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Nursing for Wellness in Older Adults Miller 8th Edition Test Bank
Chapter 1 Seeing Older Adults Through the Eyes of Wellness
1. In 2010, the revised Standards and Scope of Gerontological Nursing Practice was published.
The nurse would use these standards to:
a. promote the practice of gerontologic nursing within the acute care setting.
b. define the concepts and dimensions of gerontologic nursing practice.
c. elevate the practice of gerontologic nursing.
d. incorporate suggested interventions from others who practice gerontologic
nursing.
ANS: D
The current publishing of the Standards and Scope of Gerontological Nursing Practice in 2010
incorporates the input of gerontologic nurses from across the United States. It was not intended
to promote gerontologic nursing practice within acute care settings, define concepts or
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DIF: Remembering (Knowledge) REF: MCS: 2 OBJ: 1-1
TOP: N/A MSC: Safe and Effective Care Environment
2. When attempting to minimize the effect of ageism on the practice of nursing older adults, a
nurse needs to first:
a. recognize that nurses must act as advocates for aging patients.
b. accept that this population represents a substantial portion of those requiring
nursing care.
c. self-reflect and formulate ones personal view of aging and the older patient.
d. recognize ageism as a form of bigotry shared by many Americans.
ANS: C
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Ageism is an ever-increasing prejudicial view of the effects of the aging process and of the older
population as a whole. With nurses being members of a society holding such views, it is critical
that the individual nurse self-reflect on personal feelings and determine whether such feelings
will affect the nursing care that he or she provides to the aging patient. Acting as an advocate is
an important nursing role in all settings. Simply accepting a fact does not help end ageism, nor
does recognizing ageism as a form of bigotry.
DIF: Applying (Application) REF: N/A OBJ: 1-9
TOP: Teaching-Learning MSC: Safe and Effective Care Environment
3. When discussing factors that have helped to increase the number of healthy, independent older
Americans, the nurse includes the importance of:
a. increased availability of in-home care services.
b. government support of retired citizens.
c. effective antibiotic therapies.
TESTtherapies.
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d. the development of life-extending
ANS: C
The health and ultimate autonomy of older Americans has been positively impacted by the
development of antibiotics, better sanitation, and vaccines. These public health measures have
been more instrumental in increasing the numbers of healthy, independent older Americans than
have in-home care services, government programs, or life-extending therapies.
DIF: Remembering (Knowledge) REF: MCS: 2 OBJ: 3-3
TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance
4. Based on current data, when presenting an older adults discharge teaching plan, the nurse
includes the patients:
a. nonrelated caretaker.
b. paid caregiver.
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c. family member.
d. intuitional representative.
ANS: C
Less than 4% of older adults live in a formal health care environment. The majority of the
geriatric population lives at home or with family members.
DIF: Applying (Application) REF: N/A OBJ: 3-3
TOP: Nursing Process: Planning MSC: Safe and Effective Care Environment
5. The nurse planning care for an older adult who has recently been diagnosed with rheumatoid
arthritis views the priority criterion for continued independence to be the patients:
a. age.
b. financial status.
c. gender.
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d. functional status.
ANS: D
Maintaining the functional status of older adults may avert the onset of physical frailty and
cognitive impairment, two conditions that increase the likelihood of institutionalization.
DIF: Remembering (Knowledge) REF: MCS: 8 OBJ: 1-6
TOP: Nursing Process: Planning MSC: Physiologic Integrity
6. A nurse working with the older adult population is most likely to assess a need for a financial
social services referral for a(n):
a. white male.
b. black female.
c. Hispanic male.
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d. Asian American female.
ANS: B
The poverty rate among older black women is substantially higher than that seen among males or
females of other ethnic groups. White males had the least poverty.
DIF: Applying (Application) REF: N/A OBJ: 1-4
TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment
7. Which of the following statements made by a nurse preparing to complete a health assessment
and history on an older patient reflects an understanding of the general health status of this
population?
a. Ill need to document well regarding the medications the patient is currently
prescribed.
b. I would like to understand how supportive the patients family members are.
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c. Most older patients are beingTtreated
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d. It will be interesting to see whether this patient sees herself as being healthy.
ANS: D
It is a misconception that old age is synonymous with disease and illness. The nurse should
always determine the patients sense of wellness and independence when conducting a health and
history assessment. An assessment of medication use and family support is important for any
patient. Many older adults do have chronic health conditions, but their perception is more
important than a single number.
DIF: Applying (Application) REF: N/A OBJ: 1-4
TOP: Nursing Process: Assessment MSC: Health Promotion
8. The nurse is caring for an older adult who has been admitted to an acute care hospital for
treatment of a fractured femur. The family expresses concern about the patients pending transfer
to a subacute care facility. What response by the nurse is best?
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a. Acute care facilities lack the long-term physical therapy support your dad
requires.
b. Your dad will be much happier in a more serene, private environment.
c. The subacute facility will focus on helping your dad maintain his independence.
d. Insurance, including Medicare, will cover only a limited amount of time here.
ANS: C
The transfer of the patient to a subacute facility is based on the need to maintain the patients
level of function and independence, a task the acute care facility is not prepared to address once
the patient is physiologically stable. The patient may or may not be happier in the new setting;
the nurse should not make this judgment. It is true that insurance only pays for a limited amount
of time in an acute care facility, but this is not the best reason for the patient to transfer.
DIF: Applying (Application) REF: N/A OBJ: 1-6
TOP: Communication and Documentation
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MSC: Health Promotion and Maintenance
9. To best assure both the quality of care and the safety of the older adult patient who requires inhome unlicensed assistive personal (UAP) assistance, the geriatric nurse:
a. evaluates the competency of the UAP staff.
b. assumes the roles of case manager and patient advocate.
c. arranges for the needed UAP provided services.
d. assesses the patient for functional limitations.
ANS: A
As more care traditionally provided by professional nurses is being transferred to UAP, the nurse
must assume more responsibility for educating, training, and evaluating the competency of UAP
staff to provide safe, effective care for the older adult patient.
DIF: Applying (Application) REF: N/A OBJ: 1-2
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TOP: Communication and Documentation
MSC: Safe and Effective Care Environment
10. The nurse working with older adults understands what information about certification in
gerontologic nursing?
a. It is mandatory for those in long-term care settings.
b. It is voluntary and shows clinical expertise in an area.
c. It allows nurses to be paid by third-party payers.
d. It allows nurses to advance their careers in a job.
ANS: B
Certification is voluntary and shows that a nurse has additional knowledge and expertise in a
certain area of practice. It is not mandatory in specific care settings. It does not allow for thirdparty reimbursement. It may be part of a career ladder program, but that is not true of all work
settings.
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DIF: Remembering (Knowledge) REF: MCS: 2 OBJ: 1-2
TOP: Teaching-Learning MSC: Safe Effective Care Environment
11. A nurse works in a gerontologic clinic. What action by the nurse takes highest priority?
a. Serving as a patient advocate
b. Educating patients about diseases
c. Helping patients remain independent
d. Referring patients to home health care
ANS: C
One of the challenges and priorities of the gerontologic nurse is helping patients maintain their
independence.
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DIF: Remembering (Knowledge) REF: MCS: 10 OBJ: 1-2
TOP: Nursing Process: Implementation MSC: Health Promotion
12. A nurse is caring for an older patient in the emergency department. What information about
the patient will be most helpful in creating a plan of care?
a. Baseline physical and cognitive functioning
b. Living conditions and family support
c. Medications and current medical problems
d. Results of the Mini Mental State examination
ANS: A
The nurse is encouraged to view older patients as individuals and consider their baseline physical
and cognitive functional status as a standard by which to compare the patients current status. The
other information is also important, but the basis of individualized care begins with the patients
strengths and weaknesses.
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DIF: Applying (Application) REF: N/A OBJ: 1-6
TOP: Nursing Process: Assessment MSC: Health Promotion
13. The faculty member explains to students that many older Americans continue to work past
the retirement age. What best explains this trend?
a. Feeling healthier longer
b. Changing financial outlook
c. Becoming bored in retirement
d. A desire to give back
ANS: B
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As financial situations may have declined as a result of many economic factors, more older
adults work past their retirement age. The other options may be reasons for some to continue
working, but financial necessity is the reason the majority continue to do so.
DIF: Remembering (Knowledge) REF: MCS: 7 OBJ: 1-3
TOP: Teaching-Learning MSC: Health Promotion
14. What information does the faculty member teach students about Medicare?
a. Covers anyone with end stage renal disease
b. Part A covers some prescription costs
c. Part B covers inpatient hospital costs
d. Part D eliminates the drug donut hole
ANS: A
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end-stage kidney disease. Part A covers hospital costs. Part B is medical insurance. The donut
hole was fixed by the Affordable Care Act.
DIF: Understanding (Comprehension) REF: MCS: 9 OBJ: 1-3
TOP: Teaching-Learning MSC: Health Promotion
15. A nursing manager notes that many older patients are admitted to the nursing unit for acute
problems. What action can the manager take to most benefit this population?
a. Provide mandatory education on the needs of the older patient.
b. Provide restorative therapy programs designed for this group.
c. Ensure staffing numbers are adequate for dependent patients.
d. Encourage all nurses to obtain gerontologic certification.
ANS: B
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Many older adults need acute care for sudden illness and injury but live in a state of functional
decline, which could possibly be prevented by establishing a restorative therapy program. The
other actions will help the older patients cared for in the unit, but only to limited degrees.
DIF: Applying (Application) REF: N/A OBJ: 1-4
TOP: Nursing Process: Implementation MSC: Physiologic Integrity: Reduction of Risk Potential
16. The dean of a new nursing program wishes to ensure graduates are prepared to care for older
patients. What document should guide the dean in designing the curriculum?
a. The Nurse Practice Act for that state
b. The American Nurses Association (ANA) code of ethics for nurses
c. Healthy People 2020
d. The Recommended Baccalaureate Competencies and Curricular Guidelines
ANS: D
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The Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing
Care of Older Adults is an updated version of The Essentials of Baccalaureate Education for
Professional Nursing Practice. This document was first published by the American Association
of Colleges of Nursing (AACN) in 2008 and was updated in 2010. The other three documents do
not have information about curricular requirements to prepare students to care for the older
population.
DIF: Applying (Application) REF: N/A OBJ: 1-2
TOP: Teaching-Learning MSC: Health Promotion
17. A nurse wants to plan a community event at a retirement center. What topic would most
likely be best received?
a. Heart healthy living
b. Financial planning
c. Avoiding scams
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d. Ethnic cooking classes
ANS: A
Older adults are demanding more programs and services aimed at health maintenance and
promotion and disease and disability prevention. Based on this information, the heart healthy
living presentation would be best received.
DIF: Applying (Application) REF: N/A OBJ: 1-3
TOP: Teaching-Learning MSC: Health Promotion
18. What does the bedside nurse understand about his or her role in nursing research?
a. Research is only done by doctorally prepared nurses.
b. All nurses have a role in delivering research-based care.
c. A bedside nurse can be part of a hospital research team.
d. The bedside nurse can collectTE
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ANS: B
All nurses are charged to deliver patient-centered care based on evidence-based practice,
research, quality improvement, and informatics. The bedside nurse is part of an interdisciplinary
team that is responsible for redesigning the health care structure of the future.
DIF: Understanding (Comprehension) REF: MCS: 13 TOP: Teaching-Learning
MSC: Safe Effective Care Environment: Management of Care
MULTIPLE RESPONSE
1. The clinic nurse caring for an older diabetic patient with a sixth grade education anticipates
that the patient may experience difficulty (Select all that apply.)
a. recognizing the importance of keeping clinic appointments.
b. following a low-carbohydrate diet.
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c. paying for insulin and syringes.
d. deciding on a primary health care provider.
e. naming a health care surrogate.
ANS: A, B, C
Even though the educational level of the older population has steadily increased, as a population
they are less educated than the general population. This deficiency can account for a lack of
understanding regarding the need for medical care and the importance of following a treatment
plan. These patients may also have fewer financial resources to devote to health care issues.
DIF: Analyzing (Analysis) REF: N/A OBJ: 1-4
TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment
2. The nurse studying the history of gerontologic nursing learns which information about the
specialty? (Select all that apply.)
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a. The number of older Americans is diminishing.
b. The geriatric nursing conference group was established in 1962.
c. The gerontologic clinical nurse specialist certification was offered in 1989.
d. There were no writings about the care of older persons until World War II.
e. The first Standards of Practice for Geriatric Nursing was written in 1969.
ANS: B, C, E
The geriatric nursing conference group was established in 1962, the gerontologic clinical nurse
specialist certification was first offered in 1989, and the first Standards of Practice for Geriatric
Nursing was written in 1969. The population of older Americans is the fastest-growing subset of
the population. Writings about care of the aged can be found from as early as 1900.
DIF: Remembering (Knowledge) REF: MCS: 2-3 OBJ: 1-2
TOP: Teaching-Learning MSC: Nursing Process: Assessment
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3. The student asks the gerontologic clinic nurse why so many older people are women. What
information does the nurse provide? (Select all that apply.)
a. Reduced maternal mortality
b. Decreased deaths from infectious diseases
c. More deaths from chronic disease in men
d. More deaths in war occur in men
e. Women tend to smoke and drink less than men
ANS: A, C, D
A decrease in maternal mortality, decreased deaths from infectious diseases, and more chronic
illness in men account for the disparity in genders as people age.
DIF: Understanding (Comprehension) REF: MCS: 6 OBJ: 1-5
TOP: Teaching-Learning MSC: Health Promotion
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4. The gerontologic nurse plans community programming for older women, noting what facts
about this population subgroup? (Select all that apply.)
a. More likely to live alone
b. Increased chance of living in poverty
c. Taking care of a spouse
d. Suffering many chronic diseases
e. Living with extended families
ANS: A, B, D
Older women have a greater chance than men of living alone and in poverty. They also have a
greater degree of functional impairment and chronic disease.
DIF: Remembering (Knowledge) REF: MCS: 6 OBJ: 1-5
TOP: Nursing Process: Analysis MSC: Health Promotion
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5. The nurse knows that the most common causes of death in the older population result from
which diseases? (Select all that apply.)
a. Cerebrovascular disease
b. End-stage kidney disease
c. Heart disease
d. Cancer
e. Diabetes
ANS: A, C, D
The most common causes of death in the older population are cerebrovascular disease, heart
conditions, and cancer. End-stage renal disease and diabetes are not among the top three causes
of death.
Chapter 2 Addressing Diversity of Older Adults
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MULTIPLE CHOICE
1. A postmenopausal black woman who has been experiencing uterine bleeding tells the nurse, I
expect Ill need a total hysterectomy because when my sister had this problem thats what she had
done. The nurse recognizes that this woman belongs to a cultural subgroup whose health care
beliefs are most influenced by the:
a. biomedical model.
b. magico-religious model.
c. balance/harmony model.
d. personal experience.
ANS: A
The patient shows a tendency to identify with the biomedical model, which views the body as a
functioning machine. When a part gives out or is functioning abnormally, traditional Western
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medical treatment is sought and expected. The magico-religious models believe that health is a
reward from a higher power. The balance/harmony models state that illness is the result of a state
of imbalance in body energies. Personal experience influences all of these models.
DIF: Understanding (Comprehension) REF: MCS: 91 OBJ: 5-5
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
2. A Hispanic patient explains that the Hispanic culture believes that dietary management would
be just as effective in managing her problems as medication, so the patients prescription has not
been filled. Which action by the nurse illustrates cultural accommodation?
a. Asking the patient to give more details regarding this belief
b. Discussing how to add dietary preferences into the treatment plan
c. Offering to have a registered nutritionist discuss the situation with the patient
d. Researching the patients proposed dietary beliefs
ANS: B
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Cultural care accommodation or negotiation refers to those assistive, supportive, facilitative, or
enabling creative professional actions and decisions that help people of a designated culture
adapt to or negotiate with others for a beneficial or satisfying health outcome. The nurse can ask
the patient to share more about beliefs, offer a consultation with a nutritionist, or research the
beliefs, but these actions do not show accommodation.
DIF: Applying (Application) REF: N/A OBJ: 5-9
TOP: Caring MSC: Psychosocial Integrity
3. A geriatric nurse practitioner working with a tribe of Native Americans makes the decision to
acculturate in an attempt to provide culturally appropriate care. The nurse does this best by:
a. living the values of the tribe.
b. researching the tribes belief systems.
c. learning the language of the tribe.
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d. residing among the tribe members.
ANS: A
Acculturation is a process that occurs when a member of one cultural group adopts the values,
beliefs, expectations, and behaviors of another group, usually in an attempt to become
recognized as a member of the group. The other actions might be helpful in acculturating.
DIF: Applying (Application) REF: N/A OBJ: 5-3
TOP: Nursing process: Implementation MSC: Psychosocial Integrity
4. The nurse in an assisted living facility is practicing a form of cultural bias called
ethnocentrism when:
a. requesting the bridge group only use the game room for 2 hours at a time.
b. encouraging Christian residents to attend mass or church services.
c. repeatedly confiscating herbs and food products used in healing.
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d. telling potential patients who are Jewish that the facility does not have a kosher
kitchen,
ANS: C
Ethnocentrism is a belief that ones own cultural group is superior to that of anothers. In nursing
we have a unique culture and expect our patients to adapt to us rather than attempting to adapt to
the culture of the patient. Confiscating items used in healing rituals shows ethnocentrism and
disrespect to the resident. Limiting activities in a group room, encouraging people to attend
church services of their religion, and letting prospective Jewish residents know that the facility
does not have a kosher kitchen are not examples of ethnocentrism.
DIF: Applying (Application) REF: N/A OBJ: 5-6
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
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5. While caring for an older Korean patient, the nurse notes that the patient answers questions
regarding health history when asked but is otherwise silent and does not maintain eye contact.
Being culturally sensitive, the nurse recognizes that the patients actions are most likely a(n):
a. sign of respect for the wisdom and expertise of the nurse.
b. indication that he has no questions regarding the care he is receiving.
c. expression of discomfort discussing personal matters.
d. means of communicating his dissatisfaction with his care.
ANS: A
Asian cultures generally view eye contact as rude and are often passive in their care. The patient
may or may not have further questions. It is not a sign of discomfort or dissatisfaction.
DIF: Remembering (Knowledge) REF: MCS: 93 OBJ: 5-7
TOP: Caring MSC: Psychosocial Integrity
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6. The culturally sensitive nurse will recognize that an older adult patient with a high-context
ethnic background will appreciate:
a. not having a treatment scheduled during a favorite television program.
b. both a written and verbal explanation describing how to monitor her blood sugar
levels.
c. a concise explanation as to why her physical therapy appointment has been
canceled.
d. having a conversation about her grandchildren while her dressing is changed.
ANS: D
The interactional patterns of high-context (universalism) patients refer to the characteristics of
relationships and behaviors toward others. When a person from a high-context culture interacts
with the nurse, a more personal relationship is expected. This is not related to television shows,
teaching materials, or appointment cancellations.
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DIF: Understanding (Comprehension) REF: MCS: 92 OBJ: 5-7
TOP: Caring MSC: Psychosocial Integrity
7. In an attempt to be sensitive to varying cultural responses to touch, before shaking a patients
hand, the nurse will:
a. offer the patient his or her upturned palm.
b. wait until the patient extends his or her hand.
c. establish eye contact with the patient first.
d. address the patient by his or her full name.
ANS: B
The best way to show respect and implement the appropriate response is to follow the lead of the
patient by waiting for the patient to extend a hand.
DIF: Applying (Application) REF:
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TOP: Caring MSC: Psychosocial Integrity
8. A older Asian patient receiving physical therapy after hip surgery has developed a low-grade
fever. The patient explains that the fever will lessen if the treatment includes the principles of
yin/yang. The nurse expects to support the patient by:
a. providing privacy when his shaman visits.
b. arranging for his diet to include cold foods and liquids.
c. planning his physical therapy so it does not conflict with meditation.
d. keeping a magical amulet under his pillow.
ANS: B
The yin/yang theory proposes that health is a result of balance within the body. A principle of
this theory is that an illness is either hot or cold and must be treated by elements of the opposite
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state in order to put the system back into balance. It is not related to shaman visits, meditation, or
amulets.
DIF: Applying (Application) REF: N/A OBJ: 5-9
TOP: Caring MSC: Psychosocial Integrity
9. The nurse in an assisted living facility is preparing to admit an older adult patient who speaks
very little English. The nurse decides that it is most important that an interpreter be present when
the patient:
a. indicates a desire to talk with the physician.
b. is being oriented to the facility.
c. is required to sign official documents.
d. begins crying and is inconsolable.
ANS: C
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The more complex the decision making, the more important it is to have an interpreter present.
Although all situations would benefit from an interpreter, the most important time is when the
patient is signing official documents that have legal implications.
DIF: Applying (Application) REF: N/A OBJ: 5-8
TOP: Communication and Documentation MSC: Psychosocial Integrity
10. When attempting to provide culturally sensitive care according to the explanatory model, the
nurse asks the patient:
a. Who will be able to help you when you go home?
b. Do you think the treatment is helping?
c. When did you first notice the problem?
d. Has this illness changed your life?
ANS: D
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The gerontologic nurse uses this model to explore the meaning of the health problem from the
patients perspective.
DIF: Applying (Application) REF: N/A OBJ: 5-7
TOP: Caring MSC: Psychosocial Integrity
11. The nurse is caring for an older adult patient in need of hospitalization. The nurse is aware
this patient is a member of an ethnic group that holds a collectivist perspective on community.
The nurse best addresses the patients medical needs by:
a. calling an interpreter to assure the patient is making an informed decision.
b. assuring the patient that his spiritual advisor will meet him at the hospital.
c. arranging for admission to a hospital that is familiar with this patients culture.
d. offering to phone the patients family and ask them to come in and discuss the
hospitalization.
ANS: D
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People with a collectivist perspective derive their identity from affiliation with and participation
in a social group such as a family or clan. The needs of the group are more important than those
of the individual, and decisions are made with consideration of the effect on the whole. Health
care decisions may be made by a group (such as the tribal elders) or a group leader (such as the
oldest son). The other options may or may not be needed depending on the specifics of the
patients case.
DIF: Applying (Application) REF: N/A OBJ: 5-9
TOP: Caring MSC: Psychosocial Integrity
12. The nurse is most effectively using the concept of future time orientation when:
a. promising to help the patient call his daughter each weekend.
b. offering to complete the health assessment history after the patient eats dinner.
c. encouraging an older patient to keep a follow-up clinic appointment.
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d. arranging for a colorectal cancer screen for senior citizens.
ANS: D
In the concept of future orientation, people accept the idea that what is done now affects future
health. This means that health screenings will help detect a problem today for potentially better
health at a later time, days, weeks, or years ahead; it means that prevention may be worth
pursuing. The other actions do not show a future orientation.
DIF: Applying (Application) REF: N/A OBJ: 5-9
TOP: Caring MSC: Psychosocial Integrity
13. The student learns that which of the following is the best definition of culture?
a. A group of similarly appearing individuals
b. Shared beliefs, behaviors, and expectations of groups
c. Group beliefs about what is right and wrong
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d. Groups that come from the same part of the world
ANS: B
A culture is a set of shared and learned beliefs, behaviors, and expectations among a group of
people. The individuals in different cultures may or may not look similar. Group beliefs about
what is right or wrong are known as values. Cultural members may come from many different
parts of the world.
DIF: Remembering (Knowledge) REF: MCS: 87 OBJ: 5-3
TOP: Teaching-Learning MSC: Psychosocial Integrity
14. A student nurse expresses frustration to the faculty member regarding an ethnic older adult
who appears to be noncompliant. The student states, Why cant the patient just do what we teach
her to do? What response by the nurse is best?
a. Yes, I realize how frustrating this must be for you.
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b. People from her culture are never compliant.
c. Maybe you can find a different way to get through.
d. Culture dictates how people respond to others.
ANS: D
Culture is a blueprint for responding to individuals, family, and the community. Persons from
strong cultural backgrounds cannot just change their behavior when instructed to do so. The
nurse explains this to the student. Stating that the nurse understands the frustration is helpful but
does not give the student any information that could help him or her work with this patient.
Stating that people from a certain culture are never compliant is biased and prejudicial. Getting
through to the patient implies ethnocentrism and bias.
DIF: Applying (Application) REF: N/A OBJ: 5-7
TOP: Caring MSC: Psychosocial Integrity
15. A patient from a culture that differs
that
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What action by the nurse best demonstrates cultural care preservation?
a. Allowing the family to remain at the bedside
b. Pinning a healing amulet to the patients gown
c. Offering the family food and drink in the room
d. Giving the family time to be alone with the patient
ANS: B
Cultural care preservation refers to those assistive, supportive, facilitative, or enabling
professional actions and decisions that help people of a particular culture to retain and maintain
their well-being, to recover from illness, or to face handicaps or death. Allowing the patient to
have healing artifacts important in his or her culture nearby best demonstrates this concept. The
other actions are caring but do not demonstrate this principle.
DIF: Applying (Application) REF: N/A OBJ: 5-9
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TOP: Caring MSC: Psychosocial Integrity
16. The nurse uses the LEARN model when providing care. What event best demonstrates that
this model has been successful?
a. The nurse learns about the patients culture and how it impacts care.
b. The patient and nurse agree on a mutually acceptable plan of action.
c. The nurse listens carefully to the patients concerns and beliefs.
d. The patient understands how medical care will be beneficial.
ANS: B
The LEARN model includes listening to the patient, explaining your own perspectives,
acknowledging the similarities and differences in both viewpoints, recommending a plan of
action, and negotiating a final plan. If the patient and nurse have come to an agreement on a plan
of action, this model has been successful.
TEN/A
STBOBJ:
ANK5-7
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DIF: Evaluating (Evaluation) REF:
TOP: Caring MSC: Psychosocial Integrity
17. A new nurse is caring for a patient from Appalachia. The patient seems guarded and
secretive, which frustrates the new nurse. What advice from the mentor is most appropriate?
a. Maybe you should ask to change your assignment.
b. This is a normal behavior for this patients cultural group.
c. You could try to apologize for anything you may have done.
d. Ask the patient why she is acting so strangely around you.
ANS: B
Patients from the Appalachian culture are typically wary and guarded around strangers and view
the hospital as a place to go and die. The nurse explains this to the new nurse. Changing
assignments will not help the new nurse become culturally competent. The new nurse could ask
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the patient if there has been some offense, but this is probably not the case. Why questions put
people on the defensive and are not considered examples of therapeutic communication.
DIF: Understanding (Comprehension) REF: MCS: 87 OBJ: 5-6
TOP: Caring MSC: Psychosocial Integrity
18. A nurse is caring for an Arab American patient in the hospital. The patient has many visitors
who seem to be tiring the patient. What action by the nurse is best?
a. Limit the number of visitors the patient can have.
b. Only allow family members to visit the patient.
c. Suggest shorter visits to the patients visitors.
d. Require visitors to check in at the front desk.
ANS: C
In Arab American Muslim culture,
the
sick
aR
cultural
TEvisiting
STBAN
KS
ELisLE
.COMvalue and expectation. Although
the visits may be tiring, they may also be important to the patient. The nurse can suggest shorter
visits so the patient can have both the visitors and more rest. Limiting the number of visitors
would violate this cultural norm as would limiting visits to family only. Checking in at the front
desk serves no useful purpose.
DIF: Applying (Application) REF: N/A OBJ: 5-6
TOP: Caring MSC: Psychosocial Integrity
19. A director of nursing works in a hospital that serves many Jehovahs Witness patients. What
action by the nurse would best facilitate culturally appropriate health care?
a. Establish a bloodless surgery program.
b. Create an immunization clinic for children.
c. Employ spiritual leaders from this faith.
d. Allow faith healing ceremonies.
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ANS: A
Jehovahs Witnesses generally are opposed to receiving all blood products. A bloodless surgery
program would be a culturally competent way to improve the health care of this population.
DIF: Applying (Application) REF: N/A OBJ: 5-5
TOP: Caring MSC: Psychosocial Integrity
20. An incapacitated older adult with dementia is brought to the emergency department by a
rescue squad after falling and breaking an arm. When the patients children arrive, they are
adamantly against the patient having any medical care and insist that prayer will heal the broken
arm. What action by the nurse is most appropriate?
a. Allow the family to pray with the patient then escort them to the waiting room.
b. Call security to keep the family from interfering with medical care.
c. Check facility policies and contact the hospital social worker.
d. Call the police who can forceTthe
family
toSaccept
EST
BANK
ELLEmedical
R.COMcare.
ANS: C
This family may be Christian Scientists, who do not believe in medical care. Health crises are
thought to be errors of the mind that can be altered by prayer. The nurse should check the facility
policies for treating vulnerable adults and possibly notify social work, who can assist with
ensuring adequate treatment occurs as allowed by policy. Allowing the family to pray with the
patient is a caring action, but this complex situation requires more intervention. Calling security
or the police will antagonize the family even more and demonstrates an adversarial relationship.
DIF: Applying (Application) REF: N/A OBJ: 5-6
TOP: Communication and Documentation
MSC: Safe Effective Care Environment
MULTIPLE RESPONSE
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1. When attempting to reflect about personal cultural awareness, the nurse asks himself or herself
which of the following quetions? (Select all that apply.)
a. What image do I want to project to members of other cultures?
b. What makes a culture worthy of biased treatment?
c. Have my life experiences contributed to any biases regarding other cultures?
d. Am I uncomfortable when interacting with members of other cultures?
e. Does the patients culture rely on solid science to direct health care?
ANS: A, C, D
Self-reflection implies thinking that regards how I, the individual, perceives/believes/behaves.
Awareness of ones thoughts and feelings about others who are culturally different from oneself is
necessary to become culturally aware. No culture is worthy of biased treatment. Solid science is
an ethnocentric principle.
DIF: Applying (Application) REF: N/A OBJ: 5-4
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TOP: Caring MSC: Psychosocial Integrity
2. What does the nurse working with older adults from many different cultures know about the
demographics of culture in the United States? (Select all that apply.)
a. Hispanics will become the largest minority group by 2030.
b. Many persons of color are not counted in the census.
c. The percentage of Native Americans/Native Alaskans will decrease.
d. The number of refugees and immigrants is expected to decrease.
e. Some Native Americans want to identify as specific tribal members.
ANS: A, B, C
Hispanics are expected to be the largest minority group in the United States by 2030. Many
persons of color are not represented in the census, and this underestimates their presence. The
percentage of Native Alaskans and Native Americans will rise, as will the number of
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immigrants/refugees. Some Native Americans may not view themselves as part of this larger
group, preferring to identify as a member of a specific tribe.
DIF: Remembering (Knowledge) REF: MCS: 83 OBJ: 5-1
TOP: Communication and Documentation MSC: Psychosocial Integrity
3. A nurse working in the emergency department is seeing an older patient who does not speak
English well. The nurse calls for an interpreter. The student wants to know why the patients
minor child, who speaks English, cannot interpret. What response by the nurse is best? (Select all
that apply.)
a. The child may not accurately translate.
b. The child and older adult may be embarrassed.
c. The patient has the right to interpretation.
d. Having a child interpret takes too much time.
e. Privacy laws prohibit this practice.
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ANS: A, B, C
Although in a true emergency the nurse may have to use a child interpreter, this practice is not
recommended. The child may not have the vocabulary to translate, the child may edit the
comments, the child or older adult may be embarrassed by the medical condition, and patients
have a legal right to professional interpretation. Using an interpreter always takes more time and
privacy laws do not prohibit this practice.
Chapter 3 Applying a Nursing Model for Promoting Wellness in Older Adults
MULTIPLE CHOICE
1. When the home health nurse assists the older adult patient with rearranging furniture within
the home to prevent the patient from falling, the nurse is demonstrating:
a. health promotion.
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b. health protection.
c. health prevention.
d. disease prevention.
ANS: B
The overarching goals are to attain high-quality, long lives free of preventable disease, disability,
and injury; to eliminate disparities; create social and physical environments that promote health;
and optimize quality of life across the life span. Health protection targets five areas including
unintentional injury. Rearranging furniture to prevent falls is a health protection activity.
DIF: Applying (Application) REF: N/A OBJ: 8-1
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
2. The primary focus of the health belief model of health promotion is addressed when the nurse:
a. accompanies the assisted living residents on a walk before dinner.
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b. asks a senior citizens group what health screening they want to have.
c. plans a program on cooking diabetic-friendly meals in cooperation with a
dietician.
d. asks the patient if he believes smoking puts him at risk for lung cancer.
ANS: D
The health belief model, which was developed to determine the likelihood of an individuals
participation in health promotion, health protection, and disease prevention services, includes
assessing an individuals perception of his or her susceptibility to developing an illness. Asking
the patient about beliefs related to tobacco use and health is an activity that falls within this
model. The other activities do not.
DIF: Understanding (Comprehension) REF: MCS: 141 OBJ: 8-2
TOP: Nursing Process: Assessment MSC: Health Promotion
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3. Financial considerations are a major barrier to the older adults participation in health
promotion because:
a. most older adults have accepted poor health as a part of growing older.
b. Medicare often does not cover the cost of preventive services.
c. many already have been diagnosed with chronic illnesses.
d. they generally place more value on saving their disposable income.
ANS: B
Older adults must incur the cost of many preventive services because Medicare does not cover
them all. This can be hard on the fixed, limited income of many older adults. It is not true that
older adults accept poor health as inevitable. Health promotion activities can occur in the
presence of chronic illnesses. Some older adults do place high value on saving money, but not all
older adults are influenced by this desire.
DIF: Understanding (Comprehension) REF: MCS: 148 OBJ: 8-4
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TOP: Nursing Process: Assessment MSC: Health Promotion
4. To engage the older adults who frequently attend a senior citizens center in primary disease
prevention, the nurse:
a. immunizes those attending a weekly luncheon against the H1N1 virus.
b. arranges for a colorectal cancer screening at the center.
c. schedules a speaker to discuss cooking for diabetic patients.
d. surveys the members to identify health issues of interest to them.
ANS: A
Primary prevention refers to specific action taken to optimize the health of the older individual
by helping him or her to become more resistant to disease or to ensure that the environment will
be less harmful. Providing immunizations would be included in this level of prevention.
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Colorectal cancer screening is secondary prevention. Cooking for diabetic patients is tertiary
prevention. Surveying patients does not fall into any level of prevention.
DIF: Applying (Application) REF: N/A OBJ: 8-5
TOP: Nursing Process: Implementation MSC: Health Promotion
5. The nurse has the greatest impact on a patients health promotion when:
a. evaluating a diabetic patients ability to administer his insulin injections.
b. encouraging an obese patient to limit both fat and carbohydrate intake.
c. volunteering to take blood pressures at a community health fair.
d. educating the patient about vitamin D and calcium to prevent bone loss.
ANS: D
Health promotion includes interventions that help prevent disease and disability in a patient.
Education regarding health promotion
has
TESTissues
BANK
SEthe
LLgreatest
ER.COimpact
M on the health of a patient.
The other patients already have established diseases.
DIF: Applying (Application) REF: N/A OBJ: 8-1
TOP: Teaching-Learning MSC: Health Promotion
6. A nurse is assessing a patients ability to manage existing health problems. What question by
the nurse is most helpful?
a. Can you tell me why its important to test your blood glucose level at least daily?
b. What were the results of your most recent A1C blood test?
c. Which pharmacy do you use when your prescription needs to be refilled?
d. Have you been experiencing pain in your feet?
ANS: B
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The results of a laboratory test used to monitor glucose control will show how well the patient
has been managing the various aspects of his or her treatment plan. This information is collected
in the health perception/health management functional health pattern. The other questions do not
demonstrate the patients knowledge level.
DIF: Applying (Application) REF: N/A OBJ: 8-5
TOP: Nursing Process: Assessment MSC: Health Promotion
7. During a home visit, a nurse is assessing the nutritional awareness of an older adult patient
who lives alone. The nurse is most effective in obtaining objective information when:
a. asking to see what types of foods the patient keeps readily available.
b. reviewing the components of a healthy diet with the patient.
c. asking the patient to describe what he or she ate for all three meals yesterday.
d. observing the patient eat a meal that he or she has prepared.
ANS: D
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Objective information is best obtained when observing general appearance and various body
system indicators of nutritional status. Note height, weight, and fit of clothes. If possible, observe
the older adult eating a meal. Food available in the home does not indicate the patients
knowledge, as someone else may have bought the food. Asking the patient for information is
requesting subjective data. Reviewing a healthy diet does not allow the patient to demonstrate
knowledge.
DIF: Applying (Application) REF: N/A OBJ: 8-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
8. The nurse is discussing an older adults past marital history during the admission assessment.
The nurse can best determine that the patient has a healthy ability to cope with emotional
stressors when the patient states:
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a. After my husband died, I managed to raise and educate our two children by
myself.
b. Since my husbands death, Ive grown even closer to my sisters.
c. Its been hard since my husband died, but you manage to go on somehow.
d. After my husband died, I married a good man who was there for me and my
children.
ANS: A
This pattern encompasses the patients reserve and capacity to resist challenges to self-integrity
and his or her ability to manage difficult situations. The ability to view herself as a success in
fulfilling her responsibilities as a mother is evidence of healthy stress coping skills.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 8-5
TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity
9. An older adult patient has recently experienced some difficulty sustaining an erection as a
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result of medication he has been prescribed. The nurse best assesses the patients perception of his
own sexuality by asking:
a. How are you and your wife coping with your sexual dysfunction?
b. What problems has your sexual dysfunction caused between you and your wife?
c. What impact has this dysfunction had on your ability to be intimate with your
wife?
d. Are you and your wife prepared to deal with this dysfunction over the long term?
ANS: C
Asking about the impact of the dysfunction directly assesses the patients satisfaction or
dissatisfaction with current circumstances related to sexual function and intimacy, thus providing
the best evaluation of his self-perception of the issue.
DIF: Applying (Application) REF: N/A OBJ: 8-5
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
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10. The nurse admitting an 89-year-old patient to an assisted living facility notes that the patient
is currently taking numerous prescribed and over-the-counter medications. The nurses initial
intervention is to:
a. confirm with the physician that all the medications are required.
b. evaluate the patients understanding of why he is taking each medication.
c. explain to the patient the dangers of taking so many different medications.
d. review the listed medications for possible interactions.
ANS: D
The first nursing action is to determine if the patients health is at risk from possible drug
interactions. The other actions might be warranted, but patient safety comes first.
DIF: Understanding (Comprehension) REF: MCS: 143 OBJ: 8-6
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
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11. When assessing the older adult for bowel health, the nurse is most effective in obtaining
subjective data when asking:
a. Would you describe your bowel movements as usually normal?
b. Do you have a problem with constipation?
c. How often do you usually have a bowel movement?
d. Have your bowel movements changed recently?
ANS: C
Subjective data can be obtained through the health history. Asking the patient to identify how
often the bowels move would establish the fundamental baseline of the patients elimination
patterns. Normal is a vague term that should not be used. Asking if there are problems with
constipation or if bowel habits have changed are yes/no questions, which are generally avoided.
DIF: Applying (Application) REF: N/A OBJ: 8-5
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TOP: Nursing Process: Assessment MSC: Physiologic Integrity
12. Using social cognitive theory, which action by the nurse will have the most impact on older
adults participation in health promotion behaviors?
a. Creating a walking club in the community
b. Offering private nutritional counseling
c. Providing meals at the senior center
d. Handing out educational materials
ANS: A
According to this theory, self-efficacy and outcome expectations are influenced by successful
performance of the behavior, verbal encouragement, seeing similar people do the behavior,
decreasing unpleasant aspects of the behavior, caring approaches to facilitate the behavior, and
education about benefits. A local walking club with other seniors fulfills many of these criteria.
Private nutritional counseling does not allow the participant to see others engaged in this activity.
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Meals may or may not be healthy or palatable. Educational materials on their own may not have
great benefit.
DIF: Applying (Application) REF: N/A OBJ: 8-2
TOP: Nursing Process: Implementation MSC: Health Promotion
13. The nurse wishes to participate in a community secondary prevention activity. Which activity
does the nurse choose?
a. Administering blood pressure screening at a mall
b. Dispensing free flu vaccinations at a clinic
c. Fitting impoverished older adults with glasses
d. Teaching about the risks of sun exposure
ANS: A
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Secondary prevention is screening and early diagnosis. It aims to find people with clinical
conditions that have not yet become apparent to them. Blood pressure screening would fit this
description. Flu vaccinations and teaching about sun exposure are examples of primary
prevention. Fitting older adults with glasses is a tertiary prevention.
DIF: Applying (Application) REF: N/A OBJ: 8-5
TOP: Nursing Process: Implementation MSC: Health Promotion
14. A patient who is homeless has not followed through with getting an influenza vaccination.
What response by the nurse to a student is most appropriate?
a. Its hard to be proactive when you are hungry.
b. If the patient would just come in, we have the shot.
c. These patients never follow through on directions.
d. Too bad we cant take the shot to him where he is.
ANS: A
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Competing priorities often cause patients to seem uninterested or noncompliant with health
recommendations. According to Maslow, basic needs such as food, water, shelter, and safety
take priority over other matters. Perhaps it is a good idea to take shots into the community, but
that is not the best response by the nurse, as it does not help the student understand the situation.
The other two statements are biased and show disregard for the patients circumstances.
DIF: Applying (Application) REF: N/A OBJ: 8-4
TOP: Communication and Documentation MSC: Health Promotion
15. The nurse is seeing a 68-year old woman for a physical exam in the family practice clinic.
The woman complains about having another pelvic exam. What response by the nurse is best?
a. I know its uncomfortable, but its important to do it.
b. You are past the age where this exam is recommended.
c. Why dont you want to have your pelvic exam?
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d. This will be the last time you need this exam.
ANS: B
According to the U.S. Preventative Task Force, pelvic exams and pap smears can be
discontinued after age 65 if prior testing was normal and the patient is not at high risk for
cervical cancer. The other statements are incorrect.
DIF: Understanding (Comprehension) REF: MCS: 143 OBJ: 8-5
TOP: Teaching-Learning MSC: Health Promotion
16. A male patient complains about the digital rectal prostate exam and blood work for prostatespecific antigen (PSA) and asks, How long am I expected to do this? What response by the nurse
is best?
a. Every year for the rest of your life.
b. Until you turn 75 years of age.
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c. You can quit when you turn 80.
d. There are no guidelines on this.
ANS: B
According to the U.S. Preventative Task Force, there is no evidence that continuing routine PSA
screening past the age of 75 has any benefit, so the patient can forgo the blood test after he turns
75.
DIF: Understanding (Comprehension) REF: MCS: 143 OBJ: 8-5
TOP: Teaching-Learning MSC: Health Promotion
17. A nurse routinely assesses patients for alcohol use. What principle guides this assessment?
a. The older adult must balance risks to benefits of use.
b. Alcohol causes older adults to fall and should not be consumed.
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c. There are no data on risks or benefits after the age of 75.
d. Alcohol-related diseases are more severe in older people.
ANS: A
There are both benefits and risks to drinking alcohol. The nurse must help the older patient
determine which predominates when assessing and possibly counseling patients on their alcohol
use.
DIF: Applying (Application) REF: N/A OBJ: 8-6
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
18. An 80-year-old woman has found a lump in her breast and is in the clinic. What question by
the nurse is most appropriate?
a. How long have you had this lump?
b. If its cancer, are you willing to treat it?
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c. Do you have cancer in your family?
d. Are you having any pain right now?
ANS: B
All questions are appropriate; however, for a woman this age, further testing is not recommended
unless the patient is willing to go through with treatment for cancer. Tumors in older women
tend to be slow growing and quality of life is a bigger priority.
DIF: Applying (Application) REF: N/A OBJ: 8-6
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
19. A nurse wishes to volunteer in a tertiary health care activity. What activity would the nurse
choose?
a. Teaching about safer sexual behaviors
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b. Greeting women at an emergency pregnancy clinic
c. Assisting women who are having radiation therapy
d. Finding home health safety resources
ANS: C
Tertiary prevention aims to care for established disease. Helping women having radiation
therapy for cancer would fall into this realm. Teaching is primary prevention. The emergency
pregnancy clinic is secondary prevention. Home safety is primary prevention.
DIF: Applying (Application) REF: N/A OBJ: 8-5
TOP: Nursing Process: Implementation MSC: Health Promotion
20. A nurse is working with a woman who has been reluctant to start a walking program for her
osteoporosis. What assessment by the nurse is most important?
a. Fear of falling
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b. Lack of time
c. Lack of energy
d. Pain with movement
ANS: A
Fear of falling is a common fear in older adults and has special significance to those with
osteoporosis. The nurse should first assess for this factor. All other factors can be possible
contributors, but people usually attend to safety first.
DIF: Applying (Application) REF: N/A OBJ: 8-4
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
MULTIPLE RESPONSE
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1. A nurse planning primary disease prevention interventions for a 64-year-old patient includes
which of the following? (Select all that apply.)
a. Giving an influenza vaccination in early autumn of each year.
b. Suggesting the patient attend Cooking to Manage Hypertension classes taught by
a registered dietician.
c. Giving a pneumococcal vaccination to celebrate the patients 65th birthday.
d. Identifying several local smoking cessation support groups.
e. Providing the patient with a take-home occult stool screening kit.
ANS: A, C, D
Primary prevention refers to specific action taken to optimize the health of the older individual
by helping him or her become more resistant to disease or to ensure that the environment will be
less harmful.
DIF: Application (Apply) REF: N/A TOP: Nursing Process: Planning
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MSC: Health Promotion and Maintenance
2. A patient has not followed up with recommendations made by the nurse to participate in
cardiac rehabilitation after a myocardial infarction. What factors are most important for the nurse
to assess in determining the cause of this behavior? (Select all that apply.)
a. Out-of-pocket costs
b. Transportation problems
c. Beliefs about the benefits
d. Location of the clinic
e. Ethnicity of providers
ANS: A, B, C, D
Many factors affect the ability and willingness of patients to engage in health promotion
behaviors, including cost, transportation, beliefs, and location of the services. Ethnicity of the
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providers may be a consideration for some, but that is not a high priority for assessment in most
patients.
DIF: Applying (Application) REF: N/A OBJ: 8-2
TOP: Nursing Process: Assessment MSC: Health Promotion
3. The student learns the Medicare guidelines for preventive health and reimbursement policies.
Which statement follows the guidelines? (Select all that apply.)
a. Medicare pays for an annual pneumococcal vaccination.
b. Medicare covers annual influenza vaccinations.
c. Pap smears and pelvic exams are covered once every 2 years.
d. Annual fecal occult blood tests are covered for those who are from 50 to 85 years
of age.
e. A bone density scan is covered every 2 years (a co-payment is required).
ANS: B, D, E
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Medicare guidelines provide reimbursement for pneumococcal vaccination once and every 5
years as recommended, an annual flu vaccination, pap smears and pelvic exams every 3 years, an
annual fecal occult blood test for those who are from 50 to 85 years of age, and a bone density
scan every 2 years (however, a co-payment is required)
Chapter 4 Theoretical Perspectives on Aging Well
MULTIPLE CHOICE
1. The practitioner who believes in the free radical theory of aging is likely to recommend that
the older adult:
a. avoid excessive intake of zinc or magnesium.
b. supplement his or her diet with vitamins C and E.
c. increase intake of complex carbohydrates.
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d. avoid the use of alcohol or tobacco.
ANS: B
Vitamins C and E are two naturally occurring antioxidants that appear to inhibit the functioning
of the free radicals or possibly decrease their production in the body. The free radical theory of
aging is not related to zinc, magnesium, carbohydrates, or alcohol and tobacco.
DIF: Applying (Application) REF: N/A OBJ: 2-2
TOP: Nursing Process: Planning MSC: Health Promotion
2. To provide effective care to the older adult, the nurse must understand that:
a. older adults are not a homogeneous sociologic group.
b. little variation exists in cohort groups of older adults.
c. health problems are much the same for similar age groups of older adults.
d. withdrawal by an older adultTisEaSnormal
TBANKphysiologic
SELLER.response
COM to aging.
ANS: A
The key societal issue addressed by the age stratification theory is the concept of
interdependence between the aging person and society at large. This theory views the aging
person as an individual element of society and also as a member, with peers, interacting in a
social process. The theory attempts to explain the interdependence between older adults and
society and how they constantly influence each other in a variety of ways. Variation exists
among the members of a cohort. Health problems are not the same for every individual of the
same age. Withdrawal by an older adult is not a normal response to aging but may be a sign of
depression.
DIF: Understanding (Comprehension) REF: MCS: 16 OBJ: 2-2
TOP: Nursing Process: Planning MSC: Health Promotion and Maintenance
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3. The nurse is using the eight stages of life theory to help an older adult patient assess the
developmental stage of personal ego differentiation. The nurse does this by assisting the patient
to:
a. determine feelings regarding the effects of aging on the physical being.
b. describe feelings regarding what he or she expects the future to hold.
c. identify aspects of work, recreation, and family life that provide a sense of selfworth and pleasure.
d. elaborate on feelings about the prospect of his or her personal death.
ANS: C
During the stage of ego differentiation versus work role preoccupation, the task for older adults
is to achieve identity and feelings of worth from sources other than the work role. The onset of
retirement and termination of the work role may reduce feelings of self-worth. In contrast, a
person with a well-differentiated ego, who is defined by many dimensions, can replace the work
role as the major defining source for self-esteem. Determining feelings related to the effects of
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aging, future death, or what the future may hold is not part of this theory.
DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
4. A patient is recovering from a mild cerebral vascular accident (stroke). The home care nurse
notes that the patient is talking about updating a will and planning funeral arrangements. Which
of the following responses is most appropriate for the nurse to make?
a. You seem to be preoccupied with dying.
b. Is there anything I can do to help you?
c. Are you worried about dying before you get your affairs in order?
d. Lets focus on how you are recovering rather than on your dying.
ANS: B
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According to Pecks expansion of Eriksons theory, the older adult who has successfully achieved
ego integrity and ego transcendence accepts death with a sense of satisfaction regarding the life
led and without dwelling on its inevitability. The patients action reflects a healthy transition and
should be supported.
DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
5. Your patients spouse died recently from a sudden illness after 45 years of marriage. The
patient was the primary caregiver for the spouse during this time. The patient is now depressed
and withdrawn and has verbalized feelings of uselessness. Which action by the nurse is best?
a. Encourage the patient take up a hobby that will occupy some time.
b. Explain that volunteering would be an excellent way to stay useful.
c. Assure the patient that these feelings of sadness will pass with time.
d. Ask the patient to share some cherished memories of the spouse.
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ANS: B
Volunteering will help the patient to interact with people and feel productive and valued for the
ability to help others as stated in the activity theory. A hobby does not offer the chance to help
others. Assuring the patient that feelings will pass is false reassurance and does nothing to help
the patient to be proactive. Reminiscing is a valued activity, but it is not the best choice for
regaining a sense of usefulness.
DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
6. A patient has recently been diagnosed with end-stage renal disease. The patient has cried often
throughout the day and finally confides in the nurse that I am going home to be with my Lord.
The nurses best response is:
a. There is no reason to believe the end is near.
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b. Do you want me to call your family?
c. We have a wonderful chaplain if youd like me to call him.
d. I think this is the time for us to pray together.
ANS: C
It is important for the nurse to acknowledge the spiritual dimension of a person and support
spiritual expression and growth while addressing spirituality as a component in holistic care
without imposing upon the patient. Because the patient has made reference to the Lord, the nurse
can safely offer religion-oriented spiritual care. Telling the patient there is no reason to believe
that death is near does not help the patient work through emotions. Asking about calling the
family is a yes/no question and is not therapeutic. The nurse is assuming too much by saying it is
time to pray.
DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
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7. A nurse is responsible for the care of 20 older adults in a unit of an assisted living facility. In
order to best address the needs and wants of the entire units population, the nurse:
a. strictly adheres to facility policies so that all patients will be treated equally.
b. encourages specific age cohorts to gather in the dayroom because they share
similar interests.
c. has the unit vote on which television programs will be watched each evening.
d. schedules the patients bathing times according to their individual preferences.
ANS: D
Older adults continue to feel valued and viewed as active members of society when allowed to
maintain a sense of control over their living environment by attention to personal choices and
rituals. Adhering strictly to policies does not allow for individualized care. Not all in the same
age cohort will have similar interests. Voting on television programs does not ensure each
individual feels a sense of worth.
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DIF: Applying (Application) REF: N/A OBJ: 2-5
TOP: Nursing Process: Planning MSC: Psychosocial Integrity
8. An older patient who reports being healthy enough to cut my own fire wood is being assessed
prior to outpatient surgery. The nurse recognizes which assessment observation as a possible
result of the wear-and-tear theory?
a. Swollen finger joints
b. Red, watery eyes
c. Grimacing when raising left arm
d. Bilaterally bruising on the forearms
ANS: C
This theory proposes that cells wear out over time because of continued use. The pain caused by
movement of the shoulder is the observation most likely a result of the patients practice of
TES
TBANdo
KSnot
ELdemonstrate
LER.COMcontinued use that is part of the
cutting his own firewood. The other
choices
wear-and-tear theory of aging.
DIF: Applying (Application) REF: N/A OBJ: 2-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
9. A nurse cares for many older patients. Which finding should the nurse identify as pathologic
in a 72-year-old?
a. Two hospitalizations in 6 months for respiratory infections
b. Patient reports of sleeping only of 5 to 6 hours each night
c. Thinning hair and brittle nails
d. Dry, tissue paperlike skin
ANS: A
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Although there is an age-related decrease in immune function, reoccurring infections serious
enough to require hospitalization are not considered a normal age-related finding. Decreased
sleeping, thinning hair, brittle nails, and dry skin are all normal signs of aging.
DIF: Application (Apply) REF: N/A OBJ: 2-1
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
10. In planning the care for an older adult patient, the nurse will best promote health and
wellness by:
a. encouraging independent living and self-care.
b. scheduling regular cardiac and respiratory health screenings.
c. effectively delivering health-related educational information.
d. promoting a nutritious diet and an age-appropriate exercise routine.
ANS: C
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Providing well-prepared and effectively delivered health-related educational information will
provide the best means of promoting a patients ability to impact his or her wellness and general
health. Each of the other options is too narrow to be the most effective way to promote health
and wellness.
DIF: Applying (Application) REF: N/A OBJ: 2-5
TOP: Nursing Process: Planning MSC: Health Promotion
11. The student learning about aging theories understands that the main difference between
stochastic theories and nonstochastic theories is which of the following?
a. Stochastic theories view aging as a random, cumulative process.
b. Stochastic theories view aging as similar among all people.
c. Nonstochastic theories view aging as a result of psychosocial factors.
d. Nonstochastic theories are backed by research, whereas stochastic theories are
not.
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ANS: A
Stochastic theories view aging as a result of random events and their cumulative effects.
Nonstochastic theories view aging as a result of predetermined, timed phenomena. Both are
types of biologic theories.
DIF: Remembering (Knowledge) REF: MCS: 17 OBJ: 2-1
TOP: Teaching-Learning MSC: Physiologic Integrity: Physiologic Adaptation
12. Which theory of aging does the student learn is related to problems with DNA transcription?
a. Radical theory
b. Error theory
c. Cross linkage theory
d. Wear-and-tear theory
ANS: B
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The error theory poses that errors in DNA transcription lead to aging. The radical theory views
the effects of free radicals as critical to aging. The cross linkage theory states that normally
separated molecular structures are bound together through chemical reactions and that this
interferes with metabolic processes. The wear-and-tear theory postulates that normal activity
causes wear and tear on the body, leading to aging.
DIF: Remembering (Knowledge) REF: MCS: 19 OBJ: 2-1
TOP: Teaching-Learning MSC: Physiologic Integrity: Physiologic Adaptation
13. According to which theory does cancer occur as a possible result of aging?
a. Radical theory
b. Error theory
c. Immunity theory
d. Pacemaker theory
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ANS: C
Immunosenescence is the term used in immunity theory to describe an age-related decrease in
immune functioning. According to this theory, as people age, they are more prone to getting
cancer or autoimmune diseases because of this phenomenon. This is a nonstochastic theory.
Radical and error theories are both stochastic. The pacemaker theory looks at the interrelated role
of the neurologic and endocrine systems and aging.
DIF: Remembering (Knowledge) REF: MCS: 19 OBJ: 2-1
TOP: Teaching-Learning MSC: Physiologic Integrity: Physiologic Adaptation
14. A nurse assesses an older patient who has lost a great deal of weight in a short time. When
asked, the patient states this behavior started after the patient read a magazine article on the
benefits of extreme caloric restrictions. What response by the nurse is best?
a. That research was done on rodents and not on humans.
b. You shouldnt restrict your calories so severely.
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c. You have lost so much weight you need dietary supplements.
d. You cant believe everything you read in those magazines.
ANS: A
The metabolic theory of aging postulates that organisms have a specific metabolic lifetime and
that by lowering metabolic rate, life span can be increased. However, this has been demonstrated
in rodents and the nurse should educate the patient on this information. The other options do not
give information that will help the patient make an informed decision as to whether or not to
follow this activity.
DIF: Applying (Application) REF: N/A OBJ: 2-1
TOP: Communication and Documentation
MSC: Physiologic Integrity: Reduction of Risk Potential
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15. A nurse is caring for an older patient who is sedentary and does not want to participate in any
activities. What action by the nurse is best?
a. Inform the patient about the consequences of immobility.
b. Promote activity by explaining the use it or lose it concept.
c. Tell the patient he or she will feel better by being more active.
d. Explain the relationship of being active and being independent.
ANS: D
Activity increases circulation, provides range of motion, and leads to clearer mental functioning.
Activity helps a person remain independent and able to perform activities of daily living (ADLs)
and instrumental ADLs. Presenting information in a positive light that encourages the patient to
take control of ones own health is more likely to be successful than stressing the negative such as
consequences of immobility or the concept of use it or lose it. Telling the patient that he or she
will feel better does not give concrete information the patient can use to make decisions.
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DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Teaching-Learning MSC: Health Promotion
16. The nurse working with older patients teaches the student that disengagement theory
potentially causes which problem?
a. Fear
b. Isolation
c. Anxiety
d. Malnutrition
ANS: B
The no-longer supported disengagement theory posed that older people withdrew from society as
they aged and that this was a mutually agreed upon behavior. The result would be isolation as the
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person became focused solely on him- or herself. Fear, anxiety, or malnutrition could be a further
consequence, but isolation and withdrawal from society was expected according to this theory.
DIF: Understanding (Comprehension) REF: MCS: 22 OBJ: 2-5
TOP: Teaching-Learning MSC: Psychosocial Integrity
17. The nurse working in a long-term care facility used the developmental theory of aging in
practice. In caring for a frail, nearly bed bound patient, how can the nurse use this theory?
a. Engage the patient in intellectually stimulating activities.
b. Encourage the patient to participate in chair exercises.
c. Ensure that the patient participates in all the group activities.
d. Give the patient small chores to do for the facility.
ANS: A
In this theory, being active can mean
The nurse can engage the
TESphysical
TBANKor
SEintellectual
LLER.Cactivity.
OM
patient in intellectually stimulating activities that allows the person a sense of satisfaction. The
other options all call for physical activity, which the patient may or may not be able to perform.
DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
18. The nurse working at a long-term care facility notes that one patient who is usually outgoing
refuses to participate in games that require keeping score. What action by the nurse is best?
a. Ask the patient why he or she wont participate.
b. Assess the patients level of frustration with these activities.
c. Find other activities for the patient to participate in.
d. Do nothing; the patient can choose activities to engage in.
ANS: B
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Although it is true that patients should be able to choose activities in which to participate, the
best option is to assess the patient for frustration or anxiety associated with these types of
activities. Once that is determined, the nurse can find other activities the patient can engage in
successfully and is willing to participate in if the games are not an option. Asking why questions
often puts people on the defensive and is not a therapeutic communication technique.
DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
19. The nurse planning community events for older people uses sociologic theories to guide
practice. Which activity planned by the nurse best fits these theories?
a. Group exercise programs
b. Volunteering at a day care
c. Healthy cooking classes
d. Reminiscing therapy
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ANS: B
Using the sociologic theories to guide care, the nurse would plan events that allowed the older
adult to remain active in the community and a valued member of society. Volunteering would
offer the adult a way to stay engaged and provide a service to successive generations. Exercise
and cooking classes would more fit in the biologic theories. Reminiscing therapy is a technique
using psychological theories. All are good ideas for activities, but the one that specifically uses
sociologic theory is the volunteer work.
DIF: Applying (Application) REF: N/A OBJ: 2-2
TOP: Nursing Process: Analysis MSC: Psychosocial Integrity
20. What statement by a patient most indicates healthy aging according to Jung?
a. I wish I had traveled more when I was younger because now I cant.
b. I am proud of my past accomplishments at work and home raising my kids.
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c. My leg amputation makes things harder, but I still find a way to work.
d. I still like to read the paper and novels and enjoy a little gardening.
ANS: C
This patient shows acceptance of past accomplishments and finds value in him- or herself despite
current limitations, which is healthy aging according to Jung. The person who wants to travel
more displays remorse. The focus on past accomplishments does not show current acceptance.
Reading and gardening do not show acceptance of past accomplishments.
DIF: Analyzing (Analysis) REF: N/A OBJ: 2-2
TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity
21. A nurse is trying to teach a hospitalized older patient how to self-inject insulin. The patient is
restless and does not seem to be paying attention. What action by the nurse is best?
a. Ask if the patient needs to use the bathroom.
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b. Tell the patient youll try again later in the day.
c. Ask if the patient prefers that you teach the family.
d. Refer the patient for home health care services.
ANS: A
According to Maslow, physical needs take priority over other activities. This patient may be
hungry, cold, tired, or need to use the bathroom. Telling the patient youll try again later, asking if
you should teach the family, and referring to home health care does not provide for any unmet
physical needs.
DIF: Applying (Application) REF: N/A OBJ: 2-4
TOP: Nursing Process: Implementation MSC: Physiologic Integrity: Basic Care and Comfort
22. The new nurse at a long-term care center asks the director of nursing why he needs to learn
so many theories of aging. What response by the director is best?
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a. No theories have been proven yet.
b. A wide range of theories allows for holistic care.
c. Its required knowledge for certification exams.
d. All the theories are important, so we use them all.
ANS: B
Using a combination of different theories, each with its own focus, allows the nurse to plan
individualized, holistic nursing care.
DIF: Applying (Application) REF: N/A OBJ: 2-5
TOP: Communication and Documentation MSC: Psychosocial Integrity
MULTIPLE RESPONSE
1. According to Maslow, a fully actualized person displays which traits? (Select all that apply.)
a. Spontaneity
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b. Self-direction
c. Creativity
d. Ethical conduct
e. Acceptance of self
ANS: A, B, C, E
A fully actualized person displays the following characteristics: perception of reality; acceptance
of self, others, and nature; spontaneity; problem-solving ability; self-direction; detachment and
the desire for privacy; freshness of peak experiences; identification with other human beings;
satisfying and changing relationships with other people; a democratic character structure;
creativity; and a sense of values. Maslow does not specify ethical conduct.
Chapter 5 Gerontological Nursing and Health Promotion
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MULTIPLE CHOICE
1. The geriatric nurse recognizes that the bodys homeostatic mechanisms may be compromised
in the:
a. 79-year-old with moderate Alzheimer disease who requires assistance with all
activities of daily living (ADLs).
b. 73-year-old with a history of chronic bronchitis who lives with family.
c. 86-year-old who lost a spouse and is moving into an assisted living facility.
d. 69-year-old with peripheral vascular disease who is visited by home health care
weekly.
ANS: C
Declining physiologic function and increased prevalence of disease, particularly in the old-old
(age 85 or older), are in part a result of a reduction in the bodys ability to respond to stress
through all of its homeostatic mechanisms. The important point is that older adults often
encounter profound and repeatedTlosses;
of these losses is often
ESTBthe
ANtime
KSEbetween
LLER.the
COoccurrences
M
short, resulting in an inadequate period for resolution and return to a baseline state, thus putting
them at risk for illness. Although the other patients may have compromised homeostatic
mechanisms, the 86-year-old patient is most likely to exhibit this phenomenon.
DIF: Analyzing (Analysis) REF: N/A OBJ: 4-2
TOP: Nursing Process: Diagnosis MSC: Physiologic Integrity
2. To best minimize patient anxiety and help ensure a successful history assessment interview,
the geriatric nurse first:
a. asks whether the patient has any questions about the interview.
b. makes sure the interview area is comfortable and private.
c. explains the reason for asking the questions.
d. assures the patient that all answers will be kept confidential.
ANS: C
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To ensure a successful interview, the nurse should explain the reason for the interview to the
patient followed by a brief overview of the format to be followed. This helps alleviate anxiety
and uncertainty, and the patient can then focus on providing the information. The other options
are all important actions during the assessment interview, but they will not diminish anxiety as
much as an explanation of the purpose.
DIF: Applying (Application) REF: N/A OBJ: 4-1
TOP: Nursing Process: Implementation MSC: Emotional Needs Related to Health Problems
3. An older patient is admitted for bacterial pneumonia. The only abnormal assessment values
include a heart rate of 102 beats per minute, slight cyanosis of the nail beds, and mild confusion.
The patients daughter questions the possibility of pneumonia stating, He isnt coughing or having
any difficulty breathing. The nurse responds most appropriately by saying:
a. We are lucky to determine the problem in its early stage.
b. Respiratory problems develop only after the infection is well established.
c. People your dads age often lack
strength
toOcough.
TESthe
TBmuscular
ANKSEL
LER.C
M
d. Older adults frequently lack the typical signs of a respiratory infection.
ANS: D
The characteristic presentation of illness in older adults is more commonly one of blunted or
atypical signs and symptoms. Stating, we are lucky to determine the problem does not give any
useful information. Respiratory problems are often present early on in younger people. The lack
of coughing is not caused by weakness.
DIF: Understanding (Comprehension) REF: MCS: 57 OBJ: 4-2
TOP: Teaching-Learning MSC: Physiologic Integrity
4. A nurse aide working in the geriatric units dining room tells the nurse that a patient who was
oriented to time and place this morning is now confused about what day it is and why shes here.
The nurse appropriately directs the nurse aide to:
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a. take the patient back to her room and put her safely in bed.
b. place a falls risk identification bracelet on the patient and add the status care plan.
c. immediately take the patients vital signs and report them to her.
d. reorient the patient to time and place frequently and document the patients
response.
ANS: C
A sudden change in an older adult patients cognitive status is likely a symptom of a physiologic
stressor such as an infection. The vital signs will allow the nurse to determine the presence of a
fever or other deviation from the patients baseline vitals. The patient may or may not need or
wish to go to bed, but this does not provide any data for the nurse to evaluate. An ill patient may
need to be on fall precautions, but again this does not provide data. Reorientation may be
necessary, but if the patient has an illness, this needs to be taken care of.
DIF: Applying (Application) REF: N/A OBJ: 4-2
TESTB
ANKPhysiologic
SELLER.C
OM
TOP: Nursing Process: Implementation
MSC:
Integrity
5. The nurse most effectively implements guided reminiscence during a patient interview by:
a. reminding the patient to share important memories of the past.
b. scheduling several short interviews rather than one long one.
c. controlling the interview by selecting the memories to be discussed.
d. encouraging the patient to relive his or her memories while maintaining focus.
ANS: D
This goal-directed interviewing process helps the patient share pertinent information through
remembering. The tendency to reminisce may make it difficult for the patient to stay focused on
the topic, so it is the nurses responsibility to refocus the interview when necessary. Reminding
the patient to share memories, using several short interviews, and controlling the interview do
not make best use of this technique.
DIF: Applying (Application) REF: N/A OBJ: 4-4
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TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
6. To establish a mutually respectful relationship with an older adult patient being admitted to a
skilled nursing unit, the nurse first introduces himself and then asks:
a. how the patient would like to be addressed.
b. if the patient has any specific requests to make of the staff.
c. the patient to share a little about his or her personal likes and dislikes.
d. the patient to read the orientation materials that the facility provides.
ANS: A
Respect is shown best by acquiring knowledge regarding the preferences held by a patient; using
the patients surname is preferred unless the patient directs the staff to do otherwise. The other
options are too narrow in focus to establish a mutually respectful relationship.
DIF: Applying (Application) REF: N/A OBJ: 4-4
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TOP: Integrated Process: Caring MSC: Psychosocial Integrity
7. The nurse showing the best understanding of how personal attitude affects the interview
process during a health assessment of an older adult patient is one who:
a. proceeds with the interview as if the patient were not an older adult.
b. incorporates therapeutic communication into the assessment process.
c. treats all patients with respect regardless of age.
d. has self-reflected on his or her own feelings regarding aging.
ANS: D
The nurses own anxiety and fear of personal aging as well as a lack of knowledge regarding
older people contribute to commonly held negative attitudes, myths, and stereotypes about older
people that interfere with a successful, effective assessment interview. The nurse must
acknowledge the age-related differences in this patient. The nurse does use therapeutic
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communication, but this may be hampered by unrealized stereotypes. The nurse should treat all
patients with respect, but this statement does not give specific information on how to do so.
DIF: Applying (Application) REF: N/A OBJ: 4-4
TOP: Nursing Process: Assessment MSC: Communication and Documentation
8. An older patient is being admitted to a long-term care facility. The nurse recognizes that the
primary purpose of the initial geriatric health assessment is to:
a. identify the patients physiologic baselines.
b. ultimately create a plan of care that prevents disability and dependence.
c. initiate the therapeutic nurse-patient relationship.
d. document self-care deficiencies that the patient exhibits.
ANS: B
Specifically, the purpose of olderTadult
ESTassessment
BANKSELisLto
ERidentify
.COMpatient strengths and limitations
so that effective and appropriate interventions can be delivered to support, promote, or restore
optimum function and to prevent disability and dependence. Physiologic baseline, therapeutic
nurse-patient relationship, and self-care deficits are all important aspects of the assessment but
not the major purpose for it.
DIF: Remembering (Knowledge) REF: MCS: 55 OBJ: 4-8
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
9. A 76-year-old postsurgical diabetic patient has reported feeling dizzy and clammy. The daily
serum glucose level shows the patients levels to be within normal limits. The geriatric nurse
shows an understanding of established health norms for the older adult when stating:
a. This patients normal may not be within the typical lab norms.
b. Ill ask the lab to rerun the test so we can double-check the results.
c. There must be another reason for the symptoms.
d. Ill compare the patients baseline lab work with todays results.
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ANS: A
Relying on established norms for laboratory values when analyzing the assessment data of older
adults could lead to incorrect conclusions. The nurse should try to determine what the patients
normal range is after stabilizing the patient.
DIF: Understanding (Comprehension) REF: MCS: 56 OBJ: 4-1
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
10. A patient is being admitted after a fall that has caused a painful leg injury. In preparing to
interview the patient for a health history, the nurse is initially concerned that:
a. the family should be present to help answer questions.
b. a therapeutic nurse-patient relationship should be established.
c. the patient should be free of hearing and vision barriers.
d. the patients pain should be effectively managed.
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ANS: D
The acute pain the patient is experiencing will have the greatest impact on the success of the
health assessment interview and must be removed as a barrier for the assessment to be
successful. The other factors are important too, although depending on the cognitive status of the
patient, the family may or may not need to be present.
DIF: Application (Apply) REF: N/A OBJ: 4-5
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
11. The nurse has administered the Apgar screen tool to assess an older patients family function
status. Upon determining that the family functions at a 4, the nurse:
a. prepares to administer a more detailed tool.
b. prepares to report reasonable suspicion of elder abuse.
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c. asks the patient to identify specific family members to include in care planning
sessions.
d. notifies social services that the family is not likely to be of much support to the
patient.
ANS: D
An Apgar score of 4 to 6 suggests a moderately dysfunctional family, one that should not be
depended on to provide physical, financial, or emotional support to the patient.
DIF: Analysis (Analyze) REF: N/A OBJ: 4-9
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
12. The geriatric nurse admitting a patient to an assisted living facility recognizes the importance
of tools such as the Katz and the Barthel indexes because of the impact they have on:
a. planning the amount of help the patient will need with ADLs.
TESabout
TBANachieving
KSELLEindependence.
R.COM
b. the patients ability to be realistic
c. creating an appropriate, patient-specific nursing care plan.
d. appropriate staffing to ensure the safety needs of the patients are met.
ANS: C
These assessment tools are designed to assess a patients levels of function, particularly related to
ADL. Determination of the degree of functional independence in these areas can identify a
patients abilities and limitations, leading to appropriate interventions presented in the patients
nursing care plan. It provides more information than just how much help the patient needs, it is
not related to being realistic, and it is not designed to be used for staffing purposes.
DIF: Analysis (Analyze) REF: N/A OBJ: 4-9
TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance
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13. An older patient is reluctant to report multiple vague signs and symptoms, including lethargy,
incontinence, and weight loss that have persisted for 6 weeks. The nurse recognizes that such
symptoms place the patient at great risk for:
a. viral infection.
b. disorientation.
c. malnutrition.
d. physical frailty.
ANS: D
Self-reported vague signs and symptoms such as lethargy, incontinence, decreased appetite, and
weight loss can be indicators of functional impairment. Ignoring older adults vague symptoms
exposes them to an increased risk of physical frailty (impairments in the physical abilities).
DIF: Remembering (Knowledge) REF: MCS: 56 OBJ: 4-7
TEMSC:
STBAHealth
NKSEPromotion
LLER.CO
M Maintenance
TOP: Nursing Process: Assessment
and
14. An older patient is hospitalized after a fall that resulted in a fractured left ankle. By day 4 of
the hospitalization, which includes reduction of the fracture and analgesic drug therapy, the
patient has become mildly disoriented and is incontinent of urine. The nurse explains to the
family that these symptoms reflect the:
a. relationship between aging and both physical and psychosocial responses to
trauma.
b. response exhibited by many older adults who are hospitalized.
c. effects of stress-induced perceptual deficits often seen in the hospitalized older
adult.
d. results of the pharmacologic pain control therapy.
ANS: A
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Many serious consequences are the result of the interaction of physical and psychosocial factors
in the older patient. Although the other options have some degree of truth to them, the most
comprehensive answer is the one that relates aging to response to trauma.
DIF: Understanding (Comprehension) REF: MCS: 56 OBJ: 4-2
TOP: Teaching-Learning MSC: Physiologic Integrity
15. When unsure about how to address older patients with advanced stage Alzheimer disease, the
nurse recognizes that it is best to address the patient by:
a. a pet name, because the patients are not likely to respond to their given names.
b. the first name, to foster a friendly, relaxed atmosphere.
c. the full name, to show respect for the patients as individuals.
d. a childhood nickname, because long-term memory will likely still be intact.
ANS: C
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Nurses should address all older patients by their full name, including Mr. Mrs., or Miss, to show
respect, unless the patient specifically requests being called something else.
DIF: Application (Apply) REF: N/A OBJ: 4-4
TOP: Caring MSC: Psychosocial Integrity
16. A nurse is working with an older patient in the gerontology clinic. The patient reports a
vague decline in function and says, I guess Im just getting older. What action by the nurse is
best?
a. Help the patient find ways to cope with the changes.
b. Assess the patient for an undetected illness.
c. Ask if the patient needs any home health services.
d. Find out what the patient thinks of these changes.
ANS: B
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Vague changes and declining function are often attributed to aging but can be the only signs of
illness. The nurse should perform a thorough assessment to look for any possible ailments. If the
findings are normal and the changes are age related, the nurse can help the patient find ways to
cope, ask about home health care services, and determine the patients thoughts on the matter.
DIF: Applying (Application) REF: N/A OBJ: 4-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
17. The nurse admitting a debilitated patient to a long-term care facility initially assesses the
patient using the Katz Index. The student asks why the nurse chose that tool. What answer by the
nurse is best?
a. It is quick and simple for a baseline.
b. The Katz Index is mandated by Medicare.
c. It is comprehensive in nature.
d. It shows functioning in 12 areas.
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ANS: A
The Katz Index takes only about 5 minutes to complete and rates patients as to whether they are
totally independent or dependent in six basic functions. For the debilitated patient who will tire
easily, this is the best choice. It is not mandated by Medicare, it is not as comprehensive as other
tools, and it only shows functioning in 6 areas.
DIF: Understanding (Comprehension) REF: MCS: 71 OBJ: 4-9
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
18. A nurse assesses a patient using the Barthel Index and scores the patient as a 98. What
inference does the nurse draw from this assessment?
a. The patient is nearly dependent in all areas measured.
b. The patient is able to live independently.
c. The patient is close to independent in the areas measured.
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d. The patients cognitive status impaired the assessment.
ANS: C
The Barthel Index has a maximum score of 100, with the higher the score meaning more
independent functioning. However, the tool developers do not state that a high score equals being
able to live independently. This tool does not measure cognitive functioning.
DIF: Applying (Application) REF: N/A OBJ: 4-9
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
19. The staff members in a long-term care facility have noted a decline in cognitive function in
one of the residents; however, each time the resident is given the Short Portable Mental Status
Questionnaire (SPMSQ), the score does not change. What action by the nursing manager is best?
a. Provide in-service education on using this tool.
b. Conduct the assessment him- or herself
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c. Switch to a different screening tool
d. Determine that no changes have occurred.
ANS: C
The SPMSQ is given orally, and because it is short, it is easy to memorize. The manager should
use a different tool.
DIF: Applying (Application) REF: N/A OBJ: 4-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
20. The nurse has used the Yesavage Geriatric Depression Scale (short form) and scored the
patient at a 1. What is the nurses best action?
a. Refer the patient to a mental health practitioner.
b. Assess the patient further for depression.
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c. Ask the patient about using antidepressant medications.
d. Document findings in the patients medical record.
ANS: D
A score of 5 or more indicates possible depression that should be assessed further. A score of 1
indicates no or little depression risk. The nurse should document the findings. No other action is
needed.
DIF: Applying (Application) REF: N/A OBJ: 4-10
TOP: Nursing Process: Assessment MSC: Psychologic Integrity
21. A nurse is conducting an admission interview with an older patient admitted to a long-term
care facility. When the nurse asks about the patients former occupation, the patient states, What
do you care? I am long retired! What response by the nurse is best?
a. Your job may have exposed you to some health hazards.
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b. It helps me get to know you and your background better.
c. We have several clubs here you might be interested in.
d. No real reason, its just part of our admission interview.
ANS: A
Previous occupations may have exposed the patient to health hazards that might be important.
The question does help the nurse get to know the patient and maybe offer some activities he or
she would most likely be interested in, but thats not the main reason for the question. Saying
there is no reason to ask the question puts the entire admission interview under suspicion for
being irrelevant.
DIF: Understanding (Comprehension) REF: MCS: 66 OBJ: 4-6
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
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1. A nurse who cares for older adults recognizes which of the following clinical features
associated with dementia? (Select all that apply.)
a. Failing to remember his or her room number
b. Becoming increasingly disoriented at night
c. Working on jigsaw puzzles for hours at a time
d. Often referring to a cup as a canyon
e. Misunderstanding when told its raining cats and dogs
ANS: A, D, E
Clinical features of dementia are associated with cognitive deficiencies such as forgetfulness,
lack of inquiry, inability to correctly associate proper words to objects, and concrete thinking.
DIF: Remembering (Knowledge) REF: MCS: 57|MCS: 59
OBJ: 4-3 TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
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2. The nurse using the SPICES model to assess older patients collects data on which topics?
(Select all that apply.)
a. Sleep disorders
b. Problems with eating
c. Incontinence
d. Falls
e. Social situations
ANS: A, B, C, D
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion,
evidence of falls, and skin breakdown.
Chapter 6 Health Care for Older Adults in Various Settings
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MULTIPLE CHOICE
1. What action by the nurse is most important for preventing hospital-acquired infections in the
older population?
a. Appropriate hand hygiene
b. Rapid isolation for infection
c. Strict sterile procedures
d. Ensuring patient nutrition
ANS: A
Hand hygiene is the most effective infection control action the nursing staff can take.
DIF: Applying (Application) REF: N/A OBJ: 9-3
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
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2. The nurse on a medical acute care unit is preparing for the admission of an 84-year-old patient
with several diagnosed chronic illnesses. The nurse begins the plan of care for this patient based
on the understanding that the older adult is likely to:
a. develop hospital-induced delirium.
b. require special attention related to sensory deficits.
c. need a social services consult before discharge.
d. present with a need for a high level of nursing care.
ANS: D
The older adult is not likely to be admitted to the hospital until a high level of acuity or
complications exists. The other options may be possible, but the majority of older patients are
admitted at a high level of acuity.
DIF: Remembering (Understanding) REF: MCS: 154 OBJ: 9-1
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TOP: Teaching-Learning MSC: Physiologic Integrity
3. The nurse is planning the discharge of a 70-year-old patient who lives alone and is recovering
from a fractured ankle. What action by the nurse shows an understanding of factors affecting the
patients ultimate return to preinjury function?
a. Encourages the patient to comply with recommendations made by the physical
therapist
b. Arranges for the patients meals to be delivered daily for several weeks after
discharge
c. Assesses the barriers to self-ambulation that exist in the patients home
d. Educates the patient on the importance of a diet that promotes both bone and
muscle healing
ANS: C
In the hospital setting, health care professionals can become so involved in addressing the acute
condition that they fail to appreciate the underlying problems and how these too influence the
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patients health and recovery. Assessing for ambulation barriers in the patients home has a longterm effect on the patients ability to regain independence.
DIF: Understanding (Comprehension) REF: MCS: 154 OBJ: 9-1
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
4. The nurse in an acute care facility is caring for a patient recovering from a cerebral vascular
accident that has resulted in a mild loss of muscle function in his right arm and leg. The nurse is
best addressing the patients need via the functional model of care when:
a. assessing the patients right-sided muscle strength daily.
b. reaffirming to the patient that physical therapy will improve his muscle strength.
c. instructing the patients family on how to properly assist the patient in walking.
d. placing the telephone where the patient can reach it with his left hand.
ANS: D
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The functional models main goal may not be curing the disease but managing the disease, with a
focus on self-care and symptom management strategies. Placing the telephone where the patient
can reach it for himself is an example of a symptom management strategy. The other actions do
not increase the patients functional abilities.
DIF: Applying (Application) REF: N/A OBJ: 9-2
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
5. The nurse is caring for an older adult patient who was admitted with a stage 3 pressure ulcer
on the left heel and who also has a history of Parkinson disease and chronic renal failure. To
minimize the patients risk of developing an iatrogenic illness, the nurse:
a. uses sterile technique when changing the heels dressings.
b. reviews all the patients medications for possible adverse reactions.
c. instructs the patient to call for assistance when needing to go to the bathroom.
d. assists the patient in choosing the appropriate foods from the daily menu.
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ANS: B
Adverse drug reactions frequently precipitate hospitalizations and, although often unreported, are
among the most common iatrogenic events in the acute care setting. The hospital staff needs to
get an accurate drug history of a patient, be aware of pharmacokinetic and pharmacodynamic
changes related to aging, and have a working understanding of drug-disease, drug-drug, and
drug-food interactions in older adults. Nurses should be particularly aware of drugs that may be
high risk when used in older adults. The other actions are important for patient safety, but the
more frequent cause of iatrogenic problems is related to medication use.
DIF: Understanding (Comprehension) REF: MCS: 154 OBJ: 9-3
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
6. The nurse best addresses the possible intrinsic factors that contribute to falls experienced by
older adult patients in an acute care setting by:
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a. encouraging patients to wear their glasses.
b. keeping a low-level light on in the room at night.
c. keeping the patients bed low to the floor.
d. assessing the room for clutter on the floor.
ANS: A
Risk factors for hospital falls include both intrinsic and extrinsic factors. Intrinsic factors include
age-related physiologic changes and diseases, as well as medications that affect cognition and
balance. The other actions are important safety measures that are helpful to some patients as
well, but good vision is critical for safety.
DIF: Understanding (Comprehension) REF: MCS: 154 OBJ: 9-6
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
7. The nurse caring for an older patient is concerned when the patient begins experiencing mild
TEvital
STBsigns
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LLwithin
ER.Cnormal
OM limits for this patient. To
confusion. The nurse notes that the
best assess related symptoms, the nurse initially:
a. asks the patient to Squeeze my hand as hard as you can.
b. reviews documentation about how the patient has been eating.
c. reviews the patients medication for possible adverse reactions.
d. asks the patients daughter if her mother has been confused before.
ANS: B
Anorexia is a symptom of urinary tract infection, which occurs frequently in older adults.
Subclinical infection and inflammation can occur with presenting symptoms such as acute
confusion, functional capacity deterioration, anorexia, or nausea rather than the classic symptoms
of fever and dysuria. Although all actions are appropriate, the nurse suspecting a urinary tract
infection (UTI) will assess eating patterns.
DIF: Applying (Application) REF: N/A OBJ: 9-3
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TOP: Nursing Process: Assessment MSC: Physiologic Integrity
8. The nurse is caring for a confused patient. Which action by the nurse shows the best
understanding of managing the cascading effects of iatrogenic illnesses in this population cohort?
a. Reorienting the patient to person, place, and time frequently
b. Offering the patient liquids each time there is patient-nurse contact
c. Repositioning the patient every 2 hours
d. Using restraints to ensure patient safety only as a last resort
ANS: D
Once older adults are hospitalized, immobilization through enforced bed rest or restraint often
results in functional disability, and the subsequent occurrence of iatrogenic illnesses often
represents a vicious circle, referred to as the cascade effect, in which one problem increases the
persons vulnerability to another one. Gerontologic nurses must be leaders in advocating more
appropriate care and treatment of hospitalized older adults to prevent or at least reduce the
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occurrence of iatrogenic illness. The other actions are good nursing care but do not relate to the
cascade effect.
DIF: Applying (Application) REF: N/A OBJ: 9-3
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
9. An 80-year-old patient with visual and hearing deficits is admitted for hip replacement
surgery. The patient has begun to show mild confusion and has become resistant to care and
treatment. To minimize this problem, the nurse initially edits the patients care plan to include:
a. frequent reorientation to people in the patients environment.
b. putting on the patients glasses and hearing aid as a part of activities of daily living
(ADLs).
c. assigning the same staff to provide patient care whenever possible.
d. minimizing the number of off-unit trips for the patient.
ANS: B
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Older adults have a decreased ability to negotiate within and adapt to an unfamiliar environment,
which can be initially minimized by the use of hearing aids and eyeglasses, for example. The
other actions may be appropriate, but until the sensory deficit is corrected, the patient will most
likely remain confused.
DIF: Applying (Application) REF: N/A OBJ: 9-3
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
10. What action by the nurse best shows an understanding of the effects of acute hospitalization
on the functional abilities of the older patient?
a. Setting goals that support a short hospitalization.
b. Attempting to adapt nursing care to individual needs
c. Administering a systematic functional assessment
d. Assessing for a decline from original baseline function
ANS: D
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The nurse should assess for new onset signs or symptoms of a decline from baseline function and
then implement appropriate interventions before they trigger a downward spiral of dependency
and permanent impairment.
DIF: Understanding (Comprehension) REF: MCS: 156 OBJ: 9-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
11. Which statement by a resident best indicates that the residents psychosocial needs are being
met?
a. Im really enjoying the opportunity to select my own mealtimes.
b. I miss being at home, but I understand why I must live here.
c. I appreciate being placed on the waiting list for a private room because I prefer
living alone.
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d. Im an independent person who has always made my own decisions, and I will for
as long as I can.
ANS: A
Psychosocial needs are best met when a patient is encouraged to be independent both physically
and mentally. Making choices is a good example psychosocial needs being prioritized.
DIF: Understanding (Comprehension) REF: MCS: 169 OBJ: 9-4
TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity
12. A 70-year-old patient covered by Medicare is being admitted for stabilization of type 2
diabetes. When asked by the family why their parents care is being co-managed by a geriatric
nurse practitioner and a physician, the best explanation is that:
a. the geriatric nurse practitioner is specially trained to work with older patients.
b. research has shown that this care model often results in shorter hospital stays.
TESTBwill
ANK
SELon
LEdifferent
R.COMneeds.
c. the physician and nurse practitioner
focus
d. Medicare encourages this team concept of patient care.
ANS: B
Some studies demonstrate a significant decrease in the length of stay when patients are comanaged by a nurse practitioner and an attending physician.
DIF: Understanding (Comprehension) REF: MCS: 177 OBJ: 9-4
TOP: Teaching-Learning MSC: Safe Effective Care Environment
13. The nurse is going to educate an older patient newly diagnosed with type 2 diabetes on how
to test serum glucose levels appropriately. The nurse shows an understanding of the adaptation of
teaching techniques for this age group by:
a. providing both written and verbal instructions on the skill.
b. asking the patient if he has any hearing or vision deficits.
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c. restating the important points several times.
d. asking the patient to describe the proper technique in his own words.
ANS: B
This population often experiences sensory deficits that can affect their learning capacity. The
other actions are also appropriate, but if the patient has sensory deficits, they must be addressed
before teaching begins.
DIF: Understanding (Comprehension) REF: MCS: 169 OBJ: 9-7
TOP: Teaching-Learning MSC: Physiologic Integrity
14. The nurse at an assisted living facility is caring for a 73-year-old cognitively impaired patient
who has recently been admitted. The nurse creates a care plan that strives to help maintain the
patients independence by including:
a. sufficient time for the patient to complete self-care.
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b. encouraging the patient to make decisions regarding self-care.
c. regular assessment of the patients ability to provide self-care.
d. regular cueing by staff to direct patient self-care.
ANS: D
Cognitively impaired individuals often need supervision and cueing rather than physical
assistance to perform ADLs and instrumental activities of daily living (IADLs).
DIF: Understanding (Comprehension) REF: MCS: 158 OBJ: 9-4
TOP: Communication and Documentation MSC: Health Promotion
15. An older patient has fallen twice in the hospital in the last 2 days. What action by the nurse is
best?
a. Request restraint orders from the provider.
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b. Assess the patient for undiagnosed illness.
c. Remind the patient to call for help getting up.
d. Have a family member stay with the patient.
ANS: B
Falls are commonly associated with a new onset of illness in the older patient. The nurse assesses
for this possibility. Restraints are a last resort. The patient may be too confused or forgetful to
remember to call for help, plus this places the responsibility for safety on the patient. Family
members may not be present or able to stay with the patient continuously.
DIF: Applying (Application) REF: N/A OBJ: 9-6
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
16. A nurse is caring for an older patient in the intensive care unit. The patient has a sudden
onset of confusion. What action by the nurse is best?
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a. Request a sedative from the provider.
b. Attempt to reorient the patient.
c. Perform a sepsis screening.
d. Review lab work for today.
ANS: C
The most common presenting sign of sepsis in the older adult is confusion. The nurse assesses
the patient for this condition. Sedatives and restraints are a last resort. The nurse should attempt
to reorient the patient, but this is not the most important action. The nurse should also review lab
work, but current assessments are more important.
DIF: Applying (Application) REF: N/A OBJ: 9-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
17. Which individual would the nurse refer to the local Area Agency on Aging?
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a. One who needs housekeeping services
b. One who needs help with preparing taxes
c. One who needs nutritious meals
d. One who needs long-term care placement
ANS: C
The AAA provides resources for community members on information and referral for medical
and legal advice; psychologic counseling; preretirement and postretirement planning; programs
to prevent abuse, neglect, and exploitation; programs to enrich life through educational and
social activities; health screening and wellness promotion services; and nutrition services. The
patient needing nutritious meals would most benefit from this agency.
DIF: Understanding (Comprehension) REF: MCS: 160 OBJ: 9-4
TOP: Communication and Documentation
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MSC: Safe Effective Care Environment
18. The nursing faculty explains to students the definition of homebound. Which is the best
explanation of this situation?
a. A person uses a wheelchair for all mobility.
b. A person desires services provided at home.
c. Leaving home requires great effort.
d. No local agency is available to provide service.
ANS: C
Homebound implies that a person could leave the home for a legitimate medical reason, but he or
she must exert a great deal of effort to do so. Being in a wheelchair does not in itself cause a
person to be homebound, nor does requesting home services or not having another agency to
provide services elsewhere.
DIF: Understanding (Comprehension) REF: MCS: 162 OBJ: 9-9
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TOP: Teaching-Learning MSC: Health Promotion
19. A patient is on hospice care. Which situation would result in an acute hospitalization?
a. Progression of disease
b. Intractable pain
c. New pressure ulcer
d. Bladder infection
ANS: B
Inpatient care is available when the patient experiences acute or severe pain or symptom
management problems. The other conditions are managed without acute hospitalization.
DIF: Remembering (Knowledge) REF: MCS: 167 OBJ: 9-12
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
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20. Which action does the nurse delegate to the unlicensed assistive personnel (UAP) pertaining
to pressure ulcer prevention?
a. Assessing the patients skin daily
b. Keeping the patients skin clean and dry
c. Obtaining a special overlay mattress
d. Monitoring the patients nutritional status
ANS: B
The nurse can delegate keeping a patients skin clean and dry to the UAP. The other actions are
within the nurses scope of practice.
DIF: Applying (Application) REF: N/A OBJ: 9-17
TOP: Communication and Documentation
MSC: Safe Effective Care Environment
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MULTIPLE RESPONSE
1. A nurse is caring for a confused and frail patient. Which interventions will best minimize the
patients risk of injury related to the geriatric triad? (Select all that apply.)
a. Respond to the patients call bell promptly.
b. Ensure the bed alarm is on at all times.
c. Remain with the patient when eating.
d. Assess elimination needs every 2 hours while the patient is awake.
e. Offer the patient fluids during each visit.
ANS: A, B, D
The geriatric triad includes falls, changes in cognitive status, and incontinence. Responding
promptly to call lights, assessing for elimination needs, and having bed alarms limits falling.
DIF: Applying (Application) REF: N/A OBJ: 9-6
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TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
2. The nurse explains to the student the benefits of home health care. Which are benefits
typically associated with this care? (Select all that apply.)
a. Less exposure to iatrogenic risks
b. Less chance of becoming confused
c. Better management of chronic conditions
d. Better reimbursement from Medicare
e. Patient remains in control of environment
ANS: A, B, C, E
Many benefits exist for home health care including less risk of iatrogenic illness/injury, less
chance the patient will be acutely confused by the change of environment, better long-term
management of chronic conditions, and control of the environment by the patient.
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DIF: Understanding (Comprehension) REF: MCS: 162 OBJ: 9-9
TOP: Teaching-Learning MSC: Physiologic Integrity
3. What actions by the nursing staff in a long-term care facility display an awareness of resident
rights? (Select all that apply.)
a. Getting informed consent for the use of an antipsychotic medication
b. Reminding the unhappy resident and family about grievance processes
c. Ensuring that all residents are asked if they wish to vote in an election
d. Giving residents information on the ombudsmans name and address
e. Assessing residents for their ability to safely administer their medications
ANS: A, B, C, E
Long-term care facilities are responsible for honoring the many rights of their residents,
including setting up informed consent processes for side rails and chemical restraints, having a
TESpursuing
TBANKthe
SEresidents
LLER.Cright
OM to vote, assessing residents for
posted grievance policy and process,
the ability to safely administer their own medications, and posting information about the
ombudsman program.
Chapter 7 Assessment of Health and Functioning
MULTIPLE CHOICE
1. The leukocyte count of an older adult patient is elevated. The nurse shows the best
understanding of the effect of aging on body function when:
a. checking the patient for drug allergies before requesting an antibiotic
prescription.
b. asking that the patients temperature be taken before notifying the physician.
c. encouraging the patient to drink several glasses of water and then repeat the
laboratory tests.
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d. having the patient produce a urine sample and requesting a stat urinalysis.
ANS: B
When interpreting laboratory values and deciding the best course of treatment, the older adult
should be viewed holistically: signs, symptoms, and test results, such as the patients temperature,
should all be taken into account.
DIF: Application (Applying) REF: N/A OBJ: 19-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
2. The nurse helps minimize an older adult patients risk of developing pernicious anemia by:
a. suggesting supplementing vitamin A.
b. encouraging regular intake of citrus.
c. identifying iron-rich foods.
d. suggesting supplementing vitamin B12.
ANS: D
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Malabsorption of B12 can be caused by the effect of antibodies on gastric parietal cells and a
decrease in intrinsic factor, the underlying cause of pernicious anemia. The prevalence of
pernicious anemia increases significantly with aging. Pernicious anemia is not associated with
vitamin A, citrus, or iron.
DIF: Applying (Application) REF: N/A OBJ: 19-10
TOP: Teaching-Learning MSC: Physiologic Integrity
3. The nurse suspects that an acute postoperative infectious process may be developing in your
older adult patient. What abnormal finding best supports this suspicion?
a. A thrombocyte count of 40,000/mm3
b. Decreasing erythrocyte sedimentation rate of 10 to 20 mm/hr
c. Increasing C-reactive protein level
d. Increased partial prothrombin time
ANS: C
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C-reactive protein is a marker present in the acute phase of an inflammatory response. The other
lab values do not indicate infection.
DIF: Remembering (Knowledge) REF: MCS: 348 OBJ: 19-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. On assessing the laboratory data of an older adult patient, the nurse notes the serum potassium
level is 5.3 mEq/L. Based on this information, the nurse:
a. asks if the patient has been using a nonsteroidal antiinflammatory drug (NSAID).
b. determines if the patient is receiving a diuretic that promotes potassium loss.
c. suggests several potassium-rich foods to supplement dietary potassium intake.
d. monitors the patients urinary output for possible fluid retention.
ANS: A
A potassium level of 5.3 mEq/L is high. NSAIDs such as ibuprofen interfere with potassium
excretion. The other answers are not related to hyperkalemia.
DIF: Application (Applying) REF: N/A OBJ: 19-3
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TOP: Nursing Process: Assessment MSC: Physiologic Integrity
5. An older adult patient is experiencing symptoms commonly associated with hyperglycemia.
Which laboratory test is most reliable for detecting hyperglycemia in older adults?
a. A random serum glucose
b. An oral glucose tolerance test
c. An early morning urine test for glucose
d. A 24-hour urine glucose test
ANS: B
Appropriate glucose testing includes a fasting blood glucose, an oral glucose tolerance test, and
the hemoglobin A1C. The other options are not appropriate.
DIF: Remembering (Knowledge) REF: MCS: 352 OBJ: 19-1
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
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6. An older patient has a pressure ulcer that is resistant to healing despite aggressive therapy. The
nurse suspects the need for a protein supplement based on a(n):
a. serum creatinine level of 1.1 mg/dL.
b. acid phosphate level of 0.9 U/L.
c. folate level of 18.2 ng/mL.
d. serum albumin level of 3.1 g/dL.
ANS: D
In older adults with impaired skin integrity related to pressure ulcers, assessment of the albumin
level helps determine whether the protein balance is correct for proper wound healing to occur.
Older adults with low albumin levels need nutritional support to promote healing of wounds. The
other lab values are not related.
DIF: Remembering (Knowledge) REF: MCS: 352 OBJ: 19-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
7. An older adult patient has an elevated prostate-specific antigen (PSA) level. The nurse shares
with him that a diagnosis of prostate
confirmed
TEScancer
TBANwould
KSELbeLE
R.COM with an analysis of his:
a. alkaline phosphatase level.
b. acid phosphatase level.
c. serum amylase level.
d. uric acid level.
ANS: B
Acid phosphatase is an enzyme that is primarily located in the prostate gland. Acid phosphatase
levels are used to diagnose prostate cancer and to estimate the extent of the disease. The other
values are not related.
DIF: Understanding (Comprehension) REF: MCS: 354 OBJ: 19-10
TOP: Teaching-Learning MSC: Physiologic Integrity
8. The nurse explains to an older patient that the assessment of her thyroid health will require
both a physical examination as well as laboratory test because:
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a. thyroid studies are less accurate in older adults.
b. symptoms are similar to those caused by various infections.
c. thyroid problems can be present without overt symptoms.
d. T3 levels are normally increased during aging.
ANS: C
The presence of thyroid disease in older adults can be difficult to determine and can be present
without overt symptoms. Classic signs of thyroid disorders seen in younger adults are often
absent or clouded because of concomitant illnesses in older adults. The other options are not
correct statements.
DIF: Understanding (Comprehension) REF: MCS: 358 OBJ: 19-9
TOP: Teaching-Learning MSC: Physiologic Integrity
9. A 91-year-old patient learns that his urine protein is 8.2 mg/100 mL. When asked to explain
the significance of the result, the nurse replies:
a. It may be elevated because of a urinary tract infection.
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b. The result is not significant because its within normal limits.
c. The level is usually elevated in people your age.
d. Mild chronic renal failure causes a decrease in urine protein.
ANS: A
The presence of high protein levels in the urine warrants investigation to rule out a urinary tract
infection or kidney disease.
DIF: Understanding (Comprehension) REF: MCS: 355 OBJ: 19-6
TOP: Teaching-Learning MSC: Physiologic Integrity
10. A 71-year-old patient has a cholesterol level of 182 mg/dL. The nurse evaluates this as:
a. high.
b. low.
c. normal.
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d. unknown; no norms have been established for this age group.
ANS: A
The American Heart Association views a triglyceride level of < 100 mg/dL as desirable.
DIF: Remembering (Knowledge) REF: MCS: 353 OBJ: 19-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
11. The nurse is caring for an 88-year-old patient who was admitted to the long-term care facility
after a recent conviction of driving while intoxicated. On reviewing the laboratory work and
observing a folic acid level of 2 ng/ml, the nurse:
a. increases the patients caloric intake.
b. performs a dietary assessment on the patient.
c. provides the patient with sodium-rich foods.
d. immediately notifies the patients physician.
ANS: D
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This folic acid level is very low. Alcohol is known to interfere with the absorption of folate. The
nurse should immediately notify the physician. Increasing calories will not in itself increase
folate levels. A dietary assessment may be warranted but is not the best response. Sodium is not
related.
DIF: Analyzing (Analysis) REF: N/A OBJ: 19-10
TOP: Communication and Documentation MSC: Physiologic Integrity
12. A 66-year-old patient has a decreased calcium level. The nurse anticipates a(n):
a. elevated sodium level.
b. elevated phosphorus level.
c. decreased magnesium level.
d. decreased serum glucose level.
ANS: B
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Calcium metabolism is one of the factors that determines phosphorus levels; an inverse
relationship is present. A decrease in calcium can cause an increase in phosphorus and vice
versa.
DIF: Remembering (Knowledge) REF: MCS: 351 OBJ: 19-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
13. A patients oxygen saturation is 98%, but the patient reports shortness of breath with activity.
What action by the nurse is best?
a. Assess the patients hemoglobin.
b. Apply oxygen at 2L/nasal cannula.
c. Consult respiratory therapy.
d. Administer a bronchodilator.
ANS: A
If the patients hemoglobin is low, there may not be sufficient oxygen in the blood for the patients
needs. The nurse assesses the hemoglobin level. Applying oxygen may help the patient feel
better but does not get to the rootTofES
the
problem.
and a bronchodilator are
TB
ANKSERespiratory
LLER.COtherapy
M
not indicated.
DIF: Applying (Application) REF: N/A OBJ: 19-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
14. A patient has increased total iron binding capacity and transferrin levels. What action by the
nurse is best?
a. Prepare to administer vitamin B12.
b. Encourage the patient to eat protein.
c. Ensure the patient gets sun exposure.
d. Prepare the patient for chelating therapy.
ANS: B
High levels of transferrin and iron binding capacity may indicate iron deficiency anemia, so the
nurse encourages the patient to eat more protein. The other options are not appropriate.
DIF: Applying (Application) REF: N/A OBJ: 19-10
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TOP: Nursing Process: Implementation MSC: Physiologic Integrity
15. An older female patient develops gout and says, Why did I get this now? What response by
the nurse is best?
a. Gout can strike anyone at any time.
b. Your body apparently makes more uric acid now.
c. Uric acid rarely rises in premenopausal women.
d. Women actually have more gout than men do.
ANS: C
Because of the role of estrogen in the excretion of uric acid, elevated levels are usually not seen
before menopause in women. The other statements are incorrect.
DIF: Understanding (Comprehension) REF: MCS: 347 OBJ: 19-1
TOP: Teaching-Learning MSC: Physiologic Integrity
16. An older patient takes warfarin (Coumadin). The patients international normalized ratio
(INR) is 1.0. What action by the nurse is best?
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a. Nothing; this level is therapeutic.
b. Assess the patients diet history.
c. Prepare to administer vitamin K.
d. Double the warfarin dose.
ANS: B
The therapeutic INR is 2-3 (2-3.5 in some sources), so this level is not therapeutic. Foods rich in
vitamin K antagonize warfarin. Before consulting the provider about adjusting the dose, the
nurse should first assess the patients diet history to see if too many vitamin Krich foods are being
eaten. The dose may need adjustment. Vitamin K would be given for an overdose.
DIF: Analyzing (Analysis) REF: N/A OBJ: 19-10
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
17. An older adult has been admitted for dehydration. Which laboratory value correlates with this
condition?
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a. Na+: 160 mEq/L
b. Na+: 128 mEq/L
c. K+: 3.5 mEq/L
d. K+: 5.2 mEq/L
ANS: A
A sodium level of Na+: 160 mEq/L is high and can be seen in cases of dehydration.
Overhydration will produce a low sodium level. Potassium levels are not related.
DIF: Analyzing (Analysis) REF: N/A OBJ: 19-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
18. A patient has a low sodium level but normal blood osmolarity. What does the nurse
understand about this condition?
a. The two values are not related.
b. The patient is overhydrated.
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c. The patient has pseudohyponatremia.
d. The patient has end-stage kidney disease.
ANS: C
Pseudohyponatremia is a condition in which the serum sodium is low, but osmolarity remains
normal. The patient is not overhydrated nor does he or she have end-stage renal disease.
DIF: Remembering (Knowledge) REF: MCS: 350 OBJ: 19-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
19. A patient has heart failure and takes spironolactone (aldactone). What diet selection from the
menu shows that the patient needs more education?
a. A low-fat chicken salad sandwich
b. Salt-free vegetable soup
c. Broiled fish with lemon
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d. Salt substitute and pepper
ANS: D
Older patients have difficulty excreting potassium because of age-related kidney changes. This
patient also takes aldactone, a potassium sparing diuretic. If the patient adds a salt substitute,
normally high in potassium, the chances of developing hyperkalemia are high. The nurse needs
to provide education on other ways to flavor foods. The other diet choices are fine.
DIF: Analyzing (Analysis) REF: N/A OBJ: 19-1
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
20. An older patients BUN is 28 mg/dL and creatinine is 0.6 mg/dL. How does the nurse
interpret these findings?
a. Normal for all age groups
b. Normal for older adults
c. High for all age groups
d. Low for older adults
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ANS: B
The older adult may have elevated blood urea nitrogen (BUN) because of age-related decreases
in kidney function and a lowered creatinine resulting from decreased muscle mass.
DIF: Understanding (Comprehension) REF: MCS: 353 OBJ: 19-1
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
21. An 85-year-old patients blood gasses are as follows: pH 7.4, PAO2 75 mmHg, PACO2 38
mmHg, HCO3 25. What action by the nurse is best?
a. Administer oxygen per facemask
b. Assess the patients shortness of breath
c. Assess the patients oxygen saturation
d. Document the findings in the chart
ANS: D
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These values are normal for the patients age. If the patient had complaints, the nurse would
perform further assessments, but because the patient does not appear to have complaints, the
nurse documents the results.
DIF: Analyzing (Analysis) REF: N/A OBJ: 19-1
TOP: Communication and Documentation MSC: Physiologic Integrity
22. A patient was admitted for heart failure, and over the past 3 days the patients brain natriuretic
peptide has decreased. What action by the nurse is best?
a. Prepare to administer extra diuretics.
b. Continue with the plan of care.
c. Prepare to intubate and ventilate the patient.
d. Discuss end-of-life care with the patient.
ANS: B
A decreasing BNP indicates less fluid volume in the heart, indicating that treatment measures for
CHF are working. The nurse continues with the plan of are. The other actions are not needed.
TEN/A
STBOBJ:
ANK19-8
SELLER.COM
DIF: Applying (Application) REF:
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
23. A patient takes digoxin (Lanoxin) for heart failure with atrial fibrillation. The patient reports
yellow vision and nausea. The patients digoxin level is 1.9 ng/mL. How does the nurse explain
the situation to the patient?
a. Even with a normal blood level you may have digoxin toxicity.
b. You may have a gastrointestinal virus that is causing these symptoms.
c. You may not be getting a high enough dose of digoxin; Ill call the doctor.
d. Your cataracts may be worsening and you may need to have them removed.
ANS: A
This digoxin level is normal; however, older adults can get digoxin toxicity even with normal
blood levels. The other answers are not accurate.
Chapter 8 Medications and Other Bioactive Substances
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MULTIPLE CHOICE
1. The nurse is preparing to apply a topical cream on the arm of a cognitively impaired, anorexic
older adult patient in the terminal stage of lung cancer. The nurse carefully monitors the
effectiveness of the medication because its effectiveness will be most negatively impacted by the
patients:
a. age.
b. cognitive limitations.
c. nutritional status.
d. cancer diagnosis.
ANS: A
Topical drugs face barriers to absorption because the aged skin has decreased water content, a
relative decrease in lipid content, and a decrease in tissue perfusion. These changes may result in
impaired absorption of some medications that are administered via lotions, creams, ointments,
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and patches. The other options are not related to medication effectiveness in this situation.
DIF: Remembering (Knowledge) REF: MCS: 362 OBJ: 20-4
TOP: Nursing Process: Assessment MSC: Health Promotion
2. When administering medications to older adults, the nurse shows an understanding of the
effect of aging on drug distribution by monitoring the patients:
a. cardiac function.
b. liver function.
c. red blood cell count.
d. plasma albumin levels.
ANS: D
With age, particularly for malnourished or frail adults, plasma albumin levels may drop and
therefore should be monitored. As a result of decreased sites for protein binding, the activity of
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highly protein bound drugs, and any side effects caused by these drugs may be increased. The
other options may be appropriate for specific drugs, but not in general.
DIF: Remembering (Knowledge) REF: MCS: 362 OBJ: 20-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
3. An older adult patient has been prescribed warfarin (coumadin). The nurses primary
intervention involves daily review of the patients:
a. prothrombin time.
b. body for bruising.
c. serum creatinine level.
d. reflex tone.
ANS: A
Warfarin therapy is monitored byTthe
ratio (INR) or INR with
ESinternational
TBANKSELnormalized
LER.COM
prothrombin time.
DIF: Remembering (Knowledge) REF: MCS: 363 OBJ: 20-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. A patient with diabetes and hypothyroidism is being admitted to an assisted living facility.
During the admission assessment, the patient reports difficulty falling asleep. The nurse shows
an understanding of sleep dysfunction and the older patient when asking:
a. Have you ever been prescribed a sleeping medication?
b. How do you feel about leaving your home to live here?
c. How long have you been a diabetic?
d. Are you taking medication for your thyroid problem?
ANS: D
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Insomnia and anxiety are problems that commonly plague older adults. Because insomnia and
anxiety often occur secondary to medication side effects or secondary to medical conditions such
as dementia, thyroid abnormalities, or depression, proper diagnosis and treatment of any
underlying causes of insomnia or anxiety can help this condition. The other questions are
appropriate for an intake interview, but not specifically related to the insomnia.
DIF: Understanding (Comprehension) REF: MCS: 368 OBJ: 20-7
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
5. A patient is receiving propranolol (Inderal) for hypertension. Which outcome is the best
indicator of goal success when considering the drugs potential effect on the patients quality of
life?
a. The patient verbalizes the importance of moderate exercise.
b. The patient experiences no injuries as a result of dizziness.
c. The patients blood pressure stays within normal limits.
TESindicative
TBANKSofEL
ER.COdrug
M reaction.
d. The patient describes symptoms
anLadverse
ANS: B
The main concerns with the use of antihypertensive medications in older adults are an increased
risk of orthostatic hypotension and dehydration. Exercising and maintaining the blood pressure
within normal limits are treatment goals but do not impact quality of life like dizziness or
fainting. Having an adverse drug reaction would not improve quality of life.
DIF: Applying (Application) REF: N/A OBJ: 20-6
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
6. The nurse responsible for administering medications to the residents of a long-term care
facility shows an understanding of the risk of injury this population experiences when:
a. confirming the patients identity prior to providing the medication.
b. assessing the patient for a history of drug-related allergies.
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c. implementing the 5 rights of medication administration routinely.
d. educating patients about the purpose and side efforts of their medications.
ANS: C
The Institute of Medicine (IOM) estimates that 1.5 million ADEs and 7000 deaths occur in the
United States each year secondary to medication errors. Older adults are disproportionately
affected; more than half of the medication errors occur in long-term care facilities and more than
500,000 occur among ambulatory Medicare patients. Some references use the 6 rights of
medication administration.
DIF: Applying (Application) REF: N/A OBJ: 20-3
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
7. An older adult diabetic patient is mildly hypertensive. The nurse prepares to educate the
patient regarding angiotensin IIblocking agents. These drugs are especially useful in older adults
because they:
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a. protect the kidneys function.
b. have a well-defined therapeutic window.
c. are more effective than other drugs in the same class.
d. can be given when liver function is compromised.
ANS: A
The ACEIs and ARBs also have demonstrated value in decreasing the chance of cardiac
mortality in patients with heart failure. They also confer renal protection, which is particularly
beneficial for patients with diabetes. The other statements are not related to both the patients
conditions.
DIF: Applying (Application) REF: N/A OBJ: 20-6
TOP: Teaching-Learning MSC: Physiologic Integrity
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8. The nurse shows an understanding of medication-related risk factors common to older adults
when asking:
a. Are you aware of the possible side effects of your medications?
b. Do you regularly take any dietary supplements?
c. How do you keep track of when your medications are due?
d. How many different physicians are prescribing medications for you?
ANS: B
About 52% of older adults living in the United States take some sort of dietary supplement on a
regular basis in addition to prescription medications. This increases the potential for drug-drug
interactions. The other questions are important assessment questions to include in a medication
review.
DIF: Understanding (Comprehension) REF: MCS: 371 OBJ: 20-3
TEMSC:
STBAPhysiologic
NKSELLEIntegrity
R.COM
TOP: Nursing Process: Assessment
9. An older adult patient is having difficulty remembering when to take several of the prescribed
medications. To improve the patients compliance with the medication regimen, the nurse:
a. asks the patients spouse to consistently administer the drugs.
b. checks the drug guide to see if decreasing the frequency if the drugs is possible.
c. informs the patients physician about the drug noncompliance.
d. teaches the patient to administer daily pills with a pill dispenser.
ANS: D
The regimen should be simplified as much as possible; using a drug dispenser could make the
daily process less complicated. If the patient is still unable to manage this task, the nurse could
consult with the provider about decreasing frequency or changing medications, or the nurse
could ask the spouse to administer the medications if this were acceptable to the patient. But the
easiest and most cost-effective action is to try a pill dispenser.
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DIF: Application (Applying) REF: N/A OBJ: 20-4
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
10. The nurse is caring for an older adult who reports severe chronic pain. To best assess agerelated physiologic changes that could influence plans for initiating an appropriate drug regimen,
the nurse prepares the patient for which laboratory evaluation?
a. White blood count
b. Glomerular filtration rate
c. Serum complement level
d. Electroencephalogram
ANS: B
Many drugs are renally excreted, and there are age-related reductions in renal function. The
nurse wanting to assess for such factors that influence the selection of drugs would most likely
ESTBAN
KSELdone,
LERincluding
.COM an evaluation of the patients
anticipate the patient having renalTfunction
studies
glomerular filtration rate.
DIF: Remembering (Knowledge) REF: MCS: 363 OBJ: 20-1
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
11. An older adult patient is being assessed for possible alcohol abuse. To best assess the patients
risk potential, the nurse asks:
a. Have you ever experienced a memory loss as a result of consuming alcohol?
b. Would you drink to relax after a particularly stressful day?
c. Do you ever drink when you are alone?
d. How many alcoholic drinks do you consume each week?
ANS: D
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The nurse should start the assessment for alcohol abuse by inquiring as to the number of drinks
the patient consumes each week. The other questions can be part of an abuse assessment, but it is
easiest to start with a simple, quantitative question to open the discussion.
DIF: Applying (Application) REF: N/A OBJ: 20-10
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
12. An older adult patient is currently undergoing detoxification for alcohol at a rehabilitation
center. When assessing the patient using the Clinical Institute Withdrawal Assessment tool, the
nurse determines the patients current score to be 23. The nurse:
a. immediately institutes seizure precautions.
b. monitors the patients vital signs every 2 hours.
c. arranges for the patient to be transferred to an acute care hospital.
d. shares with the patient that the detoxification process is almost complete.
ANS: C
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The maximum score on this tool is 67, and patients who score higher than 20 should be admitted
to a hospital. The other options are incorrect.
DIF: Applying (Application) REF: N/A OBJ: 20-10
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
13. A 68-year-old man with a history of alcohol abuse is admitted to the acute care facility for
reports of abdominal pain. Based on your understanding of alcohol withdrawal, the nurse knows
that if patient is currently abusing alcohol, he will most likely:
a. experience delirium tremors within 4 hours of hospitalization.
b. develop withdrawal symptoms 48 to 72 hours after the last intake of alcohol.
c. receive 1 ounce of alcohol every 4 hours while awake.
d. be prescribed oxazepam (Serax).
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ANS: B
Symptoms tend to peak 48 to 72 hours after a patients last drink, although they may occur within
4 to 12 hours. The patient may or may not have DTs. The patient should not receive alcohol and
may or may not need medication.
DIF: Understanding (Comprehension) REF: MCS: 379 OBJ: 20-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
14. When working with a patient suspected of substance abuse, the nurse is particularly
interested in determining the cause of a patients:
a. acute abdominal pain.
b. recurring insomnia.
c. extensive history of falls.
d. chlordiazepoxide (Librium) prescription.
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ANS: C
Frequently, the symptoms of substance abuse are subtle or atypical, or they mimic symptoms of
other age-related illnesses and remain undiagnosed. Patients presenting symptoms may be erratic
changes in affect, mood, or behavior; malnutrition; bladder and bowel incontinence; gait
disturbances; and recurring falls, burns, and head trauma. Acute abdominal pain, insomnia, and
prescriptions for Librium may or may not be related to substance abuse, but falling is.
