study

A recently widowed 80-year-old man has been admitted to a long-term care facility for complaints of anorexia, loss of energy, and loss of sleep. The nurse learns that the patient is recently widowed. Prioritize the nursing actions that might be needed for this patient. (Separate letters by a comma and a space as follows: A, B, C, D.) a. Provide a quiet environment. b. Involve him in some activity. c. Be alert to suicidal tendencies. d. Spend time with the patient at mealtime.

ANS: C, B, D, A The nurse must be alert to suicidal ideation or tendencies and assess for their effect on the resident. Involving the resident in some activity can generate socialization and reduce depressive thoughts. Spending time with the patient allows for assessment of his ideation as well as giving evidence of his worth. Provision of a quiet environment is restful for all residents, but is of low priority for a suicidal person.

An 85-year-old has been increasingly confused and disoriented to place and time over the last several months. He also has difficulty remembering what he ate, who visited, and where the recreation room is. This behavior is indicative of ________________.

ANS: dementia Confusion, memory loss, and disordered thinking are early signs of dementia. Causes of dementia include malnutrition, medications, mini strokes, and Alzheimer disease.

The nurse clarifies that the diagnosis of nocturnal delirium refers to a syndrome also called _______________.

ANS: sundowning Sundowning is a syndrome in which confusion and agitation increases with the evening hours.

The nurse reminds the patient that the member of the surgical team who is responsible for obtaining the surgical consent is the ____________.

ANS: surgeon The surgeon is the person responsible for obtaining an informed surgical consent.

The factors involved in assessing the importance the patient attaches to the relief of a particular deficit include: a. needs that the nurse must assess to prioritize care, because they may be different from person to person. b. ordering needs according to Maslow's hierarchy, with lower level needs being least compelling. c. needs based on a hierarchy in which higher level needs are more prominent and demand attention before lower level needs. d. needs that are usually not known to the patient and that must be determined by the nurse.

ANS: A A person's concern relative to a needs deficit must be assessed by the nurse to meet the needs of each patient. Needs are viewed differently from one person to the next.

A 78-year-old man is admitted to the hospital after a fall from his bed at home that resulted in a fractured hip and several fractured ribs. He states, "I don't know how I broke so many bones. I only fell out of bed." The nurse can explain that: a. loss of calcium from bone occurs in older adults and can result in fractures from minor trauma. b. it is likely that an underlying disease made him more susceptible to fractures. c. the bedside table near the bed added to his injuries. d. the height of the bed will need to be lowered when he goes home to prevent further injuries.

ANS: A A physiological change of aging is loss of calcium from bone, resulting in osteoporosis and greater likelihood of fractures.

The nurse clarifies to a patient who now has an abscess following a ruptured appendix that the abscess is considered to be: a. a secondary illness. b. a life-threatening complication. c. an expected event following any surgery. d. a disorder easily treated with antibiotics.

ANS: A A secondary illness is an illness that arises from a primary disorder.

Following a colonoscopy with polyp removal, the wife of the patient is distressed that there is slight bleeding from her husband's rectum. The nurse's most helpful response would be: a. "This small amount of bleeding is expected after the removal of polyps." b. "I will notify the primary care provider about this hemorrhage." c. "I will watch your husband very carefully to assess any further hemorrhage." d. "Don't worry. This small amount of blood happens with these procedures."

ANS: A A small amount of bleeding following a colonoscopy with polyp removal is to be expected. The family should be prepared for the slight bleeding.

While completing the preoperative checklist, a patient who is almost ready for transport to the operating room states that he does not want to remove his wedding band. The nurse should: a. tape it in place on his finger. b. remind him it must be removed, and lock it in the narcotic cabinet. c. ask a family member to take care of it. d. inform him that the hospital cannot be responsible for its loss.

ANS: A A wedding band may be worn to surgery, but it must be taped to the finger in a manner that does not restrict circulation.

The patient in hospice care says to the hospice nurse, "I want you to read my obituary that I just wrote." The nurse assesses that this patient is in the Satir Blevins (2008) stage of: a. practice. b. chaos. c. integration. d. acceptance.

ANS: A According to the Satir Blevins theory of loss (2008), this patient is in the phase of practice. The patient is practicing with the writing of the obituary the fact that life is coming to an end.

The nurse assesses successful adaptation in a post stroke patient when the patient: a. learns to walk and maintain balance with the aid of a walker. b. consistently takes antihypertensive drugs. c. attempts to get out of bed unassisted. d. refuses assistance with feeding.

ANS: A Adaptation is a readjustment in habits to limitations and disabilities. Learning to walk and maintain balance with the aid of a walker is an example of this.

A nursing instructor is educating a group of nursing students about cultural values practiced by Arab Americans. The nursing instructor would recognize the need for further patient education if a nursing student states, "I will: a. offer Arab American patient's items using my left hand." b. make sure all females are cared for by females." c. refrain from sitting with the sole of my shoe visible." d. refrain from offering Arab American patient's pork."

ANS: A Arab Americans do not eat pork or drink alcohol. It is considered rude to pass things with the left hand because it is considered "unclean." It is considered rude to sit with the sole of the shoe within view of someone. Arab women are uncomfortable with care performed by males.

