study questions

Which of the following nursing actions would help minimize the psychosocial impact of bladder and/or bowel incontinence for individuals experiencing incontinence prior to going to a group dining room? a. Assess for soiled clothing and change, if necessary. b. Toilet the client and then promptly transport to the dining room. c. Provide peri-care and fresh underclothing. d. Ask the client if toileting is needed and assist as necessary.

ANS: A Deviations from normal bowel and bladder toileting can lead to chastisement, ostracism, and social withdrawal. By addressing incontinency issues prior to social interactions, such negative responses can be minimized. While toileting is appropriate, it does not directly address the social impact that may result from soiled and/or odorous clothing. Providing peri-care and clean underclothing is necessary only if incontinency has occurred. Asking to toilet the client is not necessarily an effective intervention when the client is consistently incontinent. DIF: Cognitive Level: Applying REF: p. 200 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older adult client shares with the nurse that, "I don't know what it is but it seems that I need more light for reading or even watching television as I get older." The nurse explains that aging may cause this change due to the: a. slower ability of the pupil to adjust to changes in lighting. b. impact arcus senilis has on visual acuity c. flattening and thinning of the cornea. d. retinal changes that begin to occur with aging.

ANS: A A slowed ability of the pupil to accommodate to changes in light accounts for the need of this patient to have more light in order to read. Arcus senilis does not affect vision. It is true that the cornea becomes flatter and thinner with aging, which results in astigmatism. Astigmatism does not account for the need for increased light that this patient is reporting. The changes in the retina do not account for the need for increased light that this patient is reporting. DIF: Cognitive Level: Applying REF: p. 131 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older woman with breast cancer has completed a course of external radiation and is receiving chemotherapy. After her recent chemotherapy treatment, she complains of severe weakness, dizziness, and lethargy and is admitted to the hospital. Her platelet count is 45,000. Based on this scenario, what nursing intervention is of the highest priority? a. Preventing falls b. Maintaining skin integrity c. Preventing infection d. Replacing fluids

ANS: A Fall prevention is the highest priority. The patient has at least two significant risk factors for falls (unsteady gait and complaints of dizziness). She has a platelet count of 45,000; a platelet count of less than 50,000 makes one at high risk for spontaneous bleeding. The nurse must observe for overt and covert bleeding. If the patient falls, she is very likely to have a significant injury because of the low platelet count. Maintaining skin integrity would be important in this patient because she has received external radiation, which can cause alterations in skin integrity, but this is not as high a priority. Although preventing infection is an important intervention in a patient with cancer who has received radiation and chemotherapy, there is no evidence that this patient has alterations in her laboratory values related to the treatments, so fall prevention is more critical. There are no specific indications that this patient is experiencing a fluid deficit. DIF: Cognitive Level: Analyzing REF: p. 91 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

A nurse implements a nursing care plan for a patient with constipation. Which of the following should the nurse include in the plan? a. Increasing fiber in the diet b. Administering aluminum hydroxide antacids c. Bed rest d. Restricting fluids

ANS: A Fluid intake of at least 1.5 L/day, unless contraindicated, is the cornerstone of constipation therapy, with fluids coming mainly from water. A gradual increase in fiber, either as supplements or incorporated into the diet, is generally recommended. Fiber helps stools become bulkier and softer and move through the body more quickly. Physical activity is important as an intervention to stimulate colon motility and bowel evacuation. Daily walking for 20-30 minutes, if tolerated, is helpful, especially after a meal. Aluminum hydroxide antacids are known to be constipating. DIF: Cognitive Level: Applying REF: p. 214 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse identifies that an older adult needs more education on nutritional needs when the older adult states the following: a. "Since I am an older person, I need more calories because my metabolic rate is slower" b. "Since I am an older person, I need fewer calories since my metabolic rate is slower" c. "Even though I am an older person, I still need the same amount of nutrients in order to be healthy" d. "Even though I am an older person, I still need to pay attention to my diet and activity levels."

ANS: A Generally, older adults need fewer calories because they may not be as active and metabolic rates slow down. Older adults generally require the same amount of nutrients for optimal health outcomes. Older adults need to pay attention to meeting nutritional requirements and obtaining adequate physical activity for optimal health. DIF: Cognitive Level: Applying REF: p. 172 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is assessing an older patient and notes a cluster of fluid-filled vesicles on the right thoracic area. The nurse suspects HZ. The patient asks the nurse, "I really don't understand how I got shingles. I don't even know anyone who has this infection." The nurse includes which of the following in formulating a response to the patient? a. HZ is caused by a reactivation of dormant varicella zoster virus within the sensory neuron of the dorsal root ganglion b. HZ is caused by the same virus as chickenpox and requires exposure to an individual with active chickenpox c. HZ is caused by the same virus as chickenpox and requires direct contact with an individual with HZ d. HZ is caused by the varicella zoster virus and occurs only in individuals who were never previously exposed to the virus

ANS: A HZ is a viral infection caused by a reactivation of the latent varicella zoster virus (the same virus that causes chickenpox) within the sensory neurons of the dorsal root ganglion, decades after the initial varicella zoster infection is established. HZ is infectious until the lesions are completely crusted over. Individuals do not have to have direct contact with someone who has either chickenpox or HZ in order to have a reactivation; other factors such as illness and stress can cause the reactivation. Individuals who have HZ infection were previously exposed to the varicella zoster virus. DIF: Cognitive Level: Applying REF: p. 157 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A hospitalized older adult who recently had surgery and a wound infection postoperatively is noted to be losing weight despite consuming his meal trays and snacks. One reason that this might be occurring is: a. an injury may trigger inflammatory mediators that increase metabolic rate and impair nutrient utilization. b. an injury may cause malabsorption of nutrients. c. most hospitalized older patients do not consume adequate amounts of micro- and macronutrients. d. most hospitalized patients do not have accurate weights recorded upon admission.

ANS: A One trajectory for malnutrition is inflammation-related malnutrition; in this situation, malnutrition develops as a consequence of injury, surgery, or disease that triggers inflammatory mediators that contribute to an increased metabolic rate and impaired nutrient utilization. An injury does not necessarily cause malabsorption of nutrients. There is no evidence that most hospitalized patients do not consume adequate diets, and there is also no evidence that accurate weights are not recorded for most hospitalized patients. DIF: Cognitive Level: Analyzing REF: p. 174 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older client reports to a nurse, "My daughter says there is something wrong with my hearing. I am not so sure. Yes, I have some problems hearing, but I am 78 years old. What does she expect? I noticed that at Christmas dinner, with all the racket around, I had some trouble. I think it is that my granddaughters mumble a lot, just like all young people. I guess it has been getting steadily worse; it seems to be both ears as well." Based on the client's description, the nurse suspects which of the following? a. Presbycusis b. Otosclerosis c. Tinnitus d. A perforated eardrum

ANS: A Presbycusis is a type of sensorineural hearing loss. It is slow and progressive and often ignored by older adults and considered normal aging. Symptoms include difficulty filtering background noise and understanding women and children's voices. Individuals often accuse people of mumbling. Often, it is recognized by others first, before the affected person notices it. Otosclerosis is a cause of conductive hearing loss, as is a perforated eardrum. Tinnitus is a perception of sound in one or both ears where no external sound is present. DIF: Cognitive Level: Analyzing REF: p. 143 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older man tells a nurse, "The doctor says I have something wrong with my eyes, something called presbyopia. Can you explain why I have this? I was always fortunate to have good eyesight." The nurse formulates a response based on the knowledge that: a. the lens of the eye loses elasticity causing a loss of focus for near objects. b. the cornea of the eye becomes thicker and less curved causing an increase in astigmatism. c. the lens of the eye increases in opacity causing a decrease in light refraction. d. the cornea of the eye forms a gray ring at the edges.

ANS: A Presbyopia is the loss of focus for near objects, caused by a loss of elasticity and hence a loss of accommodation of the lens of the eye. All of the other options are normal age-related changes; however, they are not related to presbyopia. DIF: Cognitive Level: Applying REF: p. 132, Table 11-1 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older woman asks a nurse in the cardiology practice, "What is the ideal number that my cholesterol levels should be? I am confused by all of the different numbers." The nurse formulates her response on the knowledge that: a. recent guidelines from the American Heart Association state that there is no "one size fits all" recommendation and that recommendations must be individualized to each patient. b. recent guidelines from the American Heart Association provide different recommendations for individuals age 65-74, 75-84, and over age 85. c. recent guidelines from the American Heart Association recommend a total serum cholesterol level below 100. d. recent guidelines from the American Heart Association recommend a total serum cholesterol level over 200.

ANS: A Recent guidelines from the American Heart Association state that there is no "one size fits all" recommendation and that recommendations must be individualized to each patient. Multiple factors that must be considered include family history, other risk factors for heart disease, and long-term risk-benefit ratios. DIF: Cognitive Level: Applying REF: p. 95 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

Which of the following statements describing oral care for the older population is correct? a. Regular dental examinations can prevent tooth loss and improve the ability to chew healthful foods. b. Losing one's teeth is considered a normal part of the aging process. c. Oral malignancies seldom occur in older adults so oral examinations are of low priority. d. Preventative dental care is covered under Medicare.

