Test Bank for Basic Geriatic Nursing 7th Edition by Paula Williams

BASIC GERIATRIC NURSING 7th EDITION BY WILLIAMS

Description Prepare for a successful career in caring for geriatric populations! Williams’ Basic Geriatric Nursing, 7th edition is an easy-to-read text which presents the theories and concepts of aging along with appropriate nursing interventions. This comprehensive book helps you understand the unique physiologic and psychosocial changes that affect the elderly adult. Threaded throughout this new edition are practical QSEN boxes and Nurse Alert features, which highlight safety, cultural considerations, health promotion, coordinated care, and home care specific to elderly patients. In addition, an online Study Guide, NCLEX®-PN review questions, and real-world clinical situation boxes help you to study for exams and apply concepts to practice.

Key Features 

Coordinated Care boxes address such topics as restraints, elder abuse, and end-of-life care as related to responsibilities of nursing assistants and other health care workers who are supervised by LPN/LVNs.

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Clinical Situation boxes present patient scenarios with lessons for appropriate nursing care and patient sensitivity.

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UNIQUE! A FREE Study Guide, presented in a comprehensive PDF format on Evolve, reinforces your understanding.

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10th grade reading level makes learning easier for you.

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Nursing Care Plans include Critical Thinking boxes to help you to assimilate and synthesize information.

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Nursing Process sections provide a framework for the discussion of the nursing care of the elderly patient as related to specific disorders.

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Cultural Considerations throughout text cover biocultural variations as well as health promotion for specific ethnic groups so you can provide culturally competent care.

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Health Promotion and Patient Teaching boxes highlight health promotion, disease prevention, and age-specific interventions.

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Home Health Considerations boxes provide information on home health care for the older adult.

Table of Contents Unit One: Overview of Aging 1.Trends and Issues 2.Theories of Aging 3.Physiologic Changes Unit Two: Basic Skills for Gerontologic Nursing 4.Health Promotion, Health Maintenance, and Home Health Considerations 5.Communicating with Older Adults 6.Maintaining Fluid Balance and Meeting Nutrition Needs 7.Medications and Older Adults 8.Health Assessment for Older Adults 9.Meeting Safety Needs of Older Adults Unit Three: Psychosocial Care of the Elderly 10.Cognition and Perception 11.Self-Perception and Self-Concept 12.Roles and Relationships 13.Coping and Stress 14.Values and Beliefs 15.End-of-Life Care 16.Sexuality and Aging Unit Four: Physical Care of the Elderly 17.Care of Aging Skin and Mucous Membranes 18.Elimination 19.Activity and Exercise 20.Sleep and Rest

Chapter 1: Trends and Issues

Multiple Choice

1. Since 1995 there has been a significant decrease in the rate of infant deathrelated to which of the following:

a. Disorders associated with short gestation and low birth weight b. Accidents c. Sudden infant death d. Newborns affected by complications of placenta, cord, and membranesANS: c Feedback

a. The rates of prematurity and low birth weight are increasing. b. The rates of accidents have increased. c. Correct. The rate of infant death related to SIDS has decreased from 87.1 to 47.2. The decrease in rate is partially attributed to placing infants on theirbacks when sleeping.

d. The rates of newborns affected by complications of placenta, cord, andmembranes have increased.

2. Tobacco use during pregnancy is associated with adverse effects on the unborn infant such as intrauterine growth restriction, preterm births, and respiratory problems. By race, which has the highest percentages of smokers?

a. American Indian and Alaskan Natives b. Asian or Pacific Islanders c. Non-Hispanic blacks d. Non-Hispanic whites ANS: a Feedback

a. 36% of American Indian and Native American women are cigarette smokers. b. 4.3% of Asian or Pacific Islander women are cigarette smokers. c. 17.1% of non-Hispanic black women are cigarette smokers. d. 19.6% of non-Hispanic white women are cigarette smokers.

KEY: Integrated Process: Clinical Problem Solving | Cognitive Level: Knowledge |Content Area: Maternity | Client Need: Safe and Effective Care Environment | Difficulty Level: Easy

3. Which of the following women is at the highest risk for health disparity?

a. A white, middle-class, 16-year-old woman b. An African American, middle-class, 25-year-old woman c. An African American, upper-middle-class, 19-year-old woman d. An Asian, low-income, 30-year-old womanANS: d Feedback

a. Although age is a risk factor, income contributes to disparity. b. Although African American women are at increased risk, income accounts forthe largest disparity.

c. Although age and race contribute to increased risk, income accounts for thelargest disparity. d. Although age and race contribute to increased risk, income accounts for thelargest disparity.

4. A neonate born at 36 weeks gestation is classified as which of the following? a. Very premature b. Moderately premature c. Late premature d. Term ANS: c Feedback

a. Very premature is less than 32 weeks’ gestation. b. Moderately premature is 32 to 33 completed weeks’ gestation. c. Correct. Late premature is 34 to 36 completed weeks’ gestation. d. Term is 37 to 42 weeks’ gestation.

5. The perinatal nurse explains to the student nurse that a goal of the HealthyPeople 2020 report is to:

a. Increase proportion of infants who are breastfed to 93.1%. b. Increase proportion of infants who are breastfed to 90.7%. c. Increase proportion of infants who are breastfed to 85.6%. d. Increase proportion of infants who are breastfed to 83.9%.ANS: d A goal of Healthy People 2020 is to increase the proportion of infants who are breastfed from 74% to 81.9%.

6. The perinatal nurse explains to the student nurse that leading cause of infant death in the United States.

is the

a. Sudden Infant Death Syndrome b. Respiratory distress of newborns c. Disorders related to short gestation and low birth weight d. Congenital malformations and chromosomal abnormalitiesANS: d 7. Which of the following statements are true related to teen pregnancies?(Select all that apply.)

a. Teen mothers are at higher risk for HIV. b. Teen mothers are at higher risk for hypertensive problems. c. The birth rate for teenaged women has increased in the past 15 years. d. Infants born to teen mothers are at higher risk for health problems.ANS: a, b, d Health statistics report higher risk for HIV, for hypertensive problems, and for health problems to infants born to teen mothers. Birth rates for teen mothers in all age categories have decreased since 1991.

Chapter 2- Theories of Aging

A) B) C) D) Ans:

1. Which of the following statements most accurately conveys an aspect of the error theoryof aging?

Perpetuation of DNA mutations results in organ and system malfunction.

Age-related dysfunction of organs, tissues, and body systems results in mutation of body DNA. The number of cell divisions is genetically predetermined.

Errors in the function of various organs contribute to changes in the genetic code of various body cells.

A Feedback: The error theory of aging proposes that genetic mutations are perpetuated through the aging process, resulting in organ malfunction and eventual decline in body function.

Organ malfunction results from, but does not cause, the genetic mutations in question. A genetic predetermination of the number of cell divisions is associated with the programmed theory of aging.

Origin: Chapter 2- Theories of Aging, 2 Chapter: 2 Client Needs: D4 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing process Objective: 2 Page and Header: 15, Genetic Theories 1. The error theory of aging proposes a cause-and-effect relationship between the genetic activity of body cells and the effects of aging. Place the following steps in the error theory of aging in the correct chronological order. Use all the options.

Ans:

A) Organ, tissue, and system malfunction B) Perpetuation of mutation during cell divisions C) DNA mutation D) Overall decline in body functions E) Decline in body functions C, B, E, A, D Feedback: The error theory of aging proposes that DNA mutations occur on a single-cell level and are perpetuated in subsequent cell divisions. The overall number of mutant cells in the

body increases and causes deleterious effects on tissues and systems and eventual decline in body function.

Origin: Chapter 2- Theories of Aging, 3 Chapter: 2 Client Needs: D4 Cognitive Level: Comprehension Difficulty: Difficult Integrated Process: Teaching/learning Objective: 2 Page and Header: 14, Evolutionary Theories 2. A nurse is explaining to an older adult client that many of the changes in his body that are currently causing him frustration may have their origins in genetic changes that may have in fact benefited him during his younger years. Which of the following theories of aging underlies the nurse's explanation?

A) Disposable soma theory B) Free radical theory C) Mutation accumulation theory D) Antagonistic pleiotropy theory Ans: D Feedback: Antagonistic pleiotropy theory proposes that genetic mutations that are problematic in later life may be rooted in mutation that played a beneficial role earlier in life. This perspective is not a component of the disposable soma theory, free radical theory, or mutation accumulation theory.

Origin: Chapter 2- Theories of Aging, 4 Chapter: 2 Client Needs: D4 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing process Objective: 2 Page and Header: 14, Free Radicals and Lipofuscin Theories 3. An 80-year-old female who enjoys good health explains to her primary care provider that she attributes her health status to her regular intake of berries, fruit juices, and green tea, which she states “help cleanse the damaging molecules out of my body.” Which of the following theories of aging underlies the client's health behaviors?

A) Free radical theory B) Biogerontology C) Disposable soma theory D) Cross-linking theory Ans: A Feedback:

The free radical theory of aging attributes damage to the accumulation of free radicals that may be countered by the intake of antioxidants. This is not an explicit component of the disposable soma or cross-linking theory of aging. Biogerontology is the study of the relationship between aging and disease.

Origin: Chapter 2- Theories of Aging, 5 Chapter: 2 Client Needs: D4 Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/learning Objective: 2 Page and Header: 15, Autoimmune Reactions 5.A nurse is discussing an older adult client's apparent increased susceptibility to infection with his family. Which of the following statements by the nurse would be most congruent with current thought around the autoimmune role in the aging process?

A) “Changes that we call 'mutations' in your father's cells make his organs more vulnerable to chronic illness and germs.”

B) “Older adults often have more difficulty fighting off infections because of their weaker immune systems, and their bodies can even attack themselves.”

C) “Diseases such as arthritis, which we term 'autoimmune,' make older people more likely to catch viruses and other bugs.”

D) “Our bodies seem to have an 'expiry date,' after which we are far more likely to get infections and develop chronic illness.”

Ans: B Feedback: Decreased immune response coupled with increased autoimmune activity is implicated in many of the effects of the aging process. The salience of mutations is associated with genetic theories of aging and autoimmune activity is not considered the direct cause of the decline in thymus and bone marrow activity. A predetermined cell life span is associated with the programmed theory of aging.

A)

Origin: Chapter 2- Theories of Aging, 6 Chapter: 2 Client Needs: C Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/learning Objective: 3 Page and Header: 16, Disengagement Theory 6.A hospital clinical educator is espousing the disengagement theory of aging when teaching staff how best to meet the needs of older clients. Which of the nurse's teaching points best captures the disengagement theory of aging?

“Older adults often benefit from a gradual and controlled withdrawal of their own

B) C) D) Ans:

interests from society's interests.”

“The disengagement between an older adult's abilities and desires can lead to frustration and, ultimately, to illness.”

“The lack of synchronicity between older adults' immune systems and their environments can be the root of many problems.”

“It is imperative that we ensure older adults remain engaged with interests and events beyond themselves.”

A Feedback: Disengagement theory postulates that disengagement between the individual and society is beneficial to both parties. It does not propose that this process of withdrawal be prevented nor that it necessarily leads to frustration or illness. The immune system is not a central component of the theory.

Origin: Chapter 2- Theories of Aging, 7 Chapter: 2 Client Needs: C Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/learning Objective: 3 Page and Header: 17, Activity Theory 7. Which of the following directives by the head nurse at a long-term care facility is most reflective of the activity theory of aging?

A) “We need to facilitate older adults' desire to step back from the responsibilities and roles they had in earlier years.”

B) “It's hard to overestimate the importance of regular, physical exercise in maintaining health and healthy aging.”

C) “We need to remember that the psychological roles and characters of our residents change profoundly in later years of life.”

D) “We have to treat our residents like younger people and keep them engaged in meaningful acts.”

Ans: D Feedback: The activity theory asserts that an older person should continue a middle-aged lifestyle, denying the existence of old age as long as possible, and that society should apply the same norms to old age as it does to middle age and not advocate diminishing activity, interest, and involvement as its members grow old. Stepping back from roles is associated with disengagement theory, and psychological roles and character are not thought to change radically in later life. Physical exercise is not a central component of activity theory.

Origin: Chapter 2- Theories of Aging, 8 Chapter: 2

Client Needs: C Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing process Objective: 3 Page and Header: 18, Developmental Tasks 8. Which of the following tasks are components of Erikson's description of the old age tasks of reconciling ego integrity with despair? Select all that apply.

A) An 80-year-old man is struggling to determine his identity apart from his lifelong career as a business leader.

B) A 79-year-old woman has established habits that promote her financial independence in spite of a lack of savings.

C) An 80-year-old man revels in his large, happy family rather than focusing on his mobility limitations resulting from Parkinson disease.

D) A 77-year-old man is trying to determine whether his life has had deep significance and meaning.

Ans: A, C, D Feedback: Deriving satisfaction from oneself rather than occupational roles, finding pleasure in spite of physical limitations, and determining meaning in the life one has lived are all aspects of Erikson's outcome of ego integrity or despair. Financial independence is not a central component of this outcome.

Origin: Chapter 2- Theories of Aging, 9 Chapter: 2 Client Needs: C Cognitive Level: Application Difficulty: Easy Integrated Process: Nursing process Objective: 4 Page and Header: 20, Box 2-2 9. Which of the following actions by a nurse who works with older adult clients in an assisted living facility is most likely to inhibit healthy aging?

A) Discussing current events with clients who read and watch television.

B) Placing a bib on each client during meal times to ensure clients maintain a clean appearance.

C) Challenging clients to learn new skills and develop preexisting talents.

D) Facilitating introductions between new and existing clients.

Ans: B Feedback: While the nurse's action may have a laudable rationale, using a bib and feeding clients who may not require either action is incongruent with promoting function and preventing helplessness. Discussing current events and facilitating new skills and relationships promote well-being.

Origin: Chapter 2- Theories of Aging, 10 Chapter: 2 Client Needs: C Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing process Objective: 3 Page and Header: 18, Developmental Tasks 10.A nurse notes that a 90-year-old male client on a geriatric medical unit of the hospital has been talking about death frequently. Given that the nurse has good rapport with client, what is the nurse's most appropriate response?

A) “Try to focus more on the positive benefits of healing rather than what might happen.”

B) “Remember that in this day and age many people can live far beyond 90 years of age.”

C) “I've noticed you've brought up the issue of dying a lot. How do you feel about that?”

D) “You'll find that aiming for health rather than thinking about death will have positive results.”

Ans: C Feedback: Preparing for death has been identified as a developmental task for later life and would be an appropriate topic for discussion given the partnership that exists between the nurse and the client and the client's desire to broach the subject.

Origin: Chapter 2- Theories of Aging, 11 Chapter: 2 Client Needs: B Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing process Objective: 1 Page and Header: 19, Applying Theories of Aging to Nursing Practice 11.Nurses need to understand the aging process in order to help their patients: A) Live longer with their long-term disabilities B) Maintain youth and delay the onset of old age C) Accept the limitations imposed by genetic tendencies toward cellular degeneration D) Postpone the negative consequences of the aging process Ans: D Feedback: The promotion of positive health practices increases the chances that an individual can delay or deter the impairments and declines that frequently accompany the aging process. Living long in a disabled state is not the most desirable objective. Maintaining youth is not an achievable goal. Accepting limitations is not necessary for many seniors

and not life enhancing for many others.

Origin: Chapter 2- Theories of Aging, 12 Chapter: 2 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Nursing process Objective: 2 Page and Header: 13, Biological Theories of Aging 12. Mrs. H and Mrs. J are the same age. While in the doctor's waiting room, they discuss their ailments and their beliefs about aging. Mrs. H argues that Mrs. J must be older because she has more ailments. The nurse settles the argument by stating a cornerstone of all biological theories of aging. Which of the following statements did the nurse most likely make?

A) Aging is a predictable cellular process.

B) Cells undergo a finite number of divisions.

C) No two individuals age identically.

D) Body systems decline at the same rate.

Ans: C Feedback: Individual variability is fundamental to all biological theories. Aging is not totally predictable, nor is it necessarily cellular in some biological theories. Body systems are often seen to decline at different rates.

Origin: Chapter 2- Theories of Aging, 13 Chapter: 2 Client Needs: D4 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing Process Objective: 3 Page and Header: 15, Genetic Theories 13. Which of the following statements is evidence that supports the programmed theory of aging?

A) The life spans attained by parents and their offspring are negatively correlated.

B) Mutations perpetuate themselves through each cycle of cell division.

C) In cultures, cells go through a finite number of cell divisions before dying.

D) In cultures, cells from older donors divide faster than those from younger donors.

Ans: C Feedback: Studies of in vitro cell proliferation have demonstrated that various species have a finite number of cell divisions. Life spans of parents and offspring are positively correlated.

Mutation perpetration is a tenet of the error theory, not the programmed theory, of aging.

Although longer life spans correlate positively with numbers of cell divisions in vitro, the rate of cell division is not affected.

Origin: Chapter 2- Theories of Aging, 14 Chapter: 2 Client Needs: D4 Cognitive Level: Analysis Difficulty: Difficult Integrated Process: Nursing process Objective: 2 Page and Header: 14, Cross-Linking Theory 14. Which of the following statements form components of both the error theory of aging and the cross-linking theory of aging?

A) Free radicals cause mutations in cells.

B) Senescence is environmentally controlled at the cellular level.

C) Changes in DNA lead to organ malfunctions.

D) Genetic programming determines life expectancy.

Ans: C Feedback: Both the error theory and the cross-linking theory assert some change in DNA that interferes with normal cell functioning. Such changes may be caused by free radicals or any of many other mutagens. Although the aging of cells may be environmentally influenced, it is not thought to be externally controlled. That genetic programming determines life expectancy is a basic tenet of the programmed theory of aging.

Origin: Chapter 2- Theories of Aging, 15 Chapter: 2 Client Needs: D4 Cognitive Level: Comprehension Difficulty: Moderate Integrated Process: Nursing process Objective: 2 Page and Header: 14, Free Radicals and Lipofuscin Theory 15. Which of the following statements underlie both the error theory of aging and the free radical theory of aging?

A) Biochemical damage accumulates over time, leading to cell death.

B) The rate of cellular death is genetically programmed.

C) The aging body produces fewer growth and repair hormones.

D) Environmental agents such as radiation and heavy metals damage DNA. Ans: A Feedback: That the rate of cell death is genetically programmed is a basic tenet of the programmed theory of aging. That the aging body produces fewer growth and repair hormones is a neuroendocrine theory. Although radiation and heavy metals may damage DNA, they are

not free radicals, and they need not be the cause of the mutations assumed by the error theory.

Origin: Chapter 2- Theories of Aging, 16 Chapter: 2 Client Needs: D4 Cognitive Level: Application Difficulty: Moderate Integrated Process: Nursing process Objective: 2 Page and Header: 15, Autoimmune Reactions 16. The nursing staff at a nursing home works closely with the staff in the Endocrinology Department at a local hospital. This relationship is maintained for the welfare of the nursing home residents, because a failing immune system in the elderly might account for: A) A decline in the rate of growth hormone production B) The increased incidence of cancer among the aged C) The oxidative activity of free radicals D) Changes in brain activity and nervous system function Ans: B Feedback: Compromises in the immune systems of the elderly may lead to a failure to recognize and destroy cancerous cells. The immune system is not involved in the production of growth hormones. The immune system does not determine the action of free radicals, although it may be involved in seeking out and destroying cells damaged by free radical activity. There is no known association between diminished immune activity and changes in the brain or nervous system action.

Origin: Chapter 2- Theories of Aging, 17 Chapter: 2 Client Needs: D4 Cognitive Level: Knowledge Difficulty: Easy Integrated Process: Nursing process Objective: 2 Page and Header: 15, Autoimmune Reactions 17. Although the immune system is affected by the aging process, the elderly are not the only individuals who have autoimmune disorders. These occur in populations of all ages because autoimmune disorders involve: A) An attack of antibodies on body cells B) An overproduction of T cells in bone marrow C) A decrease in the weight of the thymus gland D) An increase in the amount of lipofuscin in the blood Ans: A

Feedback: In autoimmune disorders, the immune system attacks and destroys the body's own cells (as opposed to those of invading, disease-causing microorganisms). There is no overproduction of T cells. Although the weight of the thymus gland decreases with age and the amount of lipofuscin increases, such changes are not characteristic of autoimmune disorders.

Origin: Chapter 2- Theories of Aging, 18 Chapter: 2 Client Needs: B Cognitive Level: Knowledge Difficulty: Easy Integrated Process: Teaching/learning Objective: 2 Page and Header: 16, Radiation Theories 18.A magazine geared toward elderly women contains an advertisement for an anti-wrinkle cream purported to remove wrinkles caused by the drying effects of years of soap use.

Knowledgeable nurses can keep their elderly female clients from being duped by this advertisement by explaining that the wrinkling of facial skin in old age results primarily from: A) Changes in the endocrine glands B) Cellular mutations arising from toxic chemicals C) Repeated exposure to ultraviolet light D) A diet high in fats and refined sugars Ans: C Feedback: Repeated exposure to ultraviolet light causes solar elastosis, the wrinkling that results from the replacement of collagen by elastin. Toxic chemicals, nutrition, and endocrine changes are not known to produce the wrinkling of the skin seen in old age.

Origin: Chapter 2- Theories of Aging, 19 Chapter: 2 Client Needs: B Cognitive Level: Application Difficulty: Moderate Integrated Process: Teaching/learning Objective: 2 Page and Header: 16, Nutrition Theories 19. Mr. B, age 72, has a history of heart disease. He insists that his high-fat diet is permissible, however, because he takes a daily supplement of gugulipid, an herb purported to reduce blood cholesterol levels. In talking with the patient, what should Mr. B's nurse do first?

A) Suggest that Mr. B ask his doctor for a prescription medication to reduce cholesterol levels

B) C) D) Ans:

Review with Mr. B the benefits associated with limiting dietary fat Introduce Mr. B to the additional benefits associated with fish oil supplements Advise Mr. B to stop using gugulipid, as herbal supplements are not regulated by the FDA B Feedback: The first duty of Mr. B's nurse is to promote positive health behaviors, which means encouraging the patient to limit his fat intake. Herbal supplements are unregulated, and their health benefits may be questionable. Whether fish oil supplements or prescription medications are advisable in this case merits further investigation.

Origin: Chapter 2- Theories of Aging, 20 Chapter: 2 Client Needs: C Cognitive Level: Knowledge Difficulty: Easy Integrated Process: Nursing process Objective: 3 Page and Header: 16, Disengagement Theory 20. Ms. E, an 80-year-old, is gradually withdrawing from society and wants society to gradually withdraw from her. She believes that this mutual withdrawal will free her from societal roles and give society the means for transferring power from the old to the young. Ms. E's grown children are concerned and say her belief has no scientific basis.

On which of the following theories of aging can Ms. E say she bases her belief?

A) Activity theory B) Developmental tasks theory C) Disengagement theory D) Continuity theory Ans: C Feedback: Disengagement theory views aging as a process in which society and the individual gradually withdraw, or disengage, from each other, to the mutual satisfaction and benefit of both.

Origin: Chapter 2- Theories of Aging, 21 Chapter: 2 Client Needs: B Cognitive Level: Application Difficulty: Difficult Integrated Process: Nursing process Objective: 3 Page and Header: 17, Activity Theory 21.A state committee is looking to improve the lives of the state's elderly. It wants to recommend that health care facilities that cater to the elderly population be required to

A) B) C) D) Ans:

base their practices on the activity theory of aging. Which of the following may be one problem with implementing the activity theory of aging?

The assumption that older people want to maintain their middle-aged lifestyle The reluctance of the elderly to give up their occupational roles at retirement age The decline in mental acuity that accompanies physical impairment in most cases Declining health, loss of roles, and shrinking circle of friends of most elderly A Feedback: The activity theory suggests that the elderly should maintain their middle-aged lifestyle to the greatest extent possible, a goal not all elderly persons will embrace. The reluctance of many elderly persons to give up their middle-aged roles is consistent with the theory.

Relatively small numbers of the elderly experience a significant decline in mental acuity.

Declining health, loss of roles, and a shrinking circle of friends are problems the activity theory seeks to minimize.

Origin: Chapter 2- Theories of Aging, 22 Chapter: 2 Client Needs: C Cognitive Level: Knowledge Difficulty: Easy Integrated Process: Nursing process Objective: 3 Page and Header: 17, Continuity Theory 22. Mr. D was friendly and active as a young adult. Now, as a 75-year-old, he enjoys visiting with his neighbors and attending a variety of sporting and cultural events. Mr. D's behavior is most consistent with which theory of aging?

A) Activity theory B) Developmental tasks theory C) Disengagement theory D) Continuity theory Ans: D Feedback: The continuity theory suggests that personality and basic patterns of behavior remain unchanged as an individual ages. This is not a central component of the other noted theories.

Origin: Chapter 2- Theories of Aging, 23 Chapter: 2 Client Needs: B Cognitive Level: Analysis Difficulty: Moderate Integrated Process: Teaching/learning Objective: 4 Page and Header: 20, Box 2-2

23. Nurse Z takes ample time to explain all medical options to her elderly patients and to

A) B) C) D) Ans:

ensure they have the information they need to make informed decisions about their care.

What is Nurse Z's best reason for taking these actions?

Full disclosure deters malpractice suits and negligence claims The activity theory of aging requires maintenance of lifestyle Information is an effective strategy for stress management Empowerment has a positive effect on health status D Feedback: Maximum control and decision making can have a positive effect on morbidity and mortality, although they do not necessarily reduce stress and are not inherent in the activity theory of aging. Even though legal considerations apply, the health of the patient is the first priority for nurses.

Chapter 03: Physiologic Changes Basic Geriatric Nursing, 7th Edition Chapter 03: Physiologic Changes Test Bank MULTIPLE CHOICE 1. The nurse keeps the environment warmer for older adults because they are more sensitive to cold because of the age-related changes in their:

a.

metabolism rate.

b.

subcutaneous tissue.

c.

musculoskeletal system.

d.

peripheral vascular system.

ANS: B The reduction of subcutaneous tissue as an age-related change causes sensitivity to cold because it is the main insulator of the body.

DIF: Cognitive Level: Application REF: 36 OBJ: 1 TOP: Sensitivity to Cold KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse reassures the distressed 75-year-old male that the wartlike dark macules with distinct borders are not melanomas, but the skin lesions of:

a.

senile lentigo.

b.

cutaneous papillomas.

c.

seborrheic keratoses.

d.

xerosis.

ANS: C Dark, slightly raised macules are seborrheic keratoses, which may be mistaken for melanomas.

DIF: Cognitive Level: Comprehension REF: 33 OBJ: 1 TOP: Seborrheic Keratosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse is accompanying a group of older adults on a July 4th outing to monitor heat prostration. Older adults are intolerant of heat because of an age-related reduction of:

a.

melanin.

b.

perspiration.

c.

body temperature.

d.

capillary fragility.

ANS: B Reduction in perspiration related to reduced sweat gland function results in possible heat intolerance from an inability to cool the body by evaporation.

DIF: Cognitive Level: Analysis REF: 34 OBJ: 2 TOP: Heat Intolerance KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse cautions the CNAs to use care when transferring or handling older adults because their vascular fragility will cause:

a.

altered blood pressure.

b.

pressure ulcers.

c.

pruritus.

d.

senile purpura.

ANS: D Increased capillary fragility results in subcutaneous hemorrhage or senile purpura from incautious handling by caregivers.

DIF: Cognitive Level: Comprehension REF: 34-35 OBJ: 7 TOP: Senile Purpura KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse assesses a stage I pressure ulcer on an older adult’s coccyx by the appearance of a:

a.

clear blister.

b.

nonblanchable area of erythema.

c.

scaly abraded area.

d.

painful reddened area.

ANS: B A red nonblanchable area is indicative of a stage I pressure ulcer.

DIF: Cognitive Level: Analysis REF: 35 OBJ: 5 TOP: Pressure Ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The CNA caring for an older adult asks if the yellow, waxy, crusty lesions on the patient’s axilla and groin are contagious. The nurse’s most helpful response is:

a.

“Yes. It is cellulitis caused by bacteria.”

b.

“No. It is seborrheic dermatitis caused by excessive sebum.”

c.

“Yes. It is an indication of scabies.”

d.

“No. It is the lesion seen with basal cell carcinoma.”

ANS: B Seborrheic dermatitis is a bothersome skin condition resulting from an excess of sebum.

DIF: Cognitive Level: Application REF: 36 OBJ: 5 TOP: Seborrheic Dermatitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse leads a group of postmenopausal older women on a daily 15-minute “walking tour” through the long-term care facility to:

a.

improve bone strength.

b.

orient them to their surroundings.

c.

improve their socialization.

d.

increase their appetite.

ANS: A Stress to long bones by weight-bearing and walking will increase bone strength.

DIF: Cognitive Level: Analysis REF: 36 OBJ: 7 TOP: Bone Strength KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. When the perplexed 70-year-old woman asks, “How in the world can my bones be brittle when I eat all the right foods?” the nurse’s most informative reply is:

a.

“Calcium loss is expected in the older adult.”

b.

“Calcium is continuously withdrawn from bone for nerve and muscle function.”

c.

“Smoking and alcohol consumption speed calcium loss from the bones.”

d.

“Walking and standing increase calcium loss from the bone.”

ANS: B Calcium is constantly withdrawn from the bone for nerve and muscle function and clotting needs.

DIF: Cognitive Level: Comprehension REF: 36-37 OBJ: 3 TOP: Calcium Loss KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. When the 70-year-old woman complains, “I weigh exactly the same as I did when I wore a size 10 and now I can barely squeeze into a size 16,” the nurse explains:

a.

“Metabolism in the older adult creates increased adipose tissue.”

b.

“Postmenopausal women gain adipose tissue related to loss of calcium.”

c.

“Decrease in muscle mass is replaced with adipose tissue.”

d.

“Kyphosis causes a redistribution of weight.”

ANS: C Decrease in muscle mass is replaced with adipose tissue, which frequently changes the appearance of the body, but not the weight.

DIF: Cognitive Level: Application REF: 39 OBJ: 4 TOP: Loss of Muscle Mass KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. When the 70-year-old postmenopausal woman asks whether her hormone replacement therapy (HRT) will prevent bone loss, the nurse’s most helpful response is:

a.

“No. HRT is not helpful after the age of 60.”

b.

“Yes. HRT will prevent bone loss but can cause a stroke, heart attack, or breast cancer.”

c.

“No. HRT is reliant on some natural estrogen production from the ovaries.”

d.

“Yes. HRT is a widely accepted therapy for prevention of bone loss.”

ANS: B HRT is helpful to prevent bone loss, but the risks of cardiovascular complications and cancer have made the choice of HRT controversial.

DIF: Cognitive Level: Analysis REF: 39 OBJ: 4 TOP: Hormone Replacement Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. An 80-year-old-woman who has osteoarthritis complains of how ugly her hands have become since she has developed Heberden nodes, which are:

a.

yellow longitudinal lines in the nails.

b.

thickened discolored fingernails.

c.

darkened areas under the fingernail.

d.

bony enlargements of distal joints of the fingers.

ANS: D Heberden nodes are bony enlargements of the distal joints of the fingers associated with osteoarthritis.

DIF: Cognitive Level: Knowledge REF: 40 OBJ: 4 TOP: Heberden Nodes KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. The nurse modifies the nursing care plan for a 62-year-old woman in an extended-care facility who is suffering a flare in her rheumatoid arthritis to include interventions to:

a.

increase fluid intake.

b.

schedule several rest periods to balance activity.

c.

reduce salt in the diet.

d.

assist with rigorous finger extension exercises.

ANS: B Balancing rest and activity allows the resident to remain relatively flexible. Joints may be splinted to reduce contracture.

DIF: Cognitive Level: Application REF: 40 OBJ: 5 TOP: Rheumatoid Arthritis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The nurse explains that emphysema is a chronic obstructive pulmonary disease characterized by the pathophysiology of:

a.

constriction of the bronchial tree, excessive mucus, and nonproductive cough.

b.

calcification of the alveoli and a dry cough.

c.

overinflation of the alveoli, making them ineffective for gas exchange.

d.

inflammation of the trachea and bronchioles, excessive mucus, and productive cough.

ANS: C Emphysema causes overinflation of the nonelastic alveoli, which disallows gas exchange in the affected alveoli and results in reduced oxygenation.

DIF: Cognitive Level: Comprehension REF: 42 OBJ: 5 TOP: Emphysema KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. The nurse explains that the pathophysiology of a myocardial infarct is that:

a.

a portion of the myocardium necroses and scars over.

b.

the coronary vessels are narrowed during the attack.

c.

the ischemic myocardium causes pain during the attack but is able to regenerate.

d.

there is damage to the myocardium but no serious alteration of cardiac output.

ANS: A The myocardium necroses and scars and does not regenerate. The degree of heart damage is related to the amount of necrosis.

DIF: Cognitive Level: Comprehension REF: 46 OBJ: 6 TOP: Myocardial Infarct KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The nurse is aware that the cardinal signs and symptoms of congestive heart failure are:

a.

dyspnea and edema.

b.

myocardial pain and hypotension.

c.

ventricular arrhythmias and cyanosis.

d.

atrial arrhythmias and polycythemia.

ANS: A Dyspnea and generalized edema are the cardinal signs and symptoms of congestive heart failure.

DIF: Cognitive Level: Application REF: 47 OBJ: 5

TOP: Congestive Heart Failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. The nurse explains that pernicious anemia is caused by:

a.

an iron deficiency.

b.

a deficiency of vitamin B12.

c.

inadequate nutrition.

d.

blood loss.

ANS: B Pernicious anemia results from a deficiency of vitamin B12.

DIF: Cognitive Level: Knowledge REF: 50 OBJ: 2 TOP: Pernicious Anemia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse alters the nursing care plan for a patient with a hiatal hernia and resultant gastrointestinal reflux to include interventions for:

a.

encouraging the patient to lie down after meals.

b.

drinking two full glasses of liquid after the evening meal.

c.

eating smaller, more frequent meals.

d.

using caffeine drinks to assist with digestion.

ANS: C Eating smaller and more frequent meals does not enlarge the stomach.

DIF: Cognitive Level: Analysis REF: 53 OBJ: 5 TOP: Hiatal Hernia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 18. The nurse suspects that the pale, edematous, listless diabetic patient who has a blood urea nitrogen (BUN) level of 35 mg/dL and a creatinine level of 4 mg/dL has:

a.

diverticulitis.

b.

congestive heart failure.

c.

chronic renal failure.

d.

benign prostatic hypertrophy.

ANS: C The increased BUN and creatinine levels indicate renal failure.

DIF: Cognitive Level: Application REF: 56 OBJ: 6 TOP: Renal Failure KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. The most appropriate intervention added to the nursing care plan for a person with Parkinson disease with a nursing diagnosis of “Nutrition, less than body requirements related to difficulty swallowing,” would be to:

a.

feed the patient at each meal.

b.

place the patient in a semi-Fowler position for mealtime.

c.

offer a thick, high-nutrition shake as a snack.

d.

encourage the patient to drink a sip of water after each bite of solid food.

ANS: C Thick shakes are easier to swallow without aspiration and will also improve nutrition.

DIF: Cognitive Level: Application REF: 58 OBJ: 5 TOP: Parkinson Disease KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 20. The nurse would anticipate that a person with a hemorrhagic CVA to the left hemisphere would exhibit:

a.

language disturbances.

b.

poor impulse control.

c.

inappropriate affect.

d.

confabulation.

ANS: A A left hemisphere CVA would most likely cause language disturbances such as aphasia, agraphia, or alexia.

DIF: Cognitive Level: Analysis REF: 61 OBJ: 5 TOP: Cerebrovascular Accident KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. When giving written discharge instructions to a person with macular degeneration, the nurse should:

a.

write the instructions in bold print.

b.

adjust the table and light to assist the patient to use peripheral vision to read.

c.

place written document directly in front of the patient to read.

d.

read the document to the patient.

ANS: B Assist the patient to use peripheral vision because central vision is lost in macular degeneration.

DIF: Cognitive Level: Analysis REF: 64 OBJ: 5 TOP: Macular Degeneration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 22. The nurse becomes aware of inadequate insulin coverage in a patient with diabetes mellitus type 1 when the patient exhibits:

a.

diminished urine output.

b.

ketones in the urine.

c.

shallow and slow respirations.

d.

extreme diaphoresis.

ANS: B When there is inadequate insulin coverage for the type 1 diabetic, the diabetic lacks the glycogen to use as energy and attempts to use fat, which creates an acid in the form of ketones.

DIF: Cognitive Level: Application REF: 70 OBJ: 5 TOP: Diabetes Mellitus Type 1 KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 23. An 80-year-old extended-care resident comes to the nurse asking for a bandage for a bleeding, dark pigmented mole with irregular shape and border. The nurse documents this assessment and reports it as a suspected:

a.

melanoma.

b.

basal cell carcinoma.

c.

cutaneous papilloma.

d.

senile lentigo.

