GERIATRIC NURSING MSU-IIT College of Nursing
a+ True + alse
Name: _____________________ _____________________ Block: ______________________ ______________________ Score: ______________________ ______________________ Date: March 19 !"1#
<$ 4l%erl) ,atients ma) ,resent (ith non-s,eci8c a,,arentl) unrelate% an% seemingl) tri'ial com,laints$ Ma)e ecause ol%er ,atients inter,ret their ,ain or %)sfunction as =normal> signs of aging$ a+ True + alse
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1$ The geriatric assessment %i&ers from a stan%ar% me%ical e'aluation in three general (a)s$ *ne of (hich is: a+ it focuses focuses on on el%erl el%erl) ) in%i'i in%i'i%ual %uals s (ith single ,ronounce% ,rolem + it em,has em,hasi.e i.es s function functional al status status an% /ualit) of life c+ it fre/uentl) fre/uentl) takes takes a%'anta a%'antage ge of a single s,ecialist %+ It focu focuses ses on on the histor) histor) of of ,resent illness of the ,t A nurse works in a long-term care facility caring for older client. Te nurse understands tat wen an older client com!lains of !ain" It is etter etter to treat treat s)m,toms s)m,toms of ,ain ,ain imme%iatel) rather than i%entif)ing the cause$ It is assume% assume% that that ,ain ,ain is a natural natural an% e0,ecte% outcome of aging Non-,harma Non-,harmacolo cologica gicall relief relief measures measures such as massages an% (arm soaks are not e&ecti'e$ It in%ica in%icates tes that that somethi something ng is (rong$ (rong$
!$ The i'e I2s of 3eriatric assessment assessmen t inclu%es the follo(ing 45C46T: Intell Intellect ectual ual im,a im,airm irment ent Immo Immoi ili lit) t) Into Intole lera ranc nce e to heat heat Iatro Iatrogen genic ic %isor %isor%er %ers s
?$ Communication arriers in histor) taking ma) e %ue to the follo(ing 45C46T: a+ cultur cultural al incom,a incom,ati tiili ilitie ties s + memo memor) r) loss loss c+ mani manic c att attac acks ks %+ hearing hearing im,air im,airmen mentt
@$ 4l%erl) are more 'ulnerale to ina%e/uate nutrition ecause of the follo(ing 45C46T: 45C46T: a+ limite% limite% %entition %entition or ill-8tting ill-8tting %entures + %imini %iminishe% she% a,,eti a,,etite te c+ ,re'a ,re'alen lentt familia familiall con%iti con%itions ons %+ lack lack of 8nanc 8nancial ial reso resourc urces es
9 $ At a minimum a nutritional n utritional assessment in'ol'es the e'aluation of : a$ curre current nt (eigh (eightt in com,a com,aris rison on to i%eal o%) (eight $ recen recentt change changes s in 'ital 'ital signs signs c$ curre current nt me%ica me%icall ,ro ,ro'i% 'i%er er %$ h),e h),era rali lime menta ntati tion on
1"$ The follo(ing are four com,onents s,eci8c to the geriatric nutritional assessment 45C46T: a+ A nutritio nutritional nal histor histor) ) ,erforme ,erforme% % (ith some 'ersion of a nutritional health checklist + A %etaile %etaile% % %ietar) %ietar) assess assessmen mentt using a ?!-hour recall =usual intake= c+ A ,h)sic ,h)sical al e0am e0am (ith (ith ,arti ,articul cular ar reference to signs associate% (ith o'er-consum,tion an% ina%e/uate nutrition %+ Selecte% Selecte% laorator laorator) ) tests tests if a,,licale
11$ Diet of ,articular concern nee%e%+ among the el%erl) ,o,ulation inclu%e a+ insurm insurmoun ounta tale le caroh caroh)%r )%rate ate an% fat intake + 8'e or or more more ser'ing ser'ings s of fruits fruits an% 'egetales c+ three three ser'i ser'ings ngs of of ,eanut ,eanuts s an% root cro,s %+ insurmounta insurmountale le /uantit) /uantit) of foo%
1!$ These ma) e in%icators of nutritional status$
7$ *ne of the areas of a geriatric care ,ro'i%er ma) choose to assess: 6ast 6ast illnesses illnesses an% their their 8nancial 8nancial im,act im,act Current Current me%icat me%ications ions their in%ica in%ications tions an% e&ects ele'ant e le'ant ,ast e%ucationa e%ucationall attai attainment nment ecent e cent an% an% im,en%in im,en%ing g ,olitic ,olitical al change change $ *ne of the areas of a geriatric care ,ro'i%er ma) choose to assess: ehail e hailitati itati'e 'e status status an% ,rognosi ,rognosis s if retire% Current Current 'eral 'eral language language an% an% ,h)sica ,h)sicall e0ercises Nutrit Nutrition ional al stat status us an% an% nee%s nee%s inancial inancial risk risk factors factors ci'il ci'il status status an% an% usiness ,romotion acti'ities$ #$ In an) me%ical histor) es,eciall) geriatric histor) taking the historian shoul% note the i%entit) of the source of information an% the assessment of their reliailit) an% o;ecti'it)$
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general a,,earance anthro,olog) genitourinar) ca'it) u,,er e0tremit) length
17$ Serum alumin is use% to hel, %etermine (hat status a+ ,rotein an% immune status + car%io'ascular an% res,irator) status c+ renal an% ui%s status %+ en%ocrine status 1$ Serum cholesterol an% homoc)steine are use% to hel, %etermine (hat a+ risk for CED + risk for 6arkinsonFs c+ risk for Al.heimerFs %+ risk for %ementia 1#$ 40ercise o,erate in oth the short an% long-term an% decreases (hat a$ 3lucose tolerance $ Strength c$ Bloo% ,ressure an% (eight %$ Agilit) an% e0iilit) 1<$ 40ercise o,erate in oth the short an% long-term an% im!ro#es (hat a$ Car%io'ascular an% cerero'ascular risk $ *steoarthritic ;oint ,ain an% sti&ness c$ Car%io,ulmonar) 8tness %$ *steo,orosis
1?$ 4l%erl) ,eo,le slee, fe(er hours$ a+ True + alse
$%. Te nurse is !erforming an assessment on an older client wo is a#ing di&culty slee!ing at nigt. 'ic statement( if made )y te client indicates tat teacing a)out im!ro#ing slee! is necessary* >I s(im three times a (eek$G >I ha'e sto,,e% smoking cigars$G >I %rink hot chocolate efore e%time$G >I rea% for " minutes efore e%time$G
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19$ Hhat is one of the common reason for most falls a+ Increase% memor) + Mania c+ Eisual im,airment %+ Im,ro'e% functional ca,acit) !"$ isk for in;ur) assessment shoul% inclu%e the follo(ing 45C46T$ a+ amient lighting + (heelchair accessiilit)
c+ %istance an% location et(een athroom kitchen an% e%room %+ Ailit) to ri%e a motor 'ehicle
!1$ *S information is like(ise otaine% as ,art of a t),ical geriatric assessment$ a+ True + alse
!!$ *S - The most common cause of loss of ,eri,heral 'ision$ a+ Common (ith age + Macular %egeneration c+ 3laucoma %+ Cataracts
!7$ *S - The most common cause of ,ain associate% (ith 'ision$ a+ Common (ith age + Macular %egeneration c+ 3laucoma %+ Cataracts
!$ The most common cause of hearing loss of high-fre/uenc) range$ a+ cerumen + %rug-in%uce% ototo0icit) c+ 6aget2s %isease %+ common (ith age
+,. Te nurse is !ro#iding instructions to a nursing assistant regarding care of an older client wit earing loss. Te nurse tells te client wit a earing loss" Are often %istracte% a'e mi%%le ear changes es,on% to lo(-,itche% tones De'elo, moist cerumen ,ro%uction
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!<$ DiJcult) eating or slee,ing o'erfatigue shortness of reath ortho,nea can manifest as (hat %isease a+ congesti'e heart failure + h),oth)roi%ism c+ %eh)%ration %+ h),okalemia
+. A nurse is caring for an older client. 'en e#aluating te clients renal function( te nurse recalls tat wic of te following canges takes !lace as !art of te normal aging !rocess* Me%ications are metaoli.e% in larger amounts$ Urine-concentrating ailit) increases$ Tuular reasor,tion increases$ The glomerular 8ltration rate 3+ %iminishes
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!@$ Transient loss of ,o(er sensation or s,eech is associate% (ith (hat ,atholog) a+ Transient ischemic attack
+ 6arkinsonFs %isease c+ Al.heimerFs %isease %+ Dementia
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+/. Te nurse is assessing an older client. Te nurse recogni0es wic of te following as an a)normal assessment 1nding in tis client* 3ingi'al retraction Decrease% ailit) to taste Diminishe% sense of smell 4'i%ence of a%ominal ascites
7"$ Hhat is the most im,ortant consi%eration (hen a geriatric ,atient %e'elo,s a chronic con%ition a+ Decline in 8nances + Decline in social acti'ities c+ Decline in functional ca,ailit) %+ Decline in cognition 71$ An acute %isor%er of attention an% gloal cogniti'e function (hich ma) result to increase% mortalit)$ a+ 6arkinsonFs + Delirium c+ Stroke %+ Traumatic Brain In;ur) 7!$ In hos,itali.e% ,atients these ha'e een foun% out to e risk factors for the %e'elo,ment of Delirium 45C46T$ a+ ,s)choacti'e me%ications + se'ere illness such as C c+ 8nancial im,airment %+ %eh)%ration 77$ These are the clinical as,ects of Delirium 45C46T$ a+ ,resents (ith an acute change in mental status + increase% ailit) to focus c+ h),oalertness an% h),eralertness %+ uctuations in eha'ior an% le'el of cognition throughout the %a) 7$ This is of im,ortance in the ,re'ention an% management of Delirium$ a+ Increase% anti-manic %rugs + Increase% ui% intake c+ Increase% sociali.ation %+ Increase% monitoring 7#$ This is the %rug of choice for ,atients (ith othersome s)m,toms of Delirium$ a+ alo,eri%ol + Mor,hine S* c+ Trama%ol %+ Atenolol
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7<$ or ,atients (ith se'ere an0iet) an% slee, %isturance the nurse might e0,ect the ,h)sician to or%er this$ a+ Cetiri.ine + Di,enh)%ramine c+ Sim'astatin %+ Kora.e,am
7?$ This is %e8ne% in'oluntar) loss of urine of suJcient se'erit) to e a social or health ,rolem$ a+ Urinar) incontinence + Urethral incontinence c+ Urinar) stasis %+ Urinar) Tract Infection
7@$ Incontinence can e manage% through the follo(ing measures 45C46T$ a+ 40ercise + Assisti'e %e'ices c+ Hithhol%ing me%ications %+ Toileting sche%ule
79$ These are factors that contriute to fecal incontinence 45C46T: a+ Increase% muscle integrit) + %ecrease% rectal sensation or com,liance c+ %eclining mental function %+ loss of ,h)sical moilit)
"$ These are causes of consti,ation 45C46TL a+ %iet high in 8er an% high ui%s + %eh)%ration c+ immoilit) %+ me%ications such as Mor,hine
1$ These are common a,,roaches to the ,re'ention of fecal incontinence an% consti,ation 45C46T: a+ changes in %iet + increase% ,h)sical acti'it) c+ ;u%icious use of la0ati'es an% enemas %+ ,s)chologic rehailitation of ,atients (ith anatomic anormalities
!$ These are intrinsic risk factors i%entif)ing ,atients at risk for fall a+ goo% e0tremit) strength + goo% gri, strength c+ gait an% alance %e8cits %+ goo% ,erformance of %ail) acti'ities
7$ These are a%%itional intrinsic risk factors i%entif)ing ,atients at risk for fall 45C46T: 'isual im,airment cogniti'e im,airment %e,ression strengthene% e0tremit) han% gri,
$ These are like(ise i%enti8e% e0trinsic risk factors i%entif)ing ,atients at risk for fall 45C46T$ a+ use of four or more ,rescri,tion %rugs + en'ironmental im,e%iments c+ ,ro,er an% con%uci'e lighting %+ asence of athroom-safet) e/ui,ment
#$ These are like(ise i%enti8e% e0trinsic risk factors i%entif)ing ,atients at risk for fall 45C46T$ a+ use of four or more ,rescri,tion %rugs + en'ironmental im,e%iments c+ ,ro,er an% con%uci'e lighting %+ asence of athroom-safet) e/ui,ment
<$ The most useful %iagnostic e'aluation to i%entif) ,atients at risk for fall$ a+ *ser'ation of the ,atient2s alance an% gait + *ser'ation of ,atientFs me%ication histor) c+ *ser'ation of ,atientFs li'ing facilit) %+ *ser'ation of ,atientFs care ,ro'i%er
?$ 6ressure ulcers are common in immoili.e% ,atients an% increase in inci%ence (ith aging$ a+ True + alse @$ Stage of ,ressure ulcer (ith nonlanchale ,ersistent+ er)thema of intact skin$ a+ Stage I + Stage II c+ Stage III %+ Stage IE 9$ Stage of ,ressure ulcer (ith ,artial-thickness skin loss in'ol'ing the e,i%ermis the %ermis or oth$ a+ Stage I + Stage II c+ Stage III %+ Stage IE #"$ Stage of ,ressure ulcer (ith e0tension into sucutaneous tissues to the %ee, fascia (ith or (ithout un%ermining$ a+ Stage I + Stage II c+ Stage III %+ Stage IE
#1$ Stage of ,ressure ulcer e0tension into muscle one or oth$ a+ + c+ %+
Stage Stage Stage Stage
I II III IE
#!$ These are inclu%e% in the management of ,ressure ulcers 45C46T: a+ use of %ail) skin assessment + use of a ,ressure-re%ucing %e'ice c+ %ocumentation of eing at risk %+ ,s)chological consultation for ,atients (ith intrinsic an% e0trinsic risk factors
#7$ Houn% care for ,ressure ulcers inclu%es 6o'i%one-Io%ine or Beta%ine$ a+ True + alse
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,2. Te #isiting nurse o)ser#ed tat te older male client is con1ned )y is daugter-in-law to is mom. 'en te nurse suggests tat e walks to te den and 3oin te family( e says( 4Im in e#eryones way5 my daugterin-law needs me to stay ere. 4Te most im!ortant action for te nurse to take is to" Sa) nothing ecause it is est for the nurse to remain neutral an% (ait to e aske% for hel,$ Suggest to the client an% %aughter-inla( that the) consi%er a nursing home for the client$ Sa) to the %aughter-in-la( >Con8ning )our father-in-la( to his room is inhuman$G Suggest a,,ro,riate resources to the client an% %aughter-in-la( such as res,ite care an% a senior citi.enFs center$ ,,. 6uring a ome care #isit( an older client com!lains of cronic consti!ation. Te nurse tells te client to"
A. Include rice and bananas in the diet. B. Increase the intake of sugar-free products. C. Increase fluid intake to at least eight glasses a day and increase dietary fiber. D. Increase potassium in the diet.
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#<$ Aging is recogni.e% ) gerontologists as a %e'elo,mental ,rocess that: is measure% in chronological )ears$ is %irectl) relate% to here%it)$ relates to eha'ioral characteristics$ egins at the time of irth$ #?$ 6rere/uisites for the nurse (orking (ith the geriatric ,atient inclu%e an un%erstan%ing that: there is a nee% for s,eciali.e% kno(le%ge$ the geriatric ,atient (ill e ,h)sicall) im,aire%$ most geriatric ,atients (ill %e'elo, %ementia$ the geriatric ,atient (ill nee% to e closel) su,er'ise%$ #@$ A ?@-)ear-ol% resi%ent of a longterm care facilit) insists on (earing high heels an% miniskirts to the %ining room for meals an% (ill not lea'e her room (ithout 8rst a,,l)ing glamorous makeu,$ The gerontological nurse assesses that the eha'ior is relate% to: insecurit) aout her a,,earance$ tr)ing to co,e (ith the changes of aging$ %enial concerning her a%'ancing age$ her fashion consciousness$
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#9$ The nurse e0,lains that the e&ects of aging on the ner'ous s)stem result in: an accelerate% loss of neurons in the rain$ gra%uall) %eclining loss of intellectual ca,ailit)$ %ecrease% con%uction s,ee% of neurons$ a loss of long-term memor) <"$ Accor%ing to Butler a (ell-kno(n gerontologist ageism: %ehumani.es the ol%er in%i'i%ual$ is ase% on the iological theor) of aging$ is ase% on natural an% ,ur,oseful occurrences$ continues to change as the ,o,ulation age$
<1$ The nurse inclu%es in her a,,roach to nursing care that ol%er a%ult ,atients (ith mil% cogniti'e im,airment MCI+ are more likel) to %e'elo,: a+ %ementia non-Al.heimerFs t),e$
+ Al.heimerFs %ementia$ c+ 6arkinsonFs %isease$ %+ ,s)chotic %isor%ers$
<<$ An @<-)ear-ol% client has sustaine% a fracture% femur an% has ha% surger) to re,air the fracture$ The client is ruing the surgical site an% moaning$ Hhich of the follo(ing is the ,riorit) nursing inter'ention 1$ A%minister the ,rescrie% ,ain me%ication !$ Assess the clientFs ,ain le'el 7$ Determine (hen the client last ha% ,ain me%ication $ Ins,ect the surgical site •
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<<$ Hhich of the follo(ing is the a,,ro,riate assessment for res,irator) %e,ression in the ol%er a%ult after the
a%ministration of an o,ioi% for analgesia es,irator) %e,ression is: 1$ more likel) after se'eral %oses of the same %rug !$ most likel) after the 8rst %ose 7$ unlikel) ecause the o,ioi% is not ,rescrie% for the ol%er a%ult in large %oses $ unlikel) if the %rug is gi'en orall)
%ail) li'ing$ Hhich of the follo(ing is the most a,,ro,riate res,onse 1+ >DonFt (orr) )our mother is safe in the long-term care facilit)$G !+ >Pou nee% to remin% )our mother ho( to ,erform her asic nee%s$G 7+ >Pour mother (ill get (orse as time goes on an% the %ementia ,rogresses$G + >This must e frustrating for )ou$G •