DIF: Applying (Application) REF: N/A OBJ: 20-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
15. A 67-year-old woman presents at the emergency department with symptoms that suggest
possible abuse of a narcotic analgesic. To best assure the patients safe care, the nurse asks:
a. When did you first start using the analgesic?
b. Have you experienced withdrawal symptoms before?
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c. Why did you initially need an analgesic?
d. What prescribed drugs are you currently taking?
ANS: D
First, if prescription drug abuse is suspected, the nurse should ask the patient or a family member
to identify all medications that the patient is currently using. The nurse and physician can then
plan for safe detoxification. In addition, the physician can try to prevent any untoward drug
interactions resulting from prescribing a new medication that is contraindicated because of an
existing prescription.
DIF: Applying (Application) REF: N/A OBJ: 20-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
16. Your patient reports frequent constipation as a result of prescription medications and asks the
nurse for advice about using a daily over-the-counter laxative. The most appropriate response by
the nurse is to:
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a. tell the patient to consult the health practitioner before using nonprescription
drugs.
b. educate the patient about the side effects of regular laxative use.
c. tell the patient to avoid laxatives because they can interfere with medications
already being taken.
d. tell the patient to consult a dietician about ways to correct chronic constipation.
ANS: A
Education regarding the importance of contacting the health practitioner (physician or
pharmacist) before taking nonprescription medication is essential for reducing the number of
unintentional medication interactions. Educating the patient on side effects and teaching the
patient nonpharmaceutical ways to manage constipation are also appropriate.
DIF: Understanding (Comprehension) REF: MCS: 371 OBJ: 20-8
TOP: Teaching-Learning MSC: Physiologic Integrity
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17. When initially planning care for the older adult patient who is prescribed clonidine patches as
part of a smoking cessation program, the nurse:
a. assesses the patient for any skin disorders on the upper arms and back.
b. determines how many cigarettes or cigars the patient smokes per day.
c. asks if the patient is currently taking any antihypertensive medications.
d. educates the patient to the possible side effects of clonidine therapy.
ANS: C
Clonidine is an antihypertensive, so knowledge of the patients medication history is vital to
avoid inducing hypotension. The other assessments are not related to patient safety.
DIF: Applying (Application) REF: N/A OBJ: 20-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
18. The nurse explains to ancillary
to diagnose in the older
TEstaff
STBthat
ANcaffeine
KSELLabuse
ER.CisOdifficult
M
adult patient because caffeine intoxication symptoms:
a. can be confused with normal effects of aging.
b. often mimic those of some cardiac disorders.
c. produce fewer symptoms in older adults than in younger adults.
d. resemble the side effects of several antihypertensive drugs.
ANS: B
Caffeine stimulates the sympathetic nervous system, often producing the rapid pulse associated
with cardiac disorders. Caffeine effects are not mistaken for normal signs of aging, produce
fewer symptoms in older adults, or resemble side effects of antihypertensives.
DIF: Understanding (Comprehension) REF: MCS: 385 OBJ: 20-5
TOP: Teaching-Learning MSC: Physiologic Integrity
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19. An older adult patient shares with the admitting nurse that she drinks one shot of whiskey
nightly to help her sleep. The nurse documents the need to:
a. assess the patient for slurred speech, lack of coordination, and nystagmus.
b. address the effects of alcohol abuse with the patient.
c. provide the patient with an alcohol substitute.
d. assess the patient for signs of agitation, as well as anxiety and seizures.
ANS: D
It is important to assess older patients for the possibility of alcohol withdrawal if agitation,
hallucinations, anxiety, or seizures develop. Because the patient admits to a shot a day, it is
possible she drinks more or uses alcohol to self-medicate for problems other than insomnia. The
nurse should monitor the patient for signs of withdrawal as a priority, because this is a medical
emergency. Slurred speech, lack of coordination, and nystagmus are signs of overindulging. The
nurse should not provide an alcohol substitute. It is appropriate to discuss the effects of alcohol,
but safety comes first.
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DIF: Applying (Application) REF: N/A OBJ: 20-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
20. The nurse is assessing patients for impending alcohol withdrawal. The nurse assesses the
patient with which of the following conditions as a priority?
a. Pulse, 58 beats/min; and BP 100/60
b. Pulse, 118 beats/min; and BP 160/90
c. Dozing off in chair and not recognizing staff
d. Reporting muscle aches and frequent stumbling
ANS: B
Manifestations of alcohol withdrawal are elevated blood pressure, elevated pulse, and autonomic
hyperactivity. In addition, fever; increased hand tremors; insomnia; nausea and vomiting;
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transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety;
and grand mal seizures may occur. The nurse should see the hypertensive, tachycardic patient as
the priority.
DIF: Applying (Application) REF: N/A OBJ: 20-12
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
MULTIPLE RESPONSE
1. To minimize the possible complications of polypharmacy among older adult patients, the
nurse assesses this population for which of the following? (Select all that apply.)
a. Number of physicians providing medical care
b. Location of pharmacies where prescriptions are filled
c. Presence of chronic illnesses
d. Tendency to borrow medication from family or friend
e. Use of over-the-counter medication
TESTBtoAself-medicate
NKSELLER.COM
ANS: A, B, C, E
Older adults are especially vulnerable to polypharmacy because many have one or more chronic
conditions requiring several medications for management. To complicate matters, patients may
see more than one provider for the same health problem and may have prescriptions filled at
more than one pharmacy. Additional contributors to polypharmacy include the use of over-thecounter and alternative medicines or supplements in the treatment of conditions. As a result, the
patient may end up taking duplicate drugs, similar drugs from the same drug class, and drugs that
are contraindicated when taken together. Borrowing medications is not usually an issue.
DIF: Applying (Application) REF: N/A OBJ: 20-6
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
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2. The nurse must be able to distinguish between alcohol intoxication and alcohol withdrawal to
intervene appropriately. The nurse suspects alcohol intoxication when the patient does which of
the following? (Select all that apply.)
a. Slurs his speech when answering questions
b. Has difficulty remembering his address
c. Reports seeing snakes in the corner of the room
d. Documents his blood pressure as 168/90
e. Experiences difficulty when walking to the bathroom
ANS: A, B, E
Signs associated with alcohol intoxication include the scent of alcohol on the breath, slurred
speech, lack of coordination, unsteady gait, nystagmus, impairment in attention or memory, and
stupor or coma. Manifestations of alcohol withdrawal are elevated blood pressure, elevated
pulse, and autonomic hyperactivity. In addition, fever; increased hand tremors; insomnia, nausea
and vomiting; transient visual, tactile,
orBauditory
TEST
ANKSEhallucinations
LLER.COM or illusions; psychomotor
agitation; anxiety; and grand mal seizures may occur.
DIF: Remembering (Knowledge) REF: MCS: 379 OBJ: 20-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
3. A 69-year-old was prescribed a benzodiazepine 3 years ago. This medication regimen
increases the patients risk for injury related to drug abuse and requires frequent patient
assessment for which of the following? (Select all that apply.)
a. Daytime sleepiness
b. Unsteady gait
c. Shortness of breath
d. Easy bleeding
e. Forgetfulness
ANS: A, B, E
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Benzodiazepines can cause excessive sedation, impaired memory, decreased psychomotor
performance, and balance disturbances and may lead to drug dependence and should not be
prescribed for extended periods of time. Shortness of breath and bleeding are not signs of side
effects.
Chapter 9 Legal and Ethical Concerns
MULTIPLE CHOICE
1. A nurse caring for older adult patients shows an understanding of the implementation of
standards of care when:
a. dialing the telephone when the patient wants to call his daughter.
b. requesting the patients favorite dessert on his birthday.
c. closing the patients door when he is praying.
d. reminding the patient to call for assistance before getting out of bed.
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ANS: D
A standard of care is a guideline for nursing practice and establishes an expectation for the nurse
to provide safe and appropriate care, such as reminding the patient to call for assistance before
getting out of bed. Standards of care may be established on national or regional levels. Dialing
the phone for the patient, closing the patients door, and requesting a special dessert are not
actions that conform to standards of care.
DIF: Applying (Application) REF: N/A OBJ: 3-1
TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment
2. A nurse new to geriatric nursing asks the nurse manager to clarify how to handle a patients
claim that she has been physically abused. The nurse manager responds most appropriately when
stating:
a. Ill show you where you can find this states reporting requirements.
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b. As a nurse you are considered a mandated reporter of elder abuse.
c. As long as you are reasonably sure abuse has occurred, report it.
d. You need to report any such claims directly to me.
ANS: A
To be responsive to the legal obligation to report reasonably suspicious acts of abuse and
because there is great variation among the states, nurses should determine the specific reporting
requirements of their jurisdictions, including where reports and complaints are received and in
what form they must be made. The statements that the nurse is a mandatory reporter and that
abuse should be reported if suspected are true, but they do not help the nurse learn to handle the
complaint. The manager may want to know about claims of abuse and it may be facility policy to
report up the chain of command, but the nurse is responsible for filing the formal complaint.
DIF: Applying (Application) REF: N/A OBJ: 3-8
TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment
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3. The nurse recognizes that a nursing aide likely to abuse an older patient is one who has:
a. ineffective verbal communication skills.
b. little experience working with the older population.
c. poor stress management skills.
d. been a victim of abuse.
ANS: C
It has been shown that the primary abusers of nursing facility residents are nurse aides and
orderlies who have never received training in stress management.
DIF: Remembering (Knowledge) REF: MCS: 32 OBJ: 3-8
TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment
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4. An older adult resident of a long-term care nursing facility frequently attempts to get out of
bed and is at risk of sustaining an injury. The nurses planned intervention to minimize the
patients risk for injury is guided by:
a. the patients right to self-determination and to be free to get out of bed.
b. an understanding that nondrug interventions must be tried before medications.
c. the knowledge that application of a vest restraint requires a physicians order.
d. the patients cognitive ability to understand and follow directions.
ANS: B
The drug use guidelines are based on the principles that certain problems can be handled with
nondrug interventions and that such forms of treatment must be ruled out before drug therapy is
initiated. The patient does have the right to self-determination, but the staff must ensure the
patients safety. Vest restraints do require an order, but environmental measures must be tried
before chemical or physical restraints. The patients cognitive abilities do not allow for unjustified
physical or chemical restraints.
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DIF: Remembering (Knowledge) REF: MCS: 35-6 OBJ: 3-7
TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment
5. During the state inspection of a skilled nursing facility, a surveyor notes suspicion that a
particular nurse may not be providing the proper standard of care. The nurse manager informs
the nurse to expect:
a. a review of the situation by the state board of nursing.
b. termination of employment from the facility.
c. mandatory remediation related to the suspect care issues.
d. unannounced reevaluation of performance within the next 3 months.
ANS: A
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In such cases, the surveyor may forward the record showing the relevant findings to the
appropriate state agency or board for review of the nurses practice, requesting a determination of
whether the nurse may have violated the states nurse practice act. Regulations do not specify that
the nurse be terminated, have remediation, or have an unannounced reevaluation.
DIF: Understanding (Comprehension) REF: MCS: 37 OBJ: 3-1
TOP: Communication and Documentation
MSC: Safe and Effective Care Environment
6. An 87-year-old patient is unsure of the purpose of a living will. The nurse describes its
purpose best when stating:
a. Its a legal document that Social Services can help you create.
b. It designates a family member to make decisions if you become incompetent.
c. It provides a written description of your wishes in the event you become
terminally ill.
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d. It assures you wont be subjected to treatments you dont want.
ANS: C
Living wills are intended to provide written expressions of a patients wishes regarding the use of
medical treatments in the event of a terminal illness or condition.
DIF: Understanding (Comprehension) REF: MCS: 39 OBJ: 3-10
TOP: Teaching-Learning MSC: Safe and Effective Care Environment
7. The nurse is caring for an unresponsive patient who has terminal cancer with a Do Not
Resuscitate order in effect. A family member tells the nurse, Ill sue you and every other nurse
here if you dont do everything possible to keep her alive. The nurse understands that protection
from legal prosecution in this situation is provided by:
a. legal immunity granted when acting according to the patients expressed wishes.
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b. the legal view that the duty to put into effect the patients wishes falls to the
physician.
c. knowledge of and compliance with facility policies and procedures regarding
end-of-life care.
d. implementing interventions that preserve the patients right to self-determination.
ANS: C
In this case, immunity applies only to the physician and not to the nurse because the physician is
given the legal duty to put into effect the patients wishes. Consequently, the nurse must rely on
effective communication with the physician, patient, and family, and on the quality of the
facilitys policies and procedures, to be sure that his or her actions are consistent with the legally
required steps.
DIF: Understanding (Comprehension) REF: MCS: 42 OBJ: 3-10
TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment
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8. The nurse is caring for a terminally ill older patient who has a living will that excludes
pulmonary and cardiac resuscitation. The family expresses a concern that the patient may change
her mind. The nurse best reassures the family by stating:
a. The nursing staff will watch her very closely for any indication she has changed
her mind.
b. We will discuss her wishes with her regularly.
c. She can change her mind about any provision in the document at any time.
d. Your mother was very clear about her wishes when she signed the document.
ANS: A
AMD provisions appropriately provide that people can change their minds at any time and by
any means. Nurses need to be alert to any indications from a patient. Based on the persons
medical condition, subtle signs such as a gesture or a nod of the head may be easily overlooked.
The patient may or may not be able to discuss her condition. Stating that the mother was very
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clear in her wishes does not take into account the fact that patients can change their minds any
time.
DIF: Applying (Application) REF: N/A OBJ: 3-7
TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment
9. A patient residing in a long-term care facility has been experiencing restlessness and has often
been found by nursing staff wandering in and out of other patients rooms during the night. The
nurse views the patients PRN antipsychotic medication order as:
a. an appropriate intervention to help assure his safety.
b. an option to be used only when all other nondrug interventions prove ineffective.
c. inappropriate unless the physician is notified and approves its use.
d. not an option because it should not be used to manage behaviors of this type.
ANS: D
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Reasons for the use of antipsychotic drugs do not include behaviors such as restlessness,
insomnia, yelling or screaming, inability to manage the resident, or wandering. The staff must
provide nondrug alternatives to help calm the patient.
DIF: Analysis (Analyze) REF: N/A OBJ: 3-7
TOP: Nursing Process: Planning MSC: Safe and Effective Care Environment
10. An alert but disoriented older patient lives with family members. The home health nurse,
being aware of the role of patient advocate, recognizes the obligation to report possible patient
abuse based on:
a. a family member stating, Its hard being a caregiver.
b. assessment showing bruises in the genital area.
c. observation of mild changes in orientation.
d. patients report of always being hungry.
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ANS: B
Even when a patient exhibits disorientation, any report of mistreatment or neglect is to be
considered reasonably suspicious and so should be reported. Bruises in the genital area raise
suspicions of abuse. The family stating caregiving is hard does not mean they dont have enough
support to cope. Mild changes in orientation may be expected in a disoriented patient. The
patient who is always hungry should be followed up with a nutrition assessment, and this may or
may not be a sign of abuse.
DIF: Application (Apply) REF: N/A OBJ: 3-8
TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment
11. An older adult patient has been approached to participate in a research study. The nurse best
advocates for the patients right of self-determination by:
a. evaluating the patients cognitive ability to understand the consequence of the
study.
ESTBA
NKinvolved.
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b. determining what risks to theTpatient
are
c. discussing the importance of the study with the patient and his family.
d. encouraging the patient to discuss the decision with trusted family or friends.
ANS: A
The right to self-determination has its basis in the doctrine of informed consent. Informed
consent is the process by which competent individuals are provided with information that
enables them to make a reasonable decision about any treatment or intervention that is to be
performed on them. The other options do not address autonomy and self-determination.
DIF Applying (Application)
REF: N/A OBJ: 3-7 TOP: Communication and Documentation
MSC: Safe and Effective Care Environment
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12. A nurse responsible for the care of older adult patients shows the best understanding of the
nursing standards of practice when basing nursing care on the:
a. physicians medical orders.
b. stated requests of the individual patient.
c. care that a responsible geriatric nurse would provide.
d. implementation of the nursing process.
ANS: C
Nursing standards of practice are measured according to the expected level of professional
practice of those in similar roles and clinical fields. Nursing care is not judged against the
physicians orders, stated requests of the patient, or implementation of the nursing process.
DIF: Remembering (Knowledge) REF: MCS: 30 OBJ: 3-1
TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment
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13. The nurse caring for an older patient who resides in an assisted living facility is asked to
obtain and witness the patients signature on a living will document. The nurse responds most
appropriately when stating:
a. I will, because such a document is so valuable to the patients plan of care.
b. Ill ask the patients family if they agree that the patient should sign the document.
c. First I need to discuss the purpose of this document with the patient.
d. Im sorry but I cannot ethically do that.
ANS: D
It is not permissible for the nurse to secure the patients signature or to witness the patients
signature on a living will document. Generally speaking, an employee or owner of a facility in
which the patient resides cannot witness this document.
DIF: Application (Apply) REF: N/A OBJ: 3-9
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TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment
14. A graduate nurse learns about the provisions of the Health Insurance Portability and
Accountability Act (HIPAA), which include which of the following?
a. Requires employers to offer health care insurance
b. Regulates the amount employers can charge for insurance
c. Mandates that employers provide specific benefits
d. Helps maintain coverage when a person changes jobs
ANS: D
HIPAA has several provisions, one of which is that it helps people maintain health care
insurance when they are changing jobs. The other statements are common misconceptions about
HIPAA.
DIF: Remembering (Knowledge) REF: MCS: 31 OBJ: 3-5
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TOP: Teaching-Learning MSC: Safe Effective Care Environment
15. The nurse manager in a long-term care facility reviews resident care plans at what interval?
a. Quarterly
b. Every 60 days
c. Annually
d. When changes occur
ANS: A
The resident care plan is routinely reviewed quarterly.
DIF: Remembering (Knowledge) REF: MCS: 33 OBJ: 3-1
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
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16. The manager of a long-term care facility is evaluating patients use of drugs. The resident on
which of the following medications would be allowed to continue taking medications to control
behavior?
a. On anxiolytics; now able to participate in group activities
b. Given a benzodiazepine at night; roommate now sleeps well
c. Given sedatives; eats 100% of meals if resident is fed
d. Taking an antipsychotic; no longer wanders at night
ANS: A
Drugs should not be used to control behavior. If used to manage health conditions, the patient
should show improvement. The patient who is now able to participate in activities shows an
increase in functional ability, so this medication is therapeutic for this patient. The other patients
are given drugs to control behavior.
DIF: Applying (Application) REF: N/A OBJ: 3-7
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TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
17. To meet current guidelines regarding incontinence in a long-term care facility, what action by
the director of nursing is best?
a. Assess residents for the ability to participate in a bladder training program.
b. Take all residents to the toilet every 2 hours and after meals.
c. Ensure all residents wear incontinence briefs, which are changed routinely.
d. Ask physicians and other providers to prescribe medications for bladder control.
ANS: A
Urinary incontinence is a common problem that can lead to several complications. The extent to
which residents participate in bladder training programs is an area of focus for facility inspectors.
Some residents may need routine toileting, wearing briefs, and medications, but they should all
be assessed for the ability to participate in bladder training.
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DIF: Applying (Application) REF: N/A OBJ: 3-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity: Reduction of Risk Potential
18. The director of nursing at a long-term care facility is getting ready for the annual inspection.
What information guides the director?
a. Visits cannot be unannounced.
b. The director must be off site during the inspection.
c. Nurses must answer questions from the inspectors.
d. Results will be shared only through the mail.
ANS: C
Nurses present during inspections must answer questions posed by the inspectors. Visits can be
unannounced. The director should be present during the survey. Results are shared during a
conference, then a report is mailed later.
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DIF: Remembering (Knowledge) REF: MCS: 36 OBJ: 3-4
TOP: Communication and Documentation
MSC: Safe Effective Care Environment
19. The nursing student learns about the Patient Self-Determination Act. What is a key provision
of this act?
a. It establishes new rights for patients in medical facilities.
b. It requires facilities to educate patients on their rights.
c. It allows families to be approached for organ donation.
d. It spells out the procedures for creating an advance directive.
ANS: B
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The intent of this law is to ensure that patients are given information about the extent to which
their rights are protected under state law. It does not establish new rights, is not related to organ
donation, and does not specify procedures for advance directives.
DIF: Remembering (Knowledge) REF: MCS: 42 OBJ: 3-7
TOP: Teaching-Learning MSC: Safe Effective Care Environment
MULTIPLE RESPONSE
1. To best address the patients right to self-determination, which of the follow questions does the
nurse ask at the time the patient is admitted to a nursing facility? (Select all that apply.)
a. Do you understand what a living will and durable power of attorney are?
b. If you have already prepared an advance care directive, can you provide it now?
c. Are you prepared to discuss your end-of-life choices with the nursing staff?
d. Have you discussed your end-of-life choices with your family or designated
surrogate?
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e. Would you like help with preparing a living will or a durable power of attorney?
ANS: A, B, D, E
All the correct options address the patients right to make an informed decision regarding health
care issues by using various advance directives. The patient does not need to discuss end-of-life
choices with the staff in order to exercise the right to self-determination.
DIF: Application (Apply) REF: N/A OBJ: 3-7
TOP: Integrated Process: Teaching-Learning
MSC: Safe and Effective Care Environment
2. What provisions for nursing service are part of the Omnibus Budget Reconciliation Act
(OBRA) as it pertains to long-term care facilities? (Select all that apply.)
a. Resident assessments
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b. Annual screenings
c. Minimum staffing
d. Ensuring resident rights
e. Registered nurse educational requirements
ANS: A, B, C, D
OBRAs service requirements include resident assessments and screenings, minimum staffing
requirements, and ensuring resident rights. Educational requirements for nurses are not part of
this mandate.
DIF: Remembering (Knowledge) REF: MCS: 33 OBJ: 3-4
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
3. The director of nursing at a certified long-term care facility overhauls the nursing assistant
training program to include which features? (Select all that apply.)
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a. 12 hours of classroom content
b. Training in infection control measures
c. Instruction on resident rights
d. 6 hours of quarterly in-service education
e. Education on safety measures
ANS: B, C, D, E
Requirements for a nursing assistants education includes training in infection control and
interpersonal skills, instruction on resident rights and safety procedures, and 6 hours of education
through in-services quarterly. Nursing assistants must have classroom training before working
with residents, but the amount of time is not specified.
DIF: Applying (Application) REF: N/A OBJ: 3-3
TOP: Teaching-Learning MSC: Safe Effective Care Environment
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4. The adult child of a long-term care facility resident receives a phone call from the director of
nursing stating that her parent has 30 days to move out of the home. Under what conditions can a
facility require a resident to move?(Select all that apply.)
a. Nonpayment for services received
b. Needs exceeding what the facility can provide
c. Stay is no longer required based on the residents medical condition
d. Facility is going out of business
e. Frequent disruptive behavior during the night
ANS: A, B, C, D
A facility can require a resident to leave in four situations: nonpayment for services, needs that
exceed what the facility can provide, the patients medical condition no longer warrants long-term
care, or the facility is going out of business. Being disruptive is not a cause for expelling a
resident.
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Chapter 10 Elder Abuse and Neglect
Question 1
Type: MCMA
During a home visit, the nurse is concerned that an older patient is experiencing caregiver
neglect. What did the nurse assess in this patient?
Standard Text: Select all that apply.
1. Agitation
2. Listlessness
3. Dry, cracked skin
4. Bruises on both arms
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5. Skin irritation on both inner thighs
Correct Answer: 2,3,5
Rationale 1: Agitation is a manifestation of psychological or emotional abuse.
Reference: MCS: 234
Rationale 2: Listlessness is a manifestation of caregiver neglect.
Reference: MCS: 234
Rationale 3: Dry, cracked skin could indicate dehydration, which is a manifestation of caregiver
neglect.
Reference: MCS: 234
Rationale 4: Bruises on both arms is a manifestation of physical abuse.
Reference: MCS: 234
Rationale 5: Skin irritation on both inner thighs could indicate urine burns, which is a
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manifestation of caregiver neglect.
Reference: MCS: 234
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 2
Type: MCMA
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An older patient who just celebrated an 85th birthday comes into the emergency department with
a fractured arm and bruises over the chest and back. The nurse suspects the patient is a victim of
physical abuse. Which individuals will the nurse specifically assess the patient as being the
abuser?
Standard Text: Select all that apply.
1. Spouse
2. Nephew
3. Granddaughter
4. Next door neighbor
5. Adult daughter caregiver
Correct Answer: 1,2,3,5
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Rationale 1: Spouses account for 11.3% of abuse cases.
Reference: MCS: 233
Rationale 2: Family members account for 21.5% of abuse cases.
Reference: MCS: 233
Rationale 3: Family members account for 21.5% of abuse cases.
Reference: MCS: 233
Rationale 4: Next door neighbors are not identified as individuals who cause abuse
cases. Reference: MCS: 233
Rationale 5: The typical abuser is an adult child, accounting for 32.6% of abuse cases.
Reference: MCS: 233
Global Rationale:
Cognitive Level: Applying
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Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Discuss current trends in elder mistreatment, including incidence and
prevalence.
Question 3
Type: MCMA
An older patient is accompanied by an adult daughter who is the patients primary caregiver for a
routine clinic visit. While in the waiting room, the adult daughter is observed sitting quietly and
not talking with the patient. During the examination, what should the nurse assess the adult
daughter for?
Standard Text: Select all that apply.
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1. Employment
2. Physical status
3. Caregiver stress
4. Substance abuse
5. History of psychopathology
Correct Answer: 3,4,5
Rationale 1: Caregivers of older adults should be assessed at each primary care visit for
caregiver stress, substance abuse, and a history of psychopathology. Employment is not
something that needs to be assessed in the caregivers of older adults.
Reference: MCS: 236
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Rationale 2: Caregivers of older adults should be assessed at each primary care visit for
caregiver stress, substance abuse, and a history of psychopathology. Physical status is not
something that needs to be assessed in the caregivers of older adults.
Reference: MCS: 236
Rationale 3: Caregivers of older adults should be assessed at each primary care visit for
caregiver stress.
Reference: MCS: 236
Rationale 4: Caregivers of older adults should be assessed at each primary care visit for
substance abuse.
Reference: MCS: 236
Rationale 5: Caregivers of older adults should be assessed at each primary care visit for a history
of psychopathology.
Reference: MCS: 236
Global Rationale:
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Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 4
Type: MCSA
Which patients seen by a nurse working in the emergency department identify a situation that
suggests a case of elder mistreatment?
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1. An 86-year-old patient who has three dime-size burned areas on the upper inner thigh
2. A 77-year-old patient who fell at home after tripping over the dog and broke an arm about 30
minutes earlier
3. A 73-year-old patient with a history of gastric ulcers who is found to be anemic after vomiting
blood 3 hours earlier
4. An 85-year-old patient who has several small areas of bruising on the back of the hands and is
taking medication for platelets and coagulation
Correct Answer: 1
Rationale 1: The patient who has skin burns suggestive of cigarette burns in an area normally
covered by clothing is suggestive of abuse.
Reference: MCS: 237
Rationale 2: A patient with a broken bone that is consistent with an injury event and seeks
ESTBANsuspect
KSELfor
LEelder
R.Cabuse.
OM
medical attention promptly is notTgenerally
Reference: MCS: 237
Rationale 3: The patient with a positive history of gastric ulcers and active bleeding would be
expected to have anemia.
Reference: MCS: 237
Rationale 4: Bruising is common in patients taking medication that affects the blood, who have
thin skin, and in the hands, which is an area that is easily bumped.
Reference: MCS: 237
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 5
Type: MCSA
The nurse suspects that an older patient has been physically abused. What must be included in
the medical workup for this patient?
1. Pelvic examination
2. Toxicological screening
3. Complete blood count and blood chemistries
4. Complete visual examination with clothing removed
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Correct Answer: 4
Rationale 1: A pelvic examination is indicated for suspected sexual abuse.
Reference: MCS: 241
Rationale 2: Toxicological screening is indicated for suspected drug abuse.
Reference: MCS: 241
Rationale 3: Complete blood count and blood chemistries would be indicated if concerns
included neglect reflected by malnutrition and dehydration.
Reference: MCS: 241
Rationale 4: If you suspect elder mistreatment or abuse, a complete visual examination of the
older person without clothing is necessary. Abusers may strike where clothing hides the resulting
bruises. You can protect privacy by assessing the older persons body one area at a time from
head to toe.
Reference: MCS: 241
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Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 6
Type: MCSA
The nurse is concerned that specific families in a community are at increased risk for
transgenerational violence. Which family situation exemplifies the transgenerational theory of
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violence?
1. Family with a daughter who abuses alcohol
2. Family with a daughter who has severe arthritis and finds it increasingly difficult to deal with
her forgetful, frail mother
3. Family with a son who, as a teenager and young adult, had serious arguments with his parents,
who were emotionally abusive to him
4. Family with a daughter who is working two jobs with significant debts and cares for her
father, who is becoming more confused and dependent
Correct Answer: 3
Rationale 1: The theory of psychopathology of the abuser refers to caregivers who have
preexisting conditions that impair their abilities to provide proper care, as in the case of an adult
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child who has an ongoing alcohol abuse problem.
Reference: MCS: 233
Rationale 2: The theory of psychopathology of the abuser refers to caregivers who have
preexisting conditions that impair their abilities to provide proper care, as in the case of an adult
child with severe arthritis.
Reference: MCS: 233
Rationale 3: The theory of transgenerational violence involves a continuum of family violence.
A child grows up in a home where a contentious family relationship and some form of abuse is
the norm. The child who was abused grows up and later becomes aggressive and abusive to the
elderly parent.
Reference: MCS: 233
Rationale 4: Situational theory or caregiver stress involves care burdens that outweigh the
caregivers abilities to deliver care. Examples of caregiver stress are severe financial or time
constraints paired with the older adult requirements for more physical care or supervision.
Reference: MCS: 233
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Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Review key reasons elder mistreatment occurs.
Question 7
Type: MCSA
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An older patient tearfully tells a nurse that she must buy the neighbors groceries or the neighbor
will not drive the patient to the store. The nurse recognizes this situation as being which type of
elder mistreatment?
1. Abuse
2. Neglect
3. Exploitation
4. Abandonment
Correct Answer: 3
Rationale 1: Abuse is any action or inaction harming or endangering the welfare of an older
adult.
Reference: MCS: 234
Rationale 2: Neglect involves failure
TESto
TBprovide
ANKSEadequate
LLER.care
COMor services for an older adult.
Reference: MCS: 234
Rationale 3: Elder mistreatment by exploitation involves the abuser taking advantage of the
older person for monetary or personal benefit. This is the case in which the older patient is being
coerced to buy the neighbors groceries.
Reference: MCS: 234
Rationale 4: Abandonment is the desertion or willful forsaking of an older person.
Reference: MCS: 234
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 8
Type: MCMA
In which situations is institutional mistreatment of older patients most likely to occur?
Standard Text: Select all that apply.
1. Staff burnout
2. Staffing shortage
3. Patient aggressiveness
4. Inadequate staff training
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5. Family members frequently visit
Correct Answer: 1,2,3,4
Rationale 1: Staff burnout may be a precipitating factor in the mistreatment of nursing home
residents.
Reference: MCS: 236
Rationale 2: Staffing shortages may be a precipitating factor in the mistreatment of nursing
home residents.
Reference: MCS: 236
Rationale 3: Patient aggressiveness was found to be a predictor of physical and psychological
abuse by staff members.
Reference: MCS: 236
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Rationale 4: Inadequate staff training may be a precipitating factor in the mistreatment of
nursing home residents.
Reference: MCS: 236
Rationale 5: Frequent family visits are not identified as being a precipitating factor in the
mistreatment of nursing home residents.
Reference: MCS: 236
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct T
clinical
ESTBassessment
ANKSELLfor
ERscreening
.COM and detection of elder
mistreatment.
Question 9
Type: MCSA
Which older patient is at greatest risk for mistreatment in the home?
1. An active older patient with well-controlled diabetes who lives alone
2. A healthy older patient who is retired from owning a business and lives with an adult son
3. An older patient with a history of coronary bypass surgery, is active, and lives with the spouse
4. An older patient with severe osteoarthritis and macular degeneration who lives with a single
daughter who has an adult son with cerebral palsy
Correct Answer: 4
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Rationale 1: Risk factors for elder mistreatment include being female, over the age of 75, having
a dependent functional status, having a poor social network, poverty, minority, cognitive
impairment, and having less than an 8th grade education. An active older patient who has a
chronic illness and lives alone is not at risk for mistreatment in the home.
Reference: MCS: 236
Rationale 2: A healthy older patient who is retired from owning a business and living with an
adult son is not at risk for mistreatment in the home.
Reference: MCS: 236
Rationale 3: Risk factors for elder mistreatment include being female, over the age of 75, having
a dependent functional status, having a poor social network, poverty, minority, cognitive
impairment, and having less than an 8th grade education. An older patient with a history of
coronary bypass surgery and lives with the spouse is not at risk for mistreatment in the home.
Reference: MCS: 236
Rationale 4: Risk factors for elder mistreatment include being female, over the age of 75, having
a dependent functional status, having
minority, cognitive
TESaTpoor
BANsocial
KSELnetwork,
LER.Cpoverty,
OM
impairment, and having less than an 8th grade education. An older patient with severe
osteoarthritis and macular degeneration who lives with a single daughter who has a son with a
health problem is at the greatest risk for mistreatment in the home.
Reference: MCS: 236
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
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Question 10
Type: MCSA
An older patient lives alone and has not bathed or changed clothing for several days. An
investigator for adult protective services visits and determines this patient is experiencing which
type of elder mistreatment?
1. Self-neglect
2. Physical abuse
3. Psychological abuse
4. Financial exploitation
Correct Answer: 1
Rationale 1: Self-neglect occurs when mentally competent patients engage in behaviors that
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threaten their own safety and well-being. Failure to maintain proper hygiene practices falls into
this category of elder mistreatment.
Reference: MCS: 234
Rationale 2: Physical abuse is the intentional infliction of physical injury or pain.
Reference: MCS: 234
Rationale 3: Psychological abuse involves the infliction of anguish or emotional abuse.
Reference: MCS: 234
Rationale 4: Financial exploitation is taking advantage of an older person for monetary or
personal benefit.
Reference: MCS: 234
Global Rationale:
Cognitive Level: Analyzing
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Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 11
Type: MCSA
A visitor to a long-term care institution witnesses an attendant scolding a patient with dementia
about being incontinent. What type of abuse is the visitor witnessing?
1. Neglect
2. Exploitation
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3. Caregiver burnout
4. Psychological abuse
Correct Answer: 4
Rationale 1: Neglect occurs when there is failure to meet the older persons needs necessary for
physical and emotional well-being.
Reference: MCS: 234
Rationale 2: Exploitation involves taking advantage of an older person for monetary or personal
benefit.
Reference: MCS: 234
Rationale 3: Caregiver burnout is not a type of abuse but could cause a caregiver to abuse an
older patient.
Reference: MCS: 234
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Rationale 4: A caregiver who scolds and ridicules a patient who is unable to care for him- or
herself is committing psychological abuse by inflicting anguish and psychological pain.
Reference: MCS: 234
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 12
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Type: MCSA
An older patient is being abused by family members in the home and asks about adult protective
services. What should the nurse explain about these services?
1. They punish persons who abuse the elderly.
2. They provide services to protect older people who may be abused or neglected.
3. They provide a way to permanently keep the older patient separated from the abuser.
4. They place older patients who cannot adequately care for themselves in nursing homes.
Correct Answer: 2
Rationale 1: Adult protective services (APS) programs are social services organized to protect
vulnerable older adults who may be abused, neglected, or exploited. APS do not punish persons
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who abuse the elderly.
Reference: MCS: 234
Rationale 2: Adult protective services (APS) programs are social services organized to protect
vulnerable older adults who may be abused, neglected, or exploited.
Reference: MCS: 234
Rationale 3: Adult protective services (APS) programs are social services organized to protect
vulnerable older adults who may be abused, neglected, or exploited. APS do not permanently
keep the older patient separated from the abuser.
Reference: MCS: 234
Rationale 4: Adult protective services (APS) programs are social services organized to protect
vulnerable older adults who may be abused, neglected, or exploited. APS do not place older
patients into nursing homes.
Reference: MCS: 234
Global Rationale:
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Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Summarize key resources for elder mistreatment information.
Question 13
Type: MCSA
What will the nurse keep in mind when documenting the suspected abuse of an older patient?
1. Photo documentation is not usually included as part of the documentation.
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2. Documentation should include objective data of the older patients reaction when the suspected
abuser is present.
3. It is important to include the nurses personal opinion of the suspected abuser and the nurses
prior experience in similar cases.
4. The details of the documentation should not be reported to the adult protective services; it is
important that they come to an independent conclusion about the issue of abuse.
Correct Answer: 2
Rationale 1: Photographic documentation is especially helpful in cases where there is observable
evidence.
Reference: MCS: 242
Rationale 2: Older adults who appear fearful when in the presence of a suspected abuser will
need careful assessment as this may be a warning sign of mistreatment. Physical indicators of
elder mistreatment that are clearly described will assist interdisciplinary members with diagnosis
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as well as with planning goals of patient care.
Reference: MCS: 242
Rationale 3: The nurse should present the facts objectively and not include personal conclusions
or other incidents not related to the case.
Reference: MCS: 242
Rationale 4: The nurses findings that led to the suspicion of abuse should be shared in the report
to adult protective services.
Reference: MCS: 242
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Create a nursing care plan for the ongoing well-being of older patients.
Question 14
Type: MCSA
An older patient is accompanied to a physicians office visit with an adult daughter who walks
with an assistive device. The older patient is hard of hearing, has osteoarthritis, and has difficulty
completing activities of daily living. Which nursing diagnosis would the nurse identify as being
the priority at this time?
1. Social isolation
2. Caregiver role strain
3. Ineffective protection
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4. Situational low self-esteem
Correct Answer: 2
Rationale 1: The diagnosis of social isolation is not a priority since there is no evidence that the
older patient is isolated.
Reference: MCS: 241
Rationale 2: Caregiver role strain is the priority since the daughter walks with an assistive
device and needs to help the older patient who is hard of hearing, has osteoarthritis, and has
difficulty completing activities of daily living. The daughter may become stressed with having to
help the older patient as well as herself with care needs.
Reference: MCS: 241
Rationale 3: There is no evidence to support that the older patient is at risk for ineffective
protection.
Reference: MCS: 241
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Rationale 4: There is no evidence to support that the older patient is experiencing situational low
self-esteem.
Reference: MCS: 241
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 4. Create a nursing care plan for the ongoing well-being of older patients.
Question 15
Type: MCMA
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An older patient has been brought into the emergency department with injuries caused by
suspected physical abuse. Which tools could the nurse use to assess this patients injuries?
Standard Text: Select all that apply.
1. Indicators of abuse screen
2. AMA assessment protocol
3. Adult protective services report
4. Brief abuse screen for the elderly
5. Hwalek-Sengstock elder abuse screening test
Correct Answer: 1,2,4,5
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Rationale 1: The indicators of abuse screen is a 29-item set of indicators for use by social
service agency practitioners to identify elder mistreatment.
Reference: MCS: 238
Rationale 2: The AMA assessment protocol is a checklist used if abuse is suspected. Reference:
MCS: 238
Rationale 3: Adult protective services do not use a specific format. Intake forms are used to
document calls of suspected elder mistreatment from public hotlines and state agencies.
Reference: MCS: 238
Rationale 4: The brief abuse screen for the elderly asks five standard questions that focus on
abuse.
Reference: MCS: 238
Rationale 5: The Hwalek-Sengstock elder abuse screening test is one 15-item assessment screen
for detecting suspected elder abuse and neglect.
Reference: MCS: 238
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Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Conduct clinical assessment for screening and detection of elder
mistreatment.
Question 16
Type: MCMA
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The home healthcare nurse is preparing an educational program for other healthcare providers
regarding elder abuse. What information should the nurse include?
Standard Text: Select all that apply.
1. The typical abuser is the spouse.
2. The typical abuser is the adult child.
3. The typical elder who is abused is a woman.
4. The majority of abuse occurs in the home setting.
5. The majority of abuse occurs in the long-term care setting.
Correct Answer: 2,3,4
Rationale 1: Spouses account for only 11.3% of abuse.
Reference: MCS: 233
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Rationale 2: Adult children account for 32.6% of abuse.
Reference: MCS: 233
Rationale 3: The typical older person who is abused is a Caucasian woman.
Reference: MCS: 233
Rationale 4: The vast majority of abuse and neglect occurs in the domestic setting.
Reference: MCS: 233
Rationale 5: Although institutional abuse can occur, the vast majority of abuse occurs in the
home setting.
Reference: MCS: 233
Global Rationale:
Cognitive Level: Applying
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Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Discuss current trends in elder mistreatment, including incidence and
prevalence.
Question 17
Type: MCSA
The home care nurse is preparing to visit an older female patient who lives in her sons home.
Prior to the visit, which risk factors for elder abuse will the nurse review?
1. Male gender
2. Hispanic race
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3. Impaired cognitive status
4. High socioeconomic status
Correct Answer: 3
Rationale 1: Females are at a higher risk for elder abuse than males.
Reference: MCS: 236
Rationale 2: Those of the Caucasian race are at a higher risk for elder abuse than other
races. Reference: MCS: 236
Rationale 3: Cognitive impairment is a risk factor for elder abuse.
Reference: MCS: 236
Rationale 4: Poverty, and not a high socioeconomic status, is a risk factor for elder abuse.
Reference: MCS: 236
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Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Discuss current trends in elder mistreatment, including incidence and
prevalence.
Question 18
Type: MCMA
The adult daughter of an older patient is researching viable skilled facilities to have the patient
admitted for long-term care needs. This research has not revealed much information about
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institutional abuse. Why is this information not readily available to the daughter?
Standard Text: Select all that apply.
1. Residents may fear retribution.
2. Managers fear adverse publicity.
3. Staff members fear losing their jobs.
4. Family members fear having to find a new agency for the patient.
5. Billing department members fear not getting paid for services provided to patients.
Correct Answer: 1,2,3,4
Rationale 1: A federal report revealed large delays in the reporting of incidents of elder
mistreatment in nursing homes. One reason for this delay is that residents may fear retribution if
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they report the abuse.
Reference: MCS: 236
Rationale 2: A federal report revealed large delays in the reporting of incidents of elder
mistreatment in nursing homes. One reason for this delay is that the managers of the facilities
may fear adverse publicity about the abuse.
Reference: MCS: 236
Rationale 3: A federal report revealed large delays in the reporting of incidents of elder
mistreatment in nursing homes. One reason for this delay is that staff members may fear losing
their jobs if they report abuse of residents.
Reference: MCS: 236
Rationale 4: A federal report revealed large delays in the reporting of incidents of elder
mistreatment in nursing homes. One reason for this delay is that families may fear having to find
a new agency for the patient.
Reference: MCS: 236
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Rationale 5: A federal report revealed large delays in the reporting of incidents of elder
mistreatment in nursing homes. Billing or payment issues are not reasons why incidents of elder
abuse in nursing homes are not being reported.
Reference: MCS: 236
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Discuss current trends in elder mistreatment, including incidence and
prevalence.
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Question 19
Type: MCSA
The nurse is caring for an older patient who has been the victim of elder abuse by an adult son.
According to the transgenerational violence theory of elder mistreatment, which situation would
have occurred with the patient?
1. The son is an alcoholic.
2. The care of the patient has overwhelmed the son.
3. The patient was abusive to the son when he was a child.
4. As a child, the son witnessed the father beating the mother.
Correct Answer: 3
Rationale 1: The son being an alcohol is an example of the psychopathology theory for abuse.
Reference: MCS: 233
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Rationale 2: The care of the patient overwhelming the son is an example of the psychopathology
theory for abuse.
Reference: MCS: 233
Rationale 3: The transgenerational violence theory suggests that elder mistreatment is thought to
be part of the family violence continuum. It begins with child abuse and ends with elder abuse.
Reference: MCS: 233
Rationale 4: The son witnessing the father beating the mother is an example of the learned
theory of abuse.
Reference: MCS: 233
Chapter 11 Cognitive Wellness
MULTIPLE CHOICE
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1. Which of the following statements is true about cognitive impairments in older adults?
a. Loss or interruption of sleep can lead to delirium.
b.Confusion is a normal and unavoidable consequence of aging.
c. Older patients who are agitated often have a lower cognitive status than those who are quietly
sitting.
d.The Mini-Mental State Examination2nd edition (MMSE-2) should be administered on
admission to detect delirium.
ANS: D
The MMSE-2 or a similar instrument should be administered to a patient at admission to
ascertain the patients baseline cognitive status. The loss or interruption of sleep, in of itself, does
not often lead to delirium. It can potentiate delirium in the presence of other factors. Confusion
or delirium is not a normal consequence of aging but an indicator of a potentially underlying
problem. The hypoactive subtype of delirium can be associated with a worse prognosis than with
the hyperactive subtype; it is easily overlooked.
PTS:1DIF:UnderstandREF:7| 48
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TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
2. At 10 PM, an older male resident attempts to climb over the bedrails. Which intervention
should the nurse implement first?
a. Talk to the resident about his behavior.
b.Call the physician, and ask for a sedative.
c. Apply a vest restraint on the resident.
d.Get a companion to keep him in the bed.
ANS: A
The resident is expressing a need that the nurse can potentially determine with gentle
questioning. Pharmacological intervention can be necessary but should not replace careful
evaluation and management of the underlying cause. Simply restraining the patient will not
address the underlying problem, and the imposition of restraints can trigger delirium. Applying a
restraint is the last resort, and the nurse must consider the problems that accompany the
application of restraints before doing so. Placing a companion in the room can be an effective
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method of keeping the resident safe if the companion can determine and meet the residents
needs.
PTS:1DIF:AnalyzeREF:55-57
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
3. A definitive diagnosis of Alzheimer disease (AD) can be made by detecting or using which
one of the following methods?
a. Clinical observation of dementia
b.Inability to speak with relevance
c. Development of neurofibrillary tangles
d.Computed axial tomographic (CAT) scan
ANS: C
Confirming the development of neurofibrillary tangles is the only accurate method for
diagnosing AD. Patients with AD can be observed for dementia and delirium, but these
ESTBAThe
NKinability
SELLEto
R.speak
COMwith relevance is a feature of
indicators are nonspecific for theTdisease.
dementia; if other causes of dementia are ruled out, then it may be dementia of the Alzheimer
type. A CAT scan is the most useful means for diagnosing a stroke.
PTS:1DIF:RememberREF:11
TOP: Nursing Process: Assessment MSC: Physiological Integrity
4. Which assessment parameter should the nurse use to differentiate between delirium and
depression in an older adult?
a. Orientationc. Course over the morning hours
b.Activity d.Psychomotor activity
ANS: A
Qualities about the patients orientation are a good method for the nurse to use for distinguishing
between delirium and depression; in delirium, orientation is usually impaired, and in depression,
orientation is normal. Activity can vary throughout the day and is not a good indicator. Delirium
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tends to be worse at night, and depression tends to be worse in the morning. The nurse avoids
using qualities about the patients psychomotor activities to distinguish between delirium and
depression in an older adult; psychomotor activities in both disorders are highly variable and
make distinctions difficult.
PTS:1DIF:UnderstandREF:38
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
5. The nurse recognizes which of the following displays may indicate hyperactive delirium?
a. Lethargy
b.Withdrawn behavior
c. Nonpurposeful repetitive movements
d.Decreased psychoactive activity
ANS: C
Patients with hyperactive delirium often wander and have nonpurposeful repetitive movements.
EST
BAindicative
NKSELLof
ERhypoactive
.COM delirium. Patients with
Lethargy and withdrawn behaviorTare
both
hyperactive delirium have increased psychoactive activity, not decreased.
PTS:1DIF:UnderstandREF:47
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
6. Which of the following approaches to hygienic care is beneficial for a patient with dementia?
a. Schedule the patients full shower at 7 AM, three mornings every week.
b.Have a team give the bath with each member washing a different body area.
c. Wash the perineal region first to remove potentially infectious material.
d.Explain each step as you go, and keep the patient covered as much as possible while bathing.
ANS: D
A person with dementia can interpret undressing for bathing as an assault. It should be performed
in a way that minimizes the intrusive and exposing aspects and maintains trust between the
person and only one caregiver.
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From the point of view of the well-being of the patient, bathing is rarely an emergency that it
must be performed at a time when the patient is not receptive. Stimulation should be kept simple
and focused, and alarming the patient should be avoided. The most sensitive and intimate areas
should be washed last, after trust has been established between the patient and the nurse, which
may have to be done anew at every encounter. From an infection-control standpoint, washing
occurs from clean to dirty areas.
PTS:1DIF:UnderstandREF:17-25
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
7. A man who is 60 years of age and lives in the British Isles develops dementia. Which qualities
of dementia does the nurse assess to prevent patient injury related to the type of dementia this
man most likely has?
a. Visual hallucinationsc. Visuospatial problems
b.Unilateral tremors d.Clumsy movements
ANS: D
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The nurse assesses the patient for failing memory and incoordination, which are characteristic of
Creutzfeldt-Jakob disease (CJD) or bovine spongiform encephalopathy (also known as mad cow
disease). This type of dementia began appearing in adults living in the British Isles who reported
eating beef from local breeders. The nurse assesses for these qualities because the age of onset is
usually around 60 years. This form of dementia progresses rapidly to death; therefore the nurse
anticipates that this man will rapidly deteriorate and must be prepared to anticipate changes in
motor activities and memory to maintain his safety and to prevent injury.
Visual hallucinations are characteristic of Lewy body dementia. Visuospatial problems are
characteristic of Parkinson disease dementia. Visuospatial problems are characteristic of
frontotemporal lobe dementia.
PTS:1DIF:ApplicationREF:10 | 40-41
TOP: Nursing Process: Assessment MSC: Physiological Integrity
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8. An older woman is recovering from a bowel resection in the intensive care unit but remains
intubated and on a mechanical ventilator. Which of the following should the nurse implement to
help prevent delirium in this woman?
a. Assess cognition with MMSE-2.
b.Provide uninterrupted periods of rest and sleep.
c. Maintain adequate sedation and pain management.
d.Cover the patients eyes with protective ophthalmic ointment.
ANS: B
Providing uninterrupted periods of rest and sleep is a challenge for the nurse in intensive care.
Because of the nature of the patients illnesses, nurses administer medications and treatments and
perform invasive procedures on a 24-hour basis, leaving patients little time for rest. Many
patients become delirious in the intensive care unit because the noise, activity, brightness, and
disturbance tend to persist around the clock, which contribute to delirium. Patients lose their
sources for maintaining orientation and stability; that is, bright lighting at all times, as well as
unfamiliar and abrupt increases in noise, can lead to a disruption in the circadian rhythm. In
addition, patients in intensive care
are
toLreceive
multiple
medications, and
TE
STmore
BANlikely
KSEL
ER.CO
M
medications that are potentially harmful can aggravate the patients cognitive difficulties.
Because this patient is intubated and on mechanical ventilation, the nurse cannot apply the
MMSE-2; the patient is unable to perform adequately. Besides, assessing for dementia is not a
prophylactic measure. Sedation and pain management, although often needed in the intensive
care unit, can contribute to delirium. Covering the eyes of a patient in intensive care with
ointment can be necessary to prevent corneal damage; however, it is likely to contribute to
delirium because the patient will be unable to see clearly.
PTS:1DIF:ApplicationREF:45
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
9. Which of the following should the nurse use to assess a nonverbal older adult for delirium?
a. Cranial nerves XI and XII
b.Confusion Assessment Method
c. MMSE-2
d.Controlled Word Association Test
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ANS: B
The Confusion Assessment Method is a tool for measuring delirium in patients who are intubated
or nonverbal. Assessing the accessory (CN XI) and hypoglossal (CN XII) cranial nerves provides
clues about the patients ability to swallow. The nurse uses the Controlled Word Association Test
to assess for a neurologic cause of an older adults cognitive dysfunction. This tool is an index of
frontal lobe functioning and provides an assessment of executive function, including the patients
frontal lobe functioning and his or her ability to refrain from distraction and perseveration. The
MMSE-2 is a valid and reliable tool to assess cognitive function; however, it is unable to
pinpoint discrete areas of neurologic dysfunction.
PTS:1DIF:ApplicationREF:7-9
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
10. An older woman has a wound infection 5 days after a below-the-knee amputation brought
about by diabetes mellitus. Which of the following is the nurses priority intervention to prevent
cognitive dysfunction and postoperative
TESTBcomplications
ANKSELLEin
R.this
COolder
M adult?
a. Remove invasive devices as soon as possible.
b.Minimize the administration of opioid analgesics.
c. Allow for self-care and independent activities.
d.Administer short-acting benzodiazepines as needed.
ANS: A
To help prevent cognitive dysfunction, postoperative complications, and an increased risk of
morbidity and mortality, the nurse recognizes that the risk factors this older adult has for
delirium include stressors, infection, and surgery; therefore to prevent cognitive decline and
additional postoperative complications, the nurse promptly removes invasive devices such as
intravenous infusions, urinary catheters, and wound drains. Removing these devices not only
reduces the risk of infection, thromboembolic events, blood loss, injury, and fluid imbalance, but
they also serve to promote mobility, promote a sense of control for the patient, and reduce the
types of situations that can frighten the patient or that the patient can misinterpret.
Poor pain management can contribute to delirium in older patients. A patient with multiple
stressors and risk factors for delirium needs additional nursing care and attention to provide a
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calming, caring therapeutic environment. The nurse must assess the patients functional status
before allowing self-care and independent activities. In addition, this older adult is likely to need
extensive physical therapy to maintain mobility. Benzodiazepines are a poor pharmacological
choice for older adults for sedation or sleep; they can contribute to delirium, are highly addictive,
and can cause rebound insomnia if suddenly withdrawn.
PTS: 1 DIF: Analyze REF: 45 TOP: Nursing Process: Planning
MSC: Physiological Integrity
11. Which medication administered for delirium under a controlled environment can reduce the
duration and severity of delirium for high-risk patients?
a. Haloperidol (Haldol) c. Fluphenazine (Prolixin)
b.Thioridazine (Mellaril)d.Chlorpromazine (Thorazine)
ANS: A
Haloperidol administered in low doses can help reduce the severity and duration of delirium for
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high-risk patients after hip surgery; however, haloperidol therapy does not reduce the incidence
of delirium in this group. In addition, atypical antipsychotic medications can also be effective
when administered in low doses under controlled circumstances.
Thioridazine is a typical antipsychotic agent and is not indicated in the prevention of delirium.
Fluphenazine is a typical antipsychotic medication and is not indicated in the prevention of
delirium. Chlorpromazine is a typical antipsychotic agent and is not indicated in the prevention
of delirium.
PTS:1DIF:RememberREF:11
TOP: Nursing Process: Assessment MSC: Physiological Integrity
12. When differentiating the characteristics of depression, delirium, and dementia, the nurse
recognized which of the following as an indicator of delirium?
a. Sudden onsetc. Insidious
b.Recent loss d.Life change
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ANS: A
Delirium can occur suddenly. Recent loss or life changes can precipitate depression. Dementia
can be insidious, slow, and occur over the course of several years.
PTS:1DIF:RememberREF:38
TOP: Nursing Process: Assessment MSC: Physiological Integrity
MULTIPLE RESPONSE
1. Which types of exercise programs are better for older adults with AD for improving mood and
function? (Select all that apply.)
a. Balance
b.Walking
c. Self-paced
d.Endurance
e. Muscle strength
f. Lasting 16 weeks or longer
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ANS: A, D, E, F
Older adults with AD can benefit from regular exercise as demonstrated by more positive affect
and mood, improved function, and less disability. Suitable exercises for older adults with AD
include exercises that improve balance. Exercises that improve endurance and exercises for
muscle strengthening are also both suitable for the older adult with AD. Research data support
the claim that exercise programs lasting 16 weeks can help improve function and mood of older
adults with AD.
Endurance, strength, and balance exercises help improve patients with AD more than walking.
Self-paced exercises are unlikely to be suitable for a patient with AD because of cognitive
dysfunction.
PTS:1DIF:UnderstandREF:2-28
TOP: Nursing Process: Assessment MSC: Physiological Integrity
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2. Which of the following is(are) the risk factors for vascular dementia (VaD) after a stroke?
(Select all that apply.)
a. Smoking
b.Male sex
c. Hypertension
d.Advancing age
e. Hyperlipidemia
f. African American
ANS: A, C, E
Smoking, hypertension, and hyperlipidemia are all risk factors for VaD after a stroke. Male sex,
advancing age, and African-American ancestry are risk factor for VaD.
PTS:1DIF:RememberREF:40 | 42
TOP: Nursing Process: Assessment MSC: Physiological Integrity
3. The community health nurse is preparing for an educational session on AD for a group of
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seniors. Which modifiable risk factors should the nurse include? (Select all that apply.)
a. Family historyc. Smoking
b.Sex
d.Obesity
ANS: C, D
Smoking cessation and obesity are both modifiable risk factors. The focus of research on AD is
on the interaction between risk-factor genes and lifestyle or environmental factors. Increasing
evidence strongly points to the potential risk roles of vascular risk factors (VRFs) and disorders
(e.g., midlife obesity, dyslipidemia, hypertension, cigarette smoking, obstructive sleep apnea,
diabetes, cerebrovascular lesions) and the potential protective roles of psychosocial factors (e.g.,
higher education, regular exercise, healthy diet, intellectually challenging leisure activities,
socially active and integrated lifestyle) in the pathogenesis and clinical manifestations of
dementia (especially AD and vascular cognitive impairment). Family history and sex are not
modifiable.
PTS: 1 DIF: Remember REF: 12 | 42 TOP: Teaching and Learning
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MSC: Physiological Integrity
4. The nurse working in a long-term care facility completes her morning assessment on a new
postoperative patient and notes a change in cognitive status from the previous day? The nurse
recognizes which of the following as a precipitating factor for delirium? (Select all that apply.)
a. Major medical treatmentc. Admission to long-term care
b.Poor sleep habits
d.Pharmacological agents
ANS: A, C, D
Major medical treatment, admission to long-term care, and pharmacological agents are all
precipitating factors for delirium. Changes in surroundings often precipitate delirium. The
development of delirium is a result of complex interactions among multiple causes. Delirium can
result from the interaction of predisposing factorsvulnerability on the part of the individual as a
result of predisposing conditions, such as cognitive impairment, severe illness, and sensory
impairment; delirium can also result from precipitating factors and insultsmedications,
procedures, restraints, and iatrogenic events. Although a single factor (e.g., infection) can trigger
TESTBAfactors
NKSEL
LEalso
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COM to be present. A highly
an episode of delirium, several co-existing
are
vulnerable older individual requires a lesser amount of precipitating factors to develop delirium.
Poor sleep habits is not a contributing factor in of itself.
Chapter 12 Psychosocial Wellness
MULTIPLE CHOICE
1. Which of the following is a true statement about the theories of aging?
a. Research data support the disengagement theory, activity theory, and continuity theory.
b.Everyone should be able to achieve the three tasks of Pecks model of integrity.
c. The exercise of rights is not a task of aging in Kellys model.
d.A person may choose to avoid pursuing inner discovery in older age.