ANS: A Melanomas are dark, irregularly shaped lesions that may cause itching or bleeding. These are potentially deadly and should be reported to obtain quick treatment.

DIF: Cognitive Level: Comprehension REF: 35 OBJ: 5 TOP: Melanoma KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. The nurse takes into consideration that the factors influencing the timing and extent of age-related changes include . (Select all that apply.)

a.

health maintenance

b.

ethnicity

c.

heredity

d.

attitude

e.

environment

ANS: A, C, E Heredity, environment, and health maintenance affect the timing and magnitude of age-related changes.

DIF: Cognitive Level: Comprehension REF: 32 OBJ: 1 TOP: Influences on Age-Related Changes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse reminds an 82-year-old man with rosacea that he should avoid that apply.)

a.

stress

b.

dairy products

c.

sun exposure

d.

spicy foods

. (Select all

e.

alcohol consumption

ANS: A, C, D, E The patient who has rosacea should avoid stress, sun exposure, spicy foods, and alcohol consumption.

DIF: Cognitive Level: Comprehension REF: 35 OBJ: 5 TOP: Rosacea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 3. The nurse is aware that in order for a person to support ossification, he or she must have an adequate intake of vitamin(s) . (Select all that apply.)

a.

A

b.

B6

c.

C

d.

D

e.

E

ANS: A, C, D Vitamins A, C, and D are necessary for bone matrix formation and replenishment.

DIF: Cognitive Level: Knowledge REF: 36 OBJ: 7 TOP: Ossification KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse uses a chart to outline the risk factors for osteoporosis, which include . (Select all that apply.)

a.

menopause

b.

smoking

c.

white female

d.

excessive high-impact exercise

e.

long-term use of phenytoin (Dilantin)

ANS: A, B, C, E Menopausal white women who smoke and have had long-term administration of phenytoin (Dilantin), heparin, or corticosteroids are at risk for osteoporosis.

DIF: Cognitive Level: Comprehension REF: 39 OBJ: 5 TOP: Risk Factors for Osteoporosis KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse outlines age-related changes in the respiratory system that put the older adult at risk for infection, which include . (Select all that apply.)

a.

reduced ciliary movement

b.

decrease in alveolar elasticity

c.

pooling of secretions

d.

flattened diaphragm

e.

calcification of costal cartilage

ANS: A, B, C The flattening of the diaphragm and the calcification of cartilages decrease respiratory effectiveness but do not support pathogen growth as do ciliary and alveolar changes.

DIF: Cognitive Level: Comprehension REF: 42 OBJ: 1 TOP: Age-Related Changes in the Respiratory System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse is aware that children with of advanced age.

have the treatment and care needs of persons

ANS: progeria A rare condition called progeria causes severe premature aging. When they are only 8 or 9 years of age, children with progeria have the physiology and appearance of 70-year-olds.

DIF: Cognitive Level: Knowledge REF: 32 OBJ: 7 TOP: Progeria KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The 75-year-old resident in a long-term care facility complains of muscle pain while riding a stationary bicycle. The nurse explains that the discomfort is related to the buildup of in the muscle.

ANS: lactic acid Elevated levels of lactic acid may result in muscle fatigue and soreness.

DIF: Cognitive Level: Comprehension REF: 38 OBJ: 7 TOP: Lactic Acid Buildup KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. When a 75-year-old male resident in an extended-care facility tells the nurse he wants to build up the muscles in his arms, the nurse recommends a(n) exercise program.

ANS: isotonic Isotonic exercises such as flexing and extending the arms while holding hand weights build tone and muscle mass.

DIF: Cognitive Level: Comprehension REF: 38 OBJ: 4 TOP: Isotonic Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation OTHER 1. Arrange these common diseases of the older adult in order of their mortality rate. a. Cancer b. Pneumonia c. Stroke d. Chronic obstructive pulmonary disease (COPD) e. Heart disease ANS: E, A, C, B, D The five leading causes of death in older adults are heart disease, cancer, stroke, pneumonia, and COPD. DIF: Cognitive Level: Comprehension REF: 33 OBJ: 1 TOP: Diseases Rated by Mortality KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

Chapter 04: Health Promotion, Health Maintenance, and Home Health Considerations Basic Geriatric Nursing, 7th Edition Chapter 04: Health Promotion, Health Maintenance, and Home Health Considerations Test Bank MULTIPLE CHOICE 1. The nurse reminds the 70-year-old male patient with hypertension who is on a sodium-restricted diet that the most effective health practice to reduce sodium intake is to:

a.

avoid all salty foods.

b.

discontinue eating at restaurants.

c.

read food labels on food containers carefully.

d.

limit the amount of salt added to food.

ANS: C Reading labels will prevent the purchase of sodium-laden foods. Sodium-restricted foods are available on most menus. Simply avoiding salty foods does not guarantee less sodium because there are many foods containing sodium that are not salty. Adding salt should be absolutely restricted, not diminished.

DIF: Cognitive Level: Analysis REF: 75 OBJ: 1 TOP: Sodium Restriction KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse takes into consideration that older adults may abuse alcohol because they use it as a(n):

a.

sleep aid.

b.

appetite stimulant.

c.

socialization activity.

d.

food source.

ANS: A Many older adults abuse alcohol to make themselves drowsy enough to sleep.

DIF: Cognitive Level: Analysis REF: 76 OBJ: 7 TOP: Alcohol Abuse KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. When the 70-year-old female patient says, “Keeping up with when to take the flu vaccine is a big hassle. I’m not going to add trying to keep up with a pneumonia vaccine as well. It’s too expensive.”

The nurse explains that the patient:

a.

can take both vaccines at the same time every fall.

b.

needs to take the pneumonia vaccine every 10 years.

c.

has Medicare coverage for both vaccines.

d.

can obtain both vaccines free of charge from the Public Health Department.

ANS: B

Pneumonia vaccine is given to individuals usually between the ages of 65 and 70 years and is repeated every 10 years. Both inoculations can usually be obtained from community clinics for a small fee.

DIF: Cognitive Level: Application REF: 76 OBJ: 7 TOP: Pneumonia Vaccine KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse reminds the 75-year-old that older adults should have visual and hearing examinations every:

a.

6 months.

b.

12 months.

c.

2 years.

d.

3 years.

ANS: B Annual examinations for vision and hearing to check for glaucoma and diminished hearing are recommended.

DIF: Cognitive Level: Knowledge REF: 76 OBJ: 1 TOP: Visual and Hearing Evaluations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. To prevent polypharmacy or potential drug-drug interactions, the nurse encourages the 75-yearold male patient to:

a.

seek medical care from only one physician.

b.

read up on all drugs that are prescribed.

c.

keep a list of drugs that he is currently taking.

d.

use only one pharmacy to fill prescriptions.

ANS: C Keeping a current drug list as a quick reference for any licensed professional to review before prescribing medication is one method to prevent polypharmacy.

DIF: Cognitive Level: Comprehension REF: 77 OBJ: 1 TOP: Prevention of Polypharmacy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The 65-year-old overweight, hypertensive male farmer tells the home health nurse that he eats two fried eggs, four pieces of bacon, and biscuits with cream gravy every morning for breakfast because he believes that a robust breakfast keeps him healthy. The nurse’s best approach would be to say:

a.

“That sort of food is not on your low-sodium diet.”

b.

“You won’t be healthy long with a diet like that.”

c.

“One egg and whole wheat toast would be even healthier.”

d.

“You should eat whole-grain cereal with fruit instead of all that fat and sodium.”

ANS: C Health maintenance practices of the older adult are influenced by personal, religious, and cultural beliefs. Using the patient’s beliefs as a basis for changing eating habits will be more successful than radically departing from lifetime habits or suggesting that they are ineffective.

DIF: Cognitive Level: Application REF: 78 OBJ: 2 TOP: Cultural Beliefs KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. The 60-year-old Asian man tells the home health nurse that he has stopped taking his antihypertensive medication because it causes him to be impotent. He reports that he is using acupuncture to control his hypertension. The nurse’s most effective response would be to say:

a.

“Uncontrolled hypertension is a real health problem.”

b.

“Does your acupuncturist check your blood pressure?”

c.

“Let me check your blood pressure to see how acupuncture is working.”

d.

“You need to talk to your real doctor about stopping this drug.”

ANS: C Problems can occur when cultural remedies are used in place of conventional medicine. Assessment of the effectiveness of the alternate therapy for treating hypertension is necessary to encourage further discussion about his treatment choice. Acupuncture can be very effective.

DIF: Cognitive Level: Analysis REF: 79 OBJ: 2 | 6 TOP: Cultural Beliefs KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse takes into consideration that the success of instructions about a diabetic diet will be largely reliant on the:

a.

clarity of the instructions.

b.

severity of the disease.

c.

timing of the instructions.

d.

motivation of the patient.

ANS: D Motivation is necessary for mastery of material and compliance with the new health information.

DIF: Cognitive Level: Analysis REF: 79 OBJ: 9 TOP: Knowledge and Motivation KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 9. The nurse is aware that the best predictor of a hypertensive patient complying with a low-sodium diet would be the fact that the patient:

a.

has adequate knowledge about the diet.

b.

is distressed about his illness.

c.

has followed a weight reduction program and lost 15 lb.

d.

does not want to have hypertensive complications.

ANS: C Previous behavior is a good indicator of future practice.

DIF: Cognitive Level: Application REF: 80 OBJ: 9 TOP: Predicting Compliance KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

10. An 80-year-old resident in an extended-care facility injured her foot on a piece of rusty wire. She tells the nurse she had a tetanus booster when she was 75. The nurse’s response will be based on the knowledge that tetanus boosters:

a.

should be repeated every 5 years.

b.

are not necessary for persons older than 70.

c.

do little good for the older adult.

d.

should be repeated with every injury, regardless of the previous booster.

ANS: D Tetanus boosters should be repeated every 10 years, unless an injury prompts the need for a booster.

DIF: Cognitive Level: Application REF: 76 OBJ: 1 TOP: Tetanus Booster KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 11. When a 70-year-old male patient taking corticosteroids for rheumatoid arthritis asks the nurse if he should take the vaccination to prevent shingles, the nurse’s most helpful response would be:

a.

“No. Persons with impaired immune systems should not take that vaccine.”

b.

“Yes. It would be a good idea to protect yourself from shingles.”

c.

“No. That vaccine is only effective in about 10% of the cases.”

d.

“Yes. The vaccine is very inexpensive and very effective.”

ANS: A The shingles vaccine should not be given to anyone with an impaired immune system.

Corticosteroids impair the immune system. The vaccine is very expensive and is only effective in about 50% of the cases.

DIF: Cognitive Level: Analysis REF: 76 OBJ: 1 TOP: Shingles Vaccine KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 12. The home health nurse suggests to the 82-year-old man that he should wear a Medic Alert bracelet to notify emergency personnel about his:

a.

artificial leg.

b.

congestive heart failure.

c.

pacemaker.

d.

eye prosthesis.

ANS: C Such health information as pacemakers, heparin therapy, and drug allergies should be made available to emergency workers.

DIF: Cognitive Level: Application REF: 77 OBJ: 1 TOP: Medic Alert Bracelets KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 13. The nurse suggests to the caregiver of a cognitively impaired patient that to assist in maintenance of personal hygiene, the caregiver might try to:

a.

give the patient a sponge bath every 3 days.

b.

establish a consistent daily schedule of meals, hygiene, and rest.

c.

verbally remind the patient to bathe.

d.

set out personal hygiene materials for easy access.

ANS: B A consistent daily schedule is helpful in setting a pattern every day and a time for self-care activities.

DIF: Cognitive Level: Application REF: 80 OBJ: 4 TOP: Cognitive Impairment KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 14. When the home health nurse observes that there is still about half of the month’s supply of Glucophage medication in the bottle at the end of the month, the nurse should ask:

a.

“Do you know what inadequately treated diabetes can do?”

b.

“Have you told your physician you are not taking your prescription?”

c.

“Are you trying to make the medication stretch for 2 months?”

d.

“Why are you being so noncompliant?”

ANS: C Many older adults with limited finances and limited access to a pharmacy will take less of a prescribed drug to conserve money.

DIF: Cognitive Level: Application REF: 81 OBJ: 5 TOP: Limited Access KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. In addition to supervision of medication protocols and nutrition needs, the presence of the caregiver provides a(n):

a.

assurance of safety.

b.

service for deep housecleaning.

c.

source of motivation.

d.

source of care that is free of charge.

ANS: C A caregiver can be a potent motivational source for adhering to health maintenance practices. The presence of a caregiver does not guarantee safety and housecleaning. Although many caregivers are family members and do not charge for providing care, other caregivers do require a fee.

DIF: Cognitive Level: Comprehension REF: 81 OBJ: 7 TOP: Caregiver Assistance KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 16. The caregiver who provides daily meals and attends to the daily needs of the older adult is classified as the caregiver.

a.

basic

b.

organizing

c.

primary

d.

designated

ANS: C The caregiver responsible for the day-to-day needs of the older adult is classified as the primary caregiver.

DIF: Cognitive Level: Comprehension REF: 81 OBJ: 10 TOP: Caregiver Classifications KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 17. The RN case worker reminds the patient who is the recipient of home health care that the unlicensed home health aide may not:

a.

transfer the patient into a bathtub.

b.

measure or dispense medication.

c.

contact family members independently.

d.

accompany the patient outside the home.

ANS: B Unlicensed persons are not allowed to dispense drugs in any setting.

DIF: Cognitive Level: Knowledge REF: 83 OBJ: 11 TOP: Home Health Aides KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 18. Because unpaid caregivers are so significant to the successful health maintenance of the older adult, the licensed home health coordinator should:

a.

tell them to call the agency if they need any further assistance.

b.

leave them entirely on their own so as not to interfere with the care they provide.

c.

critique care to improve its effectiveness.

d.

be generous with positive feedback.

ANS: D The recognition of a job well done and morale boosting are essential to the unpaid, frequently overworked, and frustrated caregiver.

DIF: Cognitive Level: Comprehension REF: 82 OBJ: 10 TOP: Nonpaid Caregivers KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 19. In counseling an older adult about exercising, the nurse suggests that activities such as walking or swimming for as little as minutes a day is beneficial.

a.

15

b.

30

c.

45

d.

60

ANS: B As little as 30 minutes preserves muscle mass and keeps joints flexible.

DIF: Cognitive Level: Knowledge REF: 75 OBJ: 1 TOP: Exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 20. The home health nurse reminds the older adult to add to the health maintenance of his teeth the practice of:

a.

a dental appointment every 2 years.

b.

using a fluoride toothpaste.

c.

thorough flossing every week.

d.

use of an electric toothbrush.

ANS: B The use of fluoride toothpaste, daily brushing and flossing, and annual dental care will enhance dental health. An electric toothbrush is not necessary.

DIF: Cognitive Level: Knowledge REF: 77 OBJ: 1 TOP: Dental Health KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 21. When the 84-year-old male complains of dry mouth, the nurse suggests that he:

a.

keep hard candy in his mouth to stimulate salivation.

b.

drink iced cola drinks several times daily for hydration.

c.

wash his mouth with an astringent mouth wash.

d.

limit alcohol intake.

ANS: D The reduction of alcohol will help eliminate dry mouth. Excessive use of hard candies, caffeinated drinks like colas, and astringent mouth washes will increase the discomfort from dry mouth.

DIF: Cognitive Level: Application REF: 78 OBJ: 1 TOP: Dry Mouth KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse lists recommended health practices for older adults, which includes . (Select all that apply.)

a.

compliance with dietary restrictions

b.

performance of regular exercise daily

c.

cessation of smoking

d.

arrangement for regular medical examinations

e.

annual psychological testing

ANS: A, B, C, D Psychological testing is not part of the recommended health practices. All of the other options listed are recommended health-seeking behaviors.

DIF: Cognitive Level: Knowledge REF: 85, Box 4-6 OBJ: 1 TOP: Recommended Health Practices KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse stresses to the older adult female that even a small amount of daily exercise can . (Select all that apply.)

a.

build muscle mass

b.

control weight

c.

retard bone loss

d.

control the blood glucose level

e.

promote a sense of well-being

ANS: B, C, D, E Regular mild exercise will maintain, not build, muscle mass; control weight and glucose levels; retard bone loss; and promote a sense of well-being.

DIF: Cognitive Level: Application REF: 75 OBJ: 1 TOP: Exercise Benefits KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse makes a list of the health evaluations that should be conducted during an annual physical examination for the older female adult, which includes . (Select all that apply.)

a.

measurement of height and weight

b.

lipid study

c.

electrocardiography

d.

rectal examination

e.

mammography

ANS: A, B, D, E Electrocardiography is not a routine part of a physical examination.

DIF: Cognitive Level: Comprehension REF: 76 OBJ: 1 TOP: Physical Examinations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. When assessing for ineffective health maintenance, the nurse should assess . (Select all that apply.)

a.

willingness to follow a health maintenance plan

b.

possible conflict between a health maintenance plan and culture

c.

the presence of prohibited items such as sweets, alcohol, and cigarettes

d.

the family’s perception of effectiveness of a health maintenance plan

e.

the level of cognitive impairment

ANS: A, B, C, E It is the patient’s, not the family’s, perception that the nurse needs to assess. All the other options listed would be a significant barrier to compliance.

DIF: Cognitive Level: Comprehension REF: 85 OBJ: 6 TOP: Assessing for Noncompliance KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. The 80-year-old woman tells the home health nurse, “I can only eat cereal because I just can’t make those dentures work!” The nurse’s most helpful suggestion would be to . (Select all that apply.)

a.

take only tiny bites of food

b.

chew slowly

c.

use a dental adhesive

d.

select soft, nonsticky foods (e.g., ground meat, boiled carrots)

e.

purée all food

ANS: A, B, C, D Puréeing food does not address the inability to eat with dentures.

DIF: Cognitive Level: Comprehension REF: 78 OBJ: 7 TOP: Impaired Nutrition Related to Dentures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. The nurse assesses factors in a 76-year-old patient’s history that might interfere with willingness to participate in health maintenance activities, which includes . (Select all that apply.)

a.

a belief that diminished health is part of aging

b.

loss of a spouse 3 months ago

c.

having a physical examination every year

d.

living in an assisted living facility and not driving

e.

having no family

ANS: A, B, E Belief that age is synonymous with declining health, loss of spouse, and no close family are all impediments to learning new health-seeking behaviors.

DIF: Cognitive Level: Comprehension REF: 80 OBJ: 7 TOP: Perceptions of Aging KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Chapter 05: Communicating with Older Adults Basic Geriatric Nursing, 7th Edition Chapter 05: Communicating with Older Adults Test Bank MULTIPLE CHOICE 1. The briefest explanation of therapeutic communication is that it:

a.

has a specific intent or purpose.

b.

is the only form of professional communication.

c.

should never be used in a social setting.

d.

requires no special skills, just a willingness to listen.

ANS: A Therapeutic communication is a style of conversation between the nurse and the patient in which there is a specific purpose or intent.

DIF: Cognitive Level: Knowledge REF: 88 OBJ: 5 TOP: Therapeutic Communication KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. The nurse is careful in the use of medical jargon while talking with an older adult patient because the use of medical jargon might become a(n):

a.

opportunity to instruct the patient.

b.

effective abbreviated communication shortcut.

c.

indicator of formal communication.

d.

communication barrier.

ANS: D The use of jargon can become a barrier because the patient may not understand and would be unwilling to disclose ignorance of terms. Habitual use makes health professionals less sensitive to persons who may not be familiar with the terms.

DIF: Cognitive Level: Comprehension REF: 89 OBJ: 1 TOP: Communication Barrier KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse uses superficial social conversation to initiate communication because this type of exchange:

a.

lets the patient know that he or she is considered to be a person, not just a patient.

b.

encourages sharing of intimate details.

c.

establishes the nurse’s role as a health care provider.

d.

blocks more meaningful therapeutic communication.

ANS: A Social conversations establish that the nurse considers the patient a person in his or her own right.

Such conversation is valuable for the nurse to discover information about the patient as a person and for the patient to discover information about the nurse as a person.

DIF: Cognitive Level: Comprehension REF: 90 OBJ: 1 | 4 TOP: Social Conversation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The nurse communicating with an older adult who has a hearing impairment will improve reception by speaking:

a.

in a higher tone, standing directly in front of the patient.

b.

more loudly from several feet away.

c.

normally with exaggerated hand gestures.

d.

in a low tone, bending close to the patient.

ANS: D Speaking in a low tone and bending near the patient is a more effective way to communicate with the hearing-impaired.

DIF: Cognitive Level: Application REF: 91 OBJ: 1 TOP: Communicating with the Hearing-Impaired KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 5. Seeing a patient with his head in his arms resting on the over-the-bed table, the nurse steps into the room and asks if the patient feels ill. The patient, without raising his head, says, “I’m fine.” The nurse should:

a.

sit down next to the bed and say, “You don’t act fine.”

b.

pat him on the shoulder and continue on rounds.

c.

say, from the doorway, “If you need anything, just call me.”

d.

assist the patient to sit up and say, “Now, that’s much better, isn’t it?”

ANS: A Reading the body language that says “I’m not fine,” the nurse should enter the room and be seated to demonstrate willingness to listen.

DIF: Cognitive Level: Application REF: 91 OBJ: 3 TOP: Body Language KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 6. When approaching an older adult to insert a catheter, the nurse should:

a.

touch the patient and say, “I need to insert this catheter.”

b.

approach the bed, turn back the cover, and announce, “The doctor wants a urine specimen.”

c.

open catheter tray at bedside, turn back the cover, and say, “Is it okay to put a tube in your bladder?”

d.

introduce yourself at the door and ask, “May I insert this catheter for a urine specimen?”

ANS: D Speaking to the patient from a public space and requesting permission to do a procedure is the best approach. All other options indicate, by the nurse’s nonverbal communication, that permission is not really required before insertion.

DIF: Cognitive Level: Application REF: 91 OBJ: 3 TOP: Invading Space KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

7. The nurse is aware that for a patient with receptive aphasia, the best method of communication would be the use of:

a.

a notepad.

b.

speaking slowly.

c.

worded flash cards.

d.

gestures.

ANS: D Gestures and/or symbols are helpful for persons with receptive aphasia because they cannot recognize the spoken or written word.

DIF: Cognitive Level: Analysis REF: 91 OBJ: 3 TOP: Use of Gestures KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The white female nurse is concerned that the 80-year-old African American male patient is not being truthful with her because of his:

a.

lack of eye contact.

b.

smiling facial expression.

c.

tone of voice.

d.

body language.

ANS: A

The nurse needs to be aware that African Americans, particularly older adults, limit eye contact as a sign of respect.

DIF: Cognitive Level: Knowledge REF: 92 OBJ: 6 TOP: Eye Contact KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. When asked about the severity of pain, the 93-year-old patient does not answer right away. The nurse should:

a.

ask rapid questions: “Is it better? Is it worse than yesterday? Is it worse than this morning?”

b.

repeat the question in a louder voice.

c.

say, “You must be feeling better because you’re not complaining.”

d.

keep eye contact and wait for the answer.

ANS: D Patient empathetic listening is the key to maintaining good communication with the older adult.

DIF: Cognitive Level: Application REF: 92 OBJ: 2 TOP: Active Listening KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. When the nurse answers the call light after a delay of 5 minutes, the angry patient says, “You made me wait an hour. I’m in pain and no one’s willing to help me.” The nurse’s best response would be:

a.

“It’s only been 5 minutes. What do you want?”

b.

“Well, I’m here now. What is your problem?”

c.

“I know it must have seemed like an hour. I’ll bring your medication.”

d.

“I was attending to another patient who’s really ill. I’ll help you now.”

ANS: C Many older adults have an altered sense of time. Waiting makes them more anxious. Responding in a defensive or grudging manner is not effective for the nurse-patient relationship.

DIF: Cognitive Level: Application REF: 93 OBJ: 4 TOP: Timing KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. The 93-year-old woman with chronic back pain is found crying. When the nurse approaches, the patient says, “I know you can’t do anything more, but I hurt so bad.” The nurse’s best intervention would be to:

a.

bring pain medication when it is time for it.

b.

assure the patient that the pain medication will take effect soon.

c.

touch the patient’s shoulder and sit quietly without speaking.

d.

distract the patient by offering a sip of water.

ANS: C Use of empathetic touch is a message of comfort. The other options do not address the patient’s distress relative to unrelieved pain.

DIF: Cognitive Level: Analysis REF: 93 OBJ: 3 TOP: Silence KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. When entering the room of a new 85-year-old female patient to complete the admission process, the nurse should initiate the conversation by saying:

a.

“Good morning, Mary. We need to get some questions answered.”

b.

“Welcome to 4B, Mrs. Miller. I’d like to get some additional information, if I may.”

c.

“Hello, sweetie. I’ll bet you thought all the admission stuff was finished, didn’t you?”

d.

“I need to finish the admission. What is your name?”

ANS: B Using a formal address is a respectful way to start a conversation with a new patient. If the patient prefers to be called something else, he or she can inform the nurse of that desire.

DIF: Cognitive Level: Comprehension REF: 94 OBJ: 1 TOP: Respect KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The nurse informing a patient about an upcoming diagnostic procedure could best relate the information by saying:

a.

“Mr. Brown, your leg is to be x-rayed in the x-ray department in an hour.”

b.

“X-ray is coming to get you for an AP and lateral of your chest.”

c.

“You can’t eat anything after supper because of some lab work.”

d.

“Mrs. Smith, the OR has notified us that they’re running behind.”

ANS: A

Clear, concise information in words that the patient can understand is the most effective method for providing information.

DIF: Cognitive Level: Application REF: 97 OBJ: 4 TOP: Informing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 14. The nurse is aware that the overuse of direct questions can:

a.

get a lot of information quickly.

b.

help the patients organize their thoughts.

c.

get minimum response answers of “yes” and “no.”

d.

make patients think that they are contributing to their health care.

ANS: C The diminished, overwhelmed patient will give minimal answers to direct questions if the technique is overused. The technique is best used to obtain factual information.

DIF: Cognitive Level: Application REF: 97 OBJ: 4 TOP: Direct Questions KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 15. The patient denies smoking, although the smell of tobacco is strong in his hospital room. The nurse confronts the patient most effectively by saying:

a.

“Don’t bother to lie to me. I know you’ve been smoking.”

b.

“It is very dangerous to smoke in bed.”

c.

“The hospital has policies against smoking.”

d.

“I can smell the tobacco, and I see your lighter on the bedside table.”

ANS: D Identifying evidence in a nonaccusatory manner establishes the point of discrepancy. Belittling the patient or quoting policy is not confrontation.

DIF: Cognitive Level: Analysis REF: 97 OBJ: 4 TOP: Confrontation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 16. When inquiring about the degree of pain, the nurse could best support the patient by asking:

a.

“Does your stomach hurt now?”

b.

“How would you describe your pain?”

c.

“When the pain occurs, does the medicine help?”

d.

“Do you use more than one pain remedy?”

ANS: B Open-ended questions allow the patient to give more elaborate answers.

DIF: Cognitive Level: Application REF: 97 OBJ: 4 TOP: Open-Ended Questions KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 17. The patient says, “When I came to the hospital yesterday, everything got confused.” The nurse’s best response would be:

a.

“What happened?”

b.

“Yes, hospital admissions can be confusing.”

c.

“Are you confused now?”

d.

“We really try to make admissions less stressful.”

ANS: A Clarifying an unclear statement with the use of an open-ended query is helpful to providing better communication.

DIF: Cognitive Level: Application REF: 97 OBJ: 4 TOP: Clarification KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 18. The nurse reminds the CNAs that only about verbal communication.

a.

7

b.

18

c.

22

d.

36

% of communication is transmitted by way of

ANS: A It is estimated that only about 7% of communication is transmitted by verbal methods. Nonverbal communication is the most effective method of communicating.

DIF: Cognitive Level: Knowledge REF: 89 OBJ: 3 TOP: Nonverbal Communication KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 19. The caring nurse will use empathetic listening in order to:

a.

encourage the patient to divulge information.

b.

gain time to pose another question to the patient.

c.

indicate the conversation has come to a close.

d.

interpret what the patient has said.

ANS: D Empathetic listening is a skill that helps the nurse interpret what the patient is saying. A nurse has not really listened until the nurse has understood what was intended by the speaker.

DIF: Cognitive Level: Application REF: 94 OBJ: 2 TOP: Empathetic Listening KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 20. When using an interpreter to speak with an 84-year-old Chinese woman, the nurse will focus on:

a.

the patient, not the interpreter.

b.

encouraging the interpreter to paraphrase.

c.

limiting questions from the patient.

d.

listening to the words, not emotional tone.

ANS: A The nurse using an interpreter should focus on the patient and the patient’s emotional tones, not the interpreter. The patient should be encouraged to ask questions. The interpreter should not paraphrase.

DIF: Cognitive Level: Comprehension REF: 96 OBJ: 6 TOP: Using an Interpreter KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 21. The nurse must tell a 94-year-old resident of a nursing home that his wife has fallen and has been hospitalized with a broken hip. In planning the delivery of this distressing news, the nurse should:

a.

hurry through the conversation to spare the resident.

b.

conserve time by delaying plans for follow-up.

c.

use social conversation before the delivery of the information.

d.

gather all pertinent information that is accurate.

ANS: D The nurse should gather all the pertinent information to address the resident’s questions. The message should be direct and simple, and time should be allowed for the resident to react. Followup plans should be considered.

DIF: Cognitive Level: Comprehension REF: 98 OBJ: 4 TOP: Delivering Bad News KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 22. The area within 18 inches of a person is known as

space.

a.

public

b.

social

c.

personal

d.

intimate

ANS: D The space within 18 inches of the body is considered intimate space.

DIF: Cognitive Level: Application REF: 91 OBJ: 1 TOP: Proxemics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 23. The area between 18 inches and 4 feet of a person is known as

a.

public

b.

social

c.

personal

d.

intimate

ANS: C A distance of 18 inches to 4 feet is considered personal space.

DIF: Cognitive Level: Application REF: 91 OBJ: 1 TOP: Proxemics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

space.

24. The area between 4 and 12 feet of a person is known as

a.

public

b.

social

c.

personal

d.

intimate

space.

ANS: B Between 4 and 12 feet is considered social space.

DIF: Cognitive Level: Application REF: 91 OBJ: 1 TOP: Proxemics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 25. The area 12 feet from a person and beyond is known as

a.

public

b.

social

c.

personal

d.

intimate

space.

ANS: A Public space is when strangers are 12 feet or more away from a person.

DIF: Cognitive Level: Application REF: 91 OBJ: 1

TOP: Proxemics KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. It is important to remember that older adults of today differ from young adults in regard to . (Select all that apply)

a.

experience with electronic tools of communication

b.

attitude about lifestyles

c.

value of money

d.

methods of communication

e.

perceptions of gender roles

ANS: B, C, D, E Older adults today do have knowledge of electronic tools of communication.

DIF: Cognitive Level: Knowledge REF: 88 OBJ: 1 TOP: Age Bracket Differences KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. The nurse is aware that successful communication is dependent on apply.)

a.

the need to share information with someone else

b.

empathetic listening

c.

assessing or correcting communication barriers

. (Select all that

d.

using perfect grammar

e.

use of a variety of communication skills

ANS: A, B, C, E Perfect grammar is not essential to successful communication.

DIF: Cognitive Level: Comprehension REF: 88 OBJ: 1 TOP: Successful Communication KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse is aware that selection of words and phraseology is significant for effective communication. The nurse should base the communication approach on the patient’s . (Select all that apply.)

a.

culture

b.

ethnicity

c.

income level

d.

perspective

e.

level of education

ANS: A, B, D, E Income level is not a consideration in effective communication.

DIF: Cognitive Level: Comprehension REF: 88 OBJ: 1 TOP: Communication with Older Adults KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The nurse is sensitive to the use of nonverbal communication from patients, which includes the interpretation of . (Select all that apply.)

a.

choice of words

b.

voice tone

c.

body language

d.

gestures

e.

facial expressions

ANS: B, C, D, E Choice of words indicates verbal communication. All other options play a part in nonverbal communication.

DIF: Cognitive Level: Comprehension REF: 90-91 OBJ: 3 TOP: Nonverbal Communication KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The nurse uses touch as a form of communication to convey

a.

affection

b.

understanding

. (Select all that apply.)

c.

concern

d.

empathy

e.

acknowledgment

ANS: A, B, C, D, E The application of touch conveys all the options.

DIF: Cognitive Level: Comprehension REF: 93 OBJ: 3 TOP: Touch KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 6. Which of the following represent “elderspeak” from the examples below? (Select all that apply.)

a.

“Ok, honey, let’s get a bath now.”

b.

“Oh, dear! We better get you a clean diaper.”

c.

“Today is Tuesday, Mr. Brown. It’s your dialysis day.”

d.

“My gracious, Mary! What in the world are you doing out here in the hall?”

e.

“You naughty girl! Just look at the front of your dress.”

ANS: A, B, D, E Using baby talk and endearing names is demeaning and is a subtle form of abuse. Giving direct information to the patient—treating the patient as an adult—is a respectful type of dialogue.

DIF: Cognitive Level: Comprehension REF: 94 OBJ: 1

TOP: Elderspeak KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. The nurse is aware that there are many communication barriers when conversing with the older adult, which includes . (Select all that apply.)

a.

hearing impairment

b.

language differences

c.

dementia

d.

pain

e.

aphasia

ANS: A, B, C, D Aphagia is the lack of ability to swallow, which affects a person’s ability to speak. All other options are communication barriers.

DIF: Cognitive Level: Knowledge REF: 95 OBJ: 1 TOP: Language Barriers KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

Chapter 06: Maintaining Fluid Balance and Meeting Nutrition Needs Basic Geriatric Nursing, 7th Edition Chapter 06: Maintaining Fluid Balance and Meeting Nutrition Needs Test Bank MULTIPLE CHOICE 1. The nurse explains that the lowest recommended daily caloric intake to meet nutritional needs of the older adult safely is calories.

a.

1000

b.

1200

c.

1400

d.

1800

ANS: B The minimal caloric intake for the older adult that will meet nutritional needs of the older adult is 1200 calories.

DIF: Cognitive Level: Knowledge REF: 103 OBJ: 2 TOP: Minimal Calorie Intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The 65-year-old woman brags that by using the MyPyramid guidelines for nutrition, she has lost 15 lb. The nurse reminds her that in order to maintain the weight loss, she must be physically active for minutes a day.

a.

15 to 20

b.

20 to 30

c.

30 to 40

d.

40 to 60

ANS: D According to the guidelines of MyPyramid, an activity period of 40 to 60 minutes a day is necessary to maintain weight loss.

DIF: Cognitive Level: Comprehension REF: 104 OBJ: 4 TOP: MyPyramid KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse recommends that the older man eat chicken and fish because these are complete proteins, which have:

a.

some molecules of carbohydrate.

b.

all the essential amino acids.

c.

high fat content.

d.

soluble fiber.

ANS: B Fish and lean chicken have all the essential amino acids and very little fat content, unlike red meat.

DIF: Cognitive Level: Analysis REF: 106 OBJ: 2 TOP: Complete Protein KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse explains that high-density lipoproteins (HDLs), the so-called “healthy fats,” are made up of:

a.

mainly proteins.

b.

mostly triglycerides.

c.

mainly cholesterol.

d.

a variety of minerals.

ANS: A HDLs are made up primarily of proteins, as opposed to lipids such as triglycerides, which are found in very-low-density lipoproteins (VLDLs) and cholesterol, which is found in low-density lipoproteins (LDLs).

DIF: Cognitive Level: Comprehension REF: 106 OBJ: 1 TOP: High-Density Lipoproteins KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse points out that the nonhealing pressure ulcers and decreasing visual acuity in a patient on a fat-restricted diet may be related to the patient’s impaired ability to metabolize vitamin:

a.

A.

b.

B6.

c.

B12.

d.

C.

ANS: A Vitamin A is a fat-soluble vitamin and helps with wound healing and night vision acuity. Persons on low-fat diets may not be able to metabolize vitamin A from food sources because of the decreased fat in their diet.

DIF: Cognitive Level: Analysis REF: 106 OBJ: 6 TOP: Vitamin A Deficiency KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The home health nurse does an ongoing assessment of the patient who has had a subtotal gastrectomy for evidence of a deficiency in vitamin:

a.

A.

b.

B6.

c.

B12.

d.

C.

ANS: C Vitamin B12 is generated from the digestion of protein in the stomach. If part of the stomach is gone (gastrectomy), there is less digestive potential for vitamin B12.

DIF: Cognitive Level: Analysis REF: 106-107 OBJ: 3 TOP: Vitamin B12 Deficiency KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The nurse giving an iron preparation in capsule form will improve its absorption by giving the patient extra:

a.

orange juice.

b.

milk products.

c.

water.

d.

caffeine drinks.

