NURSING 120 EXAM 1 QUESTIONS REVIEW.

NURSING 120 EXAM 1 QUESTIONS REVIEW EXAM 1 REVIEW 1.) An older adult comes to the clinic and reports dizziness and anorexia. The client also reports increased nocturia. What action by the nurse is best? A. Evaluate the client’s ability to ambulate. B. Listen to the client’s heart and lungs. C. Have the client provide a clean catch urine sample. D. Perform a detailed 3-day nutrition recall. 2.) An older adult patient calls for emergency transportation to the emergency department (ED). The nurse asks the patient to describe the reason for coming into the ED today, and the patient replies, “I don’t feel well at all.” The patient proceeds to describe various symptoms to the nurse. Which of the following most accurately captures the complexity involved in assessing the older adult in this scenario? A. Signs and symptoms of illness are often obscure and less predictable in older adults. B. older adults present with fewer symptoms of illness than do younger patients. C. Older adults experience fewer acute health problems but more chronic illness than do younger adults. D. Care must be taken to always assess normal age-related changes last. 3.) The nurse is conducting a functional assessment on a patient who has just been admitted to the skilled care rehabilitation facility. Which of the following best describes the functional assessment? A. It includes the new drugs a patient has been placed on when coming to the facility. B. It excludes the patient’s medical diagnosis and history and focuses only on functional ability. It includes an assessment of the patient’s physical, cognitive, affective, and social status. C. It excludes the patient’s chief complaint and reason for seeking health care. D. It excludes the patient’s medical diagnosis and history and focuses only on functional ability. 4. An older adult has been in Intensive Care (ICU) for 24 hours for pneumonia when the family notifies the nurse of an acute change in the patient’s mental status. The family member who stayed overnight noticed the patient didn’t sleep and seemed worse as it became increasingly difficult to keep the patient’s attention. What response by the nurse is best? A. “I will ask the provider to order a neuropsychiatric consultation.” B. “Once the antibiotics start working, you should see an improvement.” C. “I’ll try to limit the noise and activity outside the room.” D. “Older people often become confused in intensive care units.” 5. Ralph Johnson is an 85-year-old male who has a history of coronary artery disease, asthma, and sleep apnea. He was hospitalized in intensive care (ICU) after complaints of chest pain. He remained in the ICU for cardiac workup and was later transferred to the cardiac step-down unit. After Mr. Johnson transferred to the specialty unit, he began to exhibit an increase in confusion and patterns of restless sleep. Which of the following nursing interventions may be utilized to assist Mr. Johnson with more extended periods of sleep in a noisy nursing unit? A. Request an order for a sleeping pill if needed. B. Reduce the noise on the unit at night. C. Turn off the lights in his room at night. D. Provide a scheduled “quiet” time during the day. 6. During sleep, individuals with sleep apnea may experience recurrent episodes of cessation of respiration for up to... A. 2 minutes B. 10 seconds C. 5 minutes D. 20 seconds 7. The Centers for Disease Control and Prevention (CDC) recommends 150 minutes of moderate intensity aerobic exercise per week. What should the older adult be taught about activity? A. To be effective, exercise should last at least 45 minutes per session. B. If an individual is able to talk during exercise, that person should increase the intensity. C. Muscle strengthening should be done daily. D. Activity may be divided into smaller segments. 8. An older adult asks the nurse about starting an exercise program after several years of sedentary living. What recommendation by the nurse is best? A. It is best to start with strengthening exercises. B. You need at least 30 minutes for any benefit. C. Start by walking 5 minutes a day. D. Do not drink water before exercising. A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding is most important for the registered nurse (RN) to report to the healthcare provider? A. Fever and chills B. Confusion and dehydration C. Crackles in the lung fields D. Nausea and vomiting Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and perfusion in this frail elderly client. (A), (C) and (D) are all common with pneumonia, but the most important finding is confusion and evidence of dehydration, which require treatment for this frail elderly client A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake because food does not taste as good as it used to so they have to season most foods. What information should the RN offer the couple? A. Boredom may influence how the taste of food is perceived, and different seasonings can stimulate taste. B. With age, an increase in sodium intake is needed to compensate for a decrease in renal function. C. Short-term memory loss and confusion may be the reason they want to over-season their food. D. Taste buds often are dull due to atrophy so older clients should use other seasonings instead of salt. Rationale: Taste buds atrophy with normal aging, which influences an older client's sensitivity to taste and is often compensated for the use of stronger tasting seasonings. (A), (B), and (C) are not normal aging processes related to taste. After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a long history of smoking and still smokes a pack of cigarettes a day. Which finding should the registered nurse (RN) report to the healthcare provider? A. Barrel chest with increased chest diameter B. Crackles and pulse oximetry level of 88% C. Low hemoglobin and hematocrit levels D. Arterial blood gases indicating respiratory acidosis Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact adequate oxygenation, which should be reported to the HCP. (A) occurs due to chronic hyperinflation of the lungs and is common in clients with COPD. Anemia (C) is frequently identified in clients with COPD, and respiratory acidosis (D) due to CO2 retention contributes to a lower blood pH. An older female client recently moved to an assisted living facility. The family explains to the registered nurse (RN) that the client is unmanageable and always confused, disoriented and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond? A. Explain that she is in a new home called an assisted living community B. Question the client about her perception of where she might be now. C. Distract the client with a scenario that she is on an outing with her family. D. Reassure the client not to worry because she will meet new friends. Rationale: Reality re-orientation (A) is the best response for a client who is confused because the response is consistent and true. (B, C, and D) do not provide the client with feedback that is reality based. A new resident in an assisted living facility is an older client who is experiencing short-term memory loss and confusion. Which activity should the registered nurse (RN) schedule the client to do during the day? A. Arts and crafts B. Current events discussion group C. Group sing-along D. Daily exercise group Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the client's stress to remember. (A), (C), and a current events discussion group (B) are thought-provoking activities that require attention to detail and short-term memory to participate in the group activity which may be stressful and frustrating to the resident who has difficulty remembering sequence of the details. The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the registered nurse (RN) use to determine the client's pain? A. Use the FACE pain scale B. Ask the client to rate pain on a scale of 1 to 10 C. Observe for facial grimacing D. Review documentation of recent eating habits Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a client who cannot communicate due to Alzheimer disease. (A) and (B) may not be understood by a client with end- stage Alzheimer's disease. (D) is not a helpful tool for pain assessment. An older male client arrives at the clinic for an annual physical examination. While the nurse assesses the client, the client states that he is having intimacy problems with his wife. Which information should the nurse provide to elicit more information from the client? A. Query client to clarify the client's idea of an intimacy problem. B. Discuss benign prostatic hypertrophy (BPH) and ejaculation. C. Explore the frequency that he experiences erectile dysfunction (ED) D. Determine if the client's wife is young enough to get pregnant Rationale: Clarification of the client's concern is needed to appropriately address the specific concern about intimacy issues (A). (B), (C), and (D) are details that the client should present, not the RN. The registered nurse (RN) is caring for an older female client with a 20 year history of rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated with RA should the RN document? A. Asymmetrical joint deformity B. Small joint involvement in fingers C. Crepitation or grating sensation in joints D. Weight bearing joint involvement Rationale: Small joint involvement (B) is common in rheumatoid arthritis. (A), (C) and (D) are findings that different OA from RA. The registered nurse (RN) is re-enforcing discharge instructions with the family of an older client who was recently admitted for an intestinal obstruction. Which statement indicates that the family understands the instructions? A. Increase protein and carbohydrates in the daily diet B. Limit activity to bed rest for the first week and increase mobility incrementally each week C. Report abdominal distention, constipation or any other nausea and vomiting to the healthcare provider D. Drink liquids 2 hours after meals instead of during meals Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed immediately. (A, B, and D) are not indicated for a client who has been discharged for intestinal obstruction. An older client is transferred to a telemetry unit after placement of a pacemaker. What action should the registered nurse (RN) take first? A. View incision site B. Obtain a blood pressure C. Establish telemetry monitoring D. Evaluate client for pain Rationale: The first action is to establish continuous telemetry monitoring (C) to ensure the pacemaker is functioning properly. (A, B and D) should be implemented after the client's heart rate and rhythm are successfully being monitored. Older clients are at highest risk for abuse and neglect due to which factors? (Select all that apply.) A. Needs are greater than the caretaker's abilities B. Client's declining strength C. Fixed income D. Longer life expectancy E. Lack of exposure to technology and trends Rationale: When needs are not being met due to lack of ability of the caretaker (A), stress and feelings of failure may be expressed through neglect and abuse. Decline in strength (B) increases the older client's vulnerability to resist or respond to elder abuse. (C, D, E) do not increase the risk for neglect and abuse. An older female client who has been taking hydrocodone/acetaminophen (Lortab) q4 hours for chronic back pain for the past 5 years tells the registered nurse (RN) that she cannot live without her pain pills. When asked if she is addicted, the client states that she is not an addict because the healthcare provider prescribed the pain pills. Which coping mechanism should the RN determine the client is using about her addiction? A. Lack of knowledge about narcotic medications B. Rationalization to support narcotic use C. Transfer of blame to healthcare provider D. Justification of narcotic use due to chronic pain Rationale: The client is using rationalization to maintain self-esteem when she is questioned by stating that she is not addicted because she is taking medication prescribed by a healthcare provider. (A) may be possible, but the client is being specifically asked about possible addiction. (C) and (D) underlie the complexity of denial in addiction, but the client is trying to maintain self-esteem through rationalization. Since his arrival in an assisted living community, an older male client is having difficulty going to sleep. Which intervention should the registered nurse (RN) implement first? A. Encourage client to take a warm bath at night B. Ask the client what has helped him in the past C. Recommend that the client not take daytime naps D. Offer the client a glass of warm milk before bedtime Rationale: Asking the client (B) about his sleeping habits involves the client in his own care and preserves his autonomy as he adapts to living in a new community. (A, C, and D) are common ways to promote nighttime sleep but these should be explored with the client and his preferences. The home health registered nurse (RN) visits an older female client with an ideal conduit who has been experiencing chronic urinary tract infections (UTI). Which intervention should the RN recommend to the client to manage the frequency of UTIs? A. Force fluid intake to 1,000 ml daily B. Change appliance every 4 hours C. Attach a larger drainage bag while sleeping D. Allow bag to fill completely before emptying Rationale: (C) can prevent urinary reflux if the bag fills to near capacity or greater, which can contribute to UTIs. Forcing fluids is encouraged and should exceed urinary output, which commonly should be greater than 1,000 ml (A). (B) can increase skin irritation and increase risk for infection by exposing the portal of entry frequently. Allowing the bag to fill completely before emptying (D) increases risk of urinary reflux and UTIs. During the quarterly evaluations of the clients in the assisted living community, the registered nurse (RN) assesses for findings of failure to thrive in the older population. What findings should the RN document and report as manifestations related to failure to thrive? (Select all that apply.) A. Unintentional weight loss B. Increased weakness C. Increased amounts of sleep D. Irritation and agitation E. Seeking constant attention from caregiver A, B, C Rationale: (A, B and C) are correct. Symptoms of failure to thrive in the older population include weight loss, weakness and excessive sleep, which should be documented and evaluated by a healthcare provider immediately. (D and E) are not usual signs and symptoms of failure to thrive but should be reviewed by the healthcare provider. The registered nurse (RN) is assigned the care of an older client who returns to the unit after surgery for closed angle glaucoma. What intervention in the plan of care should the RN bring to the attention of the healthcare team? A. Assist with ambulating to commode B. Monitor intake and output q8 hours C. Administer morphine 4 mg IM q2 hour PRN pain D. Place an eye patch on operative eye during sleep Rationale: Morphine side effects include nausea, vomiting and constipation, causing straining on stool, all of which can increase intraocular pressure and cause intraocular bleeding during the postoperative period. Administration of morphine 0.4 mg IM q2 hours PRN pain (C) should be discussed with the healthcare team to determine the risk of the side effects for the client. (A), (B) and (D) are interventions that do not place the client at risk. The registered nurse (RN) is caring for an elderly client with functional incontinence who lives in an assisted living community. The client is alert and mildly confused and can self-ambulate. Which nursing intervention should the RN implement? A. Offer assistance with toileting q2 hours B. Use protective disposal undergarment instead of underwear C. Ask if the client has attempted to void q2 hours D. Obtain a prescription for intermittent catheterization Rationale: Maintaining independence and self-esteem is important for an older client with incontinence. (A) decreases the client's chances of accidents and embarrassment by introducing a toilet training program. (B) is not implemented unless toileting program is unsuccessful and the client's mental status declines. A confused client will not remember how many times he or she frequented the toilet, so (C) is not helpful for the client. (D) is not indicated for clients with functional intolerance and who can ambulate. An older adult client falls and fractures the left hip. After arthroplasty, the client has activity restrictions until healing has taken place. Which client problem concerns the nurse most? Inability to perform activities of daily living An older adult client tells the nurse, "I just don't sleep as well as I used to. Why is this and what can I do?" Which response by the nurse is correct? (Select all that apply) 2. "As you age, your melatonin levels decrease." 3. "You don't have as much growth hormone as you used to." 4. "Increase the amount of light you experience every day."