(Test Bank) Medical-Surgical Nursing Patient-Centered Collaborative Care, Single Volume

Ignatavicius,Workman, 8

Nursing

Test Bank

8th Edition

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Test Bank for Medical-Surgical Nursing Patient-Centered Collaborative Care, Single Volume, The downloadable file consists of 749 pages, and the total size of the file is 7.26 MB. Purchase now only for highly discounted price.

Author(s): Ignatavicius, Workman

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Test Bank for Medical -Surgical Nursing Patient -Centered Collaborative Care, Single Volume, 8e Donna Ignataviciu, Linda Workman (All Chapters) Chapter 1: Introduction to Medical -Surgical Nursing Practice MULTIPLE CHOICE 1. A new nurse is working with a preceptor on an inpatient medical -surgical unit. The preceptor advises the student that which is the priority when working as a professional nurse? a. Attending to holistic client needs b. Ensuring client safety c. Not making medication errors d. Providing client -focused care ANS: B All actions are appropriate for the professional nurse. However, ensuring client safety is the priority. Up to 98,000 deaths result each year from errors in hospital care, according to the 2000 Institute of Medicine report. Many more clients have suffered injuries and less serious outcomes. Every nurse has the responsibility to guard the client’s safety. DIF: Understanding/Comprehension REF: 2 KEY: Patient safety MSC: Integrated Process: Nursing Process: Intervention NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is orienting a new client and family t o the inpatient unit. What information does the nurse provide to help the client promote his or her own safety? a. Encourage the client and family to be active partners. b. Have the client monitor hand hygiene in caregivers. c. Offer the family the opportunity to stay with the client. d. Tell the client to always wear his or her armband. ANS: A Each action could be important for the client or family to perform. However, encouraging the client to be active in his or her health care as a partner is the most critical. The other actions are very limited in scope and do not provide the broad protection that being active and involved does. DIF: Understanding/Comprehension REF: 3 KEY: Patient safety MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 3. A nurse is caring for a postoperative client on the surgical unit. The client’s blood pressure was 142/76 mm Hg 30 mi nutes ago, and now is 88/50 mm Hg. What action by the nurse is best? a. Call the Rapid Response Team. b. Document and continue to monitor. c. Notify the primary care provider. d. Repeat blood pressure measurement in 15 minutes. ANS: A The purpose of the Rapid Response Team (RRT) is to intervene when clients are deteriorating before they suffer either respiratory or cardiac arrest. Since the client has manifested a significant ch ange, the nurse should call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nurse must do more than document. The primary care provider should be notified, but this is not the priority over calling the RRT. The client’s blood pressure should be reassessed frequently, but the priority is getting the rapid care to the client. DIF: Applying/Application REF: 3 KEY: Rapid Response Team (RRT)| medical emergencies MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 4. A nurse wishes to provide client -centered care in all interactions. Which action by the nurse best demonstrates this concept? a. Assesses for cultural influences affecting health care b. Ensures that all the clients’ basic needs are met c. Tells the client and family about all upcoming tests d. Thoroughly orients the client and family to the room ANS: A Competency in client -focused care is demonstrated when the nurse focuses on communication, culture, respect, compassion, client educatio n, and empowerment. By assessing the effect of the client’s culture on health care, this nurse is practicing client -focused care. Providing for basic needs does not demonstrate this competence. Simply telling the client about all upcoming tests is not prov iding empowering education. Orienting the client and family to the room is an important safety measure, but not directly related to demonstrating client -centered care. DIF: Understanding/Comprehension REF: 3 KEY: Patient -centered care| culture MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 5. A client is going to be admitted for a scheduled surgical procedure. Which action does the nurse explain is the most important thing the client can do to protect against errors? a. Bring a list of all medications and what they are for. b. Keep the doctor’s phone number by the telephone. c. Make sure all providers wash hands before entering the room. d. Write down the name of each caregiver who comes in the room. ANS: A Medication errors are the most common type of health care mistake. The Joint Commission’s Speak Up campaign encourages c lients to help ensure their safety. One recommendation is for clients to know all their medications and why they take them. This will help prevent medication errors. DIF: Applying/Application REF: 4 KEY: Speak Up campaign| patient safety MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 6. Which action by the nurse working with a client best demonstrates respect for au tonomy? a. Asks if the client has questions before signing a consent b. Gives the client accurate information when questioned c. Keeps the promises made to the client and family d. Treats the client fairly compared to other clients ANS: A Autonomy is self -determination. The client should make decisions regarding care. When the nurse obtains a signature on the consent form, assessing if the client still has questions is vital, beca use without full information the client cannot practice autonomy. Giving accurate information is practicing with veracity. Keeping promises is upholding fidelity. Treating the client fairly is providing social justice. DIF: Applying/Application REF: 4 KEY: Autonomy| ethical principles MSC: Integrated Process: Caring NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 7. A student nurse asks the faculty to explain best practices when communi cating with a person from the lesbian, gay, bisexual, transgender, and queer/questioning (LGBTQ) community. What answer by the faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Don’ t make assumptions about their health needs. c. Most LGBTQ people do not want to share information. d. No differences exist in communicating with this population. ANS: B Many members of the LGBTQ community have faced discrimination from health care providers and may be reluctant to seek health care. The nurse should never make assumptions about the needs of members of this population. Rather, respectful questions are appropriate. If approached with sensitivity, the client with any health care need is m ore likely to answer honestly. DIF: Understanding/Comprehension REF: 4 KEY: LGBTQ| diversity MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity 8. A nurse is calling the on -call physician about a client who had a hysterectomy 2 days ago and has pain that is unrelieved by the prescribed narcotic pain medication. Which statement is part of the SBAR format for communication? a. A: “I would like you to o rder a different pain medication.” b. B: “This client has allergies to morphine and codeine.” c. R: “Dr. Smith doesn’t like nonsteroidal anti -inflammatory meds.” d. S: “This client had a vaginal hysterectomy 2 days ago.” ANS: B SBAR is a recommended form of communication, and the acronym stands for Situation, Background, Assessment, and Recommendation. Appropriate background information includes allergies to medications the on -call physician might order. Situation describes what is happening right now that must be communicated; the client’s surgery 2 days ago would be considered background . Assessment would include an analysis of the client’s problem; asking for a different pain medication is a recommendation. Recommendation is a statement of what is needed or what outcome is desired; this information about the surgeon’s preference might be better placed in background . DIF: Applying/Application REF: 5 KEY: SBAR| communication MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 9. A nurse working on a cardiac unit delegated taking vital signs to an experienced unlicensed assistive personnel (UAP). Four hours later, the nurse notes the client’s blood pressure is much higher than previous readings, and the client’s mental status has changed. What action by the nurse would most likely have prevented this negative outcome? a. Determining if the UAP knew how to take blood pressure b. Double -checking the UAP by taking another blood pressure c. Providing more appropriate supervision of the UAP d. Taking the blood pressure instead of delegating the task ANS: C Supervision is one of the five rights of delegation and includes directing , evaluating, and following up on delegated tasks. The nurse should either have asked the UAP about the vital signs or instructed the UAP to report them right away. An experienced UAP should know how to take vital signs and the nurse should not have to ass ess this at this point. Double -checking the work defeats the purpose of delegation. Vital signs are within the scope of practice for a UAP and are permissible to delegate. The only appropriate answer is that the nurse did not provide adequate instruction t o the UAP. DIF: Applying/Application REF: 6 KEY: Supervision| delegation| unlicensed assistive personnel MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 10. A newly graduated nurse in the hospital states that, since she is so new, she cannot participate in quality improvement (QI) projects. What response by the precepting nurs e is best? a. “All staff nurses are required to participate in quality improvement here.” b. “Even being new, you can implement activities designed to improve care.” c. “It’s easy to identify what indicators should be used to measure quality.” d. “You should ask to be assigned to the research and quality committee.” ANS: B The preceptor should try to reassure the nurse that implementing QI measures is not out of line for a newly licensed nurse. Simply stating that all nurses are required to participate does not help the nurse understand how that is possible and is dismissive. Identifying indicators of quality is not an easy, quick process