ANS: D
Some persons do not value inner psychological exploration and remain action oriented even in an
older age, and others are still subject to the same demands of daily living as they were in middle
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age. None of these theories is clearly supported by data. Pecks tasks of ego differentiation, body
transcendence, and ego transcendence demand a great deal of courage and energy that not
everyone possesses. Tasks of aging in Kellys model are accepting reality, fulfilling
responsibility, and exercising rights.
PTS:1DIF:UnderstandREF:4-12
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
2. Which of the following is a true statement about neuropsychiatric function in older adults?
a. Overall cognitive abilities are progressively degraded by neuron loss in the cerebral cortex with
aging.
b.Improving cognitive functions in an older person calls for sporadic mental activity around
ideas the person finds significant and interesting.
c. Nerve cells regenerate in the hippocampus.
d.Mood does not influence an older person ability to remember verbal instructions.
ANS: C
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Nerve cells regenerate in the hippocampus; this is a true statement. Although neurons can
regenerate in the hippocampus, regeneration is impeded by stress. Overall cognitive abilities are
progressively degraded by neuron loss in the cerebral cortex with aging; this statement is not
true. Neuron loss does not harm overall cognitive ability, although it makes neural processes run
more slowly. Improving cognitive functions in an older person calls for sporadic mental activity
around ideas the person finds significant and interesting; this is not a true statement. Neural
functions can be retrained, but exercising the brain on a regular basis is necessary. Older adults
learn best when new information is relevant to what is already familiar. Mood does not influence
whether an older person remembers verbal instructions; this is a not a true statement. Recalling
events, including communication, is impaired by a crisis situation or anxiety.
PTS:1DIF:RememberREF:16
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
3. Which of the following statements is true about social and emotional health of older adults?
a. Contemporary society has strong norms for the behavior of adults older than 80 years.
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b.The transition to old age entails a declining level of contribution to others as one becomes
increasingly dependent on them.
c. Computers and the Internet have little to contribute to older adults in their need for social
support.
d.Nurses are often significant sources of social and emotional support for older adults.
ANS: D
Nurses are often important confidants and providers of social support in the lives of older adults.
The diversity of cultures and individuals in a society such as the United States means that norms
are almost nonexistent for those older than 80 years. Older adults have a great deal to contribute
in wisdom and by example. E-mail and online chat rooms are a means of contact and social
support for many older adults.
PTS: 1 DIF: Understand REF: 12-20| 29 Box 6-1| 33 Box 6-5| 34 Box 6-6
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
4. Which role is most likely to have a significant effect on the type of aging process experienced
by the older adult?
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a. Grandparentc. Friend
b.Spouse
d.Parent
ANS: B
The loss of a spouse is likely to be devastating for an older adult for economic and
biopsychosocial reasons. When an older adult loses a spouse, the loss can include economic
security, especially for a woman, and societal roles. Alterations in these roles are not usually as
challenging as the loss of a spouse. Grandparenting can offer the potential for enhanced social
experiences for an older adult; however, adults can age well without them when more basic
needs are met. Alterations in these roles are not always as acutely demanding as the loss of a
spouse. Alterations in these roles usually call for little or a gradual adjustment.
PTS:1DIF:UnderstandREF:12-13
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
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5. The children in an African-American family attended college because their mother worked
two jobs as they were growing up. She never finished high school, the children are grown, and
she lives alone in retirement. Which noted weakness of sociological theories on aging explains
why the social exchange theory is not applicable to this older adult?
a. Gender c. Ethnicity
b.Cultured.Opportunity
ANS: D
Social exchange theory ignores the effect that opportunity can have on aging because, according
to this theory, the mother should be living with one of the children. They had the opportunities
that she never had. Gender is not as relevant to this theory of the value of youth as being a period
where social credits are earned for old age. Culture is not as relevant to this theory as the value of
youth. Ethnicity is not as relevant to this theory as the value of youth.
PTS:1DIF:AnalyzeREF:7
TOP: Nursing Process: Assessment
TEMSC:
STBAPsychosocial
NKSELLERIntegrity
.COM
6. In which context are members of a cohort described when using the age-stratification theory to
explain the effect of similar events, conditions, and circumstances?
a. Historical c. Sociological
b.Biologicald.Chronological
ANS: A
In the age-stratification model, historical context is used to understand members of a cohort in
terms of similar events, conditions, and circumstances and the effect these have on the group as a
whole. A good example of such a cohort is older adults who lived through World War II.
Biological context is not important in considering the age-stratification theory. The agestratification theory is a sociological theory of aging that uses historical context to describe
cohorts. Chronological context of a cohort will span a range, but historical context is what
describes the cohort.
PTS:1DIF:KnowledgeREF:6
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TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
7. An older patient who was just diagnosed with a terminal disease states, All my life I attended
church, but I am still worried about what will happen after death. The nurses best response is
which of the following?
a. The unknown may be frightening. Do you want to talk about this?
b.Religious people know that God is a good God.
c. People that have had near death experiences say it is peaceful.
d.You must feel good about attending church most of your life.
ANS: A
Often the unknown is very frightening, uses the reflective technique to identify the patients
feelings regarding the fear of the unknown. Religious people know that God is a good God,
denies the patients feelings. People that have had near death experiences say it is peaceful,
focuses on the experience of others. You must feel good about attending church most of your
life, ignores the patients concern about death.
TEBox
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PTS: 1 DIF: Apply REF: 12-16| 32
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
8. An older man with severe knee pain tells the nurse how he lost his job and his home after
starting a new business when he was 48 years old. Now he lives alone and relies on Social
Security. Using Jungs theory, what in this individuals life is the most pivotal in his personality
development?
a. Living alone c. Severe knee pain
b.Meager incomed.Job and home loss
ANS: D
Jungs theorizes that the personality forms, in part, after a crisis, as an individual moves from
extroversion to introversion in aging. Living alone is a situation that is the result of many factors
coalescing in an individuals life. A meager income can be a result of the individuals life work
and other individual choices and events. His personality can affect how an individual deals with
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pain, and the pain can affect an individuals personality. However, whether the pain is old or new
is not known; thus a determination cannot be made.
PTS:1DIF:AnalyzeREF:9-10
TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance
9. The nurse plans care for older adults who are in good health but isolated from their families. If
the nurses goal is to move the adults toward gerotranscendence, which intervention should the
nurse use in the plan of care?
a. Give a daily tea party for the group.
b.Call each family to encourage visiting.
c. Assist them to resume midlife patterns.
d.Help each person with individual activities.
ANS: D
In Tornstams theory, aging offers the potential for gerotranscendence, a culmination of an
TESTgrowth
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SEL
LER.the
COolder
M adult to live contentedly with
individuals life, wisdom, and spiritual
allows
and without social activities. An older adult spends more time on meditation and solitude, and
less time on materialism and self-consciousness about body image. Individual activities or selfselected activities are satisfactory. Solitude is satisfactory. Midlife patterns are no longer relevant
to contentment.
PTS: 1 DIF: Apply REF: 12 TOP: Nursing Process: Planning
MSC: Psychosocial Integrity
10. The nurse observes older female adults learning advanced knitting techniques. The nurse
concludes that this learning activity is suitable for these women because it accomplishes which
of the following?
a. Helps maintain joint flexibility
b.Improves the groups cohesiveness
c. Provides a needed social opportunity
d.Adds to their existing knowledge base
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ANS: D
Learning advanced techniques is a suitable activity for older adults because it builds on
knowledge they already have; further, this activity is suitable because it is concrete and practical
for experienced knitters to develop advanced skills. Joint flexibility is a physical activity and not
necessarily a learning activity. The members share enjoyment of knitting; other than being
women and older, the group has no special bond on which to build. The need for socializing is
not evident.
PTS: 1 DIF: Apply REF: 19-20 TOP: Nursing Process: Evaluation
MSC: Psychosocial Integrity
11. The nurse at a nursing home wants to help decrease the risk of Alzheimer disease in the
residents. Which should the nurse do to implement this goal?
a. Keep the curtains open in their rooms.
b.Offer beads for them to string on yarn.
c. Show movies that the residents choose.
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d.Assist residents with ambulation
ANS: D
Engaging in physical activity and social interaction are associated with a lower risk for
Alzheimer disease. Keeping the curtains open can make a residents room more pleasant but is
likely to be counterproductive in lowering the risk; brightening the room can entice the resident
to stay in the room and decrease social interaction. Stringing beads is a passive and sedentary
activity and therefore unlikely to decrease the risk for Alzheimer disease; physical activity is
associated with a lower risk for Alzheimer disease. Watching movies is a sedentary but not a
mentally stimulating activity for an adult with a normal intelligence.
PTS: 1 DIF: Apply REF: 15-18 TOP: Nursing Process: Planning
MSC:Health Promotion and Maintenance
12. Which physiological change in the brain is the reason the nurse allows more time for
answering questions with older adults?
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a. Increased secretion of cholinesterase
b.Decreased secretion of neurotransmitters
c. Loss of spinal cord and brainstem neurons
d.Atrophy of dendrites in the cerebral cortex
ANS: D
Dendrites are the receiving end of neurons (receiving electrochemical signals) and the branched
ends extending from the cell body. The atrophy of dendrites contributes to slower thought
processes with aging because the synapses are impaired; this changes the transmission of
neurotransmitters that are vital in the transmission of an electrical impulse from neuron to
neuron. The secretion of cholinesterase, the enzyme that inactivates acetylcholine in the synapse,
does not increase with aging. Changes in the transmission of neurotransmitters are associated
with the atrophy of dendrites. The spinal cord and the cerebral cortex lose neurons with age, the
cerebral cortex more than the spinal cord.
PTS:1DIF:UnderstandREF:16
TOP: Nursing Process: Assessment MSC: Safe, Effective Care Environment
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13. The nurse provides opportunities for nursing home residents to read aloud to others. Which
cognitive skill is this nursing intervention most likely to improve?
a. Verbal fluency c. Object naming
b.Logical analysisd.Visuospatial skills
ANS: A
Allowing residents to read aloud helps improve and maintain verbal fluency because it provides
an opportunity to practice these skills. Reading aloud does not usually require analysis. Reading
is unlikely to improve object recall unless displaying objects is part of the reading. Visuospatial
skills require the ability to perceive the relationship of objects in terms of the space each object
occupies; reading is unlikely to improve this skill.
PTS: 1 DIF: Understand REF: 16 TOP: Nursing Process: Evaluation
MSC:Health Promotion and Maintenance
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MULTIPLE RESPONSE
1. Which statements are true about aging and the brain? (Select all that apply.)
a. Most areas of the brain do not lose brain cells.
b.Memory decline is inevitable as people age.
c. Basic intelligence remains unchanged with age.
d.The brain does not continue to make new brain cells.
ANS: A, C
Most areas of the brain do not lose brain cells. Although older adults may lose some nerve
connections, it can be part of the reshaping of the brain that comes with experience. Basic
intelligence remains unchanged with age, and older adults should be provided with opportunities
for continued learning. Many people reach older age and have no memory problems.
Participation in physical exercise, stimulating mental activity, socialization, health diet, and
stress management help brain health.
PTS:1DIF:UnderstandREF:12-Apr
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TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
2. The nurse is admitting a patient to a long-term care facility. During the admission, the patient
verbalizes a concern about getting dementia now that he is in a nursing home. In what
activity(ies) should the nurse encourage the patient to participate to maintain brain health?
(Select all that apply.)
a. Physical exercise
c. Socialization
b.Stimulating mental activityd.Increasing dietary intake
ANS: A, B, C
Many people reach older age and have no memory problems. Participation in physical exercise,
stimulating mental activity, socialization, health diet, and stress management help brain health.
An increase in dietary intake has not been shown to influence brain health.
Chapter 13 Psychosocial Assessment
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Question 1
Type: MCSA
During an interview, the nurse notes that an older patient is having mild difficulty with some
words and forgets the names of people. The patient is alert, oriented to time, person, and place,
and makes appropriate responses. What does the nurse determine this patients cognitive changes
to mean?
1. Normal signs of aging
2. Early symptoms of dementia
3. Indicators of depression in the elderly
4. Memory impairment that may be related to cerebral ischemia
Correct Answer: 1
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Rationale 1: Cognitive changes vary widely in the elderly; however, older people will not suffer
significant memory impairment. Many may experience mild problems with word finding and
remembering names. The changes observed in this patient are normal signs of aging. Reference:
MCS: 164
Rationale 2: A problem with finding words and forgetting names is not a symptom of dementia.
Reference: MCS: 164
Rationale 3: A problem with finding words and forgetting names is not a symptom of
depression.
Reference: MCS: 164
Rationale 4: A problem with finding words and forgetting names is not related to cerebral
ischemia.
Reference: MCS: 164
Global Rationale:
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Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive
functioning.
Question 2
Type: MCSA
An older patient wakes up from sleep, confused, and insists a family member is in the other
room. What information within the patients medical record should the nurse consider as a source
of the patients confusion?
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1. The patient is elderly.
2. The patients spouse recently died.
3. The patient received pain medication.
4. The patient has a history of cardiac disease.
Correct Answer: 3
Rationale 1: Age does not cause confusion.
Reference: MCS: 166
Rationale 2: The loss of a loved one may cause depression but is not identified as a reason for
confusion.
Reference: MCS: 166
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Rationale 3: Certain medications like sleeping pills, tranquilizers, and some pain medications
can cause symptoms similar to dementia.
Reference: MCS: 166
Rationale 4: Cardiac disease alone is not known to cause confusion.
Reference: MCS: 166
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 4. Examine risk factors that influence cognitive functioning in older adults.
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Question 3
Type: MCSA
The nurse is providing discharge instructions to an older patient that includes the administration
of insulin. Which strategy will the nurse use when instructing this patient to adjust to the normal
changes experienced with aging?
1. Giving written materials to compensate for short-term memory losses
2. Using tools that repeat the information until the information is understood
3. Considering holding sessions for longer periods than usual so the patient can learn
4. Providing instruction to relatives so that the patient will not need to learn everything
Correct Answer: 2
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Rationale 1: Short-term memory, or primary memory, remains relatively stable when aging.
Reference: MCS: 164
Rationale 2: Normal age-related changes include a slowing of information processing, which
results in the need for repetition of information.
Reference: MCS: 164
Rationale 3: Another age-related change includes the inability to maintain sustained attention.
Long teaching sessions would not be appropriate.
Reference: MCS: 164
Rationale 4: Assuming the patient cannot learn everything is stereotypical of the aging process.
Reference: MCS: 164
Global Rationale:
Cognitive Level: Analyzing
TESMaintenance
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Client Need: Health Promotion and
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive
functioning.
Question 4
Type: MCSA
The daughter of an older patient tells the nurse that the patient used to be a wonderful cook but
now cannot remember how to use a blender. What does this information indicate to the nurse?
1. Short-term memory loss
2. Long-term memory loss
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3. Normal cognitive change in an older person
4. Cognitive change that requires further assessment
Correct Answer: 4
Rationale 1: Short-term memory remains relatively stable when aging.
Reference: MCS: 165
Rationale 2: Long-term memory remains relatively stable when aging.
Reference: MCS: 165
Rationale 3: Normal, healthy older persons should not forget how to use a common object or
item.
Reference: MCS: 165
Rationale 4: Normal, healthy older persons who forget what an item is used for or how to use it
should be referred for further evaluation and treatment.
Reference: MCS: 165
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Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive
functioning.
Question 5
Type: MCMA
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An older patient is concerned about remembering to take prescribed medications. What strategies
should the nurse recommend to this patient?
Standard Text: Select all that apply.
1. Rely on habit to take the medication.
2. Use an assistive device such as a pillbox.
3. Suggest a family member provide the medication.
4. Discuss moving to an assisted living facility for safety.
5. Discuss reducing the number of medications with the physician.
Correct Answer: 1,2
Rationale 1: Reliance on habit helps to reduce the chances of forgetting vital information, such
as taking prescribed medications.
Reference: MCS: 165
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Rationale 2: Using assistive devices such as pillboxes helps to reduce the chances of forgetting
vital information, such as taking prescribed medications.
Reference: MCS: 165
Rationale 3: Suggesting that a family member provide the medication would be an unnecessary
burden to the family.
Reference: MCS: 165
Rationale 4: There is no reason for the patient to be transferred to an assisted living facility.
Reference: MCS: 165
Rationale 5: Consulting the healthcare provider to alter the drug schedule may be necessary but
would be considered after other strategies have been tried.
Reference: MCS: 165
Global Rationale:
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Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive
functioning.
Question 6
Type: MCSA
An older patient with cardiac disease is having sleep problems and insomnia. Of what health
problem should the nurse consider these manifestations?
1. Normal signs of aging
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2. Predictive signs of respiratory disease
3. Symptoms of the negative effects of stress
4. Expected manifestations of cardiac disease
Correct Answer: 3
Rationale 1: Sleep problems and insomnia are not normal signs of aging.
Reference: MCS: 169
Rationale 2: There is no information to suggest that sleep problems and insomnia are predictive
signs of respiratory disease.
Reference: MCS: 169
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Rationale 3: Symptoms that indicate an older person may be suffering negative effects of stress
include sleep problems and insomnia.
Reference: MCS: 169
Rationale 4: There is no information to suggest that sleep problems and insomnia are expected
manifestations of cardiac disease.
Reference: MCS: 169
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Basic Care and Comfort
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 2. Explain the
ofKage-related
TEimpact
STBAN
SELLER.changes
COM on stress and coping.
Question 7
Type: MCMA
An older African American patient is diagnosed with a mental health problem that has been
untreated for many years. What does the nurse realize as reasons for this patients problem not
being adequately treated?
Standard Text: Select all that apply.
1. Ageism
2. Poverty
3. Cultural bias
4. Discrimination
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5. Respecting medical personnel
Correct Answer: 1,2,3,4
Rationale 1: Minority elders are at risk for mental health problems because of ageism or a
negative stereotype toward older adults.
Reference: MCS: 167
Rationale 2: One factor that contributes to poor mental health in minority elders is poverty.
Reference: MCS: 167
Rationale 3: Minority elders are at risk for mental health problems because of cultural bias.
Reference: MCS: 167
Rationale 4: One factor that contributes to poor mental health in minority elders is
discrimination.
Reference: MCS: 167
ESTBANisKnot
SEidentified
LLER.Cas
OMbeing a factor that contributes to
Rationale 5: Respecting medicalTpersonnel
poor mental health in minority elders. Most minority elders mistrust medical personnel which
can contribute to poor mental health in this population.
Reference: MCS: 167
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 8
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Type: MCSA
An older patient being treated for abdominal pain reports no relief of pain and other somatic
complaints after receiving adequate pain medication. What additional intervention is indicated
for this patient?
1. Reviewing the patients lab values
2. Contacting the family to talk to the patient
3. Further assessment and treatment for depression
4. Obtaining an order for different pain medication
Correct Answer: 3
Rationale 1: The laboratory values are of no significance in this patient situation.
Reference: MCS: 172
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Rationale 2: The family may be ineffective in meeting the patients psychological needs.
Reference: MCS: 172
Rationale 3: The major signs of depression in the older person include multiple somatic
complaints and reports of persistent chronic pain.
Reference: MCS: 172
Rationale 4: Obtaining different pain medication would not treat potential psychological
problems.
Reference: MCS: 172
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 9
Type: MCMA
An older patient is demonstrating signs of paranoia. What does the nurse identify as possible
causes for this type of psychosis?
Standard Text: Select all that apply.
1. Delirium
2. Hearing loss
3. Physical illness
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4. Social isolation
5. Cognitive impairment
Correct Answer: 1,2,4,5
Rationale 1: Risk factors for paranoia include delirium.
Reference: MCS: 170
Rationale 2: Risk factors for the development of paranoia include hearing loss.
Reference: MCS: 170
Rationale 3: Risk factors for the development of adjustment disorder include physical
illness. Reference: MCS: 170
Rationale 4: Risk factors for the development of paranoia include social isolation.
Reference: MCS: 170
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Rationale 5: Risk factors for the development of paranoia include cognitive impairment.
Reference: MCS: 170
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 10
Type: MCSA
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An older patient tells the nurse that alcohol is used occasionally to combat stress. The patient is a
recent widow, retired, and admits to feeling worthless at times. The nurse realizes this patient is
at risk for which health problem?
1. Suicide
2. Paranoia
3. Dementia
4. Liver failure
Correct Answer: 1
Rationale 1: Older persons over the age of 65 have the highest suicide rates of all age groups. A
major risk factor for suicide is depression. An inappropriate feeling of worthlessness is a
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symptom of depression.
Reference: MCS: 175
Rationale 2: The patient is not demonstrating symptoms of paranoia.
Reference: MCS: 175
Rationale 3: The patient is not demonstrating symptoms of dementia.
Reference: MCS: 175
Rationale 4: Occasional use of alcohol does not necessarily indicate that the patient is at risk for
liver failure.
Reference: MCS: 175
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 11
Type: MCMA
Which cognitive changes does the nurse recognize as being normal in an older patient?
Standard Text: Select all that apply.
1. Decline in the ability to draw
2. Decrease in size of vocabulary
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3. Difficulty filtering out irrelevant information
4. Difficulty switching attention from one person to another
5. Needing to repeat information to the patient several times
Correct Answer: 1,3,4,5
Rationale 1: A decline in visuospatial task ability such as drawing declines with aging.
Reference: MCS: 164
Rationale 2: Vocabulary improves with age.
Reference: MCS: 164
Rationale 3: The ability to filter out irrelevant information declines with age.
Reference: MCS: 164
Rationale 4: The ability to switch attention between people declines with age.
Reference: MCS: 164
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Rationale 5: Information-processing speed declines with age, necessitating the need to repeat
information to the patient several times.
Reference: MCS: 164
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 1. Describe age-related changes that affect psychological and cognitive
functioning.
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Question 12
Type: MCMA
What should the nurse instruct an older patient to do to cope with age-associated cognitive
changes?
Standard Text: Select all that apply.
1. Read daily.
2. Write notes to self.
3. Play computer games.
4. Learn memory enhancement techniques.
5. Expect others to call attention to any gaffes.
Correct Answer: 1,2,3,4
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Rationale 1: One way to cope with age-associated cognitive changes is to read daily in order to
keep the mind challenged and mentally active.
Reference: MCS: 165
Rationale 2: One way to cope with age-associated cognitive changes is to write notes to self.
Reference: MCS: 165
Rationale 3: One way to cope with age-associated cognitive changes is to play computer
games. Reference: MCS: 165
Rationale 4: One way to cope with age-associated cognitive changes is to learn memory
enhancement techniques.
Reference: MCS: 165
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Rationale 5: The patient should stay positive and laugh at oneself when appropriate and not
expect others to call attention to any gaffes.
Reference: MCS: 165
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Define appropriate nursing interventions directed toward assisting the
older adult to develop coping resources, use effective coping mechanisms, and minimize the
functional consequences of stress.
Question 13
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Type: MCSA
The son of an older patient is concerned about the patients ongoing forgetfulness and asks the
nurse to explain what could be wrong with the patient. How should the nurse respond to the son?
1. Memory difficulties are hard for family members to deal with.
2. My parents are the same age as yours, and they cant remember anything.
3. Forgetfulness is common in older adults. Its nothing you need to worry about.
4. Memory difficulties can be due to underlying issues including anxiety, chronic pain, or
depression.
Correct Answer: 4
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Rationale 1: Memory difficulties are difficult for family members to deal with, but this is not the
most appropriate statement at this time. The nurse is discounting the sons feelings.
Reference: MCS: 170
Rationale 2: The nurse is showing sympathy with the statement about the parents but is not
addressing the sons feelings.
Reference: MCS: 170
Rationale 3: Forgetfulness is common in older adults, but this statement is not therapeutic.
Reference: MCS: 170
Rationale 4: Cognitive changes can be due to anxiety, chronic pain, depression, or Alzheimers
disease.
Reference: MCS: 170
Global Rationale:
Cognitive Level: Applying
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Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Examine risk factors that influence cognitive functioning in older adults.
Question 14
Type: MCMA
The nurse is preparing an educational program for nursing assistants at a long-term care facility
about psychiatric issues in older patients. Which symptoms should the nurse include?
Standard Text: Select all that apply.
1. Flat affect
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2. Fear of death
3. Changes in sleep patterns
4. Delusions and hallucinations
5. Difficulty in performing ADLs
Correct Answer: 1,2,3,4
Rationale 1: A psychiatric symptom that should be investigated and not written off as a normal
change of aging includes problems with emotional expression such as a flat affect.
Reference: MCS: 170
Rationale 2: A psychiatric symptom that should be investigated and not written off as a normal
change of aging includes a fear of death.
Reference: MCS: 170
Rationale 3: A psychiatric symptom
should
TESthat
TBA
NKSEbeLinvestigated
LER.COM and not written off as a normal
change of aging includes changes in sleep patterns.
Reference: MCS: 170
Rationale 4: A psychiatric symptom that should be investigated and not written off as a normal
change of aging includes delusions and hallucinations.
Reference: MCS: 170
Rationale 5: Difficulty in performing ADLs does not necessarily indicate a psychiatric issue.
Reference: MCS: 170
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 4. Examine risk factors that influence cognitive functioning in older adults.
Question 15
Type: MCMA
The nurse is concerned that an older patient has a problem related to regular alcohol
consumption. What did the nurse assess in this patient?
Standard Text: Select all that apply.
1. Anxiety
2. Malnutrition
3. Social isolation
4. Bruises from falling
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5. Dependence on family members
Correct Answer: 1,2,3,4
Rationale 1: Problems related to excessive or regular alcohol consumption include anxiety.
Reference: MCS: 177
Rationale 2: Problems related to excessive or regular alcohol consumption include malnutrition
or failure to prepare and eat an adequate diet.
Reference: MCS: 177
Rationale 3: Problems related to excessive or regular alcohol consumption include social
isolation because of avoiding people who do not drink or are judgmental.
Reference: MCS: 177
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Rationale 4: Problems related to excessive or regular alcohol consumption include recurrent
bruises from falls.
Reference: MCS: 177
Rationale 5: Problems related to excessive or regular alcohol consumption do not include
dependence on family members.
Reference: MCS: 177
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Detect risk
TEfactors
STBAfor
NKhigh
SELlevels
LER.ofCstress,
OM poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 16
Type: MCSA
An older patients spouse passed away 4 years ago; however, the patient still sets a place at the
dinner table for the spouse and has never removed any clothing or other personal items from the
home. What does the nurse suspect the patient is experiencing?
1. Normal grief
2. Hopelessness
3. Survivor guilt
4. Pathological grief
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Correct Answer: 4
Rationale 1: Normal grief is that which lasts within a 2-year time frame.
Reference: MCS: 171
Rationale 2: Hopelessness is when the patient sees no hope in life. This is not what the patient is
experiencing.
Reference: MCS: 171
Rationale 3: Survivor guilt is associated with a traumatic event where a person survives when
another loved one does not.
Reference: MCS: 171
Rationale 4: Grief persisting longer than 2 years is considered pathological in the United States.
Reference: MCS: 171
Global Rationale:
Cognitive Level: Analyzing
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Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 17
Type: MCMA
The nurse is preparing a presentation on grief. What information should be included regarding
factors that can affect the duration and course of grieving?
Standard Text: Select all that apply.
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1. Centrality of loss
2. Nature of the death
3. Health of the survivor
4. Cultural and ethnic influences
5. Survivors religious or spiritual belief system
Correct Answer: 1,2,3,5
Rationale 1: Factors than can affect the duration and course of grieving include the centrality of
the loss.
Reference: MCS: 171
Rationale 2: Factors than can affect the duration and course of grieving include the nature of the
death.
Reference: MCS: 171
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Rationale 3: Factors than can affect the duration and course of grieving include the health of the
survivor.
Reference: MCS: 171
Rationale 4: Factors than can affect the duration and course of grieving do not include cultural
and ethnic influences.
Reference: MCS: 171
Rationale 5: Factors than can affect the duration and course of grieving include the survivors
religious or spiritual belief system.
Reference: MCS: 171
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 18
Type: MCSA
During an assessment, the nurse learns that an older patient experiences much stress and feels the
heart racing at times. The nurse explains that this is the fight-or-flight response and is associated
with which body chemical?
1. Serotonin
2. Dopamine
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3. Epinephrine
4. Acetylcholine
Correct Answer: 3
Rationale 1: Serotonin is associated with sleep and depression.
Reference: MCS: 169
Rationale 2: Dopamine is associated with schizophrenia.
Reference: MCS: 169
Rationale 3: The fight-or-flight response stimulates epinephrine release and increases pulse,
blood pressure, blood glucose, and muscle tension.
Reference: MCS: 169
Rationale 4: Acetylcholine is associated with Alzheimers disease.
Reference: MCS: 169
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Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
Question 19
Type: MCSA
While organizing a walking program at an assisted living facility, one resident asks why older
people should exercise. Which response would be the best for the nurse to make?
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1. You arent too old to exercise.
2. Exercise can help increase your blood pressure.
3. Exercise has not been shown to have any benefits for people over 80.
4. Exercise can help reduce the negative effects of stress, which can impact your physical health.
Correct Answer: 4
Rationale 1: The statement You arent too old to exercise does not answer the residents question.
Reference: MCS: 181
Rationale 2: Exercise helps to decrease and not increase blood pressure.
Reference: MCS: 181
Rationale 3: Exercise is beneficial for all people of all ages.
Reference: MCS: 181
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Rationale 4: Exercise can help to break the cycle of long-term negative effects of stress and
reduce the harmful effects of elevated cortisol levels caused by stress.
Reference: MCS: 181
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 5. Define appropriate nursing interventions directed toward assisting the
older adult to develop coping resources, use effective coping mechanisms, and minimize the
functional consequences of stress.
Question 20
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Type: MCSA
The nurse caring for older patients in a long-term care facility is organizing a depression
screening program for the residents. How will this screening program benefit the older patients?
1. Differentiates dysthymia from delirium
2. Supports care expectations of the older patients family members
3. Depression symptoms are often associated with chronic illness and pain.
4. Depression is the easiest mood disorder to detect and treat in older patients.
Correct Answer: 3
Rationale 1: Screening an older patient for depression is not done to differentiate dysthymia
from delirium. Older patients may experience persistent feelings of sadness but not meet the
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criteria for depression.
Reference: MCS: 172
Rationale 2: Screening older patients for depression is not done to support care expectations of
older patients family members. This action helps to identify those patients who need intervention
to treat depression.
Reference: MCS: 172
Rationale 3: Depression is the mental health problem of greatest frequency and magnitude in the
older population. The risk of depression in the older person increases with other illnesses and
when ability to function becomes limited. Symptoms of depression are often associated with
chronic illness and pain.
Reference: MCS: 172
Rationale 4: Depression in older adults is often undetected and untreated. Primary healthcare
providers are often not vigilant or consistent in their diagnosis of depression and may fail to
make the diagnosis.
Reference: MCS: 172
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Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for latelife depression, treating depression in older adults, and preventing suicide.
Question 21
Type: MCSA
Which observation should indicate to the nurse to assess an older patient for depression?
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1. Flat affect
2. Hyperactivity
3. Racing thoughts
4. Pressured speech
Correct Answer: 1
Rationale 1: A flat affect or having minimal or no reaction to emotion is one clinical
manifestation of depression in an older patient.
Reference: MCS: 172
Rationale 2: Hyperactivity is a manifestation of mania.
Reference: MCS: 172
Rationale 3: Racing thoughts is a manifestation of mania.
Reference: MCS: 172
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Rationale 4: Pressured speech is when words cannot be stated quickly enough and is a
manifestation of mania.
Reference: MCS: 172
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 3. Detect risk factors for high levels of stress, poor coping, and impaired
mental health, including alcoholism, stress-related disorders, and depression.
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Question 22
Type: MCMA
The nurse is planning an educational session on suicide in the older patient population. What
information should the nurse include in this presentation?
Standard Text: Select all that apply.
1. Suicide rates are the highest in teens.
2. A patient should never be questioned about suicide intent.
3. Suicide rates are the highest in people age 65 and older.
4. An older person who contemplates suicide is more likely to complete the act than a younger
person.
5. Approximately 70% of older adults who commit suicide had visited their primary care
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physician within the previous month.
Correct Answer: 3,4,5
Rationale 1: Older persons age 65 and over have the highest suicide rates of all age groups.
Reference: MCS: 175
Rationale 2: Suicide intent is part of the nursing assessment for depression.
Reference: MCS: 175
Rationale 3: Older persons age 65 and over have the highest suicide rates of all age groups.
Reference: MCS: 175
Rationale 4: An older person who contemplates suicide is more likely to complete the act than a
younger person because older people often employ lethal methods when attempting suicide,
experience greater social isolation, and generally have poorer recuperative capacity, which
makes them less likely to recover from a suicide attempt.
Reference: MCS: 175
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Rationale 5: Approximately 70% of older adults who commit suicide had visited their primary
care physician within the previous month.
Reference: MCS: 175
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for latelife depression, treating depression in older adults, and preventing suicide.
Question 23
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Type: MCSA
Which statement made by an older patient indicates to the nurse that the patient might be
contemplating suicide?
1. I wish I could stop all of this pain.
2. God will take me when its my time.
3. Im ready to go when God calls me.
4. Im no use to anyone. I might as well be dead.
Correct Answer: 4
Rationale 1: Expressing a desire to have pain end does not indicate that an older patient is
contemplating suicide.
Reference: MCS: 176
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Rationale 2: A statement that reflects Gods will is not expressing suicidal intentions.
Reference: MCS: 176
Rationale 3: A statement that reflects Gods will is not expressing suicidal intentions.
Reference: MCS: 176
Rationale 4: The statement that reflects uselessness and being dead is one that should be
analyzed for suicidal intentions.
Reference: MCS: 176
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing
TESTBProcess:
ANKSEAssessment
LLER.COM
Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for latelife depression, treating depression in older adults, and preventing suicide.
Question 24
Type: MCSA
An older patient is prescribed a monoamine oxidase inhibitor (MAOI) medication. Which meal
choice indicates that the patient needs further education regarding this medication?
1. Pepperoni pizza and diet soda
2. Baked chicken, green beans, and cherry pie
3. Fried chicken, creamed corn, and French fries
4. Chicken salad on a croissant, carrot sticks, and fresh fruit
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Correct Answer: 1
Rationale 1: Because these drugs inhibit the metabolism of norepinephrine, hypertensive crisis
can occur if they are administered with other drugs or food that raise blood pressure such as
anticholinergics, stimulants, and foods containing tyramine including red wine, cheese, beer,
bologna, pepperoni, liver, raisins, and bananas.
Reference: MCS: 184
Rationale 2: None of these food items contain tyramine, which should be avoided in the patient
receiving a MAOI.
Reference: MCS: 184
Rationale 3: None of these food items contain tyramine, which should be avoided in the patient
receiving a MAOI.
Reference: MCS: 184
Rationale 4: None of these food items contain tyramine, which should be avoided in the patient
receiving a MAOI.
Reference: MCS: 184
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Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 5. Define appropriate nursing interventions directed toward assisting the
older adult to develop coping resources, use effective coping mechanisms, and minimize the
functional consequences of stress.
Question 25
Type: MCSA
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The nurse is planning care for an older patient diagnosed with major depression who states that
voices are telling the patient to kill himself. Which nursing diagnosis would be a priority for this
patient?
1. Social isolation
2. Risk for suicide
3. Disturbed sleep pattern
4. Altered sensory perception
Correct Answer: 2
Rationale 1: Social isolation might be causing the patient to hear voices; however, this would
not be the priority diagnosis at this time.
Reference: MCS: 184
Rationale 2: The patient is hearing
TEvoices
STBAthat
NKSare
ELtelling
LER.him
COto
M kill himself. This patient is at
risk for suicide.
Reference: MCS: 184
Rationale 3: The patient may or may not have disturbed sleep. This is not the priority diagnosis
for the patient at this time.
Reference: MCS: 184
Rationale 4: Even though the patient is hearing voices, which would be an alteration in sensory
perception, the voices are telling the patient to kill himself. This is not the priority diagnosis for
the patient at this time.
Reference: MCS: 184
Global Rationale:
Cognitive Level: Analyzing
Client Need: Psychosocial Integrity
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Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 7. Formulate interventions directed toward alleviating risk factors for latelife depression, treating depression in older adults, and preventing suicide.
Chapter 14 Impaired Cognitive Function: Delirium and Dementia
MULTIPLE CHOICE
1. An older adult is experiencing age-related postural hypotension and he fears something is
really wrong because he is the only one in his social group experiencing the problems. The nurse
responds:
a. Dont be concerned; just be very careful about your risk for falling.
b. You have had very thorough testing, so dont worry about it being serious.
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c. Its just a matter of time before they too have to watch not to get up too quickly.
d. You just dont have the compensating mechanisms of your friends.
ANS: D
The age-related symptoms of postural hypotension are dizziness or lightheadedness when
changing positions rapidly. However, compensatory processes in the cortex and subcortical areas
of the brain help aging individuals maintain relatively normal motor performance.
DIF: Understanding (Comprehension) REF: MCS: 565 OBJ: 27-2
TOP: Teaching-Learning MSC: Physiologic Integrity
2. What education by the nurse is most important to address age-related changes to the senses?
a. Installing auditory smoke alarms
b. Having regular eye checkups
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c. Being aware that hearing acuity decreases with age
d. Checking the expiration dates on foods such as dairy
ANS: A
An age-related reduction in the senses makes it less likely that an older person will smell smoke
from a fire. Loud fire alarms are important for home safety. The other factors are not as directly
related to safety.
DIF: Understanding (Comprehension) REF: MCS: 566 OBJ: 27-2
TOP: Teaching-Learning MSC: Safe Effective Care Environment
3. The nurse is conducting an admission assessment on a mildly confused older patient. The
nurse best assures an accurate history by first:
a. scoring the clients cognitive responses.
b. focusing on the client to respond.
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c. directing the questions to both patient and family.
d. arranging a Mini-Mental State Examination (MMSE).
ANS: C
An interview with the friend or family member is an appropriate method to first implement when
a patient is exhibiting confused behavior. The other options will not get accurate information for
the assessment.
DIF: Understanding (Comprehension) REF: MCS: 566 OBJ: 27-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. A nurse is caring for an older patient diagnosed with acute depression. What action by the
nurse is most important to help prevent delirium in this patient?
a. Reorienting the patient to the day, time and place frequently
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b. Being physically present to help the patient with eating meals
c. Providing the patient with opportunities to discuss depression
d. Administering antidepressive medication as prescribed
ANS: B
Depressed older adults may neglect eating or caring for a chronic medical condition,
predisposing them to the development of delirium resulting from hypoalbuminemia and possibly
electrolyte imbalances. The other actions will not prevent delirium.
DIF: Applying (Application) REF: N/A OBJ: 27-4
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
5. When assessing an older patient displaying symptoms of delirium, the nurse focuses the
assessment on:
a. the degree and duration of the symptoms.
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b. the amount of self-care deficiency the symptoms cause.
c. identifying processes that commonly result in the symptoms.
d. physiologic dysfunction resulting from the symptoms.
ANS: C
The treatment of delirium entails the identification and treatment of the underlying cause. The
nurse should assess this factor as the priority. The other assessments are of lesser priority.
DIF: Applying (Application) REF: N/A OBJ: 27-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. An 80-year-old patient is exhibiting signs of dementia representative of Alzheimer disease
(AD). The nurse supports that possibility when determining that the patient:
a. experienced a gastric resection several years ago.
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b. traveled often to third world countries.
c. was employed as a steelworker for 40 years.
d. has a history of viral encephalitis.
ANS: D
Viral illness such as herpes zoster, herpes simplex, or viral encephalitis is believed to be a
possible risk factor for AD. However, advancing age is the primary risk factor. The other options
are not related.
DIF: Remembering (Knowledge) REF: MCS: 571 OBJ: 27-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
7. When planning care for the older adult with advanced dementia, the nurse recognizes that the
best way to implement reality orientation is to:
a. place printed labels on important items, such as the telephone.
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b. place a clock and calendar in the patients immediate environment.
c. use hand gestures instead of verbal communications to demonstrate meaning.
d. show the patient a picture of a toothbrush when it is time for oral hygiene.
ANS: D
Reality orientation supports failing memory in early stages of dementia and preserves
independent functioning for a longer duration. Although written messages and signs may become
meaningless to individuals with advancing dementia, pictures often evoke a response. The other
options are not part of this strategy.
DIF: Remembering (Knowledge) REF: MCS: 579 OBJ: 27-4
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
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8. A 73-year-old patient diagnosed with vascular dementia is admitted for exacerbation of
asthma. The patient has been treated for 2 years with benzodiazepines to manage her
increasingly aggressive behavior. The nurses initial response is to:
a. identify the patient as being at high risk for falls.
b. monitor the patient for signs of benzodiazepine withdrawal.
c. notify the admitting physician immediately.
d. place the patient on strict intake and output.
ANS: C
Benzodiazepines should be reserved for acute situations and not used for the long-term
management of troubling behaviors. Long-term use can precipitate withdrawal if use is stopped
and can possibly cause seizures. The nurse should notify the physician immediately so that plans
for safely discontinuing the drug can be made.
DIF: Applying (Application) REF: N/A OBJ: 27-6
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TOP: Communication and Documentation MSC: Physiologic Integrity
9. Which of the following statements, when made by family members caring for an older patient
with dementia, indicates peaceful acceptance of the situation?
a. Im so pleased that Mother had a good day today. Im really very hopeful.
b. The hospice nurses are so helpful when I need time for myself.
c. I promised Mother I would take care of her and Ill never leave her.
d. Its the least I can do for Mother since she cared for us all these years.
ANS: B
Adjusting to the fact that dementia is irreversible and prolonged places families in situations of
dealing with grief over a long period. Nurses need to encourage caregivers to take time out from
their task and participate in self-care and health promotion activities. The other statements do not
show this acceptance as clearly.
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DIF: Evaluating (Evaluation) REF: N/A OBJ: 27-6
TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity
10. The son of a patient with possible Alzheimer disease (AD) asks the nurse if there is a
diagnostic test that can confirm the diagnosis. The nurse responds that:
a. an electroencephalogram is often very useful in diagnosing AD.
b. a positron emission tomography (PET) scan is a cheap but dependable tool.
c. magnetic resonance imaging (MRI) is often ordered for that purpose.
d. postmortem autopsy is the only definitive diagnostic tool.
ANS: D
Autopsy remains the gold standard and only definitive method for the diagnosis of AD.
DIF: Understanding (Comprehension) REF: MCS: 572 OBJ: 27-5
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TOP: Teaching-Learning MSC: Physiologic Integrity
11. An 89-year-old diagnosed with dementia was until recently responding well to cognitive
cueing techniques. The nurse shows an understanding of dementia when sharing with staff that:
a. We will implement new interventions that address the diseases progression.
b. Its important that we frequently recue the patient to improve her quality of life.
c. The patients family needs to be made aware of this decline.
d. This poor response to cueing is likely a result of advanced aging.
ANS: A
Positive responses to selected interventions may continue for a time but may decline as the
disease progresses, which results in the need to reevaluate strategies. The nursing staff cannot
evaluate the patients quality of life; only the patient can, and this patient is not capable. The
family should be informed but that is not related to understanding dementia. The change in
response is the result of advancing disease, not age.
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DIF: Applying (Application) REF: N/A OBJ: 27-6
TOP: Teaching-Learning MSC: Physiologic Integrity
12. An 80-year-old patient who is experiencing symptoms of depression and anxiety is reluctant
to comply with the prescribed treatment plan. The nurse initially addresses the issue with the
patient by asking:
a. How do you feel about how others view your mental health problem?
b. Are you concerned about paying for your psychiatric medications?
c. Did you know that depression is common among people your age?
d. Do you have any questions about your the mental health treatment plan?
ANS: A
Older adults are often reluctant to seek care from a mental health professional because they grew
up during a period when a strong stigma was attached to mental illness, mental hospitals, and
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ANK
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ER.COM
mental treatment. The other questions
doBnot
open
DIF: Applying (Application) REF: N/A OBJ: 27-8
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
13. An older adult patient being treated for chronic obstructive pulmonary disease (COPD) is
exhibiting signs of memory loss and confusion. In planning his care, the nurse should give
priority to:
a. obtaining an order for a pulmonary function test (PFT).
b. determining the potential of a possible adverse drug reaction.
c. reorienting the patient to time, place, and person frequently.
d. assessing for a family history of dementia.
ANS: B
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Two of the most common side effects of many medications taken by older adults are mental
confusion and disorientation. The initial action should be to determine the possible cause of the
symptoms. If a cause can be found, a change might be possible. There is no indication the patient
needs a PFT. Reorienting the patient is a good intervention, but it would be better to identify and
eliminate the causative factor. Assessing a family history is a potential intervention as well.
DIF: Applying (Application) REF: N/A OBJ: 27-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
14. The nurse caring for an older adult patient recovering from cardiac surgery recognizes that it
is most appropriate to assess this patient for mental health problems because:
a. cardiac surgery often results in anxiety-related issues.
b. untreated depression can contribute to the patients morbidity risks.
c. many in this age cohort have undiagnosed depression.
d. hospitalization is both anxiety and depression inducing.
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ANS: B
Depression can and should be treated when it occurs with other illnesses because untreated
depression can delay recovery from or worsen the outcome of the other illnesses. Cardiac illness
is associated with depression, but not necessarily with anxiety issues. It is true that depression in
the older population is underdiagnosed. Hospitalization can lead to depression. But the main
reason to assess for depression is because of its effects on other health conditions.
DIF: Applying (Application) REF: N/A OBJ: 27-8
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
15. When planning care for the older adult being treated for depression, the nurse addresses the
patients tertiary intervention needs best by:
a. helping the patient to identify the early symptoms of depression.
b. helping the patient deal with the physical symptoms of depression.
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c. discussing with the patient how to implement new coping skills.
d. educating the patient about the importance of being drug compliant.
ANS: C
Tertiary intervention refers to the restorative or rehabilitative functions that the nurse performs to
assist patients in the recovery process. An important aspect of tertiary intervention involving
patients with depression is teaching new coping skills to lessen the likelihood of recurring
depression. Identifying early symptoms is a secondary prevention. Treating the depression will
limit the physical symptoms. Education is generally considered primary prevention. However, in
this case it is education on part of treatment. This is not the best answer because the nurse is not
teaching about the drugs, only about the importance of being compliant.
DIF: Applying (Application) REF: N/A OBJ: 27-8
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
16. To best advocate for an olderTadult
ESTpatient
BANKbeing
SELLprescribed
ER.COMmedication to control newly
observed signs of confusion and aggressive behavior, the nurse:
a. initiates an assessment to determine possible underlying causes of the behavior.
b. contacts family to inform them of the new medication therapy being planned.
c. discusses possible nonpharmaceutical treatments with the physician.
d. documents a detailed description of the behaviors before administering the drugs.
ANS: A
In this population, such symptoms may be mistakenly assumed to be a result of normal aging, so
prescription medications may be ordered for anxiety, depression, aggressive and disruptive
behavior, or paranoid-type behavior, without assessing the reasons for the behavior. If an
underlying cause of the behavior is found, it can be treated, thereby eliminating the problem. The
other actions do not demonstrate advocacy.
DIF: Applying (Application) REF: N/A OBJ: 27-9
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TOP: Nursing Process: Assessment MSC: Physiologic Integrity
17. An older adult has been recently diagnosed with type 2 diabetes and mild retinal
deterioration. To best address the patients potential for developing situation depression, the
nurse:
a. assesses the patients coping skills.
b. Encourages the patient to participate in a depression support group.
c. assesses the patients ability to manage the symptoms.
d. educates the family on early signs of depression.
ANS: A
One of the keys to successful aging is adjusting to or, perhaps more accurately, adapting to,
although not necessarily accepting, changes that occur in ones life. The nurse assesses the
patients coping skills and methods. The patient does not need a support group before developing
depression. Managing symptoms is part of coping. Educating the family is an appropriate
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intervention but is not the priority.
DIF: Applying (Application) REF: N/A OBJ: 27-8
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
18. An older adult has a medical condition that has required hospitalization at a facility far from
home and family. To best minimize the patients risk for depression, the nurse:
a. keeps the patient informed of the expected discharge date.
b. offers to help the patient telephone family members each evening.
c. reassures the patient that early discharge is a nursing goal.
d. encourages the patient to place family photographs around the room.
ANS: B
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The family continues to be the first source of support for older adults. This support is best
achieved by regular contact through visiting or telephoning. The other options may be helpful,
but they are not the best choice.
DIF: Understanding (Comprehension) REF: MCS: 599 OBJ: 27-8
TOP: Caring MSC: Psychosocial Integrity
19. An older patient is anxious about an upcoming diagnostic test and requests something to
calm the nerves. To best address the patients need, the nurse prepares to administer a PRN dose
of:
a. clonazepam (Klonopin).
b. diazepam (Valium).
c. chlordiazepoxide (Librium).
d. lorazepam (Ativan).
ANS: D
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There are two broad categories of benzodiazepines: short-acting (e.g., alprazolam [Xanax],
lorazepam [Ativan], and oxazepam [Serax]) and long-acting (e.g., diazepam [Valium],
chlordiazepoxide [Librium], and clonazepam [Klonopin]). The short-acting agents are preferred
for older adults because of their lower potential for buildup leading to sedation and depression.
DIF: Applying (Application) REF: N/A OBJ: 27-9
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
20. While collecting a health history for an older adult patient, the nurse learns that the patient
had been prescribed Elavil 3 weeks ago and wants to stop taking it because It didnt make me feel
any better. In response to this information, the nurse shares with the patient that:
a. sudden withdrawal is likely to cause a hypertensive crisis.
b. depression seldom improves without medication.
c. realistically it will take longer for the patient to feel an improvement.
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d. in time, people adjust to the side effects.
ANS: C
Older patients may need up to 12 weeks of this medication for evaluation of a full response.
Psychotropic medications need to be started low and increases should be done slowly. The other
options are not correct.
DIF: Understanding (Comprehension) REF: MCS: 597 OBJ: 27-9
TOP: Teaching-Learning MSC: Physiologic Integrity
21. The nurse familiar with the old adult population recognizes that the patient who has the
greatest potential for successfully committing suicide is the:
a. 63-year-old Asian female.
b. 86-year-old Caucasian male.
c. 76-year-old Hispanic female.
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d. 67-year-old African-American male.
ANS: B
The highest rates of suicide are among men over the age of 85.
DIF: Remembering (Knowledge) REF: MCS: 567 OBJ: 27-9
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
22. A 65-year-old adult who recently lost his spouse is admitted to the hospital after a failed
suicide attempt. He presents with a sad affect and is reluctant to interact within the milieu. The
nursing diagnosis with priority is:
a. ineffective coping related to recent loss.
b. hopelessness related to death of spouse.
c. risk for loneliness related to loss of spouse.
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d. risk for self-directed violence related to depression.
ANS: D
This patient is at risk for another attempt at suicide, so safety is the primary concern.
DIF: Applying (Application) REF: N/A OBJ: 27-8
TOP: Nursing Process: Analysis MSC: Psychosocial Integrity
23. The nurse is caring for a severely depressed older patient. To best effect change in the
patients emotional state, the nurses initial goal is to:
a. plan interventions that will enhance the patients self-esteem.
b. introduce the patient to new coping skills.
c. assess the patients potential to self-harm.
d. develop a therapeutic nurse-patient relationship.
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ANS: D
The nurses ability to positively effect change in older adults responses to depression lies in the
development of therapeutic relationships. Assessing risk for harm is an important safety issue but
does not help the patients emotional state. The other two options come later after the relationship
has entered its working phase.
DIF: Applying (Application) REF: N/A OBJ: 27-8
TOP: Caring MSC: Psychosocial Integrity
24. An older adult is hospitalized for treatment of a mental health disorder and is prescribed
clomipramine (Anafranil). The nurse documents that the medication is having the desired effect
when the patient:
a. begins sleeping 8 hours per night.
b. engages in fewer ritualistic behaviors.
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c. reports fewer episodes of nervousness.
d. exhibits no delusionary thinking.
ANS: B
This medication is a tricyclic antidepressant that is specifically helpful for obsessive-compulsive
disorder (OCD). The other assessments are not specific indicators of the effectiveness of this
medication.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 27-8
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
25. To help manage the potential side effects of prescribed antipsychotic medications,
amantadine (Symmetrel) may be prescribed. Which statement best indicates that the nurse
understands the appropriateness of this medication for the older adult patient?
a. This medication produces few anticholinergic effects.
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b. Symmetrel is an effective dopamine agonist.
c. Extrapyramidal symptoms are best controlled by Symmetrel.
d. Older patients seem to have the fewest side effects on this medication.
ANS: A
Amantadine (Symmetrel), a dopamine agonist prescribed to manage EPS, may be used,
especially in older patients and in those with cardiovascular dysfunction, because of its reduced
anticholinergic effects. The other statements are not accurate.
DIF: Remembering (Knowledge) REF: MCS: 598 OBJ: 27-8
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. A 72-year-old is prescribed lithium. The nurse educates the patient on the importance of
biannual evaluation of which of the following? (Select all that apply.)
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a. Renal function
b. Serum glucose level
c. Liver function
d. Thyroid function
e. Red blood cell count
ANS: A, C, D
Renal, liver, and thyroid studies should be evaluated every 6 months because of the drugs
potential toxicity. Glucose and red blood cell count are not affected.
DIF: Remembering (Knowledge) REF: MCS: 597 OBJ: 27-8
TOP: Teaching-Learning MSC: Physiologic Integrity
2. A 78-year-old patient was admitted with dehydration. The nurse assesses and documents
observations that support a finding of dementia. Which of the following observations are related
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to dementia? (Select all that apply.)
a. Forgetting what she ate for lunch today
b. Crying frequently when alone
c. Inability to find her way back to her room from the dayroom
d. Being impatient with the nursing staff for not closing her door
e. Repeatedly asking to call her son
ANS: A, C, D, E
Common manifestations of dementia include repeated questions and statements, forgetting to pay
bills or take medications, increasing problems with orientation, and geographic disorientation.
Other symptoms of AD include pervasive forgetfulness and memory loss, language deterioration,
impaired ability to mentally manipulate visual information, poor judgment, confusion,
restlessness, and mood swings. Personality changes may include apathy or loss of interest in
previously enjoyed activities. Crying is not a classic sign of dementia, although depression often
accompanies dementia and this could be a sign of depression.
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DIF: Remembering (Knowledge) REF: MCS: 569 OBJ: 27-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
3. The nurse is caring for an older adult patient admitted to the hospital. What assessment
findings place the patient at risk for developing delirium during the hospitalization? (Select all
that apply.)
a. The patent takes medications to manage several chronic illnesses.
b. The patent has a history of urinary tract infections.
c. The patent is in cancer remission.
d. The patent has recently been eating poorly.
e. The patent experienced a mild heart attack 2 years ago.
ANS: A, B, D
The risk factors for delirium include advanced age, central nervous system diseases, infection,
TE
STBANKimbalances,
SELLER.trauma
COM history, gastrointestinal or
polypharmacy, hypoalbuminemia,
electrolyte
genitourinary disorders, cardiopulmonary disorders, and sensory changes. These factors can lead
to physiologic imbalances increasing the risk for confusion. Cancer remission and a heart attack
2 years prior do not increase the patients risk.
DIF: Remembering (Knowledge) REF: MCS: 569 OBJ: 27-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. A home care nurse is visiting a patient with moderate cognitive impairment from Alzheimer
disease. The patients partner expresses concern about difficulty getting the patient to eat
properly. The nurse suggests which of the following? (Select all that apply.)
a. Serving meals at the same time each day
b. Offering liquids in place of solid foods when possible
c. Offering a calorie-dense snack at bedtime
d. Cutting food into bite-sized pieces that will fit into the patients hand
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e. Asking the patent to identify favorite foods
ANS: A, C, D
It is important to support the ongoing nutrition of individuals with dementia because they may
experience decreased hunger and ability to taste food. People who demonstrate symptoms of
moderate to severe cognitive impairment may benefit from having meals in the same place at the
same time each day. Small, frequent, nutritionally dense meals and snacks should be provided.
During later stages of dementia, individuals may need to be reminded to open the mouth and
chew. Food should be soft and cut in small pieces. Liquids do not need to be substituted for solid
food. The patient may not be able to identify favorite foods, and asking may cause frustration.
Chapter 15 Impaired Affective Function: Depression
Multiple Choice
1. A client is diagnosed with persistent depressive (dysthymia) disorder. Which should a nurse
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classify as an affective symptom of this disorder?
A. Social isolation with a focus on self
B. Low energy level
C. Difficulty concentrating
D. Gloomy and pessimistic outlook on life
ANS: D
The nurse should classify a gloomy and pessimistic outlook on life as an affective symptom of
dysthymia. Symptoms of depression can be described as alterations in four areas of human
functions: affective, behavioral, cognitive, and physiological. Affective symptoms are those that
relate to the mood.
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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Psychosocial Integrity
2. A client is diagnosed with major depressive disorder. Which nursing diagnosis should a nurse
assign to this client to address a behavioral symptom of this disorder?
A. Altered communication R/T feelings of worthlessness AEB anhedonia
B. Social isolation R/T poor self-esteem AEB secluding self in room
C. Altered thought processes R/T hopelessness AEB persecutory delusions
D. Altered nutrition: less than body requirements R/T high anxiety AEB anorexia
ANS: B
A nursing diagnosis of social isolation R/T poor self-esteem AEB secluding self in room
addresses a behavioral symptom of major depressive disorder. Other behavioral symptoms
include psychomotor retardation,Tvirtually
maintaining a fetal
ESTBAnonexistent
NKSELLEcommunication,
R.COM
position, and no personal hygiene and/or grooming.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client
Need: Psychosocial Integrity
3. A nurse assesses a client suspected of having major depressive disorder. Which client
symptom would eliminate this diagnosis?
A. The client is disheveled and malodorous.
B. The client refuses to interact with others.
C. The client is unable to feel any pleasure.
D. The client has maxed-out charge cards and exhibits promiscuous behaviors.
ANS: D
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The nurse should assess that a client who has maxed-out credit cards and exhibits promiscuous
behavior would be exhibiting manic symptoms. According to the DSM-5, these symptoms would
rule out the diagnosis of major depressive disorder.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Psychosocial Integrity
4. A nurse reviews the laboratory data of a 29-year-old client suspected of having major
depressive disorder. Which laboratory value would potentially rule out this diagnosis?
A. Thyroid-stimulating hormone (TSH) level of 6.2 U/mL
B. Potassium (K+) level of 4.2 mEq/L
C. Sodium (Na+) level of 140 mEq/L
D. Calcium (Ca2+) level of 9.5 mg/dL
ANS: A
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According to the DSM-5, symptoms of major depressive disorder cannot be due to the direct
physiological effects of a general medical condition (e.g., hypothyroidism). The diagnosis of
major depressive disorder may be ruled out if the clients laboratory results indicate a high TSH
level (normal range for this age group is 0.4 to 4.2 U/mL), which results from a low thyroid
function, or hypothyroidism. In hypothyroidism metabolic processes are slowed, leading to
depressive symptoms.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Psychosocial Integrity
5. A depressed client reports to a nurse a history of divorce, job loss, family estrangement, and
cocaine abuse. According to learning theory, what is the cause of this clients symptoms?
A. Depression is a result of anger turned inward.
B. Depression is a result of abandonment.
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C. Depression is a result of repeated failures.