A nurse using active listening techniques would: a. use nonverbal cues such as leaning forward, focusing on the speaker's face, and slightly nodding to indicate that the message has been heard. b. avoid the use of eye contact to allow the patient to express herself without feeling stared at or demeaned. c. anticipate what the speaker is trying to say and help the patient express herself when she has difficulty with finishing a sentence. d. ask probing questions to direct the conversation and obtain the information needed as efficiently as possible.

ANS: A Eye contact is a culturally learned behavior and in some cases may not be appropriate. Probing questions or finishing the patient's sentence is not part of active listening and is detrimental to an interview.

A 76-year-old neighbor confides to the nurse that she is having to get up in the middle of the night to void and often wets herself before she can get to the bathroom during the day. The nurse's best explanation would be: a. "As you get older, your bladder muscle loses tone and you can hold less urine." b. "You are probably drinking too much during the day and especially before bedtime." c. "You probably have a bladder infection that should be treated with antibiotics." d. "With age, the urine becomes very concentrated and causes the bladder to empty spontaneously."

ANS: A Physiological changes of aging include decreased bladder and sphincter tone, resulting in stress incontinence and more frequent voiding.

When the nurse in a long-term facility observes a resident bringing his reading material very close to his face, the nurse assesses that the patient is experiencing: a. presbyopia. b. myopia. c. presbycusis. d. cataracts.

ANS: A Presbyopia is caused by decreased flexibility of the eye lens. This makes near vision more difficult and leads to the need for reading glasses.

The family of a patient with Alzheimer disease indicates that they want to keep the patient at home but are not sure how much longer they can care for the patient because of stress on family members. A helpful suggestion by the home health nurse would be to: a. consider use of respite services. b. face the reality of need for long-term care. c. encourage the hiring of a full time caregiver. d. encourage family counseling.

ANS: A Respite care or adult day services can provide for much needed psychological and physical rest for caregivers.

The behavior in a depressed older adult patient that would indicate that this patient is contemplating suicide is: a. giving away personal belongings. b. watching television in the activity room. c. talking with other patients. d. spending time sitting near the nurses' station.

ANS: A Signs of potential suicide include giving away treasured possessions, meticulous planning of personal affairs, sudden euphoria, and statements of death wishes. The other options do not indicate behaviors that warn of a possible upcoming suicide attempt.

A nurse clarifies that methods of tertiary prevention are designed for: a. rehabilitation. b. delay of the development of a disorder. c. screening for early detection of disease. d. using an established protocol of therapy for a specific disease.

ANS: A Tertiary prevention consists of rehabilitation measures after the disease or disorder has stabilized. Latent prevention does not exist.

A patient with newly diagnosed cancer states, "I can't stand to think about chemo." What is the most therapeutic response? a. "What about chemo concerns you?" b. "Chemo is so much better than it used to be." c. "Wow! I can sure understand that!" d. "Have you had chemo before?"

ANS: A The open-ended query invites further discussion about the patient's concerns. The other options reinforce the patient's concerns, give false reassurance, or offer a closed query.

A dying patient says, "There is no God. There is no afterlife. When it's over, it's over." What is the most therapeutic response? a. "You must feel very lonely." b. "Of course there is a God, and He loves you very much." c. "Why do you think there is no God?" d. "You are absolutely right. I think that, too."

ANS: A Verbalizing the implied helps the patient talk about present concerns. Other options either reinforce or cut off communication by imposing the nurse's beliefs.

The nurse clarifies that the immune system failure theory states that: a. older adults lose their ability to effectively respond to infections and are more likely to die from them. b. the body no longer recognizes itself and begins to attack itself, causing illness. c. toxins and harmful chemicals (free radicals) in the environment cause damage to body cells. d. the diminished activity of older adults make them susceptible to illness.

ANS: A With advancing age, the immune system of older adults has less ability to fight infections.

The nurse describes behaviors of the transition stage of illness, which are: (Select all that apply.) a. awareness of vague symptoms. b. denial of feeling ill. c. resorts to self-medication. d. withdrawal from roles and responsibilities. e. recovery from illness begins.

ANS: A, B, C The transition stage (onset) of illness is demonstrated by the patient's awareness of vague symptoms, denial of feeling ill, and initiation of self-medication; however, he or she still fulfills the roles and responsibilities of life.

The culturally competent nurse is aware that the American Indian medicine techniques are very significant to the patient. This medical intervention involves: (Select all that apply.) a. healing ceremonies. b. rituals performed by highly trained medicine people. c. burning of sweet grass. d. purging with minerals. e. drums to align the patient's heart with Mother Earth.

ANS: A, B, C, E The American Indian medicine techniques involve many specific ceremonies and rituals performed by highly trained medicine people. The burning of herbs, shaking rattles, and drumming realigns the patient with Mother Earth.

The nurse instructs a family of an 87-year-old resident in a long-term care facility that his nocturnal delirium is most likely caused by: (Select all that apply.) a. his schedule changing as a result of recent admission to the facility. b. lack of adequate medication for anxiety. c. increased shadows of the evening hours. d. dehydration. e. food allergy.

ANS: A, C, D Nocturnal delirium is a disorder about which little is known. It is believed that among its many possible causes, the most prominent are fatigue, low lighting, increased shadows of the evening hours, disruption in the body clock, and dehydration.

The nurse discusses the grief theory of Maciejewski, which outlines the stages of grief as including: (Select all that apply.) a. yearning. b. bargaining. c. anger. d. denial. e. depression.