ANS: A Vitamin C improves the absorption of iron.

DIF: Cognitive Level: Application REF: 109 OBJ: 8 TOP: Iron Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. The nurse caring for the older adult patient who is taking a diuretic for control of hypertension should monitor the patient closely for signs of:

a.

hypokalemia.

b.

hypocalcemia.

c.

hyponatremia.

d.

hyperkalemia.

ANS: A

Diuretics deplete the body of potassium, a necessary mineral.

DIF: Cognitive Level: Application REF: 109 OBJ: 6 TOP: Hypokalemia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The older adult patient in an extended-care facility has a pressure ulcer. The nurse would encourage wound healing by increasing the patient’s intake of zinc from food sources such as:

a.

meat.

b.

citrus fruit.

c.

green leafy vegetables.

d.

complex carbohydrates.

ANS: A Meat, nuts, and shellfish are dietary sources of zinc.

DIF: Cognitive Level: Application REF: 109 OBJ: 1 TOP: Zinc KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse is aware that older adults need a minimum daily fluid intake of

a.

1000

b.

2000

c.

3000

mL.

d.

4000

ANS: B The minimum daily fluid requirement is 2000 mL/day.

DIF: Cognitive Level: Comprehension REF: 110 OBJ: 2 TOP: Fluid Requirements KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. Older adults who consume excessive amounts of alcohol put themselves at risk for nutritional deficits because alcohol:

a.

decreases blood glucose levels.

b.

alters the function of some minerals.

c.

interferes with the absorption of nutrients.

d.

increases the metabolism.

ANS: C Excessive intake of alcohol interferes with the absorption of nutrients because of changes in the stomach lining.

DIF: Cognitive Level: Comprehension REF: 111 OBJ: 6 TOP: Factors Affecting Nutrition KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

12. The nurse in a retirement center who is selecting a main dish from the residents’ menu for an Orthodox Jewish man would select:

a.

crab cakes with white sauce.

b.

lamb chops with mint jelly.

c.

ham steak with red gravy.

d.

pork chops with cranberries.

ANS: B Shellfish and pork are not permitted in the diet of Orthodox Jewish persons.

DIF: Cognitive Level: Analysis REF: 115 OBJ: 8 TOP: Cultural Factors KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 13. The nurse takes into consideration that the patient who would need higher caloric intake would be the patient with a condition such as:

a.

bacterial pneumonia.

b.

osteoporosis.

c.

arthritis.

d.

stroke.

ANS: A

Persons with infections require a higher caloric intake.

DIF: Cognitive Level: Application REF: 103 OBJ: 6 TOP: Changing Caloric Needs KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. The nurse explains that most older adults need only about 50 g of protein daily, which is equivalent to approximately lb.

a.

1

b.

c.

d.

ANS: D There are approximately 450 g in a pound, so 50 g is roughly equivalent to

lb, essentially the

weight of one thin hamburger patty.

DIF: Cognitive Level: Application REF: 104 OBJ: 2 TOP: Protein Intake Equivalent KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The nurse instructing the older man in the use of MyPyramid points out that he should eat cup(s) of fruit a day.

a.

b. 1

c.

d. 2

ANS: D The MyPyramid guidelines recommend eating 2 cups of fruit daily.

DIF: Cognitive Level: Comprehension REF: 104 OBJ: 2 TOP: MyPyramid: Fruit KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. While instructing the patient who is to take oral iron supplements, the nurse indicates that:

a.

supplements should be taken between meals on an empty stomach.

b.

medication should be drunk from a nonmetal glass.

c.

the color of the stool will change to dark green or black.

d.

constipation is likely to occur.

ANS: C

Iron supplements can color the stool a dark green or black. Iron should be taken with a meal to reduce gastrointestinal irritation. The preparation should be taken through a straw. The supplement might cause diarrhea.

DIF: Cognitive Level: Comprehension REF: 109 OBJ: 8 TOP: Iron Preparations KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. When the nurse weighs an edematous patient with congestive heart failure, the weight increase from yesterday is 2.2 lb. The nurse assesses that this patient has retained of fluid.

a.

500 mL

b.

1L

c.

1500 mL

d.

2L

ANS: B The weight gain of 2.2 lb (1 kg) is equal to 1 L of fluid retention.

DIF: Cognitive Level: Application REF: 122 OBJ: 6 TOP: Fluid Retention KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The nurse encourages a group of extended care residents to sit out on the sunny patio for an hour a day during the afternoon in order to help them with the synthesis of vitamin:

a.

A.

b.

B12.

c.

D.

d.

K.

ANS: C Exposure to the sun allows the skin to synthesize vitamin D, which is required for calcium absorption.

DIF: Cognitive Level: Analysis REF: 107 OBJ: 8 TOP: Synthesis of Vitamin D KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 19. What is the caloric value (in calories per gram [cal/g]) of protein?

a.

9 cal/g

b.

4 cal/g

c.

0 cal/g

d.

7 cal/g

ANS: B Proteins yield 4 cal/g.

DIF: Cognitive Level: Comprehension REF: 103 OBJ: 1 TOP: Calorie Values KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. What is the caloric value of alcohol?

a.

9 cal/g

b.

4 cal/g

c.

0 cal/g

d.

7 cal/g

ANS: D Alcohol yields 7 cal/g.

DIF: Cognitive Level: Comprehension REF: 103 OBJ: 1 TOP: Calorie Values KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. What is the caloric value of vitamins?

a.

9 cal/g

b.

4 cal/g

c.

0 cal/g

d.

7 cal/g

ANS: C Vitamins yield no calories.

DIF: Cognitive Level: Comprehension REF: 103 OBJ: 1

TOP: Calorie Values KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 22. What is the caloric value of fat?

a.

9 cal/g

b.

4 cal/g

c.

0 cal/g

d.

7 cal/g

ANS: A Fats, which can come from either plant sources or animal sources, yield 9 cal/g.

DIF: Cognitive Level: Comprehension REF: 103 OBJ: 1 TOP: Calorie Values KEY: Nursing Process Step: N/A MSC: NCLEX: N/A MULTIPLE RESPONSE 1. The nurse takes into consideration the factors that influence nutritional needs, which include . (Select all that apply.)

a.

bone density

b.

gender

c.

climate

d.

presence of illness

e.

body temperature

ANS: B, C, D, E Bone density is not a factor, but all other options are factors that have a significant effect on nutritional needs.

DIF: Cognitive Level: Comprehension REF: 102 OBJ: 2 TOP: Influences on Nutrition KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse uses a chart to show the vital nutrients required by all persons, which are . (Select all that apply.)

a.

carbohydrates

b.

proteins

c.

vitamins and minerals

d.

fats

e.

electrolytes

ANS: A, B, C, D Electrolytes are not nutrients, but all other listed options are considered essential nutrients.

DIF: Cognitive Level: Knowledge REF: 103 OBJ: 2 TOP: Essential Nutrients KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse encourages older adults to include complex carbohydrates such as vegetables and fruits in their diet because complex carbohydrates contain . (Select all that apply.)

a.

minerals

b.

fats

c.

vitamins

d.

soluble fiber

e.

polysaccharides

ANS: A, C, D, E No fat is contained in complex carbohydrates.

DIF: Cognitive Level: Comprehension REF: 104 OBJ: 1 TOP: Complex Carbohydrates KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse is aware that older adults who do not take in adequate fluids are at risk for . (Select all that apply.)

a.

altered absorption of drugs

b.

digestive disorders

c.

constipation

d.

bleeding disorders

e.

reduced appetite

ANS: A, B, C, E Bleeding disorders are not associated with inadequate intake. All other options are problems associated with a fluid deficit.

DIF: Cognitive Level: Application REF: 109-110 OBJ: 6 TOP: Fluid Deficit KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. Older adults plagued with chronic health problems may become undernourished because they . (Select all that apply.)

a.

are too fatigued to prepare meals

b.

become frustrated when attempting to open packaging

c.

may be unable to carry groceries any distance

d.

have no interest in eating out due to health issues

e.

lack stamina to shop for groceries

ANS: A, B, C, E Having no interest in eating out is not going to cause the older adult to be malnourished. Lack of interest in eating or socialization due to a chronic health problem can cause the older adult to be malnourished. All the other options listed can result in the older adult being malnourished.

DIF: Cognitive Level: Comprehension REF: 110 OBJ: 6

TOP: Factors Affecting Nutrition KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 6. The home health nurse is painfully aware that older adults living independently have many barriers to providing themselves with adequate nutrition, which include . (Select all that apply.)

a.

difficulty chewing

b.

lack of transportation to shop

c.

use of quick frozen meals

d.

lack of motivation to cook

e.

sensory changes

ANS: A, B, D, E The availability of quick frozen foods, which are easy to prepare, offer a source of better nutrition to the older adult.

DIF: Cognitive Level: Application REF: 111 OBJ: 6 TOP: Factors Affecting Nutrition KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. An older adult who is a resident in an extended-care facility is at risk for nutritional deficits related to . (Select all that apply.)

a.

repetitive nature of meals

b.

lack of culturally significant food

c.

environmental odors

d.

reaction to being fed by others

e.

non-nutritious food choices

ANS: A, B, C, D Although the food is nutritious, the repetitive nature of the menu, the lack of culturally significant food, and environmental concerns alter the motivation to have adequate intake.

DIF: Cognitive Level: Comprehension REF: 112 OBJ: 6 TOP: Factors Affecting Nutrition KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. The nurse suggests to the older adult that sources of protein that are less expensive than meat include . (Select all that apply.)

a.

corn

b.

beans

c.

whole-grain foods

d.

cheese

e.

nuts

ANS: B, C, D, E Corn is not a source of protein.

DIF: Cognitive Level: Application REF: 106 OBJ: 1 TOP: Protein Consumption KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse cautions the older adult against taking excess vitamin supplements because some vitamins can be retained in fatty tissue and cause liver damage, including vitamin(s) . (Select all that apply.)

a.

A

b.

B6

c.

C

d.

D

e.

E

ANS: A, D, E Excess fat-soluble vitamins A, D, and E can be retained in fatty tissue and result in hepatic damage.

DIF: Cognitive Level: Application REF: 108 OBJ: 1 TOP: Vitamin Intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 07: Medications and Older Adults Test Bank MULTIPLE CHOICE 1. Why is drug testing done by pharmaceutical companies not always appropriate for the older

adult? a. The testing is not done long enough. b. The testing does not require adequate follow-up. c. The testing is not well regulated by the U.S. Food and Drug Administration. d. The testing is usually conducted on healthy young persons.

ANS: D

Long and rigorously regulated drug testing procedures most often use healthy young adults as drug testers.

DIF: Cognitive Level: Comprehension REF: pp. 130-131 OBJ: 1 TOP: Drug Testing KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 2. What is a cause for increased rate of drug absorption in an older patient? a. Change of the chemical composition of the drug b. Increased gastric pH c. Decreased strength of the drug d. Decreased gastric motility ANS: D

Decreased gastric motility can increase the rate of drug absorption due to an increased amount of time that the medication is in contact with the gastric mucosa.

DIF: Cognitive Level: Analysis REF: p. 131 OBJ: 3 TOP: Drug Absorption KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 3. What age-related changes in the stomach can cause increased drug absorption and possibly

drug toxicity?

Decreased gastric motility Gastric reflux disease Inability of gastric cells to transport the drug Decreased peristalsis

a. b. c. d.

ANS: A

Decreased motility leaves the drug in contact with the gastric mucosa for a longer period of time, which leads to increased absorption. Peristalsis is rhythmic movements of the bowels.

DIF: Cognitive Level: Application REF: p. 131 OBJ: 3 TOP: Increased Absorption KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. What should an older adult be encouraged to implement in order to prevent lithium toxicity? a. Increase fluid intake to 3500 mL daily.

b. Have the patient ambulate for 10 minutes after the drug is administered. c. Prohibit citrus fruit in the diet. d. Administer a prescribed stool softener to ensure a daily bowel movement.

ANS: A

Increase of fluids will help allow water-soluble drugs such as lithium to be diluted in the bloodstream more effectively and excreted more rapidly.

DIF: Cognitive Level: Application REF: p. 131 TOP: Distribution KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

OBJ: 9

5. An older adult is taking diazepam several times a day. What does the nurse specifically

monitor for?

Tachycardia A hangover effect Agitation Hypertension

a. b. c. d.

ANS: B

Fat-soluble drugs become trapped in the adipose tissue and are slowly released into the bloodstream, increasing the drug’s concentration.

DIF: Cognitive Level: Application REF: p. 138 OBJ: 4 TOP: Distribution KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. Why would the nurse anticipate an adverse reaction in an older adult who is taking the

protein-bound drug warfarin (Coumadin)?

Unbound active drug molecules continue to circulate in the bloodstream.

The bleeding and clotting times will decrease.

The drug becomes ineffective and does not deliver its intended therapeutic action.

Renal damage can occur from the altered drug molecules.

a. b. c. d.

ANS: A

Unbound drug molecules will still be circulating, leading to excess drug in the bloodstream.

DIF: Cognitive Level: Application REF: p. 132 | p. 134 OBJ: 4 TOP: Distribution KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. Why does the nurse frequently assess an older adult who is on a psychotropic drug? a. Older adults are less active. b. The older adult has fewer cognitive capabilities. c. Brain receptors have become hypersensitive. d. Receptor sites have lower perfusion.

ANS: C

Brain receptors in the older adult become hypersensitive as age increases, resulting in an exaggerated response to pharmacologic therapy.

DIF: Cognitive Level: Analysis TOP: Pharmacodynamics

REF: p. 132 OBJ: 7 KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. What is the major risk of polypharmacy for the older adult? a. Ignorance about his or her prescriptions b. Taking over-the-counter preparations c. Being treated by more than one physician d. Taking old prescriptions rather than consulting a physician ANS: C

Although all the options may offer an opportunity for polypharmacy, the major risk is that of the patient being treated by more than one physician at the same time.

DIF: Cognitive Level: Application TOP: Polypharmacy MSC: NCLEX: N/A

REF: pp. 132-133 OBJ: 1 KEY: Nursing Process Step: N/A

9. The home health nurse would be most concerned about self-medicating errors for the older

adult living alone who is a type 1 diabetic and is a. afflicted with early Parkinson disease. b. visually impaired. c. a rheumatoid arthritic with stiffened hands. d. paralyzed from the waist down.

ANS: B

The visually impaired diabetic is at the greatest risk for a medication error by incorrectly preparing an insulin injection.

DIF: Cognitive Level: Analysis REF: p. 143 OBJ: 12 TOP: Sensory Changes KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. What is the most reliable method of patient identification for administration of medications? a. A photograph of the patient b. An identification bracelet c. Asking the patient to repeat his or her name d. Use of the patient’s room number ANS: B

The use of an identification bracelet is the most accurate and reliable method to identify the patient.

DIF: Cognitive Level: Comprehension REF: p. 139 OBJ: 9 TOP: Patient Identification KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 11. The physician has written an order to convert an enteric-coated medication from the pill form

to the liquid form. What would be the most appropriate response of the nurse? a. Transcribe the order and change the medication administration record to show the

liquid form. b. Use up the rest of the tablets by crushing them and giving them dissolved in water. c. Order the liquid form from the pharmacy as ordered. d. Inquire if the physician wants the dose to be the same as the pill.

ANS: D

Because liquids are absorbed more rapidly, the dose might need to be lowered or the schedule of administration changed to avoid an overdose. Enteric-coated medications should not be crushed.

DIF: Cognitive Level: Analysis REF: p. 140 OBJ: 9 TOP: Liquid Medication KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. The patient complains that her medications stick in her throat. What would be an appropriate

response of the nurse?

Suggesting that she take all the pills at one time with a mouthful of water.

Offering the patient one pill at a time.

Crushing all the pills and mixing them in the patient’s breakfast cereal.

Offering a sip of water before and after each pill.

a. b. c. d.

ANS: D

Offering water before and after administration counteracts the dry mouth that causes the pills to stick. Offering one pill at a time without water does not address the problem of sticking.

DIF: Cognitive Level: Application REF: p. 141 OBJ: 9 TOP: Pill Administration KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 13.

What is a correct method of administering a transdermal medication patch?

Apply the patch at the same site every day and carry out documentation.

Fold and dispose of the used patch in the sharps container.

Warm the patch in his or her hands before application.

Cover the patch with tape to prevent dislodgement.

a. b. c. d.

ANS: B

The used patch should be folded with the sticky sides together and disposed of in the sharps container for environmental safety.

DIF: Cognitive Level: Application REF: Box 7-4, p. 142 OBJ: 6 TOP: Transdermal Patches KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 14. When the medication nurse offers a pill to the older adult patient, the patient asks, “What is

this and what is it for?” What is the best response by the nurse?

“I’m not at liberty to discuss your medication. You need to talk to your doctor.”

“That’s a ‘feel good’ pill that will make you feel better.”

“It’s a cephalosporin that has been ordered to treat your URI.” “It’s an antibiotic for the infection in your urine.”

a. b. c. d.

ANS: D

Patients have the right to know what they are taking and given a reasonable rationale for its use that they can understand.

DIF: Cognitive Level: Application TOP: Right to Know

REF: p. 143 OBJ: 10 KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. When the 80-year-old female patient refuses to take a medication because it burns her

stomach, what action should be taken by the nurse?

Crush the pill and mix it with the dessert on her meal tray.

Insist that she take it “for her own good.”

Circle and initial the dose time to show non-administration.

Document the reason for refusal and report the refusal to the charge nurse.

a. b. c. d.

ANS: D

The nurse should carry out documentation of the reason for refusal and report the refusal.

DIF: Cognitive Level: Application REF: p. 143 OBJ: 10 TOP: Refusal of Treatment KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Coordinated Care 16. What is a symptom of theophylline overdose? a. Tachycardia b. Confusion c. Hypotension d. Constipation ANS: A

Tachycardia is a significant side effect of theophylline.

DIF: Cognitive Level: Knowledge REF: Table 7-5, p. 138 OBJ: 7 TOP: Drug Overdose KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 17. Which assessment finding in a 75-year-old man on a chlorpromazine (Thorazine) protocol

should be immediately reported to the physician? a. Cough b. Headache c. Drool d. Nausea ANS: C

Drooling and difficulty swallowing are signs of drug toxicity to chlorpromazine (Thorazine).

DIF: Cognitive Level: Application REF: Table 7-5, p. 138 OBJ: 7 TOP: Drug Toxicity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 18. What site would be the best choice for an intramuscular injection to an emaciated 82-year-old

patient? a. Upper outer quadrant of the gluteus maximus b. Gluteal c. Deltoid d. Ventrogluteal ANS: D

The ventrogluteal site is the safest choice for the emaciated patient. The location is easily accessible and free from major nerves of vessels.

DIF: Cognitive Level: Application REF: p. 142 OBJ: 9 TOP: Intramuscular Injection KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 19. What is the purpose of the Beers criteria? a. Identifies medications best avoided by the older adult. b. Identifies diagnostic procedures that are considered inappropriate for a diagnosis. c. Identifies penalties for extended-care facilities that allow administration of

particular drugs. d. Identifies assessments necessary before the prescription of particular drugs.

ANS: A

The Beers criteria lists medications best not prescribed for the older adult. The lists are updated regularly, most recently in 2012.

DIF: Cognitive Level: Knowledge REF: p. 133 OBJ: 5 TOP: Beers Criteria KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk 20. What oral medication can be safely crushed? a. Plain antihypertensive medication tablet b. Sublingual tablet of nitroglycerin c. Timed-release capsule for gastric reflux d. Enteric-coated aspirin ANS: A

Only the plain tablet can be crushed. Timed-release, sublingual medications, and entericcoated medications should not be crushed.

DIF: Cognitive Level: Comprehension REF: Box 7-3, p. 141 OBJ: 9 TOP: Crushing Medication KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 21. What provisions should be included in the plan of care for a 70-year-old extended-care facility

resident who will be self-administering his medications? (Select all that apply.)

Delivery of adequate supply of medication Payment for medication Locked medication storage at bedside Medication administration record Assessment of effectiveness of medication

a. b. c. d. e.

ANS: A, C, D, E

For self-medication in an extended-care facility, the nurse should make provisions for adequate medication supply, locked storage, medication administration record, and an assessment of the effectiveness of the medication. Payment is not in the purview of the nurse.

DIF: Cognitive Level: Comprehension REF: p. 143 OBJ: 12 TOP: Medication Administration KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk 22. What information related to drug administration should be included in the nursing care plan?

(Select all that apply.) a. Schedule for drawing blood values b. Patient’s need for crushing medication c. Patient’s preference as to the use of medium in which to give crushed medicines d. Schedule of medication and dose times e. Parameters of pulse or blood pressure, if significant to administration ANS: A, B, C, E

Schedule and dose information are not considered part of the nursing care plan.

DIF: Cognitive Level: Application REF: pp. 139-140 OBJ: 8 TOP: Medication Information in the Nursing Care Plan KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 23. What measures may the older adult take to reduce the high cost of prescription drugs? (Select

all that apply.) a. Simply not fill a new prescription b. Take less than prescribed to preserve their supply c. Fill all prescriptions at once d. Save old prescription drugs for later use e. Share medications ANS: A, B, D, E

Filling prescriptions at one time can be costly even with a discount; therefore the older adult may pick and choose which ones to fill. All the other behaviors listed are methods whereby persons on a limited budget will attempt to preserve their supply of medications and contain costs.

DIF: Cognitive Level: Comprehension REF: pp. 144-145 OBJ: 12 TOP: Risks Related to Financial Factors KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 24. What factors increase the risk of medication-related problems in the older adult? (Select all

that apply.) a. Drug-testing methodology b. Age-related changes c. Polypharmacy d. Cognitive and sensory changes e. Lack of adequate medical follow-up ANS: A, B, C, D

Lack of follow-up is not identified as a factor in medication-related problems.

DIF: Cognitive Level: Comprehension REF: pp. 131-133 TOP: Factors in Medication-Related Problems MSC: NCLEX: N/A

OBJ: 1 KEY: Nursing Process Step: N/A

25. Why is self-medication with over-the-counter (OTC) drugs hazardous to the older adult?

(Select all that apply.)

OTC drugs can increase the effect of a prescribed drug.

OTC drugs can interfere with the efficacy of a prescribed drug.

OTC drugs can mask significant symptoms of primary disease.

OTC drugs are easily obtained.

OTC drugs can lead to overdose because they are not considered to be “real drugs.”

a. b. c. d. e.

ANS: A, B, C, E

OTC drugs can increase the effect of a prescribed drug, interfere with the efficacy of a prescribed drug, mask symptoms of primary diseases, and cause overdose. The fact that OTC drugs are easily obtained is a benefit, not a hazard, unless abused.

DIF: Cognitive Level: Comprehension REF: p. 136 OBJ: 11 TOP: Overuse of OTC Drugs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 26. The nurse crushes a pill and disguises the dose in the mashed potatoes of a resident in a long-

term care facility who previously refused the drug. It is then fed to the patient by the nursing assistant. This should be considered an error because it . (Select all that apply.) a. violates the patient’s right to refuse medication b. involves delegation of medication administration to the nursing assistant c. increases the amount of time for the drug administration pass d. becomes impossible to confirm the patient received the entire dose e. alters the food ANS: A, B, D

Hiding a dose of drug in a food serving that the patient had previously refused is unethical.

Delegating the administration of a drug to a nonqualified person is illegal, and because there is no guarantee the entire serving of food will be consumed, the intended dose may not be delivered.

DIF: Cognitive Level: Application REF: pp. 140-143 OBJ: 9 TOP: Disguising Drugs in Food KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies COMPLETION 27. The nurse clarifies that the term

refers to the study of how persons respond to

medicines.

ANS: pharmacodynamics DIF: Cognitive Level: Knowledge TOP: Medicating the Older Adult MSC: NCLEX: N/A

REF: p. 131 OBJ: 4 KEY: Nursing Process Step: N/A

28. The primary organ of drug metabolism is the ANS: liver

.

DIF: Cognitive Level: Knowledge TOP: Drug Metabolism MSC: NCLEX: N/A

REF: p. 132 OBJ: 3 KEY: Nursing Process Step: N/A

29. The home health nurse periodically interviews patients relative to their use of

because it is the most commonly consumed and abused nonprescription drug used by adults.

ANS: alcohol DIF: Cognitive Level: Comprehension REF: p. 136 OBJ: 11 TOP: Use of Alcohol KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies OTHER 30. Arrange the steps for preparing crushed medications to be given by feeding tube in order of

priority. a. Flush the tube to clear feeding. b. Thoroughly crush the medication. c. Administer each medication separately. d. Dissolve each crushed medication in a medicine cup. e. Flush the tube to clear the medication from the tube. f. Reconnect the feeding tube.

ANS:

B, D, A, C, E, F DIF: Cognitive Level: Application REF: p. 141 OBJ: 6 TOP: Crushed Medication per Tube KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

Chapter 08: Health Assessment of Older Adults Basic Geriatric Nursing, 7th Edition Chapter 08: Health Assessment of Older Adults Test Bank MULTIPLE CHOICE 1. The nurse clarifies that the difference between a health screening and health assessment is that a health screening:

a.

identifies persons with unmet health needs who may need a referral.

b.

assesses local health needs for the Public Health Department.

c.

collects data that will be used for research.

d.

provides appropriate treatment for identified health needs.

ANS: A Screenings are to identify unmet health needs and to refer identified persons to an appropriate resource for assessment and treatment.

DIF: Cognitive Level: Comprehension REF: 151 OBJ: 1 TOP: Screening vs. Assessment KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse charts that the “Patient stated abdominal pain is still at a level of 8 on a scale of 1 to 10 and that he is still nauseated. Patient complains of feeling cold and has an oral temperature of 97.8°.” The objective information recorded is the:

a.

pain measurement.

b.

presence of nausea.

c.

sense of cold.

d.

oral temperature.

ANS: D The objective concrete measurement of the temperature is the only objective data in the nurse’s record.

DIF: Cognitive Level: Application REF: 151 OBJ: 2 TOP: Objective Data KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse reminds the 55-year-old woman that the American Cancer Society (ACS) recommendation for persons older than 50 years is to have an annual:

a.

fecal occult blood test.

b.

sigmoidoscopy.

c.

Pap smear.

d.

pelvic examination.

ANS: A The ACS recommends an annual fecal occult blood test for persons older than 50. Sigmoidoscopy is recommended every 3 to 5 years. Pap smears and pelvic examinations are recommended every 2 to 3 years.

DIF: Cognitive Level: Comprehension REF: 152, Table 8-1

OBJ: 3 TOP: American Cancer Society Recommendations KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse is aware that the most common health threat for the older adult, regardless of ethnicity, is:

a.

hypertension.

b.

cancer.

c.

diabetes.

d.

glaucoma.

ANS: C Diabetes is the most common health threat for the older adult, regardless of ethnicity.

DIF: Cognitive Level: Comprehension REF: 158 OBJ: 3 TOP: Diabetes KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. The statement that would put the older woman most at ease during the lengthy health interview would be:

a.

“This interview will take about an hour.”

b.

“Please have a seat over there across from the desk.”

c.

“There are 75 questions we need to get answered in the next hour.”

d.

“The bathroom is behind that green door. We’ll be taking a break in about 30 minutes.”

ANS: D The “permission” to go to the bathroom and knowledge of its location will set the patient at ease. It is helpful to provide information about the probable time limits of the interview.

DIF: Cognitive Level: Application REF: 153 OBJ: 4 TOP: Physical Setting for Health Interview KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. To establish rapport, the nurse should initiate the health interview by saying:

a.

“Hello, Mrs. Smith. My name is Alice. We’ll start with a few questions before the physical exam.”

b.

“Welcome, Sara. I’m Alice. Let’s get down to some questions about your health.”

c.

“I’m Alice Jones. I’m here to do an interview about your health.”

d.

“Hey, Mrs. Smith! Are you ready for some questions about your health?”

ANS: A Addressing the patient formally and identifying yourself, as well as informing the patient of the expectation of the interview, is an appropriate approach to the older adult.

DIF: Cognitive Level: Application REF: 153 OBJ: 4 TOP: Establishing Rapport KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. The 94-year-old woman has come to the health assessment interview with her 70-year-old daughter, who answers all the interview questions for her mother. The nurse’s best approach to this situation would be to:

a.

say, “I’m speaking to your mother. Please let her answer for herself.”

b.

continue to interact with the daughter to facilitate completion of the interview.

c.

look directly at the patient and say, “Mrs. Smith, now I’d like to hear from you about your health.”

d.

document that all answers to the interview came from a third party.

ANS: C Directly addressing the older adult cues the patient and family member that the responses are expected from the patient.

DIF: Cognitive Level: Analysis REF: 153 OBJ: 4 TOP: Establishing Rapport KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The most effective method of building rapport is to open the health interview with:

a.

focusing on the problems that the patient sees as important.

b.

explaining the importance of health maintenance.

c.

informing the patient of the number of questions that will be asked.

d.

reassuring the patient that the interview is private.

ANS: A Focusing on the patient’s concerns gives the patient the perception that the nurse is concerned about him or her as a person.

DIF: Cognitive Level: Application REF: 153 OBJ: 4 TOP: Establishing Rapport KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. When interviewing a 90-year-old Chinese woman who is accompanied by her daughter, the interviewer should:

a.

use direct, short questions.

b.

address all the questions to the daughter.

c.

use pictures of body systems rather than anatomical terms.

d.

use social conversation and indirect questions.

ANS: D Persons with an Asian background consider direct questions inappropriate and they are more comfortable with indirect questioning in a social context. Rather than saying, “How many bowel movements do you have a day?” it would be better to ask, “How would you describe your digestion?”

DIF: Cognitive Level: Analysis REF: 153, Cultural Considerations OBJ: 4 TOP: Cultural Considerations KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. The nurse appropriately uses a variety of communication techniques during the health interview, which include:

a.

using medical terminology.

b.

keeping questions simple.

c.

helping patients by finishing their sentences.

d.

allowing patients to ramble as they respond.

ANS: B Keeping questions simple and asking the question in a clear voice help patients process answers.

Finishing their sentences and allowing extensive rambling are not helpful for useful interviewing.

DIF: Cognitive Level: Application REF: 153-154 OBJ: 4 TOP: Structuring the Interview KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 11. An 85-year-old man accompanied by his son is unable to recall the medications that he is presently taking. The nurse should:

a.

ask the question again.

b.

rephrase the question.

c.

ask the son for the information.

d.

leave that part of the health history blank.

ANS: C When patients are unsure of answers, it is best to move on and ask the family for objective information.

DIF: Cognitive Level: Application REF: 154 OBJ: 4 TOP: Health History KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

12. Because the nurse is aware that the 86-year-old woman has age-related loss of subcutaneous fat and a lowered metabolism rate, the nurse will take special precautions to:

a.

weigh the patient carefully without clothing.

b.

prevent the patient from becoming chilled during the examination.

c.

give fluids before the examination.

d.

elevate the patient’s head while he or she is lying in a supine position.

ANS: B Because of loss of subcutaneous fat and lower metabolism, the older adult has altered thermoregulation. Care should be taken to prevent chilling during the physical examination.

DIF: Cognitive Level: Application REF: 155 OBJ: 6 TOP: Prevention of Chilling KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. The nurse performing an assessment of a 90-year-old man suspected of having an upper respiratory infection would expect to find:

a.

temperature elevation over 100° F.

b.

elevated white blood count.

c.

history of recent periods of confusion.

d.

record of increased fluid intake.

ANS: C

The older adult does not exhibit a marked increase in temperature or in the white blood count as a response to infection. History of confusion and a decrease in appetite and fluid intake are cardinal signs of infection in the older adult.

DIF: Cognitive Level: Application REF: 155, Table 8-3 OBJ: 5 TOP: Infection Assessment in the Older Adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. During the health interview, when the older adult offers vague physical gastrointestinal complaints, complains of inability to fall asleep, has frequent periods of wakefulness during the night, and has a decrease in appetite, the nurse would be cued to inquire about:

a.

feelings of depression.

b.

time of last bowel movement.

c.

environmental stimuli that disturb sleep.

d.

frequency and size of meals.

ANS: A Vague physical complaints, sleep disturbances, and changes in appetite and food intake are signals of possible depression.

DIF: Cognitive Level: Analysis REF: 155, Table 8-3 OBJ: 4 TOP: Symptoms of Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 15. The most effective method to take an older adult’s temperature is to use a(n):

a.

electronic thermometer, because it only takes a few seconds to assess temperature.

b.

oral thermometer, because the presence of dry mucous membranes gives a more valid temperature.

c.

axillary thermometer, because its position is nearer the heart.

d.

rectal thermometer, because it is the best indicator of the body core temperature.

ANS: A The electronic thermometer is the best device because it is accurate and quick.

DIF: Cognitive Level: Comprehension REF: 156 OBJ: 8 TOP: Temperature Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. The nurse is aware that the difference between the apical pulse and radial pulse is referred to as the pulse:

a.

pressure.

b.

deficit.

c.

ratio.

d.

quality.

ANS: B The difference between the apical and radial pulse is referred to as the pulse deficit. This is a pertinent piece of information because it may indicate peripheral circulatory impairment.

DIF: Cognitive Level: Knowledge REF: 157 OBJ: 8 TOP: Pulse Deficit KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse records the assessment of crackles when the nurse auscultates:

a.

high-pitched sounds in the lung bases on inspiration.

b.

continuous low-pitched snoring sounds over major bronchi.

c.

squeaky musical sounds on expiration.

d.

coarse grating sounds on inspiration and expiration.

ANS: A Crackles are adventitious breath sounds heard on inspiration that sound like cracking paper.

Frequently, these sounds can be cleared by coughing.

DIF: Cognitive Level: Application REF: 160, Box 8-2 OBJ: 7 TOP: Adventitious Breath Sounds KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. The nurse assessing the apical pulse would place the head of the stethoscope at the:

a.

third intercostal space at proximal edge of the clavicle.

b.

fourth intercostal space at the edge of the sternum.

c.

fifth intercostal space at the middle of the clavicle.

d.

sixth intercostal space above the diaphragm.

ANS: C The correct placement of the stethoscope for the assessment of the apical pulse is at the fifth intercostal space at the midclavicular line. The pulse should be counted for a full minute.

DIF: Cognitive Level: Application REF: 157 OBJ: 8 TOP: Apical Pulse KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 19. The nurse assessing a patient for orthostatic hypotension has a reading of a seated blood pressure of 135/86. The blood pressure that would be indicative of orthostatic hypotension would be a standing blood pressure of:

a.

145/85.

b.

134/76.

c.

130/72.

d.

126/62.

ANS: D Orthostatic hypotension is suspected when the systolic reading is 20 mm Hg lower than the sitting blood pressure. Dizziness with a diastolic pressure less than 100 mm Hg should also be reported.

DIF: Cognitive Level: Analysis REF: 159 OBJ: 7 TOP: Orthostatic Hypotension KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

20. When the nurse using the Mini-Mental State Examination (MMSE) requests the patient to count by sevens (7, 14, 21, 28), the nurse is attempting to evaluate the patient’s:

a.

orientation.

b.

recall.

c.

ability to follow complex commands.

d.

attention and ability to perform calculations.

ANS: D Counting by sevens tests a person’s ability for attention and calculation.

DIF: Cognitive Level: Analysis REF: 161, Figure 8-4 OBJ: 1 TOP: Mini-Mental State Examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. The nurse explains that the Minimum Data Set (MDS) 3.0 used in extended care facilities is designed to:

a.

identify ethnic populations in long-term care.

b.

group residents into specified activity levels.

c.

organize information relative to diagnostic categories.

d.

make assessment processes more consistent.

ANS: D The MDS 3.0 is meant to standardize assessments and make them more reliable. MDS 3.0 is a computerized comprehensive assessment tool that justifies government funding.

DIF: Cognitive Level: Comprehension REF: 162 OBJ: 9 TOP: Minimum Data Set 3.0 KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation MULTIPLE RESPONSE 1. The nurse explains that health screening can be conducted by apply.)

a.

a health professional

b.

telephone interview

c.

telecomputer

d.

pen and paper surveys

e.

lay persons

. (Select all that

ANS: A, B, C, D Lay persons may not do screenings unless they are specially trained. All other modes of screening are in use today.

DIF: Cognitive Level: Knowledge REF: 151 OBJ: 1 TOP: Health Screening Modes KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 2. The nurse in a long-term care facility is aware that a health assessment will be . (Select all that apply.)

a.

the basis for the assignment of nursing diagnoses

b.

done only at admission to the facility

c.

performed only by a registered nurse

d.

a platform for the nursing care plan

e.

ongoing for the duration of the stay

ANS: A, D, E The health assessment is done on admission to the facility and is ongoing during the duration of the stay. The initial assessment can be done by any licensed professional in the long-term facility and is the basis for the nursing diagnoses and plan of care.