D. Depression is a result of negative thinking.
ANS: C
Learning theory describes a model of learned helplessness in which multiple life failures cause
the client to abandon future attempts to succeed.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Psychosocial Integrity
6. What is the priority reason for a nurse to perform a full physical health assessment on a client
admitted with a diagnosis of major depressive disorder?
A. The attention during the assessment is beneficial in decreasing social isolation.
B. Depression is a symptom of several medical conditions.
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C. Physical health complications are likely to arise from antidepressant therapy.
D. Depressed clients avoid addressing physical health and ignore medical problems.
ANS: B
Medical conditions such as hormone disturbances, electrolyte disturbances, and nutritional
deficiencies may produce symptoms of depression. These are a priority to identify and treat,
since they may be the cause of the depressive symptoms and represent physiological needs.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Physiological Integrity
7. A nurse is planning care for a child who is experiencing depression. Which medication is
approved by the U.S. Food and Drug Administration (FDA) for the treatment of depression in
children and adolescents?
A. Paroxetine (Paxil)
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B. Sertraline (Zoloft)
C. Citalopram (Celexa)
D. Fluoxetine (Prozac)
ANS: D
Fluoxetine (Prozac) is FDA approved for the treatment of depression in children and adolescents.
Fluoxetine is a selective serotonin reuptake inhibitor (SSRI) used in the treatment of depression.
All antidepressants carry an FDA warning for increased risk of suicide in children and
adolescents.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
8. A nurse admits an older client who is experiencing memory loss, confused thinking, and
apathy. A psychiatrist suspects depression. What is the rationale for performing a mini-mental
status exam?
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A. To rule out bipolar disorder
B. To rule out schizophrenia
C. To rule out neurocognitive disorder
D. To rule out a personality disorder
ANS: C
A mini-mental status exam should be performed to rule out neurocognitive disorder. The elderly
are often misdiagnosed with neurocognitive disorder such as Alzheimers disease, when
depression is their actual diagnosis. Memory loss, confused thinking, and apathy are common
symptoms of depression in the elderly.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Physiological Integrity
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9. A confused client has recently been prescribed sertraline (Zoloft). The clients spouse is taking
paroxetine (Paxil). The client presents with restlessness, tachycardia, diaphoresis, and tremors.
What complication does a nurse suspect, and what could be its possible cause?
A. Neuroleptic malignant syndrome caused by ingestion of two different serotonin reuptake
inhibitors (SSRIs)
B. Neuroleptic malignant syndrome caused by ingestion of an SSRI and a monoamine oxidase
inhibitor (MAOI)
C. Serotonin syndrome caused by ingestion of an SSRI and an MAOI
D. Serotonin syndrome caused by ingestion of two different SSRIs
ANS: D
The nurse should suspect that the client is suffering from serotonin syndrome possibly caused by
ingesting two different SSRIs (Zoloft and Paxil). Symptoms of serotonin syndrome include
ESTBANKSnausea,
ELLERabdominal
.COM pain, myoclonus, muscle
confusion, agitation, tachycardia,Thypertension,
rigidity, fever, sweating, and tremor.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
10. A client who has been taking fluvoxamine (Luvox) without significant improvement asks a
nurse, I heard about something called a monoamine oxidase inhibitor (MAOI). Cant my doctor
add that to my medications? Which is an appropriate nursing reply?
A. This combination of drugs can lead to delirium tremens.
B. A combination of an MAOI and Luvox can lead to a life-threatening hypertensive crisis.
C. Thats a good idea. There have been good results with the combination of these two drugs.
D. The only disadvantage would be the exorbitant cost of the MAOI.
ANS: B
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The nurse should explain to the client that combining an MAOI and Luvox can lead to a lifethreatening hypertensive crisis. Symptoms of hypertensive crisis include severe occipital and/or
temporal pounding headaches with occasional photophobia, sensations of choking, palpitations,
and a feeling of dread.
KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
11. A psychiatrist prescribes a monoamine oxidase inhibitor (MAOI) for a client. Which foods
should the nurse teach the client to avoid?
A. Pepperoni pizza and red wine
B. Bagels with cream cheese and tea
C. Apple pie and coffee
D. Potato chips and diet cola
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ANS: A
The nurse should instruct the client to avoid pepperoni pizza and red wine. Foods with high
tyramine content can induce hypertensive crisis within 2 hours of ingestion. Symptoms of
hypertensive crisis include severe occipital and/or temporal pounding headaches with occasional
photophobia, sensations of choking, palpitations, and a feeling of dread.
KEY: Cognitive Level: Application | Integrated Process: Teaching/Learning | Client Need:
Physiological Integrity: Pharmacological and Parenteral Therapies
12. A client who has been taking buspirone (BuSpar) as prescribed for 2 days is close to
discharge. Which statement indicates to the nurse that the client has an understanding of
important discharge teaching?
A. I cannot drink any alcohol with this medication.
B. It is going to take 2 to 3 weeks in order for me to begin to feel better.
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C. This drug causes physical dependence, and I need to strictly follow doctors orders.
D. I cant take this medication with food. It needs to be taken on an empty stomach.
ANS: B
BuSpar takes at least 2 to 3 weeks to be effective in controlling symptoms of anxiety. This is
important to teach clients in order to prevent potential noncompliance due to the perception that
the medication is ineffective.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Evaluation |
Client Need: Physiological Integrity: Pharmacological and Parenteral Therapies
13. A client is admitted to the psychiatric unit with a diagnosis of major depressive disorder. The
client is unable to concentrate, has no appetite, and is experiencing insomnia. Which should be
included in this clients plan of care?
A. A simple, structured daily schedule with limited choices of activities
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B. A daily schedule filled with activities to promote socialization
C. A flexible schedule that allows the client opportunities for decision making
D. A schedule that includes mandatory activities to decrease social isolation
ANS: A
A client with depression has difficulty concentrating and may be overwhelmed by activity
overload or the expectation of independent decision making. A simple, structured daily schedule
with limited choices of activities is more appropriate.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Planning | Client
Need: Psychosocial Integrity
14. An isolative client was admitted 4 days ago with a diagnosis of major depressive disorder.
Which nursing statement would best motivate this client to attend a therapeutic group being held
in the milieu?
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A. Well go to the day room when you are ready for group.
B. Ill walk with you to the day room. Group is about to start.
C. It must be difficult for you to attend group when you feel so bad.
D. Let me tell you about the benefits of attending this group.
ANS: B
A client diagnosed with major depressive disorder exhibits little to no motivation and must be
actively directed by staff to participate in therapy. It is difficult for a severely depressed client to
make decisions, and this function must be temporarily assumed by the staff.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Implementation |
Client Need: Psychosocial Integrity
15. A client who is diagnosed with major depressive disorder asks the nurse what causes
depression. Which of these is theTmost
ESTaccurate
BANKSresponse?
ELLER.COM
A. Depression is caused by a deficiency in neurotransmitters, including serotonin and
norepinephrine.
B. The exact cause of depressive disorders is unknown. A number of things, including genetic,
biochemical, and environmental influences, likely play a role.
C. Depression is a learned state of helplessness cause by ineffective parenting.
D. Depression is caused by intrapersonal conflict between the id and the ego.
ANS: B
Depression is likely an illness that has varied and multiple causative factors, but at present the
exact cause of depressive disorders is not entirely understood.
KEY: Cognitive Level: Application | Integrated Processes: Teaching/Learning | Client Need:
Psychosocial Integrity
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16. What client information does a nurse need to assess prior to initiating medication therapy
with phenelzine (Nardil)?
A. The clients understanding of the need for regular bloodwork
B. The clients mood and affect score, according to the facilitys mood scale
C. The clients cognitive ability to understand information about the medication
D. The clients access to a support network willing to participate in treatment
ANS: C
There are many dietary and medication restrictions when taking Nardil. A client must have the
cognitive ability to understand information about the medication and which foods, beverages,
and medications to eliminate when taking Nardil.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Physiological Integrity
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17. A client diagnosed with major depressive disorder states, Ive been feeling down for 3
months. Will I ever feel like myself again? Which reply by the nurse will best assess this clients
affective symptoms?
A. Have you been diagnosed with any physical disorder within the last 3 months?
B. Have you ever felt this way before?
C. People who have mood changes often feel better when spring comes.
D. Help me understand what you mean when you say, feeling down?
ANS: D
The nurse is using a clarifying statement in order to gather more details related to this clients
mood.
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KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Psychosocial Integrity
18. A nurse is implementing a one-on-one suicide observation level with a client diagnosed with
major depressive disorder. The client states, Im feeling a lot better, so you can stop watching me.
I have taken up too much of your time already. Which is the best nursing reply?
A. I really appreciate your concern but I have been ordered to continue to watch you.
B. Because we are concerned about your safety, we will continue to observe you.
C. I am glad you are feeling better. The treatment team will consider your request.
D. I will forward you request to your psychiatrist because it is his decision.
ANS: B
Often suicidal clients resist personal monitoring, which impedes the implementation of a suicide
plan. A nurse should continually T
observe
ESTBaAclient
NKSEwhen
LLErisk
R.Cfor
OMsuicide is suspected.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |
Client Need: Safe and Effective Care Environment
19. A newly admitted client is diagnosed with major depressive disorder with suicidal ideations.
Which would be the priority nursing intervention for this client?
A. Teach about the effect of suicide on family dynamics.
B. Carefully and unobtrusively observe on the basis of assessed data, at varied intervals around
the clock.
C. Encourage the client to spend a portion of each day interacting within the milieu.
D. Set realistic achievable goals to increase self-esteem.
ANS: B
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The most effective way to interrupt a suicide attempt is to carefully, unobtrusively observe on the
basis of assessed data at varied intervals around the clock. If a nurse observes behavior that
indicates self-harm, the nurse can intervene to stop the behavior and keep the client safe.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation |
Client Need: Safe and Effective Care Environment
20. The nurse is providing counseling to clients diagnosed with major depressive disorder. The
nurse chooses to help the clients alter their mood by learning how to change the way they think.
The nurse is functioning under which theoretical framework?
A. Psychoanalytic theory
B. Interpersonal theory
C. Cognitive theory
D. Behavioral theory
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ANS: C
Cognitive theory suggests that depression is a product of negative thinking. Helping the
individual change the way they think is believed to have a positive impact on mood and selfesteem.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Implementation
|Client Need: Psychosocial Integrity
21. Which client statement expresses a typical underlying feeling of clients diagnosed with major
depressive disorder?
A. Its just a matter of time and I will be well.
B. If I ignore these feelings, they will go away.
C. I can fight these feelings and overcome this disorder.
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D. Nothing will help me feel better.
ANS: D
Hopelessness and helplessness are typical symptoms of clients diagnosed with major depressive
disorder.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Physiological Integrity
22. A 75-year-old client with a long history of depression is currently on doxepin (Sinequan),
100 mg daily. The client takes a daily diuretic for hypertension and is recovering from the flu.
Which nursing diagnosis should the nurse assign highest priority?
A. Risk for ineffective thermoregulation R/T anhidrosis
B. Risk for constipation R/T excessive fluid loss
C. Risk for injury R/T orthostaticThypotension
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D. Risk for infection R/T suppressed white blood cell count
ANS: C
A side effect of Sinequan is orthostatic hypotension. Dehydration due to fluid loss from a
combination of diuretic medication and flu symptoms can also contribute to this problem, putting
this client at risk for injury R/T orthostatic hypotension.
KEY: Cognitive Level: Analysis | Integrated Processes: Nursing Process: Analysis | Client
Need: Physiological Integrity
23. A client is admitted with a diagnosis of persistent depressive disorder. Which client statement
would describe a symptom consistent with this diagnosis?
A. I am sad most of the time and Ive felt this way for the last several years.
B. I find myself preoccupied with death.
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C. Sometimes I hear voices telling me to kill myself.
D. Im afraid to leave the house.
ANS: A
Persistent depressive disorder is characterized by depressed mood for most of day, for more days
than not, for at least 2 years. Thoughts of death would be more consistent with major depressive
disorder; hearing voices is more consistent with a psychotic disorder; and fear of leaving the
house is more consistent with a phobia.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Psychosocial Integrity
24. A client diagnosed with major depressive disorder was raised in a strongly religious family
where bad behavior was equated with sins against God. Which nursing intervention would be
most appropriate to help the client address spirituality as it relates to his illness?
TESawareness
TBANKSunderlying
ELLER.Csources
OM of guilt.
A. Encourage the client to bring into
B. Teach the client that religious beliefs should be put into perspective throughout the life span.
C. Confront the client with the irrational nature of the belief system.
D. Assist the client to modify his or her belief system in order to improve coping skills.
ANS: A
A client raised in an environment that reinforces ones inadequacy may be at risk for experiencing
guilt, shame, low self-esteem, and hopelessness, which can contribute to depression. Assisting
the client to bring these feelings into awareness allows the client to realistically appraise
distorted responsibility and dysfunctional guilt.
KEY: Cognitive Level: Application | Integrated Processes: Nursing Process: Assessment |
Client Need: Psychosocial Integrity
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Chapter 16 Hearing
MULTIPLE CHOICE
1. An older adult patient reports burning and itching eyes. On assessment, the nurse notes
swelling of the eyelid margins bilaterally. What additional data are necessary to confirm the
nurses suspicion of blepharitis?
a. The patient reports visual disturbances such as rainbow halos.
b. The eyelids are reddened from seborrhea.
c. The patient is being treated with anticoagulants.
d. Small corneal hemorrhages are present.
ANS: B
Blepharitis is a chronic inflammation of the eyelid margins that is commonly found in older
adults. It can be caused by seborrheic dermatitis or infection. The symptoms include red, swollen
eyelids, matting and crusting along
the
TEthe
STbase
BANofKS
ELeyelash
LER.at
COthe
M margins, small ulcerations
along the lid margins, and complaints of irritation, itching, burning, tearing, and photophobia.
DIF: Remembering (Knowledge) REF: MCS: 642 OBJ: 29-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
2. The morning of her scheduled cataract extraction and intraocular lens placement of the right
eye, an older adult patient expresses concern that she will not remember her instructions for
home care. Which statement is the best response to the patients concern?
a. Is your family going to be here while youre in surgery?
b. Are you anxious about the surgery?
c. Ill reinforce the important points.
d. We will provide you with written instructions.
ANS: D
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Postoperative care requires teaching the patient and family home care procedures for the period
after cataract surgery and should be given orally as well in written form. The patient may or may
not have family present. Asking about anxiety could be important, but yes/no questions are not
therapeutic. The nurses idea of what are the important points may differ from the patients.
DIF: Understanding (Comprehension) REF: MCS: 655 OBJ: 29-2
TOP: Teaching-Learning MSC: Physiologic Integrity
3. Your 88-year-old patient is hospitalized for a retinal detachment. He is on bed rest, and both
eyes are covered with patches. Which nursing diagnosis takes priority at this time?
a. Self-esteem disturbance related to decreased independence
b. High risk for altered thought processes related to visual impairment
c. High risk for injury related to altered sensory perception
d. Impaired social interaction related to visual deficit
ANS: C
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If the eyes are patched, safety precautions, such as keeping call lights, side rails, and necessary
items within reach, must be instituted. Finally, assistance must be provided with activities of
daily living (ADLs) and walking as needed to promote comfort and safety. The other diagnoses
may be appropriate for selected patients.
DIF: Applying (Application) REF: N/A OBJ: 29-2
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
4. A 66-year-old patient has been diagnosed with type 2 diabetes mellitus and related vision loss.
Which statement demonstrates the ability to manage her condition?
a. I schedule my yearly eye examination for the week of my birthday.
b. When I notice haloes around lights, Ill know Im developing a problem with
retinopathy.
c. My sister had diabetic retinopathy, and the vessels in her eyes were scarred.
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d. I understand that the eye problems need to be diagnosed with an ophthalmoscopic
exam.
ANS: A
Patients with diabetes should have a yearly examination by an ophthalmologist. Scheduling the
exam for the week of her birthday will keep the patient from forgetting to do so. The other
statements are not related to management.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 29-3
TOP: Nursing Process: Evaluation MSC: Health Promotion
5. A 77-year-old patient who is quiet and withdrawn may have a hearing deficit related to
impacted cerumen. During the nursing assessment, the nurse confirms supporting evidence of the
condition when noting:
a. frothy drainage from the patients ears.
b. patient reports of dizziness. TESTBANKSELLER.COM
c. patient reports of a feeling of fullness in the ears.
d. gray, metallic-appearing tympanic membrane.
ANS: C
Patients with cerumen buildup may complain of ear fullness, itching, and difficulty hearing. The
patient will not have frothy drainage, dizziness, or metallic-appearing tympanic membrane from
cerumen.
DIF: Remembering (Knowledge) REF: MCS: 650 OBJ: 29-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. An older adult patient reports ringing in the ears. What additional data should the nurse gather
to help determine the cause of the patients problem?
a. History of ear surgery
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b. Use of prescription medications
c. Exercise and sleep patterns
d. Nutritional status, especially protein intake
ANS: B
Tinnitus can be a result of damage to inner structures caused by the toxic effect of certain drugs.
The other assessment findings are not as important for this problem.
DIF: Applying (Application) REF: N/A OBJ: 29-10
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
7. An older patient with presbycusis has been advised to purchase a hearing aid and asks about
its function and use. Which information is most accurate to give the patient about the function of
hearing aids?
a. Hearing aids amplify sound but do not improve the ability to hear.
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b. Hearing aids improve the ability to hear by intensifying the duration of sound
waves.
c. Hearing aids control the input of sound waves to eliminate extraneous noise.
d. Hearing aids intensify sound waves and improve the ability to hear.
ANS: A
Hearing aids amplify sound but do not improve the ability to hear. The other statements are not
accurate regarding hearing aids.
DIF: Understanding (Comprehension) REF: MCS: 654 OBJ: 29-11
TOP: Teaching-Learning MSC: Physiologic Integrity
8. An older adults chart documents that she has been diagnosed with macular dysequilibrium.
Based on an understanding of this condition and the resulting vertigo, the nurse suggests that the
patient:
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a. turn her head very slowly when looking from right to left.
b. dangle her legs at the bedside before getting out of bed.
c. use the wall for stabilization when ambulating in the hallway.
d. be careful to be seated when flexing or hyperextending her neck.
ANS: B
Macular disequilibrium is vertigo precipitated by a change of head position in relation to the
direction of gravitational force (e.g., severe dizziness when rising from bed). Dangling at the
bedside and changing positions slowly will decrease the chance of injury. The other interventions
do not relate to this disorder.
DIF: Understanding (Comprehension) REF: MCS: 655 OBJ: 29-7
TOP: Teaching-Learning MSC: Safe Effective Care Environment
9. A 96-year-old patient reports symptoms of xerostomia. The nurse attempts to minimize the
effects of the condition by:
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a. providing appropriate fluids with the patients meals.
b. cutting the patients meat into small bite-sized pieces.
c. elevating the head of the patients bed at mealtimes.
d. assisting the patient with oral care before each meal.
ANS: A
Xerostomia, commonly referred to as dry mouth, is a subjective sensation of abnormal oral
dryness. Reduced salivary flow is a common complaint of older adults. Dry mouth in the older
adult can lead to an increased risk of serious respiratory infection, impaired nutritional status,
and reduced ability to communicate. Offering appropriate fluids with meals will assist with
proper nutrition. The other options will not provide relief for this condition.
DIF: Applying (Application) REF: N/A OBJ: 29-8
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
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10. The preferred way for the nurse to communicate with a 72-year-old hearing-impaired patient
is to:
a. speak loudly into the patients unaffected ear.
b. exaggerate the form of each word.
c. provide all communication in written form.
d. speak clearly and directly, facing the person.
ANS: D
Interventions for the patient with a hearing impairment focus on aural rehabilitation and
facilitation of communication. Patients should be spoken to using a clear voice and face to face,
which gives the patient an unobstructed view of the speakers face and lips. The other techniques
are not as helpful.
DIF: Remembering (Knowledge) REF: MCS: 653 OBJ: 29-11
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ANKPhysiologic
SELLER.C
OM
TOP: Nursing Process: Implementation
MSC:
Integrity
11. A patient in a nursing home is confused, nonverbal, but pleasant. The nurse notes the patient
has suddenly become agitated and is screaming and scratching at the eyes. While the nurse is
examining the patient, the patient vomits. What action by the nurse is best?
a. Consult the provider about an ophthalmologic exam.
b. Sedate the patient so she wont injure herself.
c. Place mitts on the patients hands to avoid scratches.
d. Give the patient a prn medication for pain.
ANS: A
The patient could be having an episode of acute angle closure glaucoma, manifested by severe
pain, nausea and vomiting, and visual disturbances. Because the patient is nonverbal, the nurse
must assess for pain with behavioral changes. The nurse should contact the provider about
obtaining an ophthalmologic exam to determine if the patient has glaucoma. The other
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interventions will not help determine the cause of the problem. The nurse should attempt to
discover the source of the behavior, not just try to control it.
DIF: Analyzing (Analysis) REF: N/A OBJ: 29-2
TOP: Communication and Documentation MSC: Physiologic Integrity
12. A patient has been admitted to the postanesthesia care unit after a trabeculectomy. What
assessment takes priority?
a. Airway
b. Pain
c. Eye patch
d. Blood pressure
ANS: A
Airway always comes first when T
prioritizing
care.
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SELLER.COM
DIF: Applying (Application) REF: N/A OBJ: 29-2
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
13. A patient had cataract surgery without a lens implant. What teaching point is most important?
a. Keep your follow-up appointment with the surgeon.
b. Instill your eyedrops just like we have practiced.
c. Do not drive and be careful going up or down stairs.
d. Take acetaminophen (Tylenol) for pain.
ANS: C
If cataract surgery was performed without a lens implant, the patient will wear glasses or contact
lenses but will have a decrease in depth perception. The patient should not drive and should use
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extra caution negotiating stairs. The other instructions are appropriate for any patient having
cataract surgery.
DIF: Applying (Application) REF: N/A OBJ: 29-2
TOP: Teaching-Learning MSC: Safe Effective Care Environment
14. A patient has Mnire disease. What statement by the patient indicates a good ability to manage
the condition?
a. Because its from dehydration, I can increase salt in my food.
b. There are no medications, so I just have to learn to live with it.
c. If I get dizzy I should lie down immediately and hold my head still.
d. Because I have asthma, I cannot take any medications for Mnire disease.
ANS: C
If the patient gets dizzy, he or sheTshould
ESTBlie
ANdown
KSELand
LEhold
R.Cthe
OMhead still. A low-salt diet may
help with fluid retention in the ear. There are several medications for Menire disease, but
because of the anticholinergic properties of some of them, people with asthma, glaucoma, or
BPH should be monitored closely.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 29-7
TOP: Nursing Process: Evaluation MSC: Health Promotion
15. A patient had a chemical splash into the eye at work. What action by the occupational health
nurse takes priority?
a. Begin flushing the patients eye with cool water.
b. Call emergency medical services.
c. Ask about the patients tetanus status.
d. Tape the eye closed to prevent injury.
ANS: A
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The nurse should begin flushing the eye immediately. While the eye is being irrigated, the nurse
can call 9-1-1 and inquire about the patients last tetanus shot. The eye should not be taped shut.
DIF: Applying (Application) REF: N/A OBJ: 29-8
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
16. A patient with glaucoma is on timolol (Timoptic). The patient also takes metoprolol (Toprol)
for hypertension. The patient reports to the clinic nurse that the eyedrops Make me dizzy. What
assessment by the nurse is most appropriate?
a. Assess the patients eyedrop instillation technique.
b. Determine how long the patient has been on the drops.
c. Assess the patients gait and balance while walking.
d. Ask the patient if breakfast is eaten prior to applying the eyedrops.
ANS: A
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The patient should be using punctal occlusion (closing the lacrimal duct) when instilling these
eyedrops to avoid a cumulative, systemic effect from the combination of both beta-blockers. The
nurse can assess the other factors as well, but this is the most likely cause of the dizziness.
DIF: Analyzing (Analysis) REF: N/A OBJ: 29-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. When assessing the patients vision, the nurse should understand that older adults may report
common aging changes, including which of the following? (Select all that apply.)
a. My eyelids droop so unattractively.
b. The whites on my eyes seem a bit yellow.
c. The vision in my right eye seems blurry.
d. Ive started to use over-the-counter eye moisturizing drops.
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e. I have noticed the night driving has become more difficult.
ANS: A, B, D, E
The eyelids lose tone and become lax, which may result in ptosis of the eyelids, redundancy of
the skin of the eyelids, and malposition of the eyelids. The conjunctiva thins and yellows in
appearance. In addition, this membrane may become dry because of the diminished quantity and
quality of tear production. Peripheral vision decreases, night vision diminishes, and sensitivity to
glare increases.
DIF: Analysis (Analyze) REF: N/A
TOP: Nursing Process: Assessment| Neuromuscular MSC: Physiologic Integrity
2. An older adult diagnosed with Mnire disease is prescribed meclizine (Antivert) and
hydrochlorothiazide (HCTZ). The nurses educational instructions include which of the
following? (Select all that apply.)
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a. The need to avoid alcoholic T
beverages
b. Instructions to take the medication with food
c. Symptoms of electrolyte imbalances
d. That drowsiness is a common side effect
e. Stopping the medication if chest pain occurs
ANS: A, C, D
Meclizine may cause drowsiness; patients should be instructed to avoid alcoholic beverages
while taking this drug. A patient on a diuretic such as hydrochlorothiazide (HCTZ) needs to be
monitored for evidence of fluid or electrolyte imbalances.
DIF: Application (Apply) REF: N/A
TOP: Nursing Process: Implementation| Drug-Related Responses
MSC: Safe and Effective Care Environment
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3. Which of the following are appropriate steps to take when removing cerumen from an older
persons ear? (Select all that apply.)
a. Instill a softening agent first.
b. Use hot water and hydrogen peroxide.
c. Use a Waterpik inserted just inside the meatus.
d. Have the patient lean backward.
e. Drain water by having the patient lean forward toward the affected side.
ANS: A, C, E
The nurse instills a softening agent and uses warm (not hot) water mixed with hydrogen peroxide
or saline to irrigate the ear. A Waterpik or other irrigating equipment is used and is inserted just
inside the meatus so the tip is still visible. Tip the patients head toward the side being irrigated.
When draining, the patient can lean forward and toward the affected side.
DIF: Remembering (Knowledge) REF: MCS: 650-1 OBJ: 29-6
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TOP: Nursing Process: Implementation MSC: Physiologic Integrity
4. A nurse is assessing a patient who reports moderate tinnitus. The nurse should assess the
patient for which of the following? (Select all that apply.)
a. Use of ibuprofen (Motrin)
b. History of excessive cerumen
c. Drinking carbonated beverages
d. History of frequent headaches
e. Presence of hypertension
ANS: A, B, D, E
Beverages with caffeine are assessed; the patient may be drinking decaffeinated cola products.
The other assessments are appropriate.
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Chapter 17 Vision
MULTIPLE CHOICE
1. When examining the eye, the nurse notices that the patients eyelid margins approximate
completely. The nurse recognizes that this assessment finding:
a. Is expected.
b. May indicate a problem with extraocular muscles.
c. May result in problems with tearing.
d. Indicates increased intraocular pressure.
ANS: A
The palpebral fissure is the elliptical open space between the eyelids, and, when closed, the lid
margins approximate completely, which is a normal finding.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 281
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
2. During ocular examinations, the nurse keeps in mind that movement of the extraocular
muscles is:
a. Decreased in the older adult.
b. Impaired in a patient with cataracts.
c. Stimulated by cranial nerves (CNs) I and II.
d. Stimulated by CNs III, IV, and VI.
ANS: D
Movement of the extraocular muscles is stimulated by three CNs: III, IV, and VI.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 283
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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3. The nurse is performing an external eye examination. Which statement regarding the outer
layer of the eye is true?
a. The outer layer of the eye is very sensitive to touch.
b. The outer layer of the eye is darkly pigmented to prevent light from reflecting
internally.
c. The trigeminal nerve (CN V) and the trochlear nerve (CN IV) are stimulated
when the outer surface of the eye is stimulated.
d. The visual receptive layer of the eye in which light waves are changed into nerve
impulses is located in the outer layer of the eye.
ANS: A
The cornea and the sclera make up the outer layer of the eye. The cornea is very sensitive to
touch. The middle layer, the choroid, has dark pigmentation to prevent light from reflecting
internally. The trigeminal nerve (CN V) and the facial nerve (CN VII) are stimulated when the
outer surface of the eye is stimulated. The retina, in the inner layer of the eye, is where light
waves are changed into nerve impulses.
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DIF: Cognitive Level: Understanding (Comprehension) REF: p. 283
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
4. When examining a patients eyes, the nurse recalls that stimulation of the sympathetic branch
of the autonomic nervous system:
a. Causes pupillary constriction.
b. Adjusts the eye for near vision.
c. Elevates the eyelid and dilates the pupil.
d. Causes contraction of the ciliary body.
ANS: C
Stimulation of the sympathetic branch of the autonomic nervous system dilates the pupil and
elevates the eyelid. Parasympathetic nervous system stimulation causes the pupil to constrict.
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The muscle fibers of the iris contract the pupil in bright light to accommodate for near vision.
The ciliary body controls the thickness of the lens.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 283
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
5. The nurse is reviewing causes of increased intraocular pressure. Which of these factors
determines intraocular pressure?
a. Thickness or bulging of the lens
b. Posterior chamber as it accommodates increased fluid
c. Contraction of the ciliary body in response to the aqueous within the eye
d. Amount of aqueous produced and resistance to its outflow at the angle of the
anterior chamber
ANS: D
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Intraocular pressure is determined by a balance between the amount of aqueous produced and the
resistance to its outflow at the angle of the anterior chamber. The other responses are incorrect.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 284
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
6. The nurse is conducting a visual examination. Which of these statements regarding visual
pathways and visual fields is true?
a. The right side of the brain interprets the vision for the right eye.
b. The image formed on the retina is upside down and reversed from its actual
appearance in the outside world.
c. Light rays are refracted through the transparent media of the eye before striking
the pupil.
d. Light impulses are conducted through the optic nerve to the temporal lobes of the
brain.
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ANS: B
The image formed on the retina is upside down and reversed from its actual appearance in the
outside world. The light rays are refracted through the transparent media of the eye before
striking the retina, and the nerve impulses are conducted through the optic nerve tract to the
visual cortex of the occipital lobe of the brain. The left side of the brain interprets vision for the
right eye.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 284
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
7. The nurse is testing a patients visual accommodation, which refers to which action?
a. Pupillary constriction when looking at a near object
b. Pupillary dilation when looking at a far object
c. Changes in peripheral vision in response to light
d. Involuntary blinking in the presence
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ANS: A
The muscle fibers of the iris contract the pupil in bright light and accommodate for near vision,
which also results in pupil constriction. The other responses are not correct.
DIF: Cognitive Level: Remembering (Knowledge) REF: p. 296
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
8. A patient has a normal pupillary light reflex. The nurse recognizes that this reflex indicates
that:
a. The eyes converge to focus on the light.
b. Light is reflected at the same spot in both eyes.
c. The eye focuses the image in the center of the pupil.
d. Constriction of both pupils occurs in response to bright light.
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ANS: D
The pupillary light reflex is the normal constriction of the pupils when bright light shines on the
retina. The other responses are not correct.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 296
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
9. A mother asks when her newborn infants eyesight will be developed. The nurse should reply:
a. Vision is not totally developed until 2 years of age.
b. Infants develop the ability to focus on an object at approximately 8 months of
age.
c. By approximately 3 months of age, infants develop more coordinated eye
movements and can fixate on an object.
d. Most infants have uncoordinated eye movements for the first year of life.
ANS: C
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Eye movements may be poorly coordinated at birth, but by 3 to 4 months of age, the infant
should establish binocularity and should be able to fixate simultaneously on a single image with
both eyes.
DIF: Cognitive Level: Applying (Application) REF: p. 302
MSC: Client Needs: Health Promotion and Maintenance
10. The nurse is reviewing in age-related changes in the eye for a class. Which of these
physiologic changes is responsible for presbyopia?
a. Degeneration of the cornea
b. Loss of lens elasticity
c. Decreased adaptation to darkness
d. Decreased distance vision abilities
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ANS: B
The lens loses elasticity and decreases its ability to change shape to accommodate for near
vision. This condition is called presbyopia.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 286
MSC: Client Needs: Health Promotion and Maintenance
11. Which of these assessment findings would the nurse expect to see when examining the eyes
of a black patient?
a. Increased night vision
b. Dark retinal background
c. Increased photosensitivity
d. Narrowed palpebral fissures
ANS: B
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An ethnically based variability in the color of the iris and in retinal pigmentation exists, with
darker irides having darker retinas behind them.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 286
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
12. A 52-year-old patient describes the presence of occasional floaters or spots moving in front
of his eyes. The nurse should:
a. Examine the retina to determine the number of floaters.
b. Presume the patient has glaucoma and refer him for further testing.
c. Consider these to be abnormal findings, and refer him to an ophthalmologist.
d. Know that floaters are usually insignificant and are caused by condensed vitreous
fibers.
ANS: D
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Floaters are a common sensation with myopia or after middle age and are attributable to
condensed vitreous fibers. Floaters or spots are not usually significant, but the acute onset of
floaters may occur with retinal detachment.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 287
MSC: Client Needs: Health Promotion and Maintenance
13. The nurse is preparing to assess the visual acuity of a 16-year-old patient. How should the
nurse proceed?
a. Perform the confrontation test.
b. Ask the patient to read the print on a handheld Jaeger card.
c. Use the Snellen chart positioned 20 feet away from the patient.
d. Determine the patients ability to read newsprint at a distance of 12 to 14 inches.
ANS: C
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The Snellen alphabet chart is the most commonly used and most accurate measure of visual
acuity. The confrontation test is a gross measure of peripheral vision. The Jaeger card or
newspaper tests are used to test near vision.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 289
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
14. A patients vision is recorded as 20/30 when the Snellen eye chart is used. The nurse
interprets these results to indicate that:
a. At 30 feet the patient can read the entire chart.
b. The patient can read at 20 feet what a person with normal vision can read at 30
feet.
c. The patient can read the chart from 20 feet in the left eye and 30 feet in the right
eye.
d. The patient can read from 30 feet what a person with normal vision can read from
20 feet.
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ANS: B
The top number indicates the distance the person is standing from the chart; the denominator
gives the distance at which a normal eye can see.
DIF: Cognitive Level: Applying (Application) REF: p. 290
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
15. A patient is unable to read even the largest letters on the Snellen chart. The nurse should take
which action next?
a. Refer the patient to an ophthalmologist or optometrist for further evaluation.
b. Assess whether the patient can count the nurses fingers when they are placed in
front of his or her eyes.
c. Ask the patient to put on his or her reading glasses and attempt to read the Snellen
chart again.
d. Shorten the distance between the patient and the chart until the letters are seen,
and record that distance.
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ANS: D
If the person is unable to see even the largest letters when standing 20 feet from the chart, then
the nurse should shorten the distance to the chart until the letters are seen, and record that
distance (e.g., 10/200). If visual acuity is even lower, then the nurse should assess whether the
person can count fingers when they are spread in front of the eyes or can distinguish light
perception from a penlight. If vision is poorer than 20/30, then a referral to an ophthalmologist or
optometrist is necessary, but the nurse must first assess the visual acuity.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 290
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
16. A patients vision is recorded as 20/80 in each eye. The nurse interprets this finding to mean
that the patient:
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a. Has poor vision.
b. Has acute vision.
c. Has normal vision.
d. Is presbyopic.
ANS: A
Normal visual acuity is 20/20 in each eye; the larger the denominator, the poorer the vision.
DIF: Cognitive Level: Applying (Application) REF: p. 290
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
17. When performing the corneal light reflex assessment, the nurse notes that the light is
reflected at 2 oclock in each eye. The nurse should:
a. Consider this a normal finding.
b. Refer the individual for further
TEevaluation.
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c. Document this finding as an asymmetric light reflex.
d. Perform the confrontation test to validate the findings.
ANS: A
Reflection of the light on the corneas should be in exactly the same spot on each eye, or
symmetric. If asymmetry is noted, then the nurse should administer the cover test.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 292
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
18. The nurse is performing the diagnostic positions test. Normal findings would be which of
these results?
a. Convergence of the eyes
b. Parallel movement of both eyes
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c. Nystagmus in extreme superior gaze
d. Slight amount of lid lag when moving the eyes from a superior to an inferior
position
ANS: B
A normal response for the diagnostic positions test is parallel tracking of the object with both
eyes. Eye movement that is not parallel indicates a weakness of an extraocular muscle or
dysfunction of the CN that innervates it.
DIF: Cognitive Level: Applying (Application) REF: p. 292
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
19. During an assessment of the sclera of a black patient, the nurse would consider which of
these an expected finding?
a. Yellow fatty deposits over the cornea
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ANKlid
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b. Pallor near the outer canthusTofES
the
lower
c. Yellow color of the sclera that extends up to the iris
d. Presence of small brown macules on the sclera
ANS: D
Normally in dark-skinned people, small brown macules may be observed in the sclera.
DIF: Cognitive Level: Applying (Application) REF: p. 294
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
20. A 60-year-old man is at the clinic for an eye examination. The nurse suspects that he has
ptosis of one eye. How should the nurse check for this?
a. Perform the confrontation test.
b. Assess the individuals near vision.
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c. Observe the distance between the palpebral fissures.
d. Perform the corneal light test, and look for symmetry of the light reflex.
ANS: C
Ptosis is a drooping of the upper eyelid that would be apparent by observing the distance
between the upper and lower eyelids. The confrontation test measures peripheral vision.
Measuring near vision or the corneal light test does not check for ptosis.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 294
MSC: Client Needs: Health Promotion and Maintenance
21. During an examination of the eye, the nurse would expect what normal finding when
assessing the lacrimal apparatus?
a. Presence of tears along the inner canthus
b. Blocked nasolacrimal duct in a newborn infant
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c. Slight swelling over the upper lid and along the bony orbit if the individual has a
cold
d. Absence of drainage from the puncta when pressing against the inner orbital rim
ANS: D
No swelling, redness, or drainage from the puncta should be observed when it is pressed.
Regurgitation of fluid from the puncta, when pressed, indicates duct blockage. The lacrimal
glands are not functional at birth.
DIF: Cognitive Level: Applying (Application) REF: p. 295
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
22. When assessing the pupillary light reflex, the nurse should use which technique?
a. Shine a penlight from directly in front of the patient, and inspect for pupillary
constriction.
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b. Ask the patient to follow the penlight in eight directions, and observe for bilateral
pupil constriction.
c. Shine a light across the pupil from the side, and observe for direct and consensual
pupillary constriction.
d. Ask the patient to focus on a distant object. Then ask the patient to follow the
penlight to approximately 7 cm from the nose.
ANS: C
To test the pupillary light reflex, the nurse should advance a light in from the side and note the
direct and consensual pupillary constriction.
DIF: Cognitive Level: Applying (Application) REF: p. 296
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
23. The nurse is assessing a patients eyes for the accommodation response and would expect to
see which normal finding?
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a. Dilation of the pupils
b. Consensual light reflex
c. Conjugate movement of the eyes
d. Convergence of the axes of the eyes
ANS: D
The accommodation reaction includes pupillary constriction and convergence of the axes of the
eyes. The other responses are not correct.
DIF: Cognitive Level: Applying (Application) REF: p. 296
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
24. In using the ophthalmoscope to assess a patients eyes, the nurse notices a red glow in the
patients pupils. On the basis of this finding, the nurse would:
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a. Suspect that an opacity is present in the lens or cornea.
b. Check the light source of the ophthalmoscope to verify that it is functioning.
c. Consider the red glow a normal reflection of the ophthalmoscope light off the
inner retina.
d. Continue with the ophthalmoscopic examination, and refer the patient for further
evaluation.
ANS: C
The red glow filling the persons pupil is the red reflex and is a normal finding caused by the
reflection of the ophthalmoscope light off the inner retina. The other responses are not correct.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 298
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
25. The nurse is examining a patients retina with an ophthalmoscope. Which finding is
considered normal?
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a. Optic disc that is a yellow-orange color
b. Optic disc margins that are blurred around the edges
c. Presence of pigmented crescents in the macular area
d. Presence of the macula located on the nasal side of the retina
ANS: A
The optic disc is located on the nasal side of the retina. Its color is a creamy yellow-orange to a
pink, and the edges are distinct and sharply demarcated, not blurred. A pigmented crescent is
black and is due to the accumulation of pigment in the choroid.
DIF: Cognitive Level: Applying (Application) REF: p. 300
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
26. A 2-week-old infant can fixate on an object but cannot follow a light or bright toy. The nurse
would:
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a. Consider this a normal finding.
b. Assess the pupillary light reflex for possible blindness.
c. Continue with the examination, and assess visual fields.
d. Expect that a 2-week-old infant should be able to fixate and follow an object.
ANS: A
By 2 to 4 weeks an infant can fixate on an object. By the age of 1 month, the infant should fixate
and follow a bright light or toy.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 302
MSC: Client Needs: Health Promotion and Maintenance
27. The nurse is assessing color vision of a male child. Which statement is correct? The nurse
should:
a. Check color vision annually T
until
ESTthe
BAage
NKof
SE18Lyears.
LER.COM
b. Ask the child to identify the color of his or her clothing.
c. Test for color vision once between the ages of 4 and 8 years.
d. Begin color vision screening at the childs 2-year checkup.
ANS: C
Test boys only once for color vision between the ages of 4 and 8 years. Color vision is not tested
in girls because it is rare in girls. Testing is performed with the Ishihara test, which is a series of
polychromatic cards.
DIF: Cognitive Level: Applying (Application) REF: p. 304
MSC: Client Needs: Health Promotion and Maintenance
28. The nurse is performing an eye-screening clinic at a daycare center. When examining a 2year-old child, the nurse suspects that the child has a lazy eye and should:
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a. Examine the external structures of the eye.
b. Assess visual acuity with the Snellen eye chart.
c. Assess the childs visual fields with the confrontation test.
d. Test for strabismus by performing the corneal light reflex test.
ANS: D
Testing for strabismus is done by performing the corneal light reflex test and the cover test. The
Snellen eye chart and confrontation test are not used to test for strabismus.
DIF: Cognitive Level: Applying (Application) REF: p. 304
MSC: Client Needs: Health Promotion and Maintenance
29. The nurse is performing an eye assessment on an 80-year-old patient. Which of these
findings is considered abnormal?
a. Decrease in tear production TESTBANKSELLER.COM
b. Unequal pupillary constriction in response to light
c. Presence of arcus senilis observed around the cornea
d. Loss of the outer hair on the eyebrows attributable to a decrease in hair follicles
ANS: B
Pupils are small in the older adult, and the pupillary light reflex may be slowed, but pupillary
constriction should be symmetric. The assessment findings in the other responses are considered
normal in older persons.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 308
MSC: Client Needs: Health Promotion and Maintenance
30. The nurse notices the presence of periorbital edema when performing an eye assessment on a
70-year-old patient. The nurse should:
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a. Check for the presence of exophthalmos.
b. Suspect that the patient has hyperthyroidism.
c. Ask the patient if he or she has a history of heart failure.
d. Assess for blepharitis, which is often associated with periorbital edema.
ANS: C
Periorbital edema occurs with local infections, crying, and systemic conditions such as heart
failure, renal failure, allergy, and hypothyroidism. Periorbital edema is not associated with
blepharitis.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 313
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
31. When a light is directed across the iris of a patients eye from the temporal side, the nurse is
assessing for:
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a. Drainage from dacryocystitis.
b. Presence of conjunctivitis over the iris.
c. Presence of shadows, which may indicate glaucoma.
d. Scattered light reflex, which may be indicative of cataracts.
ANS: C
The presence of shadows in the anterior chamber may be a sign of acute angle-closure glaucoma.
The normal iris is flat and creates no shadows. This method is not correct for the assessment of
dacryocystitis, conjunctivitis, or cataracts.
DIF: Cognitive Level: Applying (Application) REF: p. 321
MSC: Client Needs: Safe and Effective Care Environment: Management of Care
32. In a patient who has anisocoria, the nurse would expect to observe:
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a. Dilated pupils.
b. Excessive tearing.
c. Pupils of unequal size.
d. Uneven curvature of the lens.
ANS: C
Unequal pupil size is termed anisocoria. It normally exists in 5% of the population but may also
be indicative of central nervous system disease.
DIF: Cognitive Level: Understanding (Comprehension) REF: p. 296
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
33. A patient comes to the emergency department after a boxing match, and his left eye is
swollen almost shut. He has bruises on his face and neck. He says he is worried because he cant
see well from his left eye. The physician suspects retinal damage. The nurse recognizes that
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signs of retinal detachment include:
a. Loss of central vision.
b. Shadow or diminished vision in one quadrant or one half of the visual field.
c. Loss of peripheral vision.
d. Sudden loss of pupillary constriction and accommodation.
ANS: B
With retinal detachment, the person has shadows or diminished vision in one quadrant or one
half of the visual field. The other responses are not signs of retinal detachment.
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 318
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
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34. A patient comes into the clinic complaining of pain in her right eye. On examination, the
nurse sees a pustule at the lid margin that is painful to touch, red, and swollen. The nurse
recognizes that this is a:
a. Chalazion.
b. Hordeolum (stye).
c. Dacryocystitis.
d. Blepharitis.
ANS: B
A hordeolum, or stye, is a painful, red, and swollen pustule at the lid margin. A chalazion is a
nodule protruding on the lid, toward the inside, and is nontender, firm, with discrete swelling.
Dacryocystitis is an inflammation of the lacrimal sac. Blepharitis is inflammation of the eyelids
(see Table 14-3).
DIF: Cognitive Level: Applying (Application) REF: p. 315
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MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
35. A 68-year-old woman is in the eye clinic for a checkup. She tells the nurse that she has been
having trouble reading the paper, sewing, and even seeing the faces of her grandchildren. On
examination, the nurse notes that she has some loss of central vision but her peripheral vision is
normal. These findings suggest that she may have:
a. Macular degeneration.
b. Vision that is normal for someone her age.
c. The beginning stages of cataract formation.
d. Increased intraocular pressure or glaucoma.
ANS: A
Macular degeneration is the most common cause of blindness. It is characterized by the loss of
central vision. Cataracts would show lens opacity. Chronic open-angle glaucoma, the most
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common type of glaucoma, involves a gradual loss of peripheral vision. These findings are not
consistent with vision that is considered normal at any age.
DIF: Cognitive Level: Applying (Application) REF: p. 286
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
36. A patient comes into the emergency department after an accident at work. A machine blew
dust into his eyes, and he was not wearing safety glasses. The nurse examines his corneas by
shining a light from the side across the cornea. What findings would suggest that he has suffered
a corneal abrasion?
a. Smooth and clear corneas
b. Opacity of the lens behind the cornea
c. Bleeding from the areas across the cornea
d. Shattered look to the light rays reflecting off the cornea
ANS: D
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A corneal abrasion causes irregular ridges in reflected light, which produce a shattered
appearance to light rays. No opacities should be observed in the cornea. The other responses are
not correct.
DIF: Cognitive Level: Applying (Application) REF: p. 296
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
37. An ophthalmic examination reveals papilledema. The nurse is aware that this finding
indicates:
a. Retinal detachment.
b. Diabetic retinopathy.
c. Acute-angle glaucoma.
d. Increased intracranial pressure.
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ANS: D
Papilledema, or choked disk, is a serious sign of increased intracranial pressure, which is caused
by a space-occupying mass such as a brain tumor or hematoma. This pressure causes venous
stasis in the globe, showing redness, congestion, and elevation of the optic disc, blurred margins,
hemorrhages, and absent venous pulsations. Papilledema is not associated with the conditions in
the other responses.
DIF: Cognitive Level: Applying (Application) REF: p. 322
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
38. During a physical education class, a student is hit in the eye with the end of a baseball bat.
When examined in the emergency department, the nurse notices the presence of blood in the
anterior chamber of the eye. This finding indicates the presence of:
a. Hypopyon.
b. Hyphema.
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c. Corneal abrasion.
d. Pterygium.
ANS: B
Hyphema is the term for blood in the anterior chamber and is a serious result of blunt trauma (a
fist or a baseball) or spontaneous hemorrhage and may indicate scleral rupture or major
intraocular trauma. (See Table 14-7 for descriptions of the other terms.)
DIF: Cognitive Level: Analyzing (Analysis) REF: p. 321
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
39. During an assessment, the nurse notices that an older adult patient has tears rolling down his
face from his left eye. Closer examination shows that the lower lid is loose and rolling outward.
The patient complains of his eye feeling dry and itchy. Which action by the nurse is correct?
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a. Assessing the eye for a possible foreign body
b. Documenting the finding as ptosis
c. Assessing for other signs of ectropion
d. Contacting the prescriber; these are signs of basal cell carcinoma
ANS: C
The condition described is known as ectropion, and it occurs in older adults and is attributable to
atrophy of the elastic and fibrous tissues. The lower lid does not approximate to the eyeball, and,
as a result, the puncta cannot effectively siphon tears; excessive tearing results. Ptosis is a
drooping of the upper eyelid. These signs do not suggest the presence of a foreign body in the
eye or basal cell carcinoma.
DIF: Cognitive Level: Applying (Application) REF: p. 314
MSC: Client Needs: Physiologic Integrity: Physiologic Adaptation
MULTIPLE RESPONSE
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1. During an examination, a patient states that she was diagnosed with open-angle glaucoma 2
years ago. The nurse assesses for characteristics of open-angle glaucoma. Which of these are
characteristics of open-angle glaucoma?Select all that apply.
a. Patient may experience sensitivity to light, nausea, and halos around lights.
b. Patient experiences tunnel vision in the late stages.
c. Immediate treatment is needed.
d. Vision loss begins with peripheral vision.
e. Open-angle glaucoma causes sudden attacks of increased pressure that cause
blurred vision.
f. Virtually no symptoms are exhibited.
ANS: B, D, F
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Open-angle glaucoma is the most common type of glaucoma; virtually no symptoms are
exhibited. Vision loss begins with the peripheral vision, which often goes unnoticed because
individuals learn to compensate intuitively by turning their heads. The other characteristics are
those of closed-angle glaucoma.
Chapter 18 Digestion and Nutrition
MULTIPLE CHOICE
1. A 73-year-old patient is concerned about staying healthy for as long as possible. When asked
what lifestyle changes the patient should consider, the nurse suggests:
a. As your metabolism slows, you will need to increase your intake of fat.
b. If you are having difficulty sleeping, a mild sedative will help you sleep.
c. Regular exercise will help you preserve function and reduce your risk for disease.
d. Minimize stress by being willing to ask your family for help when you need it.
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ANS: C
For the healthy aging person, research is showing that exercise (along with the resulting
maintenance of muscle mass) is one of the greatest determinants of maintaining vitality and
health.
DIF: Understanding (Comprehension) REF: MCS: 184 OBJ: 10-2
TOP: Teaching-Learning MSC: Health Promotion
2. The nurse caring for older adult patients best minimizes the patients risk of developing
dehydration by:
a. identifying the patients oral fluid preferences and offering them regularly.
b. carefully monitoring the effects of daily diuretics via blood sodium levels.
c. minimizing the patients reliance on laxatives by increasing dietary fiber intake.
d. carefully monitoring of the rate of infusion of all intravenous fluids prescribed.
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ANS: A
Physiologically, the decreased intake can be related to altered thirst; older adults may not feel
thirsty even when hypovolemic. The other actions may be appropriate for selected patients.
DIF: Applying (Application) REF: N/A OBJ: 10-1
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
3. A patient is newly widowed and lives alone. Which suggestion by the nurse will help the adult
children maximize the patients nutritional status?
a. Help identify possible barriers to their mother achieving good nutritional health.
b. Ensure that the patient has an adequate supply of healthy, easily prepared foods
available.
c. Contact a food delivery service to provide one nutritiously sound meal a day.
d. Arrange a schedule that allows someone to have dinner with her each evening.
ANS: D
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The lack of companionship during mealtime that can lead to depression or social isolation often
causes the patient to eat poorly and thus develop a nutritional deficiency. The patient who is
newly widowed may not have adjusted to this change in status. The other actions are also
helpful, but they are not as important for this patient.
DIF: Applying (Application) REF: N/A OBJ: 10-1
TOP: Communication and Documentation MSC: Psychosocial Integrity
4. The nurse is caring for four postsurgical patients who have experienced similar abdominal
procedures and are all 68 years of age. The nurse anticipates that the patient with the greatest risk
for complications resulting in an extended hospitalization has:
a. a history of Crohn disease.
b. developed mild confusion.
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c. an allergy to latex.
d. severe postoperative nausea and vomiting.
ANS: A
Malnourished hospitalized patients such as those with chronic digestive disorders like Crohn
disease have a greater risk of developing infections and other complications after surgery, which
can significantly increase the length and costs of hospitalization and care.
DIF: Remembering (Knowledge) REF: MCS: 188 OBJ: 10-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
5. The nurse conducting a food recall assessment on an older adult patient shows an
understanding of the requirements of the process when:
a. having the patient identify any existing food allergies.
b. asking the family to verify the patients statements.
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c. asking how the food being discussed was prepared.
d. correlating diet information with signs of malnutrition.
ANS: C
For accuracy and relevancy, the food recall must include specific information about the type of
food ingested, the preparation method, and an accurate estimate of the amount.
DIF: Applying (Application) REF: N/A OBJ: 10-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. An older adult patient has been prescribed a specialized enteral formula after an extensive
surgical procedure. The nurse anticipates and addresses a concern of many patients in this age
cohort when assuring the patient that:
a. her family can easily manage the formula after she is discharged.
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b. Medicare will cover the expense of the treatment.
c. the treatment will be discontinued as soon as she is able to eat sufficiently.
d. this is the most effective form of nutrition for her at this time.
ANS: B
Specialized enteral formulas are considerably more expensive than standard formulas and should
be used only when clearly indicated. The cost of such a treatment would be of great concern to
this cohort. The special feeding will be discontinued as soon as possible, this is the best way to
give this patient nutrition at this time, and the family can manage the feedings, but the bigger
concern is cost.
DIF: Understanding (Comprehension) REF: N/A OBJ: 10-6
TOP: Communication and Documentation MSC: Physiologic Integrity
7. During a nutritional assessment, a 79-year-old patient responds, My weight is fine. I weigh the
same as I did 15 years ago. The nurse
responds
onRthe
that older patients:
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.Cunderstanding
OM
a. generally guess their weight rather than weigh themselves.
b. often rely on how their clothes fit to determine whether their weight has changed.
c. sometimes experience altered metabolic problems that hide weight change.
d. often exchange lean muscle mass for body fat so weight stays the same.
ANS: D
With age there is a loss of lean body mass and an increase of body fat; therefore, body weight
alone can be misleading.
DIF: Remembering (Knowledge) REF: MCS: 191 OBJ: 10-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
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8. An older adult patient has experienced severe nausea and vomiting for 2 days since
undergoing abdominal surgery. A prealbumin serum blood test is ordered. The nurse explains the
rationale for the test to the patients family by saying:
a. The provider is interested in whether there is enough available protein in the
blood.
b. This test is designed to determine how the body is meeting current demands for
protein.
c. The test will tell us if the vomiting has created a problem with protein
metabolism.
d. Healing from such a surgery requires protein, and this test measures protein.
ANS: B
This test is sensitive to sudden demands on protein synthesis and is often used in the acute care
setting. Healing from surgery does require sufficient protein stores, and this test can help the
nurse, dietician, and provider determine if the patient needs extra nutritional support.
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DIF: Understanding (Comprehension) REF: MCS: 191 OBJ: 10-4
TOP: Teaching-Learning MSC: Physiologic Integrity
9. Based on recent surveys identifying nutritional information concerning the daily diet of older
adults in America, the nurse suggests:
a. substituting carbohydrates with lean protein sources.
b. adding calories through the addition of fruits and vegetables.
c. introducing a protein at each meal.
d. relying on foods that are both easy to chew and easy to digest.
ANS: B
Government-sponsored surveys have indicated that the average diet of the older adult lacks in
calories, especially in the form of fruits and vegetables. The recommendations do not include
substituting protein for carbohydrates, adding protein at each meal, and relying solely on foods
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that are easy to chew and digest, although these suggestions might be appropriate for individual
patients.
DIF: Understanding (Comprehension) REF: MCS: 192 OBJ: 10-5
TOP: Teaching-Learning MSC: Health Promotion
10. An older adult patient with a history of a myocardial infarction tells the nurse that he takes
his daily dose of prescribed aspirin with breakfast each morning. The nurses response is:
a. Food interferes with the drugs absorption, so take it between meals.
b. Taking aspirin with food increases your likelihood of stomach upset.
c. Taking the drug with food is likely to alter the taste of the food.
d. Eating as you take the aspirin is likely to result in constipation.
ANS: A
The absorption of aspirin occurs T
inEthe
soEis
greatly
STstomach
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ELL
R.
COM altered by the presence of food.
The other statements are incorrect.
DIF: Understanding (Comprehension) REF: MCS: 197 OBJ: 10-1
TOP: Teaching-Learning MSC: Physiologic Integrity
11. The nurse notes a patients prealbumin is 2 mg/dL. What action by the nurse is best?
a. Tell the patient to add more protein to the diet.
b. Conduct a nutritional screening with a standard tool.
c. Refer the patient to a registered dietician.
d. Instruct the patient to maintain good nutritional habits.
ANS: C
Normal albumin levels are above 15 mg/dl. Values below 5 mg/dL are considered a marker for
severe protein deficiency. The nurse should enlist the services of a registered dietician to help
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manage this patient. Adding more protein to the diet and conducting a nutritional screening are
not the best answers because the nurse already knows the patient is severely malnourished.
Instructing the patient to maintain his or her good nutritional habits is incorrect.
DIF: Applying (Application) REF: N/A OBJ: 10-4
TOP: Communication and Documentation MSC: Physiologic Integrity
12. A nurse works with a patient who is malnourished. What lab value does the nurse assess for
the most up-to-date information on the patients status?
a. Albumin
b. Prealbumin
c. Transferrin
d. Total iron
ANS: B
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Prealbumin has a half-life of 2 to 3 days, so it is the most accurate measure of the patients current
status. Albumins half-life is 21 days; transferrins half-life is 8 to10 days. Total iron does not
indicate current nutritional status as accurately as the others.
DIF: Remembering (Knowledge) REF: MCS: 191 OBJ: 10-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
13. The nurse has conducted a nutrition screen on a patient using the Nutrition Screening
Initiative tool. The patient scored a 4. What action by the nurse is most appropriate?
a. Refer the patient to a dietician for a nutritional assessment.
b. Encourage the patient to add more protein items to the diet.
c. Reinforce the patients good eating habits and nutrition.
d. Consult the provider about adding an iron supplement.
ANS: A
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A score of 3 or higher indicates moderate to severe nutritional risk. The nurse consults a dietician
for a more in-depth nutritional assessment. Adding more protein items to the diet is probably a
good idea, but this is not the most comprehensive answer. The nurse can reinforce the good
eating habits the patient does have, but the patient needs more intervention. The patient may or
may not need an iron supplement.
