Older Adult Exam

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? 1. Side-lying with head elevated 45 degrees 2. Sims with head elevated 90 degrees 3. Semi-Fowler's with legs elevated 4. High Fowler's using the bedside table as an arm rest.

Correct 4. High Fowler's using the bedside table as an arm rest High Fowler's position elevates the clavicles and helps the lungs to expand, thus easing respirations. The other options do not promote more comfortable breathing.

A client is admitted to the hospital with a long history of hypertension. The nurse should assess the client for which complication? 1. Cataracts 2. Esophagitis 3. Kidney failure 4. Diabetes mellitus

3. Kidney failure Some renal impairment usually is present even with mild hypertension and is attributed to the ischemia resulting from narrowed renal blood vessels and increased intravascular pressure; decreased blood flow causes atrophy of renal structures, such as tubules, glomeruli, and nephrons, leading to kidney failure. Retinopathy, resulting in blurred vision, retinal hemorrhage, and blindness, occurs with a long history of hypertension because of increased intravascular pressure, not cataracts. Esophagitis is caused by esophageal reflux disease, not a long history of hypertension. Hypertension does not cause diabetes mellitus; however, chronic elevations of serum glucose accelerate atherosclerosis, resulting in the development of hypertension.

A client being treated for hypertension reports having a persistent hacking cough. What class of antihypertensive should the nurse identify as a possible cause of this response when reviewing a list of this client's medications? 1. Angiotensin-converting enzyme (ACE) inhibitors 2. Thiazide diuretics 3. Calcium channel blockers 4. Angiotensin receptor blockers

Correct 1. Angiotensin-converting enzyme (ACE) inhibitors ACE increases the sensitivity of the cough reflex, leading to the common adverse effect sometimes referred to as an ACE cough. A cough is not a side effect of thiazide diuretics, calcium channel blockers, or angiotensin receptor blockers.

The nurse prepares a list of recommended foods for a client with hypertension that is to begin a 2-gram sodium diet. The list should include which foods? Select all that apply. 1. Beef steaks 2. Aged cheeses 3. Luncheon meats 4. Cooked broccoli 5. Dehydrated soups

Correct 1. Beef steaks 4. Cooked broccoli Beef is low in sodium. Broccoli does not have significant sodium levels. Aged cheeses are high in sodium as well as saturated fat. Luncheon meat is processed and has high sodium levels to help with its preservation. Dehydrated soups are high in sodium unless they specifically state on the package that they are low in sodium.

A client admitted for uncontrolled hypertension and chest pain was prescribed a low sodium diet and started on furosemide (Lasix). The nurse should instruct the client to include which foods in the diet? 1. Cabbage 2. Liver 3. Apples 4. Bananas

Correct 4. Bananas Furosemide is a loop diuretic that eliminates potassium by preventing renal absorption. Bananas have a significant amount of potassium. Bananas: 450 mg; cabbage: 243 mg; liver: 73.6 mg; apples: 100-120 mg.

A client with hypertension is to take an angiotensin II receptor blocker (ARB). What should the nurse teach about this medication? Select all that apply. 1. Monitor the blood pressure daily 2. Do not take NSAIDs concurrently with this medication 3. Stop treatment if a cough develops 4. Stop the medication if swelling of the mouth, lips, or face develops 5. Have blood drawn for potassium levels two weeks after starting the medication

Correct 4. Stop the medication if swelling of the mouth, lips, or face develops 5. Have blood drawn for potassium levels two weeks after starting the medication The medication should be stopped if angioedema occurs, and the health care provider should be notified. Electrolyte levels of potassium, sodium, and chloride should be obtained two weeks after the start of therapy and then periodically thereafter. Daily monitoring is not indicated. The blood pressure should be monitored at routine office visits. There is no need to avoid the use of nonsteroidal antiinflammatory drugs (NSAIDs) while taking an ARB. A dry cough may occur during treatment with ARBs; however, it is not necessary to discontinue the medication because the cough usually resolves

The nurse is assessing a group of older adults. Which should the nurse consider to be least likely to be affected by aging? 1. Sense of taste or smell 2. Gastrointestinal motility 3. Muscle or motor strength 4. Strategies to handle stress

Correct 4. Strategies to handle stress Although older adults may be faced with multiple stressors as they age, how people cope with stress remains fairly constant throughout life. Decreases in the senses of taste and smell are noted as people age. Gastrointestinal motility decreases slightly with aging; sedentary lifestyles and lack of dietary fiber compound the problem. Muscle strength decreases with aging.

A client is diagnosed with hypertension that is related to atherosclerosis. The nurse recalls that with atherosclerosis: 1. Rennin causes a gradual decrease in arterial pressure 2. Lipid plaque formation occurs within the arterial vessels 3. Mobilization of free fatty acid from adipose tissue contributes to plaque formation 4. Development of atheromas within the myocardium is characteristic

Correct 2. Lipid plaque formation occurs within the arterial vessels The term atherosclerosis means a thickening of the arterial lining by lipid plaques, which become atheromas. Arterial pressure increases, not decreases, as a result of rennin. Mobilization of free fatty acids will produce an acid-base imbalance. Atheromas develop within the lining of the arteries, not within the cardiac muscle tissue.

The nurse is caring for a client who is receiving a thiazide diuretic for hypertension. Which food selected by the client indicates to the nurse that dietary teaching about thiazide diuretics was effective? 1. Apples 2. Broccoli 3. Cherries 4. Cauliflower

Correct 2. Broccoli Thiazide diuretics are potassium-depleting agents; broccoli provides 267 mg of potassium per 100 grams. Apples provide 80 to 110 mg of potassium per 100 grams of fruit. Cherries provide 191 mg of potassium per 100 g of fruit. Cauliflower provides 206 mg of potassium per 100 g.