ANS: A Regular dental care is essential and can prevent tooth loss. Losing one's teeth is not a normal part of aging; about one-quarter of adults over age 65 are edentulous. Oral cancers occur more often in older individuals. The median age at diagnosis is 61. Oral examinations can assist in early identification and treatment. Medicare does not provide any coverage for oral care services. DIF: Cognitive Level: Remembering REF: p. 196 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse utilizes the SPICES tool (Sleep disorders, Problems with eating, Incontinence, Confusion, Evidence of falls, and Skin breakdown) to assess an older female patient in the hospital. The nurse notes that the patient has new onset urinary incontinence. The first action by the nurse is to: a. conduct a more in-depth focused assessment of the urinary incontinence. b. call the provider and obtain an order for an antibiotic for a suspected urinary tract infection. c. send a urine specimen for culture and sensitivity. d. develop a plan of care with the patient to control episodes of incontinence.

ANS: A SPICES is an assessment tool. Anything that indicates a problem in any of the categories warns the nurse that a more in-depth assessment is needed. The nurse needs to further assess the urinary incontinence prior to implementing any interventions. DIF: Cognitive Level: Analyzing REF: p. 79 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older person is admitted to the hospital with an exacerbation of congestive heart failure. The nurse notes that the patient complains of severe itching at night and has a red rash on her torso. The patient is diagnosed with scabies. The patient asks the nurse, "How did I get something like this?" The best response by the nurse is: a. "Scabies is highly contagious and spreads easily through physical contact." b. "Scabies is commonly seen in older adults due to normal age-related changes in the skin." c. "Scabies is only seen in older adults who have multiple chronic illnesses." d. "Certain medications can make you more susceptible to contracting scabies."

ANS: A Scabies is caused by a tiny burrowing mite and is highly contagious and easily passed by an infected person to family members and others in close contact by direct physical content. It is not limited to older adults, and age-related changes in the skin do not cause it or make a person more susceptible. Individuals with multiple chronic conditions are not more likely to develop scabies than other individuals. There is no evidence that medications can make an individual more susceptible. DIF: Cognitive Level: Remembering REF: p. 155 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older resident in a long-term care facility reports to the nurse that she has been noticing changes in her vision, including the appearance of halos around objects and a yellow tint to most objects. The nurse knows that these complaints are most often associated with: a. cataracts. b. glaucoma. c. diabetic retinopathy. d. age-related macular degeneration.

ANS: A Signs of cataracts include the appearance of halos around objects as light is diffused, blurring, decreased perception of light and color giving a yellow tint to most objects, and a sensitivity to glare. DIF: Cognitive Level: Remembering REF: p. 134 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The FANCAPES assessment tool focuses on the older adult's: a. ability to meet personal needs to identify the amount of assistance needed. b. ability to perform instrumental activities of daily living (IADLs). c. cognitive abilities. d. level of dementia present.

ANS: A The FANCAPES assessment tool focuses on physical functioning and evaluates the individual's ability to meet his/her needs and how much assistance is needed to meet the needs. FANCAPES evaluates physical functioning. IADLs involve more than just physical functioning. FANCAPES does not assess cognitive function, nor does it assess dementia. DIF: Cognitive Level: Remembering REF: p. 79 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance

A 77-year-old client being treated for glaucoma asks the nurse what causes glaucoma. The nurse's response is: a. the exact etiology of glaucoma is variable and often unknown. b. spasms of the orbicular muscle. c. changes to the suspensory ligaments, ciliary muscles, and parasympathetic nerves. d. bits of broken coalesced vitreous from the peripheral or central part of the retina.

ANS: A The etiology of glaucoma is variable and often unknown. However, when the natural fluids of the eye are blocked by ciliary muscle rigidity and the buildup of pressure, damage to the optic nerve occurs. Spasms of the orbicular muscle can cause the lower lid to turn inward. If it stays this way, it is called entropion. The changes described contribute to decreased accommodation. Bits of coalesced vitreous that have broken off from the peripheral or central part of the retina is the definition of floaters. DIF: Cognitive Level: Remembering REF: p. 134 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older adult client is being seen for the first time at the outpatient geriatric clinic. As a component of the nursing admission history, the nurse inquires about the use of herbs and other supplements. The basis for this inquiry is that such herbal therapy: a. may interact with prescription medications. b. is hazardous when used by older adults. c. replaces the need for prescription medications. d. causes excessive sedation in older adults.

ANS: A The gerontological nurse has the obligation to ask questions and obtain specific information about the use of herbs and supplements because they may interact with prescription medications. When used cautiously and with knowledge of potential interactions with other medications, herbs and supplements are not hazardous. They do not replace the need for prescription medications. Not all herbs and supplements cause excessive sedation. DIF: Cognitive Level: Applying REF: p. 124 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

A nursing student asks the instructor, "Our textbook discussed the obesity paradox in older adults. I am not sure I understand; isn't obesity bad for everyone?" The best response by the instructor is: a. "While there is evidence that obesity in younger people lessens life expectancy, it remains unclear whether overweight and obesity are predictors of mortality in older adults." b. "Obesity is usually not a concern in older adults, as most older people tend to weigh less than they did when they were younger." c. "Obesity is a concern in all age groups; however, over the past decade obesity in older adults has decreased." d. "Obesity in older adults is less of a concern than we once thought; individuals over age 65 with a higher BMI have a lower mortality rate."

ANS: A There is evidence that obesity in younger people contributes to a decreased life expectancy. However, in older adults, it is not clear whether obesity is a predictor of mortality. Recent evidence demonstrated that for people who have survived to 70 years of age, mortality risk is lowest in those with a BMI classified as overweight. Persons who increased or decreased BMI have a greater mortality risk than those who have a stable BMI, particularly in those aged 70-79. Obesity is prevalent in older adults. The proportion of older adults who are obese has doubled in the past 30 years. More than one-third of individuals 65 years and older are obese with a higher prevalence in those 65-74 years than in those 75 years and older. DIF: Cognitive Level: Remembering REF: p. 174 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse completes a functional status assessment of an older person using the Lawton IADL instrument, a self-reported instrument. The nurse knows that limitations of self-reported measures include that: (Select all that apply.) a. individuals tend to overestimate their functional ability. b. self-reports often differ from that of proxy reports. c. self-reports are not indicative of small changes in function. d. self-reports do not provide a valid measurement of function. e. older adults are not able to complete self-reported measurements.

ANS: A, B Individuals tend to overestimate their functional ability and often self-reported measures differ from proxy reports. Self-reported measures are a valid measurement of function, and older adults are able to complete them. The choice of tool and the type of scoring of the tool is the factor that determines if the small changes in function can be detected. DIF: Cognitive Level: Remembering REF: p. 79 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is caring for an older adult who has a gastrostomy tube. The nurse is developing a care plan related to oral care. Which of the following should the nurse consider for this patient? (Select all that apply.) a. Oral care should be provided every four hours. b. Teeth should be brushed with a toothbrush after each tube-feeding. c. Lemon glycerin swabs should be used in between feedings to keep the mouth moist. d. Foam swabs should be used in place of a toothbrush to clean the teeth after each tube-feeding. e. Oral care should be provided only twice daily if the older adult is edentulous.

ANS: A, B Tube-feeding is associated with significant pathologic contamination of the mouth, greater than in individuals who receive oral feeding. Oral care should be provided every 4 hours for patients with gastrostomy tubes and teeth should be brushed with a toothbrush after each feeding to decrease the risk of aspiration pneumonia. Lemon glycerin swabs should never be used for oral care, as they dry and inhibit saliva production. Foam swabs do not remove plaque as well as toothbrushes. Oral care is required even if the individual is edentulous. DIF: Cognitive Level: Applying REF: p. 198 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse completes a cultural assessment of an older adult who is being admitted to an assisted living facility. Reasons for completing a cultural assessment include: (Select all that apply.) a. culture guides decision-making about health, illness, and preventive care. b. culture provides direction for individuals on how to interact during health care encounters. c. culture impacts attitudes toward aging. d. all members of a culture react in the same way in similar situations. e. knowledge of culture eliminates health care disparities.

ANS: A, B, C Although knowledge of culture has the potential to optimize care, not all individuals will respond in the same way to a specific situation. Knowledge of an individual's culture will not eliminate health care disparities. DIF: Cognitive Level: Understanding REF: pp. 49-50 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity

Which of the following are age-related changes that affect hydration status? (Select all that apply.) a. Decrease in thirst sensation b. Decrease in total body water c. Decrease in ability of kidneys to maximally concentrate urine d. Decrease in bone marrow mass e. Decrease in bladder capacity

ANS: A, B, C As one ages, thirst sensation decreases and is not proportional to metabolic needs in response to dehydrating conditions. There is a decrease in total body water. The kidneys are less able to maximally concentrate urine resulting in a loss of water. While there is a decrease in bone marrow mass, this does not impact hydration status. Also, as one ages, bladder capacity decreases; however, this does not directly impact hydration status. DIF: Cognitive Level: Remembering REF: pp. 191-192, Box 15-1 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older patient is diagnosed with diabetic retinopathy. The patient asks a nurse: "Is there anything that I can do to prevent progression of this disease and blindness?" The nurse includes which of the following into the response? (Select all that apply.) a. Strict control of blood glucose levels is important in slowing disease progression b. Laser photocoagulation treatments can stop progression of the disease c. Control of blood pressure and cholesterol levels are important steps slowing disease progression d. Wearing sunglasses to protect the eyes from ultraviolet light can stop disease progression e. Eating a diet high in beta-carotene can stop disease progression

