(Test Bank) Medical-Surgical Nursing: Concepts For Interprofessional Collaborative Care

Ignatavicius,Workman, 9

Nursing

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9th Edition

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Test Bank for Medical-Surgical Nursing: Concepts For Interprofessional Collaborative Care, The downloadable file consists of 862 pages, and the total size of the file is 5.82 MB. Purchase now only for highly discounted price.

Author(s): Ignatavicius, Workman

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lOM oA R cP S D| 60 78199 Test Bank - Medical -Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 1 Chapter 01: Overview of Professional Nursing Concepts for Medical - Surgical Nursing MULTIPLE CHOICE 1. 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 nursefocuses on communication, culture, respect compassion, client education, and empowerment. By assessing the effect of the clients c ulture 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 providing empowering education. Orienting the client andfamily to theroom is animportantsafetymeasure, butnotdirectlyrelatedtodemonstratingclient -centered care. DIF: Understanding/Comprehension REF: 3 KEY: Patient -centered care| culture MSC: Integrated Process: Caring NOT: Client Needs Category: Psychosocial Integrity 2. A nurse is caring for a postoperative client on the surgical unit. The clients blood pressure was 142/76 mm Hg 30 minutes ago, and now is 88/50 mm Hg. What action by the nurse isbest? 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 suffereitherrespiratoryorcardiacarrest. Sincetheclienthasmanifestedasignificantchange, thenurseshould call the RRT. Changes in blood pressure, mental status, heart rate, and pain are particularly significant. Documentation is vital, but the nursemust do more than document. The primary care provider should be notified, but this is not the priority over calling the RRT. The clients blood pressure should be reassessed frequently, but the priority is getting the rapid care to theclient. DIF: Applying/Applica tion REF: 3 KEY: Rapid Response Team (RRT)| medical emergencies MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 3. A nurse is orienting a new client and family to 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 involveddoes. DIF: Understanding/Comprehension REF: 3 KEY: Patient safety lOM oA R cP S D| 60 78199 Test Bank - Medical -Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 2 MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 4. A new nurse is working with a preceptor on an inpatientmedical -surgical unit. The preceptor advises the student that which is the priority when working as a professionalnurse? 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 clients saf ety. 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 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 againsterrors? a. Bring a list of all medications and what they are for. b. Keep the doctors 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 Commissions Speak Up campaign encourages clients 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/Lear ning 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 autonomy? 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 nurseobtainsa signature on the consent form, assessing if the client still has questions is vital, because 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 communicating with a person from the lesbian, gay, bisexual, transgender, andqueer/questioning (LGBTQ) community. Whatanswerbythe faculty is most accurate? a. Avoid embarrassing the client by asking questions. b. Dont make assumptions about their health needs. c. Most LGBTQ people do not want to share information. lOM oA R cP S D| 60 78199 Stuvia.com - The Marketplace to Buy and Sell your Study Materia l Test Bank - Medical -Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 3 d. No differences exist in communicating with this population. ANS: B Manymembersofthe LGBTQcommunity have faceddiscrimination from health care providersandmaybe reluctant to seek health care. The nurse should never make assumptions about the needs of members of this population. Rather, respectful questionsareappropriate. If approached with sensitivity, the clientwith any health care need is more likely to answer honestly. DIF: Understanding/Comprehension REF: 4 KEY: LGBTQ| diversit y 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 order a different pain medication. b. B: This client has allergies to morphine and codeine. c. R: Dr. Smith doesnt 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. Appropriatebackgroundinformationincludesallergies to medicationsthe on-callphysicianmightorder. Situationdescribeswhat is happening rightnow thatmustbecommunicated; the clients surgery 2 days ago would be considered background. Assessment would include an analysis of the clients 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 surgeons preference might be better placed in background. DIF: Applying/ApplicationREF: 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 clients blood pressure is much higherthan previous readings, and the clients 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 assess 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 to 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 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 the nurse is best? Test Bank - Medical -Surgical Nursing: Concepts for Interprofessional Collaborative Care 9e 4 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 ac crediting body gives assurance that the facility has a focus on safety. Nurse -client ratios differ by unit type and change over time. New technology doesnt 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: Commu nication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control 11. 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 nurse isbest? a. All staff nurses are required to participate in quality improvementhere. b. Even being new, you can implement activities designed to improve care. c. Its 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 licensednurse. Simply statingthatallnursesarerequired to participatedoesnothelpthe nurseunderstand 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 doe s not give the nurse information about how to implement QI in daily practice. DIF: Applying/ApplicationREF: 6 KEY: Quality improvement MSC: Integrated Process: Communication and Documentation NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. A nurse is interested in making interdisciplinarywork ahigh priority. Which actions by the nursebest 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 Collaboratingwith theinterdisciplinary team involvesplanning, implementing, andevaluatingclient care asa team with all other disciplines included. Simply showing other caregivers the nursing care plan is not actively involving them or collaborating with 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 2. A nurse manager wishes to ensure that the nurses on the unit are practicing at their highest levels of competency. Whichareasshould themanager assess to determine if thenursing staffdemonstratecompetency according to the Institute 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 reportlists five broad core competencies thatall health care providers should practice. Theseinclude collaboratingwiththeinterdisciplinaryteam, implementingevidence -basedpractice, providingclient -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 3. The nurse utilizing evidence -based practice (EBP) considers which factors when planning care? (Select all that apply.) a. Cost -saving measures b. Nurses expertise c. Client preferences d. Research findings e. Values of the client ANS: B, C, D, E EBP consists of utilizing current evidence, the clients values and preferences, and the nurses 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 nursemanagerwants to improve hand -off communication among the staff. What actions by themanager would best help achieve this goal? (Select all that apply.) a. Attendhand -offrounds to coachandmentor. 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 reports and other critical communication is the SHARE model. SHARE standsforstandardizecriticalinformation, hardwirewithin your system, allow opportunities to askquestions, reinforce quality and measurement, and educa te and coach. Attending hand -off report 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 abo ut the information is allowing opportunities 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: SHAR E| hand -off communication MSC: Integrated Process: Nursing Process: Intervention NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care Chapter 02: Overview of Health Concepts for Medical -Surgical Nursing MULTIPLE CHOICE 1. Acid -base balance occurs when the pH level of the blood is between: a. 7.3 and 7.5 b. 7.35 and 7.45 c. 7.4 and 7.5 d. 7.25 and 7.35 ANS: B Acid -base balance is the maintenance of arterial blood pH between 7.35 and 7.45 through hydrogen ion production and elimination. DIF: Understanding/Comprehension REF: 13 KEY: Assessment MSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT: Describe common fluid, electrolyte, and acid -base imbalances. 2. The nurse would expect a patient with respiratory acidosis to have an excessive amount of a. Hydrogen ions. b. Bicarbonate. c. Oxygen. d. Phosphate. ANS: A Respiratory acidosis occurs when the arterial blood pH level falls below 7.35 and is caused by either too many hydrogen ions in the body (respiratory acidosis) or too little bicarbonate (metabolic acidosis). Excessive oxygen and phosphate are not characteristic of respiratory acidosis. DIF: Understanding/Comprehension REF: 13 KEY: Assessment MSC: Physiological Adaptation | Fluid and Electrolyte Imbalances NOT: Describe common fluid, electrolyte, and acid -base imbalances. 3. The best way for an indiv idual to maintain acid-base balance is to a. avoid or quit smoking. b. exercise regularly. c. eat healthy and well-balanced meals. d. All of the above. ANS: D Maintaining a healthy lifestyle is the best way to maintain acid -base balance. For example, most cases of COPD can be prevented by avoiding or quitting smoking, while regular exercise and a healthy diet can decrease the incidence of type-2 diabetes. DIF: Patienteducation REF: 14 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Cate gory: Health Promotion and Maintenance 4. The process to control cellular growth, replication, and differentiation to maintain homeostasis is called: a. cellular regulation. b. cellular impairment. c. cellular reproduction. d. cellular tumor. ANS: A Cellular Regulation is the term used to describe both the positive and negative aspects of cellular function within the body. DIF: Understanding/Comprehension REF: 14 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 5. A defining characteristic of malignant (cancerous) cells is: a. they cannot spread to other tissues or organs. b. they can invade healthy cells, tissues, and organs. c. they are not usually a health risk. d. none of the above. ANS: B Malignant (cancerous) cells have no comparison to the original cells from which they are derived, and they have the ability to invade healthy cells, tissues, and other organs through tumor formation and invasion. On the other hand, Benign cells do not have the ability to spread to other tissues or organs. DIF: Understanding/Comprehension REF: 14 KEY: Assessmen t MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 6. Specialized cells that circulate in the body to promote clotting arecalled: a. anticoagulants. b. proteins. c. emboli. d. platelets. ANS: D Clotting is a complex, multi -step process through which blood forms a protein -based clot to prevent excessive bleeding. Platelets (thrombocytes) are the specialized cells that circulate in the blood and are activatedwhen an injury occurs. Once activated, these cells become sticky, causing them to clump together to form a temporary, localized, solid plug. DIF: Understanding/Comprehension REF: 15 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Cate gory: Health Promotion and Maintenance 7. An increase in platelet stickiness can lead to: a. hypercoagulability b. thromobocytopenia c. embolus d. atrial fibrillation ANS: A Hypercoagulability refers to an increase in clotting ability caused by an excess of platelets or excessive plately stickiness, which can impair blood flow. The opposite end of the spectrum involves an inability to form adequate clots, which often occurswhe n there is an inadequatenumber of circulating platelets or a reduction in platelet stickiness. DIF: Understanding/Comprehension REF: 15 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 8. Signs and symptoms of thromobsis include localized redness, swelling, andwarmth: a. arterial b. venous c. partial d. atrial ANS: B Venous thrombosis is a clot formation in either superficial or deep veins, usually in the leg, and can be observed locally. DIF: Understanding/Comprehension REF: 16 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 9. A serious condition which is not locally observable and is typically manifested by decreased blood flow to a distal extremity isknown as thrombosis. a. arterial b. venous c. partial d. atrial ANS: A Arterial thrombosis is manifested by decreased blood flow (perfusion) to a distal extremity or internal organ. For examp le, the distal leg can become pale and cool in the case of a femoral arterial clot due to blockage of blood to the leg. This is an emergent condition and requires immediate intervention. DIF: Understanding/Comprehension REF: 16 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 10. A high -level thinking process that allows an individual to make decisions and judgments is known as: a. amnesia b. personality c. reasoning d. memory ANS: C Reasoning is the high -level cognitive thinking process that helps individuals make decisions and judgments. Personality is the way an individual feels and behaves, while Memory is the ability of an individual to retain and recall information. Amnesia refers to a los s of memory caused by brain trauma, congenital disorders, or acute health problems. DIF: Understanding/Comprehension REF: 16 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity 11. A form of inadequate cognition in older adults which is manifested by an acute, fluctuating confusional state is known as: a. dementia b. delerium c. amnesia d. depression ANS: B Delerium is the form of acute, fluctuating confusion which lasts from a few hours to less than 1 month and that may be treatable. Dementia is a chronic state of confusion that may last from a few months to many years and that may not be reversible. Amnesia refers to a loss of memory caused by brain trauma, congenital disorders, or acute health problem s. DIF: Understanding/Comprehension REF: 16 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Psychosocial Integrity 12. The most common causes of decreased comfort for a patient are pain and . a. light -headedness b. nausea c. emotional stress d. depression ANS: C Pain and emotional stress are the two leading causes of discomfort for a patient. For example, patients who are having surgery are often anxious and feel stressed about the procedure. This emotional stress may negatively impact the outcome of surgery. DIF: Understanding/Comprehension REF: 17 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Safe and Effective Care Environment 13. The inability to pass stool is known as . a. constipation b. obstipation c. diarrhea d. incontinence ANS: B Obstipation is the inability to pass stool during bowel elimination. Constipation refers to the condition where stool can be hard, dry, and difficult to pass through the rectum. Diarrhea is at the opposite end of the continuum from constipation, and occ urs when stool is watery and without solid form. Elimination is the general term to describe the excretion of waste from the body by the gastrointestinal tract and by the urinary system. DIF: Understanding/Comprehension REF: 18 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 14. Hypokalemia can occur in patients with prolonged diarrhea and is caused by a decrease in: a. calcium b. magnesium c. sodium d. potassium ANS: D Hypokalemia occurs when there is a decrease in serum potassium. It can be a life-threatening condition because it often causes rhythm abnormalities. An excess of potassium is referred to as Hyperkalemia. DIF: Understanding/Comprehension REF: 18 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 15. The minimum hourly urinary output in a patient should be atleast: a. 5 mL per hour b. 10 mL perhour c. 30 mL perhour d. 60 mL perhour ANS: C 30 mL perhour is the minimum hourly urinary output in a normalhealthy adult. A decrease in urinary output i a sign of diminished kidney activity and fluid deficit. DIF: Understanding/Comprehension REF: 20 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 16. The best indicator of fluid volume changes in the body is: a. skin dryness b. weight changes c. blood pressure d. pulse rate ANS: C Changes in weight are the best indicator of fluid volume changes in the body. Monitoring blood pressure, checkingpulserateand quality, and assessing skin andmucousmembranesfordrynessarestrong secondary indicators. DIF: Understanding/Comprehension REF: 20 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 17. Immunity which occurswhen antibodiesarepassed from themother to the fetus through the placentaor through breast milk is called: a. natural passive b. artifical passive c. natural active d. artifical active ANS: A Artifical passive immunity occurs via a specific transfusion. Natural active immunity occurs when an antigen enters the body and the body creates antibodies to fight off the antigen. Artifical active immunity occurs via vaccination or immunization. DIF: Understanding/Comprehension REF: 21 -22 KEY: Assessment MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance 18. A major serum protein that is below normal in patients who have inadequate nutrition is: a. Albumin b. Globulin c. Fibrinogen d. Transferrin ANS: A A serum laboratory test to measure Albumin is the most common assessment for generalized malnutrition. DIF: Understanding/Comprehension REF: 25 KEY: Assessment MSC: Integrated Proces s: Teaching/Learning NOT: Client Needs Category: Health Promotion and Maintenance Downloaded by: rubricguru | Husseinwhosane@gmail.com Downloaded by: rubricguru | Chapter 03: Common Health Problems of Older Adults MULTIPLE CHOICE 1. A nurseworkingwith olderadults in the community plansprogramming to improvemorale 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 ones 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: 32 KEY: Independence| autonomy| older adult MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Psychosocial Integrity 2. A nursecaring for an older client on a medical -surgicalunit 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 important, but will not yield information specific to the clients food preferences as they relate to constipati on. DIF: Applying/Application REF: 30 KEY: Nutrition| dentures| older adult MSC: Integrated Process: Nursing Process: Assessment NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort 3. 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: 29 KEY:Adulthood|aging|oldold MSC: Integrated Process: Teach ing/Learning NOT: Client Needs Category: Health Promotion and Maintenance 4. 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 no t address this issue. Although dehydration can cause incontinence from the irritationofconcentratedurine, this informationwillnothelppreventtheproblemofdehydration. Instructing the client to take a diuretic in the morning rather than in the evening also will not directly address this issue. DIF: Applying/Application REF: 31 KEY: Dehydration| older adult| hydration MSC: Integrated Process: Teaching/Learning NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation 5. 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. Barleysoup 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: 31 KEY: Nutrition| fiber| older adult MSC: Integrated Process: Nursing Process: Evaluation 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. Buildingstrengthandflexibility 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 clients functional abilities. DIF: Applying/Applic ation REF: 32 KEY: Exercise| functional ability| older adult MSC: Integrated Process: Nursing Process: Planning NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential 7. Anolderadultrecentlyretiredandreportsbeingdepressedandlonely. Whatinformationshouldthenurse assess as a priority? a. History of previous depression b. Previous stressful events c. Role of work in the adults 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 Downloaded by: rubricguru | Husseinwhosane@gmail.com Downloaded by: rubricguru | lose their entire social network, leading them to feeling depressed and lonely. The nur se should first assess the role that work played in the clients life. The other factors can be assessed as well, but this circumstance is commonly seen in the older population. DIF: Applying/Application REF: 32 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/KnowledgeREF: 32 KEY: Coping|relationships|olderadult MSC: Integra ted 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. Which interventi on 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. The 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: 33 KEY: Safety| falls| olderadult 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 sudden 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 medi cations. c. Evaluate the client 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 determine if the client is taking any new medications. Assessmentsfororthostatichypotension, gaitabnormalities, anddeliriummaybeimportantonce more is known about the clients condition.