Typically discussions of the topic of suicide are geared to the younger or middle-aged adult, but older adults actually account for 20% of suicide deaths in the United States. What questions should a nurse ask when, during the assessment of an older adult, the nurse suspects suicidal intent? Select all that apply. 1. "Do you think about killing yourself?" 2. "How often do you have these thoughts?" 3. "Do you have the means to kill yourself?" 4. "Have you thought about your loved ones?" 5. "How would you kill yourself if you decided to do it?" 6. "Why do you think you won't be around much longer?"

Correct 1. "Do you think about killing yourself?" 2. "How often do you have these thoughts?" 3. "Do you have the means to kill yourself?" 5. "How would you kill yourself if you decided to do it?" A nurse who suspects that an elder is suicidal must use straightforward questions such as "Have you ever thought about killing yourself?" Asking how often the client has had thoughts of suicide is also straightforward and will elicit a clear answer. Many times people who intend to commit suicide have already decided how they are going to kill themselves. Being direct in this line of questioning encourages the client to discuss his suicidal intentions. Knowing whether the client has the means to kill himself will provide a good idea of how serious his intention to commit suicide is. Trying to put the client on a guilt trip by asking about loved ones does not directly address the issue of suicide. "Why do you think you won't be around much longer?" does not directly ask about suicide.

During a routine yearly physical, an older adult says to a nurse, "I haven't had sex lately because I can't get an erection anymore!" What should the nurse's initial response be? 1. "Let's discuss this concern a little more." 2. "Be sure to tell your doctor about this problem." 3. "There is medication available for erectile dysfunction." 4. "This is an expected physiologic response to getting older."

Correct 1. "Let's discuss this concern a little more." "Let's discuss this concern a little more" communicates to the client that the nurse is willing and able to explore this concern. It is an open-ended statement that allows the client to control the direction of the conversation. By saying, "Be sure to tell your doctor about this problem," the nurse abdicates responsibility to the health care provider. The nurse is capable of and legally responsible for collecting information and exploring the client's feelings and concerns. The response, "There is medication available for erectile dysfunction" is premature; it moves immediately to a solution before adequate information has been collected. Also, the term erectile dysfunction is related to a medical diagnosis and its use at this time may increase client anxiety. Although sexual function diminishes as men age, many other factors (e.g., physiologic problems, interpersonal conflicts, emotional stress) also influence sexual function.

What is the most important information the nurse can give a client who was just diagnosed with hypertension? 1. "Long-term follow-up care is necessary." 2. "Monitor yourself for signs of hypertension." 3. "Perform occasional blood pressure measurements." 4. "Adjust your antihypertensive dose based on daily blood pressure results."

Correct 1. "Long-term follow-up care is necessary." Hypertension can affect other body tissues, such as the kidneys and eyes; follow-up care and adherence to the therapeutic regimen (e.g., medications, diet, and exercise) are imperative. Hypertension often is asymptomatic, not symptomatic. The client should maintain routine (e.g., daily, weekly) records of blood pressure results as advised. The medication regimen should be followed exactly as prescribed; doses are adjusted by the health care provider.

A newly immigrated older Chinese adult is brought to a mental health clinic when family members become concerned that their parent is depressed. In an attempt to conduct a culturally competent assessment interview, the nurse asks certain questions. Select all that apply. 1. "What brought you here for treatment today?" 2. "What do you believe is the cause of your depression?" 3. "Does religion have a role in your perception of health and wellness?" 4. "Do you have insurance that includes coverage of mental health issues?" 5. "Have you ever sought treatment for a mental health problem previously?"

Correct 1. "What brought you here for treatment today?" 2. "What do you believe is the cause of your depression?" 3. "Does religion have a role in your perception of health and wellness?" Determining the client's perception of the problem is an appropriate question that allows culturally factors to be included. Encouraging the client to discuss her problems will facilitate a clearer understanding of the factors involved. Religion often plays a significant role in a client's view of health, wellness, and recovery. Knowing whether a client has ever undergone treatment for a mental health problem reveals mental health history and how previous issues were addressed. Insurance coverage is not pertinent to the issue and is an inappropriate topic of questioning by the nurse.

An older widower who is sitting by himself in a lounge in the nursing home, says, "I'm all alone; no one has any use for me." Which response by the nurse is most therapeutic? 1. "You seem upset. Let's talk about what's bothering you." 2. "We need to be alone sometimes. It helps us get to know ourselves better." 3. "Try doing something to avoid feeling lonely. I think you should socialize more." 4. "You should focus on ways to change this. Let's play some games to improve your morale."

Correct 1. "You seem upset. Let's talk about what's bothering you." "You seem upset. Let's talk about what's bothering you" is a therapeutic approach that indicates an awareness of the client's feelings and encourages verbalization. Moralizing is a barrier to effective communication. Telling the client to do something to avoid feeling lonely and advising him to socialize more conveys a judgmental or critical attitude toward the client. Telling the client to focus on ways to change the problem and suggesting playing games to improve his morale is diverting the client's attention to something other than feelings.

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner? 1. 1 to 2 L via nasal cannula to keep SaO2 above 90%. 2. 1 to 2 L via nasal cannula to maintain SaO2 at or above 95%. 3. 3 L via mask to maintain SaO2 at 95%. 4. Do not give oxygen because it may suppress hypoxic drive in client.

Correct 1. 1 to 2 L via nasal cannula to keep SaO2 above 90%. Oxygen therapy usually is delayed until stage 4, which is very severe COPD. Usually it is administered at 1 to 2 L per minute to maintain SaO2 at or above 90%. One to 2 L to maintain the SaO2 above 95% is not necessary. Oxygen administration may not be necessary. Three liters of oxygen via a mask is unnecessary and a level of 95% may suppress the hypoxic drive in clients who are chronic CO2 retainers. Oxygen should not be given unless the chronic saturation level is less than 88%.

