Gero HESI Practice
An older male client is seeking counseling about his recent sexual issues with his partner. What issue should the registered nurse (RN) explore in this discussion? A. Certain mediations may impact sexual function B. Normal aging affects sexual function in male clients C. Safe sex is not necessary with older sexually active elders D. Sexual interest usually declines with aging in male clients
(A) Certain medications may impact sexual function Rationale: Certain medications can have a direct influence on sexual function and should be discussed with older clients (A). (B) does not have drastic effects for older male clients. Some men may experience a decline in testosterone and sperm production, but sexual dysfunction is not a part of normal aging in the male client. The incidence of STIs has increased and may be related to a lack of education for this age group about preventative measures (C). Older clients continue to have interest in sex (D) as long as there is not a direct influence of medication side effects that cause sexual dysfunction
The registered nurse (RN) is observing the skin of an older client. Which finding should the RN document as consistent with the normal aging process? A. Decreased elasticity B. Tough and leathery texture C. Shiny and edematous D. Excessive hair growth on the head
(A) Decreased elasticity Rationale: Loss of elasticity is a common finding of the normal aging process (A). The skin of elderly clients becomes thin and fragile with aging, not (B). When a client has peripheral edema, the skin can be shiny and edematous (C), which is not consistent with normal aging changes. Hair thinning and hair loss are common, not excessive hair growth (D).
An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the left forearm for for hemodialysis. After palpating the AV fistula, which finding is an indication that the AV fistula is functioning properly? A. Enlarged veins B. Redness around the site C. Decreased pulses below fistula D. Marked ecchymotic areas
(A) Enlarged veins Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to enlarge (A), which facilitate cancelation for hemodialysis. (B) may be related to local infection or inflammation and is not a normal finding. (C) and (D) are abnormal findings that should be reported immediately.
After a transurethral resection of the prostate (TURP), an older man returns to the medical surgical floor with a 3-way indwelling urinary catheter. The registered nurse (RN) observes the catheter's tubing for drainage when the client states that he needs to void. What should the RN implement based on this finding? A. Irrigate the bladder through the catheter port B. Remove the indwelling catheter C. Explain that urgency is expected D. Notify the healthcare provider of the symptom
(A) Irrigate the bladder through the catheter port Rationale: The feeling of urgency can be caused by blood clots that can occlude drainage of the catheter, which is a common occurrence in the first 72 hours after a TURP. The urgency is an indication that the client's bladder is not emptying, and the RN should irrigate catheter (A) to relieve symptoms caused by a clot. (B) and (C) should not be implemented. (D) should be implemented after determining if the irrigation was effective in relieving the client's complaint.
The home health registered nurse (RN) is reinforcing instructions to the family about how to prevent pressure ulcers for their older family member who is bedridden. Which measure should the RN discuss? A. Lift the client when turning instead of sliding B. Massage directly over reddened sites C. Change client's position every 4 hours D. Place pillows under both the knees
(A) Lift the client when turning instead of sliding Rationale: Lifting instead of sliding (A) decreases chances of friction and shearing while moving the client. (B) is not recommended for tissue that show signs of early pressure, such as a stage 1 site. (D) does not reduce risk for pressure ulcers. Reposition q2 hours, not q4 hours (C), provides the most benefit in reducing pressure ulcer formation.
The registered nurse (RN) is reinforcing discharge instructions to the family of an older client with failure to thrive. What information should the RN include to promote nutritional intake for the client? (Select all that apply.) A. Minimize stress levels by providing the client with a quiet environment during meals B. Provide food variations that the client can manage without assistance C. Assist the client with eating meals in bed in a semi-Fowler's position D. Encourage fluid intake before meals to decrease dehydration E. Offer any type of food to the client as long as calories are consumed
(A) Minimize stress level by providing the client with a quiet environment during meals (B) Provide food variations that the client can manage without assistance Rationale: (A and B) are correct and continue to promote independence and decreased stress for the client, which will increase the opportunity for nutritional intake. (C) increases dependence for the older client, which can also cause decreased self-worth and depression. (D) will make the client feel full and will decrease the client's ability to consume nutritional calories.
During the quarterly evaluations of the clients in the assisted living community, the registered nurse (RN) assesses for findings of failure to thrive in the older population. What findings should the RN document and report as manifestations related to failure to thrive? (Select all that apply.) A. Unintentional weight loss B. Increased weakness C. Increased amounts of sleep D. Irritation and agitation E. Seeking constant attention from caregiver
(A) Unintentional weight loss (B) Increased weakness (C) Increased amounts of sleep Rationale: (A, B and C) are correct. Symptoms of failure to thrive in the older population include weight loss, weakness and excessive sleep, which should be documented and evaluated by a healthcare provider immediately. (D and E) are not usual signs and symptoms of failure to thrive but should be reviewed by the healthcare provider.
An older woman asks the registered nurse (RN) how she can decrease her chances of getting cystitis. What information should the RN provide? A. Void and empty the bladder completely every 2 to 3 hours B. Take warm sits baths with bubble bath to cleanse the vulva C. Decrease fluid volume intake to reduce urgency D. Test urine pH daily using over-the-counter (OTC) dipsticks
(A) Void and empty the bladder completely every 2 to 3 hours Rationale: (A) minimizes over distention, which can compromise blood supply to the bladder wall and cause irritation to the bladder. (B and C) increase irritation to the bladder. Although (D) can inform the client of the risk of developing cystitis, testing does not help decrease the risk of bladder infections.
An older male client with heart failure (HF) complains of chronic constipation and wants to retrain his bowel. Which information should the registered nurse (RN) offer the client for establishing regular bowel habits? A. Add whole grain foods and fibrous vegetables to diet B. Drink water and fluids up to 3,000 ml daily C. Use a stool softener or glycerin suppository PRN D. Plan daily exercise based on fatigue level
(A) Add whole grain foods and fibrous vegetables to diet. Rationale: Increasing daily fiber (A) with increasing fluid intake are the best tools to use when retraining bowel habits. (B) may cause fluid overload for this older client and potentially exacerbate HF. (C) should not be advised without the healthcare provider's recommendation. The client's fatigue level may curtail how much daily exercise (D) the client can tolerate.
The home health registered nurse (RN) is changing an older client's wet to dry dressing. Which observation should the RN evaluate as a therapeutic response with the removal of the dry dressing? A. Debridement and removal of slough and eschar B. Drainage of purulent exudate from the wound C. Moist skin edges around the wound field D. Presence of capillary growth in the wound
(A) Debridement and removal of slough and eschar Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a dry gauze is used to cover the wet packing to wick drainage and bacteria away from the wound to promote healing. Removal of dried dressing provides debridement by removing exudate, sloughing tissue, and eschar (A). (B) is evidence of an infection. (C) is indicative of continuous moisture that is causing the skin edges of the wound to be vulnerable to further damage. (D) is manifested by a pink environment with serosanguineous fluid.
The registered nurse (RN) is assigned to the care of an older client with venous stasis ulcers. A primary goal in the client's plan of care is to decrease swelling in the extremities. What action should the RN take to meet this goal? A. Elevate the legs on pillows B. Decrease fluid intake C. Decrease salt intake in diet D. Increase protein intake in diet
(A) Elevate the legs on pillows Rationale: Venous insufficiency is causing intravenous fluids to move into the interstitial spaces, causing edema. To promote gravity drainage, the extremities should be elevated (A). (B) may not decrease the edema, which is due to the inability to mobilize stagnated venous blood. Dietary changes, such as (C and D) may be recommended if prescribed dietary changes are in place, but the underlying etiology is venous insufficiency.
The registered nurse (RN) is caring for an elderly client with functional incontinence who lives in an assisted living community. The client is alert and mildly confused and can self-ambulate. Which nursing intervention should the RN implement? A. Offer assistance with toileting q2 hours B. Use protective disposal undergarment instead of underwear C. Ask if the client has attempted to void q2 hours D. Obtain a prescription for intermittent catheterization
(A) Offer assistance with toileting q2 hours Rationale: Maintaining independence and self-esteem is important for an older client with incontinence. (A) decreases the client's chances of accidents and embarrassment by introducing a toilet training program. (B) is not implemented unless toileting program is unsuccessful and the client's mental status declines. A confused client will not remember how many times he or she frequented the toilet, so (C) is not helpful for the client. (D) is not indicated for clients with functional intolerance and who can ambulate.
An older resident is newly admitted to an assisted living community. Which actions should the registered nurse (RN) implement to provide the resident ways to maintain safe medication administration? (Select all that apply.) A. Locked medication storage in the client's room B. Medication administration record (MAR) C. Payment forms for prescribed medications D. Delivery of adequate supply of medication E. List of findings indicating medication effectiveness
(A), (B), (D), (E) Rationale: (A, B, D and E) are correct. For safe self-medication in an assisted living community, the resident should be provided a locked storage box (A), create a medication administration record to monitor medication (B), establish adequate medication supply (D) and a reference to evaluate the effectiveness of medications (E). (C) is not the responsibility of the nurse.
An older male client asks the registered nurse (RN) how he can reduce his incidents of hemorrhoidal flare ups. What information should the RN offer the client about how to prevent rectal discomfort? (Select all that apply.) A. Increase fiber and liquids in the diet to help prevent constipation and straining B. Change exercise program to reflect less cardio-exercise and more weight training C. Use a therapeutic cushion or frequent repositioning for periods of prolonged sitting D. Take frequent warm sits baths and do not use abrasive paper that can traumatize tissues E. Establish bowel habits by scheduling daily time to defecate when the client is not rushed
(A), (C), (D) and (E) Rationale: (A, C, D and E) are correct. Fluids, comfort measures, and establishment of a regular bowel pattern help reduce incidents of hemorrhoid inflammation. Weight training can aggravate hemorrhoids and is not effective in reducing hemorrhoid irritation.
An older male client with Parkinson's disease (PD) is discharged home with levodopa-carbidopa (Sinemet) and instructions to his wife for his care. What statement best indicates to the registered nurse (RN) that the wife understands her husband's needs? A. "It is important to keep my husband in a chair or in bed as much as possible and prevent him from falling." B. "I will notify the healthcare provider if my husband has increasing involuntary movements of his extremities." C. "Since it is difficult for my husband to eat, we should stay in the house instead of going out to dine." D. "I should expect that my husband will be incontinent of bowel and bladder as his disease advances."
(B) "I will notify the healthcare provider if my husband has increasing involuntary movements of his extremities." Rationale: Increasing involuntary movements (B) should be reported during the use of levodopa; it is an indicator that the body is failing to readjust to the changes in the level of the intracerebral neurotransmitter dopamine. The client should be encouraged to engage in exercise and regular daily activities (A). Socialization and activities as tolerated help to prevent the client from becoming depressed, so (C) is not indicated. Clients with PD usually are constipated due to muscle weakness, lack of exercise, and decreased fluid intake, but incontinence should not be an expectation related to PD.
Osteoporosis increases the risk for a hip fracture in older adults, and women are more likely to have osteoporosis than men. Women of which ethnic group have the highest risk for a hip fracture? (Arrange with the highest risk first and the lowest risk last.) A. African American B. Caucasian C. Asian D. Hispanic
(B) Caucasian (C) Asian (D) Hispanic (A) African American Rationale: Caucasian women have the highest risk for hip fractures secondary to osteoporosis. Women of Asian descent have the second highest risk, followed by Hispanic women and African American women.
The home health registered nurse (RN) is assessing an older client for a pressure ulcer. Which finding should the RN observe the area for a Stage I pressure ulcer? A. Superficial skin breakdown and flaking B. Deep pink, red or mottle skin C. Subcutaneous damage or necrosis D. Skin that blanches pink when pressed
(B) Deep pink, red or mottled skin Rationale: Temporary blanching of an area can last for over a minute due to poor circulation. Deep pink, red or mottle skin (B) is a finding consistent with Stage I pressure ulcer. (A, C and D) are evidence of a pressure ulcer at different stages of development.
An older client who recently moved into an assisted living community refuses to eat or join any activities. When evaluating the client further, what should the registered nurse (RN) focus on during the next examination? A. Anxiety B. Depression C. Exhaustion D. Confusion
(B) Depression Rationale: Depression is a symptom that an older client is likely to experience with a sudden change in living accommodations when a loss of personal identity can create low self-esteem. (A, C and D) are other symptoms that the client can exhibit, but with the sudden change in lifestyle, (B) is most likely and most important for the RN to focus on.
An older client is admitted with a preliminary diagnosis of Addison's disease. Which skin finding should the registered nurse (RN) document that is typical with Addison's disease? A. Moon face B. Hyperpigmentation C. Excessive acne D. Multiple skin tags
(B) Hyperpigmentation Rationale: Addision's disease is characterized by a deficiency in the production of adrenal cortex hormones, which results in anterior pituitary feedback to secrete stimulating hormones, such as melanocyte stimulating hormone (MSH) that increases melanin production. (B) is seen in clients with Addison's disease. (A and C) are typical of Cushing's syndrome which is due to excessive adrenal cortisol. (D) are not associated with Addison's disease.
An older male client is admitted for emergency treatment of acute closed-angle glaucoma. The registered nurse (RN) begins administering the prescribed miotic medications and glycerin (Glycol) therapy. Which intervention is most important for the RN to maintain during the client's therapy? A. Maintain lighting control in the room during therapy B. Monitor intake and output q2 hours for 24 hours C. Place an eye patch over the affected eye during sleep D. Administer the eye drops at the scheduled intervals
(B) Monitor intake and output q2 hours for 24 hours Rationale: Monitoring intake and output (B) is most important during the administration of glycerin (Glycol) due to the rapid acting osmotic diuretic effect of glycerin therapy. (A, C and D) are components of care, but the most important action during glycerin administration is evaluation of output.
The home health registered nurse (RN) visits an older woman with heart failure (HF) who is on complete bed rest. Which intervention is most important for the RN to suggest to the client to prevent complications related to immobility? A. Get as much sleep as possible B. Perform leg exercises while in bed C. increase protein intake to combat fatigue D. Invite friends to visit to decrease risk for depression
(B) Perform leg exercises while in bed. Rationale: The client is at risk for complications related to immobility. (B) should be performed frequently to decrease the risk for thrombophlebitis. (A, C and D) are measures to help the client while on bedrest, but the most important complication that the client is at risk for deep vein thrombosis.
The registered nurse (RN) is assigned the care of an older client who returns to the unit after surgery for closed angle glaucoma. What intervention in the plan of care should the RN bring to the attention of the healthcare team? A. Assist with ambulating to commode B. Monitor intake and output q8 hours C. Administer morphine 4 mg IM q2 hour PRN pain D. Place an eye patch on operative eye during sleep
(C) Administer morphine 4 mg IM q2 hour PRN pain Rationale: Morphine side effects include nausea, vomiting and constipation, causing straining on stool, all of which can increase intraocular pressure and cause intraocular bleeding during the postoperative period. Administration of morphine 0.4 mg IM q2 hours PRN pain (C) should be discussed with the healthcare team to determine the risk of the side effects for the client. (A), (B) and (D) are interventions that do not place the client at risk.
The home health registered nurse (RN) visits an older female client with an ideal conduit who has been experiencing chronic urinary tract infections (UTI). Which intervention should the RN recommend to the client to manage the frequency of UTIs? A. Force fluid intake to 1,000 ml daily B. Change appliance every 4 hours C. Attach a larger drainage bag while sleeping D. Allow bag to fill completely before emptying
(C) Attach a larger drainage bag while sleeping Rationale: (C) can prevent urinary reflux if the bag fills to near capacity or greater, which can contribute to UTIs. Forcing fluids is encouraged and should exceed urinary output, which commonly should be greater than 1,000 ml (A). (B) can increase skin irritation and increase risk for infection by exposing the portal of entry frequently. Allowing the bag to fill completely before emptying (D) increases risk of urinary reflux and UTIs.
The nursing assessment of an older female elicits information that the client is diagnosed with Raynaud's phenomenon. Which exposure should the nurse instruct the client to avoid? A. Alcohol consumption B. Warm climates C. Cold climates D. Active exercise
(C) Cold climates Rationale: Exposure to cold environments (C) can cause prolonged painful vasoconstriction of the peripheral extremities (especially in hands) in client's with Raynaud's phenomenon. (B) provides the best environment for clients suffering from this disease. There is no correlation between (A) or (D) that exacerbates Raynaud's symptoms.
A frail elderly woman visits the healthcare provider because she has been getting out of breath easily when walking long distances. Which pulmonary function change should the registered nurse (RN) expect to commonly occur with aging? A. Decreased residual volume B. Mild respiratory acidosis C. Reduced vital capacity D. Increased alveoli function
(C) Reduced vital capacity Rationale: With aging, a frail elder is likely to have a reduced vital capacity (C) due to the loss of elasticity of the lung tissue. With reduced elasticity, residual volume increases (A). Arterial pH should not change with normal aging (B). A decrease, rather than an increase, in alveoli function (D) can occur due to a thinning of the alveolar walls with age.
An older female client who is a new resident at an assisted living facility cannot remember how to get to her room. What action should the registered nurse (RN) implement? A. Schedule therapy and social activities in her room B. Ask another resident to help the client C. Show client how to follow hallway signs to her room D. Move client to a room close to nurses station
(C) Show client how to follow hallway signs to her room Rationale: Teaching the client how to follow hallway signs to her room (B) provides cues and reminders that foster independence. (A) limits social stimulation in her residential environment. (B) may be helpful and fosters peer relationships and trusts, but the client's independence should be fostered first. (D) often contributes to further confusion.
An older male client is admitted to the hospital with left-sided heart failure (HF). Which finding should the registered nurse (RN) document that is consistent with HF? A. Ascites B. Pitting edema C. Jugular distention D. Coarse and fine crackles
(D) Coarse and fine crackles Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta causes blood to back up into the pulmonary capillaries; this pushes intravascular fluid into the alveoli, which is manifested as crackles or rales. (A, B and C) are manifested in right-sided heart failure.
After a recent total hip replacement, an older female client, who transferred to a rehabilitation facility placement, asks the registered nurse (RN) if she broke her hip because she is old. How should the RN best respond? A. Hip fractures can occur in any age group and require strength conditioning B. With aging, everything tends to break down more easily the older one gets C. Older people tend to look down instead of ahead, increasing the risk of falls D. Older women commonly lose bone calcium, which increases the risk of fracture
(D) Older women commonly lose bone calcium which increases the risk of fracture. Rationale: The best response is to provide the client with an explanation based on aging and demineralization of the bone (D) in older females, especially after menopause. (A, B and C) offer other responses but are not client centered in response to her expressed self-concern.
An older male client arrives at the clinic for an annual physical examination. While the nurse assesses the client, the client states that he is having intimacy problems with his wife. Which information should the nurse provide to elicit more information from the client? A. Query client to clarify the client's idea of an intimacy problem. B. Discuss benign prostatic hypertrophy (BPH) and ejaculation. C. Explore the frequency that he experiences erectile dysfunction (ED) D. Determine if the client's wife is young enough to get pregnant
A. Query client to clarify the client's idea of an intimacy problem. Rationale: Clarification of the client's concern is needed to appropriately address the specific concern about intimacy issues (A). (B), (C), and (D) are details that the client should present, not the RN.
Since his arrival in an assisted living community, an older male client is having difficulty going to sleep. Which intervention should the registered nurse (RN) implement first? A. Encourage client to take a warm bath at night B. Ask the client what has helped him in the past C. Recommend that the client not take daytime naps D. Offer the client a glass of warm milk before bedtime
B. Ask the client what has helped him in the past. Rationale: Asking the client (B) about his sleeping habits involves the client in his own care and preserves his autonomy as he adapts to living in a new community. (A, C, and D) are common ways to promote nighttime sleep but these should be explored with the client and his preferences.
A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding is most important for the registered nurse (RN) to report to the healthcare provider? A. Fever and chills B. Confusion and dehydration C. Crackles in the lung fields D. Nausea and vomiting
B. Confusion and dehydration Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and perfusion in this frail elderly client. (A), (C) and (D) are all common with pneumonia, but the most important finding is confusion and evidence of dehydration, which require treatment for this frail elderly client.
A family member brings their aging father to the clinic because he has been alert and oriented during the day but agitated and disoriented in the evening. The registered nurse (RN) reviews the client's list of current medications with the client and family. Which action taken by the RN is most important? A. Medication review with family caregivers is the RN's responsibility B. Multiple medications can contribute to sundowner-like symptoms C. Medication recall is the best way to evaluate the client's memory D. Reviewing medication actions is a component of effective client care
B. Multiple medications can contribute to sundowner like symptoms. Rationale: Older clients may see a variety of HCP which can increase the chance of polypharmacy that compounds the workload of metabolic pathways that may be less efficient due to the aging process. Multiple medication interactions may contribute to sundowner like symptoms; reviewing medication actions and interactions provides the information that may indicate polypharmacy leading to sundowner syndromes.
An older female client who has been taking hydrocodone/acetaminophen (Lortab) q4 hours for chronic back pain for the past 5 years tells the registered nurse (RN) that she cannot live without her pain pills. When asked if she is addicted, the client states that she is not an addict because the healthcare provider prescribed the pain pills. Which coping mechanism should the RN determine the client is using about her addiction? A. Lack of knowledge about narcotic medications B. Rationalization to support narcotic use C. Transfer of blame to healthcare provider D. Justification of narcotic use due to chronic pain
B. Rationalization to support narcotic use. Rationale: The client is using rationalization to maintain self-esteem when she is questioned by stating that she is not addicted because she is taking medication prescribed by a healthcare provider. (A) may be possible, but the client is being specifically asked about possible addiction. (C) and (D) underlie the complexity of denial in addiction, but the client is trying to maintain self-esteem through rationalization.
An older client is transferred to a telemetry unit after placement of a pacemaker. What action should the registered nurse (RN) take first? A. View incision site B. Obtain a blood pressure C. Establish telemetry monitoring D. Evaluate client for pain
C. Establish telemetry monitoring. Rationale: The first action is to establish continuous telemetry monitoring (C) to ensure the pacemaker is functioning properly. (A, B and D) should be implemented after the client's heart rate and rhythm are successfully being monitored.
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake because food does not taste as good as it used to so they have to season most foods. What information should the RN offer the couple? A. Boredom may influence how the taste of food is perceived, and different seasonings can stimulate taste. B. With age, an increase in sodium intake is needed to compensate for a decrease in renal function. C. Short-term memory loss and confusion may be the reason they want to over-season their food. D. Taste buds often are dull due to atrophy so older clients should use other seasonings instead of salt.
D. Taste buds are often dull due to atrophy so older clients should use other seasonings instead of salt. Rationale: Taste buds atrophy with normal aging, which influences an older client's sensitivity to taste and is often compensated for the use of stronger tasting seasonings. (A), (B), and (C) are not normal aging processes related to taste.
An older female client arrives for an annual visit by the urologist due to a history of changes in serum values related to renal function. What changes should the registered nurse (RN) expect for an older client due to normal aging? A. Decrease in glomerular filtration rate (GFR) B. Hematuria during urinalysis C. Chronic bladder infections D. Urinary incontinence
(A) Decrease in glomerular filtration rate (GFR) Rationale: GFR often decreases (A) with normal aging due to a decrease in blood flow through the kidneys, causing renal function test results to vary the clearance of metabolic waste. (B, C and D) are not normal outcomes of aging.
An older client who is unconscious is admitted after experiencing a head injury from a fall. Glasgow Coma Scale (GCS) is prescribed to evaluate the client. Which focused assessments should the registered nurse (RN) use to determine the client's GCS score? (Select all that apply.) A. Verbal response B. Motor response C. Eye opening D. Pupillary reaction E. Hearing
(A), (B), (C) Rationale: (A, B, and C) are correct. The Glasgow Coma Scale evaluates verbal response (A), motor response (B), and eye opening (C). The GSC does not evaluate pupil reaction (D) or hearing (E).
The healthcare provider prescribes a new medication, atorvastatin (Lipitor), for an older client who arrives at the clinic for an annual physical examination. What common side effect should the registered nurse (RN) advise the client to observe with this medication? A. Constipation B. Headaches C. Muscle weakness D. Nausea and vomiting
(B) Headaches Rationale: Headaches (B) are the most common side effect with this medication, which the RN should direct the client to report. (A and C) are rare occurrences with this medication. (D) is not considered a side effect of this medication.
A 64-year-old client is admitted to the hospital with a fractured right hip. One of the concerns following surgical repair is to promote dorsiflexion. Which intervention would a nurse implement? A. Begin early ambulation B. Monitor pain level C. Provide PCA instructions D. Provide a foot board
(D) Provide a foot board Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop throughout recovery (D). (A) and good body alignment may also reduce the possibility of foot drop, however the footboard is maintained throughout recovery. (B) and (C) will alleviate pain but does not promoted dorsiflexion.
The registered nurse (RN) is caring for an older female client with a 20 year history of rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated with RA should the RN document? A. Asymmetrical joint deformity B. Small joint involvement in fingers C. Crepitation or grating sensation in joints D. Weight bearing joint involvement
B. Small joint involvement in fingers. Rationale: Small joint involvement (B) is common in rheumatoid arthritis. (A), (C) and (D) are findings that different OA from RA.
The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the registered nurse (RN) use to determine the client's pain? A. Use the FACE pain scale B. Ask the client to rate pain on a scale of 1 to 10 C. Observe for facial grimacing D. Review documentation of recent eating habits
C. Observe for facial grimacing Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a client who cannot communicate due to Alzheimer disease. (A) and (B) may not be understood by a client with end-stage Alzheimer's disease. (D) is not a helpful tool for pain assessment.
When assessing an older client, which age-related changes in the cardiovascular system should the registered nurse (RN) document? (Select all that apply.) A. Dyspnea B. Chest pain C. Cardiac murmurs D. Widening pulse pressure E. Irregular heart rate
(C), (D) Rationale: For older clients, the expected age-related changes in the cardiovascular system include murmurs (C) and widening pulse pressure (D). (A, B and E) are not normal findings and require further evaluation.
An older male client returns to the hospital after discharge 4 days ago for a TURP. The registered nurse (RN) evaluates the function of the 3-way indwelling urinary catheter and the continuous bladder irrigation system. Which finding should the RN report to the healthcare provider? A. Irrigation bag of normal saline is hanging at the level of the client's head B. The urinary output is greater than the amount of irrigation fluid instilled C. The irrigation tubing is attached to the irrigation port on the 3-way catheter D. The tubing that drains the urinary bladder has bright red urine with clots.
(D) The tubing that drains the urinary bladder has bright red urine with clots. Rationale: The presence of bright red urine with clots in the tubing draining the bladder (D) is an abnormal finding indicating active bleeding, which should have resolved 36-72 hours postoperatively and should be reported. (A, B and C) indicate that the system is functioning properly.
The home health registered nurse (RN) is visiting an older client with chronic hypertension. What evaluation is most important for the RN to complete with each visit? A. Effectiveness of medication B. Ability to ambulate C. Signs of dehydration D. Familial support
A. Effectiveness of medication Rationale: The highest priority in the care of an older client with chronic hypertension is evaluation of the effectiveness of blood pressure medication (A) and the client's compliance in order to prevent complications related to chronic disease. (B, C and D) are issues common in the older population, but the effectiveness of the blood pressure management is most important.
An older female client recently moved to an assisted living facility. The family explains to the registered nurse (RN) that the client is unmanageable and always confused, disoriented and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond? A. Explain that she is in a new home called an assisted living community B. Question the client about her perception of where she might be now. C. Distract the client with a scenario that she is on an outing with her family. D. Reassure the client not to worry because she will meet new friends.
A. Explain that she is in a new home called an assisted living community. Rationale: Reality re-orientation (A) is the best response for a client who is confused because the response is consistent and true. (B, C, and D) do not provide the client with feedback that is reality based.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that apply.) A. Needs are greater than the caretaker's abilities B. Client's declining strength C. Fixed income D. Longer life expectancy E. Lack of exposure to technology and trends
A. Needs regretter than the caretaker's abilities B. Client's declining strength Rationale: When needs are not being met due to lack of ability of the caretaker (A), stress and feelings of failure may be expressed through neglect and abuse. Decline in strength (B) increases the older client's vulnerability to resist or respond to elder abuse. (C, D, E) do not increase the risk for neglect and abuse.
An older client who is a resident in a long-term care facility is receiving medications through a gastric tube (GT). After interrupting the continuous GT feeding in which sequence should the nurse implement these actions for administration of crushed medications? (Arrange in order from first to last step.) A. Flush the feeding tube of feeding solution B. Crush the medication into a powder or fine granules C. Administer each medication separately D. Dissolve each crushed medication in a medicine cup E. Flush GT to clear the medication from the tubing F. Reconnect the gastric feeding tube
B - D - A - C - E - F Rationale: The sequence begins with crushing and dissolving the medications. Then flushing the GT of feeding formula and giving each medication separately. When all medications have been given, the feeding tubing should be flushed to clear the medication, and the GT should be reconnected. If the medications are compatible with food, the continuous GT formula can be restarted.
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a long history of smoking and still smokes a pack of cigarettes a day. Which finding should the registered nurse (RN) report to the healthcare provider? A. Barrel chest with increased chest diameter B. Crackles and pulse oximetry level of 88% C. Low hemoglobin and hematocrit levels D. Arterial blood gases indicating respiratory acidosis
B. Crackles and pulse oximetry level of 88% Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact adequate oxygenation, which should be reported to the HCP. (A) occurs due to chronic hyperinflation of the lungs and is common in clients with COPD. Anemia (C) is frequently identified in clients with COPD, and respiratory acidosis (D) due to CO2 retention contributes to a lower blood pH.
The registered nurse (RN) is re-enforcing discharge instructions with the family of an older client who was recently admitted for an intestinal obstruction. Which statement indicates that the family understands the instructions? A. Increase protein and carbohydrates in the daily diet B. Limit activity to bed rest for the first week and increase mobility incrementally each week C. Report abdominal distention, constipation or any other nausea and vomiting to the healthcare provider D. Drink liquids 2 hours after meals instead of during meals
C. Report abdominal distention, constipation, or any nausea and vomiting to the healthcare provider. Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed immediately. (A, B, and D) are not indicated for a client who has been discharged for intestinal obstruction.
A new resident in an assisted living facility is an older client who is experiencing short-term memory loss and confusion. Which activity should the registered nurse (RN) schedule the client to do during the day? A. Arts and crafts B. Current events discussion group C. Group sing-along D. Daily exercise group
D. Daily exercise group Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the client's stress to remember. (A), (C), and a current events discussion group (B) are thought-provoking activities that require attention to detail and short-term memory to participate in the group activity which may be stressful and frustrating to the resident who has difficulty remembering sequence of the details.