DIF: Cognitive Level: Comprehension REF: 151 OBJ: 1 TOP: Health Assessment KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse collects objective data by way of

a.

observation

b.

patient complaints

c.

physical examination

d.

laboratory findings

. (Select all that apply.)

e.

family input

ANS: A, C, D Patient complaints and family input are subjective data. Objective data are concrete, observable signs.

DIF: Cognitive Level: Comprehension REF: 151 OBJ: 2 TOP: Objective Data Collection KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The nurse planning a health interview with an older adult will take into consideration . (Select all that apply.)

a.

comfort of the physical setting

b.

methods to develop trust and rapport

c.

timing for minimal distractions

d.

the age and ethnicity of the patient

e.

income level

ANS: A, B, C, D Income level is not a primary consideration in the health interview.

DIF: Cognitive Level: Comprehension REF: 152 OBJ: 4 TOP: Health Interview KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

5. The nurse taking identifying information will collect data pertinent to apply.)

a.

ethnicity

b.

previous or current occupation

c.

educational background

d.

perception of general health

e.

completion of advanced directives

. (Select all that

ANS: A, B, C, E The patient’s perception of his or her general health is subjective data in the health history and is not taken in the identifying data portion of the interview.

DIF: Cognitive Level: Comprehension REF: 154, Box 8-1 OBJ: 4 TOP: Identifying Data KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The nurse uses the five techniques of physical health assessment, which include . (Select all that apply.)

a.

inspection

b.

palpation

c.

interview

d.

auscultation

e.

percussion

ANS: A, B, D, E Interviewing is not a technique of physical assessment.

DIF: Cognitive Level: Knowledge REF: 155 OBJ: 7 TOP: Physical Assessment Techniques KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. When the nurse palpates a very weak pedal pulse in the right foot, the nurse would anticipate finding other indications of diminished peripheral circulation in the right foot and leg, such as . (Select all that apply.)

a.

bruising

b.

darkened color

c.

cool skin

d.

diminished hair on limb

e.

capillary refill of 3 seconds

ANS: C, D A decreased arterial flow will produce a faint or absent pedal pulse, cool pale skin, and diminished hair on the limb. Bruising and a normal capillary refill time of 3 seconds are not indicators of impaired peripheral circulation.

DIF: Cognitive Level: Application REF: 157 OBJ: 5

TOP: Peripheral Circulation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse explains that the tool that allows the evaluation of core function in a resident in a longterm facility is the .

ANS: Minimum Data Set DIF: Cognitive Level: Knowledge REF: 162 OBJ: 9 TOP: Minimum Data Set KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

Chapter 09: Meeting Safety Needs of Older Adults Test Bank MULTIPLE CHOICE 1. An older adult man has been diagnosed as having diminished depth perception. What does the

nurse expect him to have difficulty with in his everyday activities?

Judging the height of steps.

Reading small print on food labels.

Reading street signs.

Seeing in dim light.

a. b. c. d.

ANS: A

Diminished depth perception results in an inability to judge height and depth of steps and judge distance. These deficits result in falls.

DIF: Cognitive Level: Knowledge REF: p. 165 OBJ: 1 TOP: Diminished Depth Perception KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The home health nurse is assessing the home environment of an 85-year-old patient with

Parkinson disease. What symptom of Parkinson disease makes the patient at an increased risk of falls? a. Postural hypotension b. Cognitive changes c. Altered vision d. Altered gait ANS: D

The propulsive gait and reduced ability to lift the feet make falls a constant threat to a patient with Parkinson disease.

DIF: Cognitive Level: Comprehension REF: p. 166 OBJ: 2 TOP: Fall Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 3. In order to decrease fall risk due to orthostatic hypotension, what advice should be given to an

older adult who is taking medication for hypertension?

Ambulate with a walker.

Avoid hot baths.

Avoid climbing stairs.

Sit on the side of the bed for a moment before ambulation.

a. b. c. d.

ANS: D

Sitting on the side of the bed before ambulation gives the vascular system time to adjust to a positional change.

DIF: Cognitive Level: Application REF: p. 174 OBJ: 3 TOP: Fall Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

4. What is a common reason that an older adult may deny that he has fallen? a. Fear that he will fall again b. Fear of being hospitalized for treatment c. Afraid of being seen as frail and dependent d. Fear of being considered clumsy ANS: C

Many older adults do not report falls because they fear that they will be seen as frail and dependent.

DIF: Cognitive Level: Comprehension REF: p. 166 OBJ: 2 TOP: Fall Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 5. Why is it important for the home health nurse to interview an 82-year-old patient following

the patient’s fall in the home?

So that the incident can be reflected in the home health nurse’s documentation To help the patient gain insight into the cause of the fall In order to guarantee no further falls To collect data for research purposes

a. b. c. d.

ANS: B

Gaining insight into the cause of falls will help the patient and family become aware of factors in the home that are so familiar that they are not seen as hazards. Recognition of hazards will lead to an alteration of the environment for improved safety. While the nurse will document the fall in her notes, that is not the primary reason to interview the patient. Further falls cannot be guaranteed.

DIF: Cognitive Level: Application REF: pp. 166-167 OBJ: 3 TOP: Fall Prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. What is the primary focus of a fall prevention program in a long-term care facility? a. Improving balance b. Improving muscle mass c. Improving circulation d. Increase in the knowledge base about falls ANS: A

Most exercise programs are focused on improvement of balance to reduce the incidence of falls. Improved balance is seen as an effort to improve the confidence of the older adult.

DIF: Cognitive Level: Comprehension REF: p. 167 OBJ: 4 TOP: Fall Prevention KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The daughter of an 80-year-old woman asks the home health nurse for advice in selecting a

cane for her mother, who has an unsteady gait. What cane would be a poor choice?

Wooden cane with a rubber tip Four-footed cane with a rubber grip Clear acrylic cane with a nonslip tip Colorful carved cane with a wooden tip

a. b. c. d.

ANS: D

The lack of a nonskid tip makes the colorful carved cane an inappropriate choice.

DIF: Cognitive Level: Application REF: Figure 9-1, p. 175 OBJ: 3 TOP: Assistive Devices KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 8. Why does the home health nurse give his 90-year-old patient a framed poster that says “We

need each other.”?

Insure that the patient will take care not to fall.

Remind the patient to ask for assistance when needed.

Encourage the patient to take pride in his independence.

Reinforce that the patient should not attempt any activity without help.

a. b. c. d.

ANS: B

Asking for assistance is good judgment rather than attempting risky acts without help.

DIF: Cognitive Level: Application REF: p. 174 OBJ: 4 TOP: Fall Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. What does the nurse hope to achieve by teaching tai chi daily in the long-term care facility? a. Stimulate intellectual activity b. Encourage interaction c. Improve coordination d. Demonstrate cultural awareness ANS: C

Tai chi is a low-impact, nonstressful exercise that develops balance and coordination.

DIF: Cognitive Level: Knowledge REF: pp. 167-168 OBJ: 4 TOP: Fall Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The home health nurse conducts a safety assessment in a patient’s home. Which of the

following would be identified as a fire hazard?

Baking soda near the stovetop A smoke detector in the kitchen Multiple appliances plugged into one outlet A metal container for cigarettes

a. b. c. d.

ANS: C

Multiple electrical appliances plugged into one outlet can create an overload and cause a fire.

DIF: Cognitive Level: Analysis REF: p. 170 OBJ: 3 TOP: Fire Hazard KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 11. What would be an appropriate suggestion for an 80-year-old woman who recently placed a

deadbolt lock on her door? a. Keep the door securely locked.

b. Apply similar locks on the windows. c. Leave the door unlocked, with the key in place. d. Replace the lock with a security chain.

ANS: C

Unlocked deadbolts allow rapid access by emergency personnel.

DIF: Cognitive Level: Application REF: Box 9-4, p. 170 OBJ: 3 TOP: Home Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. Which of the following would least improve home security? a. Peephole in the door at a convenient height b. Brightly lit porch c. Large dog with a loud bark d. Hook and eye latch on the screen door ANS: D

The hook and eye latch on the screen door, although a retardant, would not offer adequate security in the case of a break-in.

DIF: Cognitive Level: Analysis REF: Box 9-4, p. 170 OBJ: 3 TOP: Home Security KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 13. The home health nurse counsels a family in making safe driving “rules” for their 85-year-old

father. Which rule would not be effective in promoting safety?

Limit driving to nearby areas with easy access.

Plan ahead and know where you are going.

Wear prescribed glasses and hearing aids.

Drive below the speed limit to maintain control of the car.

a. b. c. d.

ANS: D

Driving “rules” are significant when there are no alternatives to driving. Driving slowly causes accidents.

DIF: Cognitive Level: Application REF: Box 9-5, p. 171 OBJ: 3 TOP: Driving Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 14. Which of the following may be a thermoregulation risk in the older adult? a. Inactivity b. Eating highly spiced foods c. Being overweight d. Mental illness ANS: A

Reduced activity, lower basal metabolism rate, and slowed circulatory rate contribute to the feeling of being cold.

DIF: Cognitive Level: Comprehension REF: p. 172 OBJ: 5 TOP: Thermoregulation Disorder KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. What is an expected assessment finding in an older adult suffering from hyperthermia? a. Excessive perspiration b. Bradycardia c. Temperature of 100° F d. Leg cramps ANS: D

Persons with heat exhaustion have leg and abdominal cramps; dry, hot, nonperspiring skin; tachycardia; and a temperature over 102° F. DIF: Cognitive Level: Application REF: p. 173 OBJ: 6 TOP: Heat Exhaustion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. The nurse is aware that the older adult is at greater risk for hypothermia than a younger person

because the older adult has a diminished ability to: a. convert glycogen to glucose. b. select appropriate clothing or bed linen. c. shiver. d. constrict vessels.

ANS: C

Older adults have a diminished ability to shiver. Shivering is a muscular activity that increases metabolism and body heat.

DIF: Cognitive Level: Comprehension REF: p. 173 OBJ: 4 TOP: Thermoregulation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse is volunteering at a homeless shelter. What intervention should be taken for a

patient admitted with severe hypothermia?

Give the person hot coffee or soup.

Place the person in a warm bath.

Briskly rub the person’s hands.

Wrap the person in blankets.

a. b. c. d.

ANS: D

The hypothermic individual should be moved to a warmer environment, wrapped in blankets or other insulating material, and given warm, not hot, drinks or food. Putting an individual in a warm bath may cause cardiovascular problems or skin damage.

DIF: Cognitive Level: Knowledge REF: p. 173 OBJ: 7 TOP: Thermoregulation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 18. What would be the initial choice of interventions to help prevent a fall in a confused 85-year-

old extended-care facility patient? a. Use of a vest restraint

b. Use of an electronic sensor alarm c. Placement of a wheelchair between the wall and dining table d. A tray table attached to the arms of the wheelchair ANS: B

The alarm is the best initial choice because it does not require a physician’s order. The vest restraint requires an order. The tray table and “trapping” the resident between the wall and a dining table may lead to injuries as the resident attempts to get out of confinement.

DIF: Cognitive Level: Comprehension REF: p. 175 TOP: Restraints KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Reduction of Risk

OBJ: 3

MULTIPLE RESPONSE 19. What should the home health nurse suggest in the case of a fire in the home of the older adult?

(Select all that apply.)

Keep a flashlight at the bedside Use an appropriate fire extinguisher to control fire Keep the doors open for an easy escape route Call 911 before exiting the home Open the windows to decrease smoke

a. b. c. d. e.

ANS: A

Keep a flashlight for emergency lighting in case of dense smoke or an electrical failure. Do not try to extinguish the fire, close doors and windows to prevent spread of fire, and call 911 after exiting the building.

DIF: Cognitive Level: Application REF: p. 170 OBJ: 3 TOP: Fire Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 20. What are internal factors that threaten the safety of the older adult? (Select all that apply.) a. Decrease in flexibility b. Slowed reaction time c. Gait changes d. Thermal hazards e. Postural changes ANS: A, B, C, E

Thermal hazards are not internal risk factors. All other options listed are internal risk factors.

DIF: Cognitive Level: Comprehension REF: pp. 166-167 OBJ: 2 TOP: Internal Hazards KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 21. The nurse in a long-term care facility awards stickers to certified nursing assistants who

consistently . (Select all that apply.) a. report broken tiles in the shower room and bathrooms b. mop up spills c. assist residents to hurry

d. remind residents to use walkers e. retie residents’ shoelaces ANS: A, B, D, E

Hurrying the older adult increases the risk for falls. All other options promote safety for the older adult.

DIF: Cognitive Level: Application REF: pp. 167-169 OBJ: 4 TOP: Fall Prevention KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 22. The home health nurse is assessing the patient’s home. Which of the following would be

identified as a fall risk? (Select all that apply.) a. Brightly lit rooms b. Pantry food at an accessible level c. Colorful scatter rugs marking doorways and steps d. Wearing comfortable laced tennis shoes e. Attractive, low, magazine rack beside a chair ANS: C, E

Scatter rugs and low items placed near the bed or chairs are fall hazards. All the other options listed promote safety at home.

DIF: Cognitive Level: Application REF: Box 9-3, p. 169 OBJ: 4 TOP: Fall Prevention KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 23. What are external factors that may be a safety threat to the older adult? (Select all that apply.) a. Fire hazards b. Lack of home security c. Vehicular accidents d. Thermal hazards e. Sensory deficit ANS: A, B, C, D

Sensory deficits are not external risk factors. All other options listed are.

DIF: Cognitive Level: Knowledge REF: pp. 169-174 OBJ: 2 TOP: External Risk Factors KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 24. What telephone modifications would increase safety for the older adult? (Select all that

apply.)

Placement of phones at bedside and next to a favorite chair Programming an auto dial function for quick dialing Using an answering machine with a male voice Replacing the phone cord with a 15-foot cord for ease in carrying around the phone Selecting a phone with large numbers

a. b. c. d. e.

ANS: A, B, C, E

Long cords are a fall hazard. All other options increase safety of the older adult.

DIF: Cognitive Level: Application REF: Box 9-4, p. 170 OBJ: 3 TOP: Phone Safety KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 25. The home health nurse has evaluated the community for measures that support pedestrian

safety. What safety measures would be appropriate modifications to increase safety in the community? (Select all that apply.) a. Pedestrian-controlled crosswalks b. Safety islands on wide street intersections c. Decreased time to cross at walks d. Clearly marked crosswalks at intersections e. Overhead crossings over busy streets ANS: A, B, D, E

Increased time is required for older adults to cross streets. All other options listed promote pedestrian safety.

DIF: Cognitive Level: Application REF: p. 171 OBJ: 3 TOP: Prevention of Vehicular Accidents KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 26. What factors increase the risk of vehicular accidents for the older adult? (Select all that apply.) a. Increased reflex time b. Cognitive disorders c. Altered depth perception d. Changes in night vision e. Reduced flexibility ANS: B, C, D, E

Older adults have slower reflexes. All other options listed put the older adult at risk for accidents.

DIF: Cognitive Level: Knowledge REF: p. 171 OBJ: 3 TOP: Vehicular Hazards KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 27. The daughter of a home health patient is concerned about her 92-year-old father who

continues to drive regularly. Which observations would indicate deteriorated driving skills?

(Select all that apply.) a. Paint scrapes on the mailbox at the curb b. Friends calling him to get rides to the grocery store c. Choosing not to drive at night because of night blindness d. Difficulty turning his head e. Carefully planning routes to avoid heavy traffic ANS: A, D

Paint scrapes suggest depth perception difficulty, and inability to turn the head makes backing up and checking for cross traffic difficult.

DIF: Cognitive Level: Comprehension

REF: p. 172

OBJ: 3

TOP: Driving Safety KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control COMPLETION 28. The nurse takes into consideration that the most common injuries to the older adult are the

result of

.

ANS: falls DIF: Cognitive Level: Knowledge REF: p. 166 OBJ: 1 TOP: Falls KEY: Nursing Process Step: Planning MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

Chapter 10: Cognition and Perception Basic Geriatric Nursing, 7th Edition Chapter 10: Cognition and Perception Test Bank MULTIPLE CHOICE 1. The nurse clarifies that perception differs from cognition in that perception refers mainly to:

a.

intellect.

b.

memory.

c.

judgment.

d.

interpretation.

ANS: D Perception refers mainly to the ability to interpret situations in the environment.

DIF: Cognitive Level: Comprehension REF: 180 OBJ: 1 TOP: Perception vs. Cognition KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse suspects the presence of cataracts in the older adult when the patient:

a.

holds the newspaper a good distance away while attempting to read small print.

b.

seeks an area in a room that is free from glare in order to read the newspaper.

c.

holds a hand over one eye while attempting to read small print.

d.

uses only peripheral vision while attempting to read a newspaper.

ANS: B Cataracts blur the vision and increase the sensitivity to glare.

DIF: Cognitive Level: Analysis REF: 181 OBJ: 2 TOP: Cataracts KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse approaching a patient who has profound hearing loss should:

a.

knock on the door before entering.

b.

touch the patient on the hand to gain attention.

c.

give the patient a list of interventions that the nurse plans to perform.

d.

speak in a higher tone of voice.

ANS: B Touching on the hand to gain attention before giving care is thoughtful. Giving a lengthy list is not necessary. Knocking on the door may be futile, and speaking in higher tones is not helpful because the hearing-impaired lose the ability to hear high tones first.

DIF: Cognitive Level: Comprehension REF: 183 OBJ: 7 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. When attempting to communicate with a patient who is hearing-impaired, the nurse should remember to:

a.

keep the message simple.

b.

provide lengthy explanations and information.

c.

assume understanding if the patient does not ask for clarification.

d.

use many hand gestures.

ANS: A Keeping the message simple will assist the hard of hearing to understand. Long explanations and the use of many hand gestures may be confusing. It is the responsibility of the nurse to check to confirm understanding.

DIF: Cognitive Level: Comprehension REF: 183 OBJ: 7 TOP: Communication with the Hearing-Impaired KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. In adapting the environment for a person with right-sided hemianopsia, the nurse should:

a.

approach the patient from the right side.

b.

arrange personal articles on the left side of the bed.

c.

remind the patient to avoid turning his or her head to reduce added perceptual problems.

d.

touch the patient on the right side to get his or her attention.

ANS: B Arrangement of personal items on the “good” left side is supportive to independence.

DIF: Cognitive Level: Application REF: 184 OBJ: 7 TOP: Hemianopsia KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The night nurse hears a high whistling noise coming from the hearing aids that are lying on the bedside table of the sleeping patient. The nurse should:

a.

replace the hearing aids in the patient’s ears.

b.

turn off the hearing aids.

c.

place the hearing aids in a drawer to prevent loss.

d.

ask that an audiologist be notified of the problem.

ANS: B The noise is feedback between the two active hearing aids. They should be turned off to preserve the batteries.

DIF: Cognitive Level: Application REF: 185 OBJ: 7 TOP: Hearing Aids KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. The nurse interprets a patient’s behavior changes as being characteristic of delirium because:

a.

the onset of the behavior was rapid.

b.

there is no change in the level of consciousness.

c.

of the absence of disorientation.

d.

of the absence of hallucinations.

ANS: A Delirium comes on suddenly and is accompanied by a change in the level of consciousness, disorientation, and hallucinations.

DIF: Cognitive Level: Application REF: 186, Table 10-1 OBJ: 4 TOP: Delirium KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nurse is aware that conditions that can cause delirium in the older adult include:

a.

uncontrolled pain.

b.

death of a loved one.

c.

relocation to a long-term care facility.

d.

altered sleep patterns.

ANS: A Delirium results from physiological influences such as uncontrolled pain, metabolic disturbances, or drug toxicity.

DIF: Cognitive Level: Analysis REF: 186 OBJ: 3 TOP: Delirium KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The nurse recognizes a cardinal indicator that the patient with stage 1 dementia has deteriorated to stage 2 by the presence of:

a.

inability to communicate.

b.

incontinent episodes.

c.

total dependency.

d.

forgetfulness.

ANS: B Incontinent episodes are indicative of stage 2 dementia.

DIF: Cognitive Level: Application REF: 188 OBJ: 4 TOP: Stages of Dementia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse can provide continuity for the demented patient in a general hospital by:

a.

keeping the patient in the room.

b.

reducing environmental stimuli such as the TV or radio.

c.

assigning the same personnel every day for care.

d.

attaching a bed alarm to the patient.

ANS: C Assigning the same personnel helps the demented patient have continuity of care.

DIF: Cognitive Level: Application REF: 189 OBJ: 7 TOP: Dementia KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. When the demented resident in a long-term care facility becomes combative when being prepared for a bath in the shower, the nurse should:

a.

call for assistance to complete the shower.

b.

say, “I understand you don’t want a shower, so I’ll give you a sponge bath.”

c.

medicate the patient with a sedative and complete the bath when the patient is more cooperative.

d.

say, “Okay. It’s your right to remain dirty.”

ANS: B Focusing on feelings or offering an alternative is helpful with a combative demented patient. Arguing serves no purpose other than to make the resident more upset.

DIF: Cognitive Level: Application REF: 189 OBJ: 7 TOP: Combative Patient KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. The nurse explains to a family that current Omnibus Budget Reconciliation Act (OBRA) guidelines allow the use of antipsychotic medication as a chemical restraint to control:

a.

disruptive verbal behavior.

b.

constant yelling and screaming.

c.

hallucinations.

d.

disorientation.

ANS: B The current OBRA prohibits the use of antipsychotic drugs to control nonaggressive behavior.

However, antipsychotic drugs may be prescribed for the control of constant screaming and yelling.

DIF: Cognitive Level: Application REF: 190 OBJ: 7 TOP: Use of Antipsychotic Drugs KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 13. When the patient with a cognitive disorder “acts out” because of excessive stimulation, the nurse’s most effective intervention would be to:

a.

medicate with a psychoactive drug such as lorazepam or diazepam.

b.

send the patient to his or her room for “time out.”

c.

remind the patient that acting out behavior will not be tolerated.

d.

distract the patient with a quiet activity.

ANS: D Distraction with a quiet activity and with interpersonal contact frequently interrupts acting out.

DIF: Cognitive Level: Application REF: 191 OBJ: 7 TOP: Acting Out Behavior KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. When the home health nurse is helping a family accept the diagnosis and prepare for the patient with a cognitive disorder, the nurse should:

a.

leave them literature about the disorder.

b.

instruct them about the physiological changes that cause the disorder.

c.

allow them time for expression of their feelings and grief.

d.

discuss options for placement in a long-term care facility.

ANS: C Allowing time for expression of their feelings will help the family cope and begin planning how best to care for their loved one.

DIF: Cognitive Level: Application REF: 191 OBJ: 3 TOP: Impact of Cognitive Disorder on Family KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 15. To help a male patient with expressive aphasia communicate, the nurse’s most effective intervention would be to:

a.

provide flash cards with text and pictures.

b.

be patient and ask him to repeat himself.

c.

encourage him to practice slow speech.

d.

arrange with him to blink the eyes once for “yes” and twice for “no.”

ANS: A

Flash cards or pen and paper help the patient with expressive aphasia communicate. Blinking only allows the patient to answer, not communicate needs.

DIF: Cognitive Level: Comprehension REF: 194 OBJ: 7 TOP: Expressive Aphasia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. The nurse in an extended care facility finds an 86-year-old female resident in tears and her hearing aids on the floor. The resident says, “I’ll just be deaf! I can’t stand those things in my ears! All I can hear is static, hums, and whistles!” The nurse’s most helpful response is:

a.

“Everybody says that. I’m going to put these back in the box in your bedside table.”

b.

“Those are very expensive pieces of equipment. Because you paid for them, it seems to me to just be good sense to use them.”

c.

“Let’s put them back in. You’ll get used to them in a few days.”

d.

“It’s frustrating to have something not work. Let me help you replace them and after 10 minutes, I’ll help you take them out.”

ANS: D Many people who have new hearing aids report that the sounds are “tinny” and “noisy.” When first fitted, the person may be able to tolerate the hearing aids for only a few minutes a day.

DIF: Cognitive Level: Comprehension REF: 184 OBJ: 7 TOP: Hearing Aid Adjustment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. The nurse reading the history of a newly admitted 88-year-old man with dementia sees that this resident is prone to catastrophic reactions. The nurse understands that this person will:

a.

demonstrate excessive emotional reactions.

b.

become combative with little stimulus.

c.

suddenly display self-destructive behaviors.

d.

openly expose himself or make sexual advances.

ANS: A Catastrophic reactions are reactions that are excessively emotional.

DIF: Cognitive Level: Comprehension REF: 188 OBJ: 3 TOP: Catastrophic Reactions KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 18. An 84-year-old female resident with dementia in an extended care facility rapidly paces the halls and the common areas from right after breakfast to bedtime. The nurse should include in the plan of care to:

a.

restrain the resident from pacing.

b.

apply a bracelet that sounds an alarm if the resident leaves the building.

c.

encourage rest by asking her to sit and have a glass of juice or a snack.

d.

pace with her and engage her in conversations.

ANS: C Encourage rest periods during the day by offering a snack or juice. Pacers should not be restrained from pacing. An alarm bracelet is not necessary if no attempt to leave the building is made. Pacing with her does not result in rest periods.

DIF: Cognitive Level: Application REF: 189 OBJ: 7

TOP: Pacing KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation MULTIPLE RESPONSE 1. The nurse lists indicators of hearing loss, which include

a.

understanding the female voice better than the male voice

b.

reluctance to have telephone conversations

c.

becoming irritable with background noise

d.

turning the TV up to the loudest volume

e.

responding with “off-the-wall” answers to a question

. (Select all that apply.)

ANS: B, C, D, E Because of the higher register of the female voice and that of children, the person with a hearing impairment does not understand them well. All other options are valid indicators of hearing loss.

DIF: Cognitive Level: Comprehension REF: 182 OBJ: 4 TOP: Sensory Deficit KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse is aware that memory loss in the older adult

a.

increases with age

b.

decreases in a person with more education

. (Select all that apply.)

c.

increases with the use of antihistamines

d.

decreases with the use of vitamin A

e.

decreases in persons who have many varied memories

ANS: A, B, E The use of vitamin A has no memory enhancement capability. Antihistamines do not have a history of being a cause of memory loss.

DIF: Cognitive Level: Comprehension REF: 182 OBJ: 2 TOP: Memory Loss KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse instructs a hearing-impaired patient on some methods to improve communication, which include . (Select all that apply.)

a.

informing others of the hearing deficit

b.

focusing on the speaker

c.

facing the speaker

d.

requesting the speaker to shout if necessary

e.

asking the speaker to repeat what is not clear

ANS: A, B, C, E Shouting does not help a hearing-impaired patient to understand. All other options improve communication for a hearing-impaired person.

DIF: Cognitive Level: Comprehension REF: 185 OBJ: 7 TOP: Hearing Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 4. The nurse explains that confusion is divided into three different types, which are . (Select the three that apply.)

a.

acute confusion

b.

mixed confusion

c.

idiopathic confusion

d.

generic confusion

e.

dementia

ANS: A, C, E The three types of confusion are acute confusion or delirium, idiopathic confusion, and dementia.

DIF: Cognitive Level: Comprehension REF: 186 OBJ: 3 TOP: Types of Confusion KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse can help a demented person maintain orientation by apply.)

a.

consistently calling the patient by name, usually the first name

b.

referring the patient to a calendar to note special events

. (Select all that

c.

reminding the patient about the time of day by pointing to the clock

d.

calmly taking the patient to an appointment without explanation

e.

reminding the patient of her or his whereabouts frequently

ANS: A, B, C, E Demented persons need a simple explanation of all procedures involved in their care. All other options are helpful in maintaining orientation for a demented patient.

DIF: Cognitive Level: Application REF: 189 OBJ: 7 TOP: Orientation Methods KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The nurse should include which factor(s) in a pain assessment? (Select all that apply.)

a.

What provokes it

b.

Location

c.

Radiation

d.

Severity

e.

Frequency

ANS: A, B, C, D, E All options are significant parts of a pain assessment.

DIF: Cognitive Level: Knowledge REF: 197 OBJ: 8

TOP: Pain Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. The nurse designing a teaching plan for a family caring for an older adult who is experiencing pain would stress . (Select all that apply.)

a.

giving medication before the pain becomes severe

b.

distracting the patient instead of medicating

c.

that pain reported by the older adult may be exaggerated

d.

delaying administration to reduce the risk of addiction

e.

observing the effectiveness of the medication

ANS: A, E Giving medication before pain is severe alleviates pain better and results in the patient requiring less medication. Assessment of the drug’s effectiveness is important to relay to the physician in the event the drug needs to be changed or the dose increased.

DIF: Cognitive Level: Application REF: 198 OBJ: 8 TOP: Pain Control KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort COMPLETION 1. The nurse explains that the term that describes the ability to make judgments quickly on the basis of unfamiliar stimuli is .

ANS: fluid intelligence DIF: Cognitive Level: Knowledge REF: 181 OBJ: 1 TOP: Fluid Intelligence KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 2. The center for speech located in the brain is the

area.

ANS: Broca DIF: Cognitive Level: Knowledge REF: 193 OBJ: 1 TOP: Broca Area KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 3. The person who is unable to identify time, place, or person to the point that he or she is unable to make appropriate decisions is described as .

ANS: confused DIF: Cognitive Level: Knowledge REF: 185 OBJ: 3 TOP: Confusion KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

Chapter 11: Self-Perception and Self-Concept Basic Geriatric Nursing, 7th Edition Chapter 11: Self-Perception and Self-Concept Test Bank MULTIPLE CHOICE 1. The nurse cautions a group of older adults that the greatest damage to self-worth is measuring self against:

a.

internal ideals.

b.

individual values.

c.

external standards.

d.

expressions of positive feedback.

ANS: C The use of external standards rather than internal values is an inadequate platform for self-worth.

The use of positive feedback and internal individual values supports a positive perception of selfworth.

DIF: Cognitive Level: Comprehension REF: 200 OBJ: 1 TOP: Self-Worth KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse is aware that a positive self-perception is largely dependent on the:

a.

ability to control life’s choices.

b.

financial success attained in life.

c.

family relationships.

d.

degree of wellness.

ANS: A Being in control of life’s choices increases and maintains a positive self-perception.

DIF: Cognitive Level: Comprehension REF: 201 OBJ: 1 TOP: Self-Perception KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse recognizes that a major indicator of a positive self-image in an older adult living in a long-term care facility is:

a.

feeding self independently.

b.

maintaining urinary continence.

c.

having family visitors every week.

d.

neat grooming and wearing fresh clothing.

ANS: D Neat grooming and care in personal appearance are cardinal indicators of a positive self-image.

DIF: Cognitive Level: Application REF: 201 OBJ: 1 TOP: Self-Image KEY: Nursing Process Step: Assessment

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The nurse explains that older adults often resort to cosmetic surgery to maintain the appearance of youth and self-worth because the concept of ageism has painted old age as:

a.

an inactive population of self-indulgent persons.

b.

a group that has opted to isolate themselves.

c.

physically inept and nonproductive.

d.

an antisocial but active group.

ANS: C Ageism has defined the older adult as physically inept, nonproductive, and essentially unattractive.

DIF: Cognitive Level: Comprehension REF: 202 OBJ: 1 TOP: Ageism KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The long-term care facility nurse sees evidence that the most devastating blow to the self-concept of the older adult is institutional placement because persons in a long-term care facility:

a.

are perceived as a single group.

b.

have individual needs that are not met.

c.

have lost many belongings that made up their identity.

d.

have lost social contact.

ANS: C The losses of home, spouse, car, and independence in making choices are devastating blows to someone’s self-image, even if he or she has social contacts and individual needs are met.

DIF: Cognitive Level: Application REF: 202 OBJ: 2 TOP: Institutionalization KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The nurse explains that the loss of emotional support of loved ones through death or separation makes the older adult feel:

a.

unloved and unlovable.

b.

angry with the isolation.

c.

unworthy for attention.

d.

determined to be his or her own support.

ANS: A Without an emotional support system, the older adult comes to feel unloved and unlovable.

DIF: Cognitive Level: Analysis REF: 203 OBJ: 2 TOP: Emotional Support KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. The nurse explains that long-term care facility placement for the older adult usually makes the older adult feel a sense of:

a.

rejection.

b.

safety.

c.

making a fresh start.

d.

immediate assistance at hand.

ANS: A Placement equals rejection in the minds of many older adults, even if the placement was unavoidable and necessary.

DIF: Cognitive Level: Comprehension REF: 203 OBJ: 1 TOP: Long-Term Care Facility Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 8. The admission nurse at the long-term care facility suggests that to help the older adult make an easier transition to relocation, the family should:

a.

send cards or gifts instead of personal visits.

b.

visit and call often to remind the resident that she or he is cared for.

c.

limit contact for several weeks to encourage independence.

d.

communicate with the long-term facility’s staff to inquire about the resident’s well-being.

ANS: B Frequent visits and calls by family and friends help maintain self-esteem and self-worth in the newly admitted resident.

DIF: Cognitive Level: Application REF: 203 OBJ: 2 TOP: Long-Term Care Facility Placement KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. The nurse takes into consideration that depression affects almost 50% of older adults who:

a.

live at home with a spouse.

b.

live alone.

c.

live in a long-term care facility.

d.

are hospitalized.

ANS: D Studies show that 46% of older adults who are hospitalized have symptoms of depression.

DIF: Cognitive Level: Comprehension REF: 203 OBJ: 4 TOP: Depression KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. The nurse in a long-term care facility notes signs of depression in a resident who is ordinarily positive. The nurse suspects this new affective change is related to the initiation of a drug protocol of:

a.

erythropoietin.

b.

corticosteroids.

c.

calcium replacement.

d.

broad-spectrum antibiotics.

ANS: B Depression can be caused by the initiation of drugs such as corticosteroids, glycosides, hormones, and antihypertensive agents.

DIF: Cognitive Level: Application REF: 203 OBJ: 2 TOP: Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 11. The home health nurse instructs the family caring for an 80-year-old man to be alert for signs of depression, which include:

a.

daytime napping.

b.

agitation and irritability.

c.

constant talking.

d.

seeking the company of family members.

ANS: B Irritability and agitation are signs of depression, as are mood swings, social withdrawal, and unwillingness to talk.

DIF: Cognitive Level: Application REF: 203 OBJ: 4 TOP: Signs of Depression KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

12. The home health nurse takes into consideration that as depression develops, the patient may begin to use excessive amounts of:

a.

antianxiety agents as a sedative.

b.

corticosteroids as a mood elevator.

c.

caffeine drinks as an energy booster.

d.

comfort foods as a morale booster.

ANS: A Antianxiety prescription drugs, along with tobacco and alcohol, are frequently used excessively as depression increases.

DIF: Cognitive Level: Knowledge REF: 203 OBJ: 5 TOP: Depression KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The nurse counseling a 75-year-old man who admits to the overuse of alcohol cautions him that alcohol has an increased effect on the older adult related to:

a.

lack of activity.

b.

altered nutritional intake.

c.

reduced kidney function.

d.

reduced lean muscle mass.

ANS: D

Reduced muscle mass decreases tolerance to alcohol, so relatively small amounts can cause alcohol toxicity.

DIF: Cognitive Level: Application REF: 203-204 OBJ: 4 TOP: Alcohol Use KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. The home health nurse assesses the depressed 80-year-old widow carefully for signs of substance abuse; indicators of substance abuse can easily be missed because these signs:

a.

occur only in the late evening or nighttime.

b.

are not particularly harmful to the older adult.

c.

mimic changes anticipated with the aging process.

d.

are disguised by the patient.

ANS: C Many signs that would alert the nurse to the possibility of substance abuse can be mistaken for changes associated with aging—unsteady gait, forgetfulness, sleep disturbances, and incontinence.

DIF: Cognitive Level: Application REF: 203-204 OBJ: 3 TOP: Signs of Substance Abuse KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 15. The long-term care facility nurse is aware that the resident most at risk for suicide related to depression is the:

a.

70-year-old man with diabetes.

b.

75-year-old woman with chronic obstructive pulmonary disease.

c.

80-year-old woman with a bipolar disorder.

d.

85-year-old man with schizophrenia.

ANS: C Persons with affective disorders are most at risk for suicide related to depression.

DIF: Cognitive Level: Analysis REF: 203 OBJ: 6 TOP: Suicide Risk KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 16. The home health nurse interviews the 70-year-old male patient about possible suicidal ideation after the patient:

a.

asks for assistance in writing a will.

b.

voices the intention to visit his brother.

c.

donates excess clothing to charity.

d.

asks the young widow next door for a dinner date.

ANS: A Making or altering a will is an indication of suicidal ideation.

