Ch.15-30 Flashcards
Which definition correctly describes a person’s functional ability?
a.
Functional ability is the measure of the expected changes of aging that a person is experiencing.
b.
Functional ability refers to an individual’s motivation to live independently.
c.
Functional ability refers to the level of cognition present in an older person.
d.
Functional ability refers to a person’s ability to perform activities necessary to live in modern society.
D
The nurse is preparing to perform a functional assessment of an older patient, and knows that a good approach would be to:
a.
observe the patient’s ability to perform tasks.
b.
ask the patient’s wife how well he performs tasks.
c.
review the medical record for information about the patient’s abilities.
d.
ask the patient’s physician for information about the patient’s abilities.
A
The nurse will choose which of the following tools to assess a patient’s ability to perform activities of daily living?
a.
Direct Assessment of Functional Abilities (DAFA)
b.
Lawton and Brody IADL
c.
Katz Index
d.
Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL (OARS-IADL)
C
Which of the following statements about the Lawton IADL instrument is true?
a.
The nurse uses direct observation to implement this tool.
b.
It is designed as a self-report measure of performance, rather than ability.
c.
It is not useful in the acute hospital setting.
d.
It is best used for those residing in an institutional setting.
B
The nurse is assessing an older adult’s advanced activities of daily living, which would include: a. recreational activities. b. meal preparation. c. balancing the chequebook. d. self-grooming activities.
A
When using the various instruments to assess an older person’s activities of daily living, the nurse needs to remember that a disadvantage of these instruments includes:
a.
the reliability of the tools.
b.
the self or proxy report of functional activities.
c.
the lack of confidentiality during the assessment.
d.
insufficient detail about the deficiencies identified.
B
The nurse is administering a test that is timed over 15 minutes, and assesses a person’s upper body fine and coarse motor activities, balance, mobility, coordination, and endurance. During this test, activities such as dressing and stair climbing are timed. Which test is described by these activities? a. The Up and Go Test b. The Performance Activities of Daily Living c. The Physical Performance Test d. Tinetti Gait and Balance Evaluation
C
A patient will be ready to be discharged from the hospital soon, and the patient’s family members are concerned about whether he is able to go outside alone safely. The nurse will perform which test to assess this ability? a. The Up and Go Test b. The Performance Activities of Daily Living c. The Physical Performance Test d. Tinetti Gait and Balance Evaluation
A
The nurse is assessing the forms of support an older patient has before she is discharged. Which of the following illustrates an informal source of support? a. The local senior centre b. Her cleaning lady c. Her Meals on Wheels meal delivery service d. Her neighbour, who visits with her daily
D
An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: a. depression. b. weight gain. c. hypertension. d. social phobias.
A
During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday’s events. The nurse administers the Mini Mental State Examination, which will screen for: a. dementia. b. depression. c. delirium. d. psychosis.
C
During an assessment of a newly admitted 92-year-old woman, the nurse notes that her son does not want to leave the room. The woman has signs of old bruises and healed cuts that happened “last week,” according to the son. Which of the following actions by the nurse is appropriate?
a.
Ask the son for details about the nature of the patient’s injuries.
b.
Recognize that older people are often unsteady on their feet, and that falls do occur.
c.
Notify the authorities of a potential abusive situation.
d.
Recognize that these findings do not necessarily indicate that abuse has occurred, but are signs that further assessment is needed.
D
Which of the following statements regarding common environmental hazards is most appropriate for the nurse to make during a functional assessment of an older person’s home environment?
a.
“These low toilet seats are safe because they are nearer to the ground in case of falls.”
b.
“Ask a relative or friend to help you to install grab bars in your shower.”
c.
“These small rugs are ideal for preventing you from slipping on the hard floor.”
d.
“It would be safer to keep the lighting low in this room to avoid glare in your eyes.”
B
Which of the following questions would be most appropriate for the nurse to ask when beginning to assess a person’s spirituality? a. “Do you believe in God?” b. “Do you consider yourself to be a spiritual person?” c. “What religious faith do you follow?” d. “Do you believe in the power of prayer?”
B
The nurse is preparing to assess an older adult, and discovers that he is in severe pain. Which of the following statements about pain and the older adult is true?
a.
Pain is inevitable with aging.
b.
Older adults with cognitive impairment feel less pain.
c.
Alleviating pain should take priority over other aspects of the assessment.
d.
The assessment should take priority so that care decisions can be made.
C
The nurse is assessing the abilities of an older adult. Which of the following activities are considered instrumental activities of daily living? Select all that apply. a. Feeding oneself b. Preparing a meal c. Balancing a chequebook d. Walking e. Toileting f. Grocery shopping
B,C,F
Which of the following best describes the action of the hormone progesterone during pregnancy?
a.
It produces the hormone human chorionic gonadotropin.
b.
It stimulates duct formation in the breast.
c.
It promotes sloughing of the endometrial wall.
d.
It maintains the endometrium around the fetus.
D
A female patient is experiencing nausea, breast tenderness, fatigue, and amenorrhea. Her last menstrual period was 6 weeks ago. The nurse recognizes that this patient is experiencing: a. positive signs of pregnancy. b. possible signs of pregnancy. c. probable signs of pregnancy. d. presumptive signs of pregnancy.
D
When performing the examination of a woman who is 8 weeks pregnant, the nurse notes that her cervix is a bluish colour. The nurse would document this finding as: a. Hegar’s sign. b. Homan’s sign. c. Chadwick’s sign. d. Goodell’s sign.
C
A woman who is 8 weeks pregnant is visiting the clinic for a checkup. Her systolic blood pressure is 30 mm Hg higher than her pre-pregnancy blood pressure. The nurse would:
a.
consider this a normal finding.
b.
expect the blood pressure to decrease as the estrogen levels increase throughout the pregnancy.
c.
consider this an abnormal finding, because blood pressure is typically lower at this point in the pregnancy.
d.
recommend that she decrease her salt intake in an attempt to decrease her peripheral vascular resistance.
C
A patient is being seen at the clinic for her 10-week prenatal visit. She asks when she will be able to hear the baby’s heartbeat. The nurse should reply:
a.
“The baby’s heartbeat is not usually heard until the second trimester.”
b.
“The baby’s heartbeat may be heard anywhere from the ninth to the twelfth week.”
c.
“It is often difficult to hear the heartbeat at this point, but we can try.”
d.
“It is normal to hear the heartbeat at 6 weeks. We may be able to hear it today.”
B
A patient who is in her first trimester of pregnancy tells the nurse that she is experiencing significant nausea and vomiting, and asks when it will improve. The nurse should reply:
a.
“Did your mother have significant nausea and vomiting?”
b.
“Many women experience nausea and vomiting until the third trimester.”
c.
“Usually, by the beginning of the second trimester, the nausea and vomiting improve.”
d.
“At about the time you begin to feel the baby move, the nausea and vomiting will subside.”
C
During the examination of a woman in her second trimester of pregnancy, the nurse notes the presence of a small amount of yellow drainage from the nipples. The nurse knows that this is:
a.
an indication that the woman’s milk is coming in.
b.
a sign of possible breast cancer in a pregnant woman.
c.
most likely colostrum, which is considered a normal finding at this stage of the pregnancy.
d.
an early stage in the pregnancy for lactation to begin. The woman should be referred to a specialist.
C
A woman in her second trimester of pregnancy complains of heartburn and indigestion. The nurse should offer which of the following explanations for these problems?
a.
Tone and motility of the gastrointestinal tract increase during the second trimester.
b.
Sluggish emptying of the gallbladder, resulting from the effects of progesterone, often causes heartburn.
c.
Lower blood pressure at this time decreases blood flow to the stomach and gastrointestinal tract.
d.
The enlarging uterus and altered esophageal sphincter tone predispose the woman to have heartburn.
D