1. When caring for an older patient with hypertension who has
been hospitalized after a transient ischemic (TIA), which
topic is the priority important for the nurse to include in the
discharge teaching?
a. Mechanism of action of anticoagulant therapy
b. Effect of atherosclerosis on cerebral blood vessels
c. Symptoms indicating that the patient should contact the
health care provider
d. Impact of the patient‘s family history on likelihood of
developing a serious stroke
ANS: C
One of the priority tasks for patients with chronic illnesses
is to prevent and manage a crisis. To maintain safety, the
patient needs instruction on recognizing symptoms of
concern and appropriate actions to take if these symptoms
occur. The other information may also be included in patient
teaching but is not as essential in the patient‘s safe selfmanagement of the illness.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
2. The nurse performs a comprehensive assessment of an older patient who is considering
admission to an assisted living facility. Which question would help the nurse assess the
patient‘s level of daily functioning?
a. ―Have you had any recent infections?ǁ
b. ―How frequently do you see a doctor?ǁ
c. ―Do you have a history of heart disease?ǁ
d. ―Are you able to prepare your own meals?ǁ
ANS: D
The patient‘s functional abilities such as using a phone, shopping, preparing food,
housekeeping, doing laundry, arranging transportation, taking medications, and handling
finances are useful in determining how well the patient might adapt to an assisted living
situation. The other questions will also provide helpful information but do not directly address
aspects of daily functioning.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
3. An alert older patient who takes multiple medications for chronic cardiac and pulmonary
diseases lives with a daughter who works during the day. During a clinic visit, the patient tells
the nurse that she has a strained relationship with her daughter and does not enjoy being alone
all day. In planning care for this patient, which problem should the nurse consider as the
priority?
a. Risk for injury
b. Impaired socialization
c. Caregiver role strain
d. Difficulty coping
ANS: A
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The patient‘s age and multiple medications indicate a risk for injury caused by interactions
between the multiple drugs being taken and a decreased drug metabolism rate. Drug–drug
interactions could cause the most harm to the patient and are therefore the priority. Problems
with socialization, caregiver role strain, or difficulty coping are important but not safety-level
physiologic priorities.
DIF: Cognitive Level: Analyze (Analysis)
MSC: NCLEX: Health Promotion and Maintenance
TOP: Nursing Process: Diagnosis
4. Which method would the nurse use to obtain a complete assessment of an older patient?
a. Review the patient‘s health record for previous assessments.
b. Use a geriatric assessment instrument to evaluate the patient.
c. Ask the patient to write down medical problems and medications.
d. Interview both the patient and the primary caregiver for the patient.
ANS: B
The most complete information about the patient will be obtained by using an evidence-based
assessment instrument specific to the geriatric population, which includes information about
both medical diagnoses and treatments and about functional health patterns and abilities. A
review of the medical record, interviews with the patient and caregiver, and written
information by the patient are all included in a comprehensive geriatric assessment.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
5. Which action would the nurse include in planning optimal care for an older patient who is
hospitalized with pneumonia?
a. Use a standardized geriatric care plan.
b. Consider the patient‘s current functional abilities.
c. Minimize physical activity during hospitalization.
d. Plan for the patient‘s transfer to a long-term care facility.
ANS: B
The plan of care for older adults should be individualized and based on the patient‘s current
functional abilities. A standardized geriatric care plan will not address individual patient needs
and strengths. A patient‘s need for discharge to a long-term care facility is variable. Activity
level should be designed to allow the patient to retain functional abilities while hospitalized
and also to allow any additional rest needed for recovery from the acute process.
DIF: Cognitive Level: Apply (Application)
MSC: NCLEX: Physiological Integrity
TOP: Nursing Process: Planning
6. The nurse cares for an older adult patient who lives in a rural area. Which intervention would
the nurse plan to implement to meet this patient‘s needs?
a. Suggest that the patient move closer to health care providers.
b. Obtain extra medications for the patient to last for 4 to 6 months.
c. Ensure transportation to appointments with the health care provider.
d. Assess the patient for chronic diseases that are unique to rural areas.