DIF: Cognitive Level: Application REF: 203 OBJ: 6 TOP: Suicidal Ideation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

17. The pretty 70-year-old woman who had a stroke 3 months ago has a body image disturbance related to her spastic right arm and contracted fingers of the right hand. The nurse can assist the patient to improve her damaged body image by:

a.

teaching her to write with her left hand.

b.

placing articles within easy reach of her left hand.

c.

helping her select colorful scarves or accessories to cover her right arm.

d.

showing her massage techniques to increase circulation in her right arm.

ANS: C The selection of colorful accessories to cover the arm will help with her damaged body image.

Learning to write with the left hand, learning massage techniques, and being able to reach items are good nursing care but do nothing for enhancement of body image.

DIF: Cognitive Level: Analysis REF: 205 OBJ: 10 TOP: Altered Body Image KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 18. The newly admitted 80-year-old female resident who sits in her room and stares at the TV watching cartoons can be supported to maintain her self-esteem by:

a.

encouraging her to participate in self-care activities.

b.

suggesting that she change the channel to an intellectually stimulating program.

c.

giving her privacy until she becomes accustomed to the long-term care facility.

d.

arranging for a meal tray rather than having her eat in the dining room.

ANS: A Participation in self-care activities increases self-esteem and independence and puts the resident in control of her appearance.

DIF: Cognitive Level: Application REF: 206 OBJ: 10 TOP: Support to Self-Esteem KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 19. The 75-year-old woman newly admitted to a long-term care facility seems fearful of her surroundings and is frequently tearful, saying, “I don’t know what to do!” The nurse can help allay her fear by:

a.

helping her identify and verbalize her specific fears.

b.

assuring the resident that she has nothing to be afraid of.

c.

keeping the light on in the room 24 hours a day.

d.

playing quiet music on the resident’s radio.

ANS: A Identification of specific fears helps crystallize the resident’s concern and can help define the remedy.

DIF: Cognitive Level: Application REF: 208 OBJ: 10 TOP: Allaying Fear KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 20. The long-term facility nurse is aware that the anxious female resident can frequently be calmed by:

a.

stimulating her with group activity.

b.

sedating her to allow her to sleep.

c.

allowing time alone to control her anxiety.

d.

offering a diversion of quiet activity, such as a jigsaw puzzle.

ANS: D Involving the anxious resident in a pleasant activity such as music therapy, conversation, or a craft can allay anxiety. Stimulation frequently adds to anxiety, and sedation does not address the need for anxiety-reducing coping skills.

DIF: Cognitive Level: Application REF: 209 OBJ: 10 TOP: Anxiety KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 21. The nurse admits a 70-year-old female to the long-term care facility. While assisting with the assessment, the nurse notes that the patient’s husband died 2 months ago and that she has pain daily in her deformed hands from rheumatoid arthritis, needs assistance to dress herself, and has become incontinent of urine. The most appropriate nursing diagnosis at this time is:

a.

risk for disturbed self-perception.

b.

powerlessness.

c.

hopelessness.

d.

risk for suicide.

e.

impaired social reaction.

ANS: A

Patients at risk for disturbed self-perception have had conditions that have resulted in changes in their body image, body function, loss, recent relocation, and chronic pain.

DIF: Cognitive Level: Comprehension REF: 202 OBJ: 9 TOP: Self-Perception KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation MULTIPLE RESPONSE 1. The nurse is aware that self-identity is formed by a person’s attitudes about her or his . (Select all that apply.)

a.

values

b.

ambition

c.

interaction with others

d.

high self-esteem

e.

ability to control his or her life

ANS: A, C, D, E Ambition is not a part of self-identity.

DIF: Cognitive Level: Comprehension REF: 200 OBJ: 1 TOP: Self-Identity KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. To improve the self-image of the 80-year-old man who lives with his daughter due to a failing memory, the home health nurse urges that he take control of his . (Select all that apply.)

a.

attitude toward aging

b.

financial needs

c.

physical appearance

d.

time use

e.

relationships

ANS: A, C, D, E Persons who take control of the many aspects of their personal lives and well-being will have a good self-image.

DIF: Cognitive Level: Comprehension REF: 201 OBJ: 10 TOP: Taking Control KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. To achieve Erikson’s developmental stage of integrity, the older adult must develop . (Select all that apply.)

a.

a positive attitude toward aging

b.

positive self-esteem

c.

a manageable degree of illness

d.

a ready support system

e.

control of all life choices

ANS: A, B, C, D It is necessary for the older adult to have some degree of control but not complete control of life choices for the development of integrity rather than despair.

DIF: Cognitive Level: Comprehension REF: 202 OBJ: 2 TOP: Integrity KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 4. Self-concept of the older adult is influenced by the amount and degree of change experienced in his or her . (Select all that apply.)

a.

financial security

b.

social life

c.

physical health

d.

mobility

e.

cognitive function

ANS: A, B, C, D Cognitive function is not directly related to a person’s self-concept.

DIF: Cognitive Level: Comprehension REF: 202 OBJ: 2 TOP: Age-Influenced Changes KEY: Nursing Process Step: N/A MSC: NCLEX: Comprehension 5. The nurse lists indicators for the detection of substance abuse, which include . (Select all that apply.)

a.

urinary incontinence

b.

frequent falls

c.

unsteadiness

d.

altered sleep pattern

e.

stomach complaints

ANS: B, C, D, E Urinary incontinence is not a sign of possible substance abuse.

DIF: Cognitive Level: Knowledge REF: 203-204 OBJ: 7 TOP: Signs of Substance Abuse KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The nurse, who is aware that a sense of powerlessness is related to loss of control, can help reduce this perception by . (Select all that apply.)

a.

allowing the patient to make choices whenever possible

b.

assisting the patient to perform all self-care activities

c.

respecting the patient’s right to refuse treatment

d.

explaining all procedures ahead of time

e.

adapting the environment to enhance self-care

ANS: A, C, D, E Assisting the patient in all self-care activities is going to increase the perception of powerlessness.

DIF: Cognitive Level: Comprehension REF: 210 OBJ: 10 TOP: Powerlessness KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. The nurse knows that a patient’s self-perception is influenced most significantly by his or her . (Select all that apply.)

a.

family support

b.

ethnic heritage

c.

health status

d.

financial status

e.

sense of independence

ANS: A, C, D, E A patient’s sense of independence is the most significant aspect of self-perception.

DIF: Cognitive Level: Comprehension REF: 202 OBJ: 1 TOP: Self-Perception KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

8. The nurse notices there has been a change in the behavior of an 84-year-old home patient over the past few weeks. Methods used to assess his self-perception and self-concept include . (Select all that apply.)

a.

observing his physical appearance

b.

monitoring for changes in his vital signs

c.

encouraging him to verbalize his feelings

d.

observing for changes in activities

e.

participating in group activities

ANS: A, B, C, D Patients’ self-perception is not assessed by having them participate in group activities.

DIF: Cognitive Level: Comprehension REF: 203 OBJ: 7 TOP: Self-Perception KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

Chapter 12: Roles and Relationships Basic Geriatric Nursing, 7th Edition Chapter 12: Roles and Relationships Test Bank MULTIPLE CHOICE 1. The nurse defines a role as a(n):

a.

positive standard of behavior.

b.

accepted behavior standard.

c.

sexually linked standard.

d.

unchangeable standard.

ANS: B A role is a socially accepted behavior standard; roles are not always positive or unchangeable.

DIF: Cognitive Level: Knowledge REF: 214 OBJ: 1 TOP: Role Definition KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse is aware that the status of any role is based on:

a.

age.

b.

responsibility.

c.

society.

d.

health.

ANS: C The society in which the role is assumed delegates the value or status of that role. In some societies, advanced age is valued and given high status; in others, advanced age is not given status and the role is negative.

DIF: Cognitive Level: Analysis REF: 214 OBJ: 1 TOP: Role Status KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse points out that a homogeneous society is one in which members:

a.

share a common cultural history.

b.

are diverse in role expectation.

c.

have conflicted role status.

d.

may choose or change role performance.

ANS: A A homogeneous society is one that is simple and uncomplicated, in which all members share the same culture and role expectations.

DIF: Cognitive Level: Comprehension REF: 215 OBJ: 1 TOP: Homogeneous Society KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

4. The man who has the role of father, husband, professional businessman, son, and community leader may experience:

a.

role confusion.

b.

isolation.

c.

internal role conflict.

d.

diminished self-esteem.

ANS: C The assumption of multiple roles results in conflicts because the individual roles require time and behavioral modes that may conflict with each other. For example, the behaviors that a self-directed businessman may find useful in running a successful business may conflict with being the obedient son or caring husband.

DIF: Cognitive Level: Analysis REF: 215 OBJ: 1 TOP: Internal Role Conflict KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 5. The nurse is aware that the older man who retires from his work and changes his role status will have fewer adjustment problems primarily on the basis of whether he:

a.

is financially secure.

b.

has other roles and relationships.

c.

is healthy.

d.

has a supportive family.

ANS: B Other significant roles can take the place of the role of an employed worker. The fewer roles one has, the greater the impact of retirement. Finances, health, and family are important, but not as significant to the self-image as having other satisfying roles.

DIF: Cognitive Level: Application REF: 216 OBJ: 2 TOP: Impact of Retirement KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The nurse assesses that although the college professor has retired, he still perceives himself as an educator and retains his academic title and professional association membership as a support to his:

a.

altered self-image.

b.

unchanged role as an educator.

c.

substitution for employment.

d.

habitual professional behavior.

ANS: A The loss of the active teaching position is a threat to the self-image. The retention of his academic title and membership in his professional organization is a way of coping with his retirement status.

DIF: Cognitive Level: Analysis REF: 216 OBJ: 2 TOP: Impact of Retirement KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. The nurse identifies the older adult who is most likely to experience problems with role changes as the:

a.

65-year-old grandmother who cares for her grandchildren while the mother works.

b.

70-year-old retired business owner who comes to help his son run the business.

c.

75-year-old retired physician who volunteers at a medical screening clinic.

d.

80-year-old retired school administrator who takes educational foreign cruises several times a year.

ANS: B The father who comes to work to “advise” his son is the most at risk for role conflict problems, because he has not completely given up his role as owner. This will conflict with his role as a father.

DIF: Cognitive Level: Analysis REF: 216 OBJ: 5 TOP: Impact of Retirement KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 8. The recently widowed 65-year-old man has told the nurse that he is so lost without his wife that he is planning to retire, sell his home, and move to a retirement village in another state. The nurse is aware that such a plan is:

a.

positive, because it represents a new beginning.

b.

positive, because it allows him more time to resolve his grief.

c.

risky, because he is giving up significant supports to his self-image and grief resolution process.

d.

negative, because he has not thought his plan through.

ANS: C The decision is risky because loss of home, employment, and circle of friends as support puts his self-image at risk; so many useful roles are going to be given up. The nurse is not in a position to evaluate how well he has thought out his plan. More time to resolve grief and the launching of a “new beginning” without support may not be beneficial.

DIF: Cognitive Level: Analysis REF: 217 OBJ: 5 TOP: Loss of Spouse KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. The older adult asks the nurse what is meant by the term roleless role. The nurse explains that it refers to persons who perceive:

a.

that the roles that gave life meaning are gone.

b.

“old age” as freedom to design new roles and relationships.

c.

that roles must be maintained, regardless of their lack of significance.

d.

that roles can be altered to meet and diminish damage to the self-image.

ANS: A The concept of the roleless role defines persons who view roles that were meaningful to them, such as spouse, parent, friend, or active worker, are gone.

DIF: Cognitive Level: Application REF: 217 OBJ: 4 TOP: Roleless Role KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. The nurse recognizes that the bereaved widow has entered the searching and yearning stage of grief when she exhibits:

a.

renewed interest in social activities.

b.

signs of depression.

c.

making plans for the future.

d.

denial of the loss of her husband.

ANS: B Depressive behavior is a cardinal indicator of the searching and yearning phase of grief.

DIF: Cognitive Level: Application REF: 218, Table 12-1 OBJ: 5 TOP: Stages of Grief KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. When the home health nurse suggests a grief resolution group to the older woman who was widowed 6 months ago, the widow furiously states, “I don’t want or need any help! I want my husband back!” The nurse recognizes this behavior as being characteristic of the grief stage of:

a.

shock.

b.

searching.

c.

disorientation.

d.

reorganization.

ANS: C The stage of disorientation is characterized by resistance to seeking help and irritability.

DIF: Cognitive Level: Application REF: 218, Table 12-1 OBJ: 5 TOP: Grief Stages KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. The nurse is concerned about the 80-year-old man who is exhibiting behaviors characteristic of dysfunctional grieving, such as verbalizing after the death of his wife.

a.

despair 3 months

b.

guilt and self-doubt 4 months

c.

a sense of disorganization 6 months

d.

a sense of depression and despair 1 year

ANS: D Sense of depression and despair after 1 year of bereavement may indicate dysfunctional grief.

DIF: Cognitive Level: Analysis REF: 218, Table 12-1 OBJ: 5 TOP: Dysfunctional Grieving KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The home health nurse helps a grieving widow to start grief resolution by:

a.

distracting her with social conversation.

b.

encouraging her to verbalize her grief.

c.

pointing out behaviors that are not helpful to grief resolution.

d.

focusing on her loneliness and loss.

ANS: B Verbalization, acknowledgment, and confrontation of grief initiate problem solving for grief resolution.

Encouraging the widow to focus on the negative aspects of loss and loneliness reinforce negative

ideation. Pointing out behaviors that are not helpful and distraction with social conversation are not directed at grief resolution.

DIF: Cognitive Level: Application REF: 219 OBJ: 7 TOP: Grief Resolution KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. Nurses may find dealing with grieving persons difficult because nurses:

a.

avoid discussing sources of grief.

b.

believe that intervention is usually not helpful.

c.

have their own unresolved grief.

d.

believe that grief is personal and should be dealt with independently.

ANS: A The natural desire to avoid grieving persons and reluctance to intervene cause nurses problems with helping grieving patients.

DIF: Cognitive Level: Comprehension REF: 219 OBJ: 7 TOP: Intervention for Grief Resolution KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 15. The long-term care facility nurse can promote social contact and interaction most effectively by:

a.

making a telephone available for family contact.

b.

posting a list of activities on the bulletin board.

c.

telling the patient about social rooms in the facility.

d.

accompanying the patient to a craft activity.

ANS: D The proactive intervention combines the best of all interventions: one-on-one contact, showing interest, and providing support to the patient.

DIF: Cognitive Level: Knowledge REF: 220 OBJ: 7 TOP: Encouraging Social Interaction KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 16. A 59-year-old construction worker living with his divorced son and 9-year-old grandson was admitted to the hospital 3 days ago with a massive heart attack. His son is out of town on a business trip and has been unable to visit him. His grandson had to go stay with a friend. The social worker tells the nurse that the son stated he will not be able to care for his father when he gets out of the hospital and does not know how he will afford the skilled nursing facility. The most appropriate nursing diagnosis is:

a.

impaired social interaction

b.

dysfunctional grieving

c.

social isolation

d.

interrupted family process

ANS: D The family process has been interrupted due to a change in the patient’s health. There has been a change in the roles and relationship with the son. The patient is now dependent on the son.

DIF: Cognitive Level: Analysis REF: 220 OBJ: 6

TOP: Interrupted Family Process KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 17. Which stage of grief usually resolves after approximately 2 weeks?

a.

Disorientation

b.

Shock and numbness

c.

Reorganization

d.

Searching and yearning

ANS: B The stage of grieving known as shock and numbness usually resolves within the first 2 weeks.

DIF: Cognitive Level: Analysis REF: 218, Table 12-1 OBJ: 5 TOP: Grief Stages KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 18. Which stage of grief usually resolves after approximately 2 weeks to 4 months?

a.

Disorientation

b.

Shock and numbness

c.

Reorganization

d.

Searching and yearning

ANS: D The stage of grieving known as searching and yearning usually resolves between 2 weeks and 4 months.

DIF: Cognitive Level: Analysis REF: 218, Table 12-1 OBJ: 5 TOP: Grief Stages KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 19. Which stage of grief usually resolves after approximately 4 to 7 months?

a.

Disorientation

b.

Shock and numbness

c.

Reorganization

d.

Searching and yearning

ANS: A The stage of grieving known as disorientation usually resolves after 4 to 7 months.

DIF: Cognitive Level: Analysis REF: 218, Table 12-1 OBJ: 5 TOP: Grief Stages KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 20. Which stage of grief may last up to 2 years?

a.

Disorientation

b.

Shock and numbness

c.

Reorganization

d.

Searching and yearning

ANS: C The stage of grieving known as reorganization may last up to 18 to 24 months.

DIF: Cognitive Level: Analysis REF: 218, Table 12-1 OBJ: 5 TOP: Grief Stages KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 21. The nurse knows that relationships in which many subcultures interact are described as:

a.

homogeneous.

b.

long term.

c.

impersonal.

d.

superficial.

ANS: A Homogeneous is a term used to describe the members’ roles and their culture experience.

Characteristics of a relationship include being short or long term, personal, impersonal, intimate, or superficial and are affected by role changes.

DIF: Cognitive Level: Comprehension REF: 215 OBJ: 1 TOP: Relationships KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation MULTIPLE RESPONSE

1. The nurse understands that role standards describe not only behavioral expectations but also expectations about role-appropriate . (Select all that apply.)

a.

housing

b.

clothing

c.

choice of vehicle

d.

family size

e.

support system

ANS: A, B, C, D A support system is not a role-appropriate expectation. The other options are expected standards for a set role.

DIF: Cognitive Level: Comprehension REF: 214 OBJ: 1 TOP: Role Expectations KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse is aware that an older adult may become socially isolated related to the loss of . (Select all that apply.)

a.

a spouse

b.

friends to death or relocation

c.

health

d.

home

e.

culture

ANS: A, B, C, D An individual’s culture does not have an influence on social isolation. Social isolation is related to the separation from family and friends, change in health, self-image, and financial limitations.

DIF: Cognitive Level: Knowledge REF: 217 OBJ: 5 TOP: Factors of Social Isolation KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse explains that grief is a normal response to the loss of apply.)

a.

loved ones

b.

professional roles

c.

dependence

d.

health

e.

relationships

. (Select all that

ANS: A, B, D, E The loss of independence, not dependence, is capable of stimulating a grief response that must be resolved in order to regain emotional equilibrium.

DIF: Cognitive Level: Knowledge REF: 217 OBJ: 5 TOP: Grief Response KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The nurse reassures the grieving patient that ready sources of support are available from . (Select all that apply.)

a.

friends

b.

family

c.

self-help magazines

d.

support groups

e.

therapist

ANS: A, B, D, E Friends, family, support groups, and therapy are all viable resources for grief resolution.

DIF: Cognitive Level: Knowledge REF: 219 OBJ: 7 TOP: Grief Resolution Resources KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. Methods that the nurse can use to assess dysfunctional grieving in the older adult include . (Select all that apply.)

a.

asking the patient to describe his or her relationship within the family

b.

observing the behavior of the patient when family members and friends come to visit

c.

asking questions about the patient’s profession and work history

d.

observing for changes in eating habits

e.

monitoring for changes in mental status

ANS: A, B, D, E Asking questions related to profession and work history may reveal the patient’s role and perceived self-image. Questions aimed at their work relationships, feelings about retirement, and concerns over loss of a job will aid in assessing for dysfunctional grief. Patients may completely avoid their support systems, lose interest in activities, and be unable to concentrate.

DIF: Cognitive Level: Knowledge REF: 218 OBJ: 4 TOP: Dysfunctional Grief KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation COMPLETION 1. The nurse uses a diagram to depict roles.

, which is a term for interaction between different

ANS: relationships DIF: Cognitive Level: Comprehension REF: 214 OBJ: 1 TOP: Relationship Definition KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. A society that has numerous subcultures with different or conflicting expectations is said to be a(n) society.

ANS: heterogeneous DIF: Cognitive Level: Knowledge REF: 215 OBJ: 1 TOP: Heterogeneous Society KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

Chapter 13: Copin and Stress Basic Geriatric Nursing, 7th Edition Chapter 13: Copin and Stress Test Bank MULTIPLE CHOICE 1. The nurse is aware that stress-related physical, behavioral, and cognitive changes are more likely to occur when the stress:

a.

has a sudden onset.

b.

is low level but constant.

c.

is varied and cumulative.

d.

is suppressed or denied.

ANS: C An accumulation of a variety of stressors is most likely to cause physical, behavioral, or cognitive changes.

DIF: Cognitive Level: Comprehension REF: 224 OBJ: 1 TOP: Stressors KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse is aware that in the first stage of the general adaptation syndrome (GAS), the body responds by:

a.

decreasing the heart rate.

b.

constricting peripheral vessels.

c.

decreasing blood glucose levels.

d.

decreasing blood pressure.

ANS: B The body’s response during the alarm phase of the GAS is to increase heart rate and glucose levels, constrict peripheral vessels to increase the blood pressure, and supply more blood to the brain to ready the body to be in the fight-or-flight mode.

DIF: Cognitive Level: Comprehension REF: 226, Table 13-2 OBJ: 2 TOP: General Adaptation Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. An extremely stressed woman is in the emergency department after a car wreck. She is breathing rapidly and complains of dizziness and tingling in her extremities. She says, “I think I’m having a heart attack!” The nurse recognizes these complaints as being related to:

a.

a transient ischemic attack.

b.

hyperventilation.

c.

hypotension.

d.

asthma.

ANS: B An increased respiratory rate associated with stress can lead to hyperventilation, with its attendant distressing symptoms.

DIF: Cognitive Level: Application REF: 226, Table 13-2 OBJ: 2 TOP: Hyperventilation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The student sitting in class waiting for the final examination develops nausea and excessive gas.

The nursing instructor is aware that these symptoms are caused by a stress-related:

a.

increase in the blood glucose level.

b.

release of hormones.

c.

reduction of peristalsis.

d.

decrease in adrenalin.

ANS: C The stress response of decreased peristalsis will cause abdominal distention, nausea, and gas. The continued response can result in constipation.

DIF: Cognitive Level: Application REF: 226, Table 13-2 OBJ: 2 TOP: Gastrointestinal Stress Response KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse recognizes a stress-related urinary symptom when the patient complains:

a.

“I have to urinate every 10 minutes, and there are only a few drops.”

b.

“I haven’t had to urinate for the past 8 hours.”

c.

“I void large amounts of urine every 2 hours.”

d.

“My urine has absolutely no color. It looks like water.”

ANS: A Frequent voiding of only a small amount of urine is an indicator of stress.

DIF: Cognitive Level: Application REF: 226, Table 13-2 OBJ: 2 TOP: Urinary Stress Response KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse explains that mild stress can cause a person to be:

a.

indecisive.

b.

excessively alert.

c.

unable to focus.

d.

ineffective in problem solving.

ANS: B Mild stress allows the person to be hyperalert, focused, and able to learn and solve problems. As stress increases, these abilities deteriorate.

DIF: Cognitive Level: Application REF: 225 OBJ: 2 TOP: Mild Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

7. The nurse explains that in the general adaptation syndrome (GAS), after the first alarm reaction has been successfully resolved, the following stage, when the body systems return to normal, is the state of:

a.

regeneration.

b.

resistance.

c.

restoration.

d.

reorganization.

ANS: B Resistance is the stage of the GAS in which body systems return to normal after the fight-or-flight mode.

DIF: Cognitive Level: Comprehension REF: 224 OBJ: 2 TOP: General Adaptation Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. An 80-year-old man recently became widowed, moved into a long-term care facility, and had to quit driving. He complains of fatigue and is irritable when questioned about his health. The nurse should:

a.

suggest he take a daytime nap and go to bed early.

b.

report the complaints as expected adjustments to relocation.

c.

approach him to talk about his perceptions related to his relocation.

d.

suggest that he find some quiet time in the facility’s library and read a book.

ANS: C Stress can cause fatigue and irritability. The approach from the nurse can initiate dialogue relative to his situation and his reaction to it.

DIF: Cognitive Level: Application REF: 225 OBJ: 8 TOP: Emotional Signs of Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. The nurse assesses a behavior as a sign of depression in the new admission to a long-term care facility when the resident exhibits disorganization and:

a.

frequently comes to breakfast only partially dressed.

b.

eats excessive amounts of food at mealtime.

c.

socializes with only three or four other residents.

d.

arranges daily activities in order to able to watch Jeopardy at 4:30.

ANS: A Depressive behaviors are signaled by disorganization, making frequent errors, and leaving tasks incomplete because of preoccupation with depression.

DIF: Cognitive Level: Application REF: 226 OBJ: 2 TOP: Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 10. The nurse is aware that physical illness increases stress in many older adults because physical illness:

a.

is an acceptable reason to request relief.

b.

takes away energy to cope with new stressors.

c.

stimulates the family to be more attentive.

d.

most often has a clear pharmaceutical remedy.

ANS: B Physical illness drains energy that might otherwise be mobilized to cope with stress. Many older adults think that it is acceptable to request assistance with a physical illness, the family is more attentive with the presence of a physical illness, and physical illnesses can have pharmaceutical relief, but none of those facts explain the reduced ability to cope with stress.

DIF: Cognitive Level: Analysis REF: 227 OBJ: 2 TOP: Illness and Stress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. The long-term care facility nurse is assessing a newly admitted older adult who has become active in the facility, goes to every activity, carefully makes her bed every day, does jigsaw puzzles, and chats with tablemates at mealtime. The new resident is using the defense mechanism of:

a.

projection.

b.

rationalization.

c.

intellectualization.

d.

substitution.

ANS: D Substitution prompts the person to substitute activity to reduce stress, a healthy and helpful mechanism.

DIF: Cognitive Level: Analysis REF: 227 OBJ: 3 TOP: Defense Mechanisms KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. The nurse is aware that the use of a defense mechanism is a normal response to stress and only becomes problematic if the patient uses:

a.

more than one defense mechanism at a time.

b.

the defense mechanism longer than 1 week.

c.

the defense mechanism excessively.

d.

the defense mechanism until a more durable coping mechanism is formed.

ANS: C Excessive or prolonged use of a defense mechanism to avoid dealing with stress is not a healthy use of defense mechanisms.

DIF: Cognitive Level: Comprehension REF: 227 OBJ: 3 TOP: Defense Mechanisms KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. The nurse explains that problem-focused coping strategies are based on the ability to:

a.

eliminate the cause of stress.

b.

deny the cause of stress.

c.

repress the response to stressors.

d.

use prescription drugs to alter perception of the problem.

ANS: A Elimination or changing the perception of the problem is the objective of problem-focused stress resolution strategies.

DIF: Cognitive Level: Comprehension REF: 228 OBJ: 3 TOP: Coping Strategies KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. The 80-year-old man who is experiencing stress because visual loss has caused him to quit driving says, “I have friends and family who will be my transportation. I can still get around and I’ll have entertaining company.” He is using the problem-solving method of:

a.

confrontation.

b.

escape.

c.

emotional distancing.

d.

avoidance.

ANS: C Emotional distancing requires that the patient change his or her attitude toward the stressor.

DIF: Cognitive Level: Analysis REF: 228 OBJ: 3 TOP: Emotional Distancing KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 15. The nurse clarifies that older adults who have used effective coping skills during their younger years will:

a.

continue to use the same skills without modification.

b.

modify old skills and develop new ones.

c.

be at a loss when different types of stresses present themselves.

d.

be resistant to learning new skills.

ANS: B Persons who have developed coping skills at a younger age will modify them and develop new skills.

DIF: Cognitive Level: Application REF: 228 OBJ: 8 TOP: Coping Skills KEY: Nursing Process Step: Implementation MSC: NCLEX: Comprehension 16. The timid, newly admitted 84-year-old widow has stayed in her room at the long-term care facility listening to her radio, which is playing loud jazz, and has been lying in bed fully clothed. To help her reduce her stress related to relocation, the nurse should:

a.

insist that she come out and interact with other residents.

b.

turn her radio to a more soothing station.

c.

bring two other residents into the room to socialize with her.

d.

encourage her to verbalize feelings related to relocation.

ANS: D Verbalization of concerns allows residents to identify them and deal with them more effectively.

DIF: Cognitive Level: Application REF: 228 OBJ: 8 TOP: Interventions to Reduce Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation MULTIPLE RESPONSE 1. The nurse explains that as stress increases, the person will experience that apply.)

a.

widened focus

b.

decreased problem-solving ability

c.

indecisiveness

d.

irrational behavior

e.

attention to detail

. (Select all

ANS: B, C, D As stress increases, the focus narrows, with no attention to detail, and problem-solving skills decrease, which leads to irrational behavior and indecisiveness.

DIF: Cognitive Level: Application REF: 225 OBJ: 2 TOP: Cognitive Signs of Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The long-term care facility nurse carefully assesses the newly admitted older adult for signs of depression, which include . (Select all that apply.)

a.

appetite changes

b.

weight loss

c.

complaints of minor physical ailments

d.

sleep disturbances

e.

taking part in only one social activity a day

ANS: A, B, C, D Older adults do not always present with the classic signs of depression because they may feel that they should deal with it independently, but they will have minor physical complaints. Disturbances in intake and sleep are also classic signs of depression. Voluntary socialization is not a sign of depression.

DIF: Cognitive Level: Application REF: 226, Box 13-1 OBJ: 2 TOP: Depression Related to Stress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse is aware that depression is a common symptom in older adults admitted to a long-term care facility because many residents believe that they have lost control of their lives and . (Select all that apply.)

a.

their usual coping skills have been overwhelmed

b.

they think that they have no family support

c.

they have self-knowledge that will enable them to cope with new situations

d.

they find support of self-worth through activities and making new friends

e.

they actively seek assistance to reduce depression

ANS: A, B Relocation is often overwhelming and can cause persons to feel abandoned. Seeking activities and social contacts, developing new coping skills, and asking for assistance with depression are not signs of depression, but of recovery.

DIF: Cognitive Level: Application REF: 226 OBJ: 2 TOP: Depression KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The nurse encourages a patient to use the problem-focused approach to reduce stress to . (Select all that apply.)

a.

confront a stressor

b.

use emotional distancing to alter perception of the stressor

c.

develop alternative coping skills

d.

identify all stressors

e.

practice a strategy with small stressors

ANS: A, B, C, E With the problem-focused approach, a single stressor needs to be identified, and a specific strategy for solution designed.

DIF: Cognitive Level: Analysis REF: 228 OBJ: 3 TOP: Problem-Focused Coping Strategies KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The nurse cautions that the use of avoidance is an effective stress reducer if all that apply.)

a.

the stressor has great personal significance

b.

avoidance does not affect the outcome of the event

c.

the stressor is not a frequently recurring event

d.

continued avoidance does not add stress

e.

avoidance does not diminish the self-image

. (Select

ANS: B, C, D, E Avoidance is helpful if it does not affect the outcome, the stressor is not a frequently occurring event, and if avoidance does not add stress or diminish the self-image.

DIF: Cognitive Level: Analysis REF: 227 OBJ: 3 TOP: Avoidance KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The newly admitted male resident is brought into the care-planning session so that he can have the benefit of . (Select all that apply.)

a.

maintaining some degree of control of his care

b.

rejecting the care plan

c.

voicing his preferences

d.

improving his problem-solving capabilities

e.

gaining insight to overall goals of care

ANS: A, C, E Participation in care planning does not allow outright rejection of the plan, nor will it necessarily improve problem-solving skills.

DIF: Cognitive Level: Application REF: 231 OBJ: 8 TOP: Care Planning KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. The nurse is enthusiastic about the effects of geriatric massage, which include . (Select all that apply.)

a.

improved circulation

b.

increased range of motion

c.

reduction of anxiety

d.

increased sexual potency

e.

improved mobility

ANS: A, B, C, E Sexual potency is not enhanced by geriatric massage.

DIF: Cognitive Level: Application REF: 228 OBJ: 8 TOP: Geriatric Massage KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nurse introduces several methods for coping with stress to a group of older adults at a senior citizens center. These methods include . (Select all that apply.)

a.

meditation

b.

talking with family and friends

c.

swimming

d.

alcohol use in moderation

e.

massage therapy

ANS: A, B, C, E The use of alcohol does not relieve stress but may be used in response to a stressful situation.

Alcohol use can lead to abuse in some older adults. The safe level of alcohol decreases in the elderly. Physical activity in moderation, relaxation techniques, and viable support systems provide positive interventions to cope with stress.

DIF: Cognitive Level: Application REF: 228 OBJ: 6 TOP: Methods of Relieving Stress KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse informs a group of nursing students working in the geriatric psychiatric unit that older adults are at greater risk for stress-related problems if they have . (Select all that apply.)

a.

a chronic illness

b.

suffered the loss of a spouse

c.

relocated

d.

reduced income

e.

general adaptation syndrome

ANS: A, B, C, D A chronic illness, the loss of a spouse, relocation, and reduced income are stress-producing events.

General adaptation syndrome is a theory.

DIF: Cognitive Level: Application REF: 227 OBJ: 5 TOP: Risk For Stress-Related Problems KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse explains that a Japanese stress reduction strategy that increases the energy of life force by laying-on of hands is called .

ANS: Reiki DIF: Cognitive Level: Comprehension REF: 228 OBJ: 3 TOP: Alternative Therapies KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse explains that according to the general adaptation syndrome theory, if coping skills do not resolve the initial alarm response, the body becomes depleted of its reserve and the person enters the stage.

ANS: exhaustion DIF: Cognitive Level: Comprehension REF: 224 OBJ: 2 TOP: General Adaptation Syndrome KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 14: Values and Beliefs Basic Geriatric Nursing, 7th Edition Chapter 14: Values and Beliefs Test Bank MULTIPLE CHOICE 1. It is believed that a person’s value system is well established by age:

a.

5.

b.

8.

c.

10.

d.

12.

ANS: C The value system, developed in early childhood, is well established by the age of 10 years.

DIF: Cognitive Level: Knowledge REF: 234 OBJ: 1 TOP: Value System KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 2. The culturally sensitive nurse is aware that in caring for a patient with a different value system, the nurse should:

a.

be open and nonjudgmental.

b.

treat all patients the same without concern for their value system.

c.

explain the differences between the two value systems.

d.

abandon their own value system.

ANS: A Persons are prone to view those with a different value system from their own in a negative and prejudicial manner.

DIF: Cognitive Level: Comprehension REF: 236 OBJ: 1 TOP: Value Systems Differences KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. When the 80-year-old Orthodox Jewish man dies in the hospital, the nurse should:

a.

notify the rabbi to send a member of the synagogue to stay with the body.

b.

inform the mortuary about the desire of the patient to be cremated.

c.

prepare the body for the ritual bath by temple members before embalming.

d.

facilitate removal of the body because the burial must take place 48 hours after death.

ANS: A A synagogue member will come to pray and read scripture from the time of death to the time of burial, which must take place 24 hours after death. The reader will accompany the body to the morgue, mortuary, and burial site. Jewish persons are forbidden to be cremated or embalmed.

DIF: Cognitive Level: Analysis REF: 235, Cultural Considerations OBJ: 5 TOP: Jewish Culture KEY: Nursing Process Step: Implementation

MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. The nurse is careful not to remove the yarmulke from the head of the Jewish man during care because it is a symbol of:

a.

having been circumcised.

b.

the belief that God is higher than man.

c.

God’s endless love and protection.

d.

the justice of Talmudic law.

ANS: B The yarmulke is worn by Jewish men to remind them that God is higher than man.

DIF: Cognitive Level: Application REF: 235, Cultural Considerations OBJ: 4 TOP: Jewish Culture KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. When checking the diet trays, the nurse identifies a menu choice that would be culturally inappropriate for the Muslim patient as:

a.

fish and tomatoes.

b.

liver and onions.

c.

chicken and broccoli.

d.

pork chops and sweet potatoes.

ANS: D Muslims are forbidden to eat pork or pork products.

DIF: Cognitive Level: Application REF: 235, Cultural Considerations OBJ: 4 TOP: Muslim Beliefs KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The home health nurse caring for an 85-year-old Hispanic woman anticipates that the patient will want to seek health advice from the:

a.

local pharmacist for prescription drugs.

b.

folk healer (curandero).

c.

priest of her church.

d.

close family members.

ANS: B The curandero is a significant person to the older Hispanic adult for health matters. The use of folk remedies and nonprescription OTC drugs is common.

DIF: Cognitive Level: Comprehension REF: 235, Cultural Considerations OBJ: 4 TOP: Hispanic Beliefs KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. Included in the Native American’s spiritual beliefs is that:

a.

there is no life after death.

b.

all things in the world have a spirit.

c.

after death, the spirit stays as part of the tribe.

d.

the spirit world is the protector of health.

ANS: B Native Americans believe that all things have a spirit.

DIF: Cognitive Level: Comprehension REF: 235, Cultural Considerations OBJ: 4 TOP: Native American Beliefs KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. The nurse anticipates that the 80-year-old African American woman believes that her health will be improved by:

a.

eating fresh fruits and vegetables.

b.

daily Bible reading.

c.

a visit from her pastor to pray for her recovery.

d.

the close attendance of her family.

