Exam 2: NUR 257/NUR257 Chronic Illness & Aging
| Actual Questions and Answers Latest Updated
(Graded A+)- Galen
1. Which of the following is a true statement about documentation?
a. The nurse is responsible for completing all of the Minimum Data Set (MDS).
b. Nurses should keep records of clients’ wishes.
c. Clients do not have access to their own medical records.
d. The Outcomes and Assessment Information Set (OASIS) is a complete record
of the health status of a client.
2. The federal government requires the use of a specific standardized documentation
tool for home nursing care. Which information must a home nurse add to the
approved documentation tool?
a. Functional
b. Activity
c. Demographic
d. Vital signs
i. The nurse must add the vital signs and information about the older
adult’s health care beliefs to the OASIS. The nurse does not need to
add information about the older adult’s activity level. The nurse does
not need to add information about the older adult’s functional status.
The nurse does not need to add demographic information about the
older adult to the documentation tool.
3. The OASIS was implemented to provide the format for a comprehensive
assessment in the home health care setting. How is this assessment tool used?
(Select all that apply.)
a. To evaluate the level of client disability
b. To serve as a guide for reimbursement
c. To improve the quality of care
d. To improve the communication about the individual
4. Which mental status assessment tool(s) would be appropriate for use in long-term
care facilities? (Select all that apply.)
a. The Mini-Cog
i. The Mini-Cog was developed as a tool that could establish cognitive
status more quickly than the MMSE and the limitations of educational
adjustments. It is now the recommended evidenced-based tool and
combines one aspect of the MMSE (short-term memory recall) with the
test of executive function of the Clock Drawing Test.
b. Mini-Mental State Examination (MMSE)
i. The MMSE tool has been used most often and is a 30-item instrument
that has been used to screen for cognitive difficulties and is one of the
tools often used in determining a diagnosis of dementia or delirium.
c. Montreal Cognitive Assessment (MoCA)
i. The Montreal Cognitive Assessment (MoCA) was designed as a brief
, screening instrument to provide cues leading to the hypothesis of mild
cognitive impairment.
d. Clock Drawing Test
i. The Clock Drawing Test, which has been used since 1992, is a
screening tool that helps identify those with a cognitive impairment
and is used as a measure of severity.
e. Fulmer SPICES
i. overall assessment tool developed in 2007.
5. The nurse must inform an older adult client who does not speak English about
client rights. In addition, the nurse must have the adult sign the document about
information access. Which intervention should the nurse use to maintain the
confidentiality of this older adult?
a. Present the client with a Spanish version of the information access
document.
b. Have an English-speaking family member explain the document to the client.
c. Explain the document to the client using an interpreter to ensure
understanding.
d. Instruct an interpreter to read the information access document to the
resident privately.
i. The nurse cannot ensure client understanding without discussing the
document with the client using an interpreter. The nurse cannot
delegate a nursing responsibility to a family member; the nurse does
not have the right to release the health information to anyone. In
private or public, the nurse cannot delegate this task to another
person.
6. Which one of the following is connected with the nursing home reform mandated
by a 1987 law?
a. OASIS
b. Fulmer SPICES
c. HIPAA
d. Resident Assessment Instrument (RAI)
i. The RAI must be completed for all residents receiving Medicare or
Medicaid. The HIPAA was passed in 1996 and mandates privacy
practices. The OASIS is an assessment designed for use in the home
health care setting. Fulmer SPICES is an overall assessment tool
developed in 2007.
7. A nurse is conducting a physical assessment of a 90-year-old client. The nurse
understands that special considerations when working with older adults include
which of the following?
a. The nurse needs to leave the assessment that is most painful until the end.
b. The nurse needs to first direct the assessment to that which is most
likely associated with the presenting problem.
c. Older adults do not require a “head to toe assessment,” so an abbreviated
assessment should be done.
d. It is important to complete the entire physical assessment at one time,
conducting a “head to toe assessment.”
8. A nurse utilizes the FANCAPES to assess an older adult. Which of the following are
accurate statements about this assessment? (Select all that apply.)
a. The FANCAPES is utilized as guide for the comprehensive
assessment of medically complex older adults.
b. The FANCAPES assesses an older adult’s activity abilities.
c. The FANCAPES assesses the older person’s current state of
, hydration.
d. The FANCAPES includes the Mini-Cog assessment to assess cognitive
abilities.
e. The FANCAPES includes a fall risk assessment of the older adult.
i. F – Fluids: Assesses hydration status.
ii. A – Aeration: Evaluates respiratory function.
iii. N – Nutrition: Looks at dietary intake and weight.
iv. C – Communication: Checks hearing, speech, and vision.
v. A – Activity: Assesses mobility and ability to perform ADLs.
vi. P – Pain: Identifies pain location and severity.
vii. E – Elimination: Monitors urinary and bowel function.
viii. S – Socialization: Evaluates support systems, cognition, and
emotional health.
9. A nurse assesses an older person’s instrumental activities of daily living (IADL)
utilizing the Lawton instrument. Which of the following are IADLs? (Select all that
apply.)
a. Bathing
b. Eating
c. Money management
d. Cleaning
e. Shopping
i. Shopping, cleaning, and money management are IADLs. Bathing and
eating are ADLS.
10. A nurse conducts a comprehensive assessment of an older adult client. The
nurse utilizes the Mini-Cog, a valid and reliable assessment tool to assess the
individual’s mental status. The nurse understands that the benefit of utilizing a
standard assessment tool is what?
a. A standard assessment tool will increase the client’s confidence in the nurse.
b. A standard assessment tool will increase reimbursement by Medicare and
Medicaid.
c. A standard assessment tool will increase likelihood of obtaining
accurate data.
d. A standard assessment tool is required by Medicare and Medicaid.
11. An older client is visited by a nurse in the community. The nurse is from a
Certified Home Health Agency and completes the OASIS assessment. The client is
89 years old, has a history of hypertension, and had a stroke 2 years ago. The
client was referred to the home health agency because she fell and sustained a
large laceration on her forehead which required sutures. She has been seen in the
emergency department of the local hospital three times over the past 2 months.
Based on the OASIS assessment, the nurse notes which of the following risks for
hospitalization for this client? (Select all that apply.)
a. Multiple emergency department visits (2 or more in previous 6
months)
b. Diagnosis of hypertension
c. Age over 85
d. A fall with injury
e. History of a stroke
i. Risk for hospitalization using the OASIS assessment includes history of
falls (two or more falls or any fall with injury) and multiple emergency
department visits. Age, history of stroke, and diagnosis of hypertension
are not risks as identified by the OASIS.
12. An older adult client has diabetes mellitus and requires hemodialysis for
| Actual Questions and Answers Latest Updated
(Graded A+)- Galen
1. Which of the following is a true statement about documentation?
a. The nurse is responsible for completing all of the Minimum Data Set (MDS).
b. Nurses should keep records of clients’ wishes.
c. Clients do not have access to their own medical records.
d. The Outcomes and Assessment Information Set (OASIS) is a complete record
of the health status of a client.
2. The federal government requires the use of a specific standardized documentation
tool for home nursing care. Which information must a home nurse add to the
approved documentation tool?
a. Functional
b. Activity
c. Demographic
d. Vital signs
i. The nurse must add the vital signs and information about the older
adult’s health care beliefs to the OASIS. The nurse does not need to
add information about the older adult’s activity level. The nurse does
not need to add information about the older adult’s functional status.
The nurse does not need to add demographic information about the
older adult to the documentation tool.
3. The OASIS was implemented to provide the format for a comprehensive
assessment in the home health care setting. How is this assessment tool used?
(Select all that apply.)
a. To evaluate the level of client disability
b. To serve as a guide for reimbursement
c. To improve the quality of care
d. To improve the communication about the individual
4. Which mental status assessment tool(s) would be appropriate for use in long-term
care facilities? (Select all that apply.)
a. The Mini-Cog
i. The Mini-Cog was developed as a tool that could establish cognitive
status more quickly than the MMSE and the limitations of educational
adjustments. It is now the recommended evidenced-based tool and
combines one aspect of the MMSE (short-term memory recall) with the
test of executive function of the Clock Drawing Test.
b. Mini-Mental State Examination (MMSE)
i. The MMSE tool has been used most often and is a 30-item instrument
that has been used to screen for cognitive difficulties and is one of the
tools often used in determining a diagnosis of dementia or delirium.
c. Montreal Cognitive Assessment (MoCA)
i. The Montreal Cognitive Assessment (MoCA) was designed as a brief
, screening instrument to provide cues leading to the hypothesis of mild
cognitive impairment.
d. Clock Drawing Test
i. The Clock Drawing Test, which has been used since 1992, is a
screening tool that helps identify those with a cognitive impairment
and is used as a measure of severity.
e. Fulmer SPICES
i. overall assessment tool developed in 2007.
5. The nurse must inform an older adult client who does not speak English about
client rights. In addition, the nurse must have the adult sign the document about
information access. Which intervention should the nurse use to maintain the
confidentiality of this older adult?
a. Present the client with a Spanish version of the information access
document.
b. Have an English-speaking family member explain the document to the client.
c. Explain the document to the client using an interpreter to ensure
understanding.
d. Instruct an interpreter to read the information access document to the
resident privately.
i. The nurse cannot ensure client understanding without discussing the
document with the client using an interpreter. The nurse cannot
delegate a nursing responsibility to a family member; the nurse does
not have the right to release the health information to anyone. In
private or public, the nurse cannot delegate this task to another
person.
6. Which one of the following is connected with the nursing home reform mandated
by a 1987 law?
a. OASIS
b. Fulmer SPICES
c. HIPAA
d. Resident Assessment Instrument (RAI)
i. The RAI must be completed for all residents receiving Medicare or
Medicaid. The HIPAA was passed in 1996 and mandates privacy
practices. The OASIS is an assessment designed for use in the home
health care setting. Fulmer SPICES is an overall assessment tool
developed in 2007.
7. A nurse is conducting a physical assessment of a 90-year-old client. The nurse
understands that special considerations when working with older adults include
which of the following?
a. The nurse needs to leave the assessment that is most painful until the end.
b. The nurse needs to first direct the assessment to that which is most
likely associated with the presenting problem.
c. Older adults do not require a “head to toe assessment,” so an abbreviated
assessment should be done.
d. It is important to complete the entire physical assessment at one time,
conducting a “head to toe assessment.”
8. A nurse utilizes the FANCAPES to assess an older adult. Which of the following are
accurate statements about this assessment? (Select all that apply.)
a. The FANCAPES is utilized as guide for the comprehensive
assessment of medically complex older adults.
b. The FANCAPES assesses an older adult’s activity abilities.
c. The FANCAPES assesses the older person’s current state of
, hydration.
d. The FANCAPES includes the Mini-Cog assessment to assess cognitive
abilities.
e. The FANCAPES includes a fall risk assessment of the older adult.
i. F – Fluids: Assesses hydration status.
ii. A – Aeration: Evaluates respiratory function.
iii. N – Nutrition: Looks at dietary intake and weight.
iv. C – Communication: Checks hearing, speech, and vision.
v. A – Activity: Assesses mobility and ability to perform ADLs.
vi. P – Pain: Identifies pain location and severity.
vii. E – Elimination: Monitors urinary and bowel function.
viii. S – Socialization: Evaluates support systems, cognition, and
emotional health.
9. A nurse assesses an older person’s instrumental activities of daily living (IADL)
utilizing the Lawton instrument. Which of the following are IADLs? (Select all that
apply.)
a. Bathing
b. Eating
c. Money management
d. Cleaning
e. Shopping
i. Shopping, cleaning, and money management are IADLs. Bathing and
eating are ADLS.
10. A nurse conducts a comprehensive assessment of an older adult client. The
nurse utilizes the Mini-Cog, a valid and reliable assessment tool to assess the
individual’s mental status. The nurse understands that the benefit of utilizing a
standard assessment tool is what?
a. A standard assessment tool will increase the client’s confidence in the nurse.
b. A standard assessment tool will increase reimbursement by Medicare and
Medicaid.
c. A standard assessment tool will increase likelihood of obtaining
accurate data.
d. A standard assessment tool is required by Medicare and Medicaid.
11. An older client is visited by a nurse in the community. The nurse is from a
Certified Home Health Agency and completes the OASIS assessment. The client is
89 years old, has a history of hypertension, and had a stroke 2 years ago. The
client was referred to the home health agency because she fell and sustained a
large laceration on her forehead which required sutures. She has been seen in the
emergency department of the local hospital three times over the past 2 months.
Based on the OASIS assessment, the nurse notes which of the following risks for
hospitalization for this client? (Select all that apply.)
a. Multiple emergency department visits (2 or more in previous 6
months)
b. Diagnosis of hypertension
c. Age over 85
d. A fall with injury
e. History of a stroke
i. Risk for hospitalization using the OASIS assessment includes history of
falls (two or more falls or any fall with injury) and multiple emergency
department visits. Age, history of stroke, and diagnosis of hypertension
are not risks as identified by the OASIS.
12. An older adult client has diabetes mellitus and requires hemodialysis for