DIF: Applying (Application) REF: N/A OBJ: 10-4
TOP: Communication and Documentation
MSC: Safe Effective Care Environment
14. A nurse is caring for an observant Hindu patient who has a protein deficiency. What menu
items does the nurse select for the patient?
a. Lean beef
b. Chicken
c. Beans
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d. Pork
ANS: C
Hindus do not eat any meat, so to get a food high in protein, the nurse selects beans.
DIF: Remembering (Knowledge) REF: MCS: 196
TOP: Nursing Process: Implementation | Cultural Awareness Box
MSC: Psychosocial Integrity
15. A nurse is caring for four patients. On which patient should the nurse plan to conduct a
further nutritional assessment?
a. The patient who has lost 10% of body weight in 1 month
b. The patient who has lost 5 pounds with exercise in 1 month
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c. The patient who gained 3 pounds while on vacation
d. The patient who weighs 12% over ideal body weight
ANS: A
Loss or gain of 5% of body weight in 1 month puts a patient at nutritional risk. The other patients
are not at nutritional risk.
DIF: Remembering (Knowledge) REF: MCS: 190 OBJ: 10-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
16. A patient wants to know what no sugar added on a food label means. What explanation is
best?
a. The food has no calories.
b. No sugar was added during processing.
c. The food naturally has no sugar.
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d. The food has 23% less sugar than normal.
ANS: B
No sugar added means that no sugar is added during processing (or packaging) and no
ingredients are added that contain sugar. It does not mean that the food has no calories or that the
food itself does not naturally contain sugar. A product with 23% less sugar than the original
counterpart is labeled low sugar.
DIF: Understanding (Comprehension) REF: MCS: 196 OBJ: 10-7
TOP: Teaching-Learning MSC: Health Promotion
17. The nurse teaches older adults to reduce sodium in their diets. What is the daily
recommended limit for sodium in this population?
a. 1000 mg
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b. 1500 mg
c. 2000 mg
d. 2500 mg
ANS: B
The current recommendations for sodium intake in the older population limits ingestion to 1500
mg/day.
DIF: Understanding (Comprehension) REF: MCS: 193 OBJ: 10-7
TOP: Teaching-Learning MSC: Health Promotion
18. An older adult is worried about potassium intake. What does the nurse teach this patient?
a. Unless you take a diuretic, dont worry about potassium.
b. You should take a daily potassium supplement.
c. You should try to get all yourTE
potassium
food.
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d. Potassium is not a nutrient people generally worry about.
ANS: C
The guidelines for nutrition and older individuals state that potassium intake (4700 mg/day)
should be ingested through food. Some people do need a supplement, for instance, those on
potassium-wasting diuretics. Potassium is a vital nutrient, important in electrical conduction and
muscle function.
DIF: Understanding (Comprehension) REF: MCS: 193 OBJ: 10-7
TOP: Teaching-Learning MSC: Health Promotion
19. An older patient asks why he needs a multivitamin supplement. The patient has always been
healthy, has excellent nutrition, and has never needed vitamins. What explanation by the nurse is
best?
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a. Older people tend to eat fewer calories, so its harder to get nutrients.
b. You need to have extra nutritional reserves in case of sudden illness.
c. Its recommended in all the nutritional guidelines for older adults.
d. Now that you are older, your good nutritional habits are not enough.
ANS: A
Older people do tend to eat fewer calories, making it more difficult to get all the needed
nutrients. Stating that old habits are no longer good enough is not quite accurate. Extra
nutritional reserves are a good idea, but the patient may not feel vulnerable to illness. Stating that
it is in the nutritional recommendations does not give the patient useful information.
DIF: Understanding (Comprehension) REF: MCS: 193 OBJ: 10-3
TOP: Teaching-Learning MSC: Health Promotion
20. A diabetic is struggling with the carbohydrate-controlled diet as a result of having a large
TESTBAWhat
NKSaction
ELLEby
R.the
COnurse
M is best?
extended family with many get-togethers.
a. Remind the patient of the consequences of poor control of diabetes.
b. Tell the patient that once a month he or she can eat as desired.
c. Help the patient make priorities so some favorite foods can be eaten.
d. Tell the patient to increase the insulin dose on get-together days.
ANS: C
Nurses working with patients who have dietary issues need to understand the social, emotional,
cultural, and religious ties their patients have to food, or the interventions will not be successful.
While normally maintaining a diabetic diet the patient can be assisted to prioritize foods that are
must haves and determine how to work them into the diet.
DIF: Applying (Application) REF: N/A OBJ: 10-1
TOP: Teaching-Learning MSC: Health Promotion
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21. An older woman asks the nurse why she suddenly has a deficiency in B vitamins as her
eating and cooking habits have not changed. What response by the nurse is best?
a. Something has to be different now.
b. You cant absorb B vitamins like before.
c. Your need for B vitamins has increased.
d. The guidelines have been increased.
ANS: B
Age-related gastrointestinal changes include a decrease in intestinal pH, which lowers the ability
of the gastrointestinal tract to absorb B vitamins.
DIF: Understanding (Comprehension) REF: MCS: 185 OBJ: 10-2
TOP: Teaching-Learning MSC: Physiologic Integrity
MULTIPLE RESPONSE
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1. A patient is being discharged on total parenteral nutrition (TPN). What topics do the patient
and family need to be taught? (Select all that apply.)
a. How to work the enteral feeding pump
b. Care of a central venous catheter
c. How to crush and give medications
d. Proper use of an intravenous (IV) pump
e. Actions to take if the IV becomes occluded
ANS: B, D, E
TPN is administered via a large central IV line using an IV pump. The family needs to know
how to use the pump, how to care for the catheter, and what to do if the IV line becomes
occluded. An enteral pump is not used. Meds are not crushed and given through the TPN line.
DIF: Applying (Application) REF: N/A OBJ: 10-6
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TOP: Teaching-Learning MSC: Physiologic Integrity
2. The student learning about gerontologic nursing knows that which features are commonly
associated with geriatric failure to thrive? (Select all that apply.)
a. Impaired physical function
b. Depression
c. Malnutrition
d. Cognitive decline
e. Poor dentition
ANS: A, B, C, D
According to one description of failure to thrive, components include impaired physical function,
depression, malnutrition, and cognitive decline. Poor dentition is not specifically mentioned.
Chapter 19 Urinary Function
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MULTIPLE CHOICE
1. When caring for older adults, the nurse expects to encounter the normal urinary age-related
outcome of:
a. urinary incontinence.
b. low-grade bladder infection.
c. nocturia.
d. urinary residual volume.
ANS: C
With age, increased urine formation at night leads to nocturia. The other findings are not agerelated changes.
DIF: Remembering (Knowledge) REF: MCS: 542 OBJ: 26-1
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TOP: Nursing Process: Assessment MSC: Health Promotion
2. An 87-year-old patient has suddenly become incontinent. What should the nurses first action
be?
a. Review the patients record for medications that may be causing urinary
incontinence.
b. Seek an order for an indwelling urinary catheter to prevent skin breakdown.
c. Limit the patients fluid intake to reduce the feeling of having to void so often.
d. Teach the patient to void every 2 hours when awake during the day or night.
ANS: A
Medication is a common cause of incontinence and should always be suspected as a potential
cause of new incontinence. A catheter is not needed. Limiting fluids leads to dehydration.
Voiding every 2 hours at night will disrupt sleep.
DIF: Understanding (Comprehension)
OBJ:
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M
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
3. An older adult patient reports losing urine when she bends over or gets out of a chair. What
type of incontinence does the nurse plan interventions for?
a. Overflow
b. Urge
c. Functional
d. Stress
ANS: D
Stress incontinence is commonly seen in older women who involuntarily lose urine as the result
of a sudden increase in intraabdominal pressure. Overflow incontinence consists of frequent
involuntary losses of small amounts of urine. Functional incontinence is manifested by loss of
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large volumes of urine because of a lack of awareness of the need to void or a mobility problem.
Urge incontinence is accompanied by a sudden urge to void.
DIF: Remembering (Knowledge) REF: MCS: 543 OBJ: 26-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. When assessing the patient for urinary incontinence, which patient symptom best supports the
nursing diagnosis of overflow incontinence?
a. I have small accidents ever since I developed a cystocele.
b. It burns so badly after I urinate that I hold it as long as I can.
c. I cant make it to the toilet when I feel the need to urinate.
d. I lose small amounts of urine when I sneeze or laugh hard.
ANS: A
Typically, individuals with overflow
complain
TESincontinence
TBANKSEL
LER.Cof
OMfrequent losses of small volumes
of urine, which are commonly a result of cystoceles. Burning indicates a urinary tract infection.
Not making it to the bathroom is generally functional incontinence. Losing control of the bladder
with sneezing or laughing is a manifestation of stress incontinence.
DIF: Remembering (Knowledge) REF: MCS: 543 OBJ: 26-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
5. An older cognitively impaired adult patient is being discharged to a daughters home. The
nurse knows continued success of the patients bladder training for urinary incontinence primarily
rests on the:
a. patients ability to follow instructions.
b. severity of the impairment of the urinary sphincter.
c. patients ability to sense the need to urinate.
d. daughters ability to support the training.
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ANS: D
Treating urinary incontinence in individuals with cognitive impairment requires the use of other
behavioral techniques that depend on the caregiver rather than the patient. The success of the
techniques in large part depends on the availability and motivation of the caregiver. The other
actions are not as important for the cognitively impaired persons success.
DIF: Understanding (Comprehension) REF: MCS: 548 OBJ: 26-7
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. An older adult patient is hospitalized for after an automobile crash. The nurse recognizes
symptoms suggestive of an upper urinary tract (UTI) infection when the patient:
a. voids 100 mL of urine over a 3-hour period of time.
b. is not able to state where he is or what day it is.
c. has an elevated red blood cell (RBC) count.
d. reports burning when he urinates.
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ANS: B
For many older adults, the presentation of a UTI is confusion or another change in mental status.
Burning on urination would signify a lower urinary tract infection. The other two assessments
are unrelated.
DIF: Analyzing (Analysis) REF: N/A OBJ: 26-16
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
7. An older adult woman has a resistant strain of pneumonia. To best minimize her risk of
developing acute renal failure, the nurse:
a. monitors the patients serum blood urea nitrogen (BUN) levels via diagnostic
laboratory work.
b. helps the patient select low-sodium foods from her daily menu.
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c. measures and records the patients urinary output.
d. chooses an analgesic other than ibuprofen (Motrin).
ANS: D
Patients with pneumonia often have mild to moderate pain. Nonsteroidal antiinflammatory drug
(NSAIDs) are common analgesics; however, they can cause acute kidney injury. Using another
class of drug for pain relief will help protect the patients kidneys. The patient may be at risk of
acute kidney injury because of dehydration or the nephrotoxic effects of certain antibiotics.
DIF: Applying (Application) REF: N/A OBJ: 26-11
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
8. An older patient is admitted with possible chronic renal failure (CRF). Which lab value does
the nurse notify the physician about as a priority?
a. Increased calcium level
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b. Increased red blood cells
c. Decreased BUN level
d. Decreased creatinine clearance level
ANS: D
The diagnosis of CRF is usually made based on a decrease in creatinine clearance, an elevation
of BUN level, and a decrease in red blood cells. The other findings can be documented.
DIF: Applying (Application) REF: N/A OBJ: 26-16
TOP: Communication and Documentation MSC: Physiologic Integrity
9. The nurse is admitting an older patient with benign prostate hyperplasia (BPH). The nurses
priority questioning focuses on:
a. family history of prostate disorders.
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b. onset of symptoms.
c. psychosocial impact of the diagnosis.
d. typical urinary voiding patterns.
ANS: D
The purpose of the nursing assessment for an individual with BPH is to determine the extent of
prostate enlargement and its effect on function so that appropriate nursing interventions can be
planned and implemented. The primary assessment focuses on the patients current voiding
patterns.
DIF: Understanding (Comprehension) REF: MCS: 556 OBJ: 26-16
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
10. A patient in a long-term care facility has incontinence. What assessment by the nurse is most
important before designing interventions for this problem?
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a. Cognitive status
b. Ambulatory status
c. Cardiovascular status
d. History of childbirth
ANS: A
Treatment options differ between cognitively impaired and intact individuals. If the person is not
intact, he or she has to rely on caregivers to maintain appropriate bladder function. The other
assessments can be worked into the treatment plan.
DIF: Applying (Application) REF: N/A OBJ: 26-7
TOP: Nursing Process: Analysis MSC: Physiologic Integrity
11. A male patient has benign prostatic enlargement. He is at risk for what type of acute kidney
injury?
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a. Prerenal
b. Intrarenal
c. Postrenal
d. Combined form
ANS: C
BPH would place this patient at risk for postrenal failure. Prerenal failure is often the result of
decreased cardiac output or acute fluid volume loss. Intrarenal failure consists of damage to the
actual nephrocytes.
DIF: Remembering (Knowledge) REF: MCS: 551 OBJ: 26-11
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
12. A patient has a history of smoking and now has painless hematuria. After a workup, the
patient is told the diagnosis of bladder cancer. What action by the nurse is most important?
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a. Allow the patient to verbalize feelings.
b. Educate the patient on care of an ileal conduit.
c. Teach the patient how to manage nausea.
d. Offer a social work referral to complete a living will.
ANS: A
The first intervention the nurse should provide is to be present for the patient and allow the
expression of feelings. It is too early to teach, the patient may or may not have an ileal conduit,
and the patient may not be ready to complete a living will or other advance directive.
DIF: Application REF: N/A OBJ: 26-16 TOP: Caring
MSC: Psychosocial Integrity
13. A patient being treated for prostate cancer calls the clinic to report severe back pain. What
action by the nurse is best?
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a. Advise the patient to take his pain medication.
b. Tell the patient to come in to the clinic today.
c. Make an appointment for the patient next week.
d. Encourage the patient to rest and use moist heat.
ANS: B
Prostate cancer can metastasize to the bones including the spine. If this happens, spinal cord
compression can occur. The patient is advised to come into the clinic today for evaluation. The
other options are not appropriate.
DIF: Analyzing (Analysis) REF: N/A OBJ: 26-16
TOP: Communication and Documentation MSC: Physiologic Integrity
14. A male patient reports difficulty starting a urine stream and a weak urine flow. When
prompted to seek medical attention, the patient asks why, as its obviously benign prostatic
TEnurse
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hypertrophy. What response by the
isNbest?
a. You never know; it could be cancer.
b. You should have any change checked out.
c. Only the physician can make a diagnosis,
d. BPH and prostate cancer have similar symptoms.
ANS: D
The patient should have these new symptoms checked out. Although only the provider can make
the diagnosis, the best answer is to explain that symptoms of BPH and cancer are similar. The
other options do not give useful information.
DIF: Applying (Application) REF: N/A OBJ: 26-14
TOP: Teaching-Learning MSC: Physiologic Integrity
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15. A patient treats chronic kidney failure with peritoneal dialysis. The patient notes the fluid
draining out of the abdomen is cloudy and foul smelling. What action by the nurse is best?
a. Assess the patient for other signs of infection.
b. Document the findings in the patients chart.
c. Call the rapid response team immediately.
d. Request a prescription for an antibiotic.
ANS: A
One of the complications of peritoneal dialysis is infection in the peritoneal space, or peritonitis.
The nurse should fully assess the patient for infection and notify the provider. Documentation
should occur, but the nurse needs to take action first. The rapid response team is not needed.
Antibiotics will probably be used to treat the infection.
DIF: Applying (Application) REF: N/A OBJ: 26-16
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OM
TOP: Nursing Process: Implementation
MSC:
Integrity
16. A patient is scheduled to have surgery for prostate cancer in a few weeks. What action by the
nurse is most important?
a. Discuss options and their effect on sexuality.
b. Ensure the patient has advance directives.
c. Offer the patient a tour of the operating room.
d. Determine if the patient prefers outpatient surgery.
ANS: A
Treatment for prostate cancer can affect sexual functioning, so the nurse ensures the patient
knows the risks and benefits of his choices. The other options are not necessary, although any
patient with a serious illness should have advance directives.
DIF: Applying (Application) REF: N/A OBJ: 26-15
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TOP: Teaching-Learning MSC: Psychosocial Integrity
17. A patient asks how elevating the legs at night will decrease nocturia. What is the nurses best
response?
a. All that fluid gets into circulation before you go to bed.
b. Decreased swelling makes it easier to ambulate at night.
c. It wont help; thats an old wives tale you heard.
d. This measure helps dehydrate you before bedtime.
ANS: A
Elevating the legs returns dependent fluid into circulation so the kidneys can excrete it sooner.
Without elevating the legs, that fluid movement does not happen until the patient goes to bed,
contributing to nocturia. The other answers are incorrect.
DIF: Understanding (Comprehension) REF: MCS: 547 OBJ: 26-16
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TOP: Teaching-Learning MSC: Physiologic Integrity
18. What information does the nurse share with the student about normal age-related changes in
the kidneys?
a. Renal mass increases.
b. The glomerular filtration rate decreases.
c. Poor renal function occurs after age 65.
d. There are no real age-related changes.
ANS: B
Older adults have a decreased glomerular filtration rate, decreased renal mass, but renal function
can remain good up to the ninth decade.
DIF: Remembering (Knowledge) REF: MCS: 549 OBJ: 26-10
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TOP: Teaching-Learning MSC: Health Promotion
MULTIPLE RESPONSE
1. A nurse is assessing an older patient for the possible cause of his acute urinary incontinence.
Which actions by the nurse are most important? (Select all that apply.)
a. Asking when his last normal bowel movement was
b. Monitoring his intake and output
c. Determining if he has been screened for prostatic hypertrophy
d. Asking him if he awakens during the night to urinate
e. Measuring his abdominal girth
ANS: A, C, D
Constipation or fecal impaction as well as an enlarged prostate gland (causing frequent nighttime
urination) are commonly overlooked causes of incontinence. Intake and output and abdominal
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girth are not related to possible causes
DIF: Understanding (Comprehension) REF: MCS: 542 OBJ: 26-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
2. When preparing educational information regarding benign prostatic hyperplasia (BPH) for a
group of older male patients, the nurse includes which of the following? (Select all that apply.)
a. Eighty percent of males experience the symptoms by age 80.
b. Diabetes mellitus is a risk factor.
c. It is only as the prostate enlarges that symptoms occur.
d. The resulting urinary retention can cause urinary tract infections.
e. Symptoms are a result of urethral obstruction.
ANS: A, C, D, E
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Approximately 80% of men may be diagnosed with BPH by the age of 80. In early prostatic
enlargement, the patient may be asymptomatic because the muscles may initially compensate for
increased urethral resistance. As the prostate gland enlarges, the patient begins to manifest
symptoms of an obstructive process. The symptoms may include hesitancy, a decrease in the
force of the urinary stream, terminal dribbling, a sensation of a full bladder after voiding, and
urinary retention. Urethral obstruction may cause urinary stasis, UTIs, hydronephrosis, and renal
calculi. Diabetes is not a risk factor.
DIF: Understanding (Comprehension) REF: MCS: 556 OBJ: 26-14
TOP: Teaching-Learning MSC: Physiologic Integrity
3. An older adult patients urinary incontinence is being addressed by prompted voiding. The
nurse instructs all ancillary staff to do which of the following? (Select all that apply.)
a. Provide only minimal fluids after 7 PM.
b. Keep the patient on the toilet until voiding occurs.
c. Allow the patient to void at times
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LLEscheduled.
R.COM
d. Offer toileting during the night only when the patient is awake.
e. Encourage the patient to toilet himself.
ANS: C, D
The goal is to increase a patients awareness of the need to void and, it is hoped, to increase the
frequency of self-initiated toileting. Patients are approached on a regular schedule, asked if they
are wet or dry, and then prompted to toilet. A patient should never be forced to toilet or
reprimanded for failing to toilet appropriately. Self-initiated toileting should not be discouraged.
To relieve the stress that can occur because of sleep disruption for both caregiver and patient,
toileting protocols can be modified during the nighttime hours.
DIF: Understanding (Comprehension) REF: MCS: 549 OBJ: 26-5
TOP: Nursing process: Implementation MSC: Physiologic Integrity
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4. A patient has a glomerular filtration rate (GFR) of 19 mL/min/1.73m2. What assessment
findings correlate with this condition? (Select all that apply.)
a. Fatigue
b. Weakness
c. Edema
d. No specific symptoms
e. Headaches
ANS: A, B, C
This patient is in stage 4 of chronic kidney disease. Expected assessment findings include
weakness, edema, fatigue, hypertension, heart failure, impaired cognition and immune function,
dry skin and pruritus, anorexia, nausea, malnutrition, increased bleeding, anemia, peripheral
neuropathy, and an overall decreased quality of life. In stages 1 and 2, patients are asymptomatic.
Headache is not a finding.
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DIF: Applying (Application) REF: N/A OBJ: 26-11
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
5. The nurse working in the gerontology clinic understands which facts related to incontinence?
(Select all that apply.)
a. It is a normal age-related change.
b. It is an independent predictor of nursing home admission.
c. It contributes to falls and injuries.
d. It can disrupt sleep.
e. It can lead to urinary tract infections.
ANS: B, C, D, E
Urinary incontinence is not a normal age-related development, although people commonly
believe this is true. The other statements are correct.
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Chapter 20 Cardiovascular Function
MULTIPLE CHOICE
1. The nurse is teaching cardiovascular risk factors to a group of older adults. The nurse stresses
that cigarette smokers are four times more likely to die of sudden cardiac death than nonsmokers
because smoking:
a. interferes with the development of collateral coronary vessels.
b. produces coronary artery stricture.
c. results in carbon monoxide poisoning.
d. increases platelet aggregation.
ANS: D
Smoking increases platelet aggregation and causes coronary artery spasms. Nicotine increases
TESCarbon
TBANKmonoxide
SELLERin.tobacco
COM smoke decreases the oxygenblood pressure and cardiac demands.
carrying capacity of the blood. Smoking does not interfere with collateral circulation or produce
strictures, but it may contribute to higher levels of carbon monoxide in the blood.
DIF: Understanding (Comprehension) REF: MCS: 390 OBJ: 21-2
TOP: Teaching-Learning MSC: Health Promotion
2. When assessing an older, female, African American adult, the nurse notes that she has been a
type 2 insulin-dependent diabetic 10 years. The nurse notes that the patients greatest risk for
developing secondary hypertension is her:
a. gender.
b. ethnic origin.
c. vascular system status.
d. insulin therapy.
ANS: C
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Secondary hypertension identified in the vascular system refers to elevated blood pressure
caused by underlying disease such as renal artery disease, renal parenchymal disorders,
endocrine and metabolic disorders, central nervous system (CNS) disorders, coarctation of the
aorta, and increased intravascular volume. Gender, ethnic origin, and insulin are not diseases that
cause hypertension.
DIF: Remembering (Knowledge) REF: MCS: 392 OBJ: 21-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
3. When administering Lopressor to an older adult patient with hypertension, the nurse is careful
to have the patients care plan include
a. frequent assessment for dizziness or syncope.
b. education of the signs and symptoms of thromboembolism.
c. regular evaluation of the patients muscle strength.
d. regularly scheduled serum potassium levels.
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ANS: A
Dizziness is an adverse reaction to beta-blockers such as Lopressor.
DIF: Remembering (Knowledge) REF: MCS: 398 OBJ: 21-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. The nurse educates the obese older adult patient that the single most important outcome that
will affect cardiac health is:
a. compliance with drug therapy.
b. adherence to the DASH diet.
c. 20 minutes of exercise daily.
d. a 10% reduction in weight.
ANS: D
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A 10% reduction of total weight will decrease blood pressure in many overweight individuals.
This factor has significance because it underscores the importance of weight reduction in the
older adult population. The other factors are important but not as significant to overall cardiac
health as is weight loss.
DIF: Understanding (Comprehension) REF: MCS: 392 OBJ: 21-2
TOP: Teaching-Learning MSC: Health Promotion
5. To evaluate an older patient for possible renal failure as a result of chronic untreated
hypertension, nurse prepares to:
a. schedule an ultrasound.
b. collect a urine sample.
c. monitor intake and output.
d. transport the patient to radiology.
ANS: B
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A urinalysis will investigate for proteinuria or other signs of renal failure.
DIF: Remembering (Knowledge) REF: MCS: 393 OBJ: 21-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. The nurse should assess which patient first?
a. The patient with acute shortness of breath
b. The patient with epigastric pain
c. The patient with right arm pain
d. The patient with persistent indigestion
ANS: A
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Older patients often have atypical signs and symptoms of cardiac ischemia, including shortness
of breath, fatigue, syncope, confusion, and abdominal or back pain. Shortness of breath requires
the most immediate assessment.
DIF: Applying (Application) REF: N/A OBJ: 21-4
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
7. It is suspected that an older adult patient is experiencing severe hypertension. The nurse
documents symptoms that support this diagnosis when the patient reports:
a. difficulty reading the newspapers print.
b. being fatigued after walking around the block.
c. noticing that his heart skips a beat frequently.
d. getting up from a chair too quickly makes him dizzy.
ANS: A
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The patient with severe hypertension may experience throbbing occipital headaches, confusion,
visual loss, focal deficits, epistaxis, and coma. The other manifestations are not associated with
hypertension.
DIF: Remembering (Knowledge) REF: MCS: 392 OBJ: 21-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
8. A novice nurse requires additional education on arterial vascular deficiency when suggesting
the conditions symptoms include:
a. 2+ edema in calf and foot of left leg.
b. a 2-cm ulcer between the great and second toe on the left foot.
c. skin on the left leg is cool to the touch.
d. toenails on the left foot are thick and brittle.
ANS: A
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Edema is not generally observed in cases of arterial deficiency, but rather in venous
insufficiency. The other options are manifestations of arterial vascular deficiency.
DIF: Remembering (Knowledge) REF: MCS: 415 OBJ: 21-5
TOP: Teaching-Learning MSC: Physiologic Integrity
9. The nurse shows an understanding of how anemia symptoms present in the older population
when:
a. questioning the patient about dizziness when turning from side to side in bed.
b. assessing the patient for pale oral mucous membranes.
c. asking whether the patient takes supplementary iron tablets.
d. assessing the patients weekly intake of red meat.
ANS: B
Skin color is not a good indicatorTof
pallor
Oral mucous
ES
TBAbecause
NKSELof
LEvarying
R.COpigmentation.
M
membranes, as well as conjunctivae and nail beds, are better indicators. The other options are not
related to symptoms.
DIF: Remembering (Knowledge) REF: MCS: 417 OBJ: 21-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
10. A nurse has provided discharge teaching for an older adult patient who had a pacemaker
implanted. Which statement by the patient indicates appropriate understanding of the device?
a. The battery will need charging every 2 years or so.
b. Im supposed to call my doctor if my pulse is within 10 beats of my preset rate.
c. My wife will have to be the one who makes the microwave popcorn.
d. Ill take my pulse each morning before my first cup of coffee.
ANS: D
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The radial pulse should be taken at the same time daily and recorded. The patient should notify
the provider if the pulse is lower than the preset lower limit on the pacemaker. Battery life is
longer than 2 years. Microwaves are safe to use.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 21-4
TOP: Nursing Process: Evaluation MSC: Health Promotion
11. A 76-year-old patient has been recently diagnosed with cardiac valvular disease. The nurse
assesses the patient and recognizes that the medical diagnosis is supported by:
a. cyanotic fingertips.
b. weight loss of 10 pounds in 3 months.
c. angina pain.
d. shortness of breath with activity.
ANS: D
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Individuals with valvular disease may be asymptomatic for many years, but with the
deterioration of the valves and hypertrophic changes in the atria or ventricles, symptoms become
evident. Exertional dyspnea is frequently the initial symptom. Other symptoms include dizziness,
fatigue, weakness, and palpitations. The other signs are not manifestations of valve disease.
DIF: Remembering (Knowledge) REF: MCS: 406 OBJ: 21-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
12. An older patient is upset with a blood pressure reading of 180/78 mmHg. What response by
the nurse is best?
a. It looks like you need blood pressure medicine now.
b. Most people get hypertension when they get older.
c. With age, blood vessels stiffen, raising blood pressure.
d. Dont worry, there are lots of good medications for this.
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ANS: C
With age, elastin in vessel walls decreases, making them stiffer. Systolic blood pressure (SBP) is
increased in older adults because of a loss of arterial distensibility resulting from arterial
stiffening. The other responses do not offer any useful information on the cause of the patients
condition.
DIF: Understanding (Comprehension) REF: MCS: 389 OBJ: 21-1
TOP: Teaching-Learning MSC: Health Promotion
13. An older patient is overwhelmed at the number of lifestyle changes needed to manage newly
diagnosed cardiovascular disease. What action by the nurse will reduce this barrier to teaching?
a. Tell the patient even tiny changes over time make a big difference.
b. Tell the patient that smoking is the biggest risk factor and needs to stop.
c. Help the patient choose a change and incorporate it into daily life.
d. Educate the patient on the consequences
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ELmaking
LER.Cchanges.
OM
ANS: C
Although it is true that small changes over time have a great impact, the nurse needs to do more
by helping the patient choose a small change to implement. The nurse should help the patient
work on the risk factor he or she is most willing to change. Education is important, but it will not
enable the patient to make changes.
DIF: Applying (Application) REF: N/A OBJ: 21-5
TOP: Teaching-Learning MSC: Health Promotion
14. A nurse is caring for a patient taking furosemide (Lasix). What assessment finding needs to
be reported to the provider immediately?
a. Weight gain of 1/2 pound (1.1 kg) in 24 hours
b. 2+/4+ pedal and pretibial edema
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c. Potassium level: 2.6 mEq/L
d. Sodium level: 138 mEq/L
ANS: C
Furosemide is a potassium-wasting diuretic and the patients potassium is low. This finding
should be reported. The weight gain should be charted but does not need immediate reporting.
Without knowing what the patients baseline edema is, there is no indication this needs to be
reported. The sodium level is normal
DIF: Applying (Application) REF: N/A OBJ: 21-5
TOP: Communication and Documentation MSC: Physiologic Integrity
15. An older patient is prescribed nifedipine (Procardia). What teaching topic is most important
to discuss with this patient?
a. Need to monitor blood pressure
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b. Need to follow low-salt diet
c. Need to change positions slowly
d. Need to add exercise to daily routine
ANS: C
Calcium channel blockers such as Procardia can cause orthostatic hypotension in older adults.
The nurse educates the patient on preventing this by slow position changes. The other topics are
appropriate for all patients on this medication.
DIF: Applying (Application) REF: N/A OBJ: 21-4
TOP: Teaching-Learning MSC: Physiologic Integrity
16. A patient had a heart attack and the nurse identifies the diagnosis as activity intolerance.
What assessment finding indicates a priority goal for this diagnosis is being met?
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a. Mild chest pain getting into the chair
b. Feels unsteady when getting out of bed
c. O2 saturation 98% after using the commode
d. Less dyspnea when changing positions
ANS: C
Activity intolerance is measured by changes in vital signs, electrocardiogram (ECG), and
symptoms such as chest pain or shortness of breath. The oxygen saturation indicates physiologic
tolerance to activity. The other options do not show physiologic tolerance.
DIF: Analyzing (Analysis) REF: N/A OBJ: 21-5
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
17. An older patient in the internal medicine clinic reports usually being able to walk 1 mile
without complaint. However, in the past 2 weeks, after walking just mile, the patients legs begin
ESTWhat
BANaction
KSELby
LEthe
R.nurse
COMis most appropriate?
to ache. The pain goes away withTrest.
a. Elevate the patients legs
b. Assess the pedal pulses
c. Take the patients blood pressure
d. Measure the patient for TED hose
ANS: B
This patient has intermittent claudication, a sign of peripheral arterial disease. The nurse assesses
the patients pedal pulses. Elevation will further compromise circulation and should be avoided.
A blood pressure reading is taken during all health care visits. The patient does not need TED
hose at this point.
DIF: Applying (Application) REF: N/A OBJ: 21-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
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18. A patient has peripheral vascular disease. What statement by the patient indicates a need for
further teaching?
a. I will have the podiatrist cut my toenails.
b. I will be sure to wear sturdy shoes.
c. I can only walk limited distances now.
d. I will report any injury to my foot or leg.
ANS: C
Patients with venous insufficiency are encouraged to begin a graduated exercise program. The
other statements show good understanding.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 21-5
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
MULTIPLE RESPONSE
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1. The effect of aging on the cardiovascular system is evidenced by which symptoms in an older
adult performing a stress test? (Select all that apply.)
a. Chest pain during exercise
b. Slow increase of heart rate in response to stress
c. Exercise induce dyspnea
d. Slow decrease of heart rate post exercise
e. Stress-induced arrhythmias
ANS: B, D
During stress or stimulation, the heart rate increases more slowly; however, once elevated, it
takes longer to return to the resting rate. The other manifestations are not related to age-induced
physiologic changes.
DIF: Remembering (Knowledge) REF: MCS: 389 OBJ: 21-1
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TOP: Nursing Process: Assessment MSC: Physiologic Integrity
2. A novice nurse is aware that normal aging can result in changes in the ECG of a 73-year-old
patient. The experienced geriatric nurse explains that these changes may include which of the
following? (Select all that apply.)
a. An inverted T wave
b. A notched P wave
c. A prolonged PR interval
d. Decreased amplitude of the QRS complex
e. A slurred T wave
ANS: B, C, D, E
The number of pacemaker cells located in the sinoatrial node decreases with age, which results in
less responsiveness of the cells to adrenergic stimulation. Common aging changes that are
reflected by the electrocardiogram (ECG) include a notched P wave, a prolonged PR interval,
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decreased amplitude of the QRS complex, and a notched or slurred T wave.
DIF: Remembering (Knowledge) REF: MCS: 389 OBJ: 21-1
TOP: Teaching-Learning MSC: Health Promotion
3. A nurse is planning to teach a senior citizens group heart-healthy lifestyle choices. Which
should be included? (Select all that apply.)
a. Smoking cessation tips
b. Low-carbohydrate food choices
c. Stress management techniques
d. Regular blood pressure monitoring
e. Strategies to include exercise into daily routine
ANS: A, C, D, E
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Heart-healthy lifestyle changes concern smoking cessation, stress management, blood pressure
control, exercise, weight loss, and a low-fat, low-sodium diet. Low-carbohydrate foods are not
considered part of heart-healthy lifestyles.
DIF: Understanding (Comprehension) REF: MCS: 389 OBJ: 21-4
TOP: Teaching-Learning MSC: Health Promotion
4. An older adult recovering from a myorcardial infarction (MI) has been taking subcutaneous
heparin but is now to receive oral warfarin (Coumadin). The nurse prepares to teach the patient
which topics? (Select all that apply.)
a. Administration of both medications for up to 5 days
b. Need to use a soft bristle toothbrush
c. Use of atropine as an antidote for excessive bleeding
d. Need to continue drawing partial thromboplastin times
e. Need to drink at least eight cups of fluids daily
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ANS: A, B, D
Heparin and warfarin (Coumadin) are anticoagulants used to prevent the enlargement of existing
thrombi and new clot formation after an MI. Therapeutic effects of heparin are monitored by
partial thromboplastin times; the antidote is protamine sulfate. Warfarin is monitored by the
international normalized ratio (INR); the antidote is vitamin K. Patients who initially receive
heparin for anticoagulation and who need oral anticoagulation for maintenance usually take both
forms of medication for 3 to 5 days to develop therapeutic blood levels. Bleeding is a
complication. Patients need to be taught bleeding precautions.
DIF: Understanding (Comprehension) REF: MCS: 398 OBJ: 21-3
TOP: Teaching-Learning MSC: Physiologic Integrity
5. A 77-year-old patient is being treated for cardiac arrhythmia. The nurse determines that the
patients cardiac output is adequate with which assessments? (Select all that apply.)
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a. Urine output of 140 cc over 4 hours
b. Systolic blood pressure that remains within 20 mm of baseline
c. Denial of substernal pain
d. Recollection of the birthdays of all of her grandchildren
e. Absence of rales and crackles
ANS: A, B, D, E
The patient will maintain an adequate cardiac output, as evidenced by heart rate and rhythm
within normal range, stable blood pressure, adequate peripheral pulses, mental alertness, urine
output of 30 mL/hr, and clear breath sounds. Normal mentation also denotes good cardiac output,
but the patient may have too many birthdays to remember, so this is not the best indicator of
cognitive status.
Chapter 21 Respiratory Function
MULTIPLE CHOICE
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1. The nurse best maximizes an older adults potential to avoid developing a postsurgical
respiratory infection by:
a. walking the patient to the bathroom instead of using the bedside commode.
b. encouraging compliance with prescribed antibiotic therapy.
c. evaluating the patients ability to effectively cough and deep breathe.
d. offering fluids every hour while the patient is awake.
ANS: C
Older adults have a decrease in the number and effectiveness of cilia in the tracheobronchial tree,
which results in increasing difficulty clearing secretions. The other activities also help avoid
atelectasis and infection, but evaluating the patients ability to cough and deep breathe can
indicate that other treatment measures may be needed postoperatively.
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DIF: Remembering (Knowledge) REF: MCS: 423 OBJ: 22-1
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
2. An older adults pulmonary function studies indicate that his vital capacity is reduced and his
residual volume is increased. The nurse recognizes that these test results are observed in the
patients:
a. ineffective cough reflex.
b. shallow breathing.
c. slow respiratory rate.
d. frequent respiratory infections.
ANS: B
Normal aging results in the progressive loss of elastic recoil of the lung parenchyma and
conducting airways as well as reduced elastic recoil of the lung and the opposing forces of the
ESTBas
ANcollagenic
KSELLEsubstances
R.COM surrounding the alveoli and
chest wall. The lung becomes lessTelastic
alveolar ducts stiffen and form cross-linkages that interfere with the elastic properties of the
lungs. Any and all of these structural changes make it more difficult for the older person to
ventilate.
DIF: Remembering (Knowledge) REF: MCS: 422 OBJ: 22-1
TOP: Nursing Process: Assessment MSC: Health Promotion
3. The nurse is concerned about an older adult patient developing toxic levels of the prescribed
theophylline when it is determined that the patient has a(n):
a. one pack a day smoking habit.
b. elevated serum potassium level.
c. history of chronic bronchitis.
d. chronic, nonproductive cough.
ANS: A
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Theophylline is a medication that is affected by smoking, which increases serum drug levels. The
other factors do not affect the pharmacokinetics of this drug.
DIF: Remembering REF: MCS: 425 OBJ: 22-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. The nurse is aware of the typical occurrence of comorbidities in the older adult. Motivated by
this knowledge, the nurse assesses a patient with diagnosed respiratory dysfunction for possible:
a. poor wound healing of the legs and feet.
b. ineffective absorption of vitamins and minerals.
c. abnormal urine protein levels.
d. visual problems including retinal detachment.
ANS: A
In addition, older patients are more
TElikely
STBAtoNhave
KSEcomorbidities
LLER.COMinvolving the cardiovascular and
respiratory systems. Peripheral circulation is a possible cardiovascular problem that would result
in poor wound healing. The other options are not related to having a respiratory dysfunction.
DIF: Remembering (Knowledge) REF: MCS: 425 OBJ: 22-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
5. Because the older adult is not as likely to exhibit the typical signs of ineffective gas exchange,
the nurse is particularly suspicious of:
a. a nonproductive cough in an afebrile patient.
b. irritability in a usually pleasant patient.
c. pale nail beds in a patient of color.
d. an elevated white blood cell (WBC) count in an 82-year-old patient.
ANS: B
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An early sign of respiratory problems is a change in mental status. Because the physiologic
responses to hypoxemia and hypercapnia are blunted in older patients, compensatory changes in
heart rate, respiratory rate, and blood pressure may be delayed and cerebral perfusion may suffer.
Mental status changes may include subtle increases in forgetfulness and irritability.
DIF: Applying (Application) REF: N/A OBJ: 22-1
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. The nurse is preparing information for the caregivers of a patient with chronic respiratory
issues. The nurse will make the greatest impact on their ability to provide quality care while
maintaining the patients emotional well-being by including:
a. suggestions regarding proper nutrition and exercise for the caregiver.
b. an explanation on how to preserve the patients sense of autonomy.
c. encouragement for the primary caregiver to set aside time for his or her own
interests.
d. recommendations of periodicTself-reflection
the
ESTBANKSEregarding
LLER.C
OMstressors the patient
experiences.
ANS: B
Many patients with respiratory illness feel a loss of control over their lives because of their
symptoms. They may become demanding and controlling in dealing with their families and
friends. Well-being is enhanced by having some control over ones life. The other options relate
to the caregivers.
DIF: Applying (Application) REF: N/A OBJ: 22-3
TOP: Teaching-Learning MSC: Psychosocial Integrity
7. An older patient admitted to the hospital with symptoms strongly suggestive of tuberculosis
(TB) has a negative Mantoux test. The nurse correctly anticipates that:
a. the purified protein derivative (PPD) test will be administered.
b. a chest x-ray will be ordered to detect possible infiltration.
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c. therapy consisting of a combination of bactericidal drugs will be initiated.
d. the skin test will be repeated to achieve a booster effect.
ANS: D
Tuberculin skin testing in older patients is an unreliable indicator of TB because they are more
likely to have false-negative results because of reduced immune system activity. If skin testing is
used, it is recommended that the standard 5 tuberculin unit (TU) Mantoux test be given and then
repeated to create a booster effect. The PPD is not recommended. The skin test is followed up
with a chest x-ray. Drug therapy should not begin until the patient has a diagnosis.
DIF: Remembering (Knowledge) REF: MCS: 440 OBJ: 22-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
8. An older adult patient who has tuberculosis is being treated with the drugs isoniazid 300 mg
daily, rifampin 600 mg daily, and pyrazinamide 1500 mg daily. The nurse stresses the
importance that the patient:
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a. wear tinted glasses when out in the sun.
b. minimize contact with children younger than 3 years old.
c. avoid alcohol while on the drug therapy.
d. eat and drink dairy sparingly.
ANS: C
Patients should not drink alcohol while taking isoniazid. The other recommendations are
incorrect.
DIF: Understanding (Comprehension) REF: MCS: 442 OBJ: 22-5
TOP: Teaching-Learning MSC: Physiologic Integrity
9. An 80-year-old patient is concerned about contracting pneumonia. The nurse educates her that
the key to prevention is:
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a. early recognition of the symptoms.
b. being vaccinated per government guidelines
c. minimizing contact with the public during the winter months.
d. supplementing ones daily diet with various vitamin C sources.
ANS: B
The key to pneumonia prevention is being appropriately vaccinated. All individuals should be
vaccinated at age 65 unless they have conditions that lead them to earlier vaccination.
Revaccination is indicated in certain circumstances. Signs and symptoms are subtle in the aging
population. Minimizing contact during winter months is an appropriate suggestion, just not the
best one. Vitamin C may have immune system benefits.
DIF: Remembering (Knowledge) REF: MCS: 446 OBJ: 22-3
TOP: Teaching-Learning MSC: Health Promotion
TESTBan
ANolder
KSEpatient
LLERwho
.COpresents
M
10. The nurse gives priority to assessing
with symptoms of acute
respiratory distress for which other condition?
a. Substernal chest pain
b. A history of panic attacks
c. Any known allergies
d. Bruising on the chest
ANS: A
The symptoms of asthma and respiratory distress mimic other conditions such as myocardial
ischemia. The nurse assesses for this condition as the priority over the others.
DIF: Applying (Application) REF: N/A OBJ: 22-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
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11. The nurse is caring for an older adult who has been prescribed inhaled corticosteroids for
asthma. What does the nurse teach about this medication?
a. Taken just before retiring for the night
b. Reserved for acute attacks only
c. Used in increasing doses as needed
d. How to use and rinse the inhaler
ANS: C
Corticosteroids are an effective long-term control medication that can be used in increasing
doses as needed for asthma and related disorders. It is given by the inhalation method, so the
nurse teaches the patient how to use and maintain the inhaler. The other teaching tips are
incorrect.
DIF: Applying (Application) REF: N/A OBJ: 22-3
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TOP: Teaching-Learning MSC: Physiologic
12. An older patient with severe peripheral arterial disease wishes to quit smoking. The nurse
provide education to this patient on which of the following?
a. Cold turkey method
b. Gradual reduction
c. Nicotine patches
d. Bupropion hydrochloride (Zyban)
ANS: D
Older patients should be offered assistance to quit smoking. The cold turkey and gradual
reduction methods may not work if the patient is a long-term smoker. The patient with peripheral
arterial disease should not use nicotine in any form as it causes vasoconstriction. Zyban is an
appropriate choice.
DIF: Applying (Application) REF: N/A OBJ: 22-4
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TOP: Teaching-Learning MSC: Health Promotion
13. An older adult with chronic obstructive pulmonary disease (COPD) asks why he should quit
smoking now. What response by the nurse is best?
a. It will keep your disease from getting worse.
b. There are many benefits to quitting even now.
c. It will decrease the risk of getting cancer too.
d. Youre right; there really isnt a reason to quit.
ANS: B
There are many benefits to smoking cessation including reduction in the number of respiratory
infections, improvement in the function of the mucociliary clearance of the lungs, decreased
coughing and dyspnea, increased appetite, and decreased sputum production. This is a more
comprehensive answer than keeping the disease from worsening and lowering the chance of
getting cancer.
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DIF: Understanding (Comprehension) REF: MCS: 432 OBJ: 22-4
TOP: Teaching-Learning MSC: Health Promotion
14. A patient has been taught about nutrition related to COPD. Which menu selection may
indicate a need for further teaching?
a. Bagel and cream cheese
b. Broiled chicken breast
c. Beans and peas
d. Tofu stir-fry
ANS: A
Carbohydrates should not make up more than 50% of the daily intake of calories because they
break down into carbon dioxide, worsening breathing. The other selections show good
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understanding. Of course, the nurse needs to take into consideration the amount of carbohydrates
in the entire day and not just one selection.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 22-3
TOP: Nursing Process: Evaluation MSC: Health Promotion
15. An older patient is hospitalized with influenza and is prescribed amantadine (Symmetrel).
What assessment finding would indicate this drug is not appropriate for the patient?
a. BUN 22 mg/dL
b. Creatinine 3.2 mg/dL
c. Sodium 132 mEq/L
d. Potassium 4.2 mEq/L
ANS: B
Amantadine can cause behavioralTchanges,
delirium,
ESTBAN
KSELLhallucinations,
ER.COM agitation, and seizures,
mostly in patients with impaired renal function. The creatinine is high, indicating renal disease.
The other lab values are normal.
DIF: Analyzing (Analysis) REF: N/A OBJ: 22-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
16. A frail, older patient is in the emergency room in severe respiratory distress. The patient has
had repeated hospitalizations for the same thing. After stabilizing the patient, which action by the
nurse is most appropriate?
a. Determine what the patients end-of-life wishes are.
b. Assess the family caregiver for compliance with treatment.
c. Administer intravenous (IV) fluids at a rapid rate.
d. Prepare to vaccinate the patient against pneumonia.
ANS: A
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Because of the lifesaving modalities needed to care for such a patient, the nurse and physician
work together to determine what the patients end-of-life wishes are. In the emergency
department, patient stabilization comes first, but once this has been accomplished a discussion
should occur with the patient and family about further treatment desires. The family caregiver
may or may not be adherent, or the patient may assume all self-care. IV fluids should not be
given at a rapid rate because of the risk of heart failure. The patient should receive an
immunization against pneumonia per guidelines.
DIF: Applying (Application) REF: N/A OBJ: 22-3
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
17. A patient has a pulmonary embolism and asks the nurse to explain the purpose of the heparin
infusion. What response by the nurse is best?
a. It helps dissolve the clot in your lungs.
b. It keeps you from getting septic.
c. It prevents the clot from getting
TESbigger.
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d. It prevents clots from forming in your heart.
ANS: C
Heparin keeps the clot from getting bigger and hopefully prevents further clots from forming. It
does not dissolve the clot. It does not specifically target the heart. It does not prevent sepsis.
DIF: Understanding (Comprehension) REF: MCS: 450 OBJ: 22-3
TOP: Teaching-Learning MSC: Physiologic Integrity
18. The nurse caring for patients using continuous positive airway pressure (CPAP) knows what
about treatment effectiveness?
a. Effectiveness depends on compliance.
b. Its too expensive for many older adults.
c. It is rarely effective for sleep apnea.
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d. Complicated settings make it hard to use.
ANS: A
Effectiveness is determined by compliance for nearly any regime, and unfortunately compliance
with CPAP is less than 50%. The other statements are incorrect.
DIF: Remembering (Knowledge) REF: MCS: 451 OBJ: 22-7
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. To minimize an older adults risk for developing postsurgical atelectasis, the nurse does which
of the following? (Select all that apply.)
a. Regularly assesses and medicates for pain
b. Teaches effective deep-breathing techniques
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c. Provides oxygen via nasal cannula
d. Encourages the patient to drink all fluids on meal trays
e. Assesses lung sounds frequently
ANS: A, B, D
Promotion of deep breathing, effective pain management, adequate hydration, frequent position
changes, and early mobility will decrease the risk of developing atelectasis. Providing oxygen
and assessing lung sounds will not prevent atelectasis from occurring.
DIF: Applying (Application) REF: N/A OBJ: 22-3
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
2. When teaching older adult asthmatic patients, the nurse stresses the importance of which of
the following? (Select all that apply.)
a. Being alert for the early signs of breathing problems
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b. Fostering an effective relationship with your health care provider
c. Identifying and avoid personal triggers
d. Incorporating regular rest periods into your daily routine
e. Increasing vitamin C consumption, especially during winter months
ANS: A, B, C
The prognosis for an older adult with asthma is relatively good. Success is based on a partnership
between the patient and the health care provider to properly use prescribed medications, avoid
asthma triggers, identify early signs of exacerbation, and maintain a healthy lifestyle. Rest may
or may not be an issue if the patient has mild asthma. Vitamin C may have immune system
benefits.
DIF: Understanding (Comprehension) REF: MCS: 428 OBJ: 22-3
TOP: Teaching-Learning MSC: Health Promotion
ESa Tnewly
BANK
SELLEolder
R.Cadult.
OM The patient is diagnosed with
for
admitted
3. The nurse is coordinating care T
hypertension, asthma, atrial fibrillation, mild osteoarthritis, and glaucoma. Before administering
the patients corticosteroid medication, the nurse is especially interested in which of the
following? (Select all that apply.)
a. The name of the patients hypertension medication
b. What the patient uses to manage arthritic pain
c. Whether the patient feels the asthma is well controlled
d. Whether the patient takes low-dose aspirin regularly
e. Whether the patient has ever had glaucoma-related surgery
ANS: A, B, D
Asthma may be exacerbated by the use of nonsteroidal antiinflammatory agents for arthritis,
aspirin for circulation, nonselective beta-blockers for hypertension, or glaucoma eye drops that
contain beta-blockers. Feeling that the asthma is under control and previous surgery are not
directly related.
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DIF: Application (Applying) REF: N/A OBJ: 22-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. The nurse is evaluating the effectiveness of an older patients self-management of asthma.
What does the nurse assess as the priority? (Select all that apply.)
a. How many times a week a rescue inhaler treatment is needed
b. How well the patient is able to avoid the known triggers
c. Whether the patient experience frequent respiratory infections
d. Whether the patient requires rest periods during the day
e. Whether the patient believes he or she has the support of family and friends
ANS: A, B
The evaluation of self-management is based on the patients success in following through with the
plan. Determine the frequency of rescue inhaler use, success at avoiding triggers, and the patients
TESTchanges.
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ability to monitor and address lifestyle
DIF: Evaluating (Evaluation) REF: N/A OBJ: 22-3
TOP: Nursing Process: Evaluation MSC: Health Promotion
5. The nurse encouraging an older patient to start pulmonary rehabilitation shares the benefits of
the program, including which of the following? (Select all that apply.)
a. Socialization
b. Decreased cardiac risks
c. Nutrition counseling
d. Weight management
e. Sports participation
ANS: A, B, C, D
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There are many aspects to pulmonary rehabilitation, including socialization, decreased cardiac
risks, nutrition counseling, and weight management Sports are not included, although exercise is.
Chapter 22 Safe Mobility
MULTIPLE CHOICE
1. Which nursing intervention best demonstrates the understanding that older adults are at
increased risk for falls because of normal age-related changes?
a. Speaking in a loud voice when warning the patient about safety hazards
b. Turning on bright lights so the patient can see objects such as furniture
c. Encouraging the patient to rise from a supine position slowly
d. Advising the patient to avoid exercising painful joints
ANS: C
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Older adults who lie supine and then get up quickly are likely to experience the effects of lack of
tissue elasticity when the blood pressure drops and a feeling of lightheadedness develops. It is
important to educate older individuals to change position slowly.
DIF: Understanding (Comprehension) REF: MCS: 220 OBJ: 12-4
TOP: Teaching-Learning MSC: Safe Effective Care Environment
2. An older adults risk for a fall-related injury is directly correlated to his or her ability to regain
balance. To evaluate this ability, the nurse assesses the patients:
a. inner ear for possible fluid buildup.
b. musculoskeletal hip, ankle, and shoulder strength.
c. large muscle strength in thighs and upper arms.
d. gait for steadiness.
ANS: B
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Older adults who lose their balance are able to right themselves to an upright position when the
musculoskeletal strength of the hips, ankles, and shoulders is adequate. The inability to regain
balance because of insufficient strength can result in a fall. The other options are also
possibilities, but they are not as significant as hip, ankle, and shoulder strength.
DIF: Understanding (Comprehension) REF: MCS: 221 OBJ: 12-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
3. The geriatric nurses decision to identify a specific patient as a falls risk is primarily based on
the:
a. presence of visual deficiencies and musculoskeletal weakness.
b. results determined by cognitive and physiologic assessment tools.
c. degree of frailty and functional limitation observed.
d. inability to follow instructions and communicate effectively.
ANS: C
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Research has shown that the individual with frailty and physical functional limitations is at
greatest risk for falling.
DIF: Remembering (Knowledge) REF: MCS: 222 OBJ: 12-4
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
4. An older adult has been diagnosed with presbyopia. To minimize the patients risk for falls, the
nurse suggests:
a. that the edges of steps be painted a contrasting color.
b. the patient wear sunglasses when driving.
c. the patient wear a wide-brimmed hat when spending time outdoors.
d. hanging blinds over sunny windows.
ANS: A
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If older individuals are experiencing presbyopia, a reduction in the eyes accommodation for
changes in depth, such as when ascending or descending the stairs, instruction must be given for
them to carefully watch door edges, curbs, and landing steps, which signal a change in height.
Painting the edges of steps a contrasting color will make these depth changes more visible. The
other suggestions are not related to this disorder.
DIF: Applying (Application) REF: N/A OBJ: 12-1
TOP: Teaching-Learning MSC: Safe Effective Care Environment
5. An older adult has been diagnosed with a sinus infection. To minimize the risk for a fallrelated injury, the nurse teaches the patient:
a. that there is a possibility of prodromal falls.
b. to take her antibiotic medication with food.
c. to recognize symptoms of fluid buildup in the middle ear.
d. about the increased risks of falls related to normal aging.
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ANS: A
Prodromal falling refers to the onset of frequent falling heralding an acute medical problem; an
infectious disease typically causes this type of fall. Educating the patient regarding the most
common sources of potential falls is the cornerstone of fall prevention and management. The
other options do not relate directly to this condition.
DIF: Understanding (Comprehension) REF: MCS: 224 OBJ: 12-4
TOP: Teaching-Learning MSC: Safe Effective Care Environment
6. The nurse identifies the older adult patient at the greatest risk for a fall-related injury as the:
a. male with a history of a vitamin deficiency.
b. female with a diagnosis of osteoporosis.
c. male with a cognitive deficient.
d. female with a history of depression.
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ANS: B
Serious injury from falling is more likely to occur among those with osteoporosis.
DIF: Remembering (Knowledge) REF: MCS: 223 OBJ: 12-4
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
7. An older patient diagnosed with dementia has begun behaviors that increase the risk of falling.
The patients son tells the nurse that physical restraints may be used. The nurse responds:
a. Ill document that, so that the staff can use them when necessary.
b. Physical restraints are seldom effective on patients with dementia.
c. The staff will use physical restraints only as a last resort.
d. There are more effective methods to use to help ensure her safety.
ANS: D
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Physical restraint use does not prevent falls and therefore should never be employed for safety
precautions. This is the best explanation because the nurse will then need to explain the other
measures that will be taken to keep the patient safe.
DIF: Understanding (Comprehension) REF: MCS: 223 OBJ: 12-3
TOP: Teaching-Learning MSC: Safe Effective Care Environment
8. A patient is being discharged after hip replacement surgery. The geriatric nurse recognizes that
the most effective intervention to minimize the potential of a fall injury is to:
a. identify the most common causes of falls that the patient is likely to encounter.
b. discuss what kind of in-home assistance the patient will need.
c. impress the patient with the importance of being careful not to fall.
d. educate the patient that falling is not a normal part of aging.
ANS: A
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Educating the patient regarding the most common sources of potential falls is the cornerstone of
fall prevention and management. The patient may or may not need home care assistance, telling
the patient how important it is not to fall does not provide the patient with a plan to avoid falling,
and educating the patient on normal age-related changes also does not give the patient any
information on how to avoid falling.
DIF: Understanding (Comprehension) REF: MCS: 219 OBJ: 12-4
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
9. A patient is diagnosed with bilateral osteoarthritis of the knees. To best address the long-term
risk for falls, the nurse encourages the patient to:
a. use assistive mobility devises when necessary.
b. report exacerbation of symptoms promptly.
c. add a daily walk to exercise the knees appropriately.
d. take analgesic medication as prescribed to manage joint pain.
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ANS: D
If joint pain develops and remains untreated, it can cause older adults to become sedentary or
immobile. This phenomenon of disuse and muscle atrophy contributes to muscle weakness and
can lead to an increase in falls. The other statements are also appropriate, but the patients pain
needs to first be managed before determining if assistive devices are needed. Walking will help
build strength, but the patient wont do it if it hurts too much. Reporting symptoms does not
directly affect falling.
DIF: Applying (Application) REF: N/A OBJ: 12-5
TOP: Teaching-Learning MSC: Safe Effective Care Environment
10. A cognitively impaired older adult patient is a resident at a skilled nursing facility. The nurse
acting as the patients advocate will consistently address the patients risk for injury issues based
on:
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a. preferences generally expressed by cognitive patients.
b. professional nursing knowledge.
c. implementation of the less restrictive intervention.
d. established facility policies and procedures.
ANS: D
If patients are unable to make informed choices and no family members are available, the nurse
must use nursing judgment and follow an acceptable standard of care to promote safety and
security that are defined and described in official policies and procedure manuals. The
preferences of other patients do not indicate this patients preferences. Professional nursing
knowledge can be used but must remain within the policies. Less restrictive interventions are
preferable, but again actions need to conform to policy.
DIF: Understanding (Comprehension) REF: MCS: 228 OBJ: 12-6
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
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11. When appropriately addressing safety issues, the geriatric nurse plans the patients care plan
directed by the standard of care that requires:
a. promoting both health and wellness by assuring safety.
b. minimizing the patients risk for physical injury while preserving autonomy.
c. identifying safety from injury as a patient right.
d. emphasizing beneficence as a an ethical standard of nursing care.
ANS: B
When working with older adults, the gerontologic nurse must provide a standard of care that
promotes safety and prevents foreseeable accidents or injuries while also respecting individuals
autonomy to make decisions. This requires a delicate balance. The other options do not address
standards.