ANS: C A visit from the pastor and his prayers will improve her health perception. Illness is viewed as being caused by a lack of faith or the devil.

DIF: Cognitive Level: Application REF: 235, Cultural Considerations OBJ: 4 TOP: African American Beliefs KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. The basic and most important way for the nurse to become culturally sensitive is:

a.

interaction with persons of another culture.

b.

increasing personal knowledge of another culture.

c.

remaining open-minded.

d.

reading materials about other cultures.

ANS: B Open-mindedness and understanding of other cultures assist the nurse to work effectively with persons from a variety of cultures.

DIF: Cognitive Level: Analysis REF: 236 OBJ: 1 TOP: Cultural Sensitivity KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 10. The home health nurse is aware that the conservative economic values of the 85-year-old will lead the older adult to:

a.

use credit cards rather than cash.

b.

hoard old prescription drugs for later use.

c.

seek the care of a physician frequently.

d.

seek to qualify for food stamps.

ANS: B Older adults are “savers” and avoid outlay of money until it is absolutely necessary. They are prone to hoard drugs, delay medical care, and avoid debt of any type.

DIF: Cognitive Level: Analysis REF: 237 OBJ: 4 TOP: Economic Values KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 11. The nurse is aware that basic spiritual beliefs, regardless of culture, are based on:

a.

the presence of a supreme being.

b.

faith in an afterlife existence.

c.

a rigid code of behavior.

d.

the need for an organized church.

ANS: A The awareness of a supreme being is basic to all spiritual beliefs.

DIF: Cognitive Level: Comprehension REF: 237 OBJ: 1 TOP: Spiritual Values KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. The nurse provides space on the bedside table of a terminally ill Roman Catholic Hispanic woman for the religious objects that have spiritual meaning to her, which would be a:

a.

Koran and prayer mat.

b.

rosary and vial of holy water.

c.

Torah and prayer shawl.

d.

Bible and whole kernels of corn.

ANS: B The rosary and holy water are significant religious items for the Roman Catholic.

DIF: Cognitive Level: Analysis REF: 238 OBJ: 10 TOP: Religious Objects KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. In the spiritual assessment prompt SPIRIT, the R reminds the nurse to assess the patient for the need of:

a.

rituals.

b.

religious objects.

c.

rosary.

d.

religious reading materials.

ANS: A The “R” is the prompt to inquire about the need for any religious rituals.

DIF: Cognitive Level: Comprehension REF: 239, Box 14-1

OBJ: 7 TOP: Mnemonic for Spiritual Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 14. When the spiritual leader comes to visit the bedfast patient in a long-term care facility, the nurse can enhance the visit best by:

a.

taking the resident’s roommate to the dayroom.

b.

pulling the curtain for privacy.

c.

closing the door to the room.

d.

giving notice to the CNAs of the presence of the spiritual leader.

ANS: A Although all the options increase privacy, the best intervention is to have the roommate go somewhere else.

DIF: Cognitive Level: Analysis REF: 240 OBJ: 10 TOP: Privacy for Spiritual Counseling KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation MULTIPLE RESPONSE 1. The nurse is aware that a patient’s values reflect influences from apply.)

a.

religion

b.

philosophy

. (Select all that

c.

family

d.

financial status

e.

society

ANS: A, B, C, E Financial status does not play a part in the makeup of a person’s value system.

DIF: Cognitive Level: Knowledge REF: 234 OBJ: 1 TOP: Values KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 2. The nurse takes into consideration that values and beliefs set the framework for daily life for each individual and influence . (Select all that apply.)

a.

health practices

b.

perception of illness

c.

social status

d.

spouse selection

e.

morality

ANS: A, B, D, E Social status is not influenced by values and beliefs.

DIF: Cognitive Level: Comprehension REF: 234 OBJ: 1

TOP: Influence of Values KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 3. The nurse takes into consideration to include the five pillars of the Islamic faith in the care of the Muslim male, which include . (Select all that apply.)

a.

to make a confession of faith

b.

perform five daily prayers at the appropriate time

c.

observe Ramadan

d.

make a pilgrimage to Mecca

e.

to care for children

ANS: A, B, C, D The care of children is not one of the five pillars of the Islamic faith.

DIF: Cognitive Level: Comprehension REF: 235, Cultural Considerations OBJ: 4 TOP: Muslim Culture KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 4. In planning the care of a Muslim woman, the nurse will

a.

provide time for five daily prayers

b.

address all health questions to the husband

. (Select all that apply.)

c.

assign only female caregivers

d.

keep all cut flowers and greenery out of the room

e.

remind caregivers to be especially protective of the patient’s modesty

ANS: A, C, E Muslims observe five prayers daily. Women are extremely modest and usually request female caregivers.

DIF: Cognitive Level: Application REF: 235, Cultural Considerations OBJ: 10 TOP: Muslim Beliefs KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 5. The nurse is sensitive to the cultural beliefs of Native Americans; they practice rituals for the improvement of their health by creating harmony among . (Select all that apply)

a.

mind

b.

faith

c.

wellness

d.

spirit

e.

body

ANS: A, D, E

Faith and wellness are not part of the health ritual.

DIF: Cognitive Level: Comprehension REF: 235, Cultural Considerations OBJ: 4 TOP: Native American Culture KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 6. The home health nurse listens to the 94-year-old Italian man who lives with his daughter and her family when he verbalizes his frustrations about the conflict of his grandchildren’s values with his own, such as .(Select all that apply.)

a.

hairstyle and clothing

b.

lack of reverence for age and wisdom

c.

rejection of traditional ethnic foods

d.

process of selecting a spouse

e.

desire for education

ANS: A, B, C, D The value for education would not be in conflict with Old World values.

DIF: Cognitive Level: Application REF: 236 OBJ: 8 TOP: Intrafamily Cultural Conflict KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. The culturally sensitive nurse is alert for indications of spiritual distress in the older adult, which may be evidenced by . (Select all that apply.)

a.

expressions of the meaningless of life

b.

verbalizations of guilt about past behavior

c.

an expressed need to mend a broken relationship

d.

daily prayer to a supreme being

e.

diminished hope

ANS: A, B, C, E The feeling that life has no meaning and is hopeless, preoccupation with perceived guilt, and a need to mend relationships are indicators of spiritual distress.

DIF: Cognitive Level: Application REF: 239 OBJ: 8 TOP: Spiritual Distress KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 8. When the patient asks the nurse to pray for him because he does not know how to pray, the nurse assures him that a supreme being can hear a prayer of any type, such as prayer that is . (Select all that apply.)

a.

ritualized

b.

read from a holy book

c.

structured

d.

informal and conversational

e.

recited from childhood memory

ANS: A, B, C, D, E Prayer is anything that the person makes it, from formal ritualistic prayer to an informal conversation with the supreme being. All are prayers, and all are heard.

DIF: Cognitive Level: Comprehension REF: 239, Complementary and Alternative Therapies OBJ: 10 TOP: Prayer KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 9. While working with an older adult at a clinic, the nurse is aware that health practices include . (Select all that apply.)

a.

health promotion

b.

coping with illness

c.

health maintenance patterns

d.

spiritual support

e.

religious practices

ANS: A, B, C Health practices are those behaviors that show health promotion and maintenance and coping with illness. Spiritual and religious matters are not necessarily health practices but may influence them.

DIF: Cognitive Level: Comprehension REF: 234 OBJ: 3 TOP: Health Practices KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

10. During the admission process, the registered nurse makes a nursing diagnosis of spiritual distress. Which question(s) may help clarify the situation? (Select all that apply.)

a.

“What gives you meaning to life?”

b.

“Are there any spiritual objects that you want in your room?”

c.

“Do you want a particular spiritual counselor notified?”

d.

“Is there any special religious practice that you would want us to be aware of?”

e.

“What is your cultural background?”

ANS: A, B, C, D Asking about the cultural background can lead to stereotyping. Questions regarding the meaning of life, symbolic objects, counselors, and practices will help identify sources of conflict and desired spiritual assistance.

DIF: Cognitive Level: Application REF: 239, Critical Thinking OBJ: 9 TOP: Spiritual Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation COMPLETION 1. After the burial of a Jewish man who was a resident in a long-term care facility, along with his wife, the nurse is aware that his wife and family will observe , a 7-day period of mourning.

ANS: shivah DIF: Cognitive Level: Comprehension REF: 235, Cultural Considerations OBJ: 10 TOP: Shivah KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

2. The nurse explains that Muslims have a great reverence for their holy book, called the .

ANS: Koran; Qur’an DIF: Cognitive Level: Knowledge REF: 235, Cultural Considerations OBJ: 4 TOP: Muslim Beliefs KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation

Chapter 15 End-of-Life Care BASIC GERIATRIC NURSING 7th EDITION BY WILLIAMS Question 1 For individuals known to be dying by virtue of age and/or diagnosis, which sign indicates approaching death?

•

Increased restlessness

Explanation:

As the oxygen supply to the brain decreases, the client may become restless. As the body weakens, the client will sleep more and begin to detach from the environment. For many clients, refusal of food is an indication that they are ready to die. Based on decreased intake, urinary output generally decreases in amount and frequency.

Question 2 Which is one level of hospice care covered under Medicare and Medicaid hospice benefits, includes a 5-day inpatient stay, and is provided occasionally to relive the family caregivers?

•

Respite care

Explanation:

Inpatient respite care is a 5-day inpatient stay, provided on an occasional basis to relieve the family caregivers. Routine home care entails that all services provided are included in the daily rate to the hospice. Continuous care is provided in the home for management of a medical crisis. General inpatient care provides an inpatient stay for symptoms management that cannot be provided in the home.

Question 3 A nurse is providing in-home hospice care to a 75-year-old client with lung cancer.

The nurse determines that the client is eligible for Medicare hospice benefits based on which of the following?

•

Client has a life expectancy of 6 months or less.

Explanation:

Eligibility for the Medicare Hospice Benefit includes physician certification of a client as terminally ill, with a life expectancy of 6 months or less if the disease follows its

natural course. The condition must be considered or classified as terminal, not just serious and progressive. Although the presence of family members in the home is helpful, their presence is not a criterion for eligibility. Lack of other insurance also is not a criterion for eligibility.

Question 4 A nurse is providing care to a client experiencing symptoms associated with terminal illness. Which of the following would be most appropriate to use as a means for managing the client's symptoms?

•

Client's goals

Explanation:

When managing the symptoms of a client with a terminal illness, the client's goals take precedence over the clinician's goals to relieve all symptoms at all costs.

Although the length and invasiveness of the treatment may influence decision making, ultimately it is the client's goals that determine what will be done.

Question 5 Nursing students are reviewing information about the signs and symptoms of impending death. The students demonstrate the need for additional review when they identify which of the following as a sign?

•

Muscle wasting

Explanation:

Muscle wasting occurs as the client's condition deteriorates. It is not a sign of impending death. Mental confusion, reduced urinary output, and restlessness occur as a client approaches death.

Question 6 While offering end-of-life nursing care to a 72-year-old male with late stage bone cancer, the nurse visits him at home four times weekly. At each visit the nurse assess the client, monitoring the efficacy of pain medications, adjusting doses within physician ordered parameters and discussing potential needs with the client's spouse– who is the primary caregiver. What is another very important assessment the nurse performs in this home?

•

assessment of caregiver's physical and emotional health

Explanation:

A negative factor of home care is the burden it places on the primary caregiver. If prolonged, the role of primary caregiver can be very isolating and physically exhausting because the responsibility for providing care continues 24 hours a day, day after day. Home care nurses periodically need to assess the toll on the caregiver's physical and emotional health.

Question 7 While palliative care can be offered in a multitude of settings (home, inpatient hospice, etc.), there are instances where institutionally based palliative care is most appropriate. Which factors contribute to the decision of whether to use institutional palliative care?

•

All of the options are correct

Explanation:

Factors that influence the decision to use institutionally based palliative care include the following: The client's weakness or immobility causes him or her to require more assistance than can be provided at home; the client cannot manage elimination needs; the client has uncontrolled or inadequately controlled pain or nausea; the family cannot provide adequate care; the client requires too complex and demanding care; and, finally, the caregiver is too exhausted to provide care.

Question 8 The nurse evaluates that a dying client is in the anger stage of reacting to her prognosis. Which of the following statements is most consistent with this interpretation?

•

"I took care of myself and it's not fair that this has happened."

Explanation:

Option B reflects anger--the client feels that her situation is unfair and is reacting against the circumstances. Option A reflects denial; option C is bargaining; and option D is consistent with depression.

Question 9 The family members of a dying patient are finding it difficult to verbalize feelings and show tenderness for the dying person. Which of the following nursing interventions should a nurse perform in such situations?

•

Encourage the family members to express their feelings and listen to them in their frank communication.

Explanation:

Family members usually find it difficult to communicate frankly with a dying person.

By encouraging family members to express their feelings and listening to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying patient. It is not advisable for the nurse to encourage conversations on the impending death of the patient. Being a silent observer or encouraging the family members to spend time with the dying patient may not help the family members to express their feelings.

Question 10 While offering end-of-life nursing care to a 72-year-old client with late-stage bone cancer, the nurse visits the client at home four times weekly. The nurse assesses the client each visit, monitoring the efficacy of pain medications, adjusting doses within physician ordered parameters, and discussing potential needs with the client's spouse, who is the primary caregiver. What is another very important assessment the nurse performs in the client's home?

•

caregiver's physical and emotional health

Explanation:

A negative factor of home care is the burden it places on the primary caregiver. If prolonged, the role of primary caregiver can be very isolating and physically exhausting because the responsibility for providing care continues 24 hours a day, day after day. Home care nurses periodically need to assess the toll on the caregiver's physical and emotional health. Physician-assisted suicide is currently only legal in seven states. The nurse would not independently assess the client's attitudes about this controversial topic. If the client or the client's family brought this up, the nurse would inform the physician. Although the nurse may refer the client's family to appropriate resources to help them deal with stressors such as financial needs, this assessment would be secondary to the caregiver's physical and emotional health.

Question 11 The nurse is providing home care to a dying client and has noticed over the course of several weeks that the client’s daughter is usually quiet and withdrawn when in the client’s room. Which intervention should the nurse perform in this situation?

•

Sit with the client’s daughter privately and encourage her to express her feelings frankly.

Explanation:

Failure to verbalize feelings, express emotions, and show tenderness for the dying person is often a source of regret for grieving relatives. Therefore, families must feel that they can express their feelings with nurses who are compassionate listeners. If nurses encourage family members and listen to them in their frank communication, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. Families must feel that they can express their feelings with nurses who are compassionate listeners. Reminding a family member that their loved one will die soon shows a lack of compassion in this situation.

Although the client is the nurse’s main priority, it is the nurse’s role to encourage family members to identify strengths and express feelings as a method of coping with the death of their loved one. The response regarding making the father's final days happy ones shows a lack of caring on the part of the nurse.

Question 12 A client with advanced lymphoma is confused by the different options for advance directives. The nurse should communicate which of the following information to the client?

•

The Five Wishes document includes information on the way a client wishes to be treated at the end of life.

Explanation:

The Five Wishes document, created by the organization Aging with Dignity (2015), combines components of a living will with durable power of attorney for healthcare plus much more. It has been described nationwide as an innovative, comprehensive document that goes beyond medical issues because it deals with personal, emotional, and spiritual concerns of a person in the terminal stage before death. A living will must be witnessed by unrelated witnesses, none of whom are potential heirs or a personal healthcare provider. For ethical reasons, the client's physician or other healthcare workers may not be designated as durable power of attorney for healthcare. A living will does not describe every possible lifethreatening scenario, thus allowing the proxy to interpret the client's wishes in unique circumstances.

Question 13

Why might a client who is approaching death suddenly vomit?

•

intestinal distention

Explanation:

Intestinal distention may stimulate the vomiting center. Loss of sphincter control might cause incontinence of urine and stool but not vomiting. Low cardiac output causes urine volume to diminish and toxic waste products to accumulate. Hypoxia may lead to periods of apnea (no breathing).

Question 14 The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which nursing interventions should a nurse perform in such a situation?

•

Encourage the family members to express their feelings and listen to them in their frank communication.

Explanation:

Family members usually find it difficult to communicate frankly with a dying person.

By encouraging family members to express their feelings and listening to them as they frankly communicate, you may help family members feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members to express their feelings.

Question 15 A client diagnosed with a terminal illness appoints her oldest son as the authorized individual to make medical decisions on her behalf when she is no longer able to speak for herself. Which proxy directive is the patient using?

•

Durable power of attorney for health care

Explanation:

A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. It allows another individual to make medical decisions on the client's behalf. The other options are incorrect.

Question 16

Which action by the nurse demonstrates an effective method to assess the client and the client’s family’s ability to cope with end-of-life interventions?

•

Remaining silent, allowing the client and family to respond after asking a question related to end-of-life care

Explanation:

A key to effective listening includes allowing the client and family sufficient time to reflect and respond after asking a question. Hospice nurses with effective listening skills resist the impulse to fill the empty space in communication with talk, avoid the impulse to give advice, and avoid responses indicating, "I know just how you feel."

Question 17

See full question

Medicare and Medicaid hospice benefit criteria allow clients with a life expectancy of 6 months or less to be admitted to hospice. However, the median length of stay in a hospice program is just 21.3 days. Which reason explains the underuse of hospice care services?

•

Clients and families view palliative care as giving up

Explanation:

Clients often equate hospice with giving up and are reluctant to accept hospice care. Lack of fully credentialed and trained hospice nurses is not a barrier to hospice care. Lack of Medicare funding and lack of certification for hospice service providers have not been documented as barriers to access of hospice services.

Question 18 A patient with end-stage chronic obstructive pulmonary disease is admitted to a hospice facility and asks the admitting nurse, “How long will I be allowed to stay here?” What is the best response by the nurse?

•

“When your stay reaches 6 months, you will be recertified for a continued stay.”

Explanation:

Federal rules for hospices require that eligibility be reviewed periodically. Patients who live longer than 6 months under hospice care are not discharged, provided that their physician and the hospice medical director continue to certify that they

are terminally ill with a life expectancy of 6 months or less (assuming that the disease continues its expected course).

Question 19 A terminally ill patient in pain asks the nurse to administer enough pain medication to end the suffering forever. What is the best response by the nurse?

•

“I will notify the physician that the current dose of medication is not relieving your pain.”

Explanation:

Palliative sedation is distinguished from euthanasia and physician-assisted suicide in that the intent of palliative sedation is to relieve symptoms, not to hasten death.

Palliative sedation is most commonly used when the patient exhibits intractable pain, dyspnea, seizures, or delirium, and it is generally considered appropriate in only the most difficult situations.

Question 20 A terminally ill patient is admitted to the hospital. The patient grabs the nurse’s hand and asks, “Am I dying?” What response would be best for the nurse to give?

•

“Tell me more about what’s on your mind.”

Explanation:

In response to the question “Am I dying?” the nurse could establish eye contact and follow with a statement acknowledging the patient’s fears (“This must be very difficult for you”) and an open-ended statement or question (“Tell me more about what is on your mind”). The nurse then needs to listen intently, ask additional questions for clarification, and provide reassurance only when it is realistic.

Question 1 The family members of a dying client are finding it difficult to verbalize their feelings for and show tenderness to the client. Which intervention should a nurse perform in such a situation?

•

Encourage the family members to express their feelings and listen to them in their frank communication

Explanation:

Family members usually find it difficult to communicate frankly with a dying person.

When a nurse encourages family members to express their feelings and listens to them as they frankly communicate, family members may feel more prepared to carry on a similarly honest dialogue with the dying client. It is not advisable for the nurse to encourage conversations about the impending death of the client. Being a silent observer or encouraging the family members to spend time with the dying client may not help the family members express their feelings.

Question 2 A client has been declared to have a terminal illness. What intervention will a nurse perform regarding the final decision of a dying client?

•

Respect the client's and family members' choices

Explanation:

In the final decisions of a dying client, the nurse will present options for terminal care and respect the client's and family members' choices. Sharing emotional pain is a role in providing care and comfort to dying clients and their families. When the client has a living will, physicians must abide by the client's wishes. The nurse should ask the family members about spiritual care only if the client wants someone associated with his or her religion.

Question 3 Which is also known as a proxy directive?

•

Durable power of attorney for health care

Explanation:

A durable power of attorney for health care is also known as a health care power of attorney or a proxy directive. The other options are incorrect.

Question 4 A nurse who has just taken a new nursing position at an inpatient hospice begins to question if they are "strong enough" to withstand the continual dying of clients. The nurse's mentor relates the most effective method of dealing with client loss. What action is instrumental to being able to offer effective care and comfort to dying clients?

•

exploring personal mortality and feelings on death and dying

Explanation:

Healthcare providers must acknowledge death as the final stage of growth and development (Kübler-Ross, 1975). They also must explore their own mortality and feelings about dying and death. This is the only way that they can then provide care and comfort to dying clients and their families.

Question 5 Palliative care is a structured system for care delivery that has what as its aim?

•

To prevent and relieve suffering.

Question 6 Shortly after a client's death from a long-term illness, his daughter says to the nurse, "Things changed so suddenly. I told him yesterday how much I loved him but that it was OK to let go if that's what he wanted." The nurse would identify this as what phenomenon for the daughter?

•

Waiting for permission

Explanation:

Some clients seem to forestall dying when they feel that their loved ones are not yet prepared to deal with their death. This has been described as the waiting for permission phenomenon, because death often occurs shortly after a significant family member communicates that he or she is strong enough and ready to ‘‘let go.’’

Question 7 The spouse of a terminally ill client is confused by the new terminology being used during discussions regarding the client's treatment. The nurse should explain that palliative care is: •

care that will reduce the client's physical discomfort and manage clinical symptoms.

Explanation:

Palliative care is used in conjunction with other end-of-life treatments and has many principles. Its aim is to reduce physical discomfort and other distressing symptoms but does not alter a disease's progression. Palliative care is applicable early in the course of illness, in conjunction with other therapies that are intended to prolong life. Palliative care of a terminally ill client not only provides relief from

pain and other distressing symptoms but it integrates other facets of patient care as well, including psychological and spiritual aspects. Palliative care is part of hospice care.

Question 8 A nurse is providing hospice care in Portland, Oregon to a client with terminal liver cancer. The client confides to the nurse, “I’m in agony all the time. I want this to be over now—please help me.” Which interventions should the nurse implement?

Select all that apply.

•

Control the client's pain with prescribed medication.

•

Advise the client's physician of the client's condition.

•

Encourage the client to explain his or her wishes.

Explanation:

This client lives in Oregon, one of five states that have decriminalized physicianassisted suicide, the practice of providing a means by which a client can end his or her own life. This practice is controversial, with proponents arguing the client has a right to self-determination and a relief from suffering when there is no other means of palliation (Quill & Greenlaw, 2008). Opponents, on the other hand, find it contrary to the Hippocratic Oath. In this scenario, the nurse should determine exactly what the client is asking and then support his or her wishes. It is not the nurse's role to suggest physician-assisted suicide voluntarily, however.

Question 9 A patient is diagnosed with a terminal illness and has been given less than 6 months to live. What type of referral should the nurse make to assist this patient and family at home?

•

Hospice

Explanation:

Hospice is palliative care provided to terminally ill persons and their families in the last 6 months of the patient’s life. None of the other interventions would be as appropriate or effective for this patient.

Question 10

A patient’s family member asks the nurse what the purpose of hospice is. What is the best response by the nurse?

•

“It will enable the patient to remain home if that is what is desired.”

Explanation:

The goal of hospice is to enable the patient to remain at home, surrounded by the people and objects that have been important to him or her throughout life. The patient and family make up the unit of care. Hospice care does not seek to hasten death or encourage the prolongation of life through artificial means.

1. Which of the following nursing interventions will a nurse perform to transfer heat and

A) B) C) D) Ans:

improve circulation in a dying client?

Change the position frequently.

Gently massage the arms and legs.

Administer warm intravenous fluids.

Administer intramuscular injections.

B Feedback: A nurse should gently massage the client's arms and legs to transfer heat and improve circulation in a dying client. Changing the position frequently helps protect the client's skin from breakdown. Administering warm intravenous fluids and intramuscular injections will not help transfer heat and improve circulation in a dying client.

2. Which of the following should the nurse report so that the team can consider alternative

A) B) C) D) Ans:

nutritional and fluid administration routes for a dying client?

Altered gastrointestinal function Drop in blood pressure and rapid heart rate Weight loss and inadequate food intake Irregular eating habits C Feedback: The nurse should report weight loss and inadequate food intake so that the team can consider alternative nutritional and fluid administration routes for a dying client. The nurse need not report altered gastrointestinal function because it is a normal part of the dying process. A nurse should also not report a drop in blood pressure and rapid heart rate or irregular eating habits.

3. Which of the following nursing interventions should a nurse perform to promote the

A) B) C) D) Ans:

dignity and self-esteem of a dying client?

Communicate hopefulness.

Keep the client clean and well groomed.

Share emotional pain.

Help the client live according to his or her wishes.

B Feedback: A nurse should keep the client clean, well groomed, and free of unpleasant odors to promote his or her dignity and self-esteem. Although sharing emotional pain is an essential component of care for dying clients, it will not promote their dignity and selfesteem. Communicating hopefulness helps sustain hope in dying clients. Helping the client live according to his or her wishes is a feature of hospice care.

4. Which of the following interventions should the nurse perform to prevent drying of the

oral mucous membranes and lips in a dying client?

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A) B) C) D) Ans:

Place the client in a cool temperature.

Provide water to the client at regular intervals.

Provide the client with absorbent pads.

Provide oral care, ice chips, and petroleum jelly.

D Feedback: The nurse provides oral care, ice chips, and petroleum jelly because mouth breathing makes the oral mucous membranes and lips dry. Placing the client in a cool temperature and providing water to the client at regular intervals will not help prevent drying of the oral mucous membranes. Providing the client with absorbent pads is useful only when the client has lost bladder control and does not prevent drying of the mucous membranes.

5. Which of the following nursing interventions should be implemented for the dying client

A) B) C) D) Ans:

who is incontinent of urine, with associated skin breakdown, and exhibits a decreased level of consciousness?

Insertion of an indwelling catheter Use of absorbent pads Offering a bedpan every 4 hours Assisting the client to the commode every 2 hours A Feedback: The client may need an indwelling or external catheter, particularly if skin breakdown is a problem. The other options would not be appropriate for the dying client.

6. Which of the following is an appropriate intervention for the client with pulmonary

A) B) C) D) Ans:

edema?

Administer the prescribed sedative to decrease anxiety.

Suction as needed to clear the lungs.

Position the client supine.

Use chest percussion.

A Feedback: Suctioning will not clear the lungs or ease breathing if the client has pulmonary edema. In this situation, the physician may prescribe a sedative to relieve the anxiety created by the feeling of suffocation.

7. What major complication is associated with oral intake in the client with a decreased

A) B) C) D) Ans:

level of consciousness?

Distended abdomen Nausea Aspiration Pocketing of food C

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Feedback: Difficulty in swallowing, gastric and intestinal distention, and vomiting create a potential for aspiration of fluids and a decrease in food intake.

8. Which of the following is a nursing intervention for promoting self-care in the dying

A) B) C) D) Ans:

client?

Apply glycerin to the lips.

Promote active range-of-motion exercises every hour.

Avoid oral hygiene to minimize risk of aspiration.

Assist with personal hygiene.

D Feedback: The nurse may need to assist with personal hygiene. Petroleum jelly helps keep the lips lubricated. Active range-of-motion exercises do not need to be done every hour. The nurse gives oral care and ice chips because mouth breathing makes the oral mucous membranes and lips dry.

9. Which of the following is an example of near-death awareness?

A) B) C) D) Ans:

Feeling warm and peaceful Floating above one's body Premonition regarding date and time of death Moving rapidly toward a bright light C Feedback: Near-death awareness is a phenomenon characterized by a dying client's premonition of the approximate time and date of death. Near-death experiences include feeling warm and peaceful, floating above one's body, and moving rapidly toward a bright light.

10. Which of the following is an appropriate intervention to promote sleep in the dying

A) B) C) D) Ans:

client?

Cluster necessary activities.

Awaken client every three hours.

Allow a steady stream of visitors.

Provide maximal environmental stimulation to the client.

A Feedback: Nurses must cluster activities to avoid awakening the client and to protect the client from a steady stream of healthcare workers or visitors.

11. The nurse is caring for a pediatric client who is dying. The best way to provide care and

A)

comfort to dying clients and their families is to first do which of the following?

A workshop on caring for the dying client

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B) C) D) Ans:

Use evidence-based practice in daily care regimen.

Explore own feelings on mortality and death and dying.

Participate in a support group to learn clients' feeling on care.

C Feedback: To care for others in the dying process, the nurse must explore his or her own feelings about mortality and death and dying. Understanding self provides a perspective to cope with and then support clients and families experiencing pain and grief. The other options are helpful in determining appropriate nursing care but not the first step.

12.A client has learned of a terminal illness and impending death. The client asks the nurse to explain the concepts and care that are provided under the definition of palliative care.

Which of the following would the nurse include in the explanation for this client? Select all that apply.

A) Provides pain relief B) Includes chemotherapy C) Integrates spirituality D) Hastens death E) Offers a team approach to care F) Enhances quality of life Ans: A, C, E, F Feedback: The principles of palliative care include providing relief from pain and distressing symptoms. In the early course of disease, chemotherapy and radiation may be used to define care needed, but in the later stages, chemotherapy is typically not used.

Psychological support including spirituality and bereavement counseling for family members is available. The care does not hasten nor postpone death but is aimed at enhancing a quality of the life that is remaining. A team approach meets the needs of the client and family.

13. When considering care for the dying, which awareness, by the nurse, provides the best

A) B) C) D) Ans:

rationale for general nursing care?

Comfort measures are essential during this period.

Death is the final stage of growth and development.

Care for grieving family members is important.

Technology extends death and dying.

B Feedback: When providing nursing care for the dying, it is important to recognize that death is natural, universal, and the final stage of growth and development. Comfort measures and care for grieving family members are specifics that guide nursing interventions.

Technology does not always extend death and dying.

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14. The nurse is caring for a client who just learned of his terminal diagnosis. After the

A) B) C) D) Ans:

physician leaves, the nurse remains to answer further questions so that the client can make an informed decision about further treatment. By providing all available information, the nurse is promoting which ethical principle?

The principle of justice The principle of nonmaleficence The principle of fidelity The principle of autonomy D Feedback: By promoting open discussion and informed decision making, the nurse is empowering the client to make his own decisions leading to autonomy. The principle of justice requires fairness and justice to all clients. The principle of nonmaleficence requires that nurse does not intentionally or unintentionally inflict harm on others. The principle of fidelity maintains that nurses are faithful to the care of the clients.

15.A nurse is caring for a terminally ill client who is receiving chemotherapy and radiation for an aggressive lung cancer. The treatment success is limited in shrinking the tumor, and the treatments are making the client very ill. The client states, “I feel that I would like to stop treatments. I would like to enjoy the time that I have remaining with my family.”

Which emotional reaction does the nurse recognize that the client is experiencing?

A) Denial B) Bargaining C) Anger D) Acceptance Ans: D Feedback: In the final stage, dying clients accept their fate and makes peace spiritually and with those to whom they are close. Clients begin to detach themselves socially and wish to be with only a small group of close friends and family. The other options are stages that occur earlier in the process.

16. The nurse is caring for a client who has diminished lung function due to emphysema. The

A) B) C) D) Ans:

terminally ill client is short of breath on exertion and states he has difficulty sleeping in bed. The client states, “I am so afraid of getting any worse.” Which statement, by the nurse, assists the client in sustaining hope?

“Do not worry, I will be here for you to help you with your needs.”

“I will talk with the physician to determine the next step in your care.”

“Your grandchild is almost here, and you will enjoy seeing it.”

“I hear you say that you are not sleeping well.”

B Feedback: The client is assisted in hopefulness by believing that the healthcare team will make his remaining days meaningful. By conveying a sense that the nurse will discuss the client's

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condition with the physician, the client recognizes that the healthcare team will use whatever treatment and comfort measures are available. Telling a client not to worry is not therapeutic and is condescending. Waiting for a grandchild does not address the client's thought. Reflecting what the client said for clarification opens communication but does not instill hopefulness.

17. The nurse is caring for a 90-year-old male who has never completed an advanced

A) B) C) D) Ans:

directive. The man has a son but has not seen him in several years. A neighbor has assisted him with meals and housecleaning for many years. The neighbor states that the client expressed only wanting to have comfort measures. The estranged son wants his father to be treated aggressively. Which would be the nurse's initial step?

Follow the son's directive.

Follow the neighbor's directive.

Assess the client's ability to state wishes.

Notify the physician of the discrepancy.

C Feedback: It cannot be assumed that the client is unable to make his own decisions just because of his advanced age. Before any other person is asked about the client's wishes, the client needs to be asked first. The physician, who has a healthcare relationship with the client, may also have documented information about wishes.

18.A terminally ill client is admitted to a hospice facility. The client has an advanced directive indicating that no heroic measures be used to prolong life. What is the most appropriate nursing action when death appears imminent?

A) Sit quietly and stroke the client's hand.

B) Notify the client's clergy of the potential for death.

C) Call the funeral home to notify of imminent death.

D) Move the client to a private room.

Ans: A Feedback: The nurse's greatest gift to give the client at the end of life is to spend time with the client. That time can be spent quietly. This helps the client to not feel abandoned and to die with dignity. It is premature to notify the clergy or funeral home. The nurse would not move the client to another room at this time.

19. The family of a terminally ill client is deciding between home care and a hospice facility.

A) B) C) D) Ans:

When comparing options, which factor of home care needs regular assessment?

Pain control Caregiver strain A comfortable environment Transportation to appointments B

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Feedback: A negative factor of home care is the burden it places on the primary caretaker. If prolonged, the role can be isolating and tiring. Regular assessment, by the nurse, is needed to ensure care for both client and family. Pain control is the same in home care or at a hospice facility. Although a comfortable environment is important and transportation to appointments may be needed, it is not as important.

20. The nurse is caring for a client at the end of life. The client is ordered a regular dosage of

A) B) C) D) Ans:

narcotics and short-acting narcotics for breakthrough pain. When administering the narcotics, the nurse is correct to realize which of the following?

Death is imminent.

Side effects must be treated.

Dosages are restricted.

Patient may become sedated.

B Feedback: The nurse who is administering narcotics at the end of life still must realize that there are side effects from the narcotics which must be addressed. Depending on the status of the client, death may be days or weeks away, not imminent. Pain medications are liberally given at the end of life to ensure that the client is comfortable. Typically, pain medications relax the client as the pain level is eased. The client is not sedated.

21.A nurse is caring for a terminally ill client inquiring about physician-assisted suicide.

Which statement, made by the nurse, would correctly advocate for the practice?

A) The physician administers a lethal dose of medication via IV. B) The physician provides the means for the clients to take their life.

C) The physician provides the means and waits to pronounce them dead.

D) The physician provides counseling and has a third party physician assist in the suicide.

Ans: B Feedback: Physician-assisted suicide is the practice of providing a means by which a client can end his or her life. Much controversy exists concerning the practice. Oregon, Washington, and Montana are the only states that permit physician-assisted suicide. The physician does not personally administer the dose, wait until the client is dead, or have a third party physician involved.

22. Which cardiovascular findings indicate to the nurse that the condition of the dying client

A) B) C)

is worsening?

Pulse 104 beats/minute in the morning, 62 beats/minute in the afternoon with mottled feet and ankles Pulse 72 beats/minute, irregular; patient confused and agitated Pulse 100 beats/minute, blood pressure 100/60 mm Hg, pale with poor skin turgor

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D) Ans:

Pulse 60 beats/minute, blood pressure 90/42 mm Hg, difficult to arouse A Feedback: Earlier, a client with failing cardiac function exhibits a higher pulse as the body attempts to circulate oxygen. Next, cardiac output is decreased due to ineffective filling of the chambers, impairing circulation, and diminishing the heart's own oxygen supply. The heart rate and blood pressure then decrease. Peripheral circulation is impaired with the feet and ankles becoming pale and mottled.

23. The nurse is caring for a dying client in a hospice setting. The family is unsure whether to

A) B) C) D) Ans:

go home for rest or spend the night with the client. Which body system would the nurse assess to provide the first data on decline?

Central nervous system Cardiovascular system Respiratory system Gastrointestinal system B Feedback: The key word is “first.” Failing of cardiac functioning is one of the first signs that a condition is worsening. Symptoms within the other systems can also denote deterioration over time.

24.A nurse is caring for a dying patient. The family asks the nurse why there is a rattling in their loved one's chest. Which response is most appropriate?

A) The client picked up a virus and has respiratory symptoms.

B) The client has been lying in bed and secretions pool in the lung bases.

