Foundations: Health Promotion and Care of the Older Adult

Question 1

When assessing the skin of an older adult patient who is complaining of pruritus, the nurse advises the patient that to reduce further drying of her skin, she should avoid using:

a. perfumed soap.
b. hard-milled soap.
c. antibacterial soap.
d. antiseptic soap.

Answer 1

c. antibacterial soap.

Question 2

Because thin skin and lack of subcutaneous fat predisposes the older adult to pressure ulcers, the nurse alters the care plan to include turning the bedfast patient every:

a. shift.
b. 4 hours.
c. evening.
d. 2 hours.

Answer 2

d. 2 hours.

Question 3

When the nurse attempts to assist an older adult who is having difficulty swallowing, the nurse suggests a position in which the chin is held:

a. parallel.
b. upward.
c. down.
d. to the side.

Answer 3

c. down.

Question 4

When discussing aging, the nurse clarifies that the term older adulthood applies to those who are older than:

a. 55.
b. 65.
c. 70.
d. 75.

Answer 4

b. 65.

Question 5

The nurse initiates the application of a drawsheet on every bedfast patient on her unit to facilitate lifting and to prevent _________ forces.

Answer 5

shearing

Shearing forces cause skin damage by friction; for instance, when a patient is dragged across bed linens during a position change.

Question 6

The nurse recognizes that a term referring to mechanical difficulty of swallowing is ___________.

Answer 6

dysphagia

Question 7

A change of aging related to the circulatory system includes decreased blood vessel elasticity, which leads the nurse to assess for:

a. confusion.
b. tachycardia.
c. hypertension.
d. retained secretions.

Answer 7

c. hypertension.

The blood vessels become less elastic and may lead to increased blood pressure.

Question 8

The nurse suggests that to relieve the pain of claudication the patient should:

a. rest.
b. exercise.
c. cross his legs.
d. walk.

Answer 8

a. rest.

A nursing intervention to relieve pain is to recommend the patient rest periodically until the pain subsides. The nurse could also suggest improving circulation progress by walking.

Question 9

The nurse recognizes that an older adult patient with COPD has a higher incidence of developing which age-related skeletal change that will alter the ability to exchange air effectively?

a. Osteoporosis
b. Arthritis
c. Kyphosis
d. Osteomyelitis

Answer 9

c. Kyphosis

usually caused by osteoporosis, is a curvature of the spine that alters respiration and air exchange.

Question 10

The nurse explains that the major difference between rheumatoid arthritis and osteoarthritis is that rheumatoid arthritis:

a. is degenerative.
b. affects patients over 40 years of age.
c. is inflammatory.
d. is curable.

Answer 10

c. is inflammatory.

is an inflammatory disease; osteoarthritis is degenerative.

Question 11

The nurse recognizes that arthritis affects an individual’s functional ability. Interventions are aimed at relieving:

a. pain and discomfort.
b. formation of contractures.
c. stress on affected joints.
d. inflammation and scarring.

Answer 11

c. stress on affected joints.

Interventions for older individuals with arthritis are aimed at relieving stress on affected joints.

Question 12

When an older female patient complains of painful sexual intercourse, the nurse recognizes that the probable cause is:

a. urinary incontinence.
b. arthritic joints.
c. kyphosis.
d. mucosal drying.

Answer 12

d. mucosal drying.

Sexual intercourse may be uncomfortable because of drying of the mucosa of the vagina.

Question 13

When bathing an 80-year-old woman who lives on a farm, the nurse assesses brown macules on the patient’s hands and forearms. The nurse recognizes these as _________.

Answer 13

lentigo

is a term that refers to brown-pigmented lesions on the skin of the older person who has spent a great deal of time in the sun. These macules are also called “age spots.”

Question 14

The nurse prepares the older adult patient with diabetes for which symptom of the disease that distorts tactile sensation?

a. Proprioception
b. Loss of visual acuity
c. Progressive paresis
d. Peripheral neuropathy

Answer 14

d. Peripheral neuropathy

is the presence of abnormal sensation.

Question 15

When assessing a patient who has suffered a burn injury, the nurse classifies the burn as a deep partial-thickness burn based on the observation of:

a. painful reddened skin.
b. charred skin with milky-white areas.
c. erythema and blisters.
d. erythema, pain, and swelling.

Answer 15

c. erythema and blisters.

With deep partial-thickness burns, blister formation may be seen with erythema.

Question 16

What nursing interventions will minimize the effects of venous stasis?

a. Pillows under the knee in a position of comfort
b. Sitting with the feet flat on the floor
c. Early ambulation
d. Gentle leg massage

Answer 16

c. Early ambulation

Early ambulation has been a significant factor in hastening postoperative recovery and preventing postoperative complications.

Question 17

A severely burned client is to be admitted from the emergency department. What type of room should the nurse prepare for the client?
1. A semi-private room with a noninfectious
client
2. A room with a postoperative client
3. An isolation room
4. A private room with a private bath

Answer 17

3. Burn victims should be placed in isolation because they are very susceptible to infection.

Question 18

The nurse is planning care for a newly burned client. What is the priority nursing observation to be made during the first 48 hours after the burn?

1. Hourly blood pressure
2. Assessment of skin color and capillary refill
3. Hourly urine measurement
4. Frequent assessment for pain

Answer 18

3. Fluid replacement is based on hourly measurement of urine output. The other observations are important and should be done, but they are not the highest priority.

Question 19

Cimetidine (Tagamet) is ordered IV every six hours for a person with severe burns. What is the primary reason for administering Tagamet to this client?

1. To prevent infection
2. To restore electrolyte balance
3. To promote renal function
4. To prevent Curling’s ulcers

Answer 19

4. Curling’s (stress) ulcers occur frequently in burn victims. Tagamet is a histamine blocker that reduces gastric acid and helps to prevent the development of ulcers.

Question 20

The nurse is ordered to insert an indwelling catheter in a severely burned client for which reason?

1. To prevent contamination of burned areas
2. To measure hourly urine output
3. To prevent urinary tract infection
4. To detect internal injuries quickly

Answer 20

2. Measurement of urine output is a high priority. Fluid replacement is based on output. The goal is to prevent the client from going into shock by maintaining a urine output of 50 to 100 mL/hr.

Question 21

A 28-year-old man received severe burns of the chest, abdomen, back, legs, and hands when
the house caught fire. In the emergency room, a nasogastric tube was inserted, and the client was ordered NPO. What is the primary reason for the nurse to keep this client NPO?
1. To prevent the deadly complication of aspiration
2. To make the client more comfortable
3. To help prevent paralytic ileus
4. To help prevent excessive fluid loss

Answer 21

3. Burn victims are very prone to paralytic ileus. The client will remain NPO until bowel sounds have returned.`

Question 22

Which of the following clients should have his clothing removed immediately?

1. A 32-year-old man who was burned while working on high-tension wires
2. A 14-year-old boy who suffered severe smoke inhalation during a fire at school
3. A 78-year-old man who was burned during a fire that started when the client fell asleep while smoking
4. A 19-year-old student who spilled chemicals on himself in the chemistry lab at school

Answer 22

4. Clothing should be removed from persons with chemical burns so that they will not be further contaminated. A flame burn should be smothered, and if necessary, the area should be soaked with water, but the clothing should not be removed until the person is in the emergency room. A person who suffered from smoke inhalation does not have an immediate need to remove clothing. A person who received an electrical burn does not have an immediate need to remove clothing.

Question 23

The nurse is caring for several clients who have burns over different parts of the body. The client who has burns over which part of the body is most at risk of life-threatening complications?

1. Lower torso
2. Upper part of the body
3. Hands and feet
4. Perineum

Answer 23

2. Persons with burns of the upper part of the body frequently have respiratory involvement. Airway problems increase the mortality rate.

Question 24

The nurse is caring for a client who is having silver nitrate dressings. Which lab values should the nurse monitor?

1. Blood urea nitrogen (BUN)
2. Blood gases
3. Complete blood count (CBC)
4. Serum electrolytes

Answer 24

4. Silver nitrate can cause depletion of potassium, sodium, and chloride; therefore, serum electrolytes are essential.

Question 25

A client who was severely burned goes to the Hubbard tank daily. Tanking sessions are limited to a half hour for which reason?
1. A longer period of time is too tiring.
2. Eschar becomes difficult to remove with longer
soaking.
3. Prolonged soaking causes electrolyte dilution.
4. The water becomes too cool and may cause
chilling.

Answer 25

3. The water in the Hubbard tank is hypotonic, and sodium loss occurs through the open wounds. The bath may be painful and fatiguing for the client. The primary reason is the physiological problem of sodium loss.

Question 26

A woman who has herpes simplex 1 (HSV1) around the mouth and nose asks the nurse if she can give the sores to her husband. What should the nurse include when answering this client?

1. Herpes simplex 1 (HSV1) is a fever blister and is not contagious.
2. She should not kiss her husband or anyone else because it can be transmitted to susceptible persons.
3. Fever blisters are seen only in persons who have fevers.
4. The virus is transmitted through coughing and sneezing.

