Geriatric 3

Question 1

The nurse is preparing to conduct a health history with an older patient. Which action will the nurse take to ensure the accuracy and efficiency of the patient’s health history?

1. Scheduling 30 minutes for the medical history interview
2. Requesting the patient bring a list of current medications taken regularly
3. Conducting the history in an environment with comfortable seating and proper lighting
4. Having the patient complete the past medical history form upon arrival for the appointment

Answer 1

3: To make the older patient comfortable, adequate lighting and seating should be available.

Question 2

Which nursing intervention will ensure that the nurse will provide culturally competent healthcare to an older patient?

1. Speak the patient’s primary language.
2. Use standardized assessment instruments in health evaluations.
3. Approach patients of a particular ethnic group in the same manner.
4. Know prevalence, incidence, and risk factors for diseases specific to different ethnic groups.

Answer 2

4: Knowing the prevalence, incidence, and risk factors for diseases specific to different ethnic groups is a component of cultural competence in healthcare.

Question 3

The nurse is completing the minimal data set (MDS) for an older patient. What are characteristics of this assessment?
Standard Text: Select all that apply.
1. Eliminates listing the patient’s prescribed medications
2. Identifies health insurance coverage that is not Medicare or Medicaid
3. Provides a multidimensional view of the patient’s functional capacities
4. Used primarily to determine the amount of funding the patient has for long-term care
5. Includes a core set of screening, clinical, and functional measures used in patient assessment

Answer 3

3: The items in the MDS give a multidimensional view of the patient’s functional capacities.
5: The MDS includes categories that measure physical, psychological, and psychosocial functioning of the patient.

Question 4

When completing an assessment with an older patient, the nurse will focus on which health problems since these are the leading causes of death for this population?
Standard Text: Select all that apply.
1. HIV/AIDS
2. Malignant neoplasms
3. Motor vehicle crashes
4. Cardiovascular disease
5. Pneumonia and infections

Answer 4

2: Currently, older people die from chronic illnesses such as malignant neoplasms.
5: At the beginning of the 1900s, infectious diseases topped the leading causes of death. A century later, these diseases are controlled.

Question 5

Why is it important for the interdisciplinary team to assess an older patient’s level of pain?

1. Validate that the pain is real.
2. Ensure pain management is provided.
3. Differentiate pain symptoms from other symptoms.
4. Provide the appropriate amount of help for normal activities.

Answer 5

2: A pain assessment is done to address symptom relief or pain management.

Question 6

The nurse is preparing to use the SPICES tool to assess an older patient. Which areas will the nurse assess with this tool?
Standard Text: Select all that apply.
1. Incontinence
2. Sleep disorders
3. Skin breakdown
4. Evidence of falls
5. Lower limb function

Answer 6

1: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Incontinence is assessed in this tool.
2: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Sleep disorders are assessed in this tool.
3: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Skin breakdown is assessed in this tool.
4: SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults. Evidence of falls is assessed in this tool.

Question 7

The family of an older patient in a nursing home has contacted the ombudsmen program. What will the ombudsman do for the patient?

1. Investigate the complaint.
2. Deter the patient from filing a lawsuit.
3. Pursue a lawsuit on behalf of the patient.
4. Review the patient’s record and determine if appropriate care has been given.

Answer 7

1: All states are to operate long-term care ombudsmen programs. These programs provide trained people to investigate complaints made by residents and families about care received in the facility.

Question 8

Which action should the nurse take to avoid becoming involved in a legal suit with patient care?

1. Have professional liability insurance.
2. Avoid conflicts with patients and families.
3. Document carefully all nursing care provided.
4. Report concerns about the facility to the supervisor.

Answer 8

3: Careful documentation of nursing care is the best way for the nurse to defend him- or herself should a legal suit be filed.

Question 9

Which statements are included in the Patient’s Bill of Rights?
Standard Text: Select all that apply.
1. The right to vote
2. The right to make a will and dispose of property
3. The right of the ombudsman to enforce the bill of rights
4. The right to file for malpractice if the rights are violated
5. The right to be free from chemical and physical restraints

Answer 9

1: The right to vote is in the Patient’s Bill of Rights.
2: The right to make a will and dispose of property is in the Patient’s Bill of Rights.
5: The right to be free from chemical and physical restraints is in the Patient’s Bill of Rights.

Question 10

Which scenario describes a situation in which the performance of the nurse does not meet the standard of care?

1. A nurse witnesses a patient fall and tries to assist the patient.
2. A patient with vomiting and nausea does not receive a breakfast tray.
3. A physician is questioned about an order to administer a medication that is five times the normal dosage.
4. A patient is medicated with acetaminophen for severe chest pain and the physician is not notified.

Answer 10

4: Medicating a patient with acetaminophen for severe chest pain and not notifying the physician would not be considered standard care for chest pain.

Question 11

What actions will the nurse follow when using restraints for an older patient in a long-term care facility?
Standard Text: Select all that apply.
1. Use restraints for 2 hours or less.
2. Obtain a physician’s order before using.
3. Waist restraints are the best approach to prevent patient falls.
4. Remove the patient’s eyeglasses when applying restraints.
5. Consider the use of restraints for emergency situations only.

Answer 11

1: Restraints are now limited to short-term use of 2 hours or less.
2: Restraints are used only with a physician’s order.
5: Restraints are to be ordered by a physician in emergency situations.

Question 12

The gerontological nurse is planning health promotion actions for an older patient. What information would the nurse take into consideration when planning these actions?
Standard Text: Select all that apply.
1. Patient has type 2 diabetes mellitus
2. Patient uses BIPAP machine for sleep apnea
3. Patient walks for 30 minutes 3 times a week
4. Patient attends religious services every Sunday morning
5. Patient lives alone and volunteers at the local library most afternoons

Answer 12

3: Health promotion for the older adult is focused on individual strengths, abilities, and values. Walking for 30 minutes 3 times a week would be taken into consideration for the patient.
4: Health promotion for the older adult is focused on individual strengths, abilities, and values. Attending religious services every Sunday would be taken into consideration for the patient.
5: Health promotion for the older adult is focused on individual strengths, abilities, and values. Living alone and volunteering at the local library most afternoons would be taken into consideration for the patient.

Question 13

Of the following hospital situations, which one demonstrates the need for further action and improved policies to maintain the confidentiality of patient medical information?

1. Employees are issued individual passwords to access computerized records.
2. A physician logs off a computer after accessing computerized patient records.
3. The nurse logs off the computer after accessing the laboratory record of a patient.
4. Reports of patient tests are faxed to a machine that is shared by the payroll department.

Answer 13

4: Faxing patient test reports to a machine that is shared by the payroll department could violate the confidentiality of patient medical information. Further action would be needed for this situation.

Question 14

The nurse is concerned that a patient’s privacy could be breached according to the Health Insurance Portability and Accountability Act (HIPAA) standards. Which situation would be a breach of the HIPAA standards?

1. Copies of the patient’s diagnostic test results are shredded before being discarded.
2. A nurse discusses the patient’s condition with a relative without the patient’s permission.
3. A physician who is not a caregiver of the patient is restricted from access to the patient’s chart.
4. The patient’s chart is stored in the secured office of the radiology office while the patient is having a diagnostic examination done.

Answer 14

2: A breach in patient privacy is the nurse discussing the patient’s condition with a relative without the patient’s permission.

Question 15

An older patient with confusion is prescribed to receive a blood transfusion. What should the nurse do to obtain consent for this transfusion?

1. Ask the patient’s durable power of attorney to sign the consent.
2. Withhold the blood transfusion until the patient’s mental status improves.
3. Administer the blood transfusion since a signed consent form is not necessary.
4. Explain the transfusion, help the patient sign the consent, and administer the transfusion.

Answer 15

1: The nurse who finds a patient lacking the capacity to provide consent, as in the case of a confused patient, must obtain consent from a healthcare proxy, such as the durable power of attorney.

