Medical surgical nursing in canada 4th edition lewis test bank

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Chapter 07: Older Adults Lewis: Medical-Surgical Nursing in Canada, 4th Canadian Edition MULTIPLE CHOICE 1. Findings from a health history indicate that the client takes daily supplements of the

antioxidants beta carotene, vitamin C, and vitamin E. This health practice reflects which of the following theories of biological aging? a. Free radicals b. Crosslinking c. Somatic mutation d. Telomere-telomerase depletion ANS: A

Free radicals are natural by-products of many normal cellular processes and are also created under the influence of environmental factors such as smog, tobacco smoke, and radiation. Numerous natural protective mechanisms are in place to prevent oxidative damage. Recent research has focused on the roles of various antioxidants, including vitamins C and E, in slowing down the oxidative process and, ultimately, the aging process. The somatic mutation theory focuses on spontaneous mutations. The crosslinking theory is based upon lipids, proteins, CHO, and nucleic acid reactions. The telomere-telomerase depletion theory focuses on the loss of telomeres, repeated sequences at the ends of DNA. DIF: Cognitive Level: Comprehension TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is assessing the nutritional status of an older-adult client using the SCALES

acronym. Which of the following should the nurse assess when completing the “S”? a. Serum potassium level b. Sadness or mood change c. Social support d. Sexual intimacy ANS: B

The acronym SCALES can be used to remind the nurses to assess important nutritional indicators. In the case of the “S,” the nurse is to assess sadness or mood changes.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 3. The nurse is planning care for an alert and active older-adult client who takes multiple

medications for chronic cardiac and respiratory disease and lives with a daughter who works during the day. Which nursing diagnosis is most appropriate? a. Risk for injury as evidenced by exposure to toxic chemical (drug-drug interactions) b. Social isolation related to social behavior incongruent with norms (weakness and fatigue) c. Disabled family coping related to differing coping styles between support person and client d. Caregiver role strain related to increase in care needs

ANS: A

The client’s age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. The client data do not indicate problems with social isolation, caregiver role strain, or compromised family coping.

DIF: Cognitive Level: Application TOP: Nursing Process: Diagnosis MSC: NCLEX: Health Promotion and Maintenance 4. Which of the following actions would enable the nurse to obtain the most complete

information when doing an assessment with an older-adult client? a. Interview both the client and the primary client caregiver. b. Use a geriatric assessment instrument to evaluate the client. c. Review the client’s chart for the history of medical problems. d. Ask the client to write down medical problems and medications.

ANS: B

The most complete information about the client will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the chart, interviews of the client and caregiver, and written information by the client will all be included in a comprehensive geriatric assessment.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 5. Which of the following actions should the nurse consider when developing the plan of care

for an older adult who is hospitalized for an acute illness? a. Use a standardized geriatric nursing care plan. b. Minimize activity level during hospitalization. c. Plan for transfer to a long-term care facility after the hospitalization. d. Consider preadmission functional abilities when setting client goals.

ANS: D

The plan of care for older adults should be individualized and based on the client’s current functional abilities. A standardized geriatric nursing care plan will not address individual client needs and strengths. A client’s need for discharge to a long-term care facility is variable. Activity level should be designed to allow the client to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

DIF: Cognitive Level: Application MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

6. The nurse is caring for clients in a geriatric family practice clinic with a primary health

care provider. Which of the following actions should the nurse do when caring for older adults who live in rural areas? a. Assess the client for chronic diseases that are unique to rural areas. b. Ensure transportation to appointments with the health care provider. c. Schedule appointments for the client in an urban area for better health care. d. Obtain adequate medications for the client to last for 4–6 months.

ANS: B

Transportation can be a barrier to accessing health services in rural areas. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the client plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. The client living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 7. The nurse is providing care to older adults in a Northern outreach clinic. Which nursing

action will be most helpful in decreasing the risk for drug-drug interactions? a. Teach the client to have all prescriptions filled at the same pharmacy. b. Instruct the client to avoid taking over-the-counter (OTC) medications. c. Make a medication schedule for the client as a reminder about when to take each medication. d. Have the client bring all the medications, supplements, and herbs to every health care appointment.

ANS: D

The most information about drug use and possible interactions is obtained when the client brings all prescribed medications, OTC medications, and supplements to every health care appointment. The client should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but use of supplements and herbal medications also need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the client take medications as scheduled but will not prevent drug-drug interactions.

DIF: Cognitive Level: Application MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

8. Which action will the nurse take when planning for discharge of an older-adult client who

will need daily assistance with activities such as shopping and transportation? a. Complete a referral to Medicare. b. Apply for transfer to an assisted-living facility. c. Arrange for home health care visits. d. Apply for attendance at an adult day care program.

ANS: C

Home health care visits, from an unregulated health care worker, can enable the client to remain at home but obtain assistance with shopping and transportation. Medicare, assisted-living facilities, and adult day care programs provide funding for specific medical services, but not for needs such as shopping or transportation.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Safe and Effective Care Environment

9. The nurse is caring for an older-adult client with multiple health problems who states that

who reports having “no energy” and feeling increasingly weak. The client has had a 5 kg weight loss over the last year. Which of the following interventions should the nurse implement initially? a. Ask the client about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Discuss long-term care placement with the client. d. Describe normal changes with aging to the client.

ANS: A

In the frail elderly client, nutrition is frequently compromised, and the nurse’s initial action should be to assess the client’s nutritional status. Active range of motion may be helpful in improving the client’s strength and endurance, but nutritional assessment is the priority because the client has had a significant weight loss. The client may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The client’s assessment data are not consistent with normal changes associated with aging.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 10. The nurse is admitting an acutely ill older-adult client to the hospital. Which of the

following interventions should the nurse implement during the admission process? a. Speak slowly and loudly while facing the client. b. Obtain a detailed medical history from the client. c. Interview the client before the physical assessment. d. Determine whether the client uses glasses or hearing aids.

ANS: D

Assistive devices should be in place before assessing the client to minimize anxiety and confusion. When a client is acutely ill, the physical assessment should be accomplished first to detect any physiological changes that require immediate action. Not all older clients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older clients. To avoid tiring the client, much of the medical history can be obtained from medical records.

DIF: Cognitive Level: Application TOP: Nursing Process: Planning MSC: NCLEX: Health Promotion and Maintenance 11. The home health nurse is caring for an older-adult client who lives alone and is taking

seven different prescribed medications for chronic health problems. Which of the following nursing interventions would be most appropriate to ensure medication regimen adherence? a. Use a marked pillbox to set up the client’s medications. b. Discuss the option of moving to an assisted-living facility. c. Remind the client about the importance of taking medications. d. Visit the client daily to administer the prescribed medications.

ANS: A

Since forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the client needs to move to assisted living or that the client does not understand the importance of medication regimen adherence.

Home health care is not designed for the client who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

DIF: Cognitive Level: Application MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation

12. Which information obtained by the home health nurse when making a visit to a frail

older-adult client with mild forgetfulness is of concern? a. The client tells the nurse that a close friend recently died. b. The client has lost 4.5 kg during the last month. c. The client is cared for by a daughter during the day and stays with a son at night. d. The client’s son uses a marked pillbox to set up the client’s medications weekly.

ANS: B

A 4.5 kg weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this client. It is not unusual that an elderly adult would have friends who have died.

DIF: Cognitive Level: Application MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

13. Which information about an older-adult client who is being assessed by the home health

nurse is of most concern? a. The client organizes medications in a marked pillbox “so I don’t forget them.” b. The client uses three different medications for chronic heart and joint problems. c. The client says, “I don’t go on my daily walks since I had pneumonia 3 months ago.” d. The client tells the nurse, “I prefer to manage my life without much help from others.”

ANS: C

Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the client.

Self-management is appropriate for independently living older adults. The use of three medications is not unusual for an older adult. The use of memory devices to assist with safe medication administration is recommended for older adults.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 14. The nurse is admitting an older-adult client who has urinary urgency and a possible

urinary tract infection (UTI). Which of the following actions should the nurse implement first? a. Assess the client’s orientation. b. Inspect for abdominal distension. c. Question the client about hematuria.

d. Invite the client to use the bathroom.

ANS: D

Before beginning the assessment of an older client with a UTI and urgency, the nurse should have the client empty the bladder because bladder fullness or discomfort will distract from the client’s ability to provide accurate information. The client may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the client is as comfortable as possible.

DIF: Cognitive Level: Application MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

15. The nurse is teaching an older-adult female client about her new medications and the client

replies that she “just can’t remember all that information anymore.” Which of the following changes may interfere with the clients’ ability to learn about the new medications? a. Intellectual ability declines with age. b. All mental abilities slow as individuals age. c. Declining physical health can impair cognitive function. d. Impaired vocabulary and verbal function decrease reasoning with age.

ANS: C

Declining physical health is an important factor in cognitive impairment. Intellectual ability does not decline with age. All mental abilities do not slow as an individual ages.

Vocabulary and verbal function do not decrease with age.

DIF: Cognitive Level: Application MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning

16. The nurse is admitting an older-adult client who is hospitalized with an acute illness.

Which of the following interventions should the nurse do first? a. Orientate the client to their room. b. Administer the prescribed PRN sedative medication. c. Ask the health care provider to order a vest restraint. d. Place the client in a “geri chair” near the nurse’s station for observation.

ANS: A

The older adult who moves to a different location needs a thorough orientation to the environment. The nurse should repeatedly reassure the client that he or she is safe and attempt to answer all questions. The unit should foster client orientation by displaying large-print clocks, avoiding complex or visually confusing wall designs, clearly designating doors, and using simple bed and nurse-call systems. Physical or chemical restraints may be necessary, but the nurse’s first action should be to provide an ongoing and clear physical orientation. There is no indication that the client needs observation at this time.

DIF: Cognitive Level: Application TOP: Nursing Process: Implementation MSC: NCLEX: Safe and Effective Care Environment 17. The nurse suspects that elder abuse may be occurring when a frail older-adult client with a

broken arm is brought to the emergency department by a family member. Which of these actions should the nurse take first?

a. b. c. d.

Notify an elder protective services agency about the possible abuse.

Make a referral for a home assessment visit by the home health nurse.

Have the family member stay in the waiting area while the client is assessed.

Ask the client how the injury occurred and observe the family member’s reaction.

ANS: C

The initial action should be assessment and interviewing of the client. The client should be interviewed alone because the client will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the client should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document physiological data before notifying the elder protective services agency.

DIF: Cognitive Level: Application MSC: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment

MULTIPLE RESPONSE 1. Which nursing actions will the nurse take to assess for possible malnutrition in an

older-adult client? (Select all that apply.) a. Observe for depression. b. Review laboratory results. c. Assess teeth and oral mucosa. d. Ask about transportation needs. e. Determine food likes and dislikes.

ANS: A, B, C, D

The laboratory results, especially albumin levels, may indicate chronic poor protein intake.

Transportation impacts clients’ ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance 2. The nurse is visiting a homeless shelter for older adults to provide a health-promotion

activity. Which of the following factors are associated with adult homelessness? (Select all that apply.) a. Low income b. Reduced cognitive capacity c. Decreased health problems d. Abundance of affordable housing e. Living alone ANS: A, B, E

Key factors associated with homelessness are low income, reduced cognitive capacity, and living alone. There is a shortage of affordable housing and homeless adults generally have an increase in health problems.

DIF: Cognitive Level: Application TOP: Nursing Process: Assessment MSC: NCLEX: Health Promotion and Maintenance