C) There is an accumulation of fluid in the pulmonary circulation and secretions throughout the respiratory tract.

D) Thick sputum accumulates as the client dehydrates from having little oral intake.

Ans: C Feedback: Failure of the heart's pumping function causes fluid to collect in the pulmonary circulation. Also, there is an accumulation of secretions in the respiratory tract. Both account for noisy respirations or what is called the death rattle. The client is typically not exposed to crowds where virus can be passed. Also, the symptoms the dying process would be different from that of a viral infection. It is true that secretions may pool in the lung bases; however, further symptoms cause the audible rattling in the upper bronchial tree. Although oral fluids may be limited, thick sputum is not common during the dying process.

25. As the moment of death approaches, which of the following does the nurse encourage the

A)

family to do?

Have the family sit in front of the client so they can be seen.

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B) C) D) Ans:

Rub the client's hand and arm to comfort the client.

Speak to the client in a calm and soothing voice.

Lie next to the client and hold the client.

C Feedback: Sight and touch diminish as the client approaches death; however, hearing tends to remain intact. Speaking to the client calmly is most appropriate.

26. Which of the following is the nurse's primary concern when providing end-of-life care for

A) B) C) D) E) F) Ans:

a client and the family? Select all that apply.

Maintaining client comfort Arranging plans for after death Supporting family members Providing personal care Completing a head-to-toe assessment Encouraging fluids A, C, D Feedback: Nursing care of dying clients focuses on providing palliative care to the client and supporting family members. Arranging the plans after death is not a priority at this time.

Completing a head-to-toe assessment may be completed for information but is not a priority at the end of life. There is no need to encourage fluids.

27. The family of a dying client being cared for at home is requesting information on how

A) B) C) D) Ans:

best to prepare food. Which suggestion by the nurse may stimulate appetite?

Eating alone so the client can eat at his own pace and not be hurried Providing several choices on the plate so that the client has what may appeal to him Offering high caloric foods to build fat and muscle Preparing cool or cold foods that may be better tolerated D Feedback: Preparing cool or cold foods may be tolerated better by the client and thus stimulate appetite. Hot foods may have an aroma that may cause nausea. Clients may enjoy a mealtime companion making the eating experience more pleasurable. Offering small portions is appropriate because large, multiple portions/choices may shut down the appetite. Although weight loss may be significant, clients should have the ability to pick and choose foods that interest them.

28. The nurse is caring for a client who is in the dying process. The nurse is reviewing orders

A) B)

to confirm that all is being done to meet client needs. Which additional nursing intervention may be helpful?

Lay client in the supine position.

Apply glycerin products for moisture.

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C) D) Ans:

Reposition client every 2 hours.

Remove extra blankets and covers.

C Feedback: A drop in blood pressure and heart failure lead to poor tissue and organ perfusion.

Repositioning the client every 2 hours protects the skin from breakdown. Typically, the client is at a semi-Fowler's position to assist with respiratory function. Glycerin products pull moisture from the tissue and accentuate the drying process. Extra covers are typically needed to ensure comfort.

29. The nurse is caring for a client who is interested in learning about hospice care. Which of

A) B) C) D) Ans:

the eligibility criteria would the nurse stress?

Serious, progressive illness Choice of palliative care over cure focused Limited life expectancy Physician-certified illness B Feedback: An important focus of hospice care is that care is palliative in nature. No further aggressive treatment to find a cure for the illness is administered. The client must accept this philosophy of care. The other options are factual and agreed on.

30. The family of a dying client is noticing that their loved one is short of breath, restless in

A) B) C) D) Ans:

bed, and appears to be trying to tell them something. Which nursing intervention is appropriate at this time?

Offer the bedpan to urinate.

Call the physician to obtain an anxiolytic.

Get the client out of bed to the chair.

Offer the client sips to drink.

B Feedback: Clients may become restless and agitated when experiencing difficulty breathing.

Obtaining an anxiolytic can reduce the client's anxiety and agitation. It is difficult for families to see the client agitated and trying to express something. It leaves the family feeling frustrated and with a lingering memory after death. Before death, the client loses muscle control of the bowel and bladder, needing a disposable undergarment. Sitting in the chair and offering sips to drink is not something necessary at the end of life.

31. The hospice nurse is visiting the client in the home. The client is comfortable with talking

A) B)

to the nurse. Which of the following statements, made by the client, demonstrates that the spiritual needs are being met?

“I believe that there is a better place.”

“I am comfortable and feel no pain.”

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C) D) Ans:

“Family is the most important thing to me.”

“There have been many positives in my life, and I am grateful.”

A Feedback: When the client states hopefulness in an afterlife, it is a positive statement that the spiritual needs are being met. Religious beliefs and customs influence attitudes about death. The other options are positive statements of living in the here and now. This does not address the spiritual needs.

32. All nurses care for clients who are grieving. It is important for the nurse to understand the

A) B) C) D) Ans:

grieving process for which reason?

Allows for the nurse to facilitate the grieving process Allows for the nurse to take the client through in the appropriate order Allows for the nurse to understand when the grieving process should be concluded Allows the nurse to express his or her feelings A Feedback: Grieving is a painful yet normal reaction that helps clients cope with loss and leads to emotional healing. The nurse is responsible for facilitating the grieving process and helping the client and family deal with their emotions.

33. Which action, following the death of a loved one, would the nurse witness the Chinese

A) B) C) D) Ans:

American family members doing?

Praying beside the body Washing the body Calling the spirits Perfuming the body B Feedback: Following the death of the Chinese American client, some family members prefer to wash their loved one themselves. By cleansing the body, it is a sign of respect. Many cultures offer prayers beside the body. Calling spirits and perfuming the body is not commonly completed.

34. Which statement, made by the nurse, can be most helpful when caring for a client in the

A) B) C) D) Ans:

third stage of Kübler-Ross's emotional reactions to dying?

“Let's review the laboratory results and compare them with the diagnostic tests.”

“I understand that it would be wonderful to see your daughter's graduation.”

“What makes you most angry about getting the disease?”

“I like your idea of living for today and enjoying those around you.”

B Feedback: The third stage of Elisabeth Kübler-Ross's series of reactions is bargaining. Confirming

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the intention to live to a certain time is common in this stage. Reviewing laboratory and diagnostic tests occurs in the first stage, denial. Talking about anger occurs in the second stage, anger. Living for the day is an idea which occurs in the final stage, acceptance.

35. In which scenario would the nurse, caring for the palliative care client, encourage the

A) B) C) D) Ans:

treatment of chemotherapy?

When the chemotherapy can assist in managing distressing clinical symptoms When the client and family requests to have more chemotherapy When the client feels chemotherapy will cure the disease When the chemotherapy helps the psychological state of the client A Feedback: The use of chemotherapy for a palliative care client is encouraged when used to manage distressing symptoms. Palliative care clients have accepted that the focus of care is comfort not cure. The nurse would open communication to understand why the client and family are requesting chemotherapy. The nurse continuously assesses the psychological state of the client; however, chemotherapy at this stage, typically is not helpful.

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Chapter 16: Sexuality and Aging Basic Geriatric Nursing, 7th Edition Chapter 16: Sexuality and Aging Test Bank MULTIPLE CHOICE 1. The nurse is aware that sexuality:

a.

becomes absent with age.

b.

remains part of life until death.

c.

as expressed through intercourse is not possible after the age of 65 years.

d.

must be expressed in sexual intercourse.

ANS: B Sexuality is an integral part of the makeup of each person. Although sexual expression may change, the need for sexual affection does not diminish. Intercourse is only one method of sexual expression.

DIF: Cognitive Level: Knowledge REF: 259 OBJ: 1 TOP: Sexuality KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse counsels the 70–year-old female who has remained on hormone replacement therapy (HRT) that she needs to have a:

a.

semiweekly douche to wash out cervical debris.

b.

liver function assessment annually.

c.

mammogram biannually.

d.

Pap smear annually.

ANS: D Persons on HRT should have an annual Pap smear and mammogram.

DIF: Cognitive Level: Application REF: 259 OBJ: 1 TOP: Hormone Replacement Therapy KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 3. The nurse evaluates a need for further instruction to reduce the symptoms of vaginal dryness when the 70–year-old patient says:

a.

“Vaseline was good enough for my mother. It’s good enough for me.”

b.

“I use a water-soluble lubricant to aid intercourse.”

c.

“I’m trying an estrogen cream to see if it works.”

d.

“I’ll let you know how wild yams work for vaginal dryness.”

ANS: A

Vaseline and petroleum products should be avoided because they do nothing for long-term dryness.

DIF: Cognitive Level: Application REF: 260 OBJ: 4 TOP: Vaginal Dryness KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. The nurse identifies the person most likely to experience erectile dysfunction as the 65– year-old who has sexually active in earlier years.

a.

diabetes and was very

b.

irritable bowel syndrome and was minimally

c.

chronic pancreatitis and was very

d.

osteoarthritis and was moderately

ANS: A Diabetic men are at risk for erectile dysfunction even at young ages.

DIF: Cognitive Level: Analysis REF: 260 OBJ: 4 TOP: Erectile Dysfunction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The 65-year-old male who, although he is having painful symptoms related to a benign enlargement of the prostate, refuses to consider a prostatectomy because he fears that the surgery will make him impotent. The nurse reassures him that:

a.

a prostatectomy will enhance sexual function.

b.

new techniques for a prostatectomy do not damage nerves.

c.

the prostate has nothing to do with erection or seminal fluid production.

d.

impotence following a prostatectomy is entirely psychological.

ANS: B Newer techniques do not damage nerves as was once the case when impotence following surgery was a real risk.

DIF: Cognitive Level: Application REF: 260 OBJ: 1 TOP: Erectile Dysfunction KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The 70-year-old woman who is considering coming off of hormone replacement therapy (HRT) for the reduction of postmenopausal discomfort asks the nurse what advantage is offered by tamoxifen, also called a “designer estrogen.” The nurse’s best response is that tamoxifen:

a.

provides estrogen to some tissues while acting as an antiestrogen to others.

b.

has no side effects.

c.

needs to be taken only once a week.

d.

improves the skin turgor and complexion.

ANS: A

“Designer estrogens” selectively act as an estrogen on some tissues and an antiestrogen on others. There are side effects, and the drug is usually taken twice a day.

DIF: Cognitive Level: Analysis REF: 260 OBJ: 1 TOP: Tamoxifen KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 7. The nurse teaches that some persons have found relief from postmenopausal discomfort by using phytoestrogens, which act as estrogens on some tissue and antiestrogens on others. Phytoestrogens are found in:

a.

mangos.

b.

soybeans.

c.

broccoli.

d.

lima beans.

ANS: B Soybeans are rich in phytoestrogens.

DIF: Cognitive Level: Comprehension REF: 260, Complementary and Alternative Therapies OBJ: 1 TOP: Phytoestrogens KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. The nurse recognizes a need for further instruction about sexual activity when the 65– year-old man who had a myocardial infarction 6 months ago says:

a.

“I’m enjoying the same sexual activities now as I did before my heart attack.”

b.

“I’m still pretty cautious, but our sex lives are very satisfactory.”

c.

“I’ve been told that I’m at risk for another heart attack if we have sex.”

d.

“My heart medications have made me impotent, but we’ve found other methods of sexual expression.”

ANS: C Fear, rather than an actual threat, can cause cessation of sexual relations following a heart attack.

DIF: Cognitive Level: Application REF: 260 OBJ: 2 TOP: Illness and Sexual Function KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse makes it clear to older adults in a long-term care facility that condoms are available from the medicine cart on request to:

a.

guarantee safe sex practices.

b.

reduce the incidence of sexually transmitted diseases (STDs).

c.

show acceptance of sexual expression.

d.

prevent soiling bed linens or furniture.

ANS: B STDs can still be transmitted in the older adult. Studies have shown that 10% of persons older than 50 years have been exposed to the human immunodeficiency virus (HIV). Nothing can guarantee safe sex practices.

DIF: Cognitive Level: Application REF: 261-262 OBJ: 6 TOP: STDs and the Older Adult KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The home health nurse stresses to the 70-year-old gay man who has been in a monogamous relationship for 20 years that it is especially important to name his partner as his medical power of attorney (POA) and file advance directives because:

a.

all persons older than 60 years should have a medical POA and advance directives.

b.

gay and lesbian couples are estranged from their families.

c.

life partners frequently abandon unions when terminal illness occurs.

d.

life partners have no legal standing and can be prohibited from medical decisions by family.

ANS: D Life partners have no legal standing for medical decisions unless named as medical POA. DIF: Cognitive Level: Application REF: 262 OBJ: 5 TOP: Sexual Orientation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 11. The horrified CNA runs to the nursing station and blurts out, “Do you know what Mr. and Mrs. Smith are doing? They’re having sex right there in room 210!” The nurse’s best response would be to:

a.

knock discreetly on the door and enter the room.

b.

call the charge nurse to report inappropriate sexual activity.

c.

request an order from the physician to allow intercourse.

d.

give the CNA a “Do Not Disturb” sign to put on the door of room 210.

ANS: D Privacy should be protected for appropriate sexual expression. Orders and notifying the charge nurse are not necessary, but recording the event in the nursing notes as a conjugal visit is suggested.

DIF: Cognitive Level: Application REF: 262-263 OBJ: 7 TOP: Privacy KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 12. When the cognitively impaired man is openly masturbating in the dayroom of a longterm care facility, the nurse’s best response would be to say:

a.

“This is inappropriate behavior in public areas.”

b.

“Oh my God! Don’t you know that will make you go blind?”

c.

“I think you may need some privacy” and take him to his room.

d.

“Here’s a blanket for your legs” and cover his lap with it.

ANS: C A person who is masturbating in public should be conducted to the privacy of his or her room.

DIF: Cognitive Level: Application REF: 263 OBJ: 7 TOP: Masturbation KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 13. When a married couple is admitted to the long-term care facility, the admitting nurse should show willingness to discuss sexual matters by asking:

a.

“How often do you have intercourse?”

b.

“Do you have any sexual concerns related to your admission here?”

c.

“What can we do to keep your sex life active?”

d.

“Any sexual activity should be done in private.”

ANS: B Asking about sexuality in broad terms communicates a willingness to discuss the issue.

DIF: Cognitive Level: Application REF: 261 OBJ: 7 TOP: Sexual Concerns KEY: Nursing Process Step: Implementation MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 14. When the CNA tearfully reports that a resident deliberately exposes himself to her and makes lewd suggestions, the nurse could best deal with this behavior by modifying the nursing care plan to:

a.

assign only males to care for the resident.

b.

chastise the resident for lewd behavior.

c.

restrain the hands of the resident during routine care.

d.

modify clothing choices to one-piece garments or elastic waist trousers.

ANS: D Modification of the clothing to make exposure more difficult is the best initial approach to the problem.

DIF: Cognitive Level: Application REF: 263 OBJ: 7 TOP: Inappropriate Genital Exposure KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation MULTIPLE RESPONSE 1. The nurse discusses factors that alter the sexual practice of older adults, which are . (Select all that apply.)

a.

altered health status

b.

inability to achieve orgasm

c.

erectile dysfunction

d.

loss of sexual partner

e.

slowed sexual response time

ANS: A, C, D, E Although the response is slowed, the ability to achieve orgasm remains throughout life.

DIF: Cognitive Level: Comprehension REF: 259 OBJ: 1 TOP: Age-Related Sexual Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse lists the age-related changes in the female reproductive system that affect sexual intercourse, which are . (Select all that apply.)

a.

pruritus vulvae

b.

atrophic vaginitis

c.

frequent yeast infections

d.

dyspareunia

e.

decreased response time

ANS: A, B, C, D The response time is not decreased. All of the other options are age-related changes in the female that affect satisfactory intercourse.

DIF: Cognitive Level: Application REF: 259 OBJ: 1 TOP: Age-Related Impediments to Intercourse KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse is aware that many women have abandoned hormone replacement therapy (HRT) because of the risk of . (Select all that apply.)

a.

stroke

b.

myocardial infarction

c.

liver disorders

d.

cancer

e.

bone demineralization

ANS: A, B, C, D Bone demineralization is not a risk associated with HRT, which is prescribed to prevent bone demineralization.

DIF: Cognitive Level: Application REF: 259 OBJ: 1 TOP: Hormone Replacement Therapy Risks KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. The nurse lists the sexual changes experienced by the older man, which are impairments to intercourse, such as . (Select all that apply.)

a.

erections take longer to achieve and are less firm than in younger years

b.

orgasm takes longer to achieve

c.

orgasm occurs at each intercourse

d.

erection loss occurs immediately after orgasm

e.

an increase in time between orgasms

ANS: A, B, D, E Orgasms are not always achieved with each intercourse.

DIF: Cognitive Level: Application REF: 260 OBJ: 1 TOP: Sexual Impairment KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse screening patients who complain of erectile dysfunction is aware that many drugs cause this problem, such as . (Select all that apply.)

a.

digitalis

b.

pancreatic enzyme replacement

c.

antihistamines

d.

antiparkinson drugs

e.

antidepressants

ANS: A, C, E Digitalis, antihistamines, and antidepressants all have a negative effect on sexual function.

DIF: Cognitive Level: Application REF: 261, Table 16-1

OBJ: 2 TOP: Medication and Sexual Function KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 6. The nurse is aware that many constraints prevent an older widow from engaging in sexual activity, which are that . (Select all that apply.)

a.

older women outnumber older adult men by 4:1

b.

there is an expectation that men should initiate contact

c.

display of sexual interest is considered improper

d.

older women do not desire sexual expression

e.

older women associate sexual activity with marriage

ANS: A, B, C, E Older women do retain a sexual appetite.

DIF: Cognitive Level: Application REF: 261 OBJ: 4 TOP: Loss of Sexual Partner KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Psychosocial Adaptation 7. Marriage between older adults is frequently impeded by apply.)

a.

disapproval of children

. (Select all that

b.

financial loss in case of remarriage

c.

concerns about chronic illness with either partner

d.

the lack of opportunity for sexual expression outside of marriage

e.

religious and personal values that inhibit cohabitation

ANS: A, B, C Lack of opportunity for sexual expression outside of marriage and distaste for cohabitation are factors that might encourage marriage rather than impede it.

DIF: Cognitive Level: Analysis REF: 261 OBJ: 1 TOP: Marriage and the Older Adult KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 8. The home health nurse takes into consideration the concerns of aging gay and lesbian couples, which include . (Select all that apply.)

a.

health care providers being willing to discuss a homosexual union

b.

the health care system’s focus on heterosexuality as the norm

c.

difficulty finding senior housing as a homosexual couple

d.

fear of discrimination based on sexual orientation, resulting in substandard health care

e.

delay of entry to a long-term care facility because of the possibility of not being able to share a room

ANS: B, C, D, E Health care providers are reluctant to discuss homosexual unions. All other options are possible problems related to the health care of older gay and lesbian couples.

DIF: Cognitive Level: Comprehension REF: 262 OBJ: 5 TOP: Sexual Orientation and Health Care KEY: Nursing Process Step: Planning MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 9. While asking questions about the patient’s reproductive system, the nurse is aware that sexual function can be affected by . (Select all that apply.)

a.

increasing age

b.

grief

c.

illness

d.

religion

e.

physical changes

ANS: A, B, C, E Religion does not affect sexual function. All other options can affect the individual physically and result in sexual dysfunction.

DIF: Cognitive Level: Comprehension REF: 259 OBJ: 1

TOP: Age-Related Sexual Impairment KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. Questions that the nurse might ask to assess sexual function include . (Select all that apply.)

a.

“How many alcoholic beverages do you drink a day?”

b.

“What over-the-counter and prescription medications do you take?”

c.

“How often do you engage in sexual activity?”

d.

“Have you had any recent health problems?”

e.

“When do you see your significant other?”

ANS: A, B, C, D Asking when the individual sees the significant other does not necessarily indicate that the individual is sexually active. Sexual function can be affected by excessive alcohol intake, medications, availability of sexual partners, and illness.

DIF: Cognitive Level: Application REF: 260-261 OBJ: 3 TOP: Age-Related Sexual Impairment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse explains that a decrease in estrogen and changes in the female reproductive system.

ANS: progesterone DIF: Cognitive Level: Knowledge REF: 259 OBJ: 1

are responsible for the

TOP: Age-Related Changes in the Female Reproductive System KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 17: Care of Aging Skin and Mucous Membranes Basic Geriatric Nursing, 7th Edition Chapter 17: Care of Aging Skin and Mucous Membranes Test Bank MULTIPLE CHOICE 1. When the older adult complains of the multiple raspberry-colored bruises on his extremities (senile purpura), the nurse explains that these colorful marks of increasing age are the result of:

a.

arteriosclerotic changes in the vessels.

b.

prolonged clotting time.

c.

fragility of capillary walls.

d.

reduction of subcutaneous fat.

ANS: C Age-related fragility of the capillary walls allows bright raspberry-colored bruises to develop with the mildest injury.

DIF: Cognitive Level: Comprehension REF: 266 OBJ: 3 TOP: Senile Purpura KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse assesses an area of skin on the patient’s upper thigh that is different in appearance than the surrounding skin. The documentation that is most informative is:

a.

red area on upper right thigh. Patient denies discomfort.

b.

erythematous scaly patch 2 × 2 cm on lateral aspect of right thigh. Patient denies pain.

c.

painless red patch on right thigh 2 × 2 cm.

d.

medium-size red scaly patch on right thigh. 0 drainage. 0 pain.

ANS: B The second option describes color and texture alterations, location, size, and subjective and objective data related to the lesion.

DIF: Cognitive Level: Analysis REF: 267 OBJ: 1 TOP: Skin Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse is aware that progressively graying hair is caused by:

a.

reduced melanocytes.

b.

altered blood circulation to the scalp.

c.

decreased density of hair.

d.

environmental factors.

ANS: A Decreasing melanocytes in the hair cause the hair to lose color and turn gray.

DIF: Cognitive Level: Comprehension REF: 267, Table 17-1 OBJ: 1 TOP: Gray Hair KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. When the assessment of a patient’s toenails reveals brittle thick nails with longitudinal lines in the nail, the nurse should assess for:

a.

fungal infection of the toenails.

b.

pedal pulses.

c.

history of gout.

d.

intake of dietary calcium.

ANS: B The nail changes are the result of decreased peripheral circulation. Checking for the strength of pedal pulses can add extra information related to circulation.

DIF: Cognitive Level: Analysis REF: 267, Table 17-1 OBJ: 2 TOP: Age-Related Nail Changes KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The 80-year-old woman newly admitted to a long-term care facility complains of intense itching in her axillae and antecubital fossa. There are small red lesions in linear patterns. These are all signs of:

a.

rosacea.

b.

keratosis.

c.

pruritus.

d.

scabies.

ANS: D Scabies is common in older adults, causing intense itching and small red lesions in a linear pattern.

The condition is communicable and, unless treated, can spread to the entire facility.

DIF: Cognitive Level: Comprehension REF: 268 OBJ: 1 TOP: Scabies KEY: Nursing Process Step: Assessment MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 6. The nurse reminds the CNAs that to prevent skin trauma from shearing force, the patients must:

a.

be slid across the bed linens to change position.

b.

have generous amounts of lotion applied to the skin.

c.

be lifted on draw sheets when being pulled up in bed.

d.

have frequent tub baths to soften the skin.

ANS: C Lifting patients up clear of the bed linens to move or change position will reduce the risk of shear force injury.

DIF: Cognitive Level: Comprehension REF: 268 OBJ: 2 TOP: Prevention of Shear Force Injury KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. To prevent pressure ulcers in the bedridden patient, the most effective intervention would be to:

a.

perform skin assessment every day.

b.

use a drawsheet to move the patient.

c.

change the patient’s position every 2 hours.

d.

remove wet bed linen promptly.

ANS: C Repositioning is the most effective intervention. Long periods of pressure over bony prominences are the primary cause of pressure ulcers, not wet linens, frequent assessments, or not using a drawsheet.

DIF: Cognitive Level: Analysis REF: 270 OBJ: 3 TOP: Prevention of Pressure Ulcers KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The admitting nurse gives the new long-term care facility resident a score of 20 on both the Norton Risk Assessment Scale and the Braden Scale for Predicting Pressure Sore Risk. These scores indicate that the resident has:

a.

a high probability of developing a pressure ulcer.

b.

a moderate risk of developing a pressure ulcer.

c.

a low risk of developing a pressure ulcer.

d.

at least one pressure ulcer at the time of admission.

ANS: C

Scores of 20 on the Norton and Braden Scales indicate a very low probability of developing a pressure ulcer.

DIF: Cognitive Level: Application REF: 271-272, Tables 17-3 and 17-4 OBJ: 3 TOP: Braden and Norton Skin Assessment Tools KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 9. On the admission assessment of an 80-year-old to a long-term care facility, the nurse notes that the resident’s toenails are dark, thick, and brittle; extremely misshapen; and growing at an angle from the toe. The nurse recognizes these as signs of nails.

a.

fungal infection of the

b.

ram’s horn

c.

ingrown

d.

expected age-related changes in the

ANS: A Fungal nail infections cause nails to be dark, brittle, and misshapen. The nails grow at odd angles from the toes because they are lifted from the nail bed by the infection.

DIF: Cognitive Level: Application REF: 273 OBJ: 2 TOP: Fungal Infection of Toenails KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The home health nurse suggests to the 80-year-old woman that to reduce the pruritus from dry skin, the patient should change her bathing schedule to:

a.

a hot shower every night before going to bed.

b.

a cool shower every morning using a detergent soap.

c.

a soak in a warm sudsy bath, leaving a film of soap on the skin.

d.

one shower a week, with sponge baths in between.

ANS: D A weekly shower with sponge baths in between provides adequate cleanliness and decreases dryness. Soap should be completely rinsed off. Hot showers and detergent soaps dry the skin.

DIF: Cognitive Level: Application REF: 274 OBJ: 3 TOP: Bathing KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 11. To reduce pressure ulcers in a bedridden patient, the nurse places the patient weight.

a.

directly on his side, with the trochanter

b.

supine, with the sacrum and iliac crest

c.

in a semi-Fowler position, with the sacrum and ischium

d.

in a lateral position, with body rotated 30 degrees with gluteus

bearing the

ANS: D The 30-degree lateral position places weight on the gluteus muscle, avoiding weight-bearing on bony prominences such as the trochanter, sacrum, and ischium.

DIF: Cognitive Level: Application REF: 275 OBJ: 3 TOP: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance 12. The long-term care facility nurse requests a dental consult to treat gingivitis in a resident. The nurse is aware that gingivitis, if not treated, can ultimately cause:

a.

receding gums.

b.

tooth loss.

c.

bleeding.

d.

halitosis.

ANS: B The bleeding, swelling, and receding gums of gingivitis ultimately lead to tooth loss.

DIF: Cognitive Level: Comprehension REF: 279 OBJ: 3 TOP: Gingivitis KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. The long-term care facility resident who has not worn his dentures for several months complains that the dentures no longer fit. The nurse explains that the dentures do not fit now because although he was not using them, his:

a.

gums have hypertrophied.

b.

gums have receded.

c.

jaw shape has altered.

d.

dentures have warped from disuse.

ANS: C The arch of the jaw changes to compensate for the absence of teeth.

DIF: Cognitive Level: Comprehension REF: 280 OBJ: 1 TOP: Dentures KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. When the patient complains of dry mouth, the nurse should inquire about and assess for:

a.

difficulty in chewing and swallowing.

b.

mouth ulcerations.

c.

adequate intake of vitamin B.

d.

inflammation of the tongue.

ANS: A Xerostomia causes difficulty in chewing and swallowing because food sticks to the mucous membranes and tooth surfaces.

DIF: Cognitive Level: Application REF: 280 OBJ: 1 TOP: Xerostomia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. When the older man complains of a hard white patch that has developed on the side of his tongue, the nurse should:

a.

request a dental consult to evaluate his dentures for adequate fit.

b.

examine his teeth to assess for a lost filling, which has left sharp edges on his teeth.

c.

request a medical consult for evaluation of a precancerous lesion.

d.

provide frequent, warm, salt water rinses for his mouth.

ANS: C Leukoplakia is a precancerous condition that requires a medical consultation.

DIF: Cognitive Level: Application REF: 280 OBJ: 3 TOP: Leukoplakia KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 16. When the male patient who has been on long-term antibiotic therapy inquires what may have caused his thrush, the nurse’s most informative response would be that the yeast infection occurred because:

a.

of a vitamin A deficiency.

b.

long-term antibiotic therapy has destroyed the normal flora of his mouth.

c.

he has developed an allergy to the antibiotic.

d.

oral hygiene has been inadequate.

ANS: B Long-term antibiotic therapy destroys the normal flora of the oral cavity, allowing opportunistic infections to occur. Thrush is a common yeast infection.

DIF: Cognitive Level: Application REF: 280 OBJ: 2 TOP: Superinfection KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

MULTIPLE RESPONSE 1. The nurse explains that the purpose of the hydrocolloid dressing applied to a clean stage II pressure ulcer is to . (Select all that apply.)

a.

débride the ulcer

b.

prevent shear force trauma

c.

absorb the exudate

d.

harden eschar

e.

make an air-occlusive seal

ANS: A, B, C, E The hydrocolloid dressing prevents shear force trauma to the ulcer while granulation tissue and reepithelialization are occurring during healing. It also forms an air-occlusive seal, protects the ulcer from infection, and absorbs exudate. If there were eschar present, it would soften it.

DIF: Cognitive Level: Application REF: 278, Table 17-6 OBJ: 3 TOP: Hydrocolloid Dressing KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 2. The nurse is diligent in skin care to prevent pressure ulcers. Older adults are at risk because . (Select all that apply.)

a.

the epidermal layer has thickened

b.

subcutaneous fat has diminished

c.

bruising is prevalent

d.

skin receptor cells have reduced in sensitivity

e.

the skin is dry and scaly

ANS: B, D Lack of subcutaneous fat to pad the bony prominences and reduced sensitivity to touch and pressure put older adults at risk for pressure ulcers.

DIF: Cognitive Level: Analysis REF: 266 OBJ: 1 TOP: Pressure Ulcers KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse is aware that the common symptom of pruritus in the older adult is the result of . (Select all that apply.)

a.

a reduction of sebaceous gland function

b.

a reduction in the amount of perspiration

c.

excessive bathing

d.

use of emollients

e.

environmental conditions

ANS: A, B, C, E Emollients keep the skin moist and reduce dryness. All other options listed contribute to pruritus.

DIF: Cognitive Level: Comprehension REF: 267 OBJ: 1 TOP: Pruritus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. When performing a skin assessment for pressure ulcers on an older man who is bedridden and prefers to lie on his right side, the nurse will pay special attention to the . (Select all that apply.)

a.

right ear

b.

lateral edge of the right foot

c.

sacrum

d.

medial edge of the left foot

e.

right scapula

ANS: A, B, D For this right side–lying patient, the right ear, lateral edge of the right foot, and medial edge of the left foot are probable areas for pressure ulcers.

DIF: Cognitive Level: Comprehension REF: 269, Figure 17-5 OBJ: 2 TOP: Pressure Ulcers KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. To fully assess a suspected skin breakdown over the trochanter of a dark-complexioned African American, the nurse would . (Select all that apply.)

a.

use a halogen light to examine the area

b.

palpate for local edema in the area

c.

touch the area to feel for changes in tissue temperature

d.

assess for localized pain

e.

press the area to test for blanching

ANS: A, B, C Halogen lights make a stage I area appear blue in a dark-skinned person. There is usually a local area of heat and edema. Stages I and II pressure ulcers are painless. Testing for blanching when erythema cannot be assessed is useless.

DIF: Cognitive Level: Application REF: 267, Cultural Considerations OBJ: 3 TOP: Pressure Ulcer Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The long-term care facility nurse making a list of residents whose foot care must be referred to the podiatrist would include the . (Select all that apply.)

a.

90-year-old poststroke patient with right hemiparesis

b.

85-year-old diabetic patient who is 100 lb overweight

c.

80-year-old resident with phlebitis and a stasis ulcer on the left ankle

d.

75-year-old resident with congestive heart failure (CHF)

e.

70-year-old resident with chronic obstructive pulmonary disease (COPD)

ANS: B, C Persons with diabetes or circulatory disorders should have foot care performed by a specialist.

DIF: Cognitive Level: Application REF: 273 OBJ: 2 TOP: Nail and Foot Care KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. The nurse explains that xerostomia (dry mouth) in the older adult may be caused by . (Select all that apply.)

a.

age-related reduction in saliva

b.

allergy

c.

eating highly seasoned foods

d.

inadequate fluid intake

e.

use of diuretic medications

ANS: A, D, E Reduction of saliva, inadequate fluid intake, and fluid loss through the use of diuretics can cause xerostomia.

DIF: Cognitive Level: Application REF: 280 OBJ: 1 TOP: Xerostomia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

8. The nurse recognizes the signs and symptoms of Vincent angina in a newly admitted patient, which include . (Select all that apply.)

a.

an advanced state of malnutrition

b.

enlargement of the cervical lymph nodes

c.

epistaxis

d.

dysphagia

e.

a discolored tongue

ANS: A, B, D Enlargement of the cervical lymph nodes, difficulty swallowing, and mouth ulcers in a malnourished person are indications of Vincent angina.

DIF: Cognitive Level: Application REF: 280 OBJ: 2 TOP: Vincent Angina KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. While giving a report to the CNAs, the nurse reviews interventions that will aid in maintaining the skin integrity of the residents. Appropriate interventions would include . (Select all that apply.)

a.

changing the briefs and bed linens when damp

b.

maintaining the temperature in the room at 80 degrees

c.

rinsing excess soap off the skin during a shower

d.

administering frequent pericare on the continent resident

e.

laying residents down after lunch

ANS: A, C, E Waste products and soap are irritating to the skin and must be removed promptly. Rest periods during the day will relieve pressure. Exposure to a hot, dry environment and frequent pericare to a resident who is not incontinent is going to make the skin more prone to breakdown.

DIF: Cognitive Level: Application REF: 274 OBJ: 3 TOP: Skin Integrity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. The nurse instructs a group of older adults on how to maintain intact skin by . (Select all that apply.)

a.

altering their body position every 30 minutes while sitting in the chair

b.

changing incontinent products when they become soiled

c.

using a pressure-relieving device like the “donut” to sit on

d.

routinely checking their feet for redness and indentations

e.

patting the skin dry after a shower or bath

ANS: A, B, E Frequent changes in body position, changing damp pads and briefs, and patting the skin dry will promote skin integrity. The “donut” causes pressure to surrounding area when used. Checking the feet routinely will alert the older adult to a potential problem but will not maintain skin integrity.

Changing socks daily or applying lotion to the feet will aid in maintaining skin integrity.

DIF: Cognitive Level: Application REF: 269, Table 17-2 OBJ: 3 TOP: Skin Integrity KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 1. On the admission assessment of a resident to a long-term care facility, the nurse notes a painless area on the patient’s coccyx that has partial skin loss. The nurse would record this as a stage pressure ulcer.

ANS: II 2 DIF: Cognitive Level: Application REF: 270, Figure 17-6 OBJ: 1 TOP: Staging a Pressure Ulcer KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 18: Elimination Basic Geriatric Nursing, 7th Edition Chapter 18: Elimination Test Bank MULTIPLE CHOICE 1. To encourage a normal daily bowel movement, the nurse can aid the older adult by:

a.

decreasing fluid intake.

b.

providing a warm beverage at breakfast.

c.

medicating with a mild laxative at bedtime.

d.

providing a warm shower each morning.

ANS: B Warm beverages at breakfast frequently stimulate the urge to defecate.

DIF: Cognitive Level: Comprehension REF: 286 OBJ: 6 TOP: Promoting Normal Elimination KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse assesses constipation in the patient who passes:

a.

firm stool without difficulty every 3 days.

b.

hard stool without difficulty every 2 days.

c.

soft brown stool with difficulty every 2 days.

d.

hard dry stool with difficulty every 3 days.

ANS: D Constipation is defined as a hard, dry stool that is difficult to pass.

DIF: Cognitive Level: Analysis REF: 287 OBJ: 1 TOP: Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse recognizes a need for instruction about prevention of constipation when the patient says:

a.

“I eat bran flakes or oatmeal every day to add bulk to my diet.”

b.

“Since I started eating three servings of fruit a day, I haven’t been constipated.”

c.

“I’m never constipated. I take a gentle laxative every night.”

d.

”My daily walks have kept my bowels working regularly.”

ANS: C Long-term laxative use may cause the body to become so dependent on laxatives that the patient is unable to have a normal elimination pattern without medication.

DIF: Cognitive Level: Application REF: 287 OBJ: 1 TOP: Constipation Prevention KEY: Nursing Process Step: Evaluation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse explains that a diet low in dietary fiber results in a small stool that:

a.

moves rapidly through the intestines.

b.

becomes excessively dry.

c.

overstimulates the defecation reflex.

d.

contributes to frequent bowel movements.