Question 16

The nurse is reviewing secondary prevention actions with an older patient. Which interventions should the nurse encourage the patient to complete?
Standard Text: Select all that apply.
1. Yearly depression screening
2. Colonoscopy every 10 years
3. Yearly fecal occult blood test
4. Yearly height and weight check
5. Yearly blood pressure screening

Answer 16

1: For secondary prevention, a yearly depression screening is recommended.
2: For secondary prevention, a colonoscopy is recommended every 10 years.
3: For secondary prevention, a yearly fecal occult blood test is recommended.

Question 17

An older patient recently admitted from a homeless shelter experiences cardiac arrest. The patient has no resuscitation orders. What should the nurse do first?

1. Notify the shift supervisor.
2. Notify the homeless shelter.
3. Notify the admitting physician.
4. Begin cardiopulmonary resuscitation.

Answer 17

4: If resuscitation orders are not present, the nurse should begin cardiopulmonary resuscitation on the patient.

Question 18

An older patient is diagnosed with an intestinal obstruction and needs immediate surgery. The patient’s next of kin is a granddaughter who lives in a neighboring community. Who will the nurse ask to sign the consent form for the surgery?

1. The patient
2. The patient’s daughter
3. The patient’s granddaughter
4. Both the patient and granddaughter

Answer 18

1: Unless there has been some indication of a loss of competence or a legal document exists that establishes the power of attorney, the patient has the responsibility to sign the consent form for the surgery.

Question 19

A nurse has just completed training on the Health Insurance Portability and Accountability Act (HIPAA). Which statement made by the nurse indicates that training has been successful?

1. “Faxing of information is prohibited by HIPAA.”
2. “I need to verbally provide the patient with the privacy notice.”
3. “I cannot discuss a patient’s health history with family members without the patient’s permission.”
4. “Financial information relating to payment for services is not subject to the HIPAA regulations.”

Answer 19

3: Discussing a patient’s health history with family members is not permitted without the patient’s permission.-

Question 20

The nurse needs to fax confidential patient information to another office. What actions should the nurse take when faxing this type of information?
Standard Text: Select all that apply.
1. Use a cover sheet.
2. Obtain patient permission to fax.
3. Include a confidentiality statement.
4. Verify the fax number before faxing.
5. Print the patient’s name on the cover sheet.

Answer 20

1: Fax machines are the least secure of all technologies. The nurse should use a cover sheet when faxing confidential patient information.
2: Fax machines are the least secure of all technologies. The nurse should obtain the patient’s permission before faxing confidential patient information.
3: Fax machines are the least secure of all technologies. The nurse should include a confidentiality statement when faxing confidential patient information.
4: Fax machines are the least secure of all technologies. The nurse should verify the fax number before faxing confidential patient information.

Question 21

The nurse is preparing consent forms for a newly admitted older patient to sign. For which reasons would a general consent form be needed?
Standard Text: Select all that apply.
1. Help with feeding.
2. Provide medications.
3. Assist with bathing.
4. Perform all invasive procedures.
5. Participate with dressing after morning care.

Answer 21

1: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as helping with feeding.
2: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as providing medications.
3: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as assisting with bathing.
5: Upon admission to a healthcare facility, the older person will sign a consent form for routine care, which gives permission to others to provide care such as participating with dressing after morning care.

Question 22

The nurse is determining an older patient’s ability to provide consent for a surgical procedure. Which criteria must be met?

1. Acknowledge reasonable treatment options available.
2. Verbalize the decision to undergo the surgical procedure.
3. Understand that antibiotics may be administered after the procedure.
4. Voice knowledge of the medications that will be utilized for anesthesia.

Answer 22

1: The patient must be able to make his or her understanding about the procedure known to the healthcare team.

Question 23

An older patient who previously agreed with the plan of care is now refusing prescribed medications. What should be done at this time?

1. Discharge the patient.
2. Consult with an attorney.
3. Nothing since the patient can decline treatment
4. Discuss that the patient has already agreed to have treatment.

Answer 23

3: Patients have the right to change their mind at any time.

Question 24

The daughter of an older patient asks the nurse the best way to select a physician for the patient. What advice should the nurse provide to the daughter?

1. “I would recommend you consider Dr. Smith.”
2. “An internist would be the best provider of care for the patient.”
3. “A general practitioner would provide the best type of care for the patient.”
4. “Family nurse practitioners would be the best care providers for the patient.”

Answer 24

2: Internists are physicians for adults and some take extra training. This is the recommendation that the nurse should make to the daughter.

Question 25

An older homeless patient is admitted to the hospital. The patient has no known family, is unresponsive, and his condition is considered guarded. What should be done to ensure appropriate healthcare decisions are made for this patient?

1. The homeless shelter will provide direction.
2. The patient will be represented by the hospital social worker.
3. The hospital will make decisions for the patient’s healthcare.
4. The hospital will ask a judge to appoint a guardian for the patient.

Answer 25

4: If an older person lacks decisional capacity and has no predetermined wishes, family, or healthcare proxy, the care facility may seek a court-appointed guardian who is appointed by a judge to act on behalf of the ward or the patient.

Question 26

The nurse is discussing proper nutrition with older community members at a senior citizen center. What should the nurse teach as general guidelines for healthy older individuals?
Standard Text: Select all that apply.
1. Calcium intake should be 1,000 mg for those over the age of 51 years.
2. Older individuals need to take supplements of vitamins A, C, E, and K.
3. Vitamin D intake should be 600 IU up to age 70 and 800 IU if older than 70.
4. Ingest at least 0.8 grams of protein for each kilogram of body weight each day
5. Fluid intake each day should be at least 13 cups for men and 9 cups for women.

Answer 26

3: Vitamin D intake should be 600 IU up to age 70 and 800 IU if older than 70.
4: Protein intake for older individuals should be 0.8 grams per kilogram of body weight.
5: Fluid intake each day should be at least 13 cups for men and 9 cups for women.

Question 27

A patient prescribed medications for gastroesophageal reflux disease (GERD) is at risk for altered absorption of which nutrients?
Standard Text: Select all that apply.
1. Iron
2. Calcium
3. Folic acid
4. Vitamin D
5. Vitamin B12

Answer 27

1: Medications that alter gastric pH may also alter iron absorption because of the alkalinizing effects of these medications.
2: Medications that alter gastric pH may also alter calcium absorption because of the alkalinizing effects of these medications.
5: Medications that alter gastric pH may also alter vitamin B12 absorption because of the alkalinizing effects of these medications.

Question 28

An older patient without any major health problems is experiencing decreased strength and endurance while performing some activities. What should the nurse explain as the reason for the change in strength and endurance?

1. Depression
2. Decrease in lean muscle mass
3. Lowered absorption of vitamin D
4. Increase in cholecystokinin production

Answer 28

2: Lean muscle mass diminishes with aging. This can lead to a loss of type II muscle fibers that affect strength and endurance.

Question 29

The nurse instructed an older patient on the importance of maintaining adequate hydration. Which statement by the patient indicates that additional teaching is needed?

1. “I’ll drink water and unsweetened beverages whenever I feel thirsty.”
2. “I can add an extra cup of decaffeinated coffee with breakfast and dinner.”
3. “I will set up a schedule to drink a glass of water every 2 hours throughout the day.”
4. “If I drink a lot of fluids, I’ll have to go to the bathroom more often, but I’ll get more exercise.”

Answer 29

1: The patient needs additional instructions regarding adequate fluid intake. Because the thirst mechanism becomes blunted with age, the patient cannot rely on feeling thirsty as a signal to meet hydration requirements.

Question 30

Which assessment data indicates to the nurse that an older patient is experiencing undernutrition?

1. Body mass index (BMI) of 20
2. Unintentional 3% weight loss over a month
3. Denial of taking a multiple vitamin supplement
4. Serum albumin slightly below normal, prealbumin and transferrin within normal limits

Answer 30

1: A body mass index (BMI) less than 22 in the older person is predictive of undernutrition.

Question 31

Which older patient is at greatest risk for vitamin D deficiency?

1. The patient with macrocytic anemia
2. The patient who does not drink milk
3. The patient who works outdoors daily and does not wear sunscreen
4. The patient who is taking isoniazid (INH) after a positive tuberculin skin test

Answer 31

2: Older adults at risk for poor vitamin D status include those who do not consume milk.