DIF: Remembering (Knowledge) REF: MCS: 228 OBJ: 12-6
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TOP: Nursing Process: Analysis MSC: Safe Effective Care Environment
12. Which action is best to reduce burns in the home?
a. Instruct patients to install smoke detectors,
b. Tell patients to have their water heaters checked,
c. Encourage patients to switch from gas to electric stoves,
d. Teach patients not to smoke in their houses,
ANS: B
The most common cause of burns in the home for older patients is scalding from water that is too
hot. Patients should either check and reset the temperature themselves or have someone do it for
them. The other actions are all helpful, but scalding remains the top cause of burns in the home
for this population.
DIF: Understanding (Comprehension) REF: MCS: 229 OBJ: 12-7
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TOP: Teaching-Learning MSC: Safe Effective Care Environment
13. A patient smokes. What advice does the nurse give this patient for safety?
a. Do not smoke inside the house.
b. Install working smoke detectors.
c. Only smoke during the daytime.
d. Install carbon monoxide detectors.
ANS: A
Smoking has been related to house fires for many years. The nurse can provide many
suggestions, but not smoking inside at all is the safest option. Smoke detectors work after a fire
has started. Smoking during the daytime does not eliminate the possibility of falling asleep while
smoking. Carbon monoxide detectors are important but not related to fire.
DIF: Applying (Application) REF: N/A OBJ: 12-7
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TOP: Teaching-Learning MSC: Safe Effective Care Environment
14. The nurse assesses which patient as being at the highest risk for poisoning related to mixing
garden chemicals?
a. The patient who has Parkinson disease with hand tremors
b. The patient who has low vision or uses magnifying glasses
c. The patient who has hearing impairment or wears hearing aid
d. The patient who has osteoarthritis or using a wheeled walker
ANS: A
The patient with hand tremors is at greatest risk because of the potential for inaccurate mixing
and spillage.
DIF: Applying (Application) REF: N/A OBJ: 12-7
TOP: Nursing Process: Assessment
Care
Environment
TEMSC:
STBASafe
NKSEffective
ELLER.
COM
15. The student asks the nurse why ground beef and other ground meat products are more likely
to be contaminated and cause food-borne illness. What response by the nurse is best?
a. Its because they are handled more.
b. They are from cheaper cuts of meat.
c. They are not kept cold during shipping.
d. They are made from leftover meats.
ANS: A
Ground meat products are handled more during processing, increasing the risk of being
contaminated with microbes that cause food-borne illnesses.
DIF: Understanding (Comprehension) REF: MCS: 231 OBJ: 12-7
TOP: Teaching-Learning MSC: Safe Effective Care Environment
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16. The nurse working with older patients would assess which patient as being at highest risk for
developing secondary hypothermia?
a. The patient who has osteoarthritis and limited mobility
b. The patient who has a raised rash on both arms
c. The patient who drinks four alcoholic drinks a day
d. The patient who takes furosemide (Lasix)
ANS: C
Alcohol and substance abuse increase the risk of hypothermia because of decreased awareness
and impaired judgment. Four drinks a day is excessive. Skin conditions can lead to hypothermia,
but the rash is confined to the arms. The other two conditions are not risk factors.
DIF: Applying (Application) REF: N/A OBJ: 12-8
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
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17.
A patient is brought to the emergency department after falling while shoveling snow. The
patients core temperature is 92?0F (33.3?0C). What rewarming measures does the nurse prepare
to initiate?
a. Warm blankets
b. Warm heating lamps
c. Peritoneal dialysis
d. Warmed intravenous (IV) solutions
ANS: D
A core temperature this low requires active internal rewarming. Warmed IV solutions are
appropriate. Blankets and a heating lamp are appropriate for mild hypothermia. Peritoneal
dialysis is reserved for severe cases with cardiac instability.
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DIF: Applying (Application) REF: N/A OBJ: 12-8
TOP: Nursing Process: Analysis MSC: Physiologic Integrity
18. A nurse is watching a parade during the summer and notices an older adult looking faint and
acting somewhat confused. The patient has hot dry skin. While waiting for the rescue squad,
what action by the nurse is most effective?
a. Spraying the person with a water mist
b. Giving the person iced tea to drink
c. Having the person sit down on the grass
d. Pouring cold water over the persons head
ANS: A
Spraying the person with a cold-water mist will help dissipate heat, especially if the nurse then
fans the person. Iced tea is a diuretic and will increase fluid loss. Having the person sit down is a
TES
BAshade.
NKSEPouring
LLER.cold
COMwater over the persons head is not
good idea, as long as the person sits
inTthe
as effective as a water spray mist.
DIF: Applying (Application) REF: N/A OBJ: 12-8
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
19. The nurse teaches that which of the following is the best place to store medications?
a. Bathroom medicine cabinet
b. Near the kitchen sink
c. In the laundry room
d. In a drawer in the bedroom
ANS: D
Medications should be kept away from heat, direct sunlight, and humidity. The drawer in the
bedroom is the best of the options given.
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DIF: Understanding (Comprehension) REF: MCS: 235 OBJ: 12-7
TOP: Teaching-Learning MSC: Safe Effective Care Environment
20. The nurse working with older adults understands that which age-related condition contributes
to driving safety concerns?
a. Wearing glasses
b. Hearing impairment
c. Confusion
d. Slower reflexes
ANS: D
Slower reflexes and reaction times are a normal age-related change. Wearing glasses and hearing
aids should correct the underlying problem and not be a cause for concern in themselves.
Confusion is not a normal age-related change.
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DIF: Understanding (Comprehension) REF: MCS: 235 OBJ: 12-11
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
21. A patient has had several falls ascribed to numb feet. What action by the nurse is best?
a. Assess patient for undiagnosed diabetes.
b. Instruct the patient on using a cane.
c. Ensure the patient has sturdy footwear.
d. Tell the patient to lift the feet when walking.
ANS: A
Numbness in the feet is caused by peripheral neuropathy, which is a complication of diabetes
mellitus. The nurse plans to assess the patient for this condition. The other options do not address
the lack of sensation to the feet.
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DIF: Applying (Application) REF: N/A OBJ: 12-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. When assessing an older adult for intrinsic risk factors for falls, the nurse is particularly
interested in which of the following? (Select all that apply.)
a. An unsteady gait when asked to walk without assistance
b. The presence of throw rugs in the living room of the home
c. The patients report that he wears corrective lenses
d. An inability to see changes in height because of poor lighting
e. Evidence of short-term memory deficiency
ANS: A, C, E
The most salient observations forTintrinsic
factors
ESTBArisk
NKS
ELLEfor
R.falls
COMrelate to gait, balance, stability,
and cognition. Intrinsic risk factors are a combination of age-related changes and concurrent
disease. The other two options are extrinsic factors, which relate to the environment.
DIF: Remembering (Knowledge) REF: MCS: 220-1 OBJ: 12-4
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
2. A patient is brought to the emergency department after an unexplained fall. What actions by
the nurse are most appropriate? (Select all that apply.)
a. Placing the patient on a cardiac monitor
b. Obtaining a urine sample for cultures
c. Checking a quick bedside blood glucose
d. Assessing the patient for asthma
e. Performing tests for orthostatic vital signs
ANS: A, B, C, D
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Common causes of falls include cardiac dysrhythmias, urinary tract infection, hypoglycemia, and
dehydration, so the nurse assesses for these conditions. Asthma most likely is not an issue.
Chapter 23 Integumentary Function
MULTIPLE CHOICE
1. The nurse explains that the plan of care for an older adult patient with seborrheic dermatitis of
the scalp should include:
a. cleaning lesions with a weak hydrogen peroxide solution daily.
b. cleaning the scalp with a low-dose steroidal shampoo.
c. applying hydrocortisone 10% to scalp lesions.
d. applying selenium shampoo to the scalp.
ANS: D
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A successful strategy is to wet the hair, apply selenium shampoo, and then proceed with the rest
of the bath or shower. The other measures will not be successful.
DIF: Remembering (Knowledge) REF: MCS: 611 OBJ: 28-3
TOP: Teaching-Learning MSC: Physiologic Integrity
2. An older adult patient reports simple xerosis with mild pruritus. The nurse educates her on the
importance of:
a. applying a lanolin-rich cream and avoiding scratching the areas.
b. taking warm baths and gently rubbing of affected areas with a terrycloth towel.
c. minimizing ingestion of fried foods and use of an antihistamine cream.
d. avoiding bath oils and allowing the skin to air-dry after bathing.
ANS: A
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The nurse suggests that the patient apply emollients (e.g., Lubriderm, Moisturel, or Eucerin
lotion or cream), which have more lanolin or oily substances than many commercial lotions.
Time should be planned to teach the patient and family about etiologic factors and the
importance of not scratching. The other options are not helpful and will not decrease the itching.
DIF: Understanding (Comprehension) REF: MCS: 612 OBJ: 28-3
TOP: Teaching-Learning MSC: Health Promotion
3. The nurse plans to assess for candidiasis as a priority intervention for a:
a. 60-year-old with a history of bacterial pneumonia.
b. 72-year-old incontinence of urine and feces.
c. 58-year-old with a casted left foot.
d. 90-year-old receiving antihypertensives.
ANS: B
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Candidiasis is most commonly seen in diaper-clad infants, incontinent patients, and bed-bound
individuals and in moisture-prone areas of the body (e.g., skin folds and axillae). The other
patients are not as likely to have this disorder as the incontinent patient.
DIF: Understanding (Comprehension) REF: MCS: 612 OBJ: 28-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. An 87-year-old patient developed herpes zoster after surgical repair of a hip fracture. The
priority nursing diagnosis is:
a. impaired skin integrity related to immunologic deficit.
b. self-care deficit related to severe pain and fatigue.
c. risk for infection related to impaired skin integrity.
d. pain related to inadequate pain relief from analgesia.
ANS: C
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These vesicles are extremely vulnerable to secondary bacterial infections. The other diagnoses
might be appropriate for some patients.
DIF: Applying (Application) REF: N/A OBJ: 28-3
TOP: Nursing Process: Diagnosis MSC: Physiologic Integrity
5. The presence of which skin assessment finding, if noted on an older adult patient, should
cause the nurse to suspect a premalignancy?
a. Numerous small red papules on the chest and back
b. An oozing, rough, reddish macule on the ear
c. An irregularly shaped mole on the face or shoulders
d. Brown, greasy lesions on the neck
ANS: B
Actinic keratosis begins in vascular
asNaKreddish
TEareas
STBA
SELLEmacule
R.COor
M papule that has a rough,
yellowish brown scale that may itch or cause discomfort. Actinic keratosis may evolve into
squamous cell carcinoma (SCC) if not treated, so it should receive prompt attention. Red
papules, irregularly shaped moles, and brown greasy lesions are not likely to be precancerous.
DIF: Understanding (Comprehension) REF: MCS: 615 OBJ: 28-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
6. An older adult patient has been taught measures to prevent the development of skin cancer.
Which statement, if made by the patient, indicates the need for more teaching?
a. I will certainly miss my vegetable and flower gardening.
b. I should buy a sunscreen with an SPF of 15 or higher.
c. Now I have a good excuse to wear the straw hat my spouse hates.
d. My cool long-sleeved shirts will work just fine while Im golfing.
ANS: A
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The patient is still able to garden as long as he or she takes appropriate sun precautions. The
other statements show good understanding.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 28-4
TOP: Nursing Process: Evaluation MSC: Health Promotion
7. When assessing the older adult patients skin for indications of melanoma, the nurse should
inspect for a(n):
a. thick, adherent scale with a soft center.
b. small, inflamed lesion that bleeds easily.
c. irregularly shaped multicolored mole.
d. small, purple, hard nodule beneath the skin surface.
ANS: C
Melanomas clinical hallmark is an
TEirregularly
STBANKshaped
SELLnevus
ER.C(mole),
OM papule, or plaque that has
undergone a change, particularly in color. The other options do not display the characteristic
signs.
DIF: Remembering (Knowledge) REF: MCS: 618 OBJ: 28-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
8. An older adult patient newly diagnosed with peripheral vascular disease (PVD) is being
educated on the possibility of developing a foot ulcer. What assessment finding indicates the
patient may have an ulcer resulting from this disease?
a. Deep, necrotic, and painless sore
b. Shiny, dry, cyanotic skin surrounding the ulcer
c. Ulcer appears shallow, crusty with warm skin
d. Sore that has dull pain and is oozing
ANS: B
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As the disease advances, the extremity develops a cyanotic hue and becomes cool. The skin
becomes thin, shiny, and dry and has an associated loss of hair and thickened nails, all of which
results from the diminished blood supply. This assessment finding indicates PVD.
DIF: Remembering (Knowledge) REF: MCS: 619 OBJ: 28-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
9. An older adult patient has an open, draining wound on the lower medial aspect of the right leg.
The skin surrounding the wound is reddish brown with surrounding erythema and edema. Based
on this information, the nurse edits the patients care plan to include impaired skin integrity:
a. related to altered venous circulation.
b. peripheral related to arterial insufficiency.
c. related to diabetic neuropathy.
d. open wound related to pressure ulcer.
ANS: A
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Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and
irregular borders, accompanied by varicosities, liposclerosis (brown ruddy color and thickened
skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded
by erythema and edema. Arterial insufficiency would produce shiny, taut, hairless skin. There is
no indication the patient is a diabetic. There is no indication the patient has risks for pressure
ulcers.
DIF: Applying (Application) REF: N/A OBJ: 28-5
TOP: Nursing Process: Analysis MSC: Physiologic Integrity
10. When assessing for squamous cell cancer (SCC), a home health nurse is particularly
concerned about a suspicious lesion on the:
a. leg of a 60-year-old Asian female.
b. neck of a 73-year-old Hispanic female.
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c. Lower lip of a 70-year-old African American male.
d. back of a 90-year-old Caucasian male.
ANS: C
SCC is skin cancer arising from the epidermis and is found most often on the scalp, outer ears,
lower lip, and dorsum of the hands. Approximately 90% of lip lesions can be attributed to
squamous cell carcinoma. SCC is more common in men and older adults. SCC is the most
common skin cancer in African-Americans.
DIF: Remembering (Knowledge) REF: MCS: 617 OBJ: 28-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
11. A 65-year-old man is seen in the outpatient clinic for treatment of psoriasis. The nurse
educates the patient to the possibility of developing:
a. alopecia.
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b. orange-tinged urine.
c. yellow-brown nails.
d. cherry angiomas.
ANS: C
Changes in the nails occur in approximately 30% of patients and consist of yellow-brown
discoloration with pitting, dimpling, separation of the nail plate from the underlying bed
(oncolysis), thickening, and crumbling.
DIF: Understanding (Comprehension) REF: MCS: 610 OBJ: 28-3
TOP: Teaching-Learning MSC: Physiologic Integrity
12. The nurse of a bedridden 74-year-old woman is evaluating whether the family members
understand how to position the patient correctly. The nurse is confident the family is capable of
effective positioning when it is observed that the patients:
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a. arms and legs are supported on two pillows.
b. position is changed at least every 2 hours.
c. neck is hyperflexed.
d. elbows rest on the bed.
ANS: B
In the 1950s, Kosiak (1958) found that pressure applied to rabbits ears over 2 hours would result
in ulceration. Thus, the universal recommendation of turning every 2 hours was established. The
other observations do not show the family necessarily understands effective positioning if the
patient is not turned.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 28-6
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
13. An older diabetic patient reports a candidiasis infection. When asked, the patient states all
STBrange.
ANKSWhat
ELLaction
ER.Cby
OMthe nurse is best?
blood sugars have been within theTE
target
a. Facilitate having a hemoglobin A1c drawn.
b. Teach the patient preventive measures.
c. Teach the patient about the side effects of medications.
d. Review the patients medication history.
ANS: A
Often candidiasis infections in diabetics indicate hyperglycemia. The patient may or may not be
truthful about the blood sugar reports, or the patient may be missing periods of hyperglycemia
when testing. The nurse should consult with the provider about checking an A1C. The other
options are appropriate as well but do not give information as to the background cause.
DIF: Applying (Application) REF: N/A OBJ: 28-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
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14. An older patient has been treated for a small basal cell carcinoma on the face. What
assessment finding indicates to the nurse that the goals for a priority diagnosis have been met?
a. The patient verbalizes relief there is no metastasis.
b. Wound edges are approximated without redness.
c. The patient expresses satisfaction with the cosmetic outcome.
d. The patient relates the need for proper sun protection.
ANS: B
All findings indicate positive resolution of various nursing diagnoses. However, physical
diagnoses take priority, so the best response is the one that indicates lack of infection.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 28-4
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
15. In creating community education
the nurse places the highest
TESon
TBvarious
ANKStypes
ELLEofRskin
.COcancer,
M
priority on early diagnosis of melanoma because:
a. it accounts for the largest number of mortalities.
b. extensive surgery can be avoided if caught early.
c. once it has spread there is no chance of curing it.
d. it is the most commonly occurring skin cancer.
ANS: A
Melanoma only accounts for 5% of skin cancer diagnoses but causes 75% of skin cancer
mortality. Therefore, it is critical that the condition is diagnosed promptly.
DIF: Remembering (Knowledge) REF: MCS: 618 OBJ: 28-4
TOP: Teaching-Learning MSC: Health Promotion
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16. An older diabetic patient has impaired mobility and decreased vision. The nurse examines the
patients feet at each clinical visit. The patient asks why this is necessary. What response by the
nurse is best?
a. Its part of our diabetic clinic visit protocol.
b. You may not be able to see a sore on your feet.
c. Limited mobility may keep you from checking your feet.
d. You may get an ulcer and not be able to feel it.
ANS: D
A diabetic with peripheral neuropathy may not be able to feel injuries on the feet. The injury may
progress to a nonhealing ulcer requiring amputation. If the patient had good sensation to the feet,
not being able to see or limited mobility would not be as big of a barrier because the patient
could report the symptoms. Foot assessment is part of a diabetic clinic protocol.
DIF: Analyzing (Analysis) REF: N/A OBJ: 28-5
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TOP: Teaching-Learning MSC: Physiologic Integrity
17. For which patient does the nurse add compression therapy to the nursing care plan?
a. Taut, white, shiny skin
b. Faint pedal pulses
c. Brownish skin and edema
d. Large ulcer with skin graft
ANS: C
Compression is the mainstay of venous ulcer treatment, and it should be applied when there is
brownish skin and edema. The taut white shiny skin and faint pulses indicate arterial
insufficiency, and compression will compromise circulation in those extremities even further. A
skin graft needs to be protected, as it is vulnerable until healed.
DIF: Analyzing (Analysis) REF: N/A OBJ: 28-5
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TOP: Nursing Process: Planning MSC: Physiologic Integrity
18. The nurse assesses a patient using the Braden scale. The patient scores a 13. What action is
most important to add to the patients care plan?
a. Encourage high-protein meals and snacks
b. Turn the patient every to 2 hours
c. Assess the patients skin daily
d. Monitor patients prealbumin weekly
ANS: B
A Braden scale score of 13 indicates high risk for developing a pressure ulcer. The most
important intervention is to turn the patient frequently. Good nutrition is important for wound
healing and prevention, but a high-protein snack and monitoring prealbumin do not immediately
impact the patients skin condition. Assessing the skin will not prevent an ulcer.
TEN/A
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ANK28-7
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DIF: Applying (Application) REF:
TOP: Nursing Process: Planning MSC: Physiologic Integrity
19. A patient has a purulent, foul-smelling leg wound. What wound care practice is most
appropriate?
a. Leave the wound open to the air.
b. Administer systemic antibiotics.
c. Cleanse the wound with diluted povidone iodine.
d. Prepare the patient for operative dbridement.
ANS: C
Antiseptics are not used on healthy granulating tissue. Povidone iodine must be diluted and only
used short term. A moist environment is needed for healing; leaving the wound open to air will
cause too much drying. The patient may eventually need operative dbridement. Systemic
antibiotics may or may not be needed.
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DIF: Applying (Application) REF: N/A OBJ: 28-10
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
20. A patient has a wound that is a shallow crater with surrounding erythema and warmth. What
stage pressure ulcer does the nurse chart?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
ANS: B
Stage II is a partial thickness ulcer that looks like an abrasion, blister, or shallow crater. A stage I
pressure ulcer is redness or mottled skin that does not blanch. Stage III ulcers are full thickness
deep craters. Stage IV ulcers may extend into the fascia and may be necrotic.
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DIF: Remembering (Knowledge) REF: MCS: 630-1 OBJ: 28-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. The nurse knows that several age-related changes in the integumentary system increase older
adults risk for pressure ulcers. Which factors does this include? (Select all that apply.)
a. Poor nutrition
b. Living in a nursing home
c. Thinning epidermis
d. Decreased skin elasticity
e. Vessel degeneration
ANS: C, D, E
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Thinning epidermis, decreased elasticity of the skin, and deterioration of the vasculature are all
age-related changes increasing risk of pressure ulcer development. Poor nutrition and living in a
nursing home are not expected age-related changes.
Chapter 24 Sleep and Rest
MULTIPLE CHOICE
1. A patient reports to the nurse that he seems to be sleeping less at night but now regularly
requires at least two short naps a day. He expresses a concern that something is wrong. The nurse
responds that:
a. Aging alters our sleep patterns, so what you describe is really quite common.
b. Circadian sleep rhythms are controlled by the hypothalamus, which is affected by
age.
c. Sleep patterns are affected by so many things; have you been under a lot of stress
lately?
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d. Can you be more specific about what you think is wrong with your sleep pattern?
ANS: A
The decrease in nighttime sleep and the increase in daytime napping that accompanies normal
aging may result from changes in the circadian aspect of sleep regulation.
DIF: Understanding (Comprehension) REF: MCS: 203-4 OBJ: 11-1
TOP: Teaching-Learning MSC: Physiologic Integrity
2. What is the best bedtime snack for older adult patients with failure to thrive and insomnia?
a. Ice cream in a waffle cone
b. Bowl of grapes
c. Glass of milk and a macaroon cookie
d. Cup of cream of broccoli and cheese soup
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ANS: D
This patient will benefit from a snack that includes protein and is warm while not providing
excessive liquids.
DIF: Remembering (Knowledge) REF: MCS: 206 OBJ: 11-1
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
3. An older patient is being admitted to an acute care unit after surgical repair of a fractured tibia.
To minimize any negative factors affecting the patients ability to sleep, the nurses initial
intervention is to:
a. be sure postoperative pain is being well managed.
b. manipulate the environment to manage light and noise.
c. plan care to minimize the number of times the patient is disturbed.
d. ask the patient about usual sleeping habits.
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ANS: D
Nurses can promote sleep by first assessing the patients usual sleep habits and satisfaction with
sleep. Managing postoperative pain, minimizing environmental stimuli, and encouraging
undisturbed rest are also important, but the first step in the nursing process is assessment.
DIF: Applying (Application) REF: N/A OBJ: 11-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
4. A confused older patient has been hospitalized for a cardiac problem that requires both
antihypertensive and diuretic therapies. The nurse minimizes the patients risk of disturbed sleep
by:
a. keeping the door shut so noise from the hallway is not disruptive.
b. organizing care to minimize the number of times the patient is awakened.
c. administering medications at least 4 hours before bedtime.
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d. offering to toilet the patient whenever the nurse finds the patient awake during the
night.
ANS: C
The diuretic is likely to cause the patient to urinate frequently during the night if not
administered appropriately. Because the patient is confused, the door should be left open.
Clustering cares is a good idea to promote sleep but is not the most important for this patient.
Offering to assist the patient to the bathroom when awake is also a good idea, but it is preferable
to decrease the number of times the patient is awake.
DIF: Applying (Application) REF: N/A OBJ: 11-3
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
5. An older frail adult patient has begun displaying symptoms of sleep disturbance while being
hospitalized. Since these symptoms were observed, the nurse has arranged for a bed alarm to be
placed near the patient because:
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a. lack of adequate sleep can result in delirium.
b. the patient has difficulty using the call light.
c. lack of sleep make the patient at risk for falls.
d. the patient will remember not to get out of bed.
ANS: A
One consequence of lack of sleep for elders is delirium; the bed alarm is an intervention often
used to alert staff when a patient is likely to make an ill-advised attempt at getting out of bed.
The patient may or may not be able to use the call light. The risk of falling increases with
delirium. The alarm may or may not remind the patient not to get out of bed, but it will alert the
staff to go into the room.
DIF: Applying (Application) REF: N/A OBJ: 11-3
TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment
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6. An older patient reports that sleep was being severely affected by the need to urinate
frequently. The patient states he has begun restricting his fluid intake after 5 PM to help with the
problem. The nurse responds:
a. Have you seen a decrease in waking up since you cut back on fluids?
b. You need sufficient fluids, so dont be too restrictive.
c. You need the same amount over 24 hours, so drink enough by dinnertime.
d. Have you had your prostate checked by your health care provider?
ANS: C
It is important that older adults, who as a group are at risk for inadequate fluid intake and
dehydration, not reduce the total amount of liquids drunk in 24 hours. This is a common issue in
the older population, so the nurse educates the patient on the amount of fluid he or she needs in a
24-hour period. Telling the patient dont be too restrictive does not give the patient information to
make an informed decision on fluids. The other two questions are good assessment questions, but
physiologic safety and maintenance are more important.
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DIF: Understanding (Comprehension) REF: MCS: 206 OBJ: 11-7
TOP: Teaching-Learning MSC: Health Promotion
7. An older patient being treated for symptoms of seasonal allergies reports to the nurse that
although she is careful about her caffeine intake, she has been having trouble getting to sleep at
night. The nurse responds most appropriately to this patient when stating:
a. Allergy reactions such as nasal stuffiness can cause sleep problems.
b. If you are using over-the-counter nasal decongestants, that could be the problem.
c. Many different foods contain hidden caffeine; be sure to check the labels.
d. There are many different causes of sleep disturbances besides caffeine intake.
ANS: B
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Over-the-counter medications that interfere with sleep include nasal decongestants containing
amphetamine-like substances. This is most important for this patient who has allergies. Food
labels do not always contain information on caffeine. Although there are different causes of sleep
disturbances, this options does not really give the patient useful information.
DIF: Understanding (Comprehension) REF: MCS: 207 OBJ: 11-3
TOP: Teaching-Learning MSC: Physiologic Integrity
8. The daughter of an older cognitively impaired patient responds to the nurses suggestion to
keep her father physically active by stating, Dad is so easily agitated it would be a major battle to
take him on a walk. The nurses initial response is based on the understanding that:
a. caregivers are often overwhelmed by the challenges of caring for such patients.
b. physical exercise has been proven helpful in managing anger in such patients.
c. exercise such as walking is likely to appeal to patients such as her father.
d. her fathers general health and wellness will be positively affected by walking.
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ANS: B
Physical exercise for the older adult with dementia is important for general physical well-being,
but for this patient exercise may also reduce agitation. Exercise may also cause fatigue, leading
to better sleep.
DIF: Understanding (Comprehension) REF: MCS: 211| MCS: 213
OBJ: 11-9 TOP: Teaching-Learning MSC: Physiologic Integrity
9. The nurse is preparing to instruct a family member regarding how to appropriately assist a 76year-old patient incorporate a healthy daily walk into the familys routine. The nurse includes a
suggestion that:
a. a 30-minute walk after dinner is the best form of exercise for someone that age.
b. if the patient appears to be having difficulty talking while walking, it is time to
stop.
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c. the patient should be encouraged to walk a few feet farther each evening.
d. the family member selects a flat, easily accessible walking path to follow.
ANS: B
To measure the appropriate intensity while walking for exercise, many apply the talk test: the
person exercising should be able to carry on a conversation while walking. Breathing may be
slightly labored, but a conversation should still be possible. The walker should not be out of
breath. The other suggestions may or may not be appropriate for individual patients.
DIF: Understanding (Comprehension) REF: MCS: 213 OBJ: 11-9
TOP: Teaching-Learning MSC: Health Promotion
10. An older adult patient who has been seen at a neighborhood clinic for years tells the nurse
that he will be moving to live with his son in a neighboring state. The nurse impacts the patients
health and wellness the most therapeutically when stating:
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a. Be sure to reestablish with a health care provider as soon as you get settled.
b. You seem to have a good relationship with your son; Im sure this will be a good
move.
c. You need to continue to be compliant with your plan of care regardless of where
you live.
d. Moving often causes temporary sleep disturbances, so stick to your evening
routine.
ANS: D
Relocation often causes sleep disturbances as the person adjusts to a new environment.
Maintaining an established evening routine will help the patient sleep better. The other
statements do not affect sleep.
DIF: Understanding (Comprehension) REF: MCS: 205 OBJ: 11-7
TOP: Teaching-Learning MSC: Health Promotion
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11. A patient in the early stage of Alzheimer disease is being admitted to an assisted living
facility. The admitting nurse best addresses the patients need for appropriate physical activity
when:
a. asking the patient about activities done for recreation.
b. showing the patient the exercise equipment available.
c. having the activity coordinator visit with the patient.
d. teaching the patient the connection between activity and memory.
ANS: A
The activity preferences of each resident should be assessed on admission in order to identify
activities that the patient is likely to participate in. Keeping the patient busy and active will
promote sleep. The other options are also appropriate, but assessing the patients preferences for
leisure activity is the first step.
DIF: Applying (Application) REF: N/A OBJ: 11-10
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TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
12. A patient with moderate dementia has been admitted to a long-term care facility. To address
the patients need to be engaged in purposeful activity, the nurse arranges for the patient to:
a. fold some of the units freshly washed washcloths and towels each afternoon.
b. help decide what television programs will be on in the dayroom.
c. be responsible for changing the day calendar each morning.
d. remind other diabetic patients when it is time for their finger sticks.
ANS: A
A meaningful activity has a purpose. The purpose may be to exercise arthritic joints or simply to
have fun, but the activity should not be aimless or inappropriate for the patients ability. With
dementia, the other activities are not appropriate and could lead to frustration.
DIF: Applying (Application) REF: N/A OBJ: 11-10
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TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
13. An older patient reported to the clinic nurse that since a grandson moved in a few months
ago, the patient has had problems sleeping. Which question by the nurse is most appropriate?
a. How do you feel about having a roommate?
b. Was it your decision to invite him to move in?
c. Has your sleep pattern changed since he moved in?
d. Can you be more specific about the trouble you have sleeping?
ANS: C
The introduction of a new roommate often disrupts established sleep patterns, causing sleep
disturbances. The nurse should also gather information on the specifics of the problem but
should start with the event that the patient relates as the start of the issue.
DIF: Applying (Application) REF: N/A
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14. The nurse is caring for a hospitalized patient who needs vital signs and assessments every 4
hours. The nurse last assessed the patient at midnight, and at 2 AM the nurse answers the call
light and helps the patient to the bathroom. To promote good sleep, what action by the nurse is
best?
a. Ask the patient if a sleeping medication is needed.
b. Assess the patient now and again at 6 AM.
c. Tell the patient you will be back in 2 hours.
d. Assess the patient at 4 AM while being very quiet.
ANS: B
The nurse can use judgment to assess the patient more often than ordered. In this case, assessing
the patient 2 hours early and rescheduling the next assessment conforms to the prescribed
maximum time between assessments and allows the patient 4 hours of uninterrupted rest. The
patient may or may not want a sleeping pill, but sleep without medication is best.
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DIF: Applying (Application) REF: N/A OBJ: 11-6
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
15. A patient is discussing retirement with a nurse. What suggestion pertaining to sleep does the
nurse offer?
a. Keep your same bedtime and nighttime routines.
b. If you nap during the day you can stay up later.
c. You wont need so much sleep to be rested for work.
d. Sleeping in will help revitalize your energy level.
ANS: A
For some, retirement comes with loss of daily structure, which can affect bedtime and nighttime
routines, making sleeping difficult. For best sleep the nurse suggests the patient maintain the
familiar schedule.
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DIF: Understanding (Comprehension) REF: MCS: 205 OBJ: 11-6
TOP: Teaching-Learning MSC: Physiologic Integrity
16. The nurse caring for older patients would prepare to administer which medication as a shortterm sleep aid?
a. Diazepam (Valium)
b. Diphenhydramine (Benadryl)
c. Chloral hydrate (Somnote)
d. The nurse would try other measures first
ANS: D
Benzodiazepines, hypnotics, and antihistamines all have serious side effects when taken by the
older population. Especially in the confused patient, the nurse should try other comfort measures
first, like sticking to an established nighttime routine to cue the patient to bedtime.
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DIF: Applying (Application) REF: N/A OBJ: 11-6
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
17. A patient reports waking up with frequent headaches and sore throat. What question by the
nurse is most appropriate?
a. Does acetaminophen (Tylenol) provide relief?
b. Does your partner say you snore at night?
c. Do you drink enough water during the day?
d. Do you ever wake up with night sweats?
ANS: B
Waking up with headaches and sore throat are manifestations of sleep apnea. Family members
often say the patient snores loudly during the night and wakes up gasping. The nurse should
assess for these other signs of the disorder. The other questions may or may not be appropriate if
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the patient does not snore at night.
DIF: Applying (Application) REF: N/A OBJ: 11-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
18. A patient wants to use an herbal preparation to help with decreased sleep. What response by
the nurse is best?
a. There are no research studies on these herbal preparations.
b. Why dont you try exercise during the day first?
c. Have you had a physical exam any time recently?
d. Why do you want to use an herbal product for insomnia?
ANS: C
Sleep disturbances, especially new ones, may signify a physical illness. Before simply taking
medications or supplements to treat the sleep disorder, the patient should have a physical exam to
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rule out a physical cause for the problem. The other statements are not appropriate because for
patient safety, he or she should have a checkup.
DIF: Applying (Application) REF: N/A OBJ: 11-6
TOP: Communication and Documentation MSC: Physiologic Integrity
19. The nurse needs to awaken a patient to take medication in the middle of the night. The
patient has not had any sleeping medications or other preparations that would cause drowsiness.
The nurse has to use vigorous stimulation to awaken the patient. What stage of sleep is this
patient most likely in?
a. Stage 1, nonrapid eye movement (REM)
b. Stage 2, non-REM
c. Stage 3, non-REM
d. Stage 4, non-REM
ANS: D
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In stage 4 of non-REM sleep, the person needs vigorous stimulation to be awakened. In stage 1,
the person is awakened easily, as in stage 2. Stage 3 requires moderate stimulation.
DIF: Remembering (Knowledge) REF: MCS: 203-4 OBJ: 11-3
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
20. A patient has chronic, severe asthma and takes many medications during the day. The patient
reports difficulty falling asleep at night. What medication does the nurse ask about the patient
taking?
a. Barbiturates
b. Theophylline (Theo-24)
c. Furosemide (Lasix)
d. Haloperidol (Haldol)
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ANS: B
Theophylline is associated with difficulty falling asleep and is sometimes used in patients with
asthma. The other medications are not associated with this sleep disorder or with asthma.
DIF: Applying (Application) REF: N/A OBJ: 11-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
21. The nurse has instituted bedtime routines for patients with dementia in a long-term care
facility. What assessment findings best indicate the program is effective?
a. Patients are more alert and oriented during the day.
b. Patients fall asleep within 20 to 30 minutes of going to bed.
c. Patients appear happier and more interested in activities.
d. Patients on diuretics awake less often during the night.
ANS: B
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People should be able to fall asleep within 20 to 30 minutes after going to bed, so this assessment
finding best indicates the program is working.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 11-6
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. When assessing a patients report of experiencing problems sleeping, the nurse gathers data
related to which of the following? (Select all that apply.)
a. The patient has difficulty falling asleep.
b. The patient wakes up frequently during the night.
c. The patient finds it difficult to stay asleep.
d. The patient experiences vivid dreams while sleeping.
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e. The patient has taken sleeping medication in the past.
ANS: A, B, C
Characteristics of the sleep disturbance include difficulty falling asleep, difficulty staying,
asleep, frequent nocturnal awakenings, early morning awakening, and daytime sleepiness. An
assessment should include questions related to the presence of these symptoms. Vivid dreams
and sleeping medication are also part of a sleep history but are not characteristics of sleep
disorders.
DIF: Understanding (Comprehension) REF: MCS: 209 OBJ: 11-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
2. The nurse who works with older patients explains the age-related changes in sleep to a student.
Which statements are consistent with this knowledge? (Select all that apply.)
a. The amount of time spent in REM sleep increases.
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b. REM sleep is interrupted more by awakening at night.
c. People spend more time in the lightest stage of sleep.
d. Stages 3 and 4 of non-REM sleep are not as deep.
e. Changes in circadian rhythm can affect sleep.
ANS: B, C, D, E
As people age, the amount of time spent in REM sleep decreases, and this stage of sleep is
interrupted more often by waking up at night. Stage 1 is the lightest stage of sleep and people
tend to spend more sleep time in this stage as they age. Stages 3 and 4 are not as deep. The
decrease in nighttime sleeping and increase in daytime napping can be attributed to alterations in
circadian rhythms.
Chapter 25 Thermoregulation
Question 1
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Type: MCSA
An older patient is diagnosed with an infection but has a subnormal body temperature. What
should the nurse explain to the patients family as the reason for this discrepancy?
1. The temperature regulating mechanism changes with aging.
2. The patient is on medication that drops the body temperature.
3. The diagnosis of an infection is inaccurate and will be checked.
4. The temperature was measured incorrectly and will be repeated.
Correct Answer: 1
Rationale 1: An elevated temperature is a common sign of infection but may not be present in
the frail older adult.
Reference: MCS: 297
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Rationale 2: There is no information to support that the patient is receiving antipyretics that
would alter the patients body temperature.
Reference: MCS: 297
Rationale 3: The nurse should not state that the patient received an inaccurate diagnosis. This
would have the family question the quality of care the patient is receiving.
Reference: MCS: 297
Rationale 4: There is no evidence to suggest that the patients temperature was measured
incorrectly.
Reference: MCS: 297
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
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Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe normal skin changes associated with aging.
Question 2
Type: MCSA
An older patient is recovering from abdominal surgery. Which skin changes will the nurse
consider when planning care for this patient?
1. The healing time is increased.
2. The healing time is decreased.
3. There is a need to keep the wound edges taped.
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4. Skin near the wound needs to be massaged to increase blood flow.
Correct Answer: 1
Rationale 1: Epidermal mitosis slows 30% after the age of 50, resulting in longer healing time
for older persons.
Reference: MCS: 286
Rationale 2: The healing time in older persons is increased because of the slowing of epidermal
mitosis.
Reference: MCS: 286
Rationale 3: Taping the wound edges would cause damage to the skin.
Reference: MCS: 286
Rationale 4: Massaging the skin would cause further damage to the skin.
Reference: MCS: 286
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Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 1. Describe normal skin changes associated with aging.
Question 3
Type: MCSA
The home care nurse notes that an older patient who lives alone has a large red mark on the arm.
When asked about the mark the patient states unawareness of the injury and believes it occurred
from hot water when cooking. How should the nurse interpret this finding?
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1. The patient is at risk for further injury.
2. The patient is losing short-term memory.
3. The patient is experiencing friction tears of the skin.
4. The patient is demonstrating senile purpura of the skin.
Correct Answer: 1
Rationale 1: With normal aging there is a gradual decline in both touch and pressure sensations,
causing the older adult to be at risk for injury such as burns and pressure sores.
Reference: MCS: 288
Rationale 2: There is no indication that the patient has memory loss.
Reference: MCS: 288
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Rationale 3: A skin tear is a dramatic separation of the dermis.
Reference: MCS: 288
Rationale 4: Bruised or discolored skin would be seen in senile purpura.
Reference: MCS: 288
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 1. Describe normal skin changes associated with aging.
Question 4
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Type: MCMA
An older patient is recovering from surgery to repair a fractured hip. What interventions will the
nurse use to prevent the development of a pressure ulcer in this patient?
Standard Text: Select all that apply.
1. Avoid sitting unless for meals.
2. Use pillows to protect the skin.
3. Reposition the patient every 2 hours.
4. Keep the skin dry with frequent bathing.
5. Encourage independent position changes.
Correct Answer: 1,2,3,5
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Rationale 1: Interventions to prevent pressure ulcer formation include avoiding the sitting
position unless it is for meals.
Reference: Pages 302, 305
Rationale 2: Interventions to prevent pressure ulcer formation include using pillows to protect
the skin.
Reference: Pages 302, 305
Rationale 3: Interventions to prevent pressure ulcer formation include repositioning the patient
every 2 hours.
Reference: Pages 302, 305
Rationale 4: Frequent bathing could dry out the skin and encourage the formation of ulcers,
wounds, and skin tears.
Reference: Pages 302, 305
Rationale 5: Interventions to prevent pressure ulcer formation include encouraging the patient to
make independent position changes.
TESEven
TBAsmall
NKSshifts
ELLEredistribute
R.COM the body weight and improve
perfusion of the tissue.
Reference: Pages 302, 305
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.
Question 5
Type: MCSA
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What instruction should the nurse provide to a nursing assistant who is assigned to care for an
older patient with a stage I pressure ulcer on the right heel?
1. Apply a dry dressing to the site.
2. Apply a donut under the right heal.
3. Cleanse the area with tepid water without soap.
4. Keep the head of the bed elevated to a 45-degree angle.
Correct Answer: 3
Rationale 1: A dry dressing is not indicated for this type of pressure ulcer.
Reference: MCS: 305
Rationale 2: Mechanical devices can exacerbate pressure ulcers and should not be used.
Reference: MCS: 305
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Rationale 3: The area at risk for pressure sore development should be washed gently with tepid
water, with or without minimal soap. Soap removes natural oils from the skin, and cleaning the
soap off may cause additional friction damage.
Reference: MCS: 305
Rationale 4: Elevating the head of the bed at a 45-degree angle increases pressure on the sacrum
and lower extremities which could cause the pressure ulcer to become worse.
Reference: MCS: 305
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
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Learning Outcome: 6. Explain the nursing management principles related to the care of
pressure ulcers.
Question 6
Type: MCSA
While assessing an older patients stage III pressure ulcer the nurse notes that the wound is beefy
red and grainy, and the depth has decreased by 2 mm but the width has not changed. How should
the nurse interpret this assessment finding?
1. Not healing properly
2. About to slough off tissue
3. No longer at risk for infection
4. Progressing positively toward healing
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Correct Answer: 4
Rationale 1: The wound color, texture, and decreasing depth all indicate that the wound is
healing properly.
Reference: MCS: 296
Rationale 2: The wounds color, texture, and depth do not indicate that tissue is going to be
sloughed off.
Reference: MCS: 296
Rationale 3: Any open wound is at risk for infection.
Reference: MCS: 296
Rationale 4: Healing of a decubitus fills from the wound bottom so the depth decreases before
the wound width decreases. The beefy red and grainy appearance is evidence of granulation
tissue as the capillary bed builds. These are all indicators of good wound healing.
Reference: MCS: 296
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Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 6. Explain the nursing management principles related to the care of
pressure ulcers.
Question 7
Type: MCSA
The nurse is caring for an older patient who previously had a sacral pressure ulcer that has
completely healed. What does the nurse recognize as a characteristic of the previously healed
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pressure ulcer?
1. Heal faster if reinjured
2. Break down faster if reinjured
3. Have no sensation in the injured area
4. Be at risk for infection even with intact skin
Correct Answer: 2
Rationale 1: This site will not heal faster if reinjured. The wound will never reach the prewound strength.
Reference: MCS: 296
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Rationale 2: Scarred wounds never reach the prewound strength and are more prone to reinjury
than normal tissue.
Reference: MCS: 296
Rationale 3: Sensation does return to the skin of a pressure ulcer.
Reference: MCS: 296
Rationale 4: Intact skin does not increase the risk for infection.
Reference: MCS: 296
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing
TESTBProcess:
ANKSEAssessment
LLER.COM
Learning Outcome: 6. Explain the nursing management principles related to the care of
pressure ulcers.
Question 8
Type: MCMA
After an assessment the nurse is concerned that an older patient is at risk for pressure ulcer
development because of the current nutritional status. What nutritional factors did the nurse
assess in the patient?
Standard Text: Select all that apply.
1. Diagnosis of dehydration
2. Hemoglobin level 9 mg/dL
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3. Treatment for chronic renal failure
4. Serum albumin level below normal
5. Loss of 20 pounds over the last 3 months
Correct Answer: 1,2,4,5
Rationale 1: Nutritional factors associated with pressure ulcer development include dehydration.
Reference: MCS: 295
Rationale 2: A hemoglobin level of 9 mg/dL indicates anemia, which is a nutritional factor
associated with pressure ulcer development.
Reference: MCS: 295
Rationale 3: Chronic renal failure is not specifically associated with the development of pressure
ulcer formation.
Reference: MCS: 295
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Rationale 4: Nutritional factors associated with pressure ulcer development include a decreased
serum albumin level.
Reference: MCS: 295
Rationale 5: Nutritional factors associated with pressure ulcer development include decreased
body weight.
Reference: MCS: 295
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Assessment
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Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.
Question 9
Type: MCMA
Which over-the-counter skin preparations should the nurse instruct an older patient to use with
caution?
Standard Text: Select all that apply.
1. Sunblock
2. Super-fatted soaps
3. Emollients that keep the skin moist
4. Steroid-based ointments and creams
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5. Topical lotion with an antihistamine
Correct Answer: 4,5
Rationale 1: Sunblock is appropriate to protect for UV exposure to the sun.
Reference: MCS: 300
Rationale 2: Super-fatted soaps are appropriate treatments for dry skin.
Reference: MCS: 300
Rationale 3: Emollients are an appropriate treatment for dry skin.
Reference: MCS: 300
Rationale 4: Older adults have a high rate of adverse reactions to corticosteroids, which are
frequently prescribed for skin problems. Older adults should be reminded not to buy over-thecounter preparations of this drug without specific instructions from the primary care provider. If
this medication is prescribed, directions should be strictly followed and any unusual symptoms
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reported promptly.
Reference: MCS: 300
Rationale 5: Older adults have a high rate of adverse reactions to antihistamines, which are
frequently prescribed for skin problems. Older adults should be reminded not to buy over-thecounter preparations of this drug without specific instructions from the primary care provider. If
this medication is prescribed, directions should be strictly followed and any unusual symptoms
reported promptly.
Reference: MCS: 300
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Pharmacological and Parenteral Therapies
TESTBProcess:
ANKSEImplementation
LLER.COM
Nursing/Integrated Concepts: Nursing
Learning Outcome: 5. Discuss the nursing responsibilities related to pharmacological and
nonpharmacological treatment of common skin problems.
Question 10
Type: MCMA
The nurse is preparing to cleanse an older patients abdominal wound. Which techniques should
the nurse use to perform this action?
Standard Text: Select all that apply.
1. Pour saline over the wound.
2. Apply saline-soaked gauze over the wound.
3. Squeeze a saline-filled syringe over the wound.
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4. Place gauze pads soaked with hydrogen peroxide on the wound.
5. Apply dry gauze pads over the wound and saturate with sterile water.
Correct Answer: 1,2,3
Rationale 1: Wound cleansing can be done by pouring saline over the wound.
Reference: MCS: 307
Rationale 2: Wound cleansing can be done by applying saline-soaked gauzes over the wound to
clean the debris from the wound bed.
Reference: MCS: 307
Rationale 3: Wound cleansing can be done by squeezing a saline-filled bulb syringe over the
wound.
Reference: MCS: 307
Rationale 4: Placing gauze pads soaked with hydrogen peroxide on the wound is not a
TEa Swound.
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recommended approach to cleanse
Reference: MCS: 307
Rationale 5: Applying dry gauze pads over the wound and saturating with sterile water is not a
recommended approach to cleanse a wound.
Reference: MCS: 307
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 6. Explain the nursing management principles related to the care of
pressure ulcers.
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Question 11
Type: MCSA
The nurse provides a seminar on the impact of the sun on the skin with a group of older
community members. Which statement indicates that additional teaching is necessary?
1. Sunscreen is important to wear during all daytime hours.
2. The sun should be avoided between the peak hours of 10 a.m. and 4 p.m.
3. African Americans can experience sun damage despite the dark skin tones.
4. The melanocytes in the subcutaneous tissue protect the skin from sun damage.
Correct Answer: 4
Rationale 1: Sunscreen is important to wear during all daytime hours. This statement does not
indicate that additional teaching is necessary.
Reference: MCS: 284
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Rationale 2: The sun should be avoided between the peak hours of 10 a.m. and 4 p.m. This
statement does not indicate that additional teaching is necessary.
Reference: MCS: 284
Rationale 3: African Americans can experience sun damage despite the dark skin tones. This
statement does not indicate that additional teaching is necessary.
Reference: MCS: 284
Rationale 4: Melanocytes are located in the epidermal skin layers and not the subcutaneous
tissue. This statement indicates that additional teaching is necessary.
Reference: MCS: 284
Global Rationale:
Cognitive Level: Analyzing
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Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.
Question 12
Type: MCMA
While performing a physical assessment, the nurse notes that an older patient has multiple brown
and black bands on the finger nails of the thumbs and index fingers. What does this assessment
finding indicate to the nurse?
Standard Text: Select all that apply.
1. A fungal infection
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2. Damage to the nail matrix
3. Possible melanoma of the nail
4. Benign finding often seen in African Americans
5. Finger nails split in response to recent trauma
Correct Answer: 3,4
Rationale 1: This finding is a longitudinal pigmented band and is not associated with a fungal
infection.
Reference: MCS: 289
Rationale 2: This finding is a longitudinal pigmented band and is not associated with damage to
the nail matrix.
Reference: MCS: 289
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Rationale 3: This finding is a longitudinal pigmented band and may indicate possible melanoma
of the nail.
Reference: MCS: 289
Rationale 4: This finding is a longitudinal pigmented band, is common in dark-skinned races,
and is more visible in the older adult.
Reference: MCS: 289
Rationale 5: This finding is a longitudinal pigmented band and does not mean the finger nails
are going to split in response to trauma.
Reference: MCS: 289
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.
Question 13
Type: MCMA
An older patient complains about increasing dry skin. What should the nurse explain to the
patient about this skin problem?
Standard Text: Select all that apply.
1. There is a reduction in sebum production as the body ages.
2. There is a decrease in the number of sweat glands in the body with aging.
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3. There is a change in the keratinization and lipid content in the stratum corneum.
4. There is an increase in body core temperature with aging, resulting in skin drying.
5. There is a change in the structure of the skin cell because of years of using alcohol-based
soaps.
Correct Answer: 1,3
Rationale 1: Sebum is an oily substance that keeps hair supple and lubricates the skin. Sebum
protects the skin from water loss and provides protection against infection. Sebaceous glands
increase in size with age, but the amount of sebum produced is decreased. This would explain
why the older patient is experiencing increasingly dry skin.
Reference: MCS: 289
Rationale 2: The number of sweat glands does decrease with aging but does not have a role in
the reduction of the production of sebum.
Reference: MCS: 289
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Rationale 3: Changes in the keratinization process and lipid content in the stratum corneum
cause the flaking appearance and dry sensation of the skin.
Reference: MCS: 289
Rationale 4: Changes in body temperature do not impact the dryness of the older patients
skin. Reference: MCS: 289
Rationale 5: The older patients complaint of increasingly dry skin is not because of years of
using alcohol-based soaps.
Reference: MCS: 289
Global Rationale:
Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 1. Describe normal skin changes associated with aging.
Question 14
Type: MCSA
An older patient recently diagnosed with skin cancer does not understand why the disease
developed since sunbathing has always been avoided. How should the nurse respond to this
patient?
1. Can you tell me more about your feelings?
2. Sun exposure can happen from driving a car.
3. We frequently never find out why cancer strikes.
4. This is unusual, as skin cancer normally only occurs in sunbathers.
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Correct Answer: 2
Rationale 1: Asking the patient to explain feelings does not answer the patients question. This is
an inappropriate response for the nurse to make.
Reference: MCS: 289
Rationale 2: Sun exposure can occur from routine activities such as driving or riding in a car.
Reference: MCS: 289
Rationale 3: Stating that we frequently never find out why cancer strikes does not answer the
patients question. This is an inappropriate response for the nurse to make.
Reference: MCS: 289
Rationale 4: Stating that skin cancer normally only occurs in sunbathers is an inaccurate
response. Skin cancer can occur after sun exposure, regardless how the sun exposure occurs.
Reference: MCS: 289
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Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk Potential
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 3. Delineate skin changes associated with benign and malignant skin
changes.
Question 15
Type: MCMA
The nurse is preparing discharge instructions for an older patient. For which medications should
the nurse teach the patient to avoid extended sun exposure?
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Standard Text: Select all that apply.
1. Aspirin
2. Ibuprofen
3. Amiodarone
4. Promethazine
5. Acetaminophen
Correct Answer: 2,3,4
Rationale 1: Aspirin is not a medication that causes skin sensitivity.
Reference: MCS: 290
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Rationale 2: Ibuprofen is a medication that causes skin sensitivity.
Reference: MCS: 290
Rationale 3: Amiodarone is a medication that causes skin sensitivity.
Reference: MCS: 290
Rationale 4: Promethazine is a medication that causes skin sensitivity.
Reference: MCS: 290
Rationale 5: Acetaminophen is not a medication that causes skin sensitivity.
Reference: MCS: 290
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Reduction of Risk
TESPotential
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Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 2. Identify risk factors related to common skin problems of older adults.
Question 16
Type: MCSA
The nurse notes a small, indurated, scaled spot on the upper chest of an older patient. Which type
of skin condition did the nurse assess in this patient?
1. Actinic keratosis
2. Basal cell carcinoma
3. Malignant melanoma
4. Squamous cell carcinoma
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Correct Answer: 4
Rationale 1: Actinic keratosis is a precancerous condition. The lesion appears as a sore, rough,
scaly plaque.
Reference: MCS: 291
Rationale 2: Basal cell carcinoma presents as a small fleshy bump.
Reference: MCS: 291
Rationale 3: Malignant melanoma manifests as black, brown, or multicolored nodules or
plaques.
Reference: MCS: 291
Rationale 4: Squamous cell carcinoma most often appears as a flesh-colored, erythematous,
indurated scaly plaque.
Chapter 26 Sexual Function
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MULTIPLE CHOICE
1. Which statement made by a nurse reflects a lack of understanding regarding sexual intimacy
and the older adult patient?
a. Older adults express less interest in intimacy as both acute and chronic illnesses
develop.
b. Sexual expression is considered an enhancement to the quality of the older adults
life.
c. Expressing sexual needs may be difficult or impossible for some older adults.
d. Interest in physical contact tends to persist throughout life for both genders.
ANS: A
Although the need to express interest in sexuality continues among older adults, they face several
barriers to sexual expression, including problems arising from low desire, aging, disease, and
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medications; societal beliefs; and changes in social circumstances. Sexuality remains important
as people age and develop chronic and acute illnesses.
DIF: Understanding (Comprehension) REF: MCS: 241 OBJ: 13-1
TOP: Teaching-Learning MSC: Psychosocial Integrity
2. A 70-year-old female patient shares with the nurse her concern that recently it takes more time
to achieve an organism. The nurse responds most therapeutically when answering:
a. Youve described a common result of aging for both men and women.
b. If you experience difficulty achieving orgasms, you should discuss that with your
doctor.
c. Your body produces fewer sex hormones now, and you need more stimulation to
climax.
d. I understand your concern. Lets talk more about the changes youve noticed.
ANS: C
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In both genders, the reduced availability of sex hormones in older adults results in less rapid and
less extreme vascular responses to sexual arousal. The nurse should first share this information
with the patient then offer to talk more about concerns. Although this is a normal finding, simply
stating this does not give the woman much information. The nurse should be willing to discuss
sexual concerns with the patient and not just pass the patient along to someone else.
DIF: Understanding (Comprehension) REF: MCS: 223 OBJ: 13-1
TOP: Teaching-Learning MSC: Physiologic Integrity
3. A type 2 insulin-dependent diabetic 70-year-old recently lost his wife and is experiencing
impotence. Besides educating the patient on the normal effects of aging on sexual function, the
nurse should initially include information regarding:
a. the effect that stress has on sexual performance.
b. the effect of diabetes mellitus on the vascular system.
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c. the link between depression and sexual dysfunction.
d. sexual dysfunction related to long-term use of insulin.
ANS: B
Erectile dysfunction (ED) can occur at any age. This patients chronic illness and its effect on the
vascular system have priority when educating the patient about possible causes of ED. After
discussing physiologic causes of ED, the nurse can then turn to psychosocial causes. Physical
issues take priority over psychosocial ones.
DIF: Applying (Application) REF: N/A OBJ: 13-4
TOP: Teaching-Learning MSC: Physiologic Integrity
4. Upon entering the room of a cognitively impaired older adult patient, the nurse observes that
he is exposed and rubbing his genitals. The nurses initial concern is to:
a. alert staff to be aware of this new behavior.
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b. provide the patient with privacy.
c. assess him for possible pain and fever.
d. provide a verbal cue for him to stop the behavior.
ANS: C
Dementia may result in unmet sexual needs resulting in such behavior; however, this behavior
may also indicate pain, hyperthermia, or the need to be freed from a restrained situation. Later
the nurse can inform staff of the behavior, particularly if it is a new behavior, and ensure the
patient has privacy. There is no need to cue the patient to stop this behavior as long as it is done
in a private setting.
DIF: Applying (Application) REF: N/A OBJ: 13-5
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
5. To effectively assess an older adult patients sexual needs, the nurse must initially:
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a. reflect on personal feelings that create barriers to effective communication with
the patient.
b. be familiar with the sexual needs of the older adult population.
c. assess the patients physical capacity to engage in sexual activities.
d. inform the patient of the personal nature of the detailed questioning this
assessment requires.
ANS: A
Nurses may feel intimidated or uncomfortable questioning older adults about their sexual desires
and needs. To effectively assess the patients sexual history, the nurse must first reflect on his or
her personal attitudes concerning sex and the older adult patient. The nurse should also gather
information, assess individual patients, and, if needed, let the patient know the nurse will be
asking questions related to sexuality.
DIF: Understanding (Comprehension) REF: MCS: 243 OBJ: 13-2
TOP: Nursing Process: Assessment
TEMSC:
STBAPsychosocial
NKSELLERIntegrity
.COM
6. An older adult patient recovering from a radical prostatectomy is discussing his postsurgical
care plan with the nurse when he expresses concern about long-term impotence. The nurse
initially responds:
a. Id suggest a consult with a sexuality counselor for you and your partner.
b. When youve healed sufficiently, we can discuss prosthetic devices that help.
c. There are medications called phosphodiesterase inhibitors that minimize that
problem.
d. While postsurgical erectile dysfunction is likely, it is generally temporary.
ANS: D
Radical prostatectomy, a curative treatment for cancer of the prostate gland, involves a massive
disturbance of hormone-producing glands, surrounding nerves, and urinary structures. This often
results in temporary urinary incontinence and impotence. It may take 2 to 3 years to regain
function. Referring the patient so quickly indicates a lack of willingness to discuss the issue.
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Prosthetic devices and medications imply the condition is permanent, and while the patient may
need such assistive devices, the nurse should first provide encouraging information.
DIF: Understanding (Comprehension) REF: MCS: 246 OBJ: 13-4
TOP: Teaching-Learning MSC: Physiologic Integrity
7. The charge nurse on an extended care unit recognizes an immediate need for additional unit
education regarding sexuality and the older adult when overhearing a staff member state:
a. Ive had to tell her to stop touching my breasts twice today.
b. Someone needs to tell him to keep his pants zipped.
c. I realize they have needs, but Im not sure how to handle that.
d. Its sad that Alzheimer disease causes them to become sexual perverts.
ANS: D
Although staff education about the
TEsexuality
STBANand
KSEintimacy
LLER.of
COolder
M adults should include
recognition of cues, desires, and interest in sexual activities, it needs to immediately address
eliminating stereotypes, such as the dirty old man or perverts. The nurse is within his or her
rights to limit behavior that includes touching inappropriately. A male patient may need to be
reminded to keep his pants zipped. The staff member who is unsure how to help with sexual
needs is expressing a legitimate concern.
DIF: Applying (Application) REF: N/A OBJ: 13-6
TOP: Teaching-Learning MSC: Psychosocial Integrity
8. An older adult female patient who has multiple sexual partners asks the nurse if the risk for
contracting HIV really does increase as we age. The nurse shows the best understanding of this
risk when responding:
a. Any time one engages in sex with multiple partners, the risk for contracting HIV
increases.
b. Changes in vaginal tissue and immune function increase the risk, especially if sex
is unprotected.
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c. Unless you are engaging in unprotected oral sex, your risk does not increase
substantially.
d. Yes, your risk of contracting a sexually transmitted disease (STD) including HIV,
dramatically increases as you age.
ANS: B
The age-related thinning of the vaginal mucosa and subsequent vaginal tissue disruption, as well
as age-related reductions in immune function, place older adults at increased risk for HIV
infection. The risk does increase with increasing numbers of sex partners, but this combined with
physical changes is the critical piece of information. HIV can be contracted through any sexual
activity.
DIF: Understanding (Comprehension) REF: MCS: 245 OBJ: 13-3
TOP: Teaching-Learning MSC: Physiologic Integrity
9. Through the open door of the patients room, the nurse observes a male patient and his long-
TEThe
STBnurses
ANKSpriority
ELLERintervention
.COM is directed toward:
term partner in a romantic embrace.
a. reinforcing for the staff the patients intimacy needs.
b. explaining to the patient the challenges that his relationship poses for the staff.
c. offering to discuss the barriers to intimacy that the patient and his partner face.
d. quietly closing the door to address the patients right to privacy.
ANS: D
All patients have the right to sexual expression if they are cognitively capable of making
decisions. No matter the sexual orientation of the patient, privacy should be respected unless the
need for safety is paramount. The nurse should close the door quietly. There is no need for other
action unless the staff members need to be reminded of this information.
DIF: Applying (Application) REF: N/A OBJ: 13-6
TOP: Caring MSC: Psychosocial Integrity
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10. The gerontologic nurse wants to begin assessing concerns related to sexuality among the
population of patients seen in the clinic. What action by the nurse is best?
a. Give the patients questionnaires to fill out.
b. Get permission to discuss sexuality with them.
c. Tell the patients you are now assessing sexuality.
d. Ask the patients if they have concerns about sex.
ANS: B
Many of todays older population grew up when sexuality was not openly discussed, so they may
feel uncomfortable with this topic. The nurse should bring up the subject and ask their
permission to discuss this aspect of their lives. The other options are not as likely to start an
open-ended conversation.
DIF: Applying (Application) REF: N/A OBJ: 13-7
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NKSEPsychosocial
LLER.COMIntegrity
TOP: Communication and Documentation
11. The nursing manager feels that intimacy needs are not being assessed or addressed by the
staff on the unit. What action by the manager is best?
a. Tell the staff sexuality is expected to be assessed.
b. Provide the staff with education on sexuality.
c. Obtain tools for staff to use when assessing sexuality.
d. Allow those with cultural objections to opt out.
ANS: B
Education is the first step in this process. Once staff members understand that sexuality is a
normal part of life at any age, the manager can provide tools for staff to use for assessment.
Simply telling the staff to assess sexuality does not help them overcome their discomfort.
Persons with cultural objections should be given extra time and attention to become comfortable
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with the practice, but they should realize that their patients needs come first. The manager may
be able to negotiate a comfortable agreement with these staff members.
DIF: Applying (Application) REF: N/A OBJ: 13-7
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
12. The nurse notes the patients chart lists dyspareunia as a complaint. What teaching does the
nurse plan to provide?
a. Use of water-soluble lubricants
b. Performing Kegel exercises
c. Deep breathing and relaxation
d. Use of antifungal medications
ANS: A
Dyspareunia is painful intercourse,
causes,
TEwhich
STBAhas
NKseveral
SELLE
R.COone
M of which is vaginal dryness.
The nurse can teach the woman about water-soluble lubricants. Kegel exercises are not related.
Deep breathing and relaxation do not address the physical issue. Antifungal medications are not
warranted.
DIF: Applying (Application) REF: N/A OBJ: 13-4
TOP: Teaching-Learning MSC: Physiologic Integrity
13. The nurse using the permission, limited information, specific suggestions, and intensive
therapy (PLISSIT) model offers specific suggestions when:
a. Referring the patient to a sex therapist.
b. Discussing over-the-counter lubricants.
c. Teaching safer sex practices.
d. Discussing sexual positioning after hip surgery.
ANS: D
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Specific suggestions are those related to concerns about how medical conditions affect or are
affected by sexuality. The nurse discussing positions acceptable after hip replacement surgery is
offering specific suggestions. Referring is the intensive therapy (IT) component. The other two
options fall under limited information (LI).
DIF: Applying (Application) REF: N/A OBJ: 13-7
TOP: Teaching-Learning MSC: Psychosocial Integrity
14. The patient who recently had a radical prostatectomy has the nursing diagnosis of ineffective
sexuality patterns. What assessment by the nurse best indicates that the goals for this diagnosis
have been met?
a. Patient states he can live without sex.
b. Patient says that impotence is temporary.
c. Patient states his needs are being met.
d. Patient asks about medication for ED.
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ANS: C
Goals for this diagnosis are met when the patient is satisfied with means for sexual expression.
The other options do not meet this criterion.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 13-7
TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity
15. An older adult has begun dating after being widowed for many years. The adult confides to
the nurse about having several sexual partners. What action by the nurse is best?
a. Warn the patient that the family may not appreciate the situation.
b. Teach the patient about safer sexual practices including condoms.
c. Ask the patient if there are any medical concerns related to sex.
d. Tell the patient he or she may begin to have feelings of guilt.
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ANS: B
The chances of STDs, including HIV, increase with the increased number of sexual partners.
Many older patients do not know about safer sexual practices, so for patient safety, this is the
priority.
DIF: Applying (Application) REF: N/A OBJ: 13-9
TOP: Teaching-Learning MSC: Psychosocial Integrity
16. What information about sexuality is contrary to research on sexuality in older men?
a. Erections are not as firm.
b. It takes longer to obtain erections.
c. Erectile dysfunction is inevitable.
d. Ejaculation may not be a strong.
ANS: C
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Erectile dysfunction is not an inevitable part of aging. The other statements are true.
DIF: Remembering (Knowledge) REF: MCS: 243 OBJ: 13-3
TOP: Teaching-Learning MSC: Physiologic Integrity
17.
A patient with arthritis has difficulty participating is sex because of joint pain and stiffness. What
action by the nurse is best?
a. Suggest a warm shower prior to sexual activity.
b. Ask the patient if he or she needs more pain medication.
c. Explore other ways of expressing sexuality.
d. Refer the patient to a rheumatologist.
ANS: A
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A warm shower can reduce pain and stiffness, making sexual activity more enjoyable. The
patient may need more pain medication, but the sedating effects may be counterproductive. The
patient does not indicate he or she cannot or does not want to participate in sex, so suggesting
other means of expression is not really addressing the core issue. Referral is possible, but the
nurse needs to provide some intervention first.
DIF: Applying (Application) REF: N/A OBJ: 13-9
TOP: Teaching-Learning MSC: Physiologic Integrity
18. An older male patient is seen in the family practice clinic and tells the nurse he no longer
takes his metoprolol (Toprol) because it interferes with my lifestyle. What action by the nurse is
best?
a. Warn the patient of the complications of hypertension.
b. Ask the patient if he can afford the medication.
c. Tell the patient this drug often causes erectile dysfunction.
TESand
TBA
NKSE
LL
ER.COM
d. Take the patients blood pressure
record
the
findings.
ANS: C
The nurse should let the patient know that medications in this drug class often cause erectile
dysfunction. The nurse can then assess the patient for this issue. Warning the patient of
complications does not address the core problem and neither does taking his blood pressure.
Asking the patient if he can afford the medications can be addressed later if ED is not a problem.
REF: N/A
19. A male patient takes carbamazepine (Tegretol). The spouse reports sexual dysfunction, but
the patient adamantly denies he has this problem. What response by the nurse is best?
a. Telling him, You need to think of your wifes needs too.
b. Telling him this is common and can be discussed if wanted.
c. Questioning the patient again about sexual functioning
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d. Telling the doctor to change the patients prescription
ANS: B
The nurse should provide the information that this drug causes ED and leave the door open for
the patient. This way the patient knows he has permission to bring the topic up in the future.
Repeatedly questioning the patient about sexual functioning is not likely to encourage the nursepatient relationship. Telling the doctor to change the prescription is overstepping the patients
autonomy.
DIF: Applying (Application) REF: N/A OBJ: 13-4
TOP: Caring MSC: Psychosocial Integrity
20. A patient has many sexual partners but does not use condoms. What action by the nurse is
best?
a. Ask the patient what he or she knows about HIV.
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b. Assess the patient for barriers to using condoms.
c. Give the patient statistics on HIV in older adults.
d. Tell the patient safer sex practices should be used.
ANS: B
The nurse should assess for barriers to implementing safer sexual practices. Simply giving the
information does not help the patient implement it. Telling the patient what to do does not
respect the patients autonomy.
DIF: Applying (Application) REF: N/A OBJ: 13-9
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
21. A recently widowed patient reports new onset of sexual dysfunction. There are no new
medications or illnesses. What action by the nurse is best?
a. Assess the patients alcohol intake.
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b. Refer the patient for counseling.
c. Ask if there are new partners.
d. Have the patient speak to the doctor.
ANS: A
Alcohol can have an effect on sexual functioning. The nurse first assesses for this condition, as it
is objective in nature. The patient may need a referral or to speak with the provider, but the nurse
needs to intervene first. Asking the patient if there are new partners does not address the issue.
DIF: Applying (Application) REF: N/A OBJ: 13-7
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
22. A patient lives in a long-term care facility and has mild dementia. The patient has been
showing interest in another resident. What action by the nurse is best?
a. Determining if the resident has decision-making capacity.
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b. Refusing to allow the residents to be alone together.
c. Asking the residents family if the relationship is okay.
d. Providing time for the residents to be together.
ANS: A
The first step is to determine if the resident (actually both) has decision-making capacity. If so,
the nurse allows them to be together and provides privacy when possible. If one or both residents
are not capable of making decisions, the nurse enlists the opinion of that residents family.
DIF: Applying (Application) REF: N/A OBJ: 13-5
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
23. The family of a resident in an assisted living facility contacts the director to say they are
appalled that the resident is allowed to have pornographic magazines in the room. What response
by the director is most appropriate?
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a. We will take those away immediately.
b. Your loved one has the right to have these.
c. How do you know about these magazines?
d. He cannot stay here if he has these in the room.
ANS: B
A cognitively intact adult has the right to have and view legal pornographic materials in the
privacy of his or her apartment. The director should inform the family of this information.
DIF: Applying (Application) REF: N/A OBJ: 13-9
TOP: Communication and Documentation MSC: Psychosocial Integrity
MULTIPLE RESPONSE
1. The nurse working in long-term care knows there are several barriers to sexual expression for
older patients. Which of the following
allOthat
TESTare
BAbarriers?
NKSEL(Select
LER.C
M apply.)
a. Decreasing desire
b. Medication side effects
c. Disease processes
d. Social circumstances
e. Increased libido
ANS: A, B, C, D
Many barriers to sexual expression exist for the older patient including decreased desire (libido),
side effects of medications, disease processes, and social circumstances.
DIF: Remembering (Knowledge) REF: MCS: 246 OBJ: 13-6
TOP: Teaching-Learning MSC: Psychosocial Integrity
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2. The nurse is learning about postmenopausal changes that can affect sexuality in women.
Which of the following are included? (Select all that apply.)
a. Shortening of the vagina
b. Need to void after intercourse
c. Vaginal dryness
d. Vaginal irritation needs investigation
e. Vaginal secretions diminish
ANS: A, B, C, E
Shortening of the vagina with decreased secretions and dryness as well as the need to void after
intercourse are all normal changes that accompany aging. Vaginal irritation does not necessarily
need investigation, as this is a normal finding also.
Chapter 27 Caring for Older Adults During Illness
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MULTIPLE CHOICE
1. The nurse is preparing an older widowed patient with several chronic illnesses for discharge to
home. The nurse addresses the primary nursing outcome for this patient when:
a. assuring the patient that social services will arrange for help with medical
expenses.
b. arranging for in-home assistance in areas of activities of daily living (ADLs) and
nursing care as needed.
c. educating the patient regarding the safety risks caused by these conditions.
d. identifying barriers to ensure adherence to the prescribed drug therapies.
ANS: D
A key role for the nurse caring for an older adult with a chronic condition is to help the patient
achieve optimal physical and psychosocial health. Staying adherent with drug therapy can help
achieve this outcome. Payment through a third party is not guaranteed. In-home assistance may
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or may not be needed. Education is always needed but is not the priority for achieving optimal
wellness.
DIF: Applying (Application) REF: N/A OBJ: 16-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
2. The nurse is assessing patients diagnosed with chronic disease processes for the probability of
hospitalization because of the exacerbation of related symptoms. The nurse recognizes that the
patient with the highest probability is a(n):
a. 72-year-old male with congestive heart failure (CHF).
b. 82-year-old male with type 2 diabetes.
c. 72-year-old female with chronic bronchitis.
d. 82-year-old female with osteoporosis.
ANS: A
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Individuals with chronic conditions typically have repeated hospitalizations to treat
exacerbations of their illness. The most common reasons for hospitalization in older patients are
heart disease, cancer, pneumonia, and stroke. The 72-year-old with CHF is at highest risk.
DIF: Remembering (Knowledge) REF: N/A OBJ: 16-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
3. An older patient has developed moderate muscle weakness on the left side as a result of a
cerebral vascular accident (CVA, stroke). The nurse determines the patient possesses the
healthiest view of self-wellness when heard stating:
a. Ill certainly miss hiking, but I guess Ill find something else to do outdoors.
b. I was getting too old to safely practice karate.
c. Ive decided to take up oil painting because its difficult for me to knit.
d. It was getting difficult to work in the garden anyway.
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ANS: C
After learning and mastering the requirements imposed by the condition, older adults often view
themselves as well. With a wellness-in the-foreground perspective, the disease is only one
component of their life and is not their identity, so they substitute lost abilities and resulting
pleasures with others.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 16-2
TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity
4. A 73-year-old patient has been diagnosed with congested heart failure (CHF). The nurse
provides the greatest support for this patients positive view of self-wellness by presenting
information regarding:
a. how to minimize the exacerbation of symptoms.
b. locally available supportive services.
c. the importance of adherence to medical treatment.
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d. the need to report symptoms promptly.
ANS: A
Many older adults now seek education about health promotion and management of their illness.
The nurse can support older adults by teaching self-care management in these areas. The other
actions are also valued, but learning how to control symptoms gives patients the feeling of
accomplishment.
DIF: Applying (Application) REF: N/A OBJ: 16-5
TOP: Teaching-Learning MSC: Physiologic Integrity
5. The nurse is caring for an older patient who recently immigrated to the United States from
Asia. To best address the patients apparent resistance to the medical and nursing plan of care, the
nurse:
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a. discusses the patients behavior with Asian staff members.
b. researches the patients cultural views on health care.
c. requests a cultural consultation from social services.
d. asks family members to discuss the patients views on health care.
ANS: D
Concepts of health and illness are deeply rooted in culture, race, and ethnicity and influence an
individuals (and familys) illness perceptions and health and illness behavior. The patients family
should have the best insight into the patients culturally biased beliefs. Discussing behavior with
other staff members might be a privacy violation. Researching culture may be helpful, but each
patient is an individual and should not be stereotyped. Social services may or may not be able to
provide cultural services.
DIF: Applying (Application) REF: N/A OBJ: 16-5
TOP: Communication and Documentation MSC: Psychosocial Integrity
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6. The nurse feels most confident that an older patient is prepared to assume self-management of
new type 2 insulin-dependent diabetes when the patient:
a. is heard asking her son to check the insulins expiration date.
b. is able to identify the symptoms of hypoglycemia.
c. asks why she needs to test her glucose levels so frequently.
d. inquires why she needs to have an A1C test every 3 months.
ANS: A
Adherence is greatly improved when the patient is in agreement with the treatment plan and
shows a willingness to follow it. The patient is requesting help ensuring that the insulin is not
expired. Knowledge about symptoms does not equate with adherence. Asking questions does not
indicate adherence or not.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 16-2
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TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
7. The nurse impacts the trajectory of a patients type 2 insulin-dependent diabetes best by:
a. evaluating the patients ability to administer insulin appropriately.
b. providing the patient with a written copy of the treatment plan.
c. explaining to the patient the importance of serum glucose control.
d. providing the patient with research-based nursing care.
ANS: A
The illness trajectory can be modified by actions taken by the health care provider that directly
affect the patients ability/interest to adhere to the treatment plan prescribed. The other actions are
important but do not directly affect the illness trajectory.
DIF: Applying (Application) REF: N/A OBJ: 16-3
TOP: Nursing Process: Evaluation
Health
TEMSC:
STBA
NKSEPromotion
LLER.COM
8. An older patient diagnosed with severe osteoarthritis has recently moved in with his son
ecause of a history of falls. The son describes how he and his family have eagerly assumed
responsibility for meeting all Dads needs. The nurse is most concerned that this environment will
result in the patient:
a. developing a sense of powerlessness and possibly a loss of hope.
b. becoming unnecessarily physically and emotionally dependent.
c. losing his will to get better and become independent again.
d. becoming resentful and argumentative with his sons family.
ANS: A
With no control over the meeting of his own needs, the patient may develop a sense of
powerlessness, which can result in a loss of hope. The other concerns might be a problem for
some patients, but powerlessness and loss of hope remain the priority.
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DIF: Understanding (Comprehension) REF: MCS: 286 OBJ: 16-3
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
9. To best assist an older adult patient to cope with a new diagnosis of chronic renal failure, the
nurse:
a. asks the patient to describe her usual coping strategies.
b. provides the patient with descriptions of new coping strategies.
c. initiates discussions with the patient to explain the disease.
d. offers to arrange a meeting with another patient with the diagnosis.
ANS: C
Understanding the illness and what to expect is directly related to the ability to cope. After the
patient has information, the nurse can then assess psychosocial systems.
DIF: Applying (Application) REF:
TEN/A
STBOBJ:
ANK16-3
SELLER.COM
TOP: Teaching-Learning MSC: Physiologic Integrity
10. To best help manage health care costs in older adults, the nurse entrepreneur would do which
of the following?
a. Create a telehealth system where nurses could check on patients daily.
b. Provide local transportation services for older people to keep appointments.
c. Create educational videos in multiple languages seen in the community.
d. Build a nurse-run clinic to serve the homeless and underinsured population.
ANS: A
The majority of health care expenditure is spent on chronic illness. Patients with chronic
illnesses have multiple hospitalizations for exacerbations of their conditions. Keeping chronic
conditions under control would make a difference in health care cost. A telehealth service in
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which nurses could assess and counsel patients daily could help accomplish that goal. The other
ideas are good too, but tight control of chronic conditions is a priority.
DIF: Applying (Application) REF: N/A OBJ: 16-5
TOP: Nursing Process: Implementation MSC: Health Promotion
11. A nurse is working with a patient who was diagnosed with type 2 diabetes 4 months ago. The
patients blood sugars have stayed under control. What action by the nurse is best?
a. Ask the patient what barriers to wellness still exist.
b. Remind the patient about the A1C in 2 months.
c. Review side effects of medications with the patient.
d. Ask the patient how she or he feels about diabetes.
ANS: A
Older patients typically see chronic
TEillness
STBAas
NKone
SEpart
LLEofRtheir
.COlives.
M The nurse can support older
adults by working with them to identify areas that may hinder progress along the wellness
continuum and by teaching self-care management in these areas. The nurse should assess the
patients needs from his or her point of view.
DIF: Applying (Application) REF: N/A OBJ: 16-5
TOP: Nursing Process: Assessment MSC: Health Promotion
12. A nurse is assessing quality of life (QOL) in older individuals with chronic illnesses who
attend a community center. What information is most important to assess?
a. How many days were lost to exacerbations in the last year
b. How good each individual perceives his or her QOL to be
c. How burdensome the patients treatment regime is daily
d. How often the patient needs to see a health care provider
ANS: B
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QOL is individualized for each patient, and each person is the only one who can rate his or her
quality of life. It is not dependent on objective measures such as number of health care visits or
how many days were spent sick.
DIF: Application (Applying) REF: N/A OBJ: 16-1
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
13. Nurses should evaluate health programs based on what data?
a. Effect on quality of life
b. Cost-benefit ratio of service
c. Adherence statistics
d. Ease of following through
ANS: A
Quality of life should drive treatment
TESdecisions.
TBANKSThe
ELLpatient
ER.Cand
OM health care provider should set
goals that are mutually acceptable and promote independence and quality of life. The other
factors are considerations, but quality of life is most important.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 16-5
TOP: Nursing Process: Evaluation MSC: Health Promotion
14. A student learning about the early AIDS epidemic wonders why the patients were
stigmatized. What response by the nurse was best?
a. Fear of the unknown etiology
b. Expense required government assistance
c. Patients being ashamed of their illness
d. Younger patients not having accomplishments
ANS: A
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Stigma arises out of specific characteristics of a disease or an unknown etiology, which causes
fear. In the early days of the AIDS epidemic, not much was known about transmission, which
generated fear in health care workers and the general population.
DIF: Understanding (Comprehension) REF: MCS: 286 OBJ: 16-3
TOP: Teaching-Learning MSC: Psychosocial Integrity
15. When working with older adults with chronic illness and exacerbations, what action by the
nurse is most appropriate?
a. Continually assess the patients for adherence to the regime.
b. Assess the patients for ways they can remain in control.
c. Teach the patients about the illness trajectory.
d. Routinely review all medications the patients are taking.
ANS: B
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With exacerbations, the patient loses some control over an acute phase of the illness. The patient
can be helped to maintain independence, control, and dignity by reassessing what is still within
the patients ability and desire to control. The patient may or may not be adherent, but the nurse
should not assume he or she is not. Teaching about the illness trajectory is one tool for giving
control to patients. Medication reviews should be done but are not the best action.
DIF: Applying (Application) REF: N/A OBJ: 16-3
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
16. An older patient has moved into an adult childs home after an extended stay at a
rehabilitation facility. The patient complains the child is now the boss and the child complains
about caregiving duties. What action by the nurse is best?
a. Help the older patient find another place to live.
b. Suggest that it is time for assisted living.
c. Mediate a family meeting to discuss roles.
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d. Listen empathetically but let them work it out.
ANS: C
Role reversals and role changes are common in families where an older adult has chronic
illnesses. These lost roles need to be mourned by all involved. The nurse helps most in this
situation by mediating a family meeting where roles, coping, and feelings can be discussed. The
nurse can help problem solve by assisting the individuals to identify ways in which they can keep
their traditional roles, if even only for a short time.
DIF: Applying (Application) REF: N/A OBJ: 16-3
TOP: Communication and Documentation MSC: Psychosocial Integrity
17. An older adult has chronic fatigue from several illnesses. The patient is frustrated at this
symptom. What action by the nurse is best?
a. Ask the patient to prioritize activities.
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b. Have the patient keep a fatigue diary.
c. Encourage the patient to rest in the day.
d. Instruct the patient on good sleep hygiene.
ANS: A
Helping the patient cope with fatigue is an important nursing intervention. The nurse should first
ask the patient to prioritize the activities she or he most wants to do. Then the nurse and patient
can plan strategies that will allow the patient to participate in these activities. Keeping a diary is
helpful, but knowing what interests the patient most is more important. Rest and sleep are
important, but they are not the priorities.
DIF: Applying (Application) REF: N/A OBJ: 16-3
TOP: Nursing process: Assessment MSC: Psychosocial Integrity
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18. An older patient has been admitted to the nursing unit after a car crash and surgery. When
does the nurse begin planning for rehabilitation?
a. On admission
b. When the patient is awake
c. When the patient is stable
d. When the family requests it
ANS: A
Planning for rehabilitation, like discharge planning, begins on admission.
DIF: Remembering (Knowledge) REF: MCS: 289 OBJ: 16-3
TOP: Nursing Process: Analysis MSC: Physiologic Integrity
19. A home health care nurse is conducting a functional assessment on an older woman who
lives alone. What assessment question
TESTisBlikely
ANKStoEget
LLthe
ERbest
.COinformation?
M
a. How do you manage all your medications?
b. Who shops and cleans your house for you?
c. Can you show me how you prepare a meal?
d. What parts of your body cant you wash?
ANS: C
Older patients may downplay or deny functional limitations, so the nurse gets more accurate data
asking what the patient is able to do, rather than what she or he is not able to do.
DIF: Understanding (Comprehension) REF: MCS: 290 OBJ: 16-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
20. A nurse assesses a newly admitted patient to a nursing home using the Functional
Independence Measure (FIM) and rates the patient at 20. What action by the nurse is best?
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a. Arrange admission to a rehabilitation center.
b. Plan care for a nearly dependent person.
c. Plan care for a nearly independent person.
d. Tells the family the patient is cognitively impaired.
ANS: B
Eighteen measures are accounted for in the FIM with scores ranging from 1 (dependent) to 7
(independent). A score of 20 indicates near total dependence. The FIM does not measure
cognitive status.
DIF: Applying (Application) REF: N/A OBJ: 16-3
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. Adherence to prescribed healthTcare
ESTtreatments
BANKSEby
LLaEpatient
R.COwith
M a chronic disease is best
facilitated when the nurse does which of the following? (Select all that apply.)
a. Provides the patient with information regarding his disease
b. Assesses the patients ability to understand his disease
c. Defines health and wellness for the patient
d. Helps the patient identify barriers to his personal wellness
e. Coordinates support services to facilitate the patients discharge
ANS: A, B, D, E
The five As of a patients self-management of care includes assess, advise, agree, assist, and
arrange.
DIF: Remembering (Knowledge) REF: MCS: 284 OBJ: 16-3
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
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2. The student learning about chronic disease and illness in the older population learns which
facts about this situation? (Select all that apply.)
a. One in two adults, or more than 133,000 Americans, has a chronic condition.
b. Chronic disease is the leading cause of death in those over 65.
c. About 75% of medical costs each year are spent on managing chronic disease.
d. Formerly acute conditions are now manageable chronic diseases..
e. The focus of Americas health care services is now on chronic illness
ANS: A, B, C, D
One in two adults has a chronic illness, and these problems are the leading cause of death in
those over 65 and the largest cost to our health care system. One reason for this is that formerly
acute, possibly fatal, conditions are now manageable as chronic conditions. Americas health care
system continues to be focused on acute care.
DIF: Remembering (Knowledge) REF: MCS: 282 OBJ: 16-1
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TOP: Teaching-Learning MSC: Physiologic Integrity
3. The nurse understands what about the Americans with Disabilities Act? (Select all that apply.)
a. It outlaws discrimination on the job because of disabilities.
b. It requires state governments to fund disability services.
c. It prohibits discrimination in government services to the disabled.
d. It requires all buildings to be retrofitted to allow access.
e. It provides funding for barrier-free buildings and parks.
ANS: A, C
The ADA outlawed discrimination on the basis of disability in employment, in programs and
services provided by state and local governments, and in the provision of goods and services
provided by private companies and commercial facilities. It does not mandate government
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payment for disability services, require buildings to be retrofitted, or provide funding for barrierfree facilities.
Chapter 28 Caring for Older Adults Experiencing Pain
MULTIPLE CHOICE
1. When planning care for the older adult experiencing pain, the nurse bases interventions on the
realization that:
a. generally pain control is less effective than it is for younger adults.
b. this cohort is less pain sensitive than younger adults.
c. older adults are more likely to verbally express pain than younger adults.
d. pain is undertreated in this cohort compared to younger adults.
ANS: D
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Pain is underrecognized, highly prevalent, and undertreated among older adults.
DIF: Remembering (Knowledge) REF: MCS: 256 OBJ: 14-4
TOP: Nursing Process: Analysis MSC: Physiologic Integrity
2. An older patient is observed grimacing whenever walking and getting in and out of bed. When
assessed, the patient regularly denies having any pain. To best provide the patient with effective
pain control, the nurse initially:
a. discusses the effects of untreated pain on the patients general wellness.
b. offers the patient a prescribed prn analgesic.
c. asks the patient why he is denying the presence of pain.
d. documents the symptoms that the patient is exhibiting.
ANS: A
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Older adult patients actually underreport pain and are therefore at risk for undertreatment of pain,
which may cause unnecessary suffering, exacerbation of the underlying disease, and reduction in
activities of daily living (ADLs) and quality of life. Without this information the patient is
unlikely to take the prn medication. Why questions are not therapeutic, as they place people on
the defensive. The symptoms should be documented, but this should not be the only action.
DIF: Applying (Application) REF: N/A OBJ: 14-2
TOP: Teaching-Learning MSC: Physiologic Integrity
3. The nurse caring for an older adult patient experiencing carpal tunnel syndrome anticipates the
patient will best achieve pain control when prescribed a(n):
a. narcotic (e.g., fentanyl).
b. opioid (e.g., oxycodone).
c. tricyclic antidepressant (e.g., amitriptyline [Elavil]).
d. nonpharmacologic strategy (e.g., wrist bracing).
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ANS: C
Neuropathic pain results from a pathophysiologic process involving the peripheral or central
nervous system. These types of pain respond to unconventional analgesic drugs, such as tricyclic
antidepressants. Carpal tunnel syndrome is caused by nerve injury.
DIF: Analyzing (Analysis) REF: N/A OBJ: 14-8
4. When planning care for the older adult patient with a history of persistent pain, the nurse
acknowledges the effects of the mind-body connection by including:
a. regular pain assessments.
b. prompt response to reports of pain.
c. pain consults.
d. relaxation techniques.
ANS: D
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Some mind-body therapies include meditation, relaxation, guided imagery, and cognitive
behavioral counseling. The other actions are appropriate but not related to mind-body therapies.
DIF: Remembering (Knowledge) REF: MCS: 266 OBJ: 14-8
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
5. An older adult patient has been prescribed an opioid to manage chronic pain resulting from a
shoulder injury. To eliminate a common barrier to opioid drug compliance, the nurse:
a. encourages the patient to use the opioid only as prescribed.
b. educates the patient about the appropriate management of constipation.
c. assures the patient that dizziness will decrease as therapeutic levels are reached.
d. suggests the patient take the medication with meals or a snack.
ANS: B
Older adults have a high rate of discontinuation
TESTBANKSof
ELopiates
LER.because
COM of the resulting constipation.
The treatment for constipation, especially that which is opioid induced, is readily available and
should be provided as a preventive measure before starting narcotic pain medication. The other
actions do not address this issue.
DIF: Understanding (Comprehension) REF: MCS: 263 OBJ: 14-4
TOP: Teaching-Learning MSC: Physiologic Integrity
6. The nurse is discussing pain control with an older patient who has been prescribed an opiate.
When the patient expresses concerns about the diminishing effect that the medication has had on
the pain, the nurse responds:
a. It appears that the dosage you take needs to be adjusted upward.
b. We need to be concerned about you developing a drug tolerance.
c. This drug category is well known for its low ceiling effect.
d. Opiate addiction is a concern when tolerance occurs.
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ANS: A
Tolerance is defined as the diminished effect of a drug while maintaining the same dosage over
time. It is a characteristic of opiates when given over time. With opiates, some individuals might
need higher and higher doses of a drug to maintain effectiveness. This s
hould not be confused with addiction.
DIF: Understanding (Comprehension) REF: MCS: 263 OBJ: 14-8
a. Have you noticed your heart skipping beats since you began taking this drug?
TOP: Teaching-Learning MSC: Physiologic Integrity
b. Did you know you should not to stand up too quickly?
older
being
arthritic
painmedication
with a nonsteroidal
anti-inflammatory drug
7.c.AnAre
youpatient
aware isthat
youtreated
shouldfor
take
your pain
with food?
(NSAID).
Which
best assesses
effectssince
of this
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class?
d. Have you
hadquestion
any episodes
of
ofSbreath
this medicine?
TEshortness
STBfor
ANside
K
ELLER
.Cstarting
OM
ANS: C
The most common complaint associated with NSAIDs is indigestion. Indigestion may be
reduced with antacid use or food consumption timed to coincide with analgesic intake.
DIF: Understanding (Comprehension) REF: MCS: 263 OBJ: 14-8
TOP: Teaching-Learning MSC: Physiologic Integrity
8. The nurse is caring for an older adult patient with terminal cancer who is receiving medication
via patient-controlled analgesic (PCA) pump. The nurse shows an understanding of primary endof-life concerns when asking the patient:
a. Do you have any concerns about receiving your medication intravenously?
b. Are you satisfied with the way your pain is being managed?
c. Are you worried about becoming addicted to the narcotic analgesics?
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d. Do you have any questions concerning how to use the PCA properly?
ANS: B
Terminally ill patients generally identify their main concern as pain control. The other questions
do not address this issue.
DIF: Applying (Application) REF: N/A OBJ: 14-8
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
9. The nurse is performing a pain assessment when the older adult patient reports pain in his left
shoulder that radiates down into the forearm. The nurse immediately:
a. recognizes that the patient is experiencing cardiac distress.
b. alerts the rapid response team to provide emergency care.
c. asks whether he has ever experienced this pain before.
d. questions the patient about additional
TESTBArelated
NKSEsymptoms.
LLER.COM
ANS: C
Assessment is essential in differentiating acute life-threatening pain from longstanding chronic
pain. Otherwise, disease progression and acute injury may go unrecognized and be attributed to
preexisting disease or illness. The patient may or may not be experiencing cardiac ischemia, the
rapid response team does not need to be called, and the nurse can assess for other symptoms after
determining if this pain is new or not.
DIF: Applying (Application) REF: N/A OBJ: 14-6
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
10. An older adult who injured her knee several years ago tells the nurse that she has been
managing the resulting intermittent pain with a prescription for propoxyphene (Darvon). The
nurse is concerned with this treatment plan, primarily because:
a. less expensive alternative analgesics are available.
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b. this long-term need for a narcotic warrants investigation.
c. aspirin would likely be as effective in managing the pain.
d. the knee should not still be causing pain for the patient.
ANS: B
The nurse needs to complete a full assessment to determine what type of pain the patient is
experiencing and if a narcotic is the best alternative for the patient. Other medications may be
more beneficial.
DIF: Applying (Application) REF: N/A OBJ: 14-8
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
11. The nurse is caring for a 78-year-old with a history of chronic depression. The patient
currently reports persistent left shoulder pain since having a fall a year ago. To best address the
patients pain, the nurse initially determines:
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a. if the patient is still at risk for falls.
b. the severity of the shoulder injury.
c. how effectively depression is being managed.
d. the patients ability to effectively cope with pain.
ANS: C
Persistent depression affects a persons ability to cope with the pain, so it must be treated. The
nurse should also assess fall risk but that is secondary to determining why the pain has lasted so
long and if the patient is able to cope.
DIF: Applying (Application) REF: N/A OBJ: 14-4
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
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12. Acetaminophen (Tylenol) is prescribed for a 70-year-old with chronic pain. When the patient
reports to the nurse that the maximum daily dose of medication does not control the pain, the
nurse responds:
a. Breakthrough pain can be managed with the addition of another analgesic.
b. Transcutaneous electrical nerve stimulation (TENS) is often helpful.
c. It sounds as though you have developed a tolerance for acetaminophen.
d. We will need to get your physician to prescribe another analgesic for you.
ANS: D
The patient needs a comprehensive review of pain strategies, which will probably include
changing pain medication. Using the maximum dose of acetaminophen long term can cause liver
damage, which is another reason the patient should switch medications if it is not working.
DIF: Applying (Application) REF: N/A OBJ: 14-8
TESTBAMSC:
NKSEPhysiologic
LLER.COIntegrity
M
TOP: Communication and Documentation
13. An older adult patient is prescribed an analgesic to manage the joint pain resulting from
stiffness in his right shoulder. When the patient asks about alternative therapy techniques that
might be helpful, the nurse suggests:
a. applying ice packs to the area three to four times a day.
b. placing a moderately warm heating pad to the shoulder.
c. arranging for a professional massage on a weekly basis.
d. discussing electrical nerve stimulation with the physician.
ANS: B
Heat is useful in decreasing pain and discomfort resulting from joint stiffness by increasing the
elasticity of muscles. Ice is better for acute exacerbations. Massage may or may not help but
would be more expensive. Electrical nerve stimulation is not warranted.
DIF: Understanding (Comprehension) REF: MCS: 266 OBJ: 14-8
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TOP: Teaching-Learning MSC: Physiologic Integrity
14. The nurse caring for an older cognitively impaired patient with osteoarthritis in both hands
assesses the patient for hand pain by:
a. observing for facial grimacing when the patient uses a fork to eat.
b. being alert for signs of agitation when washing the patients hands.
c. listening to detect moaning when patient makes a fist.
d. watching for signs that the patient is reluctant to shake hands.
ANS: B
Cognitively impaired patients in pain may not portray any visible signs of pain or distress or may
be unable to communicate their pain. Pain may result in agitation, as well as increased pulse,
respiration, blood pressure, and confusion. The other options are not as indicative of pain in the
cognitively impaired older adult.
ESTMCS:
BANK258
SELOBJ:
LER14-4
.COM
DIF: Remembering (Knowledge)TREF:
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
15. A director of nursing in a long-term care facility was concerned after reading that as many as
80% of residents have untreated pain. What action by the director is best?
a. Establish protocols for routine assessment.
b. Make a pain plan for every resident.
c. Involve family members in treating pain.
d. Educate the staff on how to assess pain.
ANS: A
Nursing begins with assessment. The director should implement a protocol for routine
assessments of pain in both cognitively impaired and intact residents. A pain plan cannot be
created without this assessment data. Family members should be encouraged to provide input.
The staff may or may not need to have education on assessment.
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DIF: Applying (Application) REF: N/A OBJ: 14-7
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
16. An older patient who lives alone is brought to the clinic by an adult child who reports the
patient has become depressed and no longer wants to go out of the home. What action by the
nurse is best?
a. Assess the patient for depression.
b. Ask the patient why activities are avoided.
c. Assess the patient for pain.
d. Assess the patient for elder abuse.
ANS: C
Many older adults have pain that goes untreated. Consequences of untreated pain are numerous
and include depression and withdrawal. The nurse should first assess for pain. Assessing for
ESTBANasKS
ELLAsking
ER.Cwhy
OM questions is not therapeutic, as
depression or elder abuse may beTwarranted
well.
patients tend to become defensive.
DIF: Applying (Application) REF: N/A OBJ: 14-2
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
17. A confused patient is admitted to the hospital after suffering a fall. When asked about pain,
the patient does not respond. What action by the nurse is best?
a. Ask the patient again using different words.
b. Pantomime what you are asking the patient.
c. Observe the patients nonverbal behaviors.
d. Ask the family members if they think the patient has pain.
ANS: C
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In some situations, the nurse cannot rely on the patients report of pain, so as a second method of
assessment, the nurse looks to the patients nonverbal behaviors. The nurse should be aware,
however, that the lack of specific pain behaviors does not indicate a lack of pain. The other
options may be helpful for individual patients.
DIF: Applying (Application) REF: N/A OBJ: 14-4
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
18. A patient has just had surgery. What pain control strategy is best?
a. Administer prn medications when requested.
b. Give pain medications around the clock at first.
c. Start with nonopioids then progress to opioids.
d. Ask the patient his or her preference for medication.
ANS: B
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After surgery the patient is expected to have pain. The best way to control acute pain is through
round-the-clock dosing (at least at first) to keep the patients pain from getting out of control. The
nurse should assess the patients preferences, but should assess preferences for pain levels,
because the patient may not be experienced in receiving pain medications. Opioids are expected
for acute pain from surgery.
DIF: Applying (Application) REF: N/A OBJ: 14-8
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
19. An older patient is hospitalized for the first time. After giving a dose of hydromorphone
(Dilaudid), what assessment takes priority?
a. Pain level
b. Nausea
c. Urinary retention
d. Respiratory rate
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ANS: D
Respiratory depression is common with opioid analgesics. All assessments are appropriate;
however, respiratory assessment takes priority.
DIF: Applying (Application) REF: N/A OBJ: 14-8
TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment
20. An older adult lives alone at home and is being treated for chronic pain. The home health
care nurse notes the adult is disheveled and has dirty dishes piled up in the sink. What action by
the nurse is best?
a. Notify adult protective services.
b. Arrange for hospitalization.
c. Assess the patients pain.
d. Assess the patients cognitive status.
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ANS: C
Although all actions might be appropriate depending on circumstances, because the patient is
being treated for pain and has a functional decline, the nurse should assess first for unrelieved
pain.
DIF: Applying (Application) REF: N/A OBJ: 14-8
TOP: Nursing Process: Assessment MSC: Physiologic Integrity
21. A patient has constipation as a side effect of opioid analgesics. What menu choice indicates
the patient understands nutritional therapy for this problem?
a. Scrambled eggs
b. White bread
c. Canned fruit
d. Oatmeal
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ANS: D
Constipation can be managed with high fiber and increased water. Oatmeal has the highest fiber
content of the four foods listed.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 14-1
TOP: Nursing Process: Evaluation MSC: Physiologic Integrity
22. The nurse is caring for four frail patients with pain. Which patients pain medication
prescription does the nurse question?
a. The patient taking pentazocine (Talwin)
b. The patient taking acetaminophen (Tylenol)
c. The patient taking ibuprofen (Motrin)
d. The patient taking hydromorphone (Dilaudid)
ANS: A
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Talwin should not be used in frail older people because it leads to central nervous system
excitement, confusion, and agitation. The other drugs are appropriate choices.
DIF: Applying (Application) REF: N/A OBJ: 14-8
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
MULTIPLE RESPONSE
1. When planning nursing care for an older adult who is experiencing chronic pain, the nurse
includes which of the following interventions? (Select all that apply.)
a. Maintain mobility.
b. Promote autonomy.
c. Manage any chronically painful condition.
d. Provide economical sensitive pain relief.
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e. Support the patients right to be pain-free.
ANS: A, B, C
Goals for pain management in older adults include control of chronic disease conditions that
cause pain, maintenance of mobility and functional status, promotion of maximum
independence, and improvement of quality of life.
Chapter 29 Caring for Older Adults at the End of Life
MULTIPLE CHOICE
1. The nurse documents that a newly widowed older adult patient is likely experiencing physical
grief responses when she:
a. becomes hypotensive.
b. has difficulty getting up from the chair.
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c. reports having tightness in the chest.
d. develops a red rash over her upper chest and back.
ANS: C
Physical symptoms are commonly associated with acute grief responses. Tearfulness, crying,
loss of appetite, feelings of hollowness in the stomach, decreased energy, fatigue, lethargy, and
sleep difficulties are common symptoms of grief. Other physical sensations may include tension,
weight loss or gain, sighing, feeling something stuck in ones throat, tightness in ones chest or
throat, heart palpitations, restlessness, shortness of breath, and dry mouth.
DIF: Remembering (Knowledge) REF: MCS: 326 OBJ: 18-3
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
2. The nurse is confident that an older adult is successfully completing the tasks associated with
mourning his wifes death when he:
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a. shares that, No amount of wishing will bring her back.
b. openly cries in the presence of family and friends.
c. takes cooking classes at the local community college.
d. takes a female acquaintance to the movies.
ANS: D
The last task in the process of mourning is the withdrawal of emotional energy and the
reinvestment in another relationship; this entails withdrawing emotional attachment to the lost
person and continuing on with life.
DIF: Remembering (Knowledge) REF: MCS: 328 OBJ: 18-5
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
3. Although the family of a newly widowed older adult patient lives several hours away, they are
interested in providing appropriate support. The nurse suggests it would be most helpful if they
would:
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a. telephone daily and arrange for a neighbor to help with the shopping.
b. assume responsibility for paying the bills and upkeep of the home.
c. encourage the patient to move into a smaller home and learn to drive.
d. include the patient in their yearly vacation plans
ANS: A
Loneliness and problems associated with the tasks of daily living are two of the most common
and difficult adjustments for older bereaved spouses. Calling daily will help alleviate the
loneliness. Taking over responsibilities may take away the only thing the patient has left.
Learning to drive may be important, but the family should not encourage the patient to make a
major life decision like moving now. Taking the patient on vacation is a nice idea, but this occurs
yearly versus calling daily.
DIF: Applying (Application) REF: N/A OBJ: 18-3
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TOP: Teaching-Learning MSC: Psychosocial Integrity
4. A man who recently lost his wife of 50 years shares with the nurse that hell never get over
missing her. The nurse is most therapeutic when responding:
a. We are here to help you anyway we can.
b. Focus on the beautiful memories you have of her and your life together.
c. Time will help you adjust to your loss.
d. Youll never get over your loss but you can learn to live with it.
ANS: D
The third step in the process of mourning is the adjustment to an environment in which the
deceased is missing. Older spouses have reported that they feel as though they will never get
over their loss; instead, they have learned to live with it. It is nice to let the patient know you are
here for him or her, but this does not give any useful information to help the patient. Telling the
patient to focus on memories is dismissive. The nurse should not use clichs like time will help.
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DIF: Applying (Application) REF: N/A OBJ: 18-5
TOP: Caring MSC: Psychosocial Integrity
5. The nurse documents that a patient is likely experiencing exaggerated grief when observing
which behavior?
a. Keeps telling family and friends that her spouse cant be dead.
b. Re-reads her late spouses diaries nightly since the death 2 years ago.
c. Develops severe abdominal pains on each anniversary of her spouses death.
d. Becomes agitated whenever someone refers to the spouses death or moving on.
ANS: B
Exaggerated grief reactions occur when normal feelings of anxiety, depression, or hopelessness
grow to unmanageable proportions. People with exaggerated grief may feel an overwhelming
sense of being unable to live without the deceased person. They may lose the sense that the acute
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grief is transient and may continue in this intense despair for a long time. Re-reading diaries each
night is the most specific example of this type of grief.
DIF: Applying (Application) REF: N/A OBJ: 18-4
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
6. The nurse is caring for an older adult who recently lost an adult child as a result of automobile
accident. They shared a home and enjoyed a healthy parent-child relationship. The nurse is
confident that the patient has progressed appropriately through the mourning process when the
patient is observed doing which action?
a. Tells family members that her child is in a better place.
b. Arranges for personal grief counseling.
c. Cries softly during the familys first year memorial service.
d. Plans a summer vacation with friends from work.
ANS: D
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Mourning is often used to refer to the ritualistic behaviors in which people engage during
bereavement. More recently, mourning is the term used for processes related to learning how to
live with ones loss and grief. The last task of mourning is emotionally relocating the deceased
person and moving on with life. Going on a vacation with friends is a good example of this. The
other actions do not show this resolution.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 18-5
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
7. The nurse evaluates how an older adult patient will react to the death of a spouse based on
how the patient:
a. expresses concern for his spouse during a prolonged illness.
b. reacts when their beloved dog was sent to live with an adult child.
c. demonstrates his or her philosophy of health and happiness.
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d. expresses how his spouses illness has impacted their life together.
ANS: B
Ones responses to loss and death are characterized by ones natural reaction to all kinds of losses,
not just death. Peoples responses depend on their perception of the events and the meaning of the
loss within the context of their lives and their physical, psychosocial, and spiritual life patterns.
This behavior will likely be similar for all major losses, including the relocation of a pet. The
other options do not demonstrate a grief reaction.
DIF: Applying (Application) REF: N/A OBJ: 18-4
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
8. A novice hospice nurse shows the best understanding of the nursing role related to an older
adult patients mourning over the loss of an adult child when stating:
a. I see mourning as a very individualized process.
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b. The patients coping skills need to be assessed regularly.
c. The patient needs all the help I can give to get better.
d. Hopefully the patient will be in a healthy mental state soon.
ANS: A
The goal of nursing care for older persons who are grieving and mourning is not to make them
feel better quickly, although nurses are often tempted to try to do so. Nurses should assist and
support bereaved persons through the grieving process, recognizing that pain is a normal and
healthy response to loss and allowing bereaved persons to accomplish the tasks of mourning in
their own ways.
DIF: Application (Applying) REF: N/A OBJ: 18-3
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
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9. An older adult man has been the primary caregiver for his chronically ill wife for the past 10
years. When his wife dies, the nurse prepares the family for the likely possibility that their father
will express:
a. guilt that he is alive while she is dead.
b. deep despair for his loss.
c. personal relief that she has died.
d. concern that he could have cared for her better.
ANS: C
For some older persons, the grief experience may include feelings of relief and emancipation,
especially after prolonged suffering or a difficult relationship. Because this may occur, the nurse
should let the family know of its possibility. The other options are possible too; however, the
relief response is a more universal experience.
DIF: Understanding (Comprehension) REF: MCS: 326 OBJ: 18-3
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TOP: Teaching-Learning MSC: Psychosocial Integrity
10. A hospice nurse shows the best understanding of the personal commitment to the dying
patient by:
a. providing the patient with sufficient, effective pain management therapies.
b. addressing the patients need to feel valued by those attending to his or her death.
c. being available emotionally and physically throughout the dying process.
d. empathizing with the patient and his or her family and friends during the process.
ANS: C
Once a nurse becomes committed to working with a patient and family throughout the dying
process, it is important to follow through on this commitment as much as possible. The other
options are narrower in scope.
DIF: Applying (Application) REF: N/A OBJ: 18-9
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TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
11. The nurse shows an understanding of the primary factor that facilitates the adjustment to the
loss of a spouse when asking:
a. Are you planning to continue to run your flower shop?
b. How long were you and your spouse married?
c. Does your son and his family live nearby?
d. Do you consider yourself a religious person?
ANS: A
For those who have strong social support and established patterns of independent interaction
outside the lost relationship, the adjustment process toward creating new social roles and
interactions may occur more quickly.
DIF: Applying (Application) REF: N/A OBJ: 18-5
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TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
12. The nurse determines that the daughter of a widowed older adult patient has a poor
understanding of the grieving process when she reports that:
a. Mom is going to be okay; she is a strong, independent woman.
b. Its been 16 months since Dad died, but Mom still hasnt moved on with her life.
c. My mother has agreed to come and live with me for at least a little while.
d. My mom cries when she looks at pictures of Dad, but I think she needs to cry.
ANS: B
It used to be believed that after the first anniversary of the death, grief should be resolved. This
has been shown to be inaccurate; many factors influence the time for adjustment. Older persons
who have experienced multiple losses may need more time. For some, the losses may never be
resolved; a person may simply learn to live with the feelings of grief. In any case, the time
needed for grieving is individualized.
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DIF: Applying (Application) REF: N/A OBJ: 18-3
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
13. When a 66-year-old patient dies as a result of surgical complications, the nurse begins to
facilitate the familys acceptance of their loss by:
a. preparing each family member sufficiently prior to viewing the body of their
loved one.
b. presenting the body of their loved one in an appropriate, respectful manner.
c. assuring them that the patient received the best possible care postsurgery.
d. providing them with an effective explanation of the problems that caused the
patients death.
ANS: D
Having information about the death and the events preceding and following the death is
important in helping to actualize the loss. The nurse should prepare the family members on what
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to expect when viewing the body and prepare the body in a respectful way as this shows respect
and caring. Assurances that the patient received the best care possible may sound hollow.
DIF: Applying (Application) REF: N/A OBJ: 18-9
TOP: Communication and Documentation MSC: Psychosocial Integrity
14. A hospice nurse is caring for a patient and notes the patients spouse engaged in anticipatory
grieving. What action by the spouse best demonstrates this reaction?
a. Spending time learning about the business owned by the patient
b. Receiving many visitors from church and social organizations
c. Delegating household tasks so the spouse can stay with the patient
d. Taking long walks outside then napping for extended periods
ANS: A
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Anticipatory grieving includes the processes of mourning, coping, and planning that are initiated
when the impending loss of a loved one becomes apparent. It serves to reduce shock, confusion,
and depression. The spouse learning about a business he or she will likely have to take over
shows future planning. The other actions do not.
DIF: Evaluating (Evaluation) REF: N/A OBJ: 18-4
TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity
15. The nurse knows a family whose adult child killed several people before taking his own life.
The funerals of all involved were held on the same 2 days. The nurse notes the family seems
embarrassed, uncomfortable with expressions of sorrow, and wants a very quiet funeral. What
type of grief does the nurse suspect the family has?
a. Anticipatory
b. Disenfranchised
c. Masked
d. Complicated
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ANS: B
Disenfranchised grief occurs when the loss cannot be openly acknowledged and causes
complications because there is lack of social support for the survivors. In this situation where the
adult child died under such terrible circumstances, the family may feel they have no right to
grieve when their child caused so many others grief. Anticipatory grief occurs when a death is
impending. Masked grief is a self-protective mechanism for those who cannot bear the process of
mourning. Complicated grief includes masked grief.
DIF: Remembering (Knowledge) REF: MCS: 327 OBJ: 18-4
TOP: Nursing Process: Assessment MSC: Psychosocial Integrity
16. A patient has been grieving the loss of a spouse and seems to be doing surprisingly well
when a beloved pet dies. The patient demonstrates extreme signs of sadness and despair, saying,
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I cannot possibly go on without Kitty. When working with the family, what does the nurse
suggest?
a. Get the patient another cat.
b. Suggest the patient see the physician.
c. Refer the patient to a grief therapist.
d. Suggest they take the patient on a trip.
ANS: C
This patient is demonstrating a delayed or postponed grief reaction. Doing surprisingly well may
indicate a lack of grief response at the original loss, then an exaggerated reaction to a smaller,
subsequent loss. The most appropriate action is to refer the patient and family to a grief
counselor who can help the patient work through both losses. Getting another cat dismisses the
importance of the first one. A physician visit may be needed, but a grief counselor is more
appropriate. Taking the patient on a trip will not help resolve the situation.
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DIF: Applying (Application) REF: N/A OBJ: 18-4
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
17. The nurse in the emergency department cared for a patient who had a fatal heart attack. The
nurse goes to meet the family in the private waiting room. The nurse is acting most appropriately
when responding:
a. What do you know about what happened today?
b. Im so sorry but your loved one has died.
c. We did all we could, but unfortunately it was not enough.
d. Is there someone I can call for you?
ANS: A
Asking the family to recount what they know of the events helps them actualize the death, the
first step in accepting the event. This allows the family to tell their story, at which point the nurse
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picks up with what happened in the emergency department. This also gives the family some time
to prepare for the news of the death. Immediately stating the patient has died offers no
preparation and will come as a great shock. Stating that what was done was not enough may
imply that more could have been done. Asking to call for support may be confusing, as the
family does not yet know the patient has died.
DIF: Applying (Application) REF: N/A OBJ: 18-9
TOP: Caring MSC: Psychosocial Integrity
18. A nurse is assisting a patient with a life review. What action by the nurse is best?
a. Ask the patient what his or her job was.
b. Ask about memories the patient is proud of.
c. Ask the patient about special holiday foods.
d. Ask the patient to name children and grandchildren.
ANS: B
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During the life review, if patients can see that their lives were meaningful and worth living, then
a sense of ego integrity emerges. The nurse can best assist this by asking the patient to relate
memories that evoke pride in accomplishments. The other topics can be used to guide a life
review but are too narrow in focus to be the best answer.
DIF: Applying (Application) REF: N/A OBJ: 18-9
TOP: Caring MSC: Psychosocial Integrity
19. An older patient is near the end of life and the family is concerned that the patient has a
pressure ulcer because, in their view, this denotes poor care. What explanation by the nurse is
best?
a. Youre right; we will try harder to care for her.
b. Im so sorry this is upsetting for you to see.
c. We are doing the best we can to care for your loved one.
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d. Age-related changes can make it impossible to prevent ulcers.
ANS: D
Age-related changes plus changes associated with the end of life can make preventing pressure
ulcers nearly impossible, even with the best care. The nurse gently explains this to the family.
The other statements do not give the family factual information.
DIF: Understanding (Comprehension) REF: MCS: 334 OBJ: 18-9
TOP: Teaching-Learning MSC: Physiologic Integrity
20. The family members of a dying patient are distressed at the patients restlessness and lack of
sleep. They ask the nurse to just give her something. What response by the nurse is best?
a. Administer a sedative or hypnotic.
b. Tell the family shell soon be sleeping enough.
c. Try nonpharmacologic comfort measures.
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d. Explain that medications are not used in this case.
ANS: C
Nonpharmacologic comfort measures should be implemented first because of the erratic
pharmacokinetics seen at the end of life. Drug responses and side effects vary widely and are
difficult to control. If nonpharmacologic measures do not work, medications can be tried but
must be monitored continuously.
DIF: Applying (Application) REF: N/A OBJ: 18-9
TOP: Nursing process: Implementation MSC: Physiologic Integrity
21. A dying older patient has dyspnea, which causes anxiety. What action by the nurse is best?
a. Provide oxygen for a saturation less than 90%.
b. Provide a cool fan to blow on the patient.
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c. Administer prescribed morphine sulfate.
d. Administer a prescribed bronchodilator.
ANS: C
Morphine sulfate is often used for dyspnea and has the added benefit of slight sedation, which
will help this patients anxiety. Providing oxygen based on saturations does nothing for the
patients distress; the patient may feel short of breath, even with an oxygen saturation of 100%. A
cool fan may help. There is no indication that the patient needs a bronchodilator. IF the patient
has wheezing, this would be appropriate.
DIF: Applying (Application) REF: N/A OBJ: 18-9
TOP: Nursing Process: Implementation MSC: Physiologic Integrity
22. A dying patient is being cared for at home. The family relates to the hospice nurse that they
are distressed that the patient no longer wants favorite food items. What response by the nurse is
best?
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a. Dying people dont usually want to eat.
b. Your loved one wont starve to death.
c. Why do you insist of trying to feed her?
d. Is there another way you can show caring?
ANS: D
Dying patients often have anorexia, and research shows that eating and drinking can actually
increase distressing symptoms. However, the provision of food is universally seen as an act of
caring and people place great emphasis on eating. The nurse can best help the family by helping
them identify other ways to show caring. The other options do not give any useful information
and could be seen as a cold response.
DIF: Applying (Application) REF: N/A OBJ: 18-9
TOP: Nursing Process: Implementation MSC: Psychosocial Integrity
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MULTIPLE RESPONSE
1. A nurse working with a dying patient would expect to add interventions to the care plan to
address which needs? (Select all that apply.)
a. Pain
b. Dyspnea
c. Delirium
d. Dementia
e. Restlessness
ANS: A, B, C, E
Pain, dyspnea, delirium, and restlessness are common symptoms experienced by patients at the
end of life. Dementia may be an issue for some, but it is not considered a commonly experienced
symptom.
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