A nurse is taking the blood pressure of a client with hypertension. The first sound is heard at 140 mm Hg, the second sound is a swishing sound heard at 130 mm Hg, a tapping sound is heard at 100 mm Hg, a muffled sound is heard at 90 mm Hg, and the sound disappears at 72 mm Hg. When recording just the systolic and diastolic readings, what is the diastolic pressure? 1. 72 mm Hg 2. 90 mm Hg 3. 100 mm Hg 4. 130 mm Hg

Correct 1. 72 mm Hg When the sound disappears at 72 mm Hg it is known as phase five of Korotkoff sounds; this reflects the diastolic pressure when the artery is no longer compressed and blood flows freely. 90 mm Hg is recorded as the diastolic pressure in adolescents and adults. The muffled sound heard at 90 mm Hg is phase four of Korotkoff sounds; the muffled sound represents the point at which the cuff pressure falls below the pressure within the arterial wall. This number is recorded as the diastolic pressure in infants and children. The tapping sound heard at 100 mm Hg is known as phase three of Korotkoff sounds; this reflects blood flow through an increasingly open artery as constriction of the cuff decreases. The swishing sound heard at 130 mm Hg is phase two of Korotkoff sounds; this is caused by blood turbulence.

A client with hypertension is to begin a 2-gram sodium diet. The nurse should teach the client to avoid which foods? Select all that apply. 1. Canned chili 2. Ground beef 3. Fresh salmon 4. Luncheon meat 5. Cooked broccoli

Correct 1. Canned chili 4. Luncheon meat Canned chili is very high in sodium and should be avoided. Luncheon meats are processed and have high sodium levels to help with their preservation and should be avoided. Beef is lower in sodium than are preserved meats; however, beef is high in saturated fat. Canned salmon is high in sodium, but fresh salmon is not. Broccoli does not have significant sodium levels.

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? 1. Cardiac problems 2. Joint inflammation 3. Kidney dysfunction 4. Peripheral neuropathy

Correct 1. Cardiac problems COPD causes increased pressure in the pulmonary circulation. The right side of the heart hypertrophies (cor pulmonale), causing right ventricular heart failure. The skeletal system is not directly related to the pulmonary system; joint inflammation does not occur because of COPD. Kidney dysfunction is not as closely related to the pulmonary system as is the cardiac system; kidney problems usually do not occur because of COPD. Peripheral nerves are not as closely related to the pulmonary system as to the cardiac system; peripheral neuropathy does not occur because of COPD.

The nurse is preparing discharge instructions for a client who was prescribed enalapril maleate (Vasotec) for treatment of hypertension. Which is appropriate for the nurse to include in the client's teaching? 1. Do not change positions suddenly. 2. Lightheadedness is a common adverse effect that need not be reported. 3. The medication may cause a sore throat for the first few days. 4. Schedule blood tests weekly for the first 2 months.

Correct 1. Do not change positions suddenly. Vasotec (enalapril) is classified as an ACE inhibitor. ACE stands for angiotensin-converting enzyme. Vasotec is used to treat high blood pressure (hypertension) and congestive heart failure. It can also be used to treat a disorder of the ventricles. Angiotensin is a chemical that causes the arteries to become narrow. ACE inhibitors help the body produce less angiotensin, which helps the blood vessels relax and open up, which, in turn, lowers blood pressure. Clients should be advised to change positions slowly to minimize orthostatic hypotension. A health care provider should be notified immediately if the client is experiencing lightheadedness or feeling like they are about to faint as this is a serious side effect. This medication does not cause a sore throat the first few days of treatment. Presently, there are no guidelines that suggest blood tests are required weekly for the first two months.

A nurse, caring for a client with uncontrolled diabetes, suspects that a client is experiencing hypoglycemia in response to insulin administration. What clinical manifestations lead the nurse to this conclusion? Select all that apply. 1. Headache 2. Confusion 3. Extreme thirst 4. Profuse sweating 5. Increased urination

Correct 1. Headache 2. Confusion 4. Profuse sweating Neurologic responses occur when there is an insufficient supply of glucose to the brain, thus causing clinical manifestations such as headache and confusion. Profuse sweating is a classic sign of hypoglycemia. This is triggered by lack of glucose to the nerve cells. Thirst (polydipsia) is a classic symptom of hyperglycemia. Increased urination (polyuria) is a classic sign of hyperglycemia.

After being hospitalized for a transient ischemic attack (TIA) related to hypertension, a client is discharged with a prescription of hydrochlorothiazide (HCTZ). What should the nurse instruct the client to do when taking this medication? 1. Increase the intake of potassium 2. Drink a protein supplement daily 3. Avoid eating foods high in insoluble fiber 4. Resume regular eating habits

Correct 1. Increase the intake of potassium The client must increase the dietary intake of potassium because of potassium loss associated with HCTZ. Protein supplements are not necessary. Protein should be obtained from meat, fish, and dairy products in the diet. Foods high in insoluble fiber are part of the food pyramid and should be included in the diet. The client should be taught about medication-induced deficiencies, which may necessitate a change in diet, and not just return to regular eating habits once home.

A client with diabetes asks how exercise will affect insulin and dietary needs. The nurse should respond, "Exercise: 1. Increases the need for carbohydrates and decreases the need for insulin." 2. Increases the need for insulin and increases the need for carbohydrates." 3. Decreases the need for insulin and decreases the need for carbohydrates." 4. Decreases the need for carbohydrates but does not affect the need for insulin."

Correct 1. Increases the need for carbohydrates and decreases the need for insulin." Exercise increases the uptake of glucose by active muscle cells without the need for insulin; carbohydrates are needed to supply energy for the increased metabolic rate associated with exercise. The need for insulin is decreased. The need for insulin is decreased, and the need for carbohydrates is increased. The need for insulin is decreased, and the need for carbohydrates is increased.

A client who has always been active is diagnosed with atherosclerosis and hypertension. The client is interested in measures that will help promote and maintain health. What recommendation by the nurse will help the client maintain blood vessel patency? 1. Practice relaxation techniques 2. Lead a more sedentary lifestyle 3. Decrease the amount of exercise 4. Increase saturated fats in the diet

Correct 1. Practice relaxation techniques Research has shown that decreasing stress will slow the rate of atherosclerotic development. Exercise is thought to decrease atherosclerosis and the formation of lipid plaques. Saturated fats in the diet are contraindicated because they increase the risk for atherosclerosis.

On which principle should the nurse's role be based in the maintenance or promotion of the health of older adults? 1. There is a strong correlation between successful retirement and good health. 2. Thoughts of impending death are frequent and depressing to most older adults. 3. Some of the physiological changes that occur as a result of aging are reversible. 4. Older adults can better accept the dependent state that chronic illness often causes.

Correct 1. There is a strong correlation between successful retirement and good health. The individual who can reflect on life and accept it for what it was and is able to adjust and enjoy the changes retirement brings is less likely to experience health problems, especially stress-related health problems. Most emotionally healthy older adults do not focus on death. The changes of aging are usually not reversible. Dependency often is more threatening to this age group.

A nurse is educating a client with diabetes about insulin and appropriate nutritional intake. Which statement indicates that the client understands the teaching? 1. "I can eat what I want as long as I take enough insulin." 2. "I can eat lots of foods as long as I stick to my exchange units." 3. "I should take my regular insulin at night on an empty stomach." 4. "I should eat a really small breakfast so I don't overwhelm my morning insulin."

Correct 2. "I can eat lots of foods as long as I stick to my exchange units." Eating various foods within recommended exchange units is correct. Exchange lists allow clients to select preferred foods that are acceptable within the prescribed dietary plan. The client who believes that eating anything as long as enough insulin is taken does not fully understand the diabetic teaching. Clients should adhere to a prescribed dietary plan. The client should not take regular insulin at night on an empty stomach but should have a snack before going to bed to prevent nighttime episodes of hypoglycemia. The client should eat a preset balanced breakfast, not a very small one, because it is calculated into the entire plan to balance nutrition, insulin, and exercise.

An African American woman is diagnosed with primary hypertension. She asks, "Is hypertension a disease of African American people?" What is the nurse's best response? 1. "The prevalence of hypertension is about equal for women of all races." 2. "The higher-risk population is composed of African American men and women." 3. "The highest-risk population consists of older Caucasian American men and women." 4. "The prevalence of hypertension is greater for African American women than for African American men."

Correct 2. "The higher-risk population is composed of African American men and women." African Americans represent a higher-risk population than Caucasian Americans for hypertension; the reason is unknown. African American women are more frequently affected by hypertension than are Caucasian women. African Americans of both sexes have a higher prevalence than Caucasian Americans of both sexes. African American men have a higher risk than African American women.

Metoprolol (Toprol-XL) is prescribed for a client with hypertension. For which side effect should the nurse monitor the client? 1. Hirsutism 2. Bradycardia 3. Restlessness 4. Hypertension

Correct 2. Bradycardia Beta blockers block stimulation of beta1 (myocardial) adrenergic receptors, which decreases the heart rate and blood pressure. The client should be monitored for bradycardia, which can progress to heart failure or cardiac arrest. Excessive growth of hair or presence of hair in unusual places does not occur with this medication; however, absence or loss of hair (alopecia) may occur. A side effect of this medication is fatigue, not restlessness. This medication may produce hypotension, not hypertension.

A client with COPD states, "I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this client? 1. Fatigue related to weight loss secondary to COPD 2. Imbalanced nutrition: less than body requirements, related to fatigue 3. Imbalanced nutrition: less than body requirements, related to COPD 4. Ineffective breathing pattern, related to alveolar hypoventilation

Correct 2. Imbalanced nutrition: less than body requirements, related to fatigue The response portion of the nursing diagnosis is Imbalanced nutrition: less than body requirements, and the etiology is fatigue associated with the disease process of COPD. Interventions should be planned to deal with the breathing problem and the fatigue associated with it while implementing actions to combat the weight loss. Weight loss related to COPD is not a NANDA approved nursing diagnosis. Fatigue associated with the COPD disease process is the cause of the weight loss, not COPD in itself. Altered breathing pattern is also a problem but does not specifically relate to the weight loss problem.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. They are described best as: 1. Snorting sounds during the inspiratory phase 2. Moist rumbling sounds that clear after coughing 3. Musical sounds more pronounced during expiration 4. Crackling inspiratory sounds unchanged with coughing

Correct 2. Moist rumbling sounds that clear after coughing Coarse rhonchi, particularly on expiration, indicate partial airway obstruction because of bronchiolar alterations associated with COPD. Snorting sounds are made in the nose. Wheezes are musical sounds usually heard during expiration; they are caused by rapid vibration of bronchial walls. Crackling sounds heard on inspiration that are unchanged by coughing are known as fine crackles; they result when air passes through alveoli that partially are filled with fluid.

A nurse is caring for depressed older adults. What precipitating factors for depression are most common in the older adult without cognitive problems? Select all that apply. 1. Dementia 2. Multiple losses 3. Declines in health 4. A milestone birthday 5. An injury requiring hospitalization

Correct 2. Multiple losses 3. Declines in health Depression in the older adult is most often associated with the loss of family members and friends (e.g., death, relocation) and declines in mobility, health, and income. A decline in health, particularly when associated with a chronic illness, frequently precipitates depression in older adults. Dementia is a cognitive problem. Research does not correlate the onset of depression with a milestone birthday in older adults. A traumatic injury does not precipitate the onset of depression in the older adult as often as does a chronic illness.

The nurse who is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB) is aware that this is beneficial for the client through which mechanism? 1. Increased respiratory rate to improve arterial oxygenation 2. Prolonged exhalation to decrease air trapping 3. Shortened inhalation to reduce bronchial swelling 4. Use of the diaphragm to increase the amount of inspired air

Correct 2. Prolonged exhalation to decrease air trapping Pursed-lip breathing works to decrease dyspnea and the respiratory rate through prolonging exhalation and prevention of alveolar collapse. PLB does not increase the length of inhalation and does not increase the respiratory rate. Use of the diaphragm occurs with diaphragmatic, or abdominal, breathing.