@G on a scale of " to 1"$ Hhich of the follo(ing is the e0,ecte% outcome of the nursing care for the client 1+ The client %oes not ask for ,ain me%ication !+ The client self-me%icates (ith an o'er-the-counter me%ication 7+ The client 'erali.es satisfaction (ith the le'el of ,ain an% ,ain control + The client states the ,ain is >G on a scale of " to 1" •
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<@$ The nurse assesses (hich of the follo(ing ,h)siological manifestations as in%icting that the client is e0,eriencing acute ,ain Select all that a,,l) O 1+ Eerali.ation of ,ain O !+ Cr)ing O 7+ ),ertension O + lushing O #+ Tach)car%ia O <+ Moist skin
<9$ The nurse has %etermine% that a confuse% ol%er a%ult client (ho kee,s ,ulling out the intra'enous line an% in%(elling catheter is in nee% of soft (rist restraints$ Hhich of the follo(ing shoul% the nurse inclu%e in this clientFs ,lan of care 1$ *tain a ,$r$n$ restraint or%er !$ Assess the ,lacement of the (rist restraints skin an% circulation e'er) hour an% %ocument 7$ 6lace the client in a su,ine ,osition after a,,l)ing the restraints an% secure the (rist restraints to the si%e rails (hen the client is in e% $ emo'e the restraints once e'er) four hours to ,erform acti'ities of %ail) li'ing$ •
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?"$ A famil) e0,resses concern to the nurse (hen their 9<-)ear-ol% mother (ith %ementia li'ing in a long-term care facilit) seems more confuse% an% %oes not rememer the acti'ities of
?1$ A ??-)ear-ol% client e0,resses concern to a nurse in a (alk-in ,s)chiatric clinic of >going cra.) or ha'ing Al.heimerFs %iseaseG ecause of feelings of eing o'er(helme% an% sa% all the time an% mis,lacing things$ Hhich of the follo(ing is the ,riorit) for the nurse to inclu%e in this clientFs ,lan of care 1+ Assist the client to %e'elo, areas of strength in co,ing !+ Make a ,s)chosocial assessment 7+ 40,lore the a'ailale su,,ort for the
client + Assure the client an% %is,el the i%ea of >going cra.)G ?!$ U,on a%mission to a long-term care facilit) an @7-)ear-ol% client is (ith%ra(n sitting /uietl) in a chair (ith the ack to the %oor of the room$ Hhen the nurse s,eaks to the client the client sa)s go a(a) an% lea'e me alone$ S,en% )our time on someone (ho can use it$ I ;ust %onFt (ant to li'e if I ha'e to sta) here$G Hhich of the follo(ing is the ,riorit) nursing action 1$ Create a (elcome an% cheerful atmos,here !$ 4ncourage the client to %iscuss the feelings of ho,elessness 7$ Allo( the client to ha'e ,erio%s of solitu%e as aske% for $ Assess for %e,ression an% suici%e ,otential •
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?7$ An @<-)ear-ol% client su%%enl) ecomes confuse% aout time ,lace an% ,erson$ After e'aluating the o0)gen saturation to e 9@ (hich of the follo(ing shoul% the nurse assess 8rst 1$ Hhat me%ication the client is taking !$ Eital signs 7$ 6ossiilit) of a recent fall $ The clientFs ,ain le'el ?$ The nurse assesses a
Select all that a,,l) O 1+ alos aroun% lights O !+ Decrease in 'ision O 7+ 4)e ,ain O + Anormal color ,erce,tion O #+ 3lare O <+ ea%ache •
com,lete me%ical (orku, inclu%ing a CT scan of the hea% has sho(n no me%ical cause for the cogniti'e changes$ The nurse e0,lains to the client an% famil) that the me%ical %iagnosis of Al.heimerFs %isease is ase% on 1+ The information that no other cause can e foun% for the changes !+ A loo% test for C-reacti'e ,rotein that (as ,ositi'e 7+ A loss of function seen on the MiniMental State 40amination + The results of an 0-ra) of the skull sho(ing a %ecrease in the si.e of the rain
?#$ The nurse assesses a 9!-)ear-ol% client (ho has e0,erience% a recent cereral 'ascular acci%ent CEA+ (ith cranial ner'e EII %)sfunction to e e0hiiting (hich of the follo(ing manifestations 1$ Koss of sense of smell !$ 6tosis 7$ DiJcult) of s(allo(ing $ As)mmetr) of facial features •
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?<$ The nurse shoul% inclu%e (hich of the follo(ing foo%s that has the most ,otassium ,er ser'ing (hen instructing a ?!-)ear-ol% client aout foo%s that are high in ,otassium 1+ Milk !+ *ranges 7+ Colas + Chicken ??$ A #<-)ear-ol% client %iagnose% (ith Stage I earl)-onset+ Al.heimerFs %isease li'es at home (ith famil)$ A %aughter asks the nurse >o( long (ill Da% e like this efore his memor) returnsG The est initial res,onse the nurse can make is 1+ >e ma) ne'er get etterG !+ >This is ;ust the eginning of a ,re%icte% %ecline$G 7+ >Tell me (hat )ou kno( aout Al.heimerFs %isease$G + >Is he taking his me%icine for Al.heimerFs %iseaseG
?@$ An ol%er a%ult is ,icking at clothing an% muttering >Butteries are all o'er me$G The nurse %oes not see an) utteries$ Hhich of the follo(ing is the ,riorit) for the nurse to ,erform 1$ I%entif) an) risk for in;ur) relate% to altere% thought ,rocess !$ Call for hel, 7$ 6ro'i%e a non-stimulating en'ironment $ Inform the client there are no utteries in the room
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?9$ An *l%er a%ultFs cogniti'e function has %ecline% o'er the last t(o )ears$ The famil) is concerne% ) the loss of short-term memor) an% the safet) issues ,ose% ) the forgetfulness$ A
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@"$ Hhen assessing an ol%er a%ult the nurse shoul% e alert to the clinical manifestations of %e,ression that ma) e maske% ) other chronic con%itions$ The car%inal an% ,rimar) eha'ior e0hiite% in the %e,resse% ol%er a%ult is 1+ A loss of interest in ,re'iousl) ,leasurale acti'ities !+ Inacti'it) 7+ Drinking alcohol + Cr)ing @1$ Done.e,il h)%rochlori%e Arice,t+ has een ,rescrie% for a client (ith Al.heimerFs %isease$ Hhich of the follo(ing a%'erse reactions shoul% the nurse inclu%e in the me%ication instruction gi'en to the famil) Select all that a,,l) O 1+ ea%ache O !+ Tach)car%ia O 7+ Insomnia O + ),otension O #+ Consti,ation O <+ Anore0ia @!$ Hhich of the follo(ing is a ,riorit) for the nurse to assess (hen e'aluating the h)%ration of an @?-)earol% client 1$ eight an% (eight !$ 6re'ious !-hour intake 7$ Skin turgor on the ack of the han% $ Bloo% ,ressure @7$ During ,h)sical assessment of an ol%er a%ult the nurse shoul% re,ort (hich of the follo(ing car%io'ascular changes that has occurre% as a result of %eh)%ration 1$ Hi%ene% ,ulse ,ressure !$ Tach)car%ia 7$ ),ertension $ Decrease% res,irator) rate
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@$ The nurse e'aluates (hich of the follo(ing nursing assessment 8n%ings to e consistent (ith o'er-h)%ration in a ?!-)ear-ol% client a%mitte% (ith congesti'e heart failure 1$ 6eriorital e%ema !$ 4%ema of the han%s 7$ 6ro;ectile 'omiting $ Moist rales @#$ An @"-)ear-ol% client (ho is con8ne% to e% ecause of generali.e% (eakness confusion an% %isorientation is a%mitte% to the hos,ital (ith %eh)%ration$ The famil) asks the nurse (h) the client is eing turne% e'er) t(o hours$ The nurse res,on%s that turning the client e'er) t(o hours is necessar) to ,re'ent %ecuitus ulcers as a result of ___________________$ @<$ A 97-)ear-ol% client has een functioning in%e,en%entl) in the home ut has su%%enl) ecome confuse%$ A famil) memer asks the nurse >Does this mean Da% has Al.heimerFs %iseaseG Hhich of the follo(ing is the most a,,ro,riate res,onse 1+ >It is 'er) likel) that )our father has Al.heimerFs %isease$G !+ >Hh) %o )ou think )our father has %ementiaG 7+ >Confusion can e a sign of an infection in the ol%er a%ult$G + >Pour father (ill ha'e to e monitore% o'er time$G
@?$ Before ,re,aring to use the MiniMental State 40amination for cogniti'e function in an ol%er a%ult the nurse shoul% consi%er (hich of the follo(ing limitations of the e0am 1$ The test takes one hour to a%minister !$ The client must e ale to see an% (rite 7$ The e0am must take ,lace in a %iml) lit room $ The e0am is 'ali% onl) (ith 4nglishs,eaking clients
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@@$ The nurse shoul% consi%er (hich of the follo(ing me%ical etiologies in an ol%er a%ult (ho has een health) until recentl) ut has %e'elo,e% %ementia 1+ Se0uall) transmitte% %iseases !+ 4lectrol)te imalances 7+ Arthritis + Ki'er %isease
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@9$ Hhich of the follo(ing four ol%er a%ult clients that the nurse is caring for %oes the nurse e'aluate as most atrisk for self-%irecte% 'iolence 1+ A ?<-)ear-ol% single man (ho li'es in a retirement center an% engages in communit) acti'ities !+ A (i%o(e% man (ho is @@ )ears ol% li'es alone an% has multi,le chronic illnesses 7+ An @7-)ear-ol% (oman (ho has t),e ! %iaetes mellitus an% li'es (ith her %aughter + A recentl) (i%o(e% (oman (ith multi,le chronic illnesses (ho li'es near famil) 9"$ An ol%er a%ult client (ith chronic %e,ression tells the nurse >DonFt (orr) aout me$ I can manage the ,ain of m) arthritis$ The (a) I mi0 u, m) me%ications hel,s$G The est initial res,onse of the nurse is 1+ >DonFt mi0 )our me%ications ) )ourself$ Take them onl) as ,rescrie%$G !+ >That is %angerous$ I (ill ha'e to take )our narcotics from )ou$G 7+ >That is %angerous$ I (ill ha'e to call )our %aughter an% ha'e her gi'e )ou )our me%ications$G + >Tell me (hat )ou take an% ho( )ou mi0 them$G 91$ The nurse is caring for an ol%er a%ult (ith situational %e,ression follo(ing the %eath of a s,ouse$ Hhat is the most im,ortant outcome for a nurse to ,lan for 1+ The client (ill %iscuss the s,ouse an% the meaning of the loss !+ The client (ill not cr) 7+ The client (ill s,eak of the s,ouse onl) ,ositi'el) + The client (ill a'oi% talking aout the s,ouse an% engage in social acti'ities$ 9!$ A memer of an ol%er clientFs famil) asks the nurse (h) me%ications are or%ere% a half of the usual %ose$ Hhich of the follo(ing is the most a,,ro,riate res,onse 1+ >Me%ications for the ol%er a%ult are ,rescrie% at a ,e%iatric %ose$G !+ >The metaolism of an ol%er a%ult is much like that of a chil% of the same (eight$G
7+ >Me%ications for the ol%er a%ult ma) e at lo(er %oses initiall) until res,onses are e'aluate%$G + >*l%er a%ults generall) take a lo(er %ose of a me%ication ecause of the cost$G 97$ Hhen the nurse is taking a nursing histor) on a client the client mentions >I sli,,e% on a (et s,ot on the (a) to the athroom$G Hhich of the follo(ing is a ,riorit) for the nurse to ask 1+ >a'e )ou starte% on an) ne( me%icationsG !+ >Do )ou %rink ca&einate% e'eragesG 7+ >a'e )ou e0,erience% an) incontinent e,iso%esG + >a'e )ou een feeling e0cessi'el) (eak recentl)G
a client (ith eha'ior ,rolems relate% to %ementia 1+ Inform the client (h) the nursing inter'entions are necessar) !+ Instruct the caregi'ers on the ,rocess of %ementia an% care to e gi'en 7+ Be consistent ) re,eating the same inter'ention as the clientFs %ementia ,rogresses + Assist the client to ,erform %iJcult
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!+ Increase %ail) 8er an% ui%s 7+ Kimit the a%ministration of the me%ications to se'ere ,ain + A'oi% taking the me%ication more than t(o times a %a)
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9$ Hhich of the follo(ing shoul% the nurse inclu%e in the me%ication instructions for an ol%er a%ult (ho has ack ,ain an% a mil% o,ioi% (ith co%eine has een ,rescrie% 1+ Assess the res,irations three times
a %a)
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1+ A return of memor) !+ Increase% retention of information 7+ A catastro,hic reaction + An interest in ha'ing a calen%ar •
9#$ A hos,ice nurse caring for a terminall) ill client shoul% titrate the %ose of mor,hine sulfate gi'en to an ol%er a%ult ase% on (hich of the follo(ing assessments 1+ Bloo% ,ressure !+ Ke'el of consciousness 7+ Ke'el of ,ain + e/uest of the famil) 9<$ An ol%er a%ult asks a nurse (h) a %ail) ath is necessar)$ The nurse shoul% res,on% that %ail) athing: 1+ Stimulates circulation ,ro'i%es rela0ation an% moili.es ;oints !+ A%%s h)%ration an% ,re'ents %r)
skin 7+ Inclu%ing coming an% rushing of hair hel,s to remo'e e0cess oil from the scal, + An article on the im,ortance of h)giene •
9?$ Hhich of the follo(ing is the ,riorit) nursing inter'ention for the nurse to inclu%e in the ,lan of care for
9@$ A nurse oser'es a famil) memer continuall) remin%ing a client in late Stage II Al.heimerFs %isease of the %ate an% ,lace$ The client is a%amant that it is 19!! an% in the North 6ole$ The nurse informs the famil) memer that continuall) remin%ing the client of the %ate an% ,lace (ill result in
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99$ An @"-)ear-ol% client is a%mitte% to the intensi'e care unit ecause of hemorrhaging after a stent is ,lace% on her left femoral arter) to im,ro'e circulation to the leg$ The client is confuse% not follo(ing instructions an% ,ulling at the intra'enous tuing an% in%(elling catheter$ The clientFs a%ult son tells the nurse >M) mom (as ne'er like this efore$ Hhat ha'e )ou %one to herG The est initial res,onse the nurse can make is 1+ >HeF'e %one nothing to her$ She must ha'e %ementia$G !+ >*l%er a%ults (ill ecome confuse% after a lee% to the rain from %ecrease% o0)genation$G 7+ >Pour mother is acting like she is in alcohol (ith%ra(al$ Does she %rinkG + >Pou (ill nee% to talk to )our motherFs ,h)sician to get information aout her con%ition$G 1""$ An ol%er client in a nursing facilit) su%%enl) ecomes confuse% ,aranoi% an% 'erall) ausi'e to the sta&$ Hhich of the follo(ing is the ,riorit) nursing action 1+ Ask the famil) memers if the) ha% a recent %isagreement (ith the client
!+ Assess the 'ital signs an% otain a urine s,ecimen 7+ eorient the client to ,erson ,lace an% time + Ask (hether the client is hearing 'oices$
!+ Ask the client (hat ADKs are acce,tale to ,erform 7+ 6ro'i%e total care for a client (ho is han%ica,,e% + Assess the clientFs ailities an% ,references
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Bonus Question: The nurse assesses (hich of the follo(ing eha'iors in a client in earl) Stage I Al.heimerFs %isease Select all that a,,l) O 1+ Masks forgetful eha'ior O !+ as a slo( reaction time O 7+ e,etiti'e stor)telling O + Inailit) to follo( sim,le %irections O #+ Becomes angr) (hen challenge% O <+ Change in eating ,atterns •
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Bonus Question: The nurse 8n%s an @@)ear-ol% client l)ing on the oor unres,onsi'e$ The ,riorit) nursing action for the nurse to take is 1+ Start C6 !+ Notif) the ,h)sician 7+ 6lace the client ack in e% + Assess the res,irations an% ,ulse
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Bonus Question: Hhich of the follo(ing shoul% the nurse inclu%e in the instructions gi'en to an ol%er a%ult aout self-care an% h)giene to achie'e a ,ositi'e outcome
Bonus Question: An ol%er a%ult client (ith %ementia ecomes increasingl) confuse% an% (an%ers a(a) from a long-term facilit)$ The a,,ro,riate nursing action is to 1+ Call reinforcement oJcials !+ estrain the client 7+ ollo( the client an% re%irect from a safe %istance + *&er the client a ri%e ack to the
facilit) 1+ A %etaile% %escri,tion of the ,roce%ures !+ A (ritten %escri,tion of the outcomes 7+ A %escri,tion of the care centerFs routines + An article on the im,ortance of h)giene •
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Bonus Question: The nurse e'aluates (hich factor as a ,riorit) that (ill a%'ersel) a&ect moilit) an% self-care in the ol%er a%ult 1+ Heakness !+ Ke'el of consciousness 7+ Disease + amil) assistance Bonus Question: *l%er clients ha'e in%i'i%ual ,references in carr)ing out acti'ities of %ail) li'ing ADKs+$ The nurse shoul% inclu%e (hich inter'ention as a ,riorit) for encouraging in%e,en%ence in ADKs 1+ Allo( the client to %eci%e (hen to ha'e a ath
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Bonus Question: Hhich of the follo(ing shoul% the nurse inclu%e in the e%ucation ,ro'i%e% to a ne( gra%uate nurse to ,rotect the nurse from in;ur) (hen a client (ith %ementia or %elirium ecomes aggressi'e 1+ 3entl) ,lace a han% on the clientFs shoul%er to ,romote trust !+ Kea% the client to the acti'it) area (here there are others to %istract the client 7+ 6ro'i%e a /uiet calm atmos,here an% o&er sim,le %irections + *&er the client a meal
> Too often (e un%erestimate the ,o(er of a touch a smile a kin% (or% a listening ear an honest com,liment or the smallest act of caring all of (hich ha'e the ,otential to turn a life aroun%$G Keo B$