Answer 26

2. Herpes simplex 1 (HSV1) can be transmitted through direct contact if the other person has any breaks in the skin or mucus membrane. She should not kiss anyone until after the lesions have disappeared. While blisters do sometimes occur when a person has a fever, a fever is not necessary for a herpes simplex infection. Herpes simplex virus is transmitted by direct contact, not coughing and sneezing.

Question 27

The nurse is caring for a person who has severe poison ivy. Soaks with Burrow’s solution are ordered. What is the primary reason for using Burrow’s solution soaks?

1. To disinfect the wound
2. To prevent pain from the lesions
3. To stop the pruritus associated with the condition
4. To help dry the oozing lesions

Answer 27

4. Burrow’s solution is used to help dry up oozing lesions such as poison ivy. It does not disinfect, prevent pain, or stop itching.

Question 28

A young man has extensive burns on the front and back of the chest. His treatment includes the use of Sulfamylon to the burned areas. How should the nurse apply this medication?

1. With a sterile, gloved hand
2. With a sterile applicator
3. With sterile 4 × 4’s
4. By aerosol spray

Answer 28

1. A sterile, gloved hand is the preferred way to apply topical antimicrobials.

Question 29

An electrician was wearing a glove that had a hole in it when he grabbed a “hot” wire. His coworkers came to him immediately and called the rescue squad. When the industrial nurse reached him, the electric current had been shut off. What action should the nurse take initially?

1. Dress the entrance and exit wounds
2. Check respirations and pulse rate
3. Remove clothing from the burned area
4. Roll him in a blanket

Answer 29

2. Electric burns cause cardiac arrhythmias. Checking respirations and the pulse rate is the highest priority. There is no need to remove clothing or roll a victim of an electric burn in a blanket because there are no flames. Dressing wounds is of lesser priority than assessing cardiac and respiratory functioning.

Question 30

A client who has just been diagnosed with psoriasis asks the nurse what should be done
to prevent family members from getting the condition. What should the nurse include when responding to this question?
1. Showering daily with antiseptic soap should be
sufficient.
2. Wearing clothing over the affected part and
washing clothes separately from the rest of the family are all that is necessary.
3. Psoriasis is not contagious, so no special precautions are necessary.
4. Psoriasis is transmitted primarily by direct contact with the skin.

Answer 30

3. Psoriasis is not contagious.

Question 31

The client mentions all of the following to the nurse. Which of the following should the client be encouraged to report to the physician immediately?

1. A small mole on the right thigh that has looked the same ever since the client can remember
2. A pigmented area that is pink-red in color and has been present since birth
3. Three small warts on the right hand that have been present for some time
4. A black and purple mole that is growing larger and has a funny shape

Answer 31

4. A mole that changes shape and has multiple colors and irregular borders is suggestive of malignant melanoma. This should be reported immediately. A mole that has not changed in appearance is of no particular concern. The pigmented area that has been present since birth sounds like a nevus or a birthmark and is not of particular concern. The client may want to report the three small warts and have them removed
   for cosmetic reasons. They are not an immediate threat to her health and do not need to be reported immediately.

Question 32

Protect surrounding skin

Answer 32

• non alcohol barrier film,ointment
• topical corticosteroids to reduce inflammation
• bland emollients for moisturization
• avoid fragrances, dyes

Question 33

Perfusion check - pulses

Answer 33

• palpate both dorsalis pedis and post tib pulses
• venous refill time - normal is 20 sec
• ABI
• duplex imaging

Question 34

Most essential component of venous leg ulcer treatment

Answer 34

compression

Question 35

Underlying cause of venous leg ulcers

Answer 35

venous hypertension

Question 36

Wound management

Answer 36

• debride necrotic tissue - no one method optimal
• pain management
• appropriate dressings (control exudate, bioburden, prevent periwound complications)

Question 37

Compression is used to

Answer 37

reduce, control, and minimize effects of venous hypertension

Question 38

How does compression work?

Answer 38

• enhances the calf muscle pump by providing resistance to the calf muscle contraction
• increases interstitial pressure and decreases superficial venous pressure
• reduces cross section of dilated veins which supports the function of the venous valves
• improves speed of blood flow to heart

Question 39

keratolytics

Answer 39

salicylic acid duofilm, wart remover, fostex, fung-o, mosco, panscol
aids in the removal of excessive keratin in hyperkeratotic skin disorders: warts, psoriasis, calluses, corns

Question 40

keratolytic

Answer 40

is a drug that removes excess growth of the epidermis (top layer of skin) in disorders

Question 41

keratolytics

Answer 41

are used to remove warts, calluses, corns, seborrheic keratosis (benign, variously colored skin growths arising from oil glands)