and would not be the best place to suggest a new nurse to start. Asking to be assigned to the QI committee does not give the nurse information about how to implement QI in daily practice. DIF: Applying/Application REF: 6 KEY: Quality improvement MSC: Integrated Proces s: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 11. A nurse is talking with a client who is moving to a new state and needs to find a new doctor and hospital there. What advice by th e nurse is best? a. Ask the hospitals there about standard nurse -client ratios. b. Choose the hospital that has the newest technology. c. Find a hospital that is accredited by The Joint Commission. d. Use a facility affiliated with a medical or nursing school. ANS: C Accreditation by The Joint Commission (TJC) or other accrediting body gives assurance that the facility has a focus on saf ety. Nurse -client ratios differ by unit type and change over time. New technology doesn’t necessarily mean the hospital is safe. Affiliation with a health professions school has several advantages, but safety is most important. DIF: Understanding/Comprehension REF: 2 KEY: The Joint Commission (TJC)| accreditation MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control MULTIPLE RESPONSE 1. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Which areas should the manager assess to determine if the nursing staff demonstrate competency according to the Instit ute of Medicine (IOM) report Health Professions Education: A Bridge to Quality? (Select all that apply.) a. Collaborating with an interdisciplinary team b. Implementing evidence -based care c. Providing family -focused care d. Routinely using informatics in practice e. Using quality improvement in client care ANS: A, B, D, E The IOM report lists five broad core competencies that all health care providers should practice. These include collaborating with the interdisciplinary team, implementing evidence -based practice, providing client -focused care, using informatics in client care, and using quality improvement in client care. DIF: Remembering/Knowledge REF: 3 KEY: Competencies| Institute of Medicine (IOM) MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 2. A nurse is interested in making interdisciplinary work a high priority. Which actions by the nurse best demonstrate this skill? (Select all that apply.) a. Consults with other disciplines on client care b. Coordinates discharge planning for home safety c. Participates in comprehensive client rounding d. Routinely asks other disciplines about client progress e. Shows the nursing care plans to other disciplines ANS: A, B, C, D Collaborating with the interdisciplinary team involves planning, implementing, and evaluating client care as a team with all other disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating w ith them. DIF: Applying/Application REF: 4 KEY: Collaboration| interdisciplinary team MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 3. The nurse utilizi ng evidence -based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost-saving measures b. Nurse’s expertise c. Client preferences d. Research findings e. Values of the client ANS: B, C, D, E EBP consists of utilizing current evidence, the client’s values and preferences, and the nurse’s expertise when planning care. It does not include cost -saving measures. DIF: Remembering/Knowledge REF: 6 KEY: Evidence -based practice (EBP) MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 4. A nurse manager wants to improve hand -off communication among the staff. What actions by the manager would best help achieve this goal? (Select all that apply.) a. Attend hand -off rounds to coach and mentor. b. Conduct audits of staff using a new template. c. Create a template of topics to include in report. d. Encourage staff to ask questions during hand -off. e. Give raises based on compliance with reporting. ANS: A, B, C, D A good tool for standardizing hand -off re ports and other critical communication is the SHARE model. SHARE stands for standardize critical information, hardwire within your system, allow opportunities to ask questions, reinforce quality and measurement, and educate and coach. Attending hand -off re port gives the manager opportunities to educate and coach. Conducting audits is part of reinforcing quality. Creating a template is hardwiring within the system. Encouraging staff to ask questions and think critically about the information is allowing oppo rtunities to ask questions. The manager may need to tie raises into compliance if the staff is resistive and other measures have failed, but this is not part of the SHARE model. DIF: Applying/Application REF: 5 KEY: SHARE| hand -off communication MSC: Integrated Process: Nursing Process: Intervention NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care Chapter 2: Common Health Problems of Older Adults Ignatavicius: Medical -Surgical Nursing, 8th Edition MULTIPLE CHOICE 1. A nursing faculty member working with students explains that the fastest growing subset of the older population is which group? a. Elite old b. Middle old c. Old old d. Young old ANS: C The old old is the fastest growing subset of the older population. This is the group comprising those 85 to 99 years of