Question 32

A resident in the nursing home is diagnosed with undernutrition and is unable to take in adequate food despite efforts by the multidisciplinary team and family members. Prior to insertion of a permanent feeding tube, which issue needs to be considered?

1. Equipment, care, and time needed to administer the feedings
2. The extent of the surgical intervention, cost and insurance coverage
3. The patient’s nutritional needs and tolerance of the formula feedings
4. The patient’s advanced directive and evaluation of risks, benefits, and ethical considerations

Answer 32

4: Prior to placement of a permanent feeding tube, it is important to evaluate the individual patient’s wishes and review the advanced directive. The patient and family need accurate information regarding risks, benefits, and ethical considerations associated with placement of the feeding tube.

Question 33

Which observation made by the nurse suggests that a patient is having difficulty swallowing?

1. Drooling
2. Cheilosis
3. Long furrowed tongue
4. Unintentional weight loss

Answer 33

1: Drooling suggests difficulty swallowing because the patient is unable to swallow the saliva produced in the mouth.

Question 34

An older patient is prescribed diet supplementation to combat unintentional weight loss. How should the nurse provide these supplements to the patient?

1. Serve at room temperature.
2. Provide with the next meal.
3. Provide separate from medications.
4. Provide more than an hour before the next meal.

Answer 34

4: Supplements should be given more than 1 hour before meals to minimize satiety and enable the patient to still eat at mealtime. Liquid supplements are digested more quickly than solids, thus decreasing the feeling of fullness.

Question 35

An older patient is receiving feedings through a permanent feeding tube. Which nursing intervention will decrease this patient’s risk of aspiration?

1. Administer formulas that contain fiber.
2. Keep the head of the bed elevated at a 30 to 45 degree angle.
3. The risk of aspiration no longer exists after a permanent feeding tube has been placed.
4. Flush the tube with water before and after each medication administered through the tube.

Answer 35

2: The head of the bed of patients receiving tube feedings should be elevated at a 30 to 45 degree angle to decrease the risk of aspiration.

Question 36

Which older patient would the nurse identify as being at the highest risk of dehydration from receiving nutrition through a feeding tube?

1. Receiving bolus feedings
2. Receiving 50 ml free water at 4-hour intervals
3. Receiving feedings through a jejunostomy tube
4. Receiving feedings with a formula that is 1.5 calories per ml

Answer 36

4: Tube feeding formulas that are denser than 1 calorie per milliliter are hypertonic and predispose the patient to dehydration unless the patient also receives free water.

Question 37

When planning care, for which older patients should the nurse identify as being at risk for malnutrition as a result of hypermetabolism?
Standard Text: Select all that apply.
1. Patient with a fever
2. Patient with dysphagia
3. Patient with osteoporosis
4. Patient who is a vegetarian
5. Patient with chronic lung disease

Answer 37

1: The patient with a fever is at risk for malnutrition as a result of hypermetabolism.
5: The patient with chronic obstructive pulmonary disease often is malnourished because of the increased caloric need associated with breathing efforts.

Question 38

What should the nurse instruct a caregiver to do to assist a cognitively impaired older patient to self-feed?

1. Offer the patient a variety of favorite foods.
2. Provide diversional stimuli, such as a television show, so the patient can eat without thinking about it.
3. Serve each food separately with the proper utensil and cue the patient to use the utensil to eat that particular food.
4. Place the food types in the same arrangement on the plate and relate the location to the face of a clock to assist the patient in locating the food on the plate.

Answer 38

3: Limiting the patient to one task and food, and cueing the patient to use the utensil to eat the specific food can be effective in promoting self-feeding.

Question 39

During an assessment, the nurse determines that an older patient is taking several supplements that affect blood clotting. Which supplements did the nurse assess that this patient is taking?
Standard Text: Select all that apply.
1. Zinc
2. Garlic
3. Fish oil
4. Ginseng
5. Vitamin E

Answer 39

2: A supplement with an antiplatelet effect includes garlic.
3: A supplement with an antiplatelet effect includes fish oil.
4: A supplement with an antiplatelet effect includes ginseng.
5: A supplement with an antiplatelet effect includes vitamin E.

Question 40

The nurse is concerned that an older patient is experiencing dehydration. What did the nurse assess in this patient?
Standard Text: Select all that apply.
1. Confusion
2. Headache
3. Weight gain
4. Long tongue furrows
5. Forearm tenting of the skin

Answer 40

1: Confusion is a symptom of dehydration in the older adult.
2: Headache is a symptom of dehydration in the older adult.
4: Long tongue furrows are symptoms of dehydration in the older adult.

Question 41

What should the nurse instruct an older patient to do to support healthy eating habits?
Standard Text: Select all that apply.
1. Increase fiber intake.
2. Reduce sodium intake.
3. Look for hidden sugar.
4. Enjoy olive oil and walnuts.
5. Complete a meal in 10 minutes.

Answer 41

1: Increasing fiber intake is a healthy eating tip.
2: Reduce sodium intake is a healthy eating tip.
3: Looking for hidden sugar is a healthy eating tip.
4: Enjoying good fats such as olive oil and walnuts is a healthy eating tip.

Question 42

The nurse is caring for an older patient who is receiving phenytoin. Which nutritional issues is this patient at risk for developing?
Standard Text: Select all that apply.
1. Altered swallowing
2. Reduced oral intake
3. Affected folate levels
4. Altered taste and smell
5. Affected vitamin D levels

Answer 42

2: Phenytoin causes patients to experience reduced oral intake.
3: Phenytoin affects folate levels in the body.
4: Phenytoin alters a patient’s taste and smell.
5: Phenytoin affects vitamin D levels in the body.

Question 43

An older patient receiving enteral feedings is experiencing abdominal cramps and liquid stools. Which ingredient in the patient’s tube feeding would cause these manifestations?

1. Maltose
2. Lactose
3. Fructose
4. Sucrose

Answer 43

2: Lactose is implicated in the formation of diarrhea in the patient receiving enteral feedings. A lactose-free supplement should be used for this patient.

Question 44

The nurse is planning interventions to reduce an older patient’s risk of dehydration. Which intervention would support the onset of dehydration in the patient?

1. Ensuring fresh water is available to the patient
2. Providing the prescribed diuretic with breakfast
3. Administering the prescribed diuretic with the evening meal
4. Offering a drink of water every time the patient’s room is entered

Answer 44

3: Administering prescribed diuretics with the evening meal will encourage nocturia and voluntary restriction of fluids by the patient. This will lead to dehydration.

Question 45

The nurse is instructing an older patient on the use of My Plate to ensure an adequate nutritional intake. Which food items would the nurse teach the patient to fill on one-half of the plate?
Standard Text: Select all that apply.
1. Oils
2. Fruits
3. Grains
4. Proteins
5. Vegetables

Answer 45

2: Fruits should be included for one-half of the plate.
5: Vegetables should be included for one-half of the plate.

Question 46

The nurse has instructed an older patient on the modified My Plate and caloric intake. Which patent response indicates that instruction has been effective?

1. “If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 2,000 calories.”
2. “If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 1,600 calories.”
3. “If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 2,200 calories.”
4. “If I consume the lowest daily recommended value for all of the food groups, it will result in approximately 2,400 calories.”

Answer 46

2: Following the lowest recommended values for all the food groups will result in approximately 1,600 calories of energy.

Question 47

What food items should the nurse teach an older patient to ingest to increase the dietary intake of vitamin D?

1. Eat liver at least once a week.
2. Plan to eat salmon at least twice a week.
3. Eat three servings of yogurt or cheese each day.
4. Red meat should be consumed every other day.

Answer 47

1: Food sources of vitamin D include liver, fish liver oils, and fortified milk.

Question 48

Which statement about food insecurity would the nurse include in a presentation regarding nutritional issues in the older patient?

1. “Food insecurity is when a person hoards food.”
2. “White older persons are at a higher risk for food insecurity than African Americans.”
3. “African American older persons are at a higher risk for food insecurity than Caucasian Americans.”
4. “Food insecurity is when a person is concerned that he or she is eating foods that might be harmful to his or her health.”

Answer 48

3: African Americans and Hispanic older persons are at a disproportionate risk of food insecurity compared with other households.