ANS: A, C, D, E The grief theory of Maciejewski states that the loss is accepted, but followed by denial, yearning, anger, depression, and acceptance.

The nurse is aware that the older adults of today face some functional psychosocial issues, which include: (Select all that apply.) a. altered mobility. b. becoming crime victims. c. housing. d. making provision for physical care. e. cognitive impairments.

ANS: A, D, E Altered mobility, making provisions for physical care, and dealing with cognitive impairments are functional issues the older adult must resolve. Housing and crime are external issues.

The nurse assesses a terminal illness in: a. a 76-year-old admitted to a nursing home with Alzheimer disease who is pacing and asking to go home. b. a 43-year-old with Lou Gehrig's disease who is refusing food and fluid. c. a 2-year-old child who burned her esophagus by drinking drain cleaner and who is being fed by a tube. d. a 52-year-old diagnosed with lung cancer who had part of one lung removed and has a closed chest drainage device in place.

ANS: B A terminal illness is defined as one in which a person will live only a few months, weeks, or days. A person who refuses food and hydration will generally not live more than a few days.

Which syndrome includes the alarm reaction stage, resistance stage, and exhaustion stage? a. Local adaptation syndrome b. General adaptation syndrome c. Total adaptation syndrome d. Absolute adaptation syndrome

ANS: B After the initial alarm stage (of the general adaptation syndrome), the body stabilizes and physiologic processes return to normal levels. This is followed by the resistance stage. If the stressor lasts too long, the individual may enter the third stage of adaptation, which is exhaustion.

To begin talking with a newly admitted patient about pain management, the nurse would most appropriately state: a. "You look pretty comfortable. Are you having any pain?" b. "Tell me about the pain you've been having." c. "Is this pain the same as the pain you had yesterday?" d. "Don't worry; this pain won't last forever."

ANS: B An open-ended question allows the patient to express his or her feelings or needs.

A patient has been admitted with a diagnosis of confusion. The physician's admission note states that he wants to assess for delirium versus dementia. What should the nurse be aware that the main differences include? a. Whereas delirium usually lasts several years, dementia lasts only a few days. b. Whereas delirium usually has sudden onset and is reversible, dementia is chronic and irreversible. c. Whereas dementia is usually caused by medications, delirium is not. d. Whereas dementia is easily treated with reality orientation, delirium is not.

ANS: B Delirium is a short-term, confusional state that has a sudden onset and is typically reversible. Dementia is a syndrome that is often chronic and irreversible.

The nurse clarifies to a family of a resident with Alzheimer disease that dementia differs from confusion and delirium in that dementia is: a. usually rapid in onset. b. permanent. c. caused by depression. d. effectively treatable.

ANS: B Dementia is generally a permanent condition characterized by cognitive deficits with a slow onset. It is primarily seen in Alzheimer disease patients but also occurs in persons with brain tumors.

The nurse uses a diagram to demonstrate how Dunn's theory of health and illness can be compared with a: a. plant that grows from a seed, blossoms, wilts, and dies. b. continuum, with peak wellness and death at opposite ends; the person moves back and forth in a dynamic state of change. c. ladder; from birth to death the individual moves progressively downward a ladder to eventual death. d. state of mind dependent on the individual perception of their own health or illness.

ANS: B Dunn's theory of a health continuum shows how an individual moves between peak wellness and death in a constant process.

The nurse seeks out residents with whom they reminisce in an interview regarding the resident's life story. The value of this activity is that: a. it gives the staff more time to care for other residents and perform routine care. b. it can affirm the positives of the resident's life and lead to ego integrity for the resident. c. nursing home residents have long days to pass, and any activity helps the time pass more quickly. d. students learn about the "good old days" and better appreciate the modern conveniences available today. .

ANS: B Erikson's psychosocial task for older adults is ego integrity, which can be assisted by life review and reminiscence

A nurse is gathering information from the family of a patient who is experiencing confusion. What important question should the nurse ask the family? a. "Are you sure she is confused? Maybe she just didn't hear what you were saying." b. "When did you first think she might be confused? Tell me exactly what happened." c. "Did something bad happen to her during her childhood?" d. "How can you say she is confused? She knows who she is."

ANS: B Family members may be able to provide helpful information when the patient cannot. The nurse should ask when the symptoms of confusion started and whether the confusion is constant or intermittent.

A patient is near death and the family is upset and disorganized. The most helpful intervention for the patient and the family would be for the nurse to: a. ask the family the name of their mortician. b. offer to call the spiritual advisor (eg, priest, minister, or rabbi). c. encourage the family to perform their rituals. d. encourage the family to visit the chapel.

ANS: B If death is anticipated, many people derive significant comfort from spiritual or religious beliefs or practices

When the patient says, "I can die happily if I can live long enough to see my first grandchild that will be born next month." The nurse assesses that this patient is experiencing Kübler Ross's stage of: a. denial. b. bargaining. c. anger. d. depression.

ANS: B Kübler Ross's stages of coping with death include the bargaining stage in which the person seeks the reward of extended life.

The nurse understands that the best explanation of why a particular person lives into his 90s in relatively good health is that the person: a. had healthy parents who passed on to him "good" genes and no hereditary diseases. b. has lived a healthful lifestyle, which has included preventative care, good nutrition, exercise, and a positive outlook. c. has treated illness with "old-fashioned" home remedies while avoiding the use of many prescription drugs. d. reads a lot about the newest advances in health care and tries these approaches as soon as they are publicized.

ANS: B Lifestyle and personality together probably contribute to longevity more than genetics, new medical approaches, or old-fashioned home remedies, although those may contribute in important ways. A healthy lifestyle decreases the risk of disease and its sequelae.

A patient returning from surgery complains of incisional pain that is now rated 7 in intensity on the 1-to-10 pain scale. What should the nurse be aware that pain exemplifies? a. General adaptation syndrome b. Local adaptation syndrome c. Counter-current response d. Neuroendocrine response

ANS: B Local adaptation syndrome is a short-term, local response to a specific stressor. Examples include pain, blood clotting, and wound healing.

What is the best example of normal memory change or lapse of memory? a. Relying on another person to remember names or important events b. Occasional forgetfulness or inability to recall names or facts c. Difficulty in recalling recent events d. Difficulty in recalling past events

ANS: B Memory lapses such as forgetting a name or misplacing an item are common, normal memory changes.

A blind, older adult patient is admitted to the acute care facility for dehydration and weakness. The nurse can make the admission process less stressful by: a. sending all personal belongings home with family members. b. performing the initial assessment in a nonhurried manner. c. providing a printed orientation handout regarding acute care facility policy. d. performing a quick assessment before orienting the patient to the unit.

ANS: B Older adult patients need time and support in adjusting to an acute care facility stay. An unhurried manner will show support and give the patient a little more time to adjust to the change.

The nurse is aware that a stressor as experienced by an individual is usually perceived: a. as a negative event or stimulus that affects homeostasis in maladaptive ways. b. in different ways based on previous experience and personality traits. c. as an opportunity for growth and learning. d. in similar ways if age and education are similar.

ANS: B Stressors are not perceived the same way by different people or even by the same person at different times. The experience of a stressor depends on previous experience and personality, as well as factors such as physical or emotional conditions, age, and education.

What are the adaptations to interventions that the Cognitive Developmental Approach (CDA) to caring for patients with dementia designed to achieve? a. Increase cognitive abilities. b. Adapt environment to patient. c. Offer a wide variety of choices. d. Abolish irrational fears.

ANS: B The CDA adapts implementations based on the patient's cognitive abilities as they are, modifies the environment, and offers limited choices.

When a patient in the ambulatory clinic is diagnosed as having pneumococcal pneumonia, the nurse is aware that this infection: a. is viral and will not respond to antibiotics. b. is bacterial and should respond to treatment with antibiotics. c. is fungal and is caused by the alteration of the normal flora of the lung. d. is resultant from a resistant organism and extreme caution must be taken.

ANS: B The coccal suffix indicates a bacterial infection with round cocci, which are bacteria that usually respond to antibiotic therapy.

What should a nurse assess when a patient comes from an extended family? a. Multiple wage earners b. Three generations living together c. Children from previous marriages d. Parents of different ethnic origins

ANS: B The extended family consists of relatives of either spouse who live with the nuclear family. Children, regardless of their parentage, are considered part of the nuclear family.

The nurse is caring for an anxious patient who is scheduled for surgery for colostomy placement. While the nurse is talking to the patient, the patient states, "I am so scared." The nurse's most supportive response would be: a. "Surgeries like yours are very safe." b. "What about your colostomy scares you?" c. "Why are you scared?" d. "Sounds like someone has been telling you horror stories."

ANS: B The nurse needs to address the patient's anxiety and fear first by use of open-ended questioning, because the patient might be focused on a variety of things, including poor body image or the prospect of death. Asking a "Why" question is not therapeutic and makes the patient defensive.

The nurse preparing a patient for a magnetic resonance imaging (MRI) should determine if the patient has: a. respiratory allergies. b. claustrophobia. c. fear of the dark. d. dizziness.

ANS: B The patient with claustrophobia can be reassured that there are methods to contact persons outside the cylinder.

The nurse explains that range of motion exercises are necessary so that movement improves venous circulation by: a. vasodilation. b. compression of muscles on venous walls. c. increased metabolism. d. maintaining strength in muscles.

ANS: B The range of motion exercises mimic normal muscle movement, which compresses the venous walls as a support to venous circulation.

A patient is being discharged from same-day surgery after a tonsillectomy. The nurse is aware that the patient will be in the phase of general adaptation syndrome, in which the body begins to heal after injury. Which stage is this considered? a. Alarm stage b. Resistance stage c. Exhaustion stage d. Initial stage

ANS: B The resistance stage is characterized by adapting to the stressor. If the stressor can be overcome or repaired, as in a short-term illness or injury, the body begins to heal.

The nurse takes into consideration that in the stage of resistance in Selye's GAS, the patient: a. regresses to a dependent state. b. continues to battle for equilibrium. c. becomes maladaptive. d. begins to develop stress-related disorders.

ANS: B The resistance stage is the second stage in the GAS when a patient is still attempting to find equilibrium.

When the patient says, "I don't want to go home," the nurse's best therapeutic verbal response would be: a. "I'm sure everything will be fine once you get home." b. "You don't want to go home?" c. "Doesn't your family want you to come home?" d. "I felt like that when I had surgery last year."

ANS: B The use of reflecting encourages the patient to expand on his or her feelings or thoughts.