A 54-year-old man has demonstrated increasing forgetfulness, irritability, and antisocial behavior. After the man is found disoriented and semi-naked while walking down a street, the diagnosis of dementia of the Alzheimer type is made. The client expresses fear and anxiety when he is admitted to a long-term care facility. What is the best nursing intervention in light of the client's diagnosis? 1. Exploring with him the reasons for his concerns 2. Reassuring him with the frequent presence of staff members 3. Providing him with a written schedule of planned interactions 4. Explaining to him why the admission to the facility is necessary

Correct 2. Reassuring him with the frequent presence of staff members The client needs constant reassurance because forgetfulness blocks previous explanations; the frequent presence of staff members serves as a support system. This client will be unable to explain the reasons for his concerns. The client will not be able to decode a written schedule; he needs continual reassurance. This client will not remember the explanation from one moment to the next.

What should a nurse who is caring for a hospitalized older client with dementia consider before planning care? 1. Physical contact will increase dependency needs. 2. Routines provide stability for clients with dementia. 3. Regressive behavior should be interrupted immediately. 4. Procedures do not have to be explained to clients with dementia.

Correct 2. Routines provide stability for clients with dementia. Rituals and routines in activities of daily living provide a framework and structure for clients with dementia, adding to their sense of safety and security. Touch is a universal message that denotes caring; it can be soothing and will not encourage dependency. Regressive behavior under stress has a calming effect and should be allowed. Care should be explained to all clients; simple declarative statements are usually understood.

A nurse provides instruction when the beta blocker atenolol (Tenormin) is prescribed for a client with moderate hypertension. What action identified by the client indicates to the nurse that the client needs further teaching? 1. Move slowly when changing positions. 2. Take the medication before going to bed. 3. Expect to feel drowsy when taking this drug. 4. Count the pulse before taking the medication.

Correct 2. Take the medication before going to bed. Beta blockers (BBs) should not be taken at night because the blood pressure usually decreases when sleeping. This medication blocks beta-adrenergic receptors in the heart, which ultimately lowers the blood pressure. Therefore, the drug should be taken early in the morning to maximize its therapeutic effect. Orthostatic hypotension is a side effect of BBs, and the client should change positions slowly to prevent dizziness and falls. Drowsiness is a side effect of BBs, and the client should be taught precautions to prevent injury. The pulse rate should be taken before administration because ventricular dysrhythmias and heart block may occur with BBs.

When reviewing an appropriate diet for a client with diabetes, the client expresses a dislike for sweet potatoes. What should the nurse suggest is a safe equivalent for sweet potatoes? 1. Cup of milk 2. White bread 3. Slice of avocado 4. Mayonnaise on salad

Correct 2. White bread A sweet potato is equivalent to a serving of bread. One cup of skim or nonfat milk is a serving of milk. A slice of avocado is equivalent to a serving of fat. One teaspoon of mayonnaise is equivalent to a serving of fat.

A 40-year-old male is prescribed Metformin XL (Glucophage) to control his type 2 diabetes mellitus. Which statement made by this client indicates the need for further education? 1. "I will take the drug with food." 2. "I must swallow my medication whole and not crush or chew it." 3. "I will stop taking Metformin for 24 hours before and after having a test involving dye." 4. "I will notify my doctor if I develop muscular or abdominal discomfort."

Correct 3. "I will stop taking Metformin for 24 hours before and after having a test involving dye." Metformin must be withheld for 48 hours before the use of iodinated contrast materials to prevent lactic acidosis. Metformin is restarted when kidney function has returned to normal. Metformin is taken with food to avoid adverse gastrointestinal effects. If crushed or chewed, Metformin XL will be released too rapidly and may lead to hypoglycemia. Muscular and abdominal discomfort is a potential sign of lactic acidosis and must be reported to the health care provider.

A nurse is teaching a young adolescent with type 2 diabetes about nutritional needs. Which statement demonstrates that the adolescent understands what was taught? 1. "I can have low-fat, low-cal candy bars." 2. "Regular soft drinks are better than diet ones." 3. "It's OK for me to eat one slice of pizza at a party." 4. "My fasting blood sugar should be no higher than 150."

Correct 3. "It's OK for me to eat one slice of pizza at a party." Pizza contains complex carbohydrates and protein; the child with type 1 diabetes may include a slice in the diet on special occasions. Although candy bars can be low in fat and calories, they may still have a high simple sugar content, which is contraindicated. Diet, not regular, soft drinks are preferred for an individual with type 2 diabetes; regular soft drinks are high in simple sugars. The euglycemic fasting blood glucose should be 70 to 105 mg/dL.

A 67-year-old man with type 2 diabetes sadly confides in the nurse that he has been unable to have an erection for several years. What is the best response by the nurse? 1. "At your age sex isn't that important." 2. "Sex isn't everything it's cracked up to be." 3. "You sound upset about not being able to have an erection." 4. "Maybe it's time for you to speak to your doctor about this."

Correct 3. "You sound upset about not being able to have an erection." When a client reveals something, it is important for the nurse to gather more information. The response, "You sound upset about not being able to have an erection" promotes further communication. Assessment is the first step of the nursing process. "At your age sex isn't that important" is a subjective, judgmental response that reflects the nurse's view of sexuality in older adults. "Sex isn't what all it's cracked up to be" interjects the nurse's view and violates the concept of neutrality when counseling clients. Having the client speak to his health care provider may be indicated eventually, but first the nurse must obtain more information.

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), the nurse should: 1. Initiate pulmonary hygiene to clear air passages of trapped mucus 2. Encourage continuous rapid panting to promote respiratory exchange 3. Administer oxygen at a low concentration to maintain respiratory drive 4. Encourage slow, deep breathing with inhalation longer than exhalation to increase intake

Correct 3. Administer oxygen at a low concentration to maintain respiratory drive With chronically high levels of carbon dioxide it is believed that decreased oxygen levels become the stimulus to breathe; high oxygen administration negates this mechanism. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. Initiating pulmonary hygiene to clear air passages of trapped mucus is an appropriate intervention, but is not directly related to CO2 intoxication (CO2 narcosis). Encouraging continuous rapid panting to promote respiratory exchange will not bring oxygen into the alveoli for exchange nor will it adequately remove carbon dioxide because it will increase bronchiolar obstruction. Inhalation should be of regular depth, and expiration should be prolonged to prevent carbon dioxide trapping (air trapping).

A male client with the diagnosis of primary hypertension is started on a regimen of hydrochlorothiazide (HydroDIURAL). The nurse is providing instructions regarding this medication. What information should the nurse include? 1. He should adjust the dosage daily based on his blood pressure. 2. He will experience impotence because it is an expected side effect. 3. An antihypertensive medication will likely be required for the remainder of his life. 4. One dose should be omitted if he experiences dizziness when standing up.

Correct 3. An antihypertensive medication will likely be required for the remainder of his life. If medication is necessary to control primary hypertension, usually it is a lifetime requirement. The client should not adjust the dosage without the health care provider's direction. Impotence may occur with some antihypertensive medications but not with hydrochlorothiazide. The drug should not be stopped; orthostatic hypotension can be controlled by a slow change of body position.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). The nurse should monitor the results of which laboratory test to evaluate the client for hypoxia? 1. Red blood cell count 2. Sputum culture 3. Arterial blood gas 4. Total hemoglobin

Correct 3. Arterial blood gas All of these laboratory tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status .

An older client with the diagnosis of dementia, Alzheimer type, is admitted to a nursing home. The client is confused and forgetful, wanders, and has intermittent episodes of urinary incontinence. How should the nurse plan to meet this client's elimination needs? 1. By pointing out the behavior to the client 2. By obtaining incontinence pads for the client 3. By taking the client to the bathroom at regular intervals 4. By encouraging the client to call for help when there is an urge to urinate

Correct 3. By taking the client to the bathroom at regular intervals Taking the client to the bathroom at regular intervals removes responsibility from the client, who is having difficulty recognizing and remembering to follow through on basic needs; routinely emptying the bladder may reduce episodes of incontinence. Pointing out the behavior to the client may precipitate feelings of guilt; forgetfulness is not deliberate but instead is the result of a degenerative process. Incontinence pads may eventually be obtained for the client, but it is not the initial intervention. The client may not be aware of the need to void or have the ability to control this bodily function.

An 84-year-old woman is admitted to the hospital with a diagnosis of dementia of the Alzheimer type. The nurse knows that this disorder is a: 1. Problem that first emerges in the third decade of life 2. Nonorganic disorder that occurs in the later years of life 3. Cognitive problem that is a slow and relentless deterioration of the mind 4. Disorder that is easily diagnosed through laboratory and psychological tests

Correct 3. Cognitive problem that is a slow and relentless deterioration of the mind Dementia of the Alzheimer's type accounts for 80% of dementias in older adults; it may be due to a neurotransmitter deficiency and is characterized by a steady decline in intellectual function, including memory deficits, disorientation, and decreased cognitive ability. More than 90% of people with dementia of the Alzheimer type are older than 50 years. It is an organic, not functional, disorder. Dementia of the Alzheimer type is difficult to diagnose and often is made when other causes of the dementia have been ruled out.

The nurse is caring for a client newly diagnosed with diabetes. The nurse should teach the newly diabetic client that which hypoglycemic symptom is one of the most common? 1. Kussmauls respirations 2. Tachycardia 3. Confusion 4. Anorexia

Correct 3. Confusion The most common symptoms of hypoglycemia are nervousness, weakness, perspiration, and confusion. Kussmauls respirations are associated with hyperglycemia or ketoacidosis. Bradycardia is associated with hypoglycemia, tachycardia is not. Anorexia is associated with hyperglycemia.

A health care provider prescribes oxygen given in low concentration rather than in high concentration to a client with chronic obstructive pulmonary disease (COPD). What does this prevent? 1. Decrease in red cell formation 2. Rupture of emphysematous bullae 3. Depression of the respiratory center 4. Excessive drying of the respiratory mucosa

Correct 3. Depression of the respiratory center Some clients with COPD must be given only low concentrations of oxygen; decreased oxygen blood level is a major stimulus for breathing for these clients. Prolonged hypoxia stimulates erythrocyte production; the goal of therapy is to relieve hypoxia. The pressure, rather than the concentration, at which oxygen is administered increases the risk of emphysematous bullae rupture. To prevent drying effects on secretions and the mucosa, oxygen may be humidified.

A client with type 2 diabetes is admitted for elective surgery. The health care provider prescribes regular insulin even though oral antidiabetics were adequate before the client's hospitalization. The nurse concludes that regular insulin is needed because the: 1. Client will need a higher serum glucose level while on bed rest. 2. Possibility of acidosis is greater when a client is on oral hypoglycemics. 3. Dosage can be adjusted to changing needs during recovery from surgery. 4. Stress of surgery may precipitate uncontrollable periods of hypoglycemia.

Correct 3. Dosage can be adjusted to changing needs during recovery from surgery. There is better control of blood glucose levels with short-acting (regular) insulin. The level of glucose must be maintained as close to normal as possible. The occurrence of acidosis is greater when the client is receiving exogenous insulin. The stress of surgery will precipitate hyperglycemia, which is best controlled with exogenous insulin.

A nurse provides dietary teaching about a low-sodium diet for a client with hypertension. Which nutrient selected by the client indicates an understanding about foods that are low in natural sodium? 1. Milk 2. Meat 3. Fruits 4. Vegetables

Correct 3. Fruits Fruits contain less natural sodium than do other foods. Milk is higher in natural sodium than is fruit. Meat is higher in natural sodium than is fruit. Vegetables are higher in natural sodium than is fruit.

A client newly diagnosed with diabetes arrives at the emergency room complaining of dizziness and weakness. The client's spouse reports that the client has been confused since this morning. The spouse reports that the client administered the morning dose of 10 units of regular insulin and 25 units of NPH insulin with difficulty and did not eat much breakfast. The nurse should understand the most likely cause of the client's signs and symptoms is: 1. Hyperglycemia. 2. Hyperlipidemia. 3. Hypoglycemia. 4. Hypocalcemia.

Correct 3. Hypoglycemia. Severe hypoglycemia is a finding in diabetic clients who take insulin and miss a meal. Signs and symptoms of hypoglycemia are dizziness, weakness, confusion, and disorientation. Hyperglycemia is rare in clients who are on insulin therapy and decrease their intake. Hyperlipidemia is excessive blood fat levels. Hypocalcemia is low calcium.

An obese client is diagnosed with diabetes. What increased physiological response to excessive weight should the nurse include when explaining the need for weight loss? 1. Fatty acid storage 2. Glucose oxidation 3. Insulin requirements 4. Cellular entry of glucose

Correct 3. Insulin requirements Obesity causes insulin resistance at the cellular level, so more insulin is required for transfer of glucose across cell membranes. Fatty acid metabolism is altered. Fatty acids break down; storage decreases. With obesity, oxidation of glucose decreases and insulin needs increase. Obesity causes peripheral cellular resistance to glucose entry into cells.

What should the nurse include in the plan of care for a client with dementia of the Alzheimer type, stage 2 (moderate dementia)? 1. Discuss recent current events. 2. Teach the client new social skills. 3. Maintain a daily routine of living. 4. Encourage the client to talk about past experiences.

Correct 3. Maintain a daily routine of living. The client with this disorder will be most comfortable with a familiar and repetitive daily routine because it will produce less anxiety. Cognitive changes probably make a discussion of current events unrealistic. It probably is beyond the client's capability to develop new social skills. Memory impairment may make talking about past events impossible.

A nurse is assessing a client with the diagnosis of primary hypertension. What clinical finding does the nurse identify as an indicator of primary hypertension? 1. Mild but persistent depression 2. Transient temporary memory loss 3. Occipital headache in the morning 4. Cardiac palpitation during periods of stress

Correct 3. Occipital headache in the morning Occipital headache in the morning is caused by increased vascular tension and damage to the vessels when hypertension is prolonged. Mild but persistent depression is a nonspecific response; it is not physiologically related to increased arterial blood pressure. Transient temporary memory loss occurs with transient ischemic attacks, which may be a later consequence of prolonged hypertension. Cardiac palpitation during periods of stress is a common physiologic effect of increased adrenaline released from the adrenal medulla during stress; it is not specific to hypertension.

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take? 1. Encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula 2. Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration 3. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula 4. Assist the client in assuming a position of comfort and perform postural drainage

Correct 3. Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promote respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy may be done later after the client's condition improves. Delaying intervention likely will worsen the respiratory distress.

A health care provider prescribes a diuretic for a client with hypertension. What should the nurse include in the teaching when explaining how diuretics reduce blood pressure? 1. Facilitates vasodilation 2. Promotes smooth muscle relaxation 3. Reduces the circulating blood volume 4. Blocks the sympathetic nervous system

Correct 3. Reduces the circulating blood volume Diuretics block sodium reabsorption and promote fluid loss, decreasing blood volume and reducing arterial pressure. Direct relaxation of arteriolar smooth muscle is accomplished by vasodilators, not diuretics. Vasodilators, not diuretics, act on vascular smooth muscle. Drugs that act on the nervous system, not diuretics, inhibit sympathetic vasoconstriction.

A nurse becomes aware of an older client's feeling of loneliness when the client states, "I only have a few friends. My daughter lives in another state and couldn't care less whether I live or die. She doesn't even know I'm in the hospital." The nurse identifies the client's communication as a: 1. Call for help to prevent him from acting on suicidal thoughts 2. Manipulative attempt to persuade the nurse to call the daughter 3. Reflection of depression that is causing feelings of hopelessness 4. Request for information about social support groups in the community

Correct 3. Reflection of depression that is causing feelings of hopelessness This statement provides clues that the client feels no one cares, so there is no reason the client should care. These feelings are common in depression. The clues presented do not lead to the other conclusions.

The nurse is caring for a client newly diagnosed with diabetes. When preparing the teaching plan about the importance of yearly eye examinations, the nurse should plan to instruct the client on which eye problem most associated with diabetes? 1. Cataracts 2. Glaucoma 3. Retinopathy 4. Astigmatism

Correct 3. Retinopathy Diabetic retinopathy is a leading cause of blindness in diabetics. Glaucoma and cataracts also are associated with diabetes, but retinopathy is the most common eye problem. Astigmatism is not associated with diabetes.

A client, complaining of fatigue, is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). To prevent fatigue, the nurse should: 1. Provide small, frequent meals 2. Encourage pursed-lip breathing 3. Schedule nursing activities to allow for rest 4. Encourage bed rest until energy level improves

Correct 3. Schedule nursing activities to allow for rest Rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small frequent meals may decrease pressure on the diaphragm and facilitate breathing, it does not address the client's fatigue. Although encouraging pursed-lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Bed rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.

An 80-year-old client who lives at home has dementia of the Alzheimer type, stage 1. The client is irritable and forgetful. The home care nurse concludes that this client: 1. Must be supervised closely at all times 2. Needs a home health aide to assist with activities of daily living 3. Should be allowed to function independently if therapeutically possible 4. Ought to be responsible for carrying out daily self-care activities without assistance

Correct 3. Should be allowed to function independently if therapeutically possible Priority should be given to providing nursing care to maintain an optimal level of safe function for as long as possible. Close supervision is usually not necessary during the early stages of dementia. Constant supervision can be destructive to self-esteem. A home health aide is usually not necessary during the early stages of dementia. The client may or may not be capable of performing all daily self-care activities.

An older client who lost a spouse 20 years ago comes to the community health center with a vague list of complaints and a brief life history. The couple's only child died at birth. The client lives alone and is able to perform all the activities of daily living. The client has had an active social life in the past but has outlived many friends and family members. What is an important question for the nurse to ask when taking this client's health history? 1. "Are you all alone?" 2. "How did your son die?" 3. "Do you still miss your spouse?" 4. "How do you feel about your life now?"

Correct 4. "How do you feel about your life now?" The answer to "How do you feel about your life now?" will provide the nurse with an idea of the client's hopes and frustrations without being threatening or probing. "Are you all alone?" is probing and provides little information for the nurse to use in planning care. "How did your son die?" and "Do you still miss your spouse?" are both probing, disregard the client's present situation, and provide little information for the nurse to use in planning care.

The nurse is caring for an 84-year-old man admitted with a diagnosis of severe Alzheimer dementia. In the admission assessment, the nurse notes that the client can no longer recognize familiar objects such as his glasses and toothbrush. The best term to describe this situation is: 1. Amnesia 2. Aphasia 3. Apraxia 4. Agnosia

Correct 4. Agnosia Agnosia is the term used to describe the loss of sensory ability to recognize familiar sounds and objects, as well as loved ones or even parts of the affected individual's body. Amnesia is the term for the impairment of memory both recent and remote. Aphasia is the term for the loss of language ability, which progresses with the disease. Apraxia is the term for the loss of purposeful movement in the absence of motor or sensory impairment. The individual is unable to perform purposeful tasks such as walking or putting clothing on properly.

A nurse is caring for a client with hypertension. Which assessment finding most significantly indicates that a client is hypertensive? 1. Tachycardia 2. Extended Korotkoff sound 3. Sustained systolic pressure ranging from 110 to 120 mm Hg 4. Diastolic blood pressure that remains higher than 90 mm Hg

Correct 4. Diastolic blood pressure that remains higher than 90 mm Hg A sustained diastolic pressure that exceeds 90 mm Hg reflects pathology and indicates hypertension. Tachycardia reflects the heart rate, not the pressures within the arteries. Extended Korotkoff sound is heard when measuring blood pressure by auscultation; it is unrelated to hypertension. Sustained systolic pressure ranging from 110 to 120 mm Hg is an expected systolic blood pressure.

An older adult with a diagnosis of delirium on the mental health unit begins acting out while in the dayroom. What is the initial nursing intervention? 1. Instructing the client to be quiet 2. Allowing the client to act out until fatigue sets in 3. Guiding the client from the room by gently holding the client's arm 4. Giving the client one simple direction at a time in a firm low-pitched voice

Correct 4. Giving the client one simple direction at a time in a firm low-pitched voice Clients who are out of control are seeking control and frequently respond to simple directions stated in a firm voice. "Be quiet" is a nontherapeutic order; furthermore, it is demeaning to the client. Allowing the client to act out until fatigue sets in will not help the client gain control and might be frightening to other clients in the dayroom. Guiding the client from the room by gently holding the client's arm is done only after an attempt at calming the client has failed.

A client with diabetes mellitus is able to discuss in detail the diabetic metabolic process while eating a piece of chocolate cake. What defense mechanism does the nurse identify when evaluating this behavior? 1. Projection 2. Dissociation 3. Displacement 4. Intellectualization

Correct 4. Intellectualization Intellectualization is the avoidance of a painful emotion with the use of a rational explanation that removes the event from any personal significance. Projection is the attribution of unacceptable thoughts and feelings to others. Dissociation is a temporary alteration of consciousness or identity used to handle conflict; amnesia is an example. Displacement is the discharge of a pent-up feeling, generally hostility, on an object or person perceived to be weaker than the person who aroused the feelings.

What is the priority nursing intervention for a forgetful, disoriented client with the diagnosis of dementia of the Alzheimer type? 1. Restricting gross motor activity 2. Preventing further deterioration 3. Keeping the client oriented to time 4. Managing the client's unsafe behaviors

Correct 4. Managing the client's unsafe behaviors Clients with Alzheimer disease require external controls to minimize the danger of injury due to lack of judgment. The staff should not prevent all gross motor activity; the client needs to use the muscles, or atrophy will occur. Further deterioration usually cannot be prevented in this disorder with nursing interventions; donepezil (Aricept) may help delay deterioration in some clients. It may not be possible to keep the client continuously oriented.

The nurse supports cognitive ability in clients with Alzheimer dementia by: Select all that apply. 1. Using calendars, clocks, and pictures to support memory 2. Encouraging caregivers to support protected independence 3. Providing a limited number of choices to support decision making 4. Quizzing the client regularly to assess orientation to person, place, and time 5. Administering prescribed rivastigmine (Exelon) to the client with severe Alzheimer dementia

Correct 1,2,3 1. Using calendars, clocks, and pictures to support memory 2. Encouraging caregivers to support protected independence 3. Providing a limited number of choices to support decision making Strategies that assist orientation without challenging the client and that encourage protected independence and decision making support cognitive function in mild to moderate Alzheimer disease. Interactions that quiz or challenge the client are not well tolerated and do not support cognitive functioning. Alzheimer dementia is characterized by cerebral atrophy, by the loss of acetylcholine producing nerves, and by the presence of neurofibrillary tangles and amyloid plaques. Rivastigmine is a cholinesterase inhibitor that provides a modest short-term cognitive benefit for some people with mild to moderate Alzheimer's dementia. It works by increasing acetylcholine at cholinergic synapses. It is not approved for people with severe disease.