Question 49

The nurse is using the DETERMINE nutrition screening tool when assessing the nutritional status of an older patient. Which criteria are included in this screening tool?
Standard Text: Select all that apply.
1. Disease
2. Above the age of 80
3. Reduced social contact
4. Eats fruits and vegetables
5. Needs assistance in self-care

Answer 49

1: Disease is a category in the DETERMINE nutrition screening tool.
2: Above the age of 80 is a category in the DETERMINE nutrition screening tool.
3: Reduced social contact is a category in the DETERMINE nutrition screening tool.
Needs assistance in self-care is a category in the DETERMINE nutrition screening tool.

Question 50

An older patient has an unintentional weight loss of 20 pounds in the last 3 months. What should the nurse teach the patient’s family to prevent further loss of weight?

1. Provide liquid nutritional supplements with meals.
2. Add nonfat milk powder to scrambled eggs to add more protein.
3. Encourage the patient to resume smoking to increase the appetite.
4. There is nothing to change as weight loss is a normal part of aging.

Answer 50

2: Interventions for patients with undernutrition issues include adding nonfat milk to soups, puddings, scrambled eggs, and other recipes.

Question 51

The nurse is caring for an older patient who is experiencing sleep deprivation. Which manifestation might the nurse assess in this patient?

1. Improved healing
2. Visual hallucinations
3. Fatigue occurring at night
4. Development of Alzheimer’s disease

Answer 51

2: The patient who is deprived of sleep may experience visual or auditory hallucinations.

Question 52

An older patient is telling the nurse about problems with sleeping. What does the nurse realize about sleep and the older adult?

1. The need for sleep decreases with age.
2. Disrupted sleep is not associated with depression.
3. A person should not awaken more than once during the night.
4. An older person does not have as much deep sleep as a younger person.

Answer 52

4: With aging, the amount of time spent in deep sleep decreases as the night progresses. The older person may have more difficulty obtaining the quality and quantity of sleep.

Question 53

The nurse is concerned that an older patient is experiencing sleep apnea. What did the nurse assess in this patient?
Standard Text: Select all that apply.
1. Jumpy legs
2. Sleeping with three pillows
3. Excessive daytime sleepiness
4. Excessive snoring upon inspiration
5. Complaints of choking when waking from sleep

Answer 53

3: Excessive daytime sleepiness is a manifestation of sleep apnea.
4: Excessive snoring upon inspiration is a manifestation of sleep apnea.
5: Complaints of choking when waking from sleep is a manifestation of sleep apnea.

Question 54

An older patient is having difficulty sleeping. What can the nurse instruct the patient to help improve the patient’s sleep?
Standard Text: Select all that apply.
1. Do not nap during the day.
2. Take a walk an hour before going to sleep.
3. Have a glass of wine before going to sleep.
4. Avoid reading or watching television in bed.
5. If unable to sleep, get up and go to another room.

Answer 54

1: One action to improve sleep is to avoid napping during the day.
4: The bed should be used for sex or sleep and not for reading or watching television.
5: One action to improve sleep is to get up and go to another room if unable to sleep.

Question 55

The nurse is assessing an older patient who wakes up during the night. Which finding does the nurse identify as a risk factor for disturbed sleep?

1. Patient has osteoarthritis of both hips
2. Patient ingests one cup of coffee every morning
3. Patient takes antidepressant medication in the morning
4. Patient walks for half an hour before lunch each day

Answer 55

1: A common source of pain in older adults is the chronic pain resulting from osteoarthritis. Because osteoarthritis is so common in aging, it can result in chronic sleep disruption for large numbers of older people.

Question 56

The nurse is concerned that an older patient with dementia receiving psychotropic medications for sleep is experiencing side effects. What did the nurse assess in this patient?
Standard Text: Select all that apply.
1. Dizziness
2. Constipation
3. Hallucinations
4. Daytime lethargy
5. Problems swallowing

Answer 56

1: Typical side effects of hypnotic drugs include dizziness.
2: Typical side effects of hypnotic drugs include constipation.
4: The older person who routinely takes hypnotic drugs for sleep will have a change in the architecture of the sleep cycle and may experience daytime lethargy.
5: Typical side effects of hypnotic drugs include problems with swallowing.

Question 57

The nurse is concerned that an older patient has undiagnosed sleep apnea and is at risk for which additional health problem?

1. Underweight
2. Excessive deep sleep
3. Increased risk for sudden death and stroke
4. Excessive tension in the muscles of the throat and soft palate

Answer 57

3: The person with sleep apnea is subject to episodes of hypoxemia, which increases the risk for sudden death and stroke.

Question 58

The nurse is teaching an older patient about an overnight sleep study to diagnose sleep apnea. What will the nurse include when teaching this patient?
Standard Text: Select all that apply.
1. Oxygen saturation level will be measured.
2. An electrocardiogram will be used to measure heart activity.
3. Pins will be inserted into leg muscles to measure tone and tension.
4. An electromyogram will be done to measure face and leg movements.
5. An electroencephalogram will be done to measure brain wave activity.

Answer 58

1: During an overnight sleep study, the patient’s oxygen saturation level will be measured.
2: During an overnight sleep study, an electrocardiogram will be used to measure heart activity.
4: During an overnight sleep study, an electromyogram will be done to measure face and leg movements.
5: During an overnight sleep study, an electroencephalogram will be done to measure brain wave activity.

Question 59

An older patient is diagnosed with sleep apnea. Which interventions can the nurse add to the patient’s care plan to address this health problem?
Standard Text: Select all that apply.
1. Discussing smoking cessation techniques
2. Encouraging the patient to sleep on the side
3. Instructing to avoid alcohol before going to sleep
4. Suggesting sleeping in an upright position in a chair
5. Consulting with a dietitian to discuss meal planning for weight reduction

Answer 59

1: Treatment for sleep apnea may include teaching the patient to avoid smoking since this has been known to aggravate sleep apnea.
2: Treatment for sleep apnea may include encouraging the patient to sleep on the side to keep the airway open.
3: Treatment for sleep apnea may include teaching the patient to avoid alcohol before going to sleep since this has been known to aggravate sleep apnea.
5: Treatment for sleep apnea may include weight reduction for obesity since this has been known to aggravate sleep apnea.

Question 60

An older patient with sleep apnea is prescribed continuous positive airway pressure (CPAP). What will the nurse explain to the patient about this treatment?
Standard Text: Select all that apply.
1. Pressure keeps the airway open.
2. An oral airway is inserted each night.
3. The machine is noisy and will keep the patient awake.
4. Noninvasive treatment is administered through a nasal mask.
5. The face mask is uncomfortable but the patient will get used to it.

Answer 60

1: Continuous positive airway pressure works by applying pressure to the airway in order to keep the airway open during sleep.
4: CPAP is a noninvasive treatment that is administered through a nasal mask.

Question 61

An older patient who is hospitalized has been having difficulty sleeping since admission and is prescribed a low dose of zolpidem (Ambien). What does the nurse realize about this medication?

1. Contains the hormone melatonin
2. Is associated with daytime hangover
3. Does not adversely alter the sleep architecture
4. Is safe to use along with diphenhydramine (Benadryl)

Answer 61

3: Zolpidem (Ambien) is a new drug that does not adversely alter sleep architecture.

Question 62

An older patient is being prescribed medication to help with sleep. What should the nurse include in this patient’s plan of care?

1. Diazepam is the best benzodiazepine to use for sleep.
2. A benzodiazepine should only be used for 2 weeks.
3. Lorazepam should be avoided for sleep in the older patient.
4. A higher dose of an antidepressant medication is needed for sleep.

Answer 62

2: Benzodiazepine therapy is recommended for short-term use not to exceed 2 weeks.

Question 63

Which actions should the nurse take to ensure effective sleep for older patients in a long-term care facility?
Standard Text: Select all that apply.
1. Use nightlights during the night.
2. Establish consistent nighttime routines.
3. Schedule routine care in the early evening hours.
4. Put patients to bed immediately after the evening meal.
5. Reduce noise and light disruption throughout the night.