A patient undergoing preadmission testing before same day surgery asks how long he will remain in the recovery area before being allowed to go home. The nurse's most informative response would be: a. 30 to 60 minutes. b. 2 to 6 hours. c. 5 to 6 hours. d. 6 to 8 hours.

ANS: B The usual recovery time in a same day surgery recovery area is 2 to 6 hours.

The nurse would question a new order for a tricyclic antidepressant for a patient who has had a recent: a. peptic ulcer. b. myocardial infarct. c. abdominal surgery. d. diagnosis of diabetes.

ANS: B Tricyclics are contraindicated in patients with recent myocardial infarctions because these drugs may cause cardiac arrhythmias.

The home health nurse counsels the family of a cognitively impaired man that to best provide for his welfare, the family should: (Select all that apply.) a. rearrange furniture and art to stimulate him. b. use concise and direct communication. c. enroll him in an Older Adult Activity Program. d. monitor nutrition for adequacy. e. install a door alarm that sounds when it is opened.

ANS: B, C, D, E Using direct communication enhances the impaired person's perception. Making the environment safe by installing an alarm and providing for socialization and adequate nutrition are also part of the principles of the care of the cognitively impaired.

The nursing care plan in a long-term care facility calls for the documentation of regressive behavior of a newly admitted 82-year-old resident who has had congestive heart failure and osteoarthritis. Of these behaviors observed by the nurse, which should be documented as regression? (Select all that apply.) a. Talks nonstop to staff and other residents b. Wets and soils self several times a day c. Wakes in the middle of the night and is unable to return to sleep d. Wears the same clothes day after day e. Cries frequently for no apparent reason

ANS: B, D, E Behaviors that are infantile or immature in the absence of dementia are considered regressive. Frequent episodes of crying and inattention to personal hygiene are regressive in nature. Excessive talking and wakefulness may be related to relocation anxiety, but they are not considered regressive.

When a patient becomes violent and hits a table with his cane, the initial appropriate nursing approach is to: a. medicate the patient to help control his anxiety. b. call for assistance to apply restraints. c. attempt to distract the patient. d. direct the patient in a loud authoritarian voice to sit down.

ANS: C A behavioral approach such as distraction might diffuse the situation until the cause can be determined. Chemical restraint (medication) or a restrictive restraint should not be the first intervention. Loud voices frequently increase the violent behavior.

A nurse making a home visit to a 75-year-old woman discovers that the patient stays in bed or on the couch most of the time because she is afraid of falling. The nurse should arrange for: a. a sitter to stay with the woman during the day. b. a wheelchair to increase mobility. c. a physical therapist to teach resistance training. d. a special cushion for the chair and bed to reduce the risk of decubiti.

ANS: C A physical therapist can teach resistance and balance training to help prevent falls

A patient with delirium repeatedly cries out for her husband. What is the most appropriate initial nursing intervention? a. Administer Haldol as ordered. b. Apply restraints so that the patient will not harm herself. c. Calmly tell the patient that she is in the hospital and that her husband is not there. d. Call the husband and tell him that he needs to come and stay with his wife.

ANS: C Anyone dealing with a delirious patient should be calm, warm, and reassuring. Frequent orientation to the surroundings and situation is important as well.

A patient is scheduled to have biofeedback therapy for migraine headaches. On arrival to the clinic, the patient appears anxious and fearful and tells the nurse that she does not want electric shocks. The most reassuring response by the nurse is: a. "Don't worry; this will not hurt a bit." b. "Didn't the doctor explain this procedure to you?" c. "There are no electrical shocks involved; the doctor is looking at your body's activity." d. "You seem too anxious for this procedure. Let's reschedule it at another time."

ANS: C Biofeedback involves applying electrodes to the body to look at the internal activity, so that the patient can gain control of involuntary activity.

The LPN/LVN filling out the Jewish patient's dietary menu for lunch would avoid ordering: a. meat and fish. b. milk and vegetables. c. meat and milk. d. vegetables and fruit.

ANS: C Common food practices in Judaism include not eating meat and milk at the same meal.

An older adult American Indian patient has been admitted to the hospital with abdominal pain. Along with performing a physical assessment, the nurse should also perform a: a. psychological history. b. financial history. c. cultural assessment. d. literacy assessment.

ANS: C Cultural assessment should be done to determine the cultural preferences and health beliefs to better understand how illness is affecting a patient's life.

A home health nurse working with an older adult patient assesses an early indication that this patient is developing Alzheimer disease. This early indication would be: a. wandering behavior. b. agitation. c. difficulty learning new things. d. deteriorating speech.

ANS: C Early signs of Alzheimer disease are mild short-term memory loss, difficulty learning new things, and mild depression.

A family member tells a hospitalized older adult patient to cooperate better with the treatment plan or placement in a long-term care facility will result. The nurse recognizes this statement is consistent with ___________ elder abuse. a. physical b. material c. psychological d. neglect

ANS: C Elder abuse can be inflicted physically, verbally, or emotionally.

When the nurse is conducting a class for senior citizens at a local assisted living facility, to enhance physical health, he encourages the older residents to engage in some form of exercise for at least: a. 1 hour every other day. b. 10 minutes at a time several times a day. c. 30 minutes a day, five times a week. d. 1 hour every morning.

ANS: C Exercise for as little as 30 minutes a day 5 days a week is beneficial.