ANS: B Small stools move slowly because of the understimulation of peristalsis. The stool becomes dry and leads to infrequent defecation and constipation.

DIF: Cognitive Level: Application REF: 287 OBJ: 1 TOP: Dietary Fiber KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse would be especially observant for the indication of constipation in the patient who is taking:

a.

antibiotics for an upper respiratory infection.

b.

hormones for postmenopausal symptoms.

c.

iron supplements for anemia.

d.

nonsteroidal inhalants for chronic obstructive pulmonary disease (COPD).

ANS: C Iron supplements increase the risk of constipation.

DIF: Cognitive Level: Analysis REF: 287 OBJ: 4 TOP: Medications Causing Constipation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The nurse explains that the urge to defecate (defecation reflex) can be destroyed by:

a.

frequent episodes of diarrhea.

b.

long-term use of vitamin A and vitamin B complex.

c.

repeatedly ignoring the urge.

d.

excessive fiber and bulk in the diet.

ANS: C Ignoring the urge to defecate repeatedly suppresses the urge and may destroy it completely.

DIF: Cognitive Level: Comprehension REF: 288 OBJ: 4 TOP: Defecation Reflex KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse recognizes a need to make a focused bowel assessment when the 80-year-old resident complains of:

a.

the inability to have a bowel movement every day.

b.

feeling pressure and fullness in the rectum but is unable to defecate.

c.

having had one loose stool after breakfast.

d.

ingestion and flatulence.

ANS: B Feelings of pressure and fullness without being able to defecate may indicate a fecal impaction or rectal cancer. One loose stool does not represent diarrhea. Indigestion and flatulence are common in the older adult.

DIF: Cognitive Level: Application REF: 288, Patient Teaching OBJ: 4 TOP: Assessing Bowel Problems KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse uses special caution when performing a rectal digital examination on a patient with:

a.

chronic obstructive pulmonary disease (COPD).

b.

diabetes.

c.

Parkinson disease.

d.

congestive heart failure.

ANS: D Persons with a cardiac history may experience vagal stimulation and have a sudden drop in heart rate, resulting in syncope.

DIF: Cognitive Level: Application REF: 288 OBJ: 6 TOP: Vagal Response KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. To assist an 85-year-old older adult with weak abdominal muscles to defecate, the nurse would:

a.

encourage the use of a bedpan before getting up in the morning.

b.

place a footstool under the feet of the patient when seated on the toilet.

c.

insert a finger in the patient’s rectum to stimulate the urge to defecate.

d.

instruct the patient to do isometric exercises to strengthen the abdominal muscles.

ANS: B Placement of a stool under the patient’s feet increases intra-abdominal pressure and encourages bearing down (Valsalva maneuver) to accomplish defecation.

DIF: Cognitive Level: Application REF: 289 OBJ: 6 TOP: Weak Abdominal Muscles KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. The nurse tells the older adult that a food with the double action of providing fiber and being a natural laxative is:

a.

oatmeal.

b.

pineapple.

c.

prunes.

d.

raw apple.

ANS: C Although all the options add fiber and bulk to the diet, only prunes provide a laxative effect.

DIF: Cognitive Level: Application REF: 289 OBJ: 6 TOP: Nonconstipating Foods KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. When the patient tells the home health nurse that he has begun to take psyllium (Metamucil), the nurse cautions him that to avoid fecal impaction with this drug, he should:

a.

eat several servings of fresh fruit and vegetables a day.

b.

avoid citrus fruit juices.

c.

reduce intake of carbonated drinks.

d.

increase his fluid intake to 3000 mL a day.

ANS: D Increased fluid intake is essential to dissolve the fiber in this drug completely; otherwise, fecal impaction can occur.

DIF: Cognitive Level: Application REF: 289 OBJ: 6 TOP: Psyllium KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 12. The nurse recognizes the patient who is exhibiting signs of diarrhea and will need enhanced skin care precautions as the patient who has:

a.

one unformed stool after a bolus of tube feeding.

b.

an unformed stool followed by a formed stool 3 hours later.

c.

cramping and nausea followed by an unformed stool.

d.

no abdominal discomfort but has had three unformed stools in 8 hours.

ANS: D Frequent passage of unformed stool with or without other symptoms should call for a heightened level of skin care.

DIF: Cognitive Level: Application REF: 292 OBJ: 2 TOP: Diarrhea KEY: Nursing Process Step: Assessment MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. The nurse plans to help reduce episodes of bowel incontinence by a proactive program of:

a.

encouraging intake of foods that cause mild constipation.

b.

using appropriate disposable garments, pads, and bed covering.

c.

establishing a toileting schedule.

d.

coaching the patient in Kegel exercises.

ANS: C Establishing a toileting schedule that follows the preincontinent state can train the patient’s bowel and caregivers so that incontinence is reduced.

DIF: Cognitive Level: Application REF: 293 OBJ: 6 TOP: Bowel Incontinence KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The patient complains of feeling the need to urinate and fullness and tenderness in the bladder area. The patient is restless and diaphoretic. The initial nursing intervention would be to:

a.

help the patient into a warm tub bath to stimulate voiding.

b.

catheterize the patient.

c.

palpate the bladder fundus.

d.

place heated towels over the bladder area.

ANS: C Palpation to assess distention would be the initial intervention before trying to remedy the urinary retention.

DIF: Cognitive Level: Application REF: 294 OBJ: 3 TOP: Urinary Distention KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 15. The nurse recognizes the cardinal sign of stress incontinence when the patient says:

a.

“Lifting my grandchild makes me wet my pants.”

b.

“I frequently wet myself because I just can’t get to the bathroom in time.”

c.

“My arthritis makes me so clumsy that I can’t get my pants down in time.”

d.

“Every time I have a urinary infection, I experience incontinence.”

ANS: A Stress incontinence occurs when intra-abdominal pressure increases and forces urine through a weakened urinary sphincter. Lifting, sneezing, coughing, and laughing can cause stress incontinence.

DIF: Cognitive Level: Application REF: 294 OBJ: 3 TOP: Stress Incontinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 16. The home health nurse suggests that the patient perform a frequent series of Kegel exercises to reduce incontinence by:

a.

increasing the tone of the bladder.

b.

reducing urinary retention.

c.

strengthening the urinary sphincter.

d.

sensitizing biofeedback.

ANS: C Kegel exercises, if done correctly and regularly, will strengthen the pelvic floor and will help hold back the flow of urine.

DIF: Cognitive Level: Comprehension REF: 296 OBJ: 6 TOP: Kegel Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 17. An alert, independent, 89-year-old male resident with congestive heart failure has been on Lasix for a week. Over the past 2 days he has been frequently incontinent and does not make it to the bathroom in time. His urine is now dark amber with a strong ammonia smell. He tells the nurse that he is having spasms in his lower abdomen. The nursing diagnosis that most applies to this resident is:

a.

impaired urinary elimination.

b.

functional urinary incontinence.

c.

stress urinary incontinence

d.

urge urinary incontinence.

ANS: D Urge urinary incontinence occurs with the physiologic changes of aging. The use of diuretics, increased bladder stimulation from urinary tract infections, and involuntary bladder spasms cause the older adult to have a feeling of urgency and result in incontinence.

DIF: Cognitive Level: Comprehension REF: 295 OBJ: 5 TOP: Urge Incontinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Pharmacological Therapies MULTIPLE RESPONSE 1. The nurse explains that normal bowel stimulation patterns for elimination of each person are influenced by . (Select all that apply.)

a.

level of activity

b.

diet

c.

medication

d.

fluid intake

e.

lifestyle

ANS: A, B, D, E Medications frequently disrupt normal bowel elimination patterns.

DIF: Cognitive Level: Knowledge REF: 286 OBJ: 1

TOP: Normal Bowel Elimination Patterns KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse outlines age-related changes that promote constipation in the older adult, which include . (Select all that apply.)

a.

diminished abdominal muscle tone

b.

reduced activity level

c.

inadequate fluid intake

d.

increased dietary fiber

e.

dependence on laxatives

ANS: A, B, C, E Increased dietary fiber and bulk help prevent constipation.

DIF: Cognitive Level: Application REF: 287 OBJ: 1 TOP: Factors Supporting Constipation KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse encourages fluid intake for the older adult to prevent constipation. If fluid intake is inadequate, constipation occurs because . (Select all that apply.)

a.

fluid will be withdrawn from the stool

b.

the stool becomes hard and dry

c.

less mucus is formed in the colon

d.

lumen of bowel constricts because of smaller bulk

e.

peristalsis slows

ANS: A, B, C Inadequate fluid intake causes fluid to be withdrawn from the stool for the body’s fluid needs, making the stool dry and hard. There is less mucus in the bowel from age-related changes and diminished mucus production because of decreased fluid. Slowed peristalsis is not related to fluid intake. Lumen of the bowel does not constrict because of smaller bulk.

DIF: Cognitive Level: Application REF: 287 OBJ: 6 TOP: Fluid Intake KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse assesses a risk for constipation related to pain because of the presence of conditions such as . (Select all that apply.)

a.

hemorrhoids

b.

anal fissures

c.

reduction of bowel mucus

d.

diminished abdominal muscle tone

e.

slowed peristalsis

ANS: A, B, C

Diminished tone and slowed peristalsis do not contribute to pain.

DIF: Cognitive Level: Application REF: 288 OBJ: 4 TOP: Pain-Related Constipation KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse is alerted to the possibility of a fecal impaction when the older adult patient complains of . (Select all that apply.)

a.

cramping

b.

rectal pain

c.

abdominal distention

d.

anorexia

e.

passing large amounts of liquid stool

ANS: A, B, C, D Passing large amounts of liquid stools is not a sign of a fecal impaction. All other options are indications of fecal impaction.

DIF: Cognitive Level: Application REF: 288 OBJ: 4 TOP: Fecal Impaction KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 6. The skin care for an older adult with diarrhea should include

a.

perineal care immediately after the diarrhea episode

b.

application of lotion to the buttocks

. (Select all that apply.)

c.

maintenance of dry linens

d.

patting the anal area dry rather than wiping

e.

leaving excoriated areas open to the air

ANS: A, C, D, E Lotion will not protect the skin from urine and stool. Barrier cream must be used. All other interventions listed are part of special skin care for persons with diarrhea.

DIF: Cognitive Level: Comprehension REF: 292 OBJ: 6 TOP: Diarrhea Skin Care KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 7. The nurse is aware that the broad general causes of bowel incontinence are all that apply.)

a.

inability to recognize defecation urge related to mental impairment

b.

inability to respond to defecation urge related to immobility

c.

inflammatory bowel disease

d.

increased fiber in the diet

e.

unexpected defecation when passing gas

. (Select

ANS: A, B, C, E Fiber provides bulk to waste. All other options are causes of incontinence.

DIF: Cognitive Level: Comprehension REF: 293 OBJ: 4 TOP: Causes of Bowel Incontinence KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nurse knows difficulty in bowel and bladder elimination occur in the older adult as a result of . (Select all that apply.)

a.

daily use of senna for defecation

b.

inability to get to adequate water

c.

fear of pain with defecation

d.

total privacy during elimination

e.

use of a bedpan for elimination

ANS: A, B, C, E A lack of privacy may be a hindrance to elimination.

DIF: Cognitive Level: Application REF: 287-288 OBJ: 2 TOP: Age-Related Changes That Affect Elimination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse is aware that an adult has the urge to urinate when the bladder has approximately mL of urine in it.

ANS: 300 DIF: Cognitive Level: Comprehension REF: 286 OBJ: 1 TOP: Bladder Volume KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse is aware that the urge to defecate is increased peristalsis stimulated by the defecation reflex and the reflex.

ANS: gastrocolic DIF: Cognitive Level: Comprehension REF: 286 OBJ: 1 TOP: Gastrocolic Reflex KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 19: Activity and Exercise Basic Geriatric Nursing, 7th Edition Chapter 19: Activity and Exercise Test Bank MULTIPLE CHOICE 1. The nurse explains that the slowed speed of nerve impulses will cause the older adult to:

a.

get a “scrambled” message in the brain.

b.

take longer to complete an activity.

c.

become confused.

d.

forget how to complete the activity.

ANS: B Slowed transmission causes the older adult to take more time to complete an activity because the message must travel from the source to the brain and then from the brain to the parts of the body involved in completing the activity.

DIF: Cognitive Level: Application REF: 303 OBJ: 2 TOP: Slowed Transmission KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse takes into consideration that the arthritic patient may be less likely to exercise because:

a.

fragility of the bones puts the patient at risk for fractures.

b.

numbness in the feet and legs puts the patient at risk for a fall.

c.

stiffened ligaments and tendons put the patient at risk for reduced flexibility.

d.

moving heavy edematous limbs puts the patient at risk for fatigue.

ANS: C Arthritis limits joint movement; in turn, this reduces tendon and ligament flexibility, making them stiff and limiting mobility.

DIF: Cognitive Level: Analysis REF: 303 OBJ: 5 TOP: Arthritis KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The home health nurse recognizes that the 75-year-old male patient has made an adjustment to reduced stamina when he:

a.

moved his home office to a downstairs location.

b.

used public transportation rather than driving his own car.

c.

tilled the garden plot with a motor-driven tiller.

d.

went to a senior center twice in 1 week to play dominoes.

ANS: A Moving the office to avoid climbing stairs is related to reduced stamina.

DIF: Cognitive Level: Application REF: 303 OBJ: 2 TOP: Stamina KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 4. The nurse explains that the focus of aerobic exercises such as walking and biking is to:

a.

improve cardiovascular function.

b.

build muscle mass.

c.

improve dexterity.

d.

enhance balance.

ANS: A Aerobic exercises such as walking and biking are focused on improving cardiovascular function.

DIF: Cognitive Level: Application REF: 304 OBJ: 2 TOP: Aerobic Exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. The nurse suggests to the 70-year-old woman who has painful arthritic joints that a beneficial exercise for her because of disability would be:

a.

training with hand weights.

b.

walking on a treadmill.

c.

low-impact aerobics.

d.

swimming.

ANS: D

Swimming is a pleasurable aerobic exercise for many seniors, and water exercises can help individuals with sore joints because the water provides support and eases movement.

DIF: Cognitive Level: Application REF: 304 OBJ: 2 TOP: Exercise for Arthritics KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. When the older adult confides to the home health nurse that he wants to build muscle mass so that he can look good at the apartment pool, the nurse recommends exercise.

a.

aerobic

b.

stretching

c.

resistance

d.

tai chi

ANS: C Resistance exercises using weights, elastic bands, and exercise balls can build muscle mass.

DIF: Cognitive Level: Application REF: 304 OBJ: 2 TOP: Resistance Exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 7. When the 65-year-old patient who is a type 1 diabetic informs the home health nurse that he now exercises for 1 hour a day at a club, the nurse cautions him to be sure to:

a.

drink plenty of fluids.

b.

wear clothing that allows ventilation.

c.

take hard candy to the gym when he exercises.

d.

give himself less insulin than is prescribed.

ANS: C Exercise lowers the blood sugar level. A type 1 diabetic could become hypoglycemic and need a ready source of glucose, such as in hard candy.

DIF: Cognitive Level: Analysis REF: 304 OBJ: 3 TOP: Diabetic Patients KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 8. The nurse directs an 80-year-old recovering from a fractured pelvis to participate in several isometric exercises to maintain muscle strength, such as:

a.

alternately tightening and relaxing the abdominal muscles.

b.

lifting the body up off the bed using an overhead trapeze.

c.

pushing against the bed to lift the buttocks off the bed a few inches.

d.

pressing the sole of the foot against a footboard.

ANS: A Alternately tightening and relaxing muscles maintains strength in muscles, such as the abdominals, gluteal muscles, and quadriceps. Other options are isotonic exercises that involve joint movement.

DIF: Cognitive Level: Application REF: 307 OBJ: 5 TOP: Isometric Exercises KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

9. Because isometric and isotonic exercises can cause the patient to perform an accidental Valsalva maneuver, the nurse coaches the patient to:

a.

hold the breath during an exercise cycle.

b.

breathe through the mouth.

c.

breathe deeply and rhythmically during an exercise cycle.

d.

breathe in through the nose and out through the mouth.

ANS: B Breathing through the mouth makes it impossible to hold the breath, and bearing down cannot be performed. The Valsalva maneuver increases blood pressure and may cause cardiac overload.

DIF: Cognitive Level: Application REF: 307 OBJ: 5 TOP: Valsalva Maneuver KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 10. Balance training will help the older adult recovering from a prolonged period of immobility related to a broken hip to:

a.

increase peripheral circulation.

b.

increase strength.

c.

decrease the incidence of falls.

d.

eliminate the need for ambulatory assistive devices.

ANS: C

Balance training has been shown to decrease the incidence of falls by 17%.

DIF: Cognitive Level: Application REF: 304 OBJ: 5 TOP: Balance Exercises KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 11. The fiercely independent 90-year-old woman who is recovering from a stroke frequently ambulates without the use of her walker because she says it is ugly and cumbersome. The nurse’s most effective intervention would be to:

a.

allow her to ambulate independently.

b.

place a gait belt around her and ambulate when she does.

c.

bring her walker to her and remind her that the walker is for her safety.

d.

instruct her to use a wheelchair for mobility.

ANS: C Bringing a device and reminding the patient of its purpose is an effective way to protect the patient and re-educate her about assistive devices. Use of a gait belt to assist her with every ambulation or allowing her to ambulate without an assistive device is not practical. Use of a wheelchair diminishes her mobility.

DIF: Cognitive Level: Analysis REF: 310 OBJ: 7 TOP: Rejection of Assistive Devices KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 12. The nurse cancels the outing to the park for a group of older adults in a long-term care facility on a(n):

a.

75-degree sunny day in Texas.

b.

70-degree cloudy day in Oregon.

c.

80-degree sunny day in Florida.

d.

75-degree ozone alert day in California.

ANS: D Ozone alerts are given to warn of excessive air pollution and to limit exposure to the outside environment.

DIF: Cognitive Level: Analysis REF: 312 OBJ: 5 TOP: Environmental Concerns Affecting Mobility KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 13. The care plan that is custodial in its focus is characterized by:

a.

attention to high-level wellness.

b.

plans for physiologic and safety concerns.

c.

aggressive rehabilitation goals.

d.

patient participation in his or her own care.

ANS: B Low expectations and little focus for improvement, a rather negative outlook, represent the character of the custodial care plan. The goals will be those of physiologic care and safety.

DIF: Cognitive Level: Comprehension REF: 325 OBJ: 8

TOP: Custodial Focus KEY: Nursing Process Step: N/A MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 14. The older woman who has diminished dexterity would find the activity of frustrating and difficult.

a.

working a crossword puzzle

b.

playing a round of golf

c.

playing the piano

d.

painting with watercolors

the most

ANS: D Fine motor skills are lost, which make painting with watercolors very difficult for a person with diminished dexterity.

DIF: Cognitive Level: Analysis REF: 303 OBJ: 5 TOP: Loss of Dexterity KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The home health nurse instructs the 75-year-old woman that daily exercise of a minimum of minutes daily is as beneficial as a longer period of extreme exercise on an irregular basis.

a.

15

b.

20

c.

30

d.

45

ANS: C Moderate exercise for a period of 30 minutes daily is enough to keep joints mobile and maintain strength.

DIF: Cognitive Level: Comprehension REF: 304 OBJ: 2 TOP: Regular Exercise KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease MULTIPLE RESPONSE 1. The home health nurse points out the benefits of regular exercise, which include . (Select all that apply.)

a.

maintenance of joint mobility

b.

enhancement of muscle tone

c.

promotion of sense of general well-being

d.

guarantee of weight loss

e.

promotion of regular elimination

ANS: A, B, C, E Regular exercise does not guarantee weight loss. All other listed options are benefits of regular exercise.

DIF: Cognitive Level: Knowledge REF: 303 OBJ: 1 TOP: Benefits of Exercise KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse takes into consideration that the lessened stamina of the older adult is related to an altered oxygen exchange resulting from . (Select all that apply.)

a.

flattened diaphragm

b.

loss of elasticity in the lung

c.

nutritional deficiencies

d.

decrease in size of chest cavity

e.

fragility of capillaries

ANS: A, B, C, D Fragility of capillaries does not interfere with gas exchange.

DIF: Cognitive Level: Comprehension REF: 303 OBJ: 5 TOP: Reduction of Air Exchange KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse lists factors that the patient should consider when planning an exercise program, which are . (Select all that apply.)

a.

purchasing weights

b.

wearing clothing appropriate to the type of exercise

c.

considering membership in a health club

d.

establishing realistic goals

e.

committing time for consistent regular exercise

ANS: B, C, D, E The purchase of weights is not necessary for all exercise programs. All other options listed promote the success of the exercise program.

DIF: Cognitive Level: Comprehension REF: 304 OBJ: 2 TOP: Planning an Exercise Program KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 4. The overall goals in caring for a patient with impaired physical mobility are all that apply.)

a.

increasing the patient’s participation in physical activities

b.

preserving the patient’s anatomical position and function of joints

c.

increasing the patient’s former level of mobility

d.

avoiding unnecessary restraints

e.

using assistive devices to maintain mobility

. (Select

ANS: A, B, D, E Increasing the former level of mobility is unrealistic. All other options are goals that are appropriate for improving physical mobility.

DIF: Cognitive Level: Comprehension REF: 306 OBJ: 5 TOP: Impaired Physical Mobility KEY: Nursing Process Step: Planning

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 5. When planning an exercise program for a person with activity intolerance, the nurse would consider . (Select all that apply.)

a.

identification of factors that contribute to activity intolerance

b.

arranging activities that progress from mild to more demanding

c.

rapid pacing activities to build up stamina

d.

individualizing the plan to include activities that the patient particularly likes

e.

including the patient in the planning phase

ANS: A, B, D, E Rapid pacing of activities will only result in continued activity intolerance. Pacing should be slowly increased to build stamina.

DIF: Cognitive Level: Comprehension REF: 312-314 OBJ: 6 TOP: Activity Intolerance KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The long-term goals for rehabilitation are

a.

prevention of further disability

b.

modifying the impact of the disability on lifestyle

c.

supporting adaptation to a changed lifestyle

. (Select all that apply.)

d.

focusing on a complete return to the former level of activity

e.

reestablishing the patient’s control of her or his life

ANS: A, B, C, E Rehabilitation is focused on attaining the best possible recovery with adjustment to a change in lifestyle.

DIF: Cognitive Level: Comprehension REF: 325 OBJ: 10 TOP: Rehabilitation Goals KEY: Nursing Process Step: N/A MSC: NCLEX: N/A 7. The rehabilitation nurse demonstrates a positive attitude toward care planning by . (Select all that apply.)

a.

acknowledging the impact of a traumatic amputation on therapy

b.

encouraging the resident’s input on the care plan

c.

inviting the resident and family member to attend the care plan meetings

d.

making a list of questions for the resident to ask at the care plan meeting

e.

helping the resident to perform all activities of daily living (ADLs)

ANS: A, B, C Making a list of questions for the resident and performing all the ADLs does not promote a positive attitude or allow the patient to pose his or her own questions.

DIF: Cognitive Level: Comprehension REF: 325 OBJ: 9 TOP: Attitude Toward Care Planning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 8. The nurse knows the goals of rehabilitative nursing include helping the patient to . (Select all that apply.)

a.

minimize the impact of disability

b.

return to maximum level of function

c.

increase level of independence

d.

adjust to change in lifestyle

e.

increase control of their life

ANS: A, C, D, E The goals of rehabilitative nursing do not include the return to maximum level of function, but to the most optimal level obtainable.

DIF: Cognitive Level: Comprehension REF: 325 OBJ: 11 TOP: Rehabilitation Goals KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease COMPLETION 1. To increase safe mobility for a patient recovering from a fractured left hip, the nurse would instruct the patient to place the cane on the side.

ANS: right DIF: Cognitive Level: Comprehension REF: 310 OBJ: 7 TOP: Cane Use KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

Chapter 20: Sleep and Rest Basic Geriatric Nursing, 7th Edition Chapter 20: Sleep and Rest Test Bank MULTIPLE CHOICE 1. The nurse is aware that the initial entry to deep sleep is:

a.

stage 1 nonrapid eye movement (NREM).

b.

stage 3 NREM.

c.

stage 5 NREM.

d.

rapid eye movement (REM) sleep.

ANS: B Stage 3 NREM is the initial phase of deep sleep in which there is complete muscular relaxation and vital signs begin to decline.

DIF: Cognitive Level: Comprehension REF: 329, Box 20-1 OBJ: 1 TOP: Deep Sleep KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The phenomenon of sleep walking is most likely to occur in the sleep stage of:

a.

stage 1 NREM.

b.

stage 2 NREM.

c.

stage 4 NREM.

d.

REM sleep.

ANS: C Stage 4 NREM is the deepest stage of sleep in which sleep walking is most likely to occur.

DIF: Cognitive Level: Comprehension REF: 329, Box 20-1 OBJ: 1 TOP: Sleep Walking KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse explains that older adults often experience a disturbed sleep-wake cycle because of hormonal changes, which include a(n) level.

a.

increase in angiotensin

b.

decrease in insulin

c.

increase in growth hormone

d.

decrease in melatonin

ANS: D A decrease in the melatonin level causes age-related sleep disturbances.

DIF: Cognitive Level: Application REF: 329 OBJ: 1 TOP: Hormonal Changes KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

4. The older man in a long-term care facility consistently wakes at 3 AM and does not return to sleep.

The nurse records this behavior as insomnia.

a.

sleep initiation

b.

sleep maintenance

c.

terminal

d.

undifferentiated

ANS: C Terminal insomnia is a sleep disturbance in which the patient consistently wakes at an early hour and cannot return to sleep.

DIF: Cognitive Level: Application REF: 330 OBJ: 2 TOP: Terminal Insomnia KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The newly admitted older adult who cannot fall asleep and asks for a sedative every night is most probably experiencing a difficulty with sleep:

a.

initiation related to anxiety of relocation.

b.

maintenance related to unfamiliar environment.

c.

initiation related to depression associated with relocation.

d.

maintenance related to episodes of nocturnal movement disorders.

ANS: A

Sleep initiation issues are usually associated with anxiety.

DIF: Cognitive Level: Application REF: 330 OBJ: 2 TOP: Insomnia KEY: Nursing Process Step: Assessment MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation 6. The home health nurse assesses that the patient is probably experiencing myoclonus when his wife says:

a.

“His loud snoring and jerking awake wakes me up, too.”

b.

“I am black and blue from his kicking me every night.”

c.

“He wakes up at 2 AM every morning and walks around the house.”

d.

“His constant leg movements tear up the covers and keep me awake.”

ANS: B Myoclonus is a periodic kicking movement of the lower extremities, which can be severe.

DIF: Cognitive Level: Application REF: 330 OBJ: 2 TOP: Myoclonus KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nurse would question the order for lorazepam (Ativan), 5 mg at bedtime, for a patient with:

a.

chronic obstructive pulmonary disease (COPD).

b.

any form of dementia.

c.

hypertension.

d.

sleep apnea.

ANS: D Sedation may prevent the patient with sleep apnea to awaken to restore respiration.

DIF: Cognitive Level: Application REF: 330, Table 20-1 OBJ: 3 TOP: Lorazepam KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 8. In order to assist a 75-year-old male resident in a long-term care facility to decrease his problems with sleep initiation, the nurse would:

a.

provide a heavy snack at bedtime.

b.

reschedule the 8 PM albuterol inhalation treatment to 4 PM.

c.

coach the resident in 10 minutes of exercise before bedtime.

d.

provide a cola drink, strong tea, or cocoa at bedtime.

ANS: B Albuterol is a drug that may interfere with sleep schedules.

DIF: Cognitive Level: Analysis REF: 331, Table 20-2 OBJ: 7 TOP: Insomnia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 9. The nurse cautions the patient who has just started on the antidepressant trazodone hydrochloride to help relieve insomnia to:

a.

increase fluids.

b.

avoid aged cheese and red wine.

c.

decrease sodium intake.

d.

avoid excessive exposure to the sun.

ANS: D Trazodone makes persons photosensitive.

DIF: Cognitive Level: Application REF: 330, Table 20-1 OBJ: 7 TOP: Trazodone KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 10. The 80-year-old man complains that when he goes to bed and cannot fall asleep, he tosses and turns and gets so frustrated that he gets up and drinks coffee all night. The nurse suggests that when he has not fallen asleep after 30 minutes, he should:

a.

take two tablets of a sedative medication.

b.

get up and do a mild stretching exercise for 15 minutes.

c.

remain in bed with his eyes closed.

d.

get up and read until he feels sleepy and then return to bed.

ANS: D

Getting up and reading or watching TV is more restful than experiencing the frustration of inability to fall asleep. Sleep-inducing drugs frequently have a negative effect on older adults, exercising is stimulating, and lying in bed may increase tension.

DIF: Cognitive Level: Application REF: 331 OBJ: 7 TOP: Insomnia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. The nurse clarifies that the continuous positive airway pressure (CPAP) machine decreases the incidence of episodes of sleep apnea by:

a.

stimulating inspiration to be deeper.

b.

taking over respiratory activity when the patient ceases to breathe.

c.

sounding an alarm if respirations have ceased.

d.

keeping alveoli from collapsing.

ANS: D The use of CPAP keeps alveoli from collapsing and causing periodic apnea.

DIF: Cognitive Level: Comprehension REF: 332 OBJ: 7 TOP: Continuous Positive Airway Pressure Machine KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 12. When the patient tells the home health nurse that he has flung himself out of bed three times in the course of a violent nightmare, the nurse recognizes the cardinal indicator of:

a.

myoclonus.

b.

restless legs syndrome.

c.

rapid eye movement (REM) sleep disorder.

d.

epilepsy.

ANS: C REM sleep disorders excite excessive muscle activity during a nightmare, which causes the patient to thrash about to the point that he or she falls out of bed.

DIF: Cognitive Level: Application REF: 332 OBJ: 5 TOP: REM Sleep Disorder KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. The nurse cautions that although activity and exercise during the day are an effective sleep aid, activity and exercise should be avoided within before bedtime.

a.

30 minutes

b.

1 hour

c.

2 hours

d.

3 hours

ANS: C Exercise should be avoided within 2 hours of bedtime because activity increases the metabolic rate and may interfere with sleep.

DIF: Cognitive Level: Knowledge REF: 334 OBJ: 7 TOP: Exercise KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 14. The patient is encouraged to decrease fluid intake in the late evening to prevent interruption of sleep from:

a.

increased digestive processes in the bowel.

b.

episodes of nocturia.

c.

gastroesophageal reflux.

d.

changes in body temperature.

ANS: B Reduced fluid intake in the evening will prevent nocturia, which interrupts sleep.

DIF: Cognitive Level: Knowledge REF: 334-335 OBJ: 7 TOP: Nocturia KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 15. The nurse makes arrangements to promote normal circadian rhythm in a long-term care facility by ensuring that all rooms have:

a.

bright lights during the daytime.

b.

dim lights to promote relaxation.

c.

appropriate environmental temperature.

d.

curtains for privacy.

ANS: A Bright lights during the day support normal circadian rhythm. Environmental temperature control and privacy are important but do not affect circadian rhythm.

DIF: Cognitive Level: Application REF: 333 OBJ: 7 TOP: Circadian Rhythm KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Basic Care and Comfort MULTIPLE RESPONSE 1. The nurse is aware that an older adult’s diurnal patterns can be altered by all that apply.)

a.

shift work

b.

time zone changes

c.

altered nutrition

d.

illness

e.

medications

. (Select

ANS: A, B, D, E Nutrition does not alter diurnal patterns. All other options have the potential to alter the diurnal patterns of the older adult.

DIF: Cognitive Level: Knowledge REF: 328 OBJ: 1 TOP: Factors That Disrupt Diurnal Patterns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The long-term care facility nurse takes into consideration that most residents go to sleep early and awaken early because of . (Select all that apply.)

a.

increased blood pressure

b.

drop in core temperature

c.

diminished food intake

d.

diminished hormone production

e.

decreased exposure to light

ANS: B, E Decrease in body temperature and diminished light exposure cause circadian changes, which result in going to bed early and rising early.

DIF: Cognitive Level: Analysis REF: 329 OBJ: 2 TOP: Age-Related Changes in Circadian Rhythm KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The nurse gives the antihistamine diphenhydramine (Benadryl) as a sleep aid with caution because the older adult may experience side effects, such as . (Select all that apply.)

a.

confusion

b.

urinary retention

c.

hypotension

d.

depression of respiration

e.

diarrhea

ANS: A, B, C Benadryl can cause confusion, urinary retention, and hypotension in the older adult.

DIF: Cognitive Level: Application REF: 330, Table 20-1 OBJ: 7 TOP: Antihistamines as Sedatives KEY: Nursing Process Step: N/A MSC: NCLEX: Physiological Integrity: Pharmacological Therapies 4. When mild sedation has failed to solve the problem of insomnia in the older adult, the nurse suggests . (Select all that apply.)

a.

relaxation therapy

b.

taking a cool bath or shower before bedtime

c.

listening to relaxing music

d.

arranging the sleep environment to promote sleep

e.

going to bed at a regular time after observing routine “sleep rituals”

ANS: A, C, D, E Taking a cool bath or shower will not promote relaxation. All other options listed would encourage sleep.

DIF: Cognitive Level: Comprehension REF: 331, Health Promotions OBJ: 7 TOP: Insomnia KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse explains that factors that contribute to sleep apnea include apply.)

a.

obesity

b.

diabetes

c.

hypotension

d.

African American heritage

e.

use of alcohol

. (Select all that

ANS: A, B, D, E Hypotension does not contribute to sleep apnea. All other options are considered to be factors that contribute to sleep apnea.

DIF: Cognitive Level: Comprehension REF: 331-332 OBJ: 5 TOP: Sleep Apnea KEY: Nursing Process Step: Implementation MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease 6. The wife of a patient tells the home health nurse that she suspects her husband has sleep apnea because he . (Select all that apply.)

a.

snores loudly

b.

interrupts snoring with several seconds of silence

c.

complains of daytime drowsiness

d.

frequently is incontinent of urine

e.

has episodes of myoclonus

ANS: A, B, C Incontinence and myoclonus are not associated with sleep apnea.

DIF: Cognitive Level: Application REF: 331-332 OBJ: 5 TOP: Sleep Apnea KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 7. The nursing staff helps encourage sleep in long-term care facility residents by . (Select all that apply.)

a.

using the minimum light necessary when making rounds

b.

making necessary sleep interruptions at the same time every night

c.

keeping conversational noise at the nursing station to a minimum

d.

answering call lights promptly

e.

providing heavy blankets for warmth

ANS: A, B, C, D Heavy blankets may initially feel warm to the resident but eventually make the resident uncomfortable and unable to sleep. All other options listed will help diminish sleep interruptions.

DIF: Cognitive Level: Comprehension REF: 332-333 OBJ: 7 TOP: Sleep Support KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. The nurse knows that the older adult experiences changes in patterns of sleep, which typically include . (Select all that apply.)

a.

inability to sleep throughout the night

b.

sleeping soundly all night

c.

increase in the number of hours asleep at night

d.

difficulty in arousing from deep sleep

e.

waking up early

ANS: A, E The older adult has a decreased number of hours of sleep, wakes early, and rarely sleeps soundly.

DIF: Cognitive Level: Knowledge REF: 329 OBJ: 3 TOP: Effects of Disease Processes on Sleep KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 9. The nurse assesses that the resident may be experiencing changes in sleep and rest patterns when she states . (Select all that apply.)

a.

“I don’t know why everything seems to bother me lately.”

b.

“I’ve been so clumsy.

c.

“I’m having trouble concentrating.”

d.

“My daughter says I talk in my sleep.”

e.

“I cry for no reason at all.”

ANS: A, B, C, E Sleep talking occurs within the sleep cycle. Irritability, increased accidents, difficulty paying attention, and altered emotional stability are symptoms of an altered sleep and rest pattern.

DIF: Cognitive Level: Comprehension REF: 328 OBJ: 3 TOP: Changes in Sleep and Rest Patterns KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation COMPLETION 1. The nurse reminds the CNAs that most older adults require a minimum of per day.

hours of sleep

ANS: 7.5; 7 1/2 DIF: Cognitive Level: Knowledge REF: 328 OBJ: 2 TOP: Sleep Requirements KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse encourages the long-term facility resident experiencing insomnia to drink a glass of milk with supper and again before bedtime because milk contains the sleep-inducing agent .

ANS: tryptophan DIF: Cognitive Level: Comprehension REF: 334 OBJ: 7 TOP: Tryptophan KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse clarifies that the individual’s pattern of wakefulness and sleeping is referred to as the rhythm.

ANS: circadian diurnal DIF: Cognitive Level: Knowledge REF: 328 OBJ: 1 TOP: Circadian Rhythm KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation