Old People Questions (Chp 32 Foundations)

10. A patient has been experiencing visual changes from a loss of elasticity of the lens of the eye. What condition is associated with this phenomena? 1. Cataracts 2. Presbyopia 3. Glaucoma 4. Macular degeneration

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1. Which statement best describes demographic changes in relation to the aging population in the United States? 1. The older adult population is growing twice as fast as the rest of the population. 2. Aging is a gradual process that has a predictable pattern based on gender and race. 3. The term old-old refers to those more than 100 years of age. 4. Of the population older than age 65 years, approximately 60% are men and 40% are women.

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11. Older adults often have an atypical response to illness or infection. What is an atypical response in a previously active and alert older adult? 1. Disorientation, weakness, or incontinence 2. Fever, loss of appetite, pain 3. Cough, shortness of breath, and fever 4. Purulent drainage, redness, and warmth at the site of an injury

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5. When caring for an older adult patient who is resistant to getting light exercise what should the nurse express to the patent are benefits of this activity? (Select all that apply.) 1. Improved circulation 2. Decreased constipation 3. Reduced incidence of osteoporosis 4. Reduced incidence of gouty arthritis 5. Enhanced hearing

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8. When administering medications to older adults, it is important that the nurse keep what concepts in mind? 1. Absorption, transport, and elimination of medications tend to decrease with age because of altered liver and kidney function and decreased circulation. 2. Doses sometimes need to be increased to achieve desired effects. 3. Older people use a high percentage of over-the-counter (OTC) medications, which enhance the excretion of other drugs. 4. Brain receptors become less sensitive to drugs.

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4. Which assessment finding is associated with normal aging? (Select all that apply.) 1. The integumentary system loses elasticity. 2. There is loss of muscle tone, which increases the incidence of choking and aspiration. 3. There is a gradual loss of weight because of loss of muscle tissue and fluid. 4. There is increased resistance to infection from improved immune response. 5. Personality changes are anticipated as the individual approaches age 70 years.

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12. A patient with three school-age children cares for her mother who has Alzheimer's disease. Her mother can no longer safely stay at home alone and needs continual supervision. A nursing diagnosis of caregiver role strain is made. Which nursing intervention is most appropriate? 1. Provide a calm environment with minimal distraction. 2. Access community support to provide opportunity for the caregiver to do errands and spend time with her children. 3. Assess communication patterns between the patient and her mother. 4. Encourage the use of gestures and touch to enhance communication.

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16. In a review of the patient's medical record, the intraocular pressure is noted within normal limits. What range confirms this finding? 1. 2 to 8 mm Hg 2. 10 to 22 mm Hg 3. 25 to 32 mm Hg 4. 50 to 60 mm Hg

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3. According to the "disengagement theory," people who are aging: 1. inherit a genetic program that determines their specific life expectancy. 2. gradually withdraw from society. 3. have the inability to achieve a level of acceptance, which results in anger and despair. 4. experience a change of personality and behaviors related to illness and loneliness.

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6. Which change is suggestive of osteoporosis? 1. Decreased muscle strength and joint mobility 2. Increased curvature of the spine and decreased height 3. Loss of balance and unsteady gait 4. Nocturia and sleep pattern disturbances

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13. Which is an appropriate nursing diagnosis for an older adult male with neurologic problems? (Select all that apply.) 1. Decreased cardiac output 2. Impaired verbal communication 3. Impaired urinary elimination 4. Risk for disturbed sensory perception 5. Risk for infection

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15. Aging often causes a decreased production of intrinsic factor from the stomach, thus interfering with the body's ability to utilize vitamin B12. What disease develops from this deficiency? 1. Iron-deficiency anemia 2. Aplastic anemia 3. Pernicious anemia 4. Sickle cell anemia

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9. The nurse is caring for an older adult patient who has been diagnosed with depression. The nurse correctly recognizes what characteristics about depression in the older adult as being correct? 1. Depression is uncommon in older adults. 2. Psychotherapy is generally ineffective in older adults. 3. Symptoms of depression are commonly misunderstood as normal changes of aging. 4. Many older adults are treated for depression.

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14. In data collection from an older adult, the patient discusses intimacy concerns. When developing the plan of care, the nurse correctly recognizes which of the following as the primary reason for decreased sexual activity in many older adults? 1. Painful sexual intercourse because of vaginal dryness or pain 2. Loss of interest as a normal part of the aging process 3. Treatment of other conditions with medications that induce impotence 4. Lack of a sexual partner

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17. What normal age-related changes may impact sleep in the older adult? 1. The center of Broca's area 2. The cerebellum 3. The thalamus and globus pallidus 4. The reticular formation

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2. The nursing student demonstrates knowledge of general concepts regarding older adults with which statement? 1. "Most people become senile when they become old." 2. "Most older adults in this society are lonely and isolated with less than monthly contact with family and friends." 3. "Approximately 25% of the older adult population resides in a long-term care facility." 4. "Most older people have at least one chronic condition and rate their health as 'good.' "

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7. What description for the term dementia is most appropriate? 1. A sudden change in mental status that results from hypoxia, electrolyte imbalances, or some other treatable condition 2. A state of physical and mental deterioration associated with normal aging 3. Loss of awareness of person, place, and time 4. A progressive impairment of intellectual function that interferes with normal activities

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37. When bathing an 80-year-old woman who lives on a farm, the nurse assesses brown macules on the patient's hands and forearms. The nurse recognizes these as _________.

ANS: lentigo Lentigo is a term that refers to brown-pigmented lesions on the skin of the older person who has spent a great deal of time in the sun. These macules are also called "age spots." PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1075 OBJ: 5 TOP: Integumentary alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

13. What should be suggested to a patient to aid with the pain of claudication? a. Rest b. Exercise c. Cross legs d. Stand

ANS: A A nursing intervention to relieve pain is to recommend the patient rest periodically until the pain subsides. Exercise and standing for long periods of time can exacerbate the pain. Crossing the legs can limit blood flow to the extremities and increase pain. PTS: 1 DIF: Cognitive Level: Application REF: Page 1084 OBJ: 8 TOP: Circulatory alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

33. When assessing the older adult, the nurse considers which aspect of the patient's routine as a possible contributor to constipation? a. Intake of antacids several times a day b. Taking a laxative once a week c. Excessive exercise routine d. Eating two apples a day

ANS: A Intake of antacids is constipating. All other options decrease the risk of constipation. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1080 OBJ: 8 TOP: Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

14. The nurse recommends a breathing technique to help a patient with chronic obstructive pulmonary disease (COPD) to empty the lungs of used air and to promote inhalation of adequate oxygen. What is this method of breathing called? a. Pursed-lip breathing b. Increased inspiration c. Vital capacity d. Decreased expiration

ANS: A Pursed-lip breathing can help empty the lungs of used air and promote inhalation of additional oxygen. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1086 OBJ: 8 TOP: Chronic obstructive pulmonary disease (COPD) KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

36. Which approaches should be included when teaching medication safety to an older, homebound adult? (Select all that apply.) a. Always dispose of expired medications in the toilet or the sink; never throw them in the trash can. b. Never share medications with others. c. If a medication is not finished as prescribed, save it for future use. d. Keep medications in their original containers. e. Always request child-proof containers, even if the patient has trouble opening the lids.

ANS: A, B, D Expired medications should always be disposed of in the toilet or sink; they should never be thrown in the trash where they could be retrieved by others. Medications should never be shared with anyone else. Medications should always be stored in their original containers. A prescription should always be taken as prescribed by the physician. Medications should never be saved for future use. If an older adult has trouble opening child-proof medication containers, he should request non-childproof lids. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1101-1103 OBJ: 8 TOP: Medication practices KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

34. What should the nurse do to help the dysphagic patient? (Select all that apply.) a. Sit the patient upright b. Reduce distraction during mealtime c. Offer fluid from a straw d. Thicken liquids e. Cue the patient to swallow

ANS: A, B, D, E Offering fluids using a straw increases the possibility of choking or aspiration. All other options would be beneficial to the dysphagic patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1079 OBJ: 8 TOP: Gastrointestinal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

35. Which statements are myths that have been disproved concerning aging? (Select all that apply.) a. All older adults are senile. b. Most older adults live in their own homes. c. Older adults are poor. d. Older adults have frequent contact with family members. e. Older adults are disabled.

ANS: A, C, E All older adults are not senile; this is a myth. Mental decline is not inevitable. Older adults are not all poor; this is a myth. Older adults have a lower poverty rate than younger adults. Older adults are not all disabled; this is a myth. Most are able to manage their own care. Most older adults do live in their own homes and have frequent contact with family members. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1072, Box 32-3 OBJ: 2 TOP: Aging Myths KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

21. What is the best test to identify the risk of osteoporosis in postmenopausal women? a. Skeletal x-ray b. Bone density scan c. Calcium blood level d. CAT scan

ANS: B Bone density testing can identify women at risk for fractures. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1089 OBJ: 5 TOP: Osteoporosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

9. The patient complains to the nurse about a newly developed intolerance to milk. What should the nurse suggest to fulfill calcium needs? a. Rye bread b. Yogurt c. Apples d. Raisins

ANS: B Lactose, primarily found in milk, is a common source of food intolerance. Dairy products are an important source of calcium, which is needed to prevent osteoporosis. Lactose-intolerant individuals need to replace milk with cheese and yogurt, which are processed and digested more easily. PTS: 1 DIF: Cognitive Level: Application REF: Page 1079 OBJ: 8 TOP: Gastrointestinal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

1. When discussing aging, to whom does the term older adulthood apply? a. Age 55 and above b. Age 65 and above c. Age 70 and above d. Age 75 and above

ANS: B Older adulthood begins at about age 65. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1068 OBJ: 1 TOP: Aging KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

19. The nurse is assisting an older adult patient out of bed when suddenly the patient begins to fall. What is the likely cause of the fall? a. Fever b. Orthostatic hypotension c. Dehydration d. A decrease in venous return

ANS: B Orthostatic hypotension occurs when the patient changes position. In the older adult, the loss of elasticity in the vessels slows the vascular accommodation to sudden postural changes to a standing position. PTS: 1 DIF: Cognitive Level: Application REF: Page 1101 OBJ: 10 TOP: Musculoskeletal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

11. The older adult female patient is concerned about incontinence when she sneezes. What is the correct terminology for this type of incontinence? a. Urge incontinence b. Stress incontinence c. Overflow incontinence d. Functional incontinence

ANS: B Stress incontinence results from increased abdominal pressure, which occurs with coughing or sneezing. Urge incontinence occurs after a sudden urge to void and is associated with cystitis, tumors, stones, and CNS disorders. Overflow incontinence is associated with diabetic neuropathy and spinal cord injuries. Functional incontinence results from unwillingness or inability to get to the toilet. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1081 OBJ: 5 TOP: Incontinence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

3. When was the Social Security Act, which was the first major legislation providing financial security for older adults, passed? a. 1930 b. 1935 c. 1940 d. 1945

ANS: B The first major legislation to provide financial security for older adults was the Social Security Act of 1935. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1073 OBJ: 1 TOP: Legislation KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

23. What is age-related vision change caused by the loss of elasticity of the lens called? a. Nearsightedness b. Cataracts c. Presbyopia d. Blepharitis

ANS: C Age-related changes include presbyopia and farsightedness resulting from a loss of elasticity of the lens. Cataracts are due to opacity of the lens. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1093 OBJ: 5 TOP: Sensory alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

31. Which areas are affected only minimally by age? a. Physical activity b. Productivity c. Cognition d. Sexuality

ANS: C Aging has little influence on cognition. Only through disease processes is cognition altered. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1096 OBJ: 5 TOP: Aging KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity

27. What is the most common cause of dementia? a. Multi-infarct b. Medications c. Alzheimer disease d. Parkinson disease

ANS: C Alzheimer disease is the most common cause of dementia. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1098 OBJ: 9 TOP: Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

4. When assessing the skin of an older adult patient who is complaining of pruritus, what should the nurse advise the patient to avoid to reduce further drying of her skin? a. Perfumed soap b. Hard-milled soap c. Antibacterial soap d. Lotion soap

ANS: C Antibacterial soap is very drying. PTS: 1 DIF: Cognitive Level: Application REF: Page 1075 OBJ: 8 TOP: Integumentary alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

20. To help prevent falls related to muscle weakness, what type of exercises should be selected for the aging patient? a. Daily b. Running c. Weight-bearing d. Aerobic

ANS: C Appropriate interventions to increase muscle strength begin with weight-bearing exercises. They do not have to be done daily to be effective. Running and aerobic exercise would not be appropriate or effective for the aging patient. PTS: 1 DIF: Cognitive Level: Application REF: Page 1101 OBJ: 8 TOP: Musculoskeletal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

10. The older adult patient complains to the nurse about nocturia. This problem is most likely related to: a. loss of bladder tone. b. decrease in testosterone. c. decrease in bladder capacity. d. intake of caffeine.

ANS: C At least 50% of older men and 70% of older women must get up two or more times during the night to empty their bladders, a condition known as nocturia (excessive urination at night). The most significant age-related change is the decrease in bladder capacity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1081 OBJ: 5 TOP: Incontinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

15. The nurse reminds the 80-year-old patient that her respiratory system has decreased resistance to respiratory infections. For what is this patient at increased risk? a. COPD b. Bronchitis c. Pneumonia d. Atelectasis

ANS: C Decreased resistance to respiratory infections places older adults at higher risk for pneumonia. PTS: 1 DIF: Cognitive Level: Application REF: Page 1086 OBJ: 5 TOP: Respiratory alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

16. The nurse recognizes that an older adult patient with COPD has a higher incidence of developing which age-related skeletal change that will alter the ability to exchange air effectively? a. Osteoporosis b. Arthritis c. Kyphosis d. Osteomyelitis

ANS: C Kyphosis, usually caused by osteoporosis, is a curvature of the spine that alters respiration and air exchange. PTS: 1 DIF: Cognitive Level: Application REF: Page 1089 OBJ: 5 TOP: Musculoskeletal alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

28. What is one positive aspect of Parkinson disease? a. The disease does not alter ability to communicate b. Anti-Parkinson drugs have few side effects c. Intellectual function is not impaired d. Involuntary movements can be controlled

ANS: C Parkinson disease does not impair the intellect. The disease does alter the ability to communicate. Anti-Parkinson drugs have many side effects. The involuntary movements associated with the disease cannot be controlled. PTS: 1 DIF: Cognitive Level: Application REF: Page 1099 OBJ: 4 TOP: Parkinson disease KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

2. When the nurse discusses prevention of cardiac disease, falls, and depression with a group of older adults, the benefits of what are important to stress? a. Nutrition b. Medications c. Exercise d. Sleep

ANS: C Primary prevention stresses exercise for the prevention of cardiac disease, falls, and depression. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1069 OBJ: 1 TOP: Health promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

17. What is a major difference between rheumatoid arthritis and osteoarthritis? a. Rheumatoid arthritis is degenerative. b. Rheumatoid arthritis only affects patients over 40 years of age. c. Rheumatoid arthritis is inflammatory. d. Rheumatoid arthritis is curable.

ANS: C Rheumatoid arthritis is an inflammatory disease; osteoarthritis is degenerative. Rheumatoid arthritis can affect patients at any age. Neither type of arthritis is curable. PTS: 1 DIF: Cognitive Level: Application REF: Pages 1087-1088 OBJ: 5 TOP: Arthritis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

29. When should family members of a stroke victim expect to see some of the neurologic involvement disappear? a. Within 2 to 3 weeks b. Within 1 to 2 months c. Within 3 to 6 months d. Within 6 to 9 months

ANS: C Some of the initial neurologic deficits of a Cerebrovascular Accident may disappear in 3 to 6 months. PTS: 1 DIF: Cognitive Level: Application REF: Page 1100 OBJ: 4 TOP: Stroke KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

12. A change of aging related to the circulatory system includes decreased blood vessel elasticity. For what should the nurse assess? a. Confusion b. Tachycardia c. Hypertension d. Retained secretions

ANS: C The blood vessels become less elastic because of aging and may lead to increased blood pressure. PTS: 1 DIF: Cognitive Level: Application REF: Page 1083 OBJ: 5 TOP: Circulatory alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

30. When communicating with an older adult patient, the nurse becomes aware of the fact that the patient is well satisfied with his accomplishments over a lifetime and has no regrets concerning aging. Which of Erikson's developmental stages has the patient achieved? a. Acceptance b. Withdrawal c. Ego integrity d. Interaction

ANS: C The last stage of life is acceptance of life and it results in ego integrity. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1072, Box 32-4 OBJ: 3 TOP: Aging KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity

6. At mealtime, the older adult seems to be eating less food than would be adequate. Compared to the younger adult, what is a requirement for the older adult? a. More fluids b. Less calcium c. Fewer calories d. More vitamins

ANS: C The older adult requires 30 calories per kilogram of body weight, whereas the younger adult requires 40 calories. PTS: 1 DIF: Cognitive Level: Application REF: Page 1077 OBJ: 5 TOP: Gastrointestinal alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance

8. An older adult is having difficulty swallowing. What position should the nurse recommend to aid in swallowing? a. Chin parallel b. Chin upward c. Chin down d. Chin to the side

ANS: C The upright position, leaning slightly forward with the chin down, improves swallowing with the assistance of gravity. PTS: 1 DIF: Cognitive Level: Application REF: Page 1079 OBJ: 8 TOP: Gastrointestinal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

24. When communicating with an older adult patient who has difficulty hearing, how should the nurse change her speech? a. Speak very loudly b. Speak rapidly c. Lower the tone of the voice d. Raise the tone of the voice

ANS: C To communicate with a patient with a hearing loss, the nurse should lower the tone of the voice. PTS: 1 DIF: Cognitive Level: Application REF: Page 1095 OBJ: 8 TOP: Sensory alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

32. How often does a 76-year-old need a screening for preventative health? a. Every 2 years b. Every 6 months c. Every 3 years d. Every year

ANS: D A complete physical is recommended annually after 75. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1070, Table 32-1 OBJ: 6 TOP: Health promotion KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

18. For what is the older adult patient at increased risk because of age-related changes in the musculoskeletal system? a. Fractures due to poor uptake of calcium b. Heart attacks due to increased effort to ambulate c. Respiratory failure due to kyphosis d. Falls related to posture changes

ANS: D Falls are the leading cause of accidental death in individuals over 65, in part because of posture changes brought on by aging. PTS: 1 DIF: Cognitive Level: Analysis REF: Page 1087, Table 32-8 OBJ: 7 TOP: Musculoskeletal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance

7. The older patient informs the nurse that food has no taste and therefore the patient has no appetite. What is this most likely caused by? a. Tasteless food b. Overuse of salt c. Lack of variety d. Loss of taste buds

ANS: D Older adults may experience a loss of appetite. Change in taste as a result of decreased saliva production and a decreased number of taste buds may make food unappealing. PTS: 1 DIF: Cognitive Level: Application REF: Page 1078 OBJ: 5 TOP: Gastrointestinal alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

25. Which symptom of diabetes distorts tactile sensation? a. Proprioception b. Loss of visual acuity c. Progressive paresis d. Peripheral neuropathy

ANS: D Peripheral neuropathy is the presence of abnormal sensation and it distorts tactile sensation. PTS: 1 DIF: Cognitive Level: Comprehension REF: Page 1091 OBJ: 4 TOP: Diabetes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

5. Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure ulcers, the nurse alters the care plan to include turning the bedfast patient how often? a. Once every shift b. Every 4 hours c. Each evening d. Every 2 hours

ANS: D Pressure ulcers can be avoided by repositioning the patient every 2 hours. PTS: 1 DIF: Cognitive Level: Application REF: Page 1076 OBJ: 8 TOP: Integumentary alterations KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

22. When an older female patient complains of painful sexual intercourse, what should the nurse recognize as the probable cause? a. Urinary incontinence b. Arthritic joints c. Kyphosis d. Mucosal drying

ANS: D Sexual intercourse may be uncomfortable because of drying of the mucosa of the vagina. PTS: 1 DIF: Cognitive Level: Application REF: Page 1092 OBJ: 5 TOP: Reproductive alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

26. What is the result of a slowing of the impulse transmission in the nervous system? a. Hypertension b. Hearing deficit c. Decrease in tactile sensations d. Longer reaction time

ANS: D When nerve impulses in the nervous system of an older adult slow down, the result is a longer reaction time. PTS: 1 DIF: Cognitive Level: Application REF: Page 1095 OBJ: 5 TOP: Neurologic alterations KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity

39. The nurse recognizes that a term referring to mechanical difficulty of swallowing is ___________.

ANS: dysphagia Dysphagia is a term that refers to mechanical difficulties in swallowing. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1079 OBJ: 5 TOP: Gastrointestinal alterations KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity

38. The nurse initiates the application of a draw sheet on every bedfast patient on her unit to facilitate lifting and to prevent _________ forces.

ANS: shearing Shearing forces cause skin damage by friction; for instance, when a patient is dragged across bed linens during a position change. PTS: 1 DIF: Cognitive Level: Knowledge REF: Page 1076 OBJ: 8 TOP: Integumentary alterations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity