening programs E. Teach the client about correct body mechanics and the availability of mechanical appliances
B., C., D.
A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? A. "Your primary care provider must have forgotten to prescribe it" B. "Your condition is not severe enough to have physical therapy approved" C. "Your joints are still inflamed, and physical therapy can be harmful" D. "Physical therapy is not helpful for persons who suffer from RA"
C.
A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. What clinical finding requires the nurse to notify the primary healthcare provider? A. Lack of a productive cough 2 days postoperatively B. Rectal temperature of 100.2 F 3 days postoperatively C. Complaints of right sided chest pain 6 days postoperatively D. Fatigue in the leg on the unaffected side 5 days postoperatively
C.
A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? A. Increased skin elasticity and an increase in testosterone production B. Impaired fat digestion and an increase in pepsin production C. Increased blood pressure and decreased cardiac output D. An increase in body warmth and some swallowing difficulties
C.
An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? A. Assess the client's mobility B. Monitor respirations and breathing effort C. Teach coughing and deep-breathing exercises D. Determine normal activity levels and note when the client tires
C.
An older client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the clinic nurse teach the client? A. "Drink fruit juices if you start to feel dehydrated" B. "Thirst is a good guide to use to determine fluid intake." C. "Fluids should be increased if the urine is getting darker." D. "Water should be consumed when the skin becomes dry."
C.
Nursing actions for an older adult should include health education and promotion of self care. Which is most important when working with an older adult client? A. Encouraging frequent naps B. Strengthening the concept of agism C. Reinforcing the clients strengths and promoting reminiscing D. Teaching the client to increase calories and focusing on a high-carbohydrate diet
C.
The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? A. Thinning subcutaneous layer B. Degeneration of elastic fibers C. Decreased dermal blood flow D. Benign proliferation of capillaries
C.
What should the nurse assess to determine whether a 75 year old individual is meeting the development tasks associated with aging? A. Achievement of a personal philosophy B. Adaptation to the children leaving home C. Attainment of sense of worth as a person D. Adjustment to life in an assisted living facility
C.
When nurses are conducting health assessment interviews with older clients, they should: A. Leave a written questionnaire for clients to complete at their leisure B. Ask family members rather than the client to supply the necessary information C. Spend time in several short sessions to elicit more complete information from the clients D. Keep referring to previous questions to ascertain that the information given by clients is correct
C.
When teaching about aging, the nurse explains that older adults usually have what characteristic? A. Inflexible attitudes B. Periods of confusion C. Slower reaction times D. Some senile dementia
C.
Which intrinsic factor is associated with the fall of an older adult? A. Wet floors B. Poor lighting C. Deconditioning D. Inappropriate footwear
C.
A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? A. Side lying with head elevated 45 degrees B. Sims with head elevated 90 degrees C. Semi-Fowler with legs elevated D. High-Fowler using the bedside table to rest arms
D.
An older client is seen in the primary healthcare provider's office. Upon initial nursing assessment the nurse notes the client's height has decreased by 1 inch since the last visit a year ago. The nurse knows that what is the most likely reason for this finding? A. The nurse was in error B. Older adults are not active enough so they lose bone mass. C. Older adults have poor posture so they are shorter. D. Older adults may have osteoporosis-related height changes.
D.
The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate? A. Asking the family member to step out of the room so the client can rest B. Placing a vest restraint on the client to prevent the client from falling out of bed C. Explaining to the family that it is common for older clients to get confused while in the hospital D. Requesting the nursing assistant to stay with the client while the nurse calls the PCP
D.
The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? A. Oxygen therapy B. Cardiac monitoring C. Nutrition supplements D. Venous Thromboembolism (VTE) prevention
D.