ANS: A, B, C Constant strict control of blood pressure, blood glucose, and cholesterol and laser photocoagulation treatments can halt progression of the disease. Laser treatment can reduce vision loss in 50% of patients. Neither protecting the eyes from ultraviolet light nor eating a diet high in beta-carotene has been proven to be effective in stopping disease progression. DIF: Cognitive Level: Applying REF: p. 136 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is performing preoperative teaching for an older adult who is scheduled to have a cataract extraction and lens implant. The nurse includes which of the following in the teaching plan? (Select all that apply.) a. Avoid lifting heavy objects after the surgery b. Avoid bending from the waist after the surgery c. Take stool softeners as needed d. Maintain strict control of your blood sugar and blood pressure e. Maintain a dry sterile dressing over the eye for 10 days

ANS: A, B, C Postcataract surgery the individual needs to avoid heavy lifting, straining, and bending from the waist. Fall prevention is also very important as is complying with eye drop administration. Maintaining strict blood sugar and blood pressure control is most important for diabetic retinopathy, not cataract extraction. There usually is not a dressing over the operative site, and not for 10 days. DIF: Cognitive Level: Applying REF: pp. 134-135

An older patient complains of pruritus. The nurse suggests which of the following interventions to alleviate the patient's complaint? (Select all that apply.) a. Use only nonperfumed laundry detergent and fabric softeners b. Avoid sudden temperature changes c. Wear loose-fitting clothing d. Apply heat to affected areas e. Exercise vigorously for at least 30 minutes daily

ANS: A, B, C Pruritus is aggravated by heat, sudden temperature changes, sweating, restrictive clothing, fatigue, exercise and anxiety, perfumed detergents, and fabric softeners. DIF: Cognitive Level: Applying REF: p. 154 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

Symptoms of gastroesophageal reflux disease (GERD) in older adults include: (Select all that apply.) a. heartburn. b. regurgitation. c. abdominal pain within one hour of eating. d. vomiting. e. fever and elevated white blood cell count.

ANS: A, B, C Symptoms of GERD include heartburn, regurgitation, persistent cough, exacerbation of asthma, laryngitis, and intermittent chest pain. In addition, abdominal pain within one hour of eating and worsening of symptoms upon lying down are common. Vomiting is not associated with GERD and neither is fever and elevated white blood cell count. DIF: Cognitive Level: Remembering REF: p. 177 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse identifies a need to assess a patient's cognitive status. The nurse chooses to use the MMSE. The nurse knows that the patient must have which of the following abilities? (Select all that apply.) a. Number fluency b. Familiarity with analog clocks c. Ability to hear and see d. Ability to sit up for 10 minutes e. Ability to speak English

ANS: A, B, C The MMSE requires number fluency, ability to see and hear and hold a pencil, and experience with analog clocks. The instrument is available in languages other than English. It is a cognitive status exam and does not require that the patient be able to sit up. DIF: Cognitive Level: Remembering REF: p. 81 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

Which of the following are subscales on the Braden Scale for predicting pressure ulcers? (Select all that apply.) a. Nutrition b. Moisture c. Mobility d. Age e. BMI

ANS: A, B, C The six subscales of the Braden Scale are sensory perception, activity, mobility, moisture, friction and shear, and nutrition. DIF: Cognitive Level: Remembering REF: p. 165 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is providing glaucoma education for a group of older adults in a senior center. The nurse knows that the following groups are most likely to develop glaucoma. (Select all that apply.) a. African Americans b. Mexican Americans c. Individuals with a family history of glaucoma d. Individuals with diabetes e. Asian Americans

ANS: A, B, C, D African Americans are at risk of developing glaucoma at an earlier age than other racial and ethnic groups. Mexican Americans, individuals with a family history of glaucoma, and individuals with diabetes are among the other high-risk groups. Asian Americans are more likely to lose eyesight from age-related macular degeneration than other groups. DIF: Cognitive Level: Remembering REF: p. 133 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

Factors that complicate assessment of older adults include: (Select all that apply.) a. presence of multiple comorbid conditions. b. atypical presentation of illness. c. difficulty in differentiating symptoms of disease from normal age-related changes. d. increase in iatrogenic illness. e. lack of assessment instruments specific for the older adult population.

ANS: A, B, C, D Factors that complicate assessment of older adults include difficulty differentiating disease symptoms from normal age-related changes, the presence of multiple comorbidities, atypical presentations of illness, and the presence of iatrogenic illness. There are many assessment tools that are designed specifically for use in the older adult population. DIF: Cognitive Level: Remembering REF: p. 85 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse in a clinic setting that provides care for an ethnically diverse population of older clients shows an understanding of the LEARN Model to direct the assessment process when: (Select all that apply.) a. recognizing that the client's hands are clenched as she answers the assessment questions. b. asking the client to describe what he thinks will help him feel better. c. explaining to the client that herbal remedies may not be sufficient treatment for his chest congestion. d. acknowledging that the client has a different view of the appropriate treatment. e. suggesting to the client that it would be beneficial if she would trust her health care provider to prescribe the correct treatment.

ANS: A, B, C, D The LEARN Model implements active listening to both the client's verbal and nonverbal communication as a means of obtaining insight into the client's perspective of his or her medical problem. This model also encourages the nurse to recognize that the perceptions may differ and to explain the differences in perceptions to the client. The model advocates arriving at a mutually agreed upon treatment plan rather than encouraging the client to surrender personal autonomy in the decision-making. DIF: Cognitive Level: Remembering REF: p. 50 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity

An elderly man is brought to the geriatrics clinic by his wife because of his increasing confusion. As part of his medical workup, the nurse practitioner orders which of the following laboratory tests? (Select all that apply.) a. Basic metabolic panel b. Vitamin D level c. Thyroid stimulating panel d. Vitamin B12 e. Serum albumin level

ANS: A, B, C, D The following laboratory tests are part of a workup for a change in mental status: Basic metabolic panel, vitamin D level, vitamin B12, thyroid stimulating panel. Serum albumin is not part of a dementia workup. DIF: Cognitive Level: Remembering REF: p. 92 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

A nurse is conducting an assessment of an older patient's eyes. The nurse expects to see which of the following normal age-related changes of the external eye? (Select all that apply.) a. The eyelids are less elastic and droopy b. The eyes are very dry c. The eyelids may not close completely d. There is a loss of eyelashes e. The lower lid may be turned outward

ANS: A, B, C, E Normal age-related changes in the external eye include a loss of elasticity causing drooping. Eyes become drier, and the eyelids may not close completely. Decreases in orbital muscle strength may result in entropion, the outward turning of the lower lid. Loss of eyelashes is not a normal age-related change. DIF: Cognitive Level: Remembering REF: p. 132, Table 11-1 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse in an assisted living community notes that one of the residents who has hearing impairment and new bilateral hearing aids frequently does not wear the hearing aids. The nurse knows that which of the following factors contribute to low hearing aid use after purchase? (Select all that apply.) a. Difficulty placing hearing aid properly in the ear b. Stigma associated with wearing a hearing aid c. Difficulty changing the batteries in the hearing aid d. Ineffectiveness of hearing aids for individuals with age-related hearing loss e. Hearing annoying loud noises

ANS: A, B, C, E Options A, B, C, and E are all factors associated with low use after purchase. Option D is incorrect; most individuals with age-related hearing loss do experience some hearing enhancement with hearing aid use. DIF: Cognitive Level: Remembering REF: p. 145 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An otherwise healthy older adult reports having begun to experience problems "holding my water." The nurse shows an understanding of interventions that may help minimize the problem of urinary incontinency when: (Select all that apply.) a. asking whether the client smokes tobacco. b. assessing the average amount of caffeine the client drinks daily. c. asking if the client has been evaluated for diabetes recently. d. suggesting the client keep a record of the amount of fluids ingested daily. e. reviewing the client's current medication list.

ANS: A, B, C, E Risk factors for urinary incontinence include tobacco use, caffeine consumption, and increased urine resulting from diabetes and certain medications. Keeping record of fluid intake will have little or no impact on urine incontinence. DIF: Cognitive Level: Applying REF: p. 202, Box 16-4 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is assessing a patient's activities of daily living. The nurse will assess which of the following? (Select all that apply.) a. Eating b. Continence c. Toileting d. Self-medication administration e. Bathing

ANS: A, B, C, E The basic activities of daily living include eating, transfer, toileting, bathing, continence, and dressing. Self-medication administration is an independent activity of daily living (IADL). DIF: Cognitive Level: Remembering REF: p. 80 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older patient tells a nurse. "The nurse practitioner told me that these ugly purple bruises on my arms are called purpura and are due to fragile blood vessels. I still don't understand why this happens to me." The nurse responds based on the knowledge that: (Select all that apply.) a. purpura is due to normal age-related changes. b. the incidence of purpura increases with age. c. purpura is a precancerous skin condition. d. individuals who take blood thinners are especially prone to purpura. e. individuals prone to purpura should make sure that affected areas are open to the air.

ANS: A, B, D Purpura is due to normal age-related changes and hence the incidence increases with age. Individuals who take blood thinners are especially prone to purpura. Purpura is not a precancerous condition. Individuals who are prone to purpura are encouraged to wear protective garments such as long sleeves and long pants. DIF: Cognitive Level: Applying REF: p. 155 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older adult complains of xerostomia. Which of the following interventions should the nurse implement for this patient? (Select all that apply.) a. Encourage the patient to brush and floss teeth regularly. b. Encourage the patient to have regular dental screenings. c. Provide antiseptic mouthwash (e.g., Listerine) for the patient. d. Encourage adequate intake of water. e. Provide saliva substitutes.

ANS: A, B, D, E Individuals with xerostomia should have regular dental screenings and be encouraged to practice good oral hygiene. Adequate intake of water is important, as is avoidance of alcohol and caffeine. Saliva substitutes may be helpful. Antiseptic mouthwashes usually contain alcohol, which can further dry the mouth. DIF: Cognitive Level: Applying REF: p. 195 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

Which of the following nursing interventions should be implemented to prevent dehydration in hospitalized older adults? (Select all that apply.) a. Implementing intake and output recording for any patients with fever, diarrhea, vomiting, or an infection b. Limiting duration of NPO requirements for diagnostic tests and procedures c. Administering IV fluids to all hospitalized older adults d. Limiting the use of diuretic medications in hospitalized older adults e. Making sure that hospitalized patients have easy access to fluids

ANS: A, B, E In order to prevent dehydration, it is essential to closely monitor hospitalized older adults. Any individual who develops fever, diarrhea, vomiting, or an infection should be monitoring closely by implementing intake and output records and providing additional fluids. NPO requirements for diagnostic tests and procedures should be as short as possible. It is not appropriate to administer IV fluids to all hospitalized older adults. IV fluids are administered when there is a clinical indication. It is not appropriate to limit the use of diuretics. Diuretics are an important treatment for many older patients. Hydration management involves acute and ongoing management of oral intake. Oral hydration is the first line of treatment for dehydration prevention. DIF: Cognitive Level: Applying REF: p. 194 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is educating a group of nursing assistants in long-term care on the prevention of skin tears. Which of the following interventions should the nurse include in the education? (Select all that apply.) a. Lubricate the resident's skin with moisturizers twice daily b. Ensure that the resident has adequate nutrition and hydration c. Bathe the resident in hot soapy water d. Avoid the use of lifting shifts when transferring the resident e. Dress the resident in long sleeves and long pants to protect the extremities

ANS: A, B, E Soapless bathing, tepid water, and moisturizers twice daily are recommended to prevent skin tears. Heavy soaps and hot water dry out the skin increasing the risk of skin tears. Lifting sheets are recommended as are the use of long sleeves and long pants to protect the extremities. DIF: Cognitive Level: Applying REF: pp. 155-156, Box 13-4 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older person reports hearing whistling in both ears when no external sounds are present and is diagnosed with tinnitus. Which of the following are causes of tinnitus? (Select all that apply.) a. Exposure to loud noises b. Use of a hearing aid c. Cerumen buildup d. Side effects of medications e. Age-related changes in the middle and inner ear

ANS: A, C, D Hearing aids are not known as a cause or a trigger to worsen tinnitus and are at times used to amplify environmental noise to mask tinnitus. Tinnitus is not an age-related change, although it occurs in about 11% of individuals who have presbycusis. Exposure to loud noise and cerumen buildup are known to exacerbate or cause tinnitus. Over 200 prescription and nonprescription medications have tinnitus as a side effect. There are also many ototoxic medications. DIF: Cognitive Level: Remembering REF: p. 149 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is caring for an older adult with xerosis. Which of the following interventions should the nurse include in the patient's plan of care? (Select all that apply.) a. Encourage adequate fluid intake b. Encourage daily baths of at least 20 minutes c. Maintain a humid environment d. Apply water-laden emulsions to skin immediately after bathing e. Use only deodorant soaps when bathing

ANS: A, C, D Xerosis is extremely dry, itchy skin. Adequate intake of water is essential in rehydrating the skin. Long duration baths or showers should be avoided, and daily bathing may not be needed. An environment of 60% humidity is recommended. Water-laden emulsions should be applied immediately after bathing. Deodorant soaps should be avoided except in the axilla and groin. DIF: Cognitive Level: Applying REF: p. 154 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse is confident that the client who takes glucosamine sulfate daily is conscientious of the safety issues involved when hearing the client state: (Select all that apply.) a. "I'm always careful to buy the same brand of glucosamine sulfate." b. "If glucosamine sulfate wasn't safe the drug store wouldn't sell it." c. "My pharmacist is so helpful when I have questions about the herbals I take." d. "The liquid form of glucosamine sulfate is what I consistently take." e. "I made sure my physician knew that I was allergic to strawberries."

ANS: A, C, D, E Regarding product safety, there is no standardization among manufacturers, so the amount of active ingredients per dose among brands is inconsistent; herbs and supplements should be purchased from reputable sources; herbs are available in different forms, making accurate dosing difficult; and persons who have allergies to certain plants may have allergies to herbs in the same plant family. There is insufficient research data to confidently make a statement about the safety of such herbal therapy. DIF: Cognitive Level: Applying REF: p. 124 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

Many older adults have a vitamin B12 deficiency. Reasons for this include which of the following? (Select all that apply.) a. Normal age-related changes in the stomach include a lower production of gastric acid making vitamin B12 absorption less efficient b. The major source of vitamin B12 is sunlight, and older adults are less likely to be outdoors and absorb vitamin B12 in this manner c. Proton pump inhibitors, a frequently prescribed medication in older adults, impairs absorption of vitamin B12 from food d. Most older adults do not consume five servings of fruits and vegetables daily, which is the main dietary source of vitamin B12 e. Certain antibiotics and anticonvulsant medication increase the risk of vitamin B12 deficiency

ANS: A, C, E A normal age-related change in the stomach is the production of less gastric acid, which makes vitamin B12 absorption less efficient. For most older adults, intake of vitamin B12 is usually adequate. Use of proton pump inhibitors and H2 receptor blockers for more than a year can lead to lower serum vitamin B12 levels by impairing absorption of the vitamin from food. Certain antibiotics and anticonvulsants can also increase the risk of vitamin B12 deficiency. While it is true that older adults may be outdoors less, the major source of vitamin B12 is not sunlight. While it is also true that older adults may not consume five servings of fruits and vegetables daily, fruit and vegetables are the major sources of vitamins A, C, and E and potassium. DIF: Cognitive Level: Remembering REF: p. 173 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse interviewing an older adult for a nursing history recognizes that the client is experiencing symptomology inconsistent with normal aging of the urinary tract when the client reports: (Select all that apply.) a. finding it more difficult in the last few months to start voiding. b. having two bladder infections in the last 4 years. c. getting up once or twice each night to urinate. d. occasionally experiencing pain when urinating. e. needing to urinate at least every 2 hours during the day.

ANS: A, D Difficulty and pain are not characteristics of urination normally attributed to aging. In about 10-20% of well older adults, aging of the urinary tract is associated with an increased frequency of involuntary bladder contractions. These changes may lead to frequency, nocturia, urgency, and vulnerability to infection. DIF: Cognitive Level: Applying REF: p. 201 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A 74-year-old woman who is in the hospital for rehabilitation following hip replacement has been experiencing incontinence since admission. Which of the following interventions are likely to facilitate the restoration of the patient's bladder function? (Select all that apply.) a. Assess the patient's recent voiding pattern. b. Request an order for an indwelling catheter from the patient's physician. c. Teach the patient how to meet hydration needs while still limiting fluid intake. d. Assist the patient to use the bathroom. e. Request an order for medication to decrease bladder spasms.

ANS: A, D When a patient experiences new onset incontinence, the first step is assessment. Assisting the patient to the bathroom has many beneficial aspects to it and it provides a private setting where the patient is in the most normal physiological position to urinate. Placing an indwelling catheter is not a solution to urinary incontinence. Limiting fluids is not indicated in this patient. There is no indication that this patient is having bladder spasms. DIF: Cognitive Level: Applying REF: pp. 203-204 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older adult is having difficulty sleeping and asks a nurse, "My neighbor told me that I should take melatonin to help me sleep. What do you think about this?" The nurse responds to the individual's question using the knowledge that: (Select all that apply.) a. in the natural state melatonin is produced by the pineal gland and regulates the sleep-wake cycle. b. melatonin is available in both immediate and extended release forms; however, only the immediate form is effective. c. there are no significant adverse effects to melatonin. d. it must be used with caution in a patient that is taking other medications that have central nervous system depressant effects. e. evidence shows that it is effective at decreasing sleep onset latency, improving quality of sleep, and improving morning wakefulness.

ANS: A, D, E In the natural state, melatonin is endogenously produced by the pineal gland and is an important signal in regulating the sleep-wake cycle. Melatonin must be used with caution in patients who are taking other medications that cause drowsiness or have central nervous system depressant effects. Studies have demonstrated that melatonin is effective at decreasing sleep onset latency, improving quality of sleep, and improving morning wakefulness. Melatonin is available in both an immediate and extended release form, and both forms are effective. There are adverse effects to melatonin, which include dizziness, nausea, and drowsiness. DIF: Cognitive Level: Applying REF: p. 120 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

A nurse is preparing to hand feed an older adult with a history of a right cerebrovascular accident (CVA) with facial weakness and dysphagia. Which techniques should the nurse utilize when feeding this patient? (Select all that apply.) a. Sit the patient upright in a chair at 90 degrees. b. Allow the patient to sit upright for 15 minutes after the meal is completed. c. Feed the patient only liquids to make swallowing easier. d. Place the solid food in the left side of the mouth. e. Have the patient swallow twice for every mouthful of food given.

ANS: A, E When feeding a patient with dysphagia, it is important to have the patient sit upright at 90 degrees and to remain upright for an hour following the meal. Other important techniques include having the patient swallow twice for every mouthful of food given. This patient has a history of a right CVA, which would mean that the patient has left-sided weakness. The food needs to be placed in the nonimpaired side of the mouth, which in this case would be the right side. Since the patient has a CVA, the intake of "thin liquids" can increase risk for aspiration. DIF: Cognitive Level: Applying REF: p. 186, Box 14-18

An older adult who is within a normal weight range asks a nurse, "I have heard that it is important to limit the amount of fats in my diet, but I don't know how much I should be taking in daily. Can you help me?" The best response by the nurse is: a. "Someone of your age needs to limit fats." b. "Since you are at your ideal weight, you should limit your daily fat grams to half your weight." c. "Fat intake will depend on the presence of any cardiac issues." d. "Read food labels well and focus your diet on low-fat foods."

ANS: B A simple technique to determine how much fat a person should consume is to divide the ideal weight in half and allowing that number of grams of fat. The remaining options don't address the issue of how much fat should be eaten daily. DIF: Cognitive Level: Applying REF: p. 173 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse is most concerned by observing when assisting with an older client's bath: a. A firm, irregularly-shaped, pink-colored nodule b. A slightly raised multicolor lesion with an asymmetrical, irregular border c. A pearly papule with prominent blood vessels d. Rough, scaly, sandpaper-like patches that are slightly tender

ANS: B A slightly raised multicolor lesion with an asymmetrical irregular border is characteristic of melanoma that accounts for less than 5% of skin cancer cases, but it causes most skin cancer deaths. A firm, irregularly-shaped, pink-colored nodule or persistent red lesion is characteristic of squamous cell carcinoma. A pearly papule with prominent blood vessels is a characteristic of a basal cell carcinoma. A tender, rough, scaly, sandpaper-like patch is a characteristic of actinic keratoses (a precancerous lesion). DIF: Cognitive Level: Applying REF: p. 159 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A 69-year-old patient in the geriatric clinic has an annual physical examination and a complete blood count and serum electrolytes are drawn. While the physical examination was uneventful, the laboratory results show an elevated blood urea nitrogen (BUN). The nurse will then: a. ask that the test be rerun since the client showed no physical signs of renal failure. b. review the client's medication list since BUN can be affected by many specific medications. c. instruct the client on collecting a 24-hour urine specimen for a more detailed analysis. d. assure the client that an elevated BUN is normal in older adults.

ANS: B BUN can be elevated as a result of certain medication therapies and so the nurse should assess for this possibility. An elevated BUN is not diagnostic of renal failure alone and will not necessarily be reflected in physical symptoms. A 24-hour urine sample will not generally be done to determine BUN levels. An elevated BUN is not expected as a normal part of aging. Renal functioning decreases substantially with aging, but in most cases the body is able to compensate adequately with only slight increases in laboratory findings. DIF: Cognitive Level: Applying REF: p. 96 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

An older patient reports the following symptoms to a nurse during a routine visit to the geriatric clinic: blurry vision, the need for more light when reading, and blind spots in the middle of his visual field. He also states, "Strangely enough my peripheral vision continues to be pretty good." The nurse suspects that the patient has which of the following? a. Glaucoma b. Age related macular degeneration c. Diabetic retinopathy d. Cataracts

ANS: B Blurry vision, needing more light, and blind spots in the middle of the visual field (scotomas) are all characteristics of age related macular degeneration. The other three eye diseases do not present with these symptoms. DIF: Cognitive Level: Applying REF: pp. 135-136 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A 78-year-old man is being evaluated in the geriatric clinic. His daughter reports that he has been very forgetful lately, and she is concerned that he might be "senile." The advanced practice nurse administers the clock-drawing test and the patient draws a distorted circular shape and places the numbers all on one side of the shape. Based on his performance, the nurse concludes that the patient: a. probably has Alzheimer's disease. b. needs further evaluation. c. probably has delirium. d. needs a functional status assessment.

ANS: B Cognitively intact persons rarely produce errors on the clock-drawing test, such as grossly distorted contour. A low score on the clock-drawing test requires further evaluation. Alzheimer's disease is not a diagnosis using a mental status assessment tool. It is definitively diagnosed with a brain biopsy. The clock-drawing test does not assess for delirium. A low score on the clock-drawing test does not necessarily warrant a functional status assessment. DIF: Cognitive Level: Understanding REF: p. 81 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance

An older female patient tells a nurse the following: "In my culture, women are the silent partner in the family. Men make all of the decisions. However, when we came to the United States, all that changed. I became an American. I am in charge of my family just like my husband." This is an example of: a. enculturation. b. acculturation. c. ethnicity. d. culture competence.

ANS: B Enculturation is defined as cultural beliefs passed down from one generation to the next. Acculturation is the process by which persons from one culture adapt to another. Ethnicity is defined as the cultural group that one identifies with. Cultural competence involves stepping outside our own biases and understanding that others bring a different set of values. DIF: Cognitive Level: Applying REF: p. 40 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity

A female nurse is caring for an older woman from the Hasidic Jewish community. The woman's son is at the patient's bedside. The nurse notes that when she communicates with the patient and her son, the son does not maintain eye contact with her and also notes that he withdraws when she attempts to shake his hand. The best response by the nurse is to: a. carry on conversation with the patient only, ignoring the son. b. continue conversing with both the patient and the son. c. ask the son to leave since he is not comfortable with her. d. ask the patient why the son will not engage with her.

ANS: B In some cultures, direct eye contact or contact between men and women is seen as a sexual advance. This is true in the Hasidic culture. Options A and C are disrespectful to the patient and her son. Option D may put the son in an uncomfortable position. DIF: Cognitive Level: Analyzing REF: p. 48 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Psychosocial Integrity

The nurse is conducting a presurgical interview when it is noted that the older adult patient's medication list includes Tylenol 650 mg four times a day for arthritic pain, gingko 80 mg twice a day, and glucosamine chondroitin 500 mg three times per day. The nurse proceeds to share with the client that in order to minimize the risk for postsurgical complications, there is the need to refrain from taking: a. glucosamine chondroitin for 1-2 weeks due to a potential for excess anesthetic sedation. b. ginkgo for 2 weeks due to the potential for increased bleeding. c. Tylenol for 24-48 hours due to the potential for increased bleeding. d. gingko for 1 week due to the potential for an allergic reaction during surgery.

ANS: B It is recommended that ginkgo be discontinued for 2 weeks preoperatively due to the potential for increased bleeding. There is no evidence that ginkgo is associated with allergic reactions during surgery. There are no recommendations for discontinuation of glucosamine chondroitin, and glucosamine is not associated with a potential for increased sedation from anesthetics. Tylenol is not associated with a potential for increased bleeding. DIF: Cognitive Level: Analyzing REF: p. 123, Table 10-1 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

An older client in a long-term care facility is receiving an annual physical examination and is ordered laboratory tests that include a complete blood count, serum electrolytes, and thyroid tests. When the client's son questions why these tests are being ordered by saying, "Dad is 85 why are you bothering him?" the nurse's response is based on an understanding that: a. the health care provider ordering the tests needs to explain the rationale to the son. b. when conducted annually, all of the tests are helpful in promoting maximum health for older adults in the long-term care setting. c. the tests are useful, but only if clinically indicated. d. the complete blood count and serum electrolytes are useful screening tests, but the usefulness of the thyroid test should be questioned.

ANS: B Laboratory tests are a fast and accurate way of assessing key parts of an older person's physical functioning. It is within the nurse's scope of practice to answer the son's question and it does not need to be referred to the health care provider. The laboratory tests are being used as annual screening and therefore do not need to be clinically indicated. Excessive sleepiness is not normal in an 85-year-old and may be a sign of a thyroid disorder. DIF: Cognitive Level: Applying REF: p. 92 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

You have four rooms to choose from for your older client to be admitted this afternoon. Which room would you choose? a. A brightly lit, blue room with cozy throw rugs b. An orange-carpeted room with soft lighting and yellow walls c. A brightly lit, blue room with an EZ-Glide wax floor d. A fluorescent-lighted room with green walls and a glossy, tiled floor

ANS: B Light colors such as red, orange, and yellow are more easily seen by aging eyes. Softer lighting will help reduce some of the glare and is also easier seen by aging eyes. Fidelity of color is less accurate with the blues, greens, and violets of the spectrum, and the slowed ability of the pupils to adjust to light makes glare a problem. Glare can come from sunlight, but a brightly waxed floor and glossy tile can also cause glare. DIF: Cognitive Level: Applying REF: p. 138 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older patient learns that he has metastatic cancer. The patient states: "I must have angered God." This is an example of which type of belief? a. Biomedical b. Magico-religious c. Naturalistic d. Ayurvedic

ANS: B Magico-religious: views illness as caused by actions of a higher authority. Biomedical: views disease as a result of abnormalities in structure and function and disease caused by intrusion of pathogens into the body. Naturalistic: based on the concepts of balance. Health is seen as a sign of balance. Ayurvedic: the oldest known paradigm in the naturalistic system. Illness is seen as an imbalance. DIF: Cognitive Level: Remembering REF: p. 46 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Psychosocial Integrity

The nurse preparing an educational program focused on herbal supplement targets as a likely interested group: a. Inner-city females who live below the poverty level b. White females who own their own successful businesses c. Male Hispanic Americans who are single, divorced, or widowed d. Men and women from small rural communities who are self-employed farmers

ANS: B Non-Hispanic, white, older, normal-to-underweight women with more education were found to use dietary supplements more than any other racial, ethnic, age, or gender group. DIF: Cognitive Level: Applying REF: p. 115 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse assesses a nursing home resident's pressure ulcer to be a "healing stage III." The primary reason reverse staging is never used is because: a. even though all tissue layers are replaced as a wound heals, the healed skin is not as strong as it originally was. b. not all tissue layers are replaced as a wound heals, and the healed skin is not as strong as it originally was. c. reimbursement in nursing homes does not allow for reverse staging to be utilized. d. the collagen layer is not replaced during wound healing.

ANS: B Not all tissue layers are replaced as a wound heals. The wound fills with granulation tissue composed of endothelial cells, fibroblasts, collagen, and extracellular matrix. Muscle, subcutaneous fat, and dermis are not replaced. The healed skin is not as strong as it originally was. Reimbursement in long-term care is not the primary reason for not using reverse staging. DIF: Cognitive Level: Remembering REF: p. 161 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older woman asks a nurse, "You always seem to be telling me that I need to drink more water. How much water do I really need to drink?" The nurse bases her response on the knowledge that older adults should consume at least: a. 1000 mL of fluid per day. b. 1500 mL of fluid per day. c. 2000 mL of fluid per day. d. 2500 mL of fluid per day.

ANS: B Older adults, with the exception of those who require a fluid restriction, should consume at least 1500 mL of fluid per day. DIF: Cognitive Level: Remembering REF: p. 191 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An older adult asks a nurse, "I hear a lot about limiting the amount of fat in my diet and eating a balanced diet. It is confusing. Can you help me understand what a balanced diet for me would be?" The nurse bases a response on which of the following? a. 10-15% of total calories should be from fat, 30-40% from carbohydrates, and 35-75% from protein b. 20-35% of total calories should be from fat, 45-65% from carbohydrates, and 10-35% from protein c. 45-65% of total calories should be from fat, 20-35% from carbohydrates, and 10-35% from protein d. 20-35% of total calories should be from fat, 10-25% from carbohydrates, and 50-75% from protein

ANS: B Recommendations for older adults are that 20-35% of total calories should be from fat, 45-65% from carbohydrates, and 10-35% from protein. DIF: Cognitive Level: Remembering REF: p. 173 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A 78-year-old female patient was recently diagnosed with atrial fibrillation and started on Coumadin (warfarin) for stroke prophylaxis. A nurse provides extensive education on warfarin including the need for routine blood testing. The woman states the following to a nurse: "I understand all that you have taught me, but I do not know what a good number for the INR test is." The nurse bases her response on the knowledge that the recommended INR is: a. 1.0-2.0. b. 2.0-3.0. c. 3.0-4.0. d. 4.0-5.0.

ANS: B Recommended INR for an individual with atrial fibrillation for stroke prevention in individuals over age 75 is 2.0-3.0. DIF: Cognitive Level: Applying REF: p. 97 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

During an admission interview, a patient tells the nurse about taking Ginkgo biloba daily. The nurse responds to this information by inquiring whether the client: a. has ever been screened for depression. b. experiences gastrointestinal (GI) upset. c. has concerns regarding impotence. d. has reoccurring bouts of bronchitis.

ANS: B Side effects of Ginkgo biloba include GI upset and should be assessed for by the nurse. Neither depression, nor impotence, nor chronic bronchitis conditions are generally self-treated with Gingko biloba. These conditions are not considered typical side effects of Gingko biloba either. DIF: Cognitive Level: Applying REF: p. 118 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse is reviewing the postsurgical laboratory values of an older adult client. The client's erythrocyte sedimentation rate (ESR) is 20 mm/hr. The nurse initially responds to this data by: a. asking the client if he or she has been diagnosed with any chronic inflammatory diseases. b. recognizing that the value is normal for older adults. c. notifying the client's health care provider immediately. d. requesting that the laboratory rerun the test.

ANS: B The ESR can be slightly elevated (10-20 mm/hr) in healthy older adults, especially those with a chronic disease that results in inflammation. Asking the client if he or she has such a diagnosis is not the initial response. This slight elevation does not warrant immediate notification or rerunning of the test. DIF: Cognitive Level: Applying REF: p. 91 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

A limitation of the Katz Index of activities of daily living (ADLs) is that: a. completion of the tool requires the joint efforts of the interdisciplinary team. b. all ADLs are weighted equally. c. it puts a heavier weight on the cognitive abilities necessary to perform ADLs. d. it provides a range of performance for each task.

ANS: B The Katz Index assigns an equal weight to all of the ADLs, and because of that, it cannot be used to identify the particular area of need or change in any one task. Any health care professional can complete the Katz Index, although input from the interdisciplinary team is valuable. The Katz Index does not address the cognitive abilities necessary to perform ADLs. The ADLs are considered in dichotomous terms only, the ability to compete the task independently or the complete inability to do so. DIF: Cognitive Level: Remembering REF: p. 80 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance

An older adult's nutritional status is screened by a nurse using the Mini Nutritional Assessment (MNA). The older adult scores a score of "10" on the screening portion of the tool. The best action by the nurse is to: a. refer the patient to a dietician. b. complete the assessment portion of the tool. c. conduct a 72-hour calorie count. d. initiate nutritional supplements between meals.

ANS: B The MNA is both a screening tool and a detailed assessment. It is validated for use in individuals over age 65 and intended for use by professionals. If an individual scores less than a 12 on the screening portion of the tool, then the assessment portion must be completed. The assessment portion needs to be completed before any interventions or referrals are taken, as the information that is obtained in the assessment will guide the choice of interventions. DIF: Cognitive Level: Applying REF: p. 180 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

When comparing the Older American's Resources and Services (OARS) with the Katz Index of ADLs, what is true? a. The Katz Index and the OARS both measure only ADL performance b. The OARS is a comprehensive assessment tool that measures ability in five areas; the Katz Index measures only ADL performance c. The OARS is used only for older adults in the long-term care setting; the Katz Index is used in all settings d. The OARS is not valid for use in older adults who are cognitively impaired, whereas the Katz Index is

ANS: B The OARS evaluates ability, disability, and capacity at which the person is able to function. Five dimensions are assessed: social resources, economic resources, physical health, mental health, and ADLs. The Katz Index only evaluates ADL ability. Both instruments are used in a variety of care settings and are valid for use with cognitively impaired older adults. DIF: Cognitive Level: Understanding REF: p. 84 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Health Promotion and Maintenance

A resident of a long-term care facility is assessed by a nurse upon admission to the facility. The assessment includes a comprehensive health, social, and functional profile. The tool that the nurse utilizes is: a. Outcomes and Assessment Information Set (OASIS). b. Resident Assessment Instrument (RAI). c. Older Americans Resources and Services (OARS). d. Comprehensive Geriatric Assessment (CGS). e. Mini Mental Status Examination (MMSE).

ANS: B The OASIS is used in the homecare setting. The RAI is used in the long-term care setting. OARS is a functional status instrument. Comprehensive geriatric assessment is not a specific tool but rather an approach to assessment. The MMSE is a mental status assessment tool. DIF: Cognitive Level: Remembering REF: p. 85 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

When asked by an older adult client, "What is the difference between my normal laboratory values and the ones for a 55-year-old?" The nurse responds based on the understanding that there are: a. age-adjusted ranges for older adults for all of the common laboratory findings, similar to those for infants and children. b. no age-adjusted ranges for older adults due to the large variations within the age group and the increasing number of factors that influence the results. c. age-adjusted ranges only for the over-85 age group; there are no expected changes in the 65- to 84-year-old age group. d. age-adjusted ranges only for the hematological tests, which are due mostly to changes in the bone marrow.

ANS: B There are no age-adjusted ranges for laboratory values due to the variation within the group, as well as the many chronic illnesses of older adults. The older one is, the more likely variations are to be seen. Although several age-related hematological changes occur, mainly from changes in the bone marrow, few are clinically significant. DIF: Cognitive Level: Remembering REF: p. 88 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is observing a nurse aide perform denture care for a resident in the nursing home. The nurse recommends that the nurse aide receive additional education on denture care when the nurse observes which of the following? a. The nurse aide places a face cloth in the sink and fills the sink half full with water. b. The nurse aide uses toothpaste to clean the dentures. c. The nurse aide utilizes a specially designed denture brush to clean the dentures. d. The nurse aide stores the dentures in a denture cup filled with denture cleansing solution.

ANS: B Toothpaste is not used to clean dentures since it abrades denture surfaces. All of the other options are correct steps in the process to cleanse dentures. DIF: Cognitive Level: Remembering REF: p. 197, Box 15-12 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

When a client who routinely takes the herb St. John's Wort (SJW) shares that his or her "hay fever is really bad right now," the nurse initially: a. notifies the primary care provider that the client has been self-medicating for hay fever. b. compares the client's current blood pressure to his/her baseline blood pressure. c. stresses the need to avoid over-the-counter (OTC) medications containing monoamines. d. suggests that the client stop taking the herb until the hay fever has improved.

ANS: B When taking SJW, people should be warned not to take medications containing monoamines, such as medications for nasal decongestants, hay fever, and asthma, because this combination may cause hypertension. The primary care provider should not be notified until the BP monitoring is known. Avoiding specific OTC medications and stopping the herb is information the client should have been given prior. DIF: Cognitive Level: Analyzing REF: p. 123 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

A nurse is providing an educational session on vaccines to a group of older adults. The nurse is discussing the zoster vaccine (Zostavax). Which of the following information should the nurse include in the education? a. Zostavax should only be given to individuals who have never had an episode of herpes zoster (HZ) b. Zostavax is recommended for all individuals over age 60 that have no contraindications to the vaccine c. Zostavax should not be given to anyone with a chronic cardiac or respiratory condition d. Zostavax will always prevent an individual from developing Herpes Zoster

ANS: B Zostavax is recommended for all persons 60 and older who have no contraindications to the vaccine, including persons with a previous episode of Herpes Zoster (HZ) and those with chronic conditions. The vaccine does not guarantee that an individual will not get HZ; however, individuals who get the vaccine cut their risk in half and if they do get HZ, it is likely that they will get a milder case. DIF: Cognitive Level: Remembering REF: p. 157 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is caring for an older adult in a hospital who has an indwelling catheter. The nurse assesses the patient based on the knowledge that which of the following are correct indications for an indwelling catheter? (Select all that apply.) a. To assist with incontinence management b. To manage acute urinary retention c. To assist in healing of open sacral or perineal wounds in incontinent patients d. To accurately measure urinary output in critically ill patients e. To prevent falls related to toileting in hospitalized older patients

ANS: B, C, D Indwelling urinary catheters are appropriate in the management of acute urinary retention, to assist in the healing of open sacral or perineal wounds in incontinent patients, and when accurate measurement of urinary output is essential in managing a critically ill patient. Urinary catheters are not an appropriate intervention for the management of incontinence and do not prevent falls related to toileting in hospitalized patients. DIF: Cognitive Level: Remembering REF: p. 209 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse caring for a cognitively impaired older adult client shows an understanding of the unique clinical symptoms of constipation in this population when: (Select all that apply.) a. checking documentation to determine if the client has had a bowel movement in the last 24-36 hours. b. questioning staff as to whether the client has any unexplained falls in the last few days. c. asking the client to name all of his or her children and grandchildren. d. requesting that the client's temperature be taken now and again in 4 hours. e. reviewing the client's food intake over the last 24-36 hours.

ANS: B, C, D, E It is important to note that alterations in cognitive status, incontinence, increased temperature, poor appetite, or unexplained falls may be the only clinical symptoms of constipation in the cognitively impaired or frail older person. Frequency of defecation is not necessarily an indicator of constipation since it is such a personal characteristic. DIF: Cognitive Level: Applying REF: pp. 212-213 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is developing a care plan for an older adult in a long-term care facility that has a nutritional problem. Which of the following interventions are appropriate to ensure adequate nutrition? (Select all that apply.) a. Assign a nursing aide to feed the resident to ensure adequate consumption of meals b. Supervise the resident during meals c. Provide a pleasant eating environment d. Provide nutritional supplements for the resident e. Assess the resident for ability to feed himself/herself

ANS: B, C, D, E Nurses hold an important role in ensuring adequate nutrition. Interventions that support this goal include supervision of eating, modification of the environment to be pleasing for eating, and assessing the individual for issues related to performance at mealtimes. Feeding a resident is not indicated unless it is known that the resident cannot feed himself/herself. It is important to promote independence as much as possible. DIF: Cognitive Level: Applying REF: p. 183 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse is performing an admission assessment on an older patient who presented with a high fever and cough, reduced oral intake for 3 days, and lower extremity weakness. The patient has sunken eyes, and the patient's skin turgor over the sternum is poor. The nurse suspects that the patient is dehydrated. Which of the following are indicators of dehydration in this patient? (Select all that apply.) a. Poor skin turgor over the sternum b. Lower extremity weakness c. High fever d. Sunken eyes e. Cough

ANS: B, D Older adults often present atypically when dehydrated. Skin turgor over the sternum is not a reliable marker in older adults due to the loss of subcutaneous tissue with aging. Lower extremity weakness and sunken eyes may indicate dehydration. High fever and cough can be associated with many other conditions and are not typically signs of dehydration. DIF: Cognitive Level: Applying REF: p. 193 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

An 89-year-old hospitalized female patient tells a nurse, "I go to the bathroom really often, but I manage this by not drinking too much before I go to bed so I can sleep for the night." The patient has no pain or discomfort with voiding. The nurse considers this finding to be a: a. manifestation of urge incontinence. b. manifestation of a urinary tract infection. c. normal age-related change in an 89-year-old woman. d. manifestation of diabetes.

ANS: C A decreased bladder capacity is a normal age-related change. Urinating frequently with no other symptoms is not a manifestation of infection or diabetes. Urge incontinence is not a correct response as the patient is not experiencing incontinence. DIF: Cognitive Level: Applying REF: p. 201 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A paper on culture and illness would be likely to include the statement that: a. culture is the same as ethnicity. b. ethnic groups always share common geographic origin and religion. c. ethnicity involves recognized traditions, symbols, and literature. d. most members of an ethnic group exhibit identical cultural traits.

ANS: C Ethnicity is a complex phenomenon including traditions, symbols, literature, folklore, food preferences, and dress. It is a shared identity. Ethnicity is more than just culture. It is social differentiation based on culture. Even within ethnic groups, there is considerable diversity. DIF: Cognitive Level: Remembering REF: p. 44 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity

A nurse administers hypodermoclysis (HDC) to an older nursing home resident. The purpose of hypodermoclysis is: a. to rehydrate an individual with severe dehydration. b. to quickly administer 4-5 L of fluid within a 24-hour period. c. to rehydrate an individual with mild to moderate dehydration. d. as a supplement to IV hydration to expedite rehydration.

ANS: C HDC is an infusion of isotonic fluids into the subcutaneous space. It is an alternative to IV administration for individuals with mild to moderate dehydration. It cannot be used in individuals with severe dehydration or for any situation requiring more than 3 L over 24 hours. DIF: Cognitive Level: Remembering REF: p. 194 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

Regarding health care disparities, it is true that older adults of color have: a. equal risk factors for vulnerability as do all older adults. b. equal risk factors for vulnerability as do the young adults of color. c. increased risk factors for vulnerability if they are female. d. an increase in risk factors for vulnerability if care is provided by public facilities.

ANS: C Older females of color have an added risk factor for vulnerability (gender) than do males of the same age and ethnic group. Ethnicity is an added factor for vulnerability. Age is an additional risk factor for vulnerability. Health care disparities are found across a wide range of clinical settings. DIF: Cognitive Level: Remembering REF: p. 41 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity

The nurse is confident that the client who chooses to take red rice yeast daily for dyslipidemia has an understanding of its possible side effects when the client: a. has regular laboratory work to monitor cholesterol levels. b. shows caution by slowly rising from the chair. c. states, "If I start noticing muscle pain, I'll stop taking the pills." d. schedules regular, yearly glaucoma screenings.

ANS: C Persons need to know the potential side effects of red yeast rice, similar to those of lovastatin, such as muscle pain. Regular cholesterol monitoring will not aid in the identification or management of possible side effects. The need to rise slowly from a chair is not directly related to the side effect of muscle pain. There is no current research to support the need for regular glaucoma screens as a precaution when taking red rice yeast. DIF: Cognitive Level: Analyzing REF: p. 120 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

An older resident of a long-term care facility diagnosed with dementia has in the last 48 hours become more confused than usual and while usually requiring help with toileting has been incontinent of urine. The client's health care provider orders a complete blood count and serum electrolytes. When the laboratory tests are all within normal limits, the nurse initially: a. attributes the changes in the resident's functioning to advancing dementia. b. suggests that the resident be placed on broad-spectrum antibiotics to prevent infections. c. speaks with the health care provider regarding the changes in the client's function and the possibility of obtaining a urine culture. d. changes the plan of care to include bladder training and implement a 24-hour calorie count.

ANS: C Waiting for usual signs of infection or illness in older adults can be fatal. In older adults, signs of infection may be absent or not seen until the patient is septic or very ill. The nurse needs to be alert to the subtle changes in the patient. A change in mental status may be indicative of an infection. Laboratory values do not always change in older adults, often not until the patient is very ill. Placing a patient on broad-spectrum antibiotics does not prevent infections. This action may in fact cause bacteria to become drug resistant. All evidence points to the changes in functioning being attributable to acute illness. The nurse needs to respond to the acute illness first. DIF: Cognitive Level: Applying REF: p. 90 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

An older nursing home resident reports that her hearing loss is getting worse. What is the first action of the nurse? a. Refer the resident for an evaluation for a hearing aid b. Raise her voice when speaking to the resident c. Examine the resident's ears for cerumen impaction d. Teach the resident to read lips

ANS: C When hearing loss is suspected or a person with existing hearing loss experiences increasing difficulty, it is important to first check for cerumen impaction. Hearing aids are not the first intervention since the cause of the hearing loss has not been determined. Hearing aids do not help all type of hearing losses. Raising one's voice is not effective; it often makes hearing more difficult. Lip reading may be a useful skill for an individual with hearing loss, but it is critical to first ascertain what the cause of the hearing loss is. DIF: Cognitive Level: Analyzing REF: p. 144 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

In a long-term care facility, a nurse is having a discussion with the nurse aides about ways to deal with dementia clients who are uncooperative with mouth care. Appropriate methods to use include: a. speaking to the client sternly and instructing the client to open the mouth and cooperate immediately. b. having another nurse aide assist in holding the client's mouth open with a tongue depressor. c. involving the client in the process of oral hygiene, such as using the hand over hand technique to brush the client's teeth. d. quickly performing oral hygiene without explanation since the client is uncooperative.

ANS: C With uncooperative individuals, it is important for the caregiver to be at eye level and explain all actions with step-by-step instructions. Speaking to the client sternly, having another nurse aide hold the patient's mouth open, or performing oral hygiene without an explanation will only serve to agitate the patient. Involving the client and having the client participate to the extent possible is important. Using a hand over hand technique is effective. DIF: Cognitive Level: Analyzing REF: p. 197 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A nurse in the ambulatory care setting is preparing to do an interview with a non-English-speaking client. The nurse secures an interpreter. In order to have the most effective interview, the nurse should do which of the following? (Select all that apply.) a. Look and speak to the interpreter b. Use technical terminology to ensure accuracy c. Allow more time for the interview d. Watch the client's nonverbal communication e. Have the interpreter check whether the client understands the communication

ANS: C, D For the most effective interview the nurse should look and speak directly to the client, avoid the use of jargon and technical terminology, observe the client's nonverbal communications, and clarify understanding by asking the client to state in his/her own words what he or she understood, facilitated by the interpreter. The interview will take longer. DIF: Cognitive Level: Remembering REF: p. 48 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Psychosocial Integrity

Ethnocentrism is defined as: a. an understanding of another's cultural beliefs and practices. b. a conflict that occurs when an individual interacts with another whose beliefs differ from his own. c. application of limited knowledge about one person with characteristics specific to another person. d. a belief that one's ethnic group is superior to that of another.

ANS: D A belief that one's ethnic group is superior to that of another is the definition of ethnocentrism. Ethnocentrism does not involve an understanding of the beliefs of others. A conflict that occurs when an individual interacts with another whose beliefs differ from his own is the definition of cultural conflict. Application of limited knowledge about one person with characteristics specific to another person is the definition of stereotyping. DIF: Cognitive Level: Remembering REF: p. 42 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Psychosocial Integrity

An older patient asks a nurse, "My doctor referred me to a hearing specialist who thinks that surgery for a cochlear implant may be beneficial for me. Can you tell me how one of those things works?" The nurse formulates a response based on the knowledge that: a. a cochlear implant is permanent, surgically-implanted hearing aid. b. a cochlear implant speeds up the conduction of sound to the auditory nerve. c. a cochlear implant functions as an artificial auditory nerve. d. a cochlear implant directly stimulates the auditory nerve.

ANS: D A cochlear implant bypasses damaged portions of the ear and directly stimulates the auditory nerve. DIF: Cognitive Level: Analyzing REF: p. 146 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The major focus regarding nursing education for the older adult regarding the use of herbal supplements is the: a. high risk of herbal overdose since the manufacturing process lacks effective controls. b. likelihood that the client will substitute herbals for more expensive prescribed medications. c. expense of the herbal supplements since they are seldom covered by insurance. d. possibility of dangerous interactions between herbals and the client's prescription medications.

ANS: D A major issue in the use of herb and other supplements is the risk for interactions. This is especially a concern due to the number of medications already taken by elders. While the remaining options are all legitimate concerns, they are not unique to the older adult consumer. DIF: Cognitive Level: Applying REF: p. 122 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

A 78-year-old patient has a history of osteoarthritis and lives alone in a two-story home. The bathroom is on the first level and the bedroom is on the second level. The patient states, "I am so upset. I have been wetting the bed at night." What type of incontinence does the patient most likely have? a. Mixed incontinence b. Stress incontinence c. Urge incontinence d. Functional incontinence

ANS: D Functional incontinence is defined as incontinence that is due to the individual being unable to get to the toilet as a result of barriers, including environmental barriers. DIF: Cognitive Level: Applying REF: p. 203, Box 16-1 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

A 74-year-old client who has experienced a progressive loss of hearing acuity in recent years obtains a new hearing aid. Which of the following should be included in the nurse's teaching plan? a. "Many people find that hearing aids only help with certain types of hearing loss that are caused by previous noise exposure." b. "With the right hearing aid, you can expect your hearing to be back to normal." c. "Hearing aids are covered by Medicare Part B." d. "Even though hearing aids will help you, they also bring challenges like distorted speech and amplified background noise."

ANS: D Hearing aids do bring challenges, such as distorted speech and amplified background noise. Although hearing aids are not indicated for all individuals with hearing loss, they are not restricted to those with hearing loss due to excessive noise exposure. Hearing aids do not restore hearing to normal. Medicare does not cover the cost of hearing aids. DIF: Cognitive Level: Analyzing REF: p. 145 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

The nurse admitting a client to a same day surgery unit makes the decision to notify the surgical team to cancel the procedure based on the client's statement that: a. "Will I start taking my St. John's wort as soon as I can eat again?" b. "I've haven't taken my ginkgo for exactly 10 days." c. "I didn't want to risk catching a cold so I took my echinacea with just a sip of water." d. "It seemed strange not taking my garlic pill this morning."

ANS: D Herbs that can affect bleeding and clotting time, such as garlic, ginger, ginkgo, and ginseng, should be especially noted and reported to the surgical team. There is no known surgery-related risk involved with the regular self-medication of St. John's Wort or echinacea. Ginkgo should be stopped at least 7 days prior to surgery. DIF: Cognitive Level: Analyzing REF: p. 123 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

A home care nurse is caring for an older patient from a different culture who is bed-bound and high risk for development of a pressure ulcer. The nurse discusses the plan of care with the patient's daughter, emphasizing the importance of turning every 2 hours and posts a turning clock on the wall. When the nurse returns later in the week, the turning clock has been removed, and the patient's daughter reports that she turns her mother occasionally. She states, "I am taking very good care of my mother. You just don't understand; our ways do not involve doing things on schedules." The best response by the nurse is: a. "You must follow my guidelines and turn her every 2 hours, or I will not be able to take care of her." b. "I understand that you value your culture, but culture cannot stop you from providing good care to your mother." c. "I understand that you care very much for your mother. Perhaps caring for her is too much for you." d. "How can we best work together to provide the best care for your mother?"

ANS: D In providing cross-cultural care it is important that the nurse work with the patient and family and listen carefully and find a way to include the values and beliefs of the patient in the plan of care. DIF: Cognitive Level: Analyzing REF: p. 43 TOP: Integrated Process: Communication and Documentation MSC: Client Needs: Psychosocial Integrity

When a nursing interview identifies that a client is daily taking doses of herbal supplements, the nurse's priority is to: a. evaluate the effectiveness of the herbal supplement self-treatment. b. determine why the client feels the need to take the herbal supplements. c. identify when the herbal supplementation began. d. discuss the client's knowledge regarding the herbal supplements' side effects.

ANS: D The conversation about the client's use of herbal supplements should focus first on the client's understanding of the herbs' uses, side effects, dosage, and safety concerns. Once the therapeutic communication has established a nonjudgmental nature, the nurse can go on to if the client feels the supplements are effective, why the client feels the need to take the supplements, and when the supplements were started. DIF: Cognitive Level: Analyzing REF: pp. 123-124 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Pharmacological and Parenteral Therapies

An older patient is diagnosed with sensorineural hearing loss. The nurse knows that causes of sensorineural hearing loss include: (Select all that apply.) a. tumors of the middle ear. b. cerumen impaction. c. infections of the external and middle ear. d. age-related hearing impairment. e. excessive and loud noise.

ANS: D, E A, B, and C are all associated with conductive hearing loss. Age-related hearing impairment, or presbycusis, is a form of sensorineural hearing loss. Excessive and loud noise can cause noise-induced hearing loss, which is also a common type of sensorineural hearing loss. DIF: Cognitive Level: Remembering REF: p. 144 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance

When a client asks, "What could be causing my triglycerides to be so low; I'm really careful about my diet?" the nurse responds by asking the client: (Select all that apply.) a. "Is your type 2 diabetes well managed?" b. "Have you ever been diagnosed with renal failure?" c. "Do you have a history of pancreatitis?" d. "Are you on medication for hyperthyroidism?" e. "Could you tell me how you are careful about your diet?"

ANS: D, E Abnormally low triglyceride levels are suggestive of malnutrition or hyperthyroidism. Reasons for elevated levels include chronic renal failure and poorly controlled diabetes. Severely elevated triglyceride levels (greater than 2000 mg/dL) are a strong risk factor for pancreatitis. DIF: Cognitive Level: Applying REF: p. 95 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Physiological Adaptation

A patient tells the nurse, "Every time I laugh or cough, I wet myself." Which type of urinary incontinence is this patient describing? a. Urge b. Functional c. Stress d. Mixed

ANS: C Stress incontinence is defined as the loss of a small amount urine with activities that increase intraabdominal pressure such as coughing, sneezing, exercise, lifting, or bending. DIF: Cognitive Level: Applying REF: p. 203, Box 16-1 TOP: Integrated Process: Teaching/Learning MSC: Client Needs: Health Promotion and Maintenance