age. The young old are between 65 and 74 years of age; the middle old are between 75 and 84 years of age; and the elite old are over 100 years of age. DIF: Remembering/Knowledge REF: 9 KEY: Adulthood| aging| old old MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 2. A nurse working with older adults in the community plans programming to improve morale and emotional health in this population. What activity would best meet this goal? a. Exercise program to improve physical function b. Financial planning seminar series for older adults c. Social events such as dances and group dinners d. Workshop on prevention from becoming an abuse victim ANS: A All activities would be beneficial for the older population in the community. However, failure in performing one’s own activities of daily living and participating in society has direct effects on morale and life satisfaction. Those who lose the ability to function independently often feel worthless and empty. An exercise program designed to maintain and/or improve physical functioning would best address this need. DIF: Applying/Application REF: 12 KEY: Independence| autonomy| older adult MSC: Integra ted Process: Nursing Process: Planning NOT: Client Needs Category: Psychosocial Integrity 3. A nurse caring for an older client on a medical -surgical unit notices the client reports frequent constipation and only wants to eat softer foods such as rice, bread, and puddings. What assessment should the nurse perform first? a. Auscultate bowel sounds. b. Check skin turgor. c. Perform an oral assessment. d. Weigh the client. ANS: C Poorly fitting dentures and other dental problems are often manifested by a preference for soft foods and constipation from the lack of fiber. The nurse should perform an oral assessment to determine if these problems exist. The other assessments are impor tant, but will not yield information specific to the client’s food preferences as they relate to constipation. DIF: Applying/Application REF: 10 KEY: Nutrition| dentures| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 4. A nurse caring for an older adult has provided education on high -fiber foods. Which menu selection by the client demonstrates a need for further review? a. Barley soup b. Black beans c. White rice d. Whole wheat bread ANS: C Older adults need 25 to 50 grams of fiber a day. White rice is low in fiber. Foods high in fiber include barley, beans, and whole wheat products. DIF: Applying/Application REF: 11 KEY: Nutrition| fiber| older adult MSC: Integrated Process: Nursing Process: Evaluation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. A nurse is working with an older client admitted with mild dehydration. What teaching does the nurse provide to best address this issue? a. “Cut some sodium out of your diet.” b. “Dehydration can cause incontinence.” c. “Have something to drink every 1 to 2 hours.” d. “Take your diuretic in the morning.” ANS: C Older adults often lose their sense of thirst. Since they should drink 1 to 2 liters of water a day, the best remedy is to have the older adult drink something each hour or two, whether or not he or she is thirsty. Cutting “some” sodium from the diet will not address this issue. Although dehydration can cause incontinence from the irritation of concentrated urine, this information will not help prevent the problem of dehydration. Instructing the client to take a diuretic in the morning rather than in the ev ening also will not directly address this issue. DIF: Applying/Application REF: 11 KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 6. A home health care nurse is planning an exercise program with an older client who lives at home independently but whose mobility issues prevent much activity outside the home. Which exercise regimen would be most beneficial to this adult? a. Building strength and flexibility b. Improving exercise endurance c. Increasing aerobic capacity d. Providing personal training ANS: A This older adult is mostly homebound. Exercise regimens for homebound clients include things to increase functional ability for activities of daily living. Strength and flexibility will help the client to be able to maintain independence longer. The other plans are good but will not specifically maintain the client’s functional abilities. DIF: Applying/Application REF: 12 KEY: Exercise| functional ability| older adult MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physi ological Integrity: Reduction of Risk Potential 7. An older adult recently retired and reports “being depressed and lonely.” What information should the nurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adult’s life d. Usual leisure time activities ANS: C Often older adults lose support systems when their roles change. For instance, when people retire, they may lose their entire social network, leading them to feeling depressed and lonely. The nurse should first assess the role that work played in the clien t’s life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population. DIF: Applying/Application REF: 12 KEY: Depression| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 8. A nurse is assessing coping in older women in a support group for recent widows. Which statement by a participant best indicates potential for successful coping? a. “I have had the same best friend for decades.” b. “I think I am coping very well on my own.” c. “My kids come to see me every weekend.” d. “Oh, I have lots of friends at the senior center.” ANS: A Friendship and support enhance coping. The quality of the relationship is what is most important, however . People who have close, intimate, stable relationships with others in whom they confide are more likely to cope with crisis. DIF: Remembering/Knowledge REF: 12 KEY: Coping| relationships| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Psychosocial Integrity 9. A home health care nurse has conducted a home safety assessment for an older adult. There are five concrete steps leading out from the front door. Whic h intervention would be most helpful in keeping the older adult safe on the steps? a. Have the client use a walker or cane on the steps. b. Install contrasting color strips at the edge of each step. c. Instruct the client to use the garage door instead. d. Tell the client to use a two -footed gait on the steps. ANS: B As a person ages, he or she may experience a decreased sense of touch. T he older adult may not be aware of where his or her foot is on the step. Installing contrasting color strips at the end of each step will help increase awareness. If the client does not need an assistive device, he or she should not use one just on stairs. Using an alternative door may be necessary but does not address making the front steps safer. A two -footed gait may not help if the client is unaware of where the foot is on the step. DIF: Applying/Application REF: 13 KEY: Safety| falls| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 10. An older adult is brought to the emergency department because of sudde n onset of confusion. After the client is stabilized and comfortable, what assessment by the nurse is most important? a. Assess for orthostatic hypotension. b. Determine if there are new medications. c. Evaluate the clien t for gait abnormalities. d. Perform a delirium screening test. ANS: B Medication side effects and adverse effects are common in the older population. Something as simple as a new antibiotic can cause confusion and memory loss. The nurse should determi ne if the client is taking any new medications. Assessments for orthostatic hypotension, gait abnormalities, and delirium may be important once more is known about the client’s condition. DIF: Applying/Application REF: 13 KEY: Medications| medication sa fety| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 11. An older adult client takes medication three times a day and becomes confused about which medication should be taken at which time. The client refuses to use a pill sorter with slots for different times, saying “Those are for old people.” What action by th e nurse would be most helpful? a. Arrange medications by time in a drawer. b. Encourage the client to use easy -open tops. c. Put color -coded stickers on the bottle caps. d. Write a list of when to take each medication. ANS: C Color -coded stickers are a fast, easy -to-remember system. One color is for morning meds, one for evening meds, and the third color is for nighttime meds. Arranging medications by time in a drawer might b e helpful if the person doesn’t accidentally put them back in the wrong spot. Easy -open tops are not related. Writing a list might be helpful, but not if it gets misplaced. With stickers on the medication bottles themselves, the reminder is always with the medication. DIF: Applying/Application REF: 14 KEY: Medications| medication safety| older adult MSC: Integrated Process: Nursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 12. An older adult client is in the hospital. The client is ambulatory and independent. What intervention by the nurse would be most helpful in preventing falls in this client? a. Keep the light on in the bathroom at night. b. Order a bedside commode for the client. c. Put the client on a toileting schedule. d. Use siderails to keep the client in bed. ANS: A Although this older adult is independent and ambulatory, being hospitalized can create confusion. Getting up in a dark, unfamiliar environment can contribute to falls. Keeping the light on in the bathroom will help reduce the likelihood of falling. The cli ent does not need a commode or a toileting schedule. Siderails used to keep the client in bed are considered restraints and should not be used in that fashion. DIF: Applying/Application REF: 21 KEY: Falls| safety| older adult MSC: Integrated Process: N ursing Process: Implementation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 13. An older client had hip replacement surgery and the surgeon prescribed morphine sulfate for pain. The client is allergic to morphine and reports pain and muscle spasms. When the nurse calls the surgeon, which medication should he or she suggest in place of the morphine? a. Cyclobenzaprine (Flexeril) b. Hydromorphone hydrochloride (Dilaudid) c. Ketorolac (Toradol) d. Meperidine (Demerol) ANS: B Cyclobenzaprine (used for muscle spasms), ketorolac, and meperidine (both used for pain) are all on the Beers list of potentially inappropriate medications for use in older adults and should not be