Answer 63

1: Interventions to ensure effective sleep for older patients in a long-term care facility include using nightlights during the night.
2: Interventions to ensure effective sleep for older patients in a long-term care facility include establishing consistent nighttime routines.
3: Interventions to ensure effective sleep for older patients in a long-term care facility include scheduling routine care in the early evening hours.
5: Interventions to ensure effective sleep for older patients in a long-term care facility include reducing noise and light disruption throughout the night.

Question 64

How should the nurse explain rapid eye movement (REM) sleep to an older patient?

1. Is when dreaming occurs
2. Is necessary for physical restoration
3. Involves sudden sustained muscle contractions in the extremities
4. Is accompanied by slowing of the heart rate and a fall in blood pressure

Answer 64

1: Dreaming occurs during REM sleep.

Question 65

The nurse is implementing sleep restriction therapy with an older patient. What intervention will be performed to support this plan of treatment?

1. Structuring patient naps to occur midmorning and midafternoon
2. Putting on the television in the room after getting the patient ready for sleep
3. Teaching the patient to watch the second hand move on the clock while waiting to fall asleep
4. Planning to wake the patient up at the same time each morning regardless of the sleep obtained

Answer 65

4: In sleep restriction therapy, the patient is to be woken up from sleep at the same time every morning, regardless of the amount of sleep obtained the previous night.

Question 66

An older patient with insomnia lives in an assisted living facility and is seen reading in the lounge area most nights. Which issue causes the greatest concern for the nurse caring for this patient?

1. The patient has significant underlying problems.
2. Insomnia is linked to cardiac dysfunction if it is not managed.
3. Liability is created by a patient who is unsupervised in the lounge areas.
4. The patient’s ability to function during the day may be hindered by these episodes.

Answer 66

4: Insomnia is defined as an inability to fall asleep or stay asleep on most nights and lasting for over a month. The individual experiencing insomnia is at risk for daytime drowsiness and may experience problems with concentration and function.

Question 67

An older patient in a long-term care facility does not sleep much at night and prefers to stay up late reading. The patient takes “power naps” during the day. How should the nurse respond to this patient’s plan to acquire adequate sleep?

1. Naps are sufficient to restore the missed sleep time.
2. Older people do not need as much sleep as younger adults.
3. Napping may simply contribute to the problem getting to sleep at night.
4. There is no problem as long as the total number of hours slept per 24-hour period is at least 8.

Answer 67

3: Napping during the day may make it more difficult to get to sleep at night.

Question 68

An older patient has been reading about the use of melatonin for sleep. Which statement indicates that the patient needs more instruction about this pharmacological agent?

1. “Melatonin is a hormone my body makes.”
2. “Nausea is a side effect associated with melatonin.”
3. “Older adults may have reduced levels of melatonin.”
4. “I will need to have a prescription from my physician to obtain it.”

Answer 68

4: Melatonin is available over-the-counter. A prescription from a physician is not needed.

Question 69

An older patient with difficulty sleeping wants to use an herbal remedy to help getting to sleep since problems with hay fever and nasal congestion are interfering with “drifting off” at night. Which herbal remedy should the nurse caution the patient to avoid?

1. Lemon balm
2. A glass of warm milk
3. A cup of chamomile tea
4. A small turkey sandwich

Answer 69

3: The use of chamomile products is contraindicated with allergies to ragweed. The patient has hay fever and seasonal allergies, which may be associated with ragweed.

Question 70

During an assessment, the nurse learns that an older patient does not feel refreshed in the morning after sleeping and reports that family members complain about the loud snoring at night. Which assessment finding supports sleep apnea as a potential problem for this patient?

1. Short stature
2. Hypertension
3. Female gender
4. Thin body build

Answer 70

2: Risk factors for sleep apnea include hypertension

Question 71

The nurse is planning care for an older patient who reports interrupted sleep because of needing to void during the night. Which common age-related changes is this symptom most likely associated with?
Standard Text: Select all that apply.
1. Nocturia
2. Kidney stones
3. Urinary frequency
4. Urinary tract infection
5. Benign prostatic hypertrophy

Answer 71

1: Older people may be awakened from sleep because of the need to urinate. Common age-related alterations in urinary tract function include nocturia.
3: Older people may be awakened from sleep because of the need to urinate. Common age-related alterations in urinary tract function include urinary frequency.
5: Older people may be awakened from sleep because of the need to urinate. Common age-related alterations in urinary tract function include benign prostatic hypertrophy.

Question 72

An older patient does not understand why an alcoholic drink cannot be provided before going to sleep in the evening. What should the nurse explain to the patient?

1. Alcohol has an initially depressant effect.
2. Alcohol can increase the time needed to fall asleep.
3. Alcohol is disruptive of the second half of the sleep cycle.
4. Alcohol can enable an individual to sleep through the entire night.

Answer 72

3: Alcohol use at bedtime is associated with disruption during the second portion of the sleep cycle.

Question 73

During a routine physical examination, an older patient reports having problems falling asleep at night despite engaging in vigorous activities to become tired in the evening. How should the nurse respond to the patient?

1. “You should vary your routine each day.”
2. “You should time activities to end within an hour of bedtime.”
3. “Exercise is recommended, but it should not be done closer than 3 hours to bedtime.”
4. “Lighten your exercise routine in the afternoon; concentrate exercise toward the morning hours.”

Answer 73

2: Exercise close to bedtime can cause difficulty falling asleep.

Question 74

An older patient is prescribed paroxetine hydrochloride (Paxil) for depression. When discussing the medication, which patient statements indicate the need for additional instruction?
Standard Text: Select all that apply.
1. “I may feel tired after taking this medication.”
2. “I can drive my car while taking this medication.”
3. “I should take this medication with my breakfast.”
4. “I should take this medication before eating my evening meal.”
5. “I cannot take this medication with any of my other medications.”

Answer 74

1: Paroxetine hydrochloride (Paxil) is a stimulating antidepressant and will not make the patient feel tired after taking it.
4: This medication should be taken with breakfast. If taken with dinner, it can interfere with sleep since it is a stimulating antidepressant.
5: There is no evidence to suggest that paroxetine hydrochloride (Paxil) cannot be taken with other prescribed medications.

Question 75

After completing an assessment, the nurse reviews the older patient’s medications. Which medication may cause problems with sleep?

1. Benadryl
2. Ibuprofen
3. Vitamin B
4. Ferrous sulfate

Answer 75

1: Antihistamines such as diphenhydramine (Benadryl) should not be used for sleep because of their anticholinergic side effects and the potential to decrease respiratory drive.

Question 76

An older patient is diagnosed with an infection but has a subnormal body temperature. What should the nurse explain to the patient’s family as the reason for this discrepancy?

1. The temperature regulating mechanism changes with aging.
2. The patient is on medication that drops the body temperature.
3. The diagnosis of an infection is inaccurate and will be checked.
4. The temperature was measured incorrectly and will be repeated.

Answer 76

1: An elevated temperature is a common sign of infection but may not be present in the frail older adult.

Question 77

An older patient is recovering from abdominal surgery. Which skin changes will the nurse consider when planning care for this patient?

1. The healing time is increased.
2. The healing time is decreased.
3. There is a need to keep the wound edges taped.
4. Skin near the wound needs to be massaged to increase blood flow.

Answer 77

1: Epidermal mitosis slows 30% after the age of 50, resulting in longer healing time for older persons.

Question 78

The home care nurse notes that an older patient who lives alone has a large red mark on the arm. When asked about the mark the patient states unawareness of the injury and believes it occurred from hot water when cooking. How should the nurse interpret this finding?

1. The patient is at risk for further injury.
2. The patient is losing short-term memory.
3. The patient is experiencing friction tears of the skin.
4. The patient is demonstrating senile purpura of the skin.

Answer 78

1: With normal aging there is a gradual decline in both touch and pressure sensations, causing the older adult to be at risk for injury such as burns and pressure sores.

Question 79

An older patient is recovering from surgery to repair a fractured hip. What interventions will the nurse use to prevent the development of a pressure ulcer in this patient?
Standard Text: Select all that apply.
1. Avoid sitting unless for meals.
2. Use pillows to protect the skin.
3. Reposition the patient every 2 hours.
4. Keep the skin dry with frequent bathing.
5. Encourage independent position changes.

Answer 79

1: Interventions to prevent pressure ulcer formation include avoiding the sitting position unless it is for meals.
2: Interventions to prevent pressure ulcer formation include using pillows to protect the skin.
3: Interventions to prevent pressure ulcer formation include repositioning the patient every 2 hours.
5: Interventions to prevent pressure ulcer formation include encouraging the patient to make independent position changes. Even small shifts redistribute the body weight and improve perfusion of the tissue.

Question 80

What instruction should the nurse provide to a nursing assistant who is assigned to care for an older patient with a stage I pressure ulcer on the right heel?

1. Apply a dry dressing to the site.
2. Apply a donut under the right heal.
3. Cleanse the area with tepid water without soap.
4. Keep the head of the bed elevated to a 45-degree angle.

Answer 80

3: The area at risk for pressure sore development should be washed gently with tepid water, with or without minimal soap. Soap removes natural oils from the skin, and cleaning the soap off may cause additional friction damage.

Question 81

While assessing an older patient’s stage III pressure ulcer the nurse notes that the wound is beefy red and grainy, and the depth has decreased by 2 mm but the width has not changed. How should the nurse interpret this assessment finding?

1. Not healing properly
2. About to slough off tissue
3. No longer at risk for infection
4. Progressing positively toward healing

Answer 81

4: Healing of a decubitus fills from the wound bottom so the depth decreases before the wound width decreases. The beefy red and grainy appearance is evidence of granulation tissue as the capillary bed builds. These are all indicators of good wound healing.

Question 82

The nurse is caring for an older patient who previously had a sacral pressure ulcer that has completely healed. What does the nurse recognize as a characteristic of the previously healed pressure ulcer?

1. Heal faster if reinjured
2. Break down faster if reinjured
3. Have no sensation in the injured area
4. Be at risk for infection even with intact skin

Answer 82

2: Scarred wounds never reach the prewound strength and are more prone to reinjury than normal tissue.

Question 83

After an assessment the nurse is concerned that an older patient is at risk for pressure ulcer development because of the current nutritional status. What nutritional factors did the nurse assess in the patient?
Standard Text: Select all that apply.
1. Diagnosis of dehydration
2. Hemoglobin level 9 mg/dL
3. Treatment for chronic renal failure
4. Serum albumin level below normal
5. Loss of 20 pounds over the last 3 months

Answer 83

1: Nutritional factors associated with pressure ulcer development include dehydration.
2: A hemoglobin level of 9 mg/dL indicates anemia, which is a nutritional factor associated with pressure ulcer development.
4: Nutritional factors associated with pressure ulcer development include a decreased serum albumin level.
5: Nutritional factors associated with pressure ulcer development include decreased body weight.

Question 84

Which over-the-counter skin preparations should the nurse instruct an older patient to use with caution?
Standard Text: Select all that apply.
1. Sunblock
2. Super-fatted soaps
3. Emollients that keep the skin moist
4. Steroid-based ointments and creams
5. Topical lotion with an antihistamine

Answer 84

4: Older adults have a high rate of adverse reactions to corticosteroids, which are frequently prescribed for skin problems. Older adults should be reminded not to buy over-the-counter preparations of this drug without specific instructions from the primary care provider. If this medication is prescribed, directions should be strictly followed and any unusual symptoms reported promptly.
5: Older adults have a high rate of adverse reactions to antihistamines, which are frequently prescribed for skin problems. Older adults should be reminded not to buy over-the-counter preparations of this drug without specific instructions from the primary care provider. If this medication is prescribed, directions should be strictly followed and any unusual symptoms reported promptly.

Question 85

The nurse is preparing to cleanse an older patient’s abdominal wound. Which techniques should the nurse use to perform this action?
Standard Text: Select all that apply.
1. Pour saline over the wound.
2. Apply saline-soaked gauze over the wound.
3. Squeeze a saline-filled syringe over the wound.
4. Place gauze pads soaked with hydrogen peroxide on the wound.
5. Apply dry gauze pads over the wound and saturate with sterile water.

Answer 85

1: Wound cleansing can be done by pouring saline over the wound.
2: Wound cleansing can be done by applying saline-soaked gauzes over the wound to clean the debris from the wound bed.
3: Wound cleansing can be done by squeezing a saline-filled bulb syringe over the wound.

Question 86

The nurse provides a seminar on the impact of the sun on the skin with a group of older community members. Which statement indicates that additional teaching is necessary?

1. “Sunscreen is important to wear during all daytime hours.”
2. “The sun should be avoided between the peak hours of 10 a.m. and 4 p.m.”
3. “African Americans can experience sun damage despite the dark skin tones.”
4. “The melanocytes in the subcutaneous tissue protect the skin from sun damage.”

Answer 86

4: Melanocytes are located in the epidermal skin layers and not the subcutaneous tissue. This statement indicates that additional teaching is necessary.

Question 87

While performing a physical assessment, the nurse notes that an older patient has multiple brown and black bands on the finger nails of the thumbs and index fingers. What does this assessment finding indicate to the nurse?
Standard Text: Select all that apply.
1. A fungal infection
2. Damage to the nail matrix
3. Possible melanoma of the nail
4. Benign finding often seen in African Americans
5. Finger nails split in response to recent trauma

Answer 87

3: This finding is a longitudinal pigmented band and may indicate possible melanoma of the nail.
4: This finding is a longitudinal pigmented band, is common in dark-skinned races, and is more visible in the older adult.

Question 88

An older patient complains about increasing dry skin. What should the nurse explain to the patient about this skin problem?
Standard Text: Select all that apply.
1. There is a reduction in sebum production as the body ages.
2. There is a decrease in the number of sweat glands in the body with aging.
3. There is a change in the keratinization and lipid content in the stratum corneum.
4. There is an increase in body core temperature with aging, resulting in skin drying.
5. There is a change in the structure of the skin cell because of years of using alcohol-based soaps.

Answer 88

1: Sebum is an oily substance that keeps hair supple and lubricates the skin. Sebum protects the skin from water loss and provides protection against infection. Sebaceous glands increase in size with age, but the amount of sebum produced is decreased. This would explain why the older patient is experiencing increasingly dry skin.
3: Changes in the keratinization process and lipid content in the stratum corneum cause the flaking appearance and dry sensation of the skin.

Question 89

An older patient recently diagnosed with skin cancer does not understand why the disease developed since sunbathing has always been avoided. How should the nurse respond to this patient?

1. “Can you tell me more about your feelings?”
2. “Sun exposure can happen from driving a car.”
3. “We frequently never find out why cancer strikes.”
4. “This is unusual, as skin cancer normally only occurs in sunbathers.”

Answer 89

2: Sun exposure can occur from routine activities such as driving or riding in a car.

Question 90

The nurse is preparing discharge instructions for an older patient. For which medications should the nurse teach the patient to avoid extended sun exposure?
Standard Text: Select all that apply.
1. Aspirin
2. Ibuprofen
3. Amiodarone
4. Promethazine
5. Acetaminophen

Answer 90

2: Ibuprofen is a medication that causes skin sensitivity.
3: Amiodarone is a medication that causes skin sensitivity.
4: Promethazine is a medication that causes skin sensitivity.

Question 91

The nurse notes a small, indurated, scaled spot on the upper chest of an older patient. Which type of skin condition did the nurse assess in this patient?

1. Actinic keratosis
2. Basal cell carcinoma
3. Malignant melanoma
4. Squamous cell carcinoma

Answer 91

4: Squamous cell carcinoma most often appears as a flesh-colored, erythematous, indurated scaly plaque.

Question 92

An older patient requests a small, inflated donut to sit on to relieve pressure. What response by the nurse is most appropriate?

1. “I will obtain the device for you.”
2. “Using the donut can cause skin breakdown.”
3. “I will need to get an order from the physician.”
4. “You will need to wait until discharge and use this at home.”

Answer 92

2: The use of a donut applies pressure and results in tissue anoxia. The patient may indeed feel that pressure is lessened, but this is due to the loss of sensation. The use of the devices should be avoided.

Question 93

The daughter of an older patient sees a reddened area on the patient’s coccyx and wants to massage the area to improve circulation. What response by the nurse is indicated?

