Exam 1 prep u practice questions (33, 23)
An older adult client comes to the health center reporting difficulty sleeping. Which statement by the client would the nurse need to address? "I find myself napping on and off throughout the day." "I go to bed around 10:30 pm every night." "I try not to be too active once I've eaten dinner." "I don't drink coffee or alcohol."
"I find myself napping on and off throughout the day."
A nurse is conducting an education session about appropriate measures to promote sleep with an older adult who is experiencing frequent awakenings at night and then awakening early in the morning. The nurse determines that the education was successful when the client states: "I need to try and go to bed and get up at the same time each night." "I should avoid coffee, but tea is okay to drink before bed." "I should continue to take my sleep medication for as long as I need to." "I should do some mild exercises about 2 hours before bedtime."
"I need to try and go to bed and get up at the same time each night."
The nurse is teaching a client about good posture when lying down to go to sleep. Which teaching will the nurse include? "Picture yourself with good posture standing; that is how good lying posture works." "Your feet should be at 45-degree angles from the legs." "Keep knees and legs very straight." "Sleep with your head tilted to one side to take pressure off your neck."
"Picture yourself with good posture standing; that is how good lying posture works."
A nurse is teaching an older adult client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following? "Dementia is an acute process and develops suddenly." "Sundowning is a common problem of dementia." "Alzheimer's disease (AD) is a reversible neurologic illness." "Delirium progressively affects cognitive function and is a chronic process."
"Sundowning is a common problem of dementia."
A nurse is teaching an older adult client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following? "Sundowning is a common problem of dementia." "Delirium progressively affects cognitive function and is a chronic process." "Dementia is an acute process and develops suddenly." "Alzheimer's disease (AD) is a reversible neurologic illness."
"Sundowning is a common problem of dementia."
The UAP asks the nurse what hand rolls are used for when providing client care. What is the appropriate nursing response? "To prevent foot drop." "To help client to turn independently." "To preserve the client's functional ability to grasp and pick up objects." "To prevent the legs from rotating outward."
"To preserve the client's functional ability to grasp and pick up objects."
A nurse is preparing a presentation for a group of older adults about promoting safety while maintaining their mobility. Based on the nurse's understanding of factors placing the older adult at risk for falls, which area would the nurse most likely address? Select all that apply. changes in bowel function environmental hazards diminished strength medication use hearing loss
-Environmental hazards -diminished strength -medication use
A nurse is screening for Alzheimer disease (AD) in clients in a long-term care facility. Which facts regarding AD are accurate? Select all that apply. Scientists estimate that more than 5 million people have AD. AD primarily affects young to middle adults. AD is a progressively serious but not a life-threatening disease. AD affects brain cells and is characterized by patchy areas of the brain that degenerate. Nearly half of 85-year-old adults have AD AD accounts for about one-third of the cases of dementia in the United States.
-Scientists estimate that more than 5 million people have AD. -AD affects brain cells and is characterized by patchy areas of the brain that degenerate. -Nearly half of 85-year-old adults have AD.
The nurse provides care for a client who has had a stroke and is at high risk for aspiration. In which position(s) does the nurse place the client to maintain an open airway? Select all that apply. Supine Modified supine Semi-Fowler Fowler Upright
-Semi-fowler -Fowler -Upright
The nurse and an unlicensed assistive personnel (UAP) are transferring a client from a bed onto a stretcher. Prior to the move, where should the nurse position the stretcher? alongside the bed 1 in (2.5 cm) either lower or higher alongside the bed at the same height alongside the bed 2 in (5 cm) lower alongside the bed 2 in (5 cm) higher
Alongside the bed at the same height.
A 79-year-old female is admitted to a long-term care facility. She is incontinent of urine and feces and has impaired cognition. What is the best nursing intervention to prevent skin breakdown for this resident? Insert an indwelling catheter to prevent urine from causing skin breakdown Turn her every hour when in bed Assist her to the toilet every 2 hours and after meals Ask her to call the nurse when she feels the need for elimination
Assist her to the toilet every 2 hours and after meals.
An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition? Delirium Dementia Depression Disorientation
Delirium Rationale: Delirium is a temporary state of confusion that is often precipitated by drug interactions or the effects of new drugs.
A 78-year-old woman is status post right hip fracture after a fall. She has stopped going to her church over the past few months. She has also asked her neighbor to help her and do her gardening, an activity she previously loved. The client tells the nurse "I just don't enjoy gardening like I used to. I am always worried about falling." What would most concern the nurse regarding the client? Generalized anxiety disorder Bipolar disorder Realistic caution Depression
Depression.
Erikson identified ego integrity vs. despair and disgust as the last stage of human development, which begins at about 60 years of age. Which intervention would best foster older clients' ego integrity? Encouraging life review Distracting the client Praising the client Promoting independent living
Encouraging life review
The nurse manager is assessing the unit for proper work ergonomics. Which finding will require immediate intervention by the nurse manager? Equipment is positioned to the side, 50 degrees away. A small dolly is used to transport heavy items. Work is being carried out under sources of non-glare lighting. Chairs have firm back support and allow the feet to touch the floor.
Equipment is positioned to the side, 50 degrees away.
A nurse is caring for an older adult client who has been confined to bed for several weeks following a fall. The client has been exhibiting symptoms of sundowner's syndrome. Which of the following are characteristics of sundowner's syndrome? Feeling agitated and wakeful at night Requiring longer time to fall asleep Awakening more frequently Napping during the daytime
Feeling agitated and wakeful at night.
The middle adult is sometimes called the "sandwich generation". According to Erikson, the developmental task of the middle adult is what? Initiative versus guilt Ego-integrity versus despair Generativity versus stagnation Goal attainment versus crisis
Generativity versus stagnation
A client had a mild stroke with residual left-sided weakness. While teaching the client about walking with the cane, the nurse will offer which instruction? Hold your cane on the right side. You may switch hands with your cane if you become tired. Lean into the cane as it supports you. Hold the cane 6 in (15 cm) in front of you.
Hold your cane on the right side.
A nurse receives an order to apply graduated compression stockings for a client at risk for venous thromboembolism. How should the nurse apply the stockings? Apply the stockings at night when the client is going to bed. If the client was sitting up, have him or her lie down and elevate feet for 15 minutes before applying stockings. Avoid the use of powders on the legs before applying stockings. Apply the stockings after the client has been sitting up for an hour.
If the client was sitting up, have him or her lie down and elevate feet for 15 min before applying stockings
The nurse is reminiscing with a 72-year-old client with early onset dementia while providing care in a long-term care facility. How does the nurse implement this form of therapy to maximize the therapeutic value? Listen to the client's stories and ask questions to facilitate ego integrity and provide companionship. Ask questions about the client's childhood and any unresolved relationship issues that may be preventing the client's peace and acceptance of the aging process. Ask family members to participate in activities that help the client remember important aspects of life and health so he/she can move through the final stages of aging. Encourage the client to talk about special life experiences so discussions regarding death and dying can be easier and can prepare the client for declining health.
Listen to the client's stories and ask questions to facilitate ego integrity and provide companionship.
The nurse practitioner is examining a 55-year-old female client. Which of the following findings would be uncommon for this age group? Agility gradually decreases Presbyopia occurs Menopause occurs Lower extremity pulses are weak
Lower extremity pulses are weak
After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client sit up on the side of the bed? near the client's hip, with legs shoulder width apart and one foot near the head of the bed to the dominant side of the client, with legs together and one foot near the head of the bed to the nondominant side of the client, with legs together and one foot near the head of the bed. near the client's hip, with legs together
Near the client's hip, with legs shoulder width apart and one foot near the head of the bed
A nurse caring for older adults in a long-term care facility is teaching a novice nurse characteristic behaviors of older adults. Which statement is not considered ageism? Intelligence declines with age. Old age begins at age 65. Most older adults are ill and institutionalized. Personality is not changed by chronologic aging.
Personality is not changed by chronologic aging
The nurse is delegating inactive client positioning to a UAP. What directions will the nurse include? using a sheet to drag and lift the client helping the client change positions every 4 hours providing skin care before repositioning placing the client in good alignment with joints slightly flexed
Placing the client in a good alignment with joints slightly flexed.
An 80-year-old client tells the nurse that he has been dizzy since starting to take an herbal remedy for arthritis in addition to prescribed medications. The nurse recognizes that the client may be experiencing the effects of which of the following? Polypharmacy Sleep disorder Fluid volume overload Cascade iatrogenesis
Polypharmacy Explanation:Polypharmacy, the use of many medications at the same time, can pose many hazards for older adults. Alternative therapies, such as herbal remedies, have the potential to interact with prescribed drugs. Fluid volume overload and sleep disorders are not the cause of dizziness. Cascade iatrogenesis is a sequence of adverse events in a frail, older adult
The nurse is caring for a client who has a lower-body injury and who is able to partially assist with transfers. The nurse should: teach the client to pull up with the headboard. provide the client with an overhead trapeze. manually roll the client to the side of the bed. use a pull sheet whenever moving the client.
Provide the client with an overhead trapeze.
The home care nurse is visiting an older adult client in the home to assess a leg wound and change the dressings. The nurse is aware that the client receives money monthly but there is no food in the house, no adequate heat, and the client states, "My sister takes my check and cashes it every month." What is the correct action by the nurse? Tell the client to talk with the sister and have her replace the money she has stolen. Take the client to the local hospital Emergency Department. Report the incident to social service informing them the client has no food or heat. Call the police and tell them to swear a warrant for the arrest of the sister.
Report the incident to social service informing them the client has no food or heat
When working with a client who has a fractured wrist, the nurse applies what knowledge about the bones in the body? Short bones contribute to movement. Flat bones are found in the spinal column. The wrist is classified as an irregular bone. Long bones are relatively thin and contribute to shape.
Short bones contribute to movement.
The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern? joint stiffness after sitting for an hour walking with a slow and uncoordinated movement a change in pulse from 80 to 84 after walking up 20 stairs shortness of breath after walking up five stairs
Shortness of breath after walking up five stairs
The nurse is caring for a client with rectal bleeding. The nurse will place the client into which position to facilitate rectal examination? prone Fowler's supine Sims'
Sim's
There is an 86-year-old female on the medical inpatient unit. She explains that the hospital is quite noisy and that she is having difficulty sleeping. Which is not true regarding sleep in the older adult? Stage 1 sleep increases in the older adult. Chronic cardiovascular or respiratory illness can interfere with sleep. Sleep medications are usually the first choice in treating sleep disturbance. Deep sleep declines in the older adult.
Sleep medications are usually the first choice in treating sleep disturbance.
Based on an understanding of the cognitive changes that normally occur with aging, what might the nurse expect a newly hospitalized older adult to do? withdraw from strangers take longer to respond and react talk rapidly but be confused interrupt with frequent questions
Take longer to respond and react
A nurse is preparing a presentation for a group of older adults about health promotion. Which statistic would the nurse need to keep in mind about this group? The older adult population appears to be younger than in the past. The group experiencing the largest growth is those 85 years of age and older. The number of older adults has begun to plateau since the year 2000. Life expectancy has increased for men but not for women.
The group experiencing the largest growth is those 85 years of age and older.
Using proper body mechanics, which motions would the nurse make to move an object? The nurse uses the muscles of the back to help provide the power needed in strenuous activities. The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling. The nurse directly lifts an object rather than sliding, rolling, pushing, or pulling it, thus reducing the energy needed to lift the weight against the pull of gravity. The nurse balances the head over the shoulders, leans forward, and relaxes the stomach muscles when moving an object.
The nurse uses the internal girdle and a long midriff to stabilize the pelvis and to protect the abdominal viscera when stooping, reaching, lifting, or pulling.
A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as: exploitation. neglect. emotional abuse. abandonment.
abandonment
The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? decrease in flexibility unequal pupil size stumbling gait reports of pain in the lower back
decrease in flexibility
The nurse is performing an assessment of an older adult client. What finding does the nurse document as a normal age-related change? stumbling gait reports of pain in the lower back unequal pupil size decrease in flexibility
decrease in flexibility
A nurse is preparing to medicate an older adult client with an opioid analgesic. Which information will the nurse obtain first to decide about administering the medication? Observing client behavior to determine if coincides with report of pain Obtaining family feedback about client's pain level Taking the clients vital signs to determine if indicative of pain Determining if the client is able to communicate pain verbally or nonverbally
determine if the client is able to communicate pain verbally or nonverbally
The nurse is caring for an older adult client on the medical unit admitted for diagnostic testing. The client is alert and oriented and lives independently. The client was wearing glasses upon admission. Which nursing intervention will be most effective in the prevention of falls for this client? ensuring the client's glasses are close by the bed placing a bed alarm on the bed moving the client to a room close to the nurse's station using a gait belt each time the client ambulates
ensuring the client's glasses are close by the bed
A nurse encourages residents of a long-term care facility to continue a similar pattern of behavior and activity that existed in their middle adulthood years to ensure healthy aging. This intervention is based on which aging theory? Disengagement theory Identity-continuity theory Life review theory Activity theory
identity-continuity theory
The nurse observes an older adult client walking with knees slightly flexed and body leaning. What does the nurse identify the client is demonstrating? should have an orthopedic consultation. requires crutches for mobility. requires a better walking shoe. is demonstrating a common gait for the older adult.
is demonstrating a common gait for the older adult
As a part of his workout regimen, a 21-year-old college football player often engages in both a 10-minute squat hold and 10-minute lateral arm hold. These are examples of what type of exercise? isotonic aerobic isometric anaerobic
isometric
A nurse is interviewing a client about the client's usual activity level. The client states, "I swim laps 2 to 3 times a week and walk 1 to 2 miles twice a week. The nurse interprets this activity as which type of exercise? isokinetic isotonic range-of-motion isometric
isotonic
A nurse is working with a client who has a history of lung disease and arthritis to develop an exercise program. The nurse instructs the client to take which action before beginning the program? choose a specific single-exercise activity understand that the activity will have positive benefits. obtain a pre-exercise medical examination for clearance pick an activity the client enjoys to promote adherence
obtain a pre-exercise medical examination for clearance.
A nurse caring for older adults in a long-term care facility is teaching a novice nurse characteristic behaviors of older adults. Which statement is not considered ageism? Most older adults are ill and institutionalized. Old age begins at age 65. Intelligence declines with age. Personality is not changed by chronologic aging.
personality is not changed by chronologic aging.
A 74-year-old client has kyphosis and is reporting discomfort of the cervical vertebrate. Which nursing intervention is most appropriate? positioning the client on the stomach contacting the primary care physician placing a small towel under the neck administering a muscle relaxer
placing a small towel under the neck
The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk? increased metabolic rate increase in circulating fibrinolysin predisposition to renal calculi increase in the movement of secretions in the respiratory tract
predisposition to renal calculi
In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client? Social isolation Sleep deprivation Noncompliance Grieving
sleep deprivation
The nurse wishes to keep a client from sliding down toward the foot of the bed. Into which position will the nurse place the client? slight Trendelenburg prone supine Sims'
slight trendelenburg
A nurse has attended an inservice workshop that addressed the phenomenon of ageism in the health care system. Which of the following practices is indicative of ageism? Assessing the skin turgor of an older adult differently than that of a younger adult Speaking to older adults with the presumption that they have mild cognitive deficits Implementing falls prevention measures in a setting where older adults receive care Providing slightly smaller servings of food for clients who are older adults
speaking to older adults with the presumption that they have mild cognitive deficits