When assisting a patient with a severe visual impairment who wishes to feed himself, the nurse could best facilitate the patient's eating by: a. placing the plate on his lap. b. seating the patient in a chair and placing over-the-bed table appropriately. c. orienting the patient to the position of foods on the plate using a clock face description. d. placing each food in a separate container or bowl.

ANS: C It is best to orient a visually impaired patient to the position of the foods on the plate by describing the plate as if it is a clock face (3 o'clock, 6 o'clock, and so on).

A nurse says to a patient, "I am going to take your TPR, and then I'll check to see whether you can have a PRN analgesic." In considering factors that affect communication, the nurse has: a. used terminology to clearly inform the patient of what she is doing. b. given information that is unnecessary for the patient to know. c. used medical jargon, which might not be understood by the patient. d. taken into consideration the patient's need to know what is happening.

ANS: C Medical jargon such as abbreviations or medical terminology is often misunderstood, even by well educated people.

The nurse points out that there are many myths about older adults that are not true. The statement that reflects the most accuracy about older adults is: a. most old people live in nursing homes. b. genetics is the main factor in longevity. c. the optimistic, happy person generally lives longer. d. most old people are isolated from their families.

ANS: C Myths about old people include: most old people live in nursing homes, genetics is the main factor in longevity, and most old people are isolated from their families. It is true that a major contributor to longer life is that the optimistic, happy person generally lives longer.

The nurse is aware that in order to provide effective support to grieving patients and families, the nurse must: a. keep a professional distance from the situation. b. understand all the theories of grief. c. solidify his or her own view of death. d. stay positive and optimistic at all times.

ANS: C Nurses must understand and solidify their own view of death before they can offer effective support to dying patients and their significant others. Constant optimism and positive attitudes are not always appropriate.

The nurse believes that patient teaching of how to give insulin and monitor blood glucose levels will improve the level of the patient's: a. physiological well-being. b. security, by providing psychological comfort. c. self-esteem, by promoting independence and learning. d. self-actualization, by seeking knowledge and truth.

ANS: C Patient education activities that are to be used after discharge enhance independence and promote self- esteem.

The nurse caring for a terminally ill patient with renal failure would question an order for pain control that prescribed: a. methadone. b. oxycodone. c. meperidine. d. morphine.

ANS: C Patients in renal failure cannot adequately clear meperidine (Demerol) from their system and will become oversedated.

The nurse is delivering a meal tray to a patient in a skilled nursing facility who is a Muslim. The nurse should confirm the meal is free of: a. raw fruits. b. eggplant. c. pork. d. lamb.

ANS: C People of the Muslim faith are prohibited from eating pork.

The patient inquires about how his body will kill pathogens unassisted by antibiotics. The nurse responds that a process called phagocytosis will: a. stimulate the body to make more white blood cells. b. create antibodies against the pathogen. c. engulf and destroy the pathogen. d. stimulate the production of interferons.

ANS: C Phagocytes that are stored in the GI tract, liver, and spleen kill pathogens by engulfing and destroying the invaders and cleaning up the debris.

A nurse is instructing a patient about relaxation techniques for pain management. The patient should: a. keep bright lights on in the room. b. use this technique as a way to wake up in the morning. c. tense and relax individual muscle groups, starting with the toes and feet. d. try to tense and relax all of the muscles of the body at the same time.

ANS: C Relaxation involves alternately tensing and relaxing the toes and feet, then working upward through the leg, the abdomen, the chest, the arms, and finally, the neck and head.

In order to minimize the risk of aspiration in a resident with advanced Alzheimer disease, the person feeding the patient should: a. keep a suction machine available. b. have the patient consume only liquids. c. remind the patient to chew and swallow. d. offer large amounts of water after each bite.

ANS: C Reminding the demented patient to chew and swallow will help prevent the resident from holding food in his mouth.

When the nurse plans to use reminiscence as a psychosocial approach to managing confusion with cognitively impaired patients, the nurse should: a. use plants, pictures, and animals to encourage interactions in the group. b. use memory aids such as television, radio, clock, and calendar. c. encourage individual and group sharing of information about previous life experiences. d. increase socialization roles in the group, such as serving each other refreshments.

ANS: C Reminiscence involves individual and group sharing about previous life experiences.

When a 68-year-old recent retiree confides in the health clinic nurse that he has felt depressed and withdrawn since retirement, the nurse suggests that he: a. talk with the primary care provider about antidepression medication. b. arrange his day so that he is able to take a nap in the afternoon. c. set a small goal for himself to be met every day. d. eat three regular meals as he did when he was employed.

ANS: C Setting a small goal to be met allows for direction in the day. Many recent retirees miss the regulation of employment.

An 82-year-old man is alert and oriented and in good physical health except for some arthritic pain that "slows me down, but I just keep moving." He lives alone in an apartment in a senior citizen complex but enjoys the company of other residents and takes part in the social activities there. His lifestyle is an example of: a. an exception to the expected norm. b. the disengagement theory. c. the activity theory. d. the biological theory.

ANS: C The activity theory states that persons who remain active and interested in outside activities live longer.

A nurse gives the example of when an individual becomes frightened and experiences an increased heart rate and mental activity along with increased blood flow to the skeletal muscles and dilated pupils. The person is experiencing an alarm reaction that helps the body defend against stressors. What type of response is the alarm reaction considered? a. Positive feedback response b. Negative feedback response c. Fight-or-flight response d. Homeostasis response

ANS: C The alarm reaction causes the body to respond to stress physiologically. Hormone levels, heart rate, cardiac output, respiratory rate, oxygen intake, and mental energy are increased, and the pupils dilate. These reactions together are called the fight-or-flight response.

What initial nursing action should be implemented when assisting a patient with dementia to dress? a. Hand the patient her clothes and ask her to put them on. b. Hand the patient each article of clothing separately and ask her to put it on. c. Assist her with each article, giving specific instructions such as, "Put your arm in this hole." d. Put the patient's clothes on without assistance from the patient.

ANS: C The goal should be to maintain the highest level of functioning possible, but tasks must be broken down into individual steps to be performed one at a time.

An elderly Hispanic male was admitted with a severe headache and is anxious. The patient tells the nurse that he was given the mal de ojo. The culturally competent nurse understands that mal de ojo means that the patient believes that he: a. has a blockage in the intestine from the influence of Susto. b. has an opposition in polarities problem because of the effect of empacho. c. was given the evil eye, which is thought to cause weeping and headache. d. has had a separation of the soul from the body. .

ANS: C The mal de ojo literally means "the evil eye" cast from someone, which can bring fear, irritability, headache, and weeping

The nurse explains to the patient who has pneumococcal pneumonia that the lungs serve as the: a. mode of transfer. b. transmission of the disease. c. reservoir. d. organisms that cause the infection.

ANS: C The reservoir is the place where the organism is found, such as a wound or, in this case, the infected lungs. Droplets are modes of transmission from the reservoir.

A nurse is assessing a patient for the possibility of confusion. What two major types of confusion should the nurse be aware of to appropriately assess this patient? a. Acute and chronic senility b. Temporary and permanent confusion c. Delirium and dementia d. Senility and senile dementia

ANS: C The two major types of confusion are acute confusional states, or delirium, and chronic confusion dementia.

A patient will be started on furosemide (Lasix). The primary care provider has also ordered potassium chloride (KCl) 40 mEq. There is a bottle of KCl labeled 45 mEq per 15 mL. How many milliliters should the patient receive? a. 10.8 mL b. 12.6 mL c. 13.3 mL d. 14 mL

ANS: C Using the drug problem formula "desired over on hand" (D/H), divide 40 by 45 and multiply by 15, which equals 13.3 mL (ie, 40/45 = 0.88 ́ 15 = 13.33).

The nurse assesses that a person is in the acceptance stage of illness when the patient: a. looks to home remedies to become well. b. reassumes usual responsibilities and roles. c. assumes the "sick" role. d. rejects medical treatment.

ANS: C When a person enters the acceptance stage of illness, he or she assumes the "sick role" and withdraws from usual responsibilities and will frequently seek medical treatment at this time.

While a nurse is dressing a patient who has dementia as a result of Huntington disease, the patient states, "I don't want to wear clothes today" and begins to resist help putting on her clothes. What is the nurse's most appropriate action? a. Tell the patient that she must wear clothes or she cannot see her family later. b. Get another nurse to help her force the patient to get dressed. c. Talk to the patient about her family coming this afternoon and continue to assist the patient gently with dressing. d. Let the patient go without clothes but make her stay in her room.

ANS: C When patients with dementia resist activities such as bathing or dressing, avoiding confrontations and diverting their attention elsewhere are best.

An 82-year-old patient expresses concern of always being cold. Based on knowledge of the physical changes associated with aging, the nurse could appropriately respond: (Select all that apply.) a. "Wrap up warmly, because the cold feeling is a result of decreased bone calcium that occurs with aging." b. "Chronic constipation can lead to a sense of cold because of the reduced peristalsis." c. "Subcutaneous fat is reduced as part of aging. This fat helps to keep you warm decreases." d. "A low level of thyroid hormone causes you to feel cold." e. "Eat more protein foods to help your body generate heat."

ANS: C, D Decreased subcutaneous fat and slowed thyroid production contribute to older people feeling cold.

The home health nurse assesses an 80-year-old who has fallen twice in the last 10 days. The nurse discovers that the patient uses a cane for ambulation stability, drinks up to 6 cups of coffee a day, has altered depth perception because of cataracts, and has recently carpeted her home with a smooth tight weave carpet. The nurse suspects the cause of her recent falls to be: a. the use of the cane. b. the new carpet. c. the large intake of caffeine. d. the altered depth perception.

ANS: D Altered depth perception, changes in gait, and slow reaction times may cause falls in older adults. The cane helps with stability, and the smooth tight weave carpet should not cause falls.

For the nurse to provide support to families of patients who have died, it is most important to: a. have an understanding that all people deal with death in due time. b. read a number of articles about death and dying. c. have a personal experience of a similar nature. d. deal with personal feelings about death and dying.

ANS: D Before someone can be a support person to someone who has lost a loved one, he or she must have dealt with personal feelings about death.

A nurse is caring for an 86-year-old patient who still takes pride in the fact that he drives. The nurse suggests that his driving be limited to: a. back roads. b. large shopping centers. c. going to church and the grocery store. d. daytime driving.

ANS: D Daytime driving is the safest in areas that are familiar. Back roads may be hard to navigate and help may not always be available.

An important factor to consider when assessing the hygiene needs of a patient is that: a. the patient knows best what is needed in his hygiene routine. b. the routine of the agency will determine when the patient is able to bathe. c. hygiene is not as important as other needs of the patient. d. the patient may not have the same hygiene practices as the nurse.

ANS: D Different cultures have different views of hygiene practices, such as use of deodorant, shaving, or daily bathing. These needs are an important part of health and recovery from illness.

Before integrating humor in the care of an Asian patient, the nurse should: a. develop jokes about the patient's condition. b. develop jokes about the doctors and nurses. c. ask the patient whether jokes are understood. d. ask the patient's feelings about hearing a joke or funny story.

ANS: D Humor and laughter are used at the bedside to distract patients from pain, and they have a positive effect on the body. However, it is important to check with the patient first to find out whether it might be considered disrespectful.

A female patient of Asian descent was admitted to the medical-surgical unit with possible lung cancer. A male nurse is preparing to perform a physical assessment. It is best for the male nurse to: a. ask the family members to leave the room to ensure patient privacy. b. perform the procedure accurately and quickly to lessen patient anxiety. c. examine only the affected body systems to decrease patient discomfort. d. ask the patient for permission to perform the assessment before starting.

ANS: D Many cultures do not permit the touching of a female by a male outside of the family; the male nurse should ask for permission before touching her.

A Hispanic patient approaches the Asian nurse and, standing very close, touches the nurse's shoulder during their conversation. The nurse begins to step back to 18 to 24 inches, while smiling and nodding to the patient. This situation is most likely an example of: a. the nurse's need to maintain a professional role rather than a social role. b. a patient's attempt to keep the nurse's attention. c. a nurse's need to establish a more appropriate location for conversation. d. a difference in culturally learned personal space of the nurse and the patient.

ANS: D Personal space between people is a culturally learned behavior; Asians, North American natives, and Northern European people generally prefer more personal space than people of Hispanic, Southern European, or Middle Eastern cultures.

A patient experiencing pain states that guided imagery has made the pain more manageable in the past. To assist this patient, the nurse should: a. find a focal point in the room. b. bring a newspaper or deck of cards according to patient choice. c. obtain skin lotion and a towel to give a back rub. d. read from a script that helps the patient visualize a restful place.

ANS: D Persons who have difficulty with imagery can be assisted by someone reading a script to help a patient mentally travel to a favorite spot that is relaxing, soothing, or peaceful.

Included in Maslow's hierarchy, physiological needs are those that: a. nurture intimacy. b. foster independence. c. encourage social interaction. d. protect from harm.

ANS: D Physiological needs are those that are essential to human life, such as oxygenation, nutrition, and elimination. Protection from physical harm, from a nursing standpoint, is often equivalent in importance to physical needs.

The family of a retired army veteran diagnosed with Alzheimer disease is concerned about obtaining care for the patient while away on vacation. The home health nurse informs the family that the Department of Veterans Affairs offers in facility care for patients with dementia for up to: a. 10 days a year. b. 15 days a year. c. 20 days a year. d. 30 days a year.

ANS: D The Department of Veterans Affairs offers in facility care for demented patients who are veterans for up to 30 days a year.

The nurse in a long-term care facility emphasizes to the family of a resident recently admitted that one of the purposes of the creative behavioral therapies is to: a. entertain the residents who have become bored. b. stimulate an avid interest in music or art. c. keep the residents out of their rooms. d. slow the rate of deterioration.

ANS: D The creative behavioral therapies of art, music, dancing, and humor are designed to delay the deterioration of the resident.

When a new admission to an extended care facility wanders about listlessly, eats only a small amount of each meal, and keeps himself isolated, the nurse can intervene by: a. assisting with feeding at each meal. b. reminding him that he is in a safe and secure area. c. socializing with him in the privacy of his room. d. supporting him to interact with an exercise group.

ANS: D The membership and social interaction in a group may provide a means for a sense of belonging

A nurse clarifies that a neuroendocrine response involves both the autonomic nervous system and the endocrine system. Which syndrome is this considered? a. Local adaptation b. Total adaptation c. Acute adaptation d. General adaptation

ANS: D The neuroendocrine response primarily involves the autonomic nervous and endocrine systems and is considered part of the general adaptation syndrome, which is physiologic and affects the entire body.

A depressed older adult patient was started on antidepressant drug therapy 3 weeks ago. The highest nursing priority when working with this patient at this time would be: a. stimulating appetite. b. providing reality orientation. c. encouraging socialization. d. protecting the patient from self-injury.

ANS: D The primary nursing responsibility for a depressed patient is to protect him from self-injury, especially after the patient has been started on antidepressant therapy. Before that time, the patient may not have had the energy to commit self-injury.

An 85-year-old widow who lives alone has fallen several times in the last month and has been noted by her children to be confused about her medications and to frequently "forget" what is cooking on the stove until it is burned. These observations indicate that: a. she needs to be hospitalized to determine the cause of her confusion and falls. b. home delivery of a hot meal every day would solve her cooking risk. c. nursing home placement would be the best solution to her problems of aging. d. further assessment is needed to evaluate an increased level of assistance.

ANS: D The widow is showing signs of needing additional assistance. It might include home delivered meals or nursing home placement, but further assessment needs to be performed. Acute care hospitalization is not indicated in this situation.