ANS: C
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Transportation can be a barrier to accessing health services in rural areas. The patient living in
a rural area may lose the benefits of a familiar situation and social support by moving to an
urban area. Chronic diseases are not unique to rural areas. Because medications may change,
the nurse should help the patient plan for obtaining medications through alternate means such
as the mail or delivery services, not by buying large quantities of the medications.
DIF: Cognitive Level: Apply (Application)
MSC: NCLEX: Health Promotion and Maintenance
TOP: Nursing Process: Planning
7. Which nursing action would be most helpful in decreasing the risk for drug–drug interactions
in an older adult?
a. Teach the patient to have all prescriptions filled at the same pharmacy.
b. Make a schedule for the patient as a reminder of when to take each medication.
c. Ask the patient to bring all medications, supplements, and herbs to each
appointment.
d. Instruct the patient to avoid taking any over-the-counter medications or
supplements.
ANS: C
The most information about drug use and possible interactions is obtained when the patient
brings all prescribed medications, OTC medications, and supplements to every health care
appointment. The patient should discuss the use of any OTC medications with the health care
provider and obtain all prescribed medications from the same pharmacy. Use of supplements
and herbal medications need to be considered in order to prevent drug–drug interactions. Use
of a medication schedule will help the patient take medications as scheduled but will not
prevent drug–drug interactions.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
8. A patient who has just relocated to a long-term care facility is exhibiting signs of stress related
to the move. Which action would the nurse include in the plan of care?
a. Remind the patient that making changes is usually stressful.
b. Discuss the reason for the move to the facility with the patient.
c. Restrict family visits until the patient is accustomed to the facility.
d. Have staff members write notes welcoming the patient to the facility.
ANS: D
Having staff members write notes will make the patient feel more welcome and comfortable at
the long-term care facility. Discussing the reason for the move and reminding the patient that
change is usually stressful will not decrease the patient‘s stress about the move. Family
member visits will decrease the patient‘s sense of stress about the relocation.
DIF: Cognitive Level: Apply (Application)
MSC: NCLEX: Psychosocial Integrity
TOP: Nursing Process: Planning
9. An older patient who reports having ―no energyǁ and feeling increasingly weak has lost 12
pounds over the past year. Which action would the nurse take?
a. Ask the patient about daily dietary intake.
b. Schedule regular range-of-motion exercise.
c. Describe normal changes associated with aging.
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d. Discuss long-term care placement with the patient.
ANS: A
In a frail older patient, nutrition is frequently compromised, and the nurse‘s initial action
should be to assess the patient‘s nutritional status. Interventions such as active range of
motion may be helpful in improving the patient‘s strength and endurance, but nutritional
assessment is the priority because the patient has had a significant weight loss. The patient
may be a candidate for long-term care placement, but more assessment is needed before this
can be determined. The patient‘s assessment data are not consistent with normal changes
associated with aging.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
10. The nurse is admitting an acutely ill, older adult to the hospital. Which action would the nurse
take?
a. Speak slowly and loudly while facing the patient.
b. Perform a physical assessment before interviewing the patient.
c. Ask all family members to leave now and return the next day.
d. Begin by obtaining a detailed medical history from the patient.
ANS: B
When a patient is acutely ill, the physical assessment should be accomplished first to detect
any physiologic changes that require immediate action. Not all older patients have hearing
deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To
avoid tiring the patient, some of the medical history can be obtained from medical records.
The patient may wish to have family present. After the initial physical assessment to
determine the patient‘s current condition, the family may be able to provide comfort and
support to the patient.
DIF: Cognitive Level: Apply (Application)
MSC: NCLEX: Health Promotion and Maintenance
TOP: Nursing Process: Planning
11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital
with a chronic foot infection. Which intervention is the priority for the nurse to include in the
discharge plan for this patient?
a. Teach the patient how to assess and care for the foot infection.
b. Refer the patient to social services for assessment of resources.
c. Schedule the patient to return to outpatient services for foot care.
d. Give the patient written information about shelters and meal sites.