1. “I will record these findings in the medical record.”
2. “I will need to obtain an order from the physician to perform a massage.”
3. “Massaging the area may actually cause more harm to a potentially compromised area of skin.”
4. “Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care.”

Answer 93

3: The presence of redness may indicate the presence of a stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted.

Question 94

The nurse is performing a skin assessment on an older African American patient. Which findings would be considered normal for this patient?
Standard Text: Select all that apply.
1. Bluish gums
2. Many small, dark papules on the face
3. Purple, hard ,smooth area on the upper arm
4. Multiple skin tears with clear fluid drainage
5. Freckle-like pigmentation of the tongue borders

Answer 94

1: Some dark-skinned people have bluish gums.
2: Many small dark papules on the face are dermatosis papulosa nigra, a type of Seborrheic keratoses that only occurs in African Americans.
5: Dark-skinned people may have freckle-like pigmentations of the tongue borders which is a normal finding.

Question 95

An older patient has a Braden Scale pressure ulcer risk score of 18. What does this score mean to the nurse?

1. The patient is at a low risk for the development of a pressure ulcer.
2. This patient is at a high risk for the development of a pressure ulcer.
3. The score is inconclusive and the assessment repeated within 3 days.
4. This score is inconclusive and shows no significant risk pressure ulcer development.

Answer 95

2: The Braden Scale is used to evaluate a patient’s risk for the development of pressure ulcers. A score of 16 or less indicates a pressure sore risk and the need for a prevention plan.

Question 96

The nurse is caring for an older patient with a stage II pressure ulcer. Which product will the nurse use to clean the wound at the next dressing change?

1. Saline
2. Dakin’s solution
3. Povidone-iodine
4. Hydrogen peroxide

Answer 96

1: The safest, most cost effective and most common cleansing agent for wounds is isotonic saline.

Question 97

The nurse is treating a skin tear on an older patient’s lower leg. Which dietary selection contains ingredients that will be most favorable to wound healing for this patient?

1. Cereal, milk, and toast
2. Bacon, toast, and coffee
3. Eggs, toast, and orange juice
4. Ham slices, milk, and applesauce

Answer 97

3: Protein and vitamin C are needed for tissue healing. Eggs and orange juice contain the most amounts of healing foods for the patient.

Question 98

The nurse is planning care for an older patient with pneumonia and a stage II pressure ulcer. Which nursing diagnosis would have the greatest priority for this patient’s care?

1. Acute Pain related to destruction of tissue
2. Knowledge Deficit related to care of skin disorder
3. Risk for Infection related to impaired skin integrity
4. Potential for Infection related to impaired skin integrity

Answer 98

1: Pain is the most significant problem initially. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned.

Question 99

An older patient has a nonhealing stage III pressure ulcer. Which treatment would be indicated for this patient’s wound?

1. Cadexomer
2. Silver sulfadiazine
3. Nanocrystalline silver
4. Topical antibiotic cream

Answer 99

2: Silver sulfadiazine is the topical antimicrobial of choice for the nonhealing ulcer.

Question 100

Which actions would the nurse take to prevent skin tears on an older patient with friable skin?
Standard Text: Select all that apply.
1. Avoid harsh soaps.
2. Apply silk tape over dressings.
3. Ensure an adequate fluid intake.
4. Use a lift sheet to reposition in bed.
5. Apply skin-moisturizing cream to arms and legs twice a day.

Answer 100

1: An intervention to prevent skin tears is to avoid harsh soaps.
3: An intervention to prevent skin tears is to ensure an adequate fluid intake.
4: An intervention to prevent skin tears is to use a lift sheet to reposition the patient in bed.
5: An intervention to prevent skin tears is to apply skin-moisturizing cream to the arms and legs twice a day.

Question 101

The nurse learns that an older patient has a decrease in accommodation. What would the nurse assess in this patient?

1. Blurred vision
2. Sensitivity to light
3. Narrowing of field of vision
4. Difficulty reading small print

Answer 101

4: Accommodation is the ability of the lens to change shape and focus images clearly. This loss of pliability in the lens contributes to the decrease in near vision, which generally occurs around the age of 40. This would be demonstrated by the patient’s difficulty reading small print.

Question 102

An older patient has sensitivity to light. What should the nurse teach the patient to help with this problem?

1. Dim the lights on sunny days.
2. Place dark patterned rugs on stairs.
3. Use supplementary lamps near work.
4. Remove lampshades to provide more light.

Answer 102

3: Using supplementary lamps near work is correct because the ability to adapt to varying degrees of light declines with age and there is a need for increased light.

Question 103

The nurse is reviewing an older patient's currently prescribed medications. Which medications have side effects that increase visual disturbances?
Standard Text: Select all that apply.
1. Propranolol (Inderal)
2. Warfarin (Coumadin)
3. Tamoxifen (Nolvadex)
4. Amiodarone (Cordarone)
5. Calcium carbonate (Tums)

Answer 103

1: The side effects of propranolol (Inderal) include blurred vision and dry eyes.
3: The side effects of tamoxifen (Nolvadex) include retinopathy and blurred vision.
4: The side effects of amiodarone (Cordarone) include blurred vision, corneal changes, optic neuropathy, and halos.

Question 104

An older patient has sensorineural hearing loss. Which health problems should the nurse recognize as causing this type of hearing loss? 
Standard Text: Select all that apply.
1. Presbycusis
2. Meniere's disease
3. Impacted cerumen
4. Otitis media infection
5. Tympanic membrane perforation

Answer 104

1: Sensorineural hearing loss can be caused by presbycusis or loss of hearing due to age-related changes in the inner ear.
2: Meniere’s disease causes edema is in the inner ear leading to damage to the nerve.

Question 105

An otoscopic examination of an older patient reveals a red, bulging membrane with absent distorted light reflex. Which condition would the nurse suspect?

1. Scar tissue
2. Otitis media
3. External otitis
4. Ruptured tympanic membrane

Answer 105

2: Otitis media is correct because infected fluid in the middle ear causes the red, bulging membrane and the absent distorted light reflex is caused by the increasing middle ear pressure.

Question 106

Which interventions should the nurse perform when an older patient reports a change in hearing?
Standard Text: Select all that apply.
1. Perform a Rinne test.
2. Eliminate extraneous noise.
3. Review prescribed medications.
4. Report the change to the physician.
5. Speak in a tone that includes shouting.

Answer 106

2: Eliminating extraneous noise helps most older patients because they first lose high-pitch sounds and sounds become distorted with a combination of TV, visitors, and personnel all talking at the same time.
3: Medications prescribed must be reviewed because many have side effects that cause hearing loss.
4: The physician should be notified of hearing changes to change medications as appropriate and to do referrals as necessary.

Question 107

The nurse documents that an older patient has hypogeusia. What is this patient experiencing?

1. Dulled sensitivity to touch
2. Blunting of the sense of taste
3. A downward and outward deviation of the eye
4. Dry mouth occurring with salivary gland dysfunction

Answer 107

2: Blunting of the sense of taste is hypogeusia.

Question 108

An older patient with diabetes has an oral infection and is on antibiotics. Which manifestations might the nurse observe in this patient?

1. Increased weight
2. Increased appetite
3. Increased gustatory sensation
4. Increased salt or sugar intake

Answer 108

4: Increased salt or sugar intake is correct because older people use excessive salt or sugar to compensate for a diminished sense of taste. Sense of taste is affected by diabetes, infections, and medications.

Question 109

Which interventions should the nurse use to help a patient with xerostomia?
Standard Text: Select all that apply.
1. Use a humidifier.
2. Provide oral fluids after meals.
3. Provide sugar-free hard candies.
4. Reinforce regular dental examinations.
5. Increase medications from once a day to twice a day.

Answer 109

1: Using a humidifier adds moisture to the air and can help with xerostomia that may interfere with sleep.
3: Providing sugar-free hard candies is correct because it helps stimulate salivary secretions without increasing blood sugar.
4: Reinforcing regular dental examinations is correct because caries can cause infections and mal-fitting dentures can irritate dry oral mucosa.

Question 110

Which is a pathophysiological cause that the nurse recognizes in an older patient with hyposmia?

1. Increased neurotransmitters
2. Injury of the olfactory mucosa
3. Increased number of sensory cells
4. Lower thresholds for common odors

Answer 110

2: Injury of the olfactory mucosa causes changes in olfactory function.

Question 111

An older patient is prescribed antihistamines. What will the nurse assess as side effects of this medication?
Standard Text: Select all that apply.
1. Altered taste
2. Altered smell
3. Altered touch
4. Altered vision
5. Altered hearing

Answer 111

1: Antihistamines can affect taste.
2: Antihistamines can affect smell.
4: Antihistamines can affect vision.

Question 112

The nurse is completing an assessment of an older patient's eyes. Which findings does the nurse identify as being normal age-related changes?
Standard Text: Select all that apply.
1. Cataracts
2. Ectropion
3. Entropion
4. Glaucoma
5. Arcus senilis

Answer 112

2: An ectropion is when the bottom eye lid sags outward and is no longer in contact with the eye.
3: An entropion is when the lid turns inward, bringing the eyelashes in contact with the eyeball and causing irritation and abrasion to the cornea.
5: Arcus senilis are corneal calcium deposits that have cosmetic implications only.

Question 113

The nurse has identified the diagnosis Self-Care Deficit for an older patient with hyposmia. What should the nurse teach the patient prior to being discharged to home?
Standard Text: Select all that apply.
1. Date and label all foods.
2. Remove kitchen waste weekly.
3. Use colognes as bath substitute.
4. Establish a schedule for house cleaning.
5. Place natural gas detectors near gas heater or stove.

Answer 113

1: Dating and labeling all foods may prevent a patient who is unable to smell from becoming ill with spoiled food products.
4: Establishing a schedule for house cleaning will prevent malodors from permeating the house and being offensive to visitors when the patient is unable to detect such odors.
5: Placing natural gas detectors near gas heater or stove needs to be done because the inability to smell gas increases the potential for fire and explosions.

Question 114

Which statement should the nurse emphasize when teaching a patient with neuropathy from diabetes?

1. “Set water heater at 120°F.”
2. “Avoid hand and foot massages.”
3. “Use a mirror to inspect feet daily.”
4. “Increase medication for pain as necessary.”

Answer 114

3: Older patients with diabetes mellitus should place a mirror on the wall close to the floor, remove their shoes, and examine the bottoms of their feet daily for blisters, redness, or ulcerations.

Question 115

Which interventions should the nurse suggest an older patient use to reduce safety issues in the home?
Standard Text: Select all that apply.
1. Use lampshades to prevent glare.
2. Recommend designed rug patterns.
3. Increase lighting in high-traffic areas.
4. Add extra lighting in areas that are dark.
5. Paint the edges of stairs to identify steps.

Answer 115

1: One intervention to improve safety issues in the home is to use lampshades to prevent glare.
3: One intervention to improve safety issues in the home is to increase lighting in high-traffic areas.
4: One intervention to improve safety issues in the home is to add extra lighting in areas that are dark.
5: One intervention to improve safety issues in the home is to paint the edges of stairs to identify steps.

Question 116

An older patient who wears glasses is being admitted to a long-term care facility. Which action should the nurse take when assessing the patient’s visual acuity?

1. Ask the patient to wear the glasses.
2. Ask the patient to remove the glasses.
3. Allow the patient to choose whether or not to remove the glasses.
4. If the patient wears glasses to eat then glasses should be removed.

Answer 116

1: The older person with glasses should wear them during the vision assessment.

Question 117

A 75-year-old patient complains that his vision continues to get worse every year. How should the nurse respond to this patient’s complaint?

1. “I certainly understand your frustration.”
2. “The problems you are experiencing are likely the early stages of glaucoma.”
3. “The visual problems you are reporting become increasingly common after age 70.”
4. “Maybe you have a medical problem that may be causing these drastic visual problems.”

Answer 117

3: Visual acuity tends to diminish gradually after the age of 50 and then more rapidly after the age of 70.

Question 118

A family is making home modifications for a visually impaired older family member. Which recommendation should the home care nurse make to the family?

1. Remove lamp shades to increase lighting.
2. Use soft blue, gray, and light green tones.
3. Install motion-sensor lights when possible.
4. Install reflective floors to provide increased lighting to the environment.

Answer 118

3: The use of motion-sensor lights will provide illumination when the visually impaired man walks into the room.

Question 119

The daughter of an older patient is concerned that the patient continues to drive at age 81. What should the nurse share with the daughter and patient about motor vehicle accidents and older people?

1. The elderly have few wrecks, as they are more cautious drivers.
2. There are few studies available looking at this particular concern.
3. The risks of seniors over age 80 are similar to those of teen drivers.
4. Accidents are the result of cognitive changes not related to sensory problems.

Answer 119

3: It is estimated that drivers over the age of 80 have a crash rate per mile driven that is equivalent to that of teenage motorists.

Question 120

An older patient wants to use holistic ways to reduce the risk of age-related macular degeneration. What should the nurse instruct the patient to consume to promote eye health?

1. Cabbage, eggs, and orange juice
2. Whole-wheat bread, eggs, and milk
3. Sweet potatoes, spinach, and broccoli
4. Lean meats, whole-wheat breads, and blueberries

Answer 120

3: The Age-Related Eye Disease Study (AREDS) conducted by the National Eye Institute found a 25% risk reduction in the development of age-related macular degeneration by consuming high doses of antioxidants (vitamins C and E and beta-carotene) and zinc. Sweet potatoes, spinach, and broccoli are excellent sources of beta-carotene. Broccoli is also a good source of vitamin C.

Question 121

An older patient is being treated for glaucoma with Timoptic. Which assessment finding indicates an adverse effect associated with the medication?

1. Diarrhea
2. Slow heat rate
3. Excessive salivation
4. Reduced urinary output

Answer 121

2: A slow heart rate is called bradycardia, and must be evaluated because Timoptic is a beta blocker and is associated with bradycardia in some patients.

Question 122

An older patient, experiencing a significant loss of hearing after being involved in an explosion, wants to know how long the loss will last. Which response by the nurse is most appropriate at this time?

1. “Surgery will help restore the hearing you have lost.”
2. “Hearing loss attributed to loud noises is normally reversible.”
3. “Loud noises can cause immediate, permanent losses of hearing.”
4. “The most common cause of hearing impairments is the result of exposure to loud noises.”

Answer 122

3: Very loud sounds of short duration, such as an explosion or gunfire, can cause immediate, severe, and permanent loss of hearing.

Question 123

The home care nurse observes a buildup of cerumen in both ears of an older patient. What should the nurse do to help this patient?

1. Instruct the patient to use a curate to remove the cerumen.
2. Show the patient how to use a bulb syringe to remove the cerumen.
3. Advise the patient to seek medical attention to remove the cerumen.
4. Teach the patient to use a cotton-tipped swab to remove the cerumen.

Answer 123

3: Cerumen buildup is a common problem in the elderly. The removal of it from the elderly is best performed by a trained professional.

Question 124

When assessing the tympanic membrane of an older patient, the nurse notes the presence of two jagged white lines. What does this finding indicate to the nurse?

1. The tympanic membrane appears to be ruptured.
2. This is a sign of chronic infection of the tympanic membrane.
3. The white lines are consistent with a past history of a tympanic rupture.
4. The presence of these markings is consistent with the presence of an infection.

Answer 124

3: Some older adults have jagged white scars across the tympanic membrane as a result of ruptured eardrums from infections when they were children before the widespread use of antibiotics.

Question 125

The nurse is planning a teaching session for nursing assistants regarding effective communication with hearing-impaired patients. Which principles should be included in the program?
Standard Text: Select all that apply.
1. Use gestures if appropriate.
2. Raise voice pitch when talking.
3. Pause at the end of each sentence.
4. Stand 1 to 2 feet away from the patient.
5. Speak in a normal tone of voice during the interaction.

Answer 125

1: Nursing interventions to use when speaking to an individual with a hearing impairment include using gestures when appropriate.
3: Pausing at the end of the sentence will allow the patient the opportunity to respond to the conversation and take in the information being relayed.
5: Speaking in a normal tone of voice is helpful. Shouting is not helpful.