Geri Nclex: FINAL

Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions? Select all that apply. One, some, or all responses may be correct. 1 Area rugs on the floor 2 Clogged, dirty fireplace 3. Multiple electrical cords 4 Multiple prescribed medications 5 Wheeled walker with uneven leg

All are correct

What is the best resource (of those listed below) for identifying information regarding an older adult's current functional ability? A. Psychological tests and related exams B. Diagnostic x-rays and lab tests C. Family members who visit occasionally and call weekly D. Neighbor who visits daily and helps the person to the store weekly.

D. Neighbor who visits daily and helps the person to the store weekly.

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.

a. Assess for soiled clothing and change, if necessary.

The registered nurse (RN) is giving home care instructions to a client who was treated for injuries due to a fall. Which statement made by the client indicates a need for additional instruction? 1 "I should walk on soft scatter rugs at home." 2 "I should drink 3000 mL of water every day." 3 "I should eat fruits and vegetables six times a day." 4 "I should exercise the joints above and below the cast daily."

"I should walk on soft scatter rugs at home."

One of the most significant changes that impact the elderly person and his or her family is: 1. Loss of independence 2. Change in physical appearance 3. Decrease of financial resources 4. Sensory and cognitive decline

1. Loss of independence

Myths relating to aging include that most elderly: (select all that apply) 1. Live in instutional settings 2. Suffer from a significant loss of intellectualfunction 3. Have frequent interaction with family and friends 4. Experience significant personality changes 5. Are seriously depressed 6. Are sick, frail and depent on others

1, 2, 4, 5, and 6

When assessing an alert for an elderly woman who was admitted to the emergency room accompanied by her daughter with whom she resides, the nurse would become suspicious of abuse if: (select all that apply) 1. Bruises are observed on the arms and upper body 2. The daughter answers all the questions for her mother 3. She has body odor and soiled clothes 4. The woman states she does not like seeing the doctor 5. The daughter states her mother does not get along with the grandchildren 6. Skin in intact with good turgor

1, 2, and 3

A student nurse observes caregivers in a long-term care facility where she is employed. Which of the following observations might indicate abusive behavior? (Select all that apply) 1. Failing to close bedside curtains during care activities 2. Use of physical restraints to decrease wandering behavior 3. Providing extra snacks for good behavior 4. Laughing and talking with co-workers while providing care 5. Speaking negatively about an elderly client while in the break room 6. Responding slowly to the call light of a demanding elderly person

1, 2, and 6

The nurse is aware that the best predictor of an elderly person falling is: 1. A history of pervious falls 2. Use of multiple medications 3. Sensory deficits 4. Alterations in balance

1. A history of pervious falls

Durable power of attorney for health care enables the health care agent to: 1. Decide whether the elderly person should be resuscitated 2. Act only when the elderly person is unable to act for herself or himself 3. Determine when the elderly person should be hospitalized 4. Change care decisions if he or she thinks these will benefit the elderly person

2. Act only when the elderly person is unable to act for herself or himself

The leading cause of injury and preventable source of mortality and morbidity in older adults is 1. presbycusis. 2. car accidents. 3. pneumonia. 4. falls.

4. Falls

The leading cause of injury and preventable source of mortality and morbidity in older adults is: 1. presbycusis. 2. car accidents. 3. pneumonia. 4. falls.

4. Falls

In addition to aging, which of the following may contribute to hearing loss in the older adult? (Select all that apply.) A) Exposure to loud noises B) Recurrent otitis media and trauma C)Excessive hair in the ear D) Certain medications E) Diabetes

A) Exposure to loud noises B) Recurrent otitis media and trauma C) Certain medications E) Diabetes

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

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.

Which attempt by the family to prevent an older, frail adult from falling causes the home health nurse concern? a. Keeping several low wattage night-lights on in the evening b. Installing wooden railings on the stairway to the bathroom c. Keeping the side rails up on the client's bed at night d. Encouraging the client to use a cane when ambulating

ANS: C

When a cognitively impaired, wealthy, white client is noted to have burns on her upper back, her son states that the patient burned herself when attempting to shower. Which statement by a member of the team reflects a need for further education on elder abuse? (Select all that apply.) a. "She is wealthy; abuse does not happen in people of financial means." b. "Even if we are not sure, we are legally bound to report our suspicions." c. "We need to consider that most abusers are either adult children or spouses." d. "Her cognitive deficiencies put her at risk for elder abuse." e. "The client is white and race places an important role in who is likely to be abused."

A, E

A nurse is caring for a frail older adult in a long-term care facility and is concerned about preventing hypothermia. Which of the following interventions should the nurse implement? (Select all that apply.) a. Make sure that the temperature in the resident's room is at least 65 degrees Fahrenheit. b. Cover residents well when in bed and while bathing. c. Provide a head covering for the resident. d. Maintain resident in bed covered with heavy blankets at all times. e. Provide hot, high-protein meals and bedtime snacks.

A, b, c, e

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

A,B,C

What is the initial nursing intervention in preventing polypharmacy? A. Obtain a thorough medication history. B. Discontinue all herbal preparations. C. Refer the patient to a geriatric practitioner. D. Consult a pharmacist to review all medications.

A. Obtain a thorough medication history

An elderly patient has acute confusion after undergoing abdominal surgery. The patient most likely has: A. delirium. B. anxiety. C. dementia. D. depression

A. delirium.

A 75-year-old female asks a nurse "I know I should be moving, but how much is the right amount of exercise for me?" The best response of the nurse is: a. "You need to engage in 30 minutes of moderate intensity exercise on at least 5 days a week." b. "You need to engage in at least 30 minutes of moderate intensity exercise every day of the week." c. "Since you are 75, the recommendations are 30 minutes of moderate exercise three times a week." d. "There are no specific recommendations for someone of your age; just keep moving."

ANS: A

A frail, elderly widow is admitted to the hospital after sustaining a fall. The client lives alone and has no living relatives. After cognitive testing reveals mild cognitive impairment, the interdisciplinary team on the Acute Care for the Elderly Unit recommends long-term care placement and that a durable power of attorney for health care (DPOA-HC) be established. When the client seems confused over what a DPOA-HC's responsibilities are, the nurse responds that: a. "A DPOA-HC is a person you name to make health care decisions for you when you can't make them for yourself." b. "A DPOA-HC is a person you trust to make financial decisions for you and to manage your money." c. "A DPOA-HC is a person appointed by the court to make sure you get good care and to manage your affairs." d. "A DPOA-HC is a person who is appointed by the court to make nursing home placement decisions for your care."

ANS: A

A nurse at a senior center promotes activity by leading exercise programs. Which of the following is a benefit of such exercise? a. Improvement of mood b. Cardiovascular stress c. Painful and stiff joints d. Depression

ANS: A

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

A nurse is assessing an older adult's risk for falls. One of the questions that she asks is whether the older adult has fallen in the past year. She asks this because individuals who have fallen: a. have a higher risk of falling again than persons who did not fall in the past year. b. are more likely to sustain injuries if they fall again than persons who did not fall in the past year. c. have most likely developed a fear of falling as compared to persons who did not fall in the past year. d. are most likely to have a balance disorder as compared to persons who did not fall in the past year.

ANS: A

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

An 88-year-old woman is admitted to the hospital with a diagnosis of pneumonia. She has a history of hypertension and congestive heart failure and is on a total of five different medications for these chronic conditions. The nurse caring for the woman develops a care plan that includes the diagnosis Risk for Falls. A priority nursing intervention for this client is to: a. perform a fall assessment. b. keep all of the side rails up on the client's bed at nighttime. c. place the client on bed rest so that she does not fall. d. assess the client's dietary intake for calcium adequacy.

ANS: A

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

An older client admitted to the hospital after having sustained a fall at home is diagnosed with a right hip fracture and experienced a surgical reduction of the fracture. At 2:30 AM, she awakens from sleep insisting that her daughter is in the other room and wants to see her. Attempts to reorient her to the surroundings are unsuccessful. In reviewing the client's record, what data would be considered a primary risk factor for the delirium? a. History of dementia b. Death of the client's husband last month c. The client's age d. History of cardiac disease

ANS: A

The area in which nurses have the greatest effect on the safe, effective medication therapy of an older client is: a. educating the client to all aspects of the medication. b. assessing for adverse reactions to the medication. c. monitoring overall health of the client as it is affected by the medication. d. evaluating the outcomes resulting from the medication.

ANS: A

The nurse is caring for an older client who experienced a hip replacement surgery 10 hours ago. Which intervention will help minimize this client's risk of developing delirium? a. Requesting that staff offer fluids each time they interact with the client b. Medicating the client to best facilitate restorative sleep c. Encouraging the client to remain still and thus minimize pain d. Suggesting that visitors are limited to family members only

ANS: A

What factor is an important contribution to polypharmacy in older adults? a. Inadequate communication among medical care providers b. Implementation of Medicare Part D prescription drug benefit c. Use of generic medications d. Increasing popularity of dietary and herbal supplements

ANS: A

The nursing assessment of an 80-year-old patient who demonstrates some confusion but no anxiety reveals that the patient is a fall risk because she continues to get out of bed without help despite frequent reminders. The initial nursing intervention to prevent falls for this patient is to: A. Place a bed alarm device on the bed. B. Place the patient in a belt restraint. C. Provide one-on-one observation of the patient. D. Apply wrist restraints.

ANS: A Place a bed alarm device on the bed.

A nurse working in an emergency department is caring for an 89-year-old woman who was brought to the hospital by her daughter for a fracture of the right arm. The woman is wheelchair dependent and lives with her widowed daughter who is the primary caregiver. The daughter states that her mother got up out of the wheelchair unassisted to go to the bathroom and fell. The patient cannot recall the circumstances of the fall. The patient is weeping and cradling her right arm. The patient's history reveals two previous wrist fractures over the course of the past year. The nurse notes several large ecchymotic areas on the right hand and left arm and on the left side of the body and the back. The ecchymoses are in various stages of healing. Upon assessment, the patient is non-weight-bearing (NWB). The nurse suspects physical abuse based on which of the following findings? (Select all that apply.) a. Bruises are in various stages of healing. b. The fracture is inconsistent with the patient's functional ability. c. Caregiver suffering stress from caring for a functionally-dependent individual. d. Patient is crying. e. Patient has a history of previous wrist fractures.

ANS: A, B

A nurse is preparing education for a group of older adults and caregivers at a senior center on elder abuse. The nurse is preparing to discuss seniors who are more likely to be abused or neglected. The nurse includes which of the following? (Select all that apply.) a. Individuals with cognitive impairment b. Individuals who abused the caregiver earlier in life c. Individuals who live in an institutional setting d. Individuals who are married and living with a spouse e. Men living alone or in a household with family members

ANS: A, B, C

Which assessment finding is a contributor to an older client's risk for falls? (Select all that apply.) a. Client is awaiting cataract surgery on right eye. b. Client's type 2 diabetes is poorly controlled with diet and exercise alone. c. Client reports a fall in the last year. d. Client has a history of contact dermatitis and psoriasis. e. Client attends Tai Chi classes at the senior center.

ANS: A, B, C

A couple who is caring for their aging parents are concerned about factors that put them at risk for falls. Which factors are most likely to contribute to an increase in falls in the elderly? (Select all that apply.) A. Inadequate lighting B. Throw rugs C. Multiple medications D. Doorway thresholds E. Cords covered by carpets F. Staircases with handrails

ANS: A, B, C, D, E

Which intervention to manage wandering in clients in a long-term care facility should be implemented? (Select all that apply.) a. Camouflaging doorways b. Close observation to identify the person's individual patterns c. Engaging the person in social interactions d. Using physical restraints to prevent wandering to maintain safety e. Providing enclosed pathways for walking

ANS: A, B, C, E

The benefits of telehealth include that it: (Select all that apply.) a. promotes self-management of illness in rural and underserved areas. b. facilitates remote physical assessment and monitoring of chronic conditions. c. decreases costs by replacing the role of the nurse with technology. d. decreases costs by reducing hospital readmissions. e. is reimbursed by all health care insurances.

ANS: A, B, D

Which precaution would be beneficial in minimizing an older adult's risk of being a victim of fraud? (Select all that apply.) a. Do not allow uninvited salespersons into your home. b. Never provide personal information to telephone sales solicitors. c. Rely on the advice of people who only friends have recommended. d. Contact the local Medicare or Medicaid service office for information when needed. e. Keep your bank account and credit card numbers with you at all times.

ANS: A, B, D

A group of older women in an assisted living facility are talking about one of the residents who fell and fractured her hip. The women ask a nurse the following: "It seems like so many of us fall and break our hips, and then it is downhill from there. Is this really true?" In formulating a response, the nurse considers which of the following? (Select all that apply.) a. Hip fractures are a leading cause of hospitalization for older people. b. The major cause of hip fractures is falls. c. Women have significantly higher mortality rates from hip fractures than do men. d. Nearly all older patients who sustain a hip fracture will regain prefracture mobility status within 1 year. e. Hip fractures are associated with very high morbidity and mortality.

ANS: A, B, E

An older adult is referred to a geriatric nurse practitioner because of changes in memory and reports by family members that "there is something different about her." The nurse practitioner evaluates the older adult for potentially reversible causes for the changes, which include: (Select all that apply.) a. depression. b. delirium. c. osteoporosis. d. rheumatoid arthritis. e. medication side effects.

ANS: A, B, E

What information should be included in an informational program to be presented on burn prevention to a senior citizens group? (Select all that apply.) a. Do not smoke in bed or when sleepy b. Wear well-fitted clothing when cooking or when grilling outdoors c. Establish a meeting place for all family members outside of the home in case of a fire d. Establish a plan for exiting each room of your home in the case of a fire e. Have a fire extinguisher readily available in the kitchen

ANS: A, B, E

Differences in the presentation of patients with Alzheimer's Disease (AD) and Lewy bodies (LB) are: (Select all that apply.) a. individuals with LB develop motor symptoms, and individuals with AD do not. b. individuals with AD display impairments in judgment whereas individuals with LB do not. c. the use of traditional antipsychotic medication is contraindicated for individuals with LB. d. LB usually occurs in individuals under age 60, and AD occurs in individuals only over age 60. e. individuals with LB develop language symptoms, and individuals with AD do not.

ANS: A, C

A home health nurse is making a home visit to an older patient. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. Which of the following are hazards in the home? (Select all that apply.) a. The absence of railings on the stairway b. Night-lights in all rooms c. Clutter throughout the home d. A small throw rug outside of the shower stall e. Grab bars in bathroom beside toilet

ANS: A, C, D

An older adult is diagnosed with Alzheimer's Disease. The nurse knows that this diagnosis is made on the presence of which of the following? (Select all that apply.) a. A decline from a previous level of functioning b. Fluctuation of symptoms over the course of a 24-hour period c. An insidious onset d. A gradual decline in cognitive abilities e. The cognitive changes worsen in the evening hours

ANS: A, C, D

A nurse is caring for a 92-year-old female patient who was admitted to the hospital 1 day after she had outpatient cataract surgery. The patient who lives in an assisted living facility became very confused and agitated and was found wandering in the lobby of the building in her nightgown. She refused to return to her room and stated that there were "bad men" in her room. The patient has a history of dementia, diabetes, heart failure, and is on seven different medications. She was widowed 1 year ago. The nurse suspects that she has delirium. What are the patient's risk factors for delirium? (Select all that apply.) a. Age of 92 b. Residing in an assisted living facility c. History of dementia d. Female gender e. Recent cataract surgery

ANS: A, C, E

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

A nurse is admitting and orienting an older adult to the hospital unit. She discusses fall prevention and demonstrates the use of the call bell to the patient. The patient's daughter asks: "Why don't you just put up all the side rails to prevent my mother from getting out of bed by herself and falling. That should work, right?" The best response by the nurse is: a. "Side rails have only proven to be effective in decreasing falls in patients who have already fallen." b. "There is no evidence that side rail use decreases falls, and in fact there is a greater risk of injury." c. "Side rails are only effective when used with patients who have dementia." d. "Side rails do not decrease falls, but they do decrease fall-related injuries."

ANS: B

A nurse measures an older adult's blood pressure on the right arm and notes a reading of 150/100. The nurse waits 5 minutes and measures the blood pressure again in the right arm and obtains a reading of 152/100. What is the next action by the nurse? a. Immediately contact the medical provider. b. Measure the blood pressure in the left arm. c. Measure the blood pressure in sitting and standing positions. d. Document the findings in the medical record; elevated blood pressures are normal in older adults.

ANS: B

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

The Beers Criteria is an effective tool for health care professionals prescribing and/or managing the medication therapy of older adults since it identifies medications that for this population: a. are not typically covered by drug benefit plans. b. have a higher than usual risk for injury. c. are likely to be abused. d. generally cause allergic reactions.

ANS: B

The nurse is preparing educational material concerning fire safety in the home. What research data will be included in the material? a. Most fires occur during the daytime hours. b. Fire mortality is highest in adults older than 80 years of age. c. Most people who die in fires are killed by the flames. d. Most fires occur outside the home.

ANS: B

The nurse is providing care to a client diagnosed with dementia. What option is an example of the appropriate use of implied consent by the nurse? a. Preparing to draw blood from a client's arm after asking, "Can I see your arm?" b. Changing the client's dressing when the client asks, "Will you change this bandage now?" c. Using the client's monthly allowance to buy a watch when he continuously asks for the time d. Arranging for a benign mole to be removed after the client states, "I don't like this here."

ANS: B

The nurse is recommending that a client diagnosed with moderate stage Alzheimer's disease attend a support group when he becomes defensive about not driving his automobile and the effects it will have on "being stuck at home." Which is the priority outcome expected for this client when attending the group sessions? a. Facilitates socialization thus minimizing the effects of social isolation b. Helps with minimizing the loss as a factor in causing depression c. Provides caregivers with respite while assuring the client is well attended to d. Allows for the opportunity for a mental health professional to assess the client

ANS: B

A nurse is caring for a patient with a diagnosis of delirium. Which of the following is an expected assessment finding for this patient? a. Normal attention span b. Fluctuation in symptoms c. Normal sleep cycle d. Increased appetite

ANS: B A hallmark of delirium is fluctuation in symptoms. Patients with delirium typically have decreased attention spans and an altered sleep-wake cycle. Classic symptoms of delirium do not involve changes in appetite; however, patients often have a decreased appetite.

The daughter of an older patient says to a nurse, "I am so concerned that my dad is still driving. He is dangerous! He has had a couple of accidents and I am worried that he is going to kill himself or, worse, somebody else. What can I do?" The nurse recommends which of the following involved type action strategies for driving cessation? (Select all that apply.) a. Report the person to the division of motor vehicles for license suspension. b. Hold a family meeting with the person to discuss the situation and come to a mutual agreement of the problem. c. Arrange for alternate transportation for the person. d. Confiscate the keys to the car. e. Ask the patient's physician to write a prescription for the person to stop driving.

ANS: B, C

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

An antihypertensive medication has been prescribed for an older patient with hypertension. The patient tells a clinic nurse that he would like to take an herbal substance to help lower his blood pressure instead of the prescription medication. Which of the following should the nurse do? (Select all that apply.) a. Tell the patient that herbal substances are less effective than prescription medications b. Encourage the patient to discuss the use of an herbal substance with his primary care provider c. Explore with the patient which herbal substance he is planning on taking d. Educate the patient on possible interactions of the herbal substance with his other medications e. Instruct the patient not to take the herbal substance, as it is dangerous

ANS: B, C, D

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

A homecare nurse visits a client in the home to conduct a fall risk assessment. The nurse assesses the client and the home for extrinsic risk factors for falls. Which of the following are extrinsic risk factors? (Select all that apply.) a. The client has an unsteady gait. b. The client uses a cane, but the cane is not the appropriate size for the client. c. The client's home is cluttered. d. The client is on two different medications that cause orthostatic hypotension. e. There are no grab bars in the client's bathroom.

ANS: B, C, E

A nurse is educating a group of older adults on the benefits of an exercise program. The nurse includes education on when not to exercise. Which of the following should the nurse include in the education? (Select all that apply.) a. Do not exercise if your resting heart rate is over 80 b. Do not exercise if your blood pressure is greater than 200 systolic and 100 diastolic c. It is important to wait 30 minutes after a big meal before engaging in vigorous exercise d. Do not exercise if a joint that you are using to exercise is red, warm, and painful e. Do not exercise if you have a fever and muscle aches

ANS: B, D, E

A nurse suspects elder mistreatment in which of the following patients seen in the emergency department? (Select all that apply.) a. An 85-year-old male with cardiac disease who is taking blood thinners and has multiple bruises on his arms and hands b. An 86-year-old female nursing home resident admitted to the hospital with vaginal bleeding and three large bruises on her inner thigh c. A 77-year-old woman who fell at home and broke her arm after tripping over her cat d. A 73-year-old man with a history of gastric ulcers who is vomiting blood and found to be anemic and has a low BMI e. A 69-year-old man with a history of diabetes who is admitted for diabetic foot ulcers wearing dirty clothing and smells like urine

ANS: B, E

A nurse suspects that her next-door neighbor, an older woman, is a victim of elder abuse by her daughter. What is the appropriate action for the nurse to do in this situation? a. Because the neighbor is not a patient, the nurse should not get involved. b. Visit the neighbor frequently to confirm the suspicions. c. Complete a confidential report with the adult protective services in the area. d. Ask the neighbor herself if she is being abused.

ANS: C

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 performing the initial assessment on a new client in a geriatric outpatients practice, the most effective method the nurse can implement to elicit an accurate medication assessment is to ask that the client: a. make a list of all her current medications. b. work with a family member to make a list of her medications. c. bring in all of the medications that she is currently taking. d. allow her previous primary care provider to provide a list of medications.

ANS: C

Which of the following statements made by a family caregiver would a nurse consider most indicative of elder abuse? a. "I get so frustrated because my father used to be so competent and now cannot even feed himself." b. "Mom cannot pay her own bills anymore. We went to the bank and arranged for me to have access to her checking account and help her pay the bills." c. "My dad wanders at night and I can't be bothered with him. I mix sleeping pills in his dinner so that he will fall asleep." d. "Mom asks me to do everything for her, but I think it is better if she keeps on doing as much as she is capable of."

ANS: C

A patient on prolonged bed rest is at an increased risk to develop this common complication of immobility if preventive measures are not taken: A. Myoclonus B. Pathological fractures C. Pressure ulcers D. Pruritus

ANS: C Immobility is a major risk factor for pressure ulcers. Any break in the integrity of the skin is difficult to heal. Preventing a pressure ulcer is much less expensive than treating one; therefore preventive nursing interventions are imperative.

Which of the following are physiological outcomes of immobility? A. Increased metabolism B. Reduced cardiac workload C. Decreased lung expansion D. Decreased oxygen demand

ANS: C Physiologic outcomes of immobility include decreased metabolism, increased cardiac workload, decreased lung expansion, and increased oxygen demand.

A homecare nurse visits an older female adult at home who has peripheral vascular disease to monitor her status. The nurse determines that the client needs additional teaching when the client states which of the following? (Select all that apply.) a. "I need to try and elevate my legs above the level of my heart every time I sit down and all night." b. "I really need to try and avoid sitting in one position for a long period of time." c. "I know that I need to wear these compression stockings 24 hours a day." d. "I will wash my feet and legs with strong antibacterial soap twice daily." e. "I need to examine my feet daily for any cuts, sores, or openings."

ANS: C, D

A homecare nurse visits an older female adult at home who has peripheral vascular disease to monitor her status. The nurse determines that the client needs additional teaching when the client states which of the following? (Select all that apply.) a. "I need to try and elevate my legs above the level of my heart every time I sit down and all night." b. "I really need to try and avoid sitting in one position for a long period of time." c. "I know that I need to wear these compression stockings 24 hours a day." d. "I will wash my feet and legs with strong antibacterial soap twice daily." e. "I need to examine my feet daily for any cuts, sores, or openings."

ANS: C, D

The family of a patient who is confused and ambulatory insists that all four side rails be up when the patient is alone. What is the best action to take in this situation? (Select all that apply.) A. Contact the nursing supervisor. B. Restrict the family's visiting privileges. C. Ask the family to stay with the patient if possible. D. Inform the family of the risks associated with side-rail use. E. Thank the family for being conscientious and put the four rails up. F. Discuss alternatives that are appropriate for this patient with the family.

ANS: C, D, F

A home health nurse is making a home visit to an older patient. A nurse conducts a home safety assessment and screens the environment for potential hazards for falls. The nurse recommends that the patient eliminate which of the following? (Select all that apply.) a. Night-lights b. Railings on the stairway c. Loose carpeting on the floors d. The use of a cane e. Excess clutter

ANS: C, E

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

Which option is an example of elder exploitation? a. A homebound client is left alone for days at a time by the caregiver. b. An older client is smacked if he doesn't eat all of his food. c. A client diagnosed with Alzheimer's disease is bathed only twice a month. d. A homebound client can only get groceries by agreeing to pay for her neighbor's groceries, too.

ANS: D

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

__________ is the intentional infliction of physical or emotional discomfort or the deprivation of basic needs necessary for comfort or survival.

Abuse

Myth regarding older adult population in the US... The nurse is aware that the majority of older adults are?

Active and involved in their own community

The home health nurse is instructing the family of an elderly client about safety precautions that should be taken in the bathroom. Which information should the nurse provide? Select All That Apply. 1.Use raised toilet seats. 2.Set up grab bars in the shower. 3.Purchase a sturdy shower chair for the client. 4.Place a throw rug on the floor to dry wet feet. 5.Install a fixed shower head on the wall for the client.

Answer: 1, 2, 3

An 82-year-old client is admitted with a fractured hip from a fall at home. The initial assessment reveals that the client is incontinent at times, suffers from dizziness when standing, and is on multiple medications. Which is the primary safety risk for this client? 1.Infection 2.Falls 3.Violence 4.Poisoning

Answer: 2

The nurse is caring for an unsteady client who keeps getting out of his or her chair due to confusion. What is the best intervention for this client? 1.Keep the client in bed with the side rails up. 2.Place a chair alarm under the client's chair. 3.Apply restraints to the client to keep the client in place. 4.Provide the client with some distraction activities.

Answer: 2

Which is an effective nursing intervention for preventing falls? 1.Requiring family to remain with the client 2.Use of bed alarms 3.Application of restraints 4.Administration of sedation

Answer: 2

The nurse in a long-term care facility is caring for a 70-year-old client who has a history of type 2 diabetes mellitus, hypertension, and Parkinson disease. The client takes antihypertensive medications, insulin, and carbodopa/levodopa. The client has functional incontinence due to a shuffling gait and uses a wheeled walker for ambulation. Which factors place the client at risk for falls? Select All That Apply. 1.Insulin injections 2.Parkinson disease 3.Wheeled walker use 4.Functional incontinence 5.Type 2 diabetes mellitus 6.Antihypertensive medications

Answer: 2, 3, 4, 6

Which nursing interventions are important for the home health nurse to perform to promote safety when caring for elderly clients? Select All That Apply. 1.Removing throw rugs 2.Moving electrical cords 3.Changing positions slowly 4.Using visual and hearing aids 5.Taking pain medication prior to movement

Answers: 1, 2, 3, 4

When do you do fall assessments?

At Admission With any changes Annually

A 79-year-old client resides independently in the community. The visiting home health nurse finds that despite it being 90 degrees Fahrenheit outside, the windows are closed and the client is wearing a sweater. The nurse initially recognizes that this behavior may be related to: a. cognitive changes that diminish the individual's awareness of temperature changes. b. age-related neurosensory changes that diminish awareness of temperature changes. c. a delirium-related acute illness that is affecting body heat production. d. age-related motor deficiencies that result in self-neglect.

B

The nurse includes interventions to improve impaired physical activity in the plan of care for the older resident. Which of the following interventions should the nurse include? (Select all that apply.) A) Develop an exercise program that promotes maximum heart rate. B) Encourage family to assist in efforts to increase the patient's mobility. C) Include passive range of motion (PROM) in plan. D) Promote a nutritional intake of calcium and protein. E) Provide diversional activities based on the patient's interests and level of function.

B D E

An older client is diagnosed with venous insufficiency of the lower extremities. The nurse expects the client to display which of the following signs and symptoms? (Select all that apply.) a. Thin, shiny dry skin b. Reddish brown discoloration of the skin of the legs c. Pain when the legs are elevated d. Varicose veins e. Legs are cool to touch

B, D

Which mental change is associated with aging? A. Confusion B. Gradual decline in cognitive skills C. Depression D. Inappropriate behavior

B. Gradual decline in cognitive skills

Which statement is true regarding falls in the elderly? A. Most falls occur in the garage. B. Hip fractures resulting from falls are a leading cause of placement in long-term care facilities. C. Fall risk decreases with addition of medications. D. Sedatives reduce the risk of falls.

B. Hip fractures resulting from falls are a leading cause of placement in long-term care facilities.

An elderly patient who experiences nighttime confusion wanders from his room into the room of another patient. Which intervention will best decrease this patient's nighttime confusion? A. Administering a sedative at the hour of sleep B. Leaving a night-light on during the evening and night shifts C. Assigning a nursing assistant to sit with him until he falls asleep D. Allowing the patient to share a room with another elderly patient

B. Leaving a night-light on during the evening and night shifts

A 76-year-old adult female is brought to a neighborhood client after being found wandering around the local park. The client appears disheveled and reports being hungry. Which of the following assessment and interview findings would cause the nurse to suspect elder abuse? (Select all that apply.) A. Falls asleep in the examination room B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healing

B. Repeatedly states, "Don't hurt me." C. Chafing around wrists and ankles D. Bruises in various stages of healing

A patient with dementia wanders throughout the skilled nursing facility. A nursing intervention for wandering may include: A. administering a sedative. B. maintaining a regular activity program. C. locking the patient's room from the outside. D. keeping a staff member with the patient when wandering

B. maintaining a regular activity program.

A nurse plans for the discharge of a 75-year-old patient who has the diagnosis of osteoporosis. Which of these actions would the nurse consider first? a. Avoid stressful situations. b. Schedule an annual DXA/DEXA scan. c. Remove clutter from the floors of the home. d. Encourage consumption of a high-protein diet.

C

What should the nurse include in the teaching plan for self-medication practices of older adults? A. Eliminate unnecessary medications. B. Substitute herbal preparations for certain prescribed medications. C. Develop a drug reminder system and schedule. D. Pharmacy shop for the cheapest medications.

C. Develop a drug reminder system and schedule.

When a fall results in injury and hospitalization, a cycle of disuse may occur over time. When establishing a care plan for the patient and family to prevent this, it is important to remember disuse is most likely a result of: A. Decreasing muscle strength. B. Decreased joint mobility. C. Fear of repeated falls. D. Changes in sensory perception.

C. Fear of repeated falls.

Appropriate nursing care for a patient with urinary incontinence is to: A. insert an indwelling Foley catheter. B. order oxybutynin chloride (Ditropan). C. encourage fluids to decrease the urine concentration so it is less irritating. D. recommend herbal approaches to reduce incontinence.

C. encourage fluids to decrease the urine concentration so it is less irritating.

What are alternatives to restraints?

Call Lights Alarms Assistive devices Sitter

List three nursing interventions the nurse could implement that would reduce the risk for falls.

Examples include the following: • Verify safety of the environment (adequate lighting, avoid clutter on floors, no scatter rugs, frequently used items at shoulder height or lower, etc.). • Teach patient to wear appropriate footwear. • Allow adequate time for tasks or activities .• Teach person how to use assistive devices such as canes, walkers, wheelchairs, etc., if necessary. • Encourage older person to ask for help when necessary.

The nurse is performing a musculoskeletal assessment on an 81-yr-old patient whose mobility has been progressively declining. How should the nurse safely assess range of motion (ROM) in the affected leg? Observe the patient's unassisted ROM in the affected leg. Perform passive ROM, asking the patient to report any pain. Ask the patient to lift progressive weights with the affected leg. Move both the patient's legs from a supine position to full flexion.

Observe the patient's unassisted ROM in the affected leg. Observing the patient's active ROM is more accurate and safer than lifting weights. Passive ROM should be performed with extreme caution; it may cause harm when performed on older patients.

One of the common myths about elders is...

They are all senile and act like "old people"

Group activities are important for elders because..

They encourage development of sociocultural competence, language, and intellectual skills

a home-care nurse is assigned to care for an older adult living at home. which is the first action the home-care nurse should employ to prevent falls by this older adult? a. conduct a comprehensive risk assessment b. encourage the client to remove throw rugs in the home c. suggest installation of adequate lighting throughout the home d. discuss with the client the expected changes of aging that place one at risk

a. conduct a comprehensive risk assessment

An older adult is referred to a geriatric nurse practitioner because of changes in memory and reports by family members that "there is something different about her." The nurse practitioner evaluates the older adult for potentially reversible causes for the changes, which include: (Select all that apply.) a. depression. b. delirium. c. osteoporosis. d. rheumatoid arthritis. e. medication side effects.

a. depression. b. delirium. e. medication side effects.

which nursing intervention enhances an older adult's sensory perception and thereby helps prevent injury when walking from the bed to the bathroom? a. providing adequate lighting b. raising the itch of the voice c. holding onto the client's arm d. removing environmental hazards

a. providing adequate lighting

A nurse is discussing the importance of exercise with a 78-year-old female who states: "I know I should be exercising, but I have arthritis in my knees and it is painful. Can you recommend a type of exercise that would be beneficial and cause me less pain?" Which of the following exercises should the nurse recommend? a. Tennis b. Swimming c. Dancing d. Use of a treadmill and elliptical machine in the gym

b. Swimming

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

c. Stress

The risk management coordinator is preparing a program on the factors that contribute to falls in a hospital setting. which factor that most often contributes to falls should be included in this program? a. wet floors b. frequent seizures c. advanced age of clients d. misuse of equipment by nurses

c. advanced age of clients

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

d. Functional incontinence

A 72-year-old patient hospitalized with pneumonia is disoriented and confused 2 days after admission. Which assessment information obtained by the nurse about the patient indicates that the patient is experiencing delirium rather than dementia? a. The patient is disoriented to place and time but oriented to person. b. The patient has a history of increasing confusion over several years. c. The patient's speech is fragmented and incoherent. d. The patient was oriented and alert when admitted.

d. The patient was oriented and alert when admitted.

A nurse is caring for a confused client. which should the nurse do to prevent this client from falling? a. encourage the client to use the corridor handrails b. place the client in a room near the nurses' station c. reinforce how to use the call bell d. maintain close supervision

d. maintain close supervision

a nurse is caring for a client with dementia. which time of day is of most concern for the nurse when trying to protect this client from injury? a. afternoon b. morning c. evening d. night

d. night

A nurse is teaching a a class about management and treatment of diabetic retinopathy. All of the following statements are correct EXCEPT:a.) Laser photocoagulation is used to destroy leaking blood vesselsb.) Medications called vascular endothelial growth factor inhibitors (anti-VEGF) are injected intravitreallyc.) Proper control of diabetes mellitus is criticald.) Treatments are aimed at restoring lost vision

d.) Treatments are aimed at restoring lost vision