ANS: B
An interprofessional approach, including social services, is needed when caring for homeless
older adults. Even with appropriate teaching, a homeless individual may not be able to
maintain adequate foot care because of a lack of supplies or a suitable place to accomplish
care. Older homeless individuals are less likely to use shelters or meal sites. A homeless
person may fail to keep appointments for outpatient services because of factors such as fear of
institutionalization or lack of transportation.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
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12. The home health nurse cares for an older adult patient who lives alone and takes several
different prescribed medications for chronic health problems. Which intervention by the nurse
would support both the patient‘s self-management and medication adherence?
a. Use a marked pillbox to set up the patient‘s medications.
b. Discuss the option of moving to an assisted living facility.
c. Remind the patient about the importance of taking medications.
d. Visit the patient daily to administer the prescribed medications.
ANS: A
Because forgetting to take medications is a common cause of medication errors in older
adults, the use of medication reminder devices is helpful when older adults have multiple
medications to take. There is no indication that the patient needs to move to assisted living or
that the patient does not understand the importance of medication compliance. Home health
care is not designed for the patient who needs ongoing assistance with activities of daily living
or instrumental ADLs.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Physiological Integrity
13. The home health nurse visits an older patient with mild forgetfulness. Which new information
would be of most concern to the nurse in planning care?
a. The patient has lost 10 lb (4.5 kg) during the past month.
b. The patient tells the nurse that a close friend recently died.
c. The patient is cared for by a daughter during the day and stays with a son at night.
d. The patient‘s son uses a marked pillbox to set up the patient‘s medications weekly.
ANS: A
A 10-pound weight loss may be an indication of depression, elder neglect, or acute physical
illness and requires further assessment by the nurse. The use of a marked pillbox and planning
by the family for 24-hour care are appropriate for this patient. It is not unusual that an older
adult would have friends who have died, and the nurse should assess the patient for grief, but
that is not the priority.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
14. Which statement, if made by an older adult patient, would be of most concern to the nurse in
planning care?
a. ―I prefer to manage my life without much help from other people.ǁ
b. ―I take three different medications for my heart and joint problems.ǁ
c. ―I don‘t go on daily walks anymore since I had pneumonia 3 months ago.ǁ
d. ―I set up my medications in a marked pillbox so I don‘t forget to take them.ǁ
ANS: C
Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should
develop a plan to prevent further deconditioning and restore function for the patient.
Self-management is appropriate for independently living older adults. On average, an older
adult takes seven different medications so the use of three medications is not unusual for this
patient. The use of memory devices to assist with safe medication administration is
recommended for older adults.
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DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
15. Which patient is most likely to need a referral for long-term nursing care management?
a. 72-yr-old who had a hip replacement after a fall at home
b. 64-yr-old who developed sepsis after a ruptured peptic ulcer
c. 76-yr-old who had a cholecystectomy and bile duct drainage
d. 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)
ANS: D
Osteoarthritis and obesity are chronic problems that will require planning for long-term
interventions such as physical therapy and nutrition counseling. The other patients have acute
problems that are less likely to require long-term management.
DIF: Cognitive Level: Analyze (Analysis)
MSC: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Planning
16. An older adult being admitted is assessed at high risk for falls. Which action would the nurse
take first?
a. Use a bed alarm system on the patient‘s bed.
b. Administer the prescribed PRN sedative medication.
c. Ask the health care provider to order a vest restraint.
d. Position the patient in a geriatric recliner with locking tray.
ANS: A
The use of the least restrictive restraint alternative is required. Physical or chemical restraints
may be necessary, but the nurse‘s first action should be an alternative such as a bed alarm.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
17. An older adult patient presents to the emergency department with a broken arm and visible
scattered bruises healing at different stages. Which action would the nurse take first?
a. Make a referral for a home assessment visit by the home health nurse.
b. Ask the patient and family member to explain how the injury occurred.
c. File a report with an elder protective services agency about possible abuse.
d. Have the family member stay in the waiting area while the patient is assessed.
ANS: D
The initial action should be assessment and interviewing of the patient. The patient should be
interviewed alone because the patient will be unlikely to give accurate information if the
abuser is present. If abuse is occurring, the patient should not be discharged home for a later
assessment by a home health nurse. The nurse needs to collect and document data before
notifying the elder protective services agency.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Assessment
MSC: NCLEX: Safe and Effective Care Environment
18. An older patient has chronic health problems and increasing weakness. The patient‘s family
members are considering placement for the patient in a long-term care (LTC) facility. Which
action by the nurse will be most helpful in assisting the patient to make this transition?
a. Have the family select an LTC facility that is relatively new.
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b. Ask the patient‘s preference for the choice of an LTC facility.
c. Explain the reasons for the need to live in LTC to the patient.
d. Request that the patient be placed in a private room at the facility.
ANS: B
The stress of relocation is likely to be less when the patient has input into the choice of the
facility. The age of the long-term care facility does not indicate a better fit for the patient or
better quality of care. Although some patients may prefer a private room, others may adjust
better when given a well-suited roommate. The patient should understand the reasons for the
move but will make the best adjustment when involved with the choice to move and the
choice of the facility.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
19. The nurse manages the care of older adults in an adult health day care center. Which action
can the nurse delegate to assistive personnel (AP)?
a. Plan daily activities based on the individual patient needs and desires.
b. Obtain information about food and medication allergies from patients.
c. Take blood pressures daily and document in individual patient records.
d. Teach family members how to cope with patients who are cognitively impaired.
ANS: C
Measurement and documentation of vital signs are included in AP education and scope of
practice. Obtaining patient health history, planning activities based on the patient assessment,
and patient education are all actions that require clinical judgment and are in the scope of
practice for the registered nurse.
DIF: Cognitive Level: Apply (Application)
MSC: NCLEX: Safe and Effective Care Environment
TOP: Nursing Process: Planning
20. A family caregiver tells the home health nurse, ―I feel like I can never get away to do anything
for myself.ǁ Which action by the nurse would directly address this concern?
a. Assist the caregiver in finding respite services.
b. Assure the caregiver that the work is appreciated.
c. Encourage the caregiver to discuss feelings openly with the nurse.
d. Tell the caregiver that family members provide excellent patient care.
ANS: A
Respite services allow family caregivers to have time away from their caregiving
responsibilities. The other actions may also be helpful, but the caregiver‘s statement clearly
indicates the need for some time away.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
MULTIPLE RESPONSE
1. Which nursing actions would the nurse take to assess for possible malnutrition in an older
adult patient? (Select all that apply.)
a. Screen for depression.
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b.
c.
d.
e.
Review laboratory results.
Determine food preferences.
Inspect teeth and oral mucosa.
Ask about transportation needs.
ANS: A, B, D, E
The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor
protein intake or high-fat or high-cholesterol intake. Transportation affects the patient‘s ability
to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor
condition may decrease the ability to chew and swallow. Food likes and dislikes are not
necessarily associated with malnutrition.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
2. The nurse is assessing an older adult patient who lives at home. Which factors would increase
the risk for the patient to experience elder mistreatment? (Select all that apply.)
a. Immobility
b. Depression
c. Alcohol use
d. Low income
e. Social support
f. Cognitive decline
g. Living with a spouse
ANS: A, B, C, D, F
Many factors put community-dwelling older adults at risk for domestic EM. These include (1)
physical or cognitive problems that leads to an inability to perform ADLs (and thus produces
dependence on others for care), (2) any psychiatric diagnoses, including dementia and
depression, (3) alcohol use, (4) decreased social support; (5) living with a large number of
household members other than a spouse and (6) low income. The presence of social support or
living with a spouse do not increase the risk.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment
MSC: NCLEX: Health Promotion and Maintenance
Chapter 06: Caring for Lesbian, Gay, Bisexual, Transgender, Queer or Questioning,
and Gender Diverse Patients
Harding: Lewis’s Medical-Surgical Nursing, 12th Edition
MULTIPLE CHOICE
1. A new patient has not completed the health history form item indicating either male or female
gender. The patient tells the nurse that neither option is accurate. Which response would the
nurse provide?
a. ―How would you identify yourself?ǁ
b. ―I think you are dressed like a male.ǁ
c. ―What type of genitalia do you have?ǁ
d. ―Choose one or the other, it doesn‘t matter.ǁ
ANS: A
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It is best to ask the person how they currently identify; gender identity refers to a person‘s
self-perceived gender. A follow up question could include the sex assigned at birth. Gender
expression refers to how someone expresses their gender in an outward appearance clothing or
accessories; it may be the same or different than their genitalia and their sex assigned at birth.
Saying that the identification does not matter is dismissive and would not support a positive
patient- provider relationship.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment
MSC: NCLEX: Psychosocial Integrity
2. A patient who identifies as a gay male is scheduling knee surgery. Which question would the
nurse ask?
a. Have you always been gay?
b. When was your last HIV test?
c. Are you currently sexually active?
d. Do you plan to have gender changing surgery?
ANS: B
HIV is disproportionately high among men who have sex with men; HIV status has
implications for immune function and prevention of infection after surgery. Questions related
to gender identification are not pertinent to planning for the surgery and may be offensively
intrusive.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
3. A patient who is 40 years of age and identifies as lesbian is completing a health history.
Which health behavior would the nurse identify as increasing this patient‘s risk for breast
cancer?
a. Tobacco avoidance
b. Never having children
c. Frequent physical activity
d. Maintaining normal weight
ANS: B
Lesbians may have risk factors leading to a higher incidence of breast cancer. Risk factors
associated with these higher rates include tobacco use, obesity, and never having children
(nulliparity). Regular physical activity and maintaining normal weight are associated with
decreased risk of breast cancer.
DIF: Cognitive Level: Apply (Application)
MSC: NCLEX: Health Promotion and Maintenance
TOP: Nursing Process: Planning
4. A patient who is being admitted for surgery tells the nurse that the preferred pronoun is ―theyǁ
rather than he or she. What response would the nurse provide?
a. ―I will avoid talking about you so that I do not accidentally offend you.ǁ
b. ―I will use the word that you prefer and ask that other staff do the same.ǁ
c. ―That word is not important now because you will be asleep for surgery.ǁ
d. ―We need to address you with words based on your visible characteristics.ǁ
ANS: B
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Ask if the patient has any gender specific pronouns (e.g., he/him, she/her, they/them). Make
note to use the preferred pronouns when talking about the patient, such as when providing
handoff report. Dismissing the importance of the pronoun or addressing the patient based on
appearance is not respectful.
DIF: Cognitive Level: Apply (Application)
TOP: Nursing Process: Implementation
MSC: NCLEX: Psychosocial Integrity
5. A patient who has colon cancer and is near the end of life tells the nurse that estranged family
members may try to take over health decisions when the patient is unable to make them. The
patient would prefer that a long-term partner make any needed health decisions. Which
recommendation is most important for the nurse to make?
a. ―Write down your preferences and mail them to your family members.ǁ
b. ―Complete legal forms to designate your partner as the healthcare proxy.ǁ
c. ―Tell your primary care physician who will make those decisions for you.ǁ
d. ―Encourage family members and your partner to get along with one another.ǁ
ANS: B
Lesbian, gay, bisexual, transgender, queer or questioning, and gender diverse (LGBTQ+)
persons often have difficulty having their partnership recognized as valid, especially if the
patient‘s family disputes their rights. Counsel LGBTQ+ patients on the importance of having
a health care proxy and a will to legally protect their end-of-life choices.
DIF: Cognitive Level: Analyze (Analysis)
TOP: Nursing Process: Implementation
MSC: NCLEX: Safe and Effective Care Environment
6. A nurse is reviewing health assessment records for several patients undergoing gender
affirming hormone therapy (GAHT). Which finding would be important to report to the
primary care provider?
a. A transgender man on testosterone therapy reports cessation of menses.
b. A transgender woman develops an enlarged but symmetrical prostate gland.
c. A transgender man who began testosterone therapy six months ago has increased
body hair.
d. A transgender woman who is taking estrogen and an anti-androgen agent develops
breast buds.
ANS: B
Persons in the process of gender change may have health risk factors based on their anatomy,
current hormone therapy, and behaviors; a transgender woman may still have a prostate and
be at risk for prostate cancer. Transgender men who start testosterone therapy will typically
experience cessation of menses and increased body hair within the first few months of starting
therapy. Transgender women who are starting feminizing hormones with estrogen and an
anti-androgen agent may develop breast buds after several months of therapy.
DIF: Cognitive Level: Analyzing (Analysis)
TOP: Nursing Process: Assessment
MSC: NCLEX: Physiological Integrity
7. The nurse in the primary care clinic is completing a health history for a new patient who
reports being in the process of gender change. The patient asks the nurse, ―Why do you need
to know so much personal information?ǁ Which response would the nurse provide?
a. ―I don‘t want to be surprised with what I will find when I examine you.ǁ
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