suggested. The nurse should suggest hydromorphone hydrochloride. DIF: Remembering/Knowledge REF: 16 KEY: Medications| Beers list| older adult MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 14. A nurse admits an older client from a home environment where she lives with her adult son and daughter -in-law. The client has urine burns on her skin, no dentures, and several pressure ulcers. What action by the nurse is most appropriate? a. Ask the family how these problems occu rred. b. Call the police department and file a report. c. Notify Adult Protective Services. d. Report the findings as per agency policy. ANS: D These findings are suspicious for abuse. Health care providers are mandatory reporters for suspected abuse. The nurse should notify social work, case management, or whomever is designated in policies. That person can then assess the situation further. If t he police need to be notified, that is the person who will notify them. Adult Protective Services is notified in the community setting. DIF: Applying/Application REF: 19 KEY: Abuse| older adult MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care 15. A nurse caring for an older client in the hospital is concerned the client is not competent to give consent for u pcoming surgery. What action by the nurse is best? a. Call Adult Protective Services. b. Discuss concerns with the health care team. c. Do not allow the client to sign the consent. d. Have the client’s family sign the consent. ANS: B In this situation, each facility will have a policy designed for assessing competence. The nurse should bring these concerns to an interdisciplinary care team meeting. There may be physiologic reasons for the client to be temporarily too confused or incomp etent to give consent. If an acute condition is ruled out, the staff should follow the legal procedure and policies in their facility and state for determining competence. The key is to bring the concerns forward. Calling Adult Protective Services is not a ppropriate at this time. Signing the consent should wait until competence is determined unless it is an emergency, in which case the next of kin can sign if there are grave doubts as to the client’s ability to provide consent. DIF: Applying/Application REF: 16 KEY: Competence| autonomy| older adult MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes which components? (Select all that apply. ) a. Dementia b. Exhaustion c. Slowed physical activity d. Weakness e. Weight gain ANS: B, C, D Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and weakness. Weight gain and dementia are not part of this cluster of manifestations. DIF: Remembering/Knowledge REF: 9 KEY: Frailty| frail elderly| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Health Promotion and Maintenance 2. A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in younger adults. Which foods found in an older adult’s kitchen might indicate an adequate intake of these nutrients? (Select all that apply.) a. 1% milk b. Carrots c. Lean ground beef d. Oranges e. Vitamin D supplements ANS: A, B, D, E Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is healthier than more fatty cuts, bu t does not contain these needed nutrients. DIF: Applying/Application REF: 10 KEY: Nutrition| nutritional requirements| older adults MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. A nurse working with older adults assesses them for common potential adverse medication effects. For what does the nurse assess? (Select all that apply.) a. Constipation b. Dehydration c. Mania d. Urinary incontinence e. Weakness ANS: A, B, E Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and incontinence are not among the common adverse effects, although urinary reten tion is. DIF: Remembering/Knowledge REF: 14 KEY: Medications| adverse effects MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies 4. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in the hospital. The nursing staff assesses for which fac tors? (Select all that apply.) a. Confusion b. Evidence of abuse c. Incontinence d. Problems with behavior e. Sleep disorders ANS: A, C, E SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of falls. DIF: Remembering/Knowledge REF: 20 KEY: SPICES| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 5. A visiting nurse is in the home of an older adult and notes a 7 -pound weight loss since last month’s visit. What actions should the nurse perform first? (Select all that apply .) a. Assess the client’s ability to drive or transportation alternatives. b. Determine if the client has dentures that fit appropriately. c. Encourage the client to continue the current exercise plan. d. Have the client complete a 3 -day diet recall diary. e. Teach the client about proper nutrition in the older population. ANS: A, B, D Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client. There is no information in the question about the older adult needing to lose weight, so e ncouraging him or her to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper nutrition is a good idea, but teaching needs to be tailored to the client’s needs, which the nurse does not yet know. DIF: Applying/Application REF: 10 KEY: Nutrition| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation