NURS 311 A&E I Comprehensive_Test_Bank | A&E I Comprehensive_Test_Bank_12 Weeks & 50 Chapters
A&E I Comprehensive Testbank
Table of Contents
Week 1 Care of Older Adults: Culture, Spirituality, Communication,
Sexuality, Infection Control
Chronic Illness and Older Adults__________________________________________________3
Infection Prevention and Control_________________________________________________51
Week 2 Critical Thinking, The Nursing Process, Loss, Death, and Grief
Critical Thinking in Nursing Practice_____________________________________________86
Planning Nursing Care________________________________________________________110
Implementing Nursing Care____________________________________________________119
The Experience of Loss, Death and Grief__________________________________________136
Week 3 Safety and Fall Prevention among Older Adults, Preventing
Complications of Immobility
Patient Safety and Quality_____________________________________________________146
Activity and Exercise__________________________________________________________181
Week 4 Skin and Wound Care Hygiene, Introduction to Pharmacology and
Skin Integrity and Wound Care__________________________________________________231
Week 5 Fluid & Electrolytes, Dehydration
Fluid, Electrolyte and Acid-Base Balance_________________________________________251
Week 6 Pain and Sleep
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Week 7 Concepts related to Oxygenation, Circulation, and Tissue Perfusion,
Chronic Obstructive Pulmonary Disease
Obstructive Pulmonary Diseases________________________________________________314
Week 8 Diabetes Mellitus
Week 9 Hypertension, Stroke
Week 10 Documentation and Informatics
Documentation and Informatics______________________________________368
Week 11 Nutrition, Dysphagia_____________________________________382
Week 12 Care of the Surgical Patient________________________________398
Care of Older Adults: Culture, Spirituality, Communication,
Sexuality, Infection Control
Chapter 05: Chronic Illness and Older Adults Lewis: Medical-Surgical Nursing,
1. When caring for an older patient with hypertension who has been hospitalized after a transient
ischemic (TIA), which topic is the most important for the nurse to include in the discharge
a) Effect of atherosclerosis on blood vessels
b) Mechanism of action of anticoagulant drug therapy
c) Symptoms indicating that the patient should contact the health care provider
d) Impact of the patient’s family history on likelihood of developing a serious stroke
One of the tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient
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needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to
take if these symptoms occur. The other information may also be included in patient teaching but
is not as essential in the patient’s self-management of the illness.
2. The nurse performs a comprehensive assessment of an older patient who is considering
admission to an assisted living facility. Which question is the most important for the nurse to
a) “Have you had any recent infections?”
b) “How frequently do you see a doctor?”
c) “Do you have a history of heart disease?”
d) “Are you able to prepare your own meals?”
The patient’s functional abilities, rather than the presence of an acute or chronic illness, are more
useful in determining how well the patient might adapt to an assisted living situation. The other
questions will also provide helpful information but are not as useful in providing a basis for
determining patient needs or for developing interventions for the older patient.
3. An alert older patient who takes multiple medications for chronic cardiac and pulmonary
diseases lives with a daughter who works during the day. During a clinic visit, the patient
verbalizes to the nurse that she has a strained relationship with her daughter and does not enjoy
being alone all day. Which nursing diagnosis should the nurse assign as the priority for this
a) Social isolation related to fatigue
b) Risk for injury related to drug interactions
c) Caregiver role strain related to family employment schedule
d) Compromised family coping related to the patient’s care needs
The patient’s age and multiple medications indicate a risk for injury caused by interactions
between the multiple drugs being taken and a decreased drug metabolism rate. Problems with
social isolation, caregiver role strain, or compromised family coping are not physiologic
priorities. Drug–drug interactions could cause the most harm to the patient and are therefore the
4. Which method should the nurse use to gather the most complete assessment of an older
a) Review the patient’s health record for previous assessments.
b) Use a geriatric assessment instrument to evaluate the patient.
c) Ask the patient to write down medical problems and medications.
d) Interview both the patient and the primary caregiver for the patient.
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The most complete information about the patient will be obtained through the use of an
assessment instrument specific to the geriatric population, which includes information about both
medical diagnoses and treatments and about functional health patterns and abilities. A review of
the medical record, interviews with the patient and caregiver, and written information by the
patient are all included in a comprehensive geriatric assessment.
5. Which intervention should the nurse implement to provide optimal care for an older patient
who is hospitalized with pneumonia?
a) Plan for transfer to a long-term care facility.
b) Minimize activity level during hospitalization.
c) Consider the preadmission functional abilities.
d) Use an approved standardized geriatric nursing care plan.
The plan of care for older adults should be individualized and based on the patient’s current
functional abilities. A standardized geriatric nursing care plan will not address individual patient
needs and strengths. A patient’s need for discharge to a long-term care facility is variable.
Activity level should be designed to allow the patient to retain functional abilities while
hospitalized and also to allow any additional rest needed for recovery from the acute process.
6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should
the nurse plan to implement to meet this patient’s needs?
a) Suggest that the patient move closer to health care providers.
b) Obtain extra medications for the patient to last for 4 to 6 months.
c) Ensure transportation to appointments with the health care provider.
d) Assess the patient for chronic diseases that are unique to rural areas.
Transportation can be a barrier to accessing health services in rural areas. The patient living in a
rural area may lose the benefits of a familiar situation and social support by moving to an urban
area. There are no chronic diseases unique to rural areas. Because medications may change, the
nurse should help the patient plan for obtaining medications through alternate means such as the
mail or delivery services, not by purchasing large quantities of the medications.
7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in
an older adult?
a) Teach the patient to have all prescriptions filled at the same pharmacy.
b) Make a schedule for the patient as a reminder of when to take each medication.
c) Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements.
d) Ask the patient to bring all medications, supplements, and herbs to each appointment.
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The most information about drug use and possible interactions is obtained when the patient
brings all prescribed medications, OTC medications, and supplements to every health care
appointment. The patient should discuss the use of any OTC medications with the health care
provider and obtain all prescribed medications from the same pharmacy, but use of supplements
and herbal medications also need to be considered in order to prevent drug–drug interactions.
Use of a medication schedule will help the patient take medications as scheduled, but will not
prevent drug–drug interactions.
8. A patient who has just moved to a long-term care facility has a nursing diagnosis of relocation
stress syndrome. Which action should the nurse include in the plan of care?
a) Remind the patient that making changes is usually stressful.
b) Discuss the reason for the move to the facility with the patient.
c) Restrict family visits until the patient is accustomed to the facility.
d) Have staff members write notes welcoming the patient to the facility.
Having staff members write notes will make the patient feel more welcome and comfortable at
the long-term care facility. Discussing the reason for the move and reminding the patient that
change is usually stressful will not decrease the patient’s stress about the move. Family member
visits will decrease the patient’s sense of stress about the relocation.
9. An older patient complains of having “no energy” and feeling increasingly weak. The patient
has had a 12-lb weight loss over the past year. Which action should the nurse take initially?
a) Ask the patient about daily dietary intake.
b) Schedule regular range-of-motion exercise.
c) Discuss long-term care placement with the patient.
d) Describe normal changes associated with aging to the patient.
In a frail older patient, nutrition is frequently compromised, and the nurse’s initial action should
be to assess the patient’s nutritional status. Active range of motion may be helpful in improving
the patient’s strength and endurance, but nutritional assessment is the priority because the patient
has had a significant weight loss. The patient may be a candidate for long-term care placement,
but more assessment is needed before this can be determined. The patient’s assessment data are
not consistent with normal changes associated with aging.
10. The nurse is admitting an acutely ill, older patient to the hospital. Which action should the
a) Speak slowly and loudly while facing the patient.
b) Obtain a detailed medical history from the patient.
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c) Perform the physical assessment before interviewing the patient.
d) Ask a family member to go home and retrieve the patient’s cane.
When a patient is acutely ill, the physical assessment should be accomplished first to detect any
physiologic changes that require immediate action. Not all older patients have hearing deficits,
and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring
the patient, much of the medical history can be obtained from medical records. After the initial
physical assessment to determine the patient’s current condition, then the nurse could ask
someone to obtain any assistive devices for the patient if applicable.
11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital
with a chronic foot infection. Which intervention is the most appropriate for the nurse to include
in the discharge plan for this patient?
a) Teach the patient how to assess and care for the foot infection.
b) Refer the patient to social services for assessment of resources.
c) Schedule the patient to return to outpatient services for foot care.
d) Give the patient written information about shelters and meal sites.
An interprofessional approach, including social services, is needed when caring for homeless
older adults. Even with appropriate teaching, a homeless individual may not be able to maintain
adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older
homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to
keep appointments for outpatient services because of factors such as fear of institutionalization
or lack of transportation.
12. The home health nurse cares for an older adult patient who lives alone and takes several
different prescribed medications for chronic health problems. Which intervention, if
implemented by the nurse, would best encourage medication compliance?
a) Use a marked pillbox to set up the patient’s medications.
b) Discuss the option of moving to an assisted living facility.
c) Remind the patient about the importance of taking medications.
d) Visit the patient daily to administer the prescribed medications.
Because forgetting to take medications is a common cause of medication errors in older adults,
the use of medication reminder devices is helpful when older adults have multiple medications to
take. There is no indication that the patient needs to move to assisted living or that the patient
does not understand the importance of medication compliance. Home health care is not designed
for the patient who needs ongoing assistance with activities of daily living or instrumental ADLs.
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13. The home health nurse visits an older patient with mild forgetfulness. Which new information
is of most concern to the nurse?
a) The patient tells the nurse that a close friend recently died.
b) The patient has lost 10 lb (4.5 kg) during the past month.
c) The patient is cared for by a daughter during the day and stays with a son at night.
d) The patient’s son uses a marked pillbox to set up the patient’s medications weekly.
A 10-pound weight loss may be an indication of elder neglect or depression and requires further
assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour
care are appropriate for this patient. It is not unusual that an 86-yr-old would have friends who
14. Which statement, if made by an older adult patient, would be of most concern to the nurse? a.
“I prefer to manage my life without much help from other people.”
a) “I prefer to manage my life without much help from other people.”
b) “I take three different medications for my heart and joint problems.”
c) “I don’t go on daily walks anymore since I had pneumonia 3 months ago.”
d) “I set up my medications in a marked pillbox so I don’t forget to take them.”
Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should
develop a plan to prevent further deconditioning and restore function for the patient. Selfmanagement is appropriate for independently living older adults. On average, an older adult
takes seven different medications so the use of three medications is not unusual for this patient.
The use of memory devices to assist with safe medication administration is recommended for
15. The nurse assesses an older patient who takes diuretics and has a possible urinary tract
infection (UTI). Which action should the nurse take first?
a) Palpate over the suprapubic area.
b) Inspect for abdominal distention.
c) Question the patient about hematuria.
d) Request the patient empty the bladder.
Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse
should have the patient empty the bladder because bladder fullness or discomfort will distract
from the patient’s ability to provide accurate information. The patient may seem disoriented if
distracted by pain or urgency. The physical assessment data are obtained after the patient is as
comfortable as possible.
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16. Which patient is most likely to need long-term nursing care management?
a) 72-yr-old who had a hip replacement after a fall at home
b) 64-yr-old who developed sepsis after a ruptured peptic ulcer
c) 76-yr-old who had a cholecystectomy and bile duct drainage
d) 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)
Osteoarthritis and obesity are chronic problems that will require planning for long-term
interventions such as physical therapy and nutrition counseling. The other patients have acute
problems that are not likely to require long-term management.
17. An older adult being admitted is assessed at high risk for falls. Which action should the nurse
a) Use a bed alarm system on the patient’s bed.
b) Administer the prescribed PRN sedative medication.
c) Ask the health care provider to order a vest restraint.
d) Place the patient in a “geri-chair” near the nurse’s station.
The use of the least restrictive restraint alternative is required. Physical or chemical restraints
may be necessary, but the nurse’s first action should be an alternative such as a bed alarm.
18. An older adult patient presents with a broken arm and visible scattered bruises healing at
different stages. Which action should the nurse take first?
a) Notify an elder protective services agency about possible abuse.
b) Make a referral for a home assessment visit by the home health nurse.
c) Have the family member stay in the waiting area while the patient is assessed.
d) Ask the patient how the injury occurred and observe the family member’s reaction.
The initial action should be assessment and interviewing of the patient. The patient should be
interviewed alone because the patient will be unlikely to give accurate information if the abuser
is present. If abuse is occurring, the patient should not be discharged home for a later assessment
by a home health nurse. The nurse needs to collect and document data before notifying the elder
protective services agency.
19. The family of an older patient with chronic health problems and increasing weakness is
considering placement in a long-term care (LTC) facility. Which action by the nurse will be most
helpful in assisting the patient to make this transition?
a) Have the family select a LTC facility that is relatively new.
b) Ask the patient’s preference for the choice of a LTC facility.
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c) Explain the reasons for the need to live in LTC to the patient.
d) Request that the patient be placed in a private room at the facility.
The stress of relocation is likely to be less when the patient has input into the choice of the
facility. The age of the long-term care facility does not indicate a better fit for the patient or
better quality of care. Although some patients may prefer a private room, others may adjust
better when given a well-suited roommate. The patient should understand the reasons for the
move but will make the best adjustment when involved with the choice to move and the choice
of the facility.
20. The nurse manages the care of older adults in an adult health day care center. Which action
can the nurse delegate to unlicensed assistive personnel (UAP)?
a) Obtain information about food and medication allergies from patients.
b) Take blood pressures daily and document in individual patient records.
c) Choose social activities based on the individual patient needs and desires.
d) Teach family members how to cope with patients who are cognitively impaired.
Measurement and documentation of vital signs are included in UAP education and scope of
practice. Obtaining patient health history, planning activities based on the patient assessment,
and patient education are all actions that require critical thinking and will be done by the
1. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult
patient (select all that apply)?
a) Assess for depression.
b) Review laboratory results.
c) Determine food preferences.
d) Inspect teeth and oral mucosa.
e) Ask about transportation needs.
ANS: A, B, D, E
The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor
protein intake or high-fat or high-cholesterol intake. Transportation affects the patient’s ability to
shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor
condition may decrease the ability to chew and swallow. Food likes and dislikes are not
necessarily associated with malnutrition.
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Chapter 09: Cultural Awareness
Potter et al.: Fundamentals of Nursing, 9th Edition
1. A nurse is working at a health fair screening people for liver cancer. Which population group should the
nurse monitor most closely for liver cancer?
While Asian Americans generally have lower cancer rates than the non-Hispanic Caucasian population, they
also have the highest incidence rates of liver cancer for both sexes compared with Hispanic, non-Hispanic
Caucasians, or non-Hispanic African-Americans.
2. A nurse is caring for an immigrant with low income. Which information should the nurse consider when
planning care for this patient?
Populations with health disparities (immigrant with low income) have a significantly increased incidence of
disease or increased morbidity and mortality when compared with the general population. Although
Americans’ health overall has improved during the past few decades, the health of members of marginalized
groups has actually declined.
3. A nurse is assessing the health care disparities among population groups. Which area is the nurse
While health disparities are the differences among populations in the incidence, prevalence, and outcomes of
health conditions, diseases and related complications, health care disparities are differences among populations
in the availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment,
management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their
4. A nurse is providing care to a patient from a different culture. Which action by the nurse indicates cultural
b. Asian Americans
c. Non-Hispanic Caucasians
d. Non-Hispanic African-Americans
a. There is a decreased frequency of morbidity.
b. There is an increased incidence of disease.
c. There is an increased level of health.
d. There is a decreased mortality rate.
a. Accessibility of health care services
b. Outcomes of health conditions
c. Prevalence of complications
d. Incidence of diseases
a. Communicates effectively in a multicultural context
b. Functions effectively in a multicultural context
c. Visits a foreign country
d. Speaks a different language
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Cultural competence refers to a developmental process that evolves over time that impacts ability to effectively
function in the multicultural context. Communicates effectively and speaking a different language indicates
linguistic competence. Visiting a foreign country does not indicate cultural competence.
5. The nurse learns about cultural issues involved in the patient’s health care belief system and enables patients
and families to achieve meaningful and supportive care. Which concept is the nurse demonstrating?
The nurse is demonstrating culturally congruent care. Culturally congruent care, or care that fits a person’s life
patterns, values, and system of meaning, provides meaningful and beneficial nursing care. Marginalized groups
are populations left out or excluded. Health care disparities are differences among populations in the
availability, accessibility, and quality of health care services (e.g. screening, diagnostic, treatment,
management, and rehabilitation) aimed at prevention, treatment, and management of diseases and their
complications. Transcultural nursing is a comparative study of cultures in order to understand their similarities
(culture that is universal) and the differences among them (culture that is specific to particular groups).
6. A nurse is beginning to use patient-centered care and cultural competence to improve nursing care. Which
step should the nurse take first?
Becoming more aware of your biases and attitudes about human behavior is the first step in providing patientcentered care, leading to culturally competent care. It is helpful to think about cultural competence as a lifelong
process of learning about others and also about yourself. Learning about the world view, developing cultural
skills, and understanding organizational forces are not the first steps.
7. A nurse is performing a cultural assessment using the ETHNIC mnemonic for communication. Which area
will the nurse assess for the “H”?
The “H” in ETHNIC stands for healers: Has the patient sought advice from alternative health practitioners?
While health, history, and homeland are important, they are not components of “H.”
8. The nurse is caring for a patient of Hispanic descent who speaks no English. The nurse is working with an
interpreter. Which action should the nurse take?
a. Marginalized groups
b. Health care disparity
c. Transcultural nursing
d. Culturally congruent care
a. Assessing own biases and attitude
b. Learning about the world view of others
c. Understanding organizational forces
d. Developing cultural skills
a. Use long sentences when talking.
b. Look at the patient when talking.
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Direct your questions to the patient. Look at the patient, instead of looking at the interpreter. Pace your speech
by using short sentences, but do not break your sentences. Observe the patient’s nonverbal and verbal
9. Which action indicates the nurse is meeting a primary goal of cultural competent care for patients?
Although cultural competence and patient-centered care both aim to improve health care quality, their focus is
slightly different. The primary aim of cultural competence care is to reduce health disparities and increase
health equity and fairness by concentrating on people of color and other marginalized groups, like transgender
patients. Patient-centered care, rather than cultural competence care, provides individualized care and restores
an emphasis on personal relationships; it aims to elevate quality for all patients.
10. The nurse is caring for a Chinese patient using the Teach-Back technique. Which action by the nurse
indicates successful implementation of this technique?
The Teach-Back technique asks open-ended questions, like what will you tell your spouse about changing the
dressing, to verify a patient’s understanding. When using the Teach-Back technique do not ask a patient, “Do
you understand?” or “Do you have any questions?” Does this make sense and do you think you can do this at
home are closed-ended questions. Would you tell me if you don’t understand something so we can go over it is
not verifying a patient’s understanding about the teaching.
11. A nurse is using core measures to reduce health disparities. Which group should the nurse focus on to cause
the most improvement in core measures?
To improve results, the nurse should focus on the highest disparity. Poor people received worse care than highincome people for about 60% of core measures. American Indians and Alaska Natives received worse care than
Caucasians for about 30% of core measures.
12. A nurse is designing a form for lesbian, gay, bisexual, and transgender (LGBT) patients. Which design
should the nurse use?
c. Use breaks in sentences when talking.
d. Look at only nonverbal behaviors when talking.
a. Provides care to transgender patients
b. Provides care to restore relationships
c. Provides care to patients that is individualized
d. Provides care to surgical patients
a. Asks, “Does this make sense?”
b. Asks, “Do you think you can do this at home?”
c. Asks, “What will you tell your spouse about changing the dressing?”
d. Asks, “Would you tell me if you don’t understand something so we can go over it?”
b. Poor people
c. Alaska Natives
d. American Indians
a. Use partnered rather than married.
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Include LGBT-inclusive language on forms and assessments to facilitate disclosure, knowing that disclosure is
a choice impacted by many factors. For example, provide options such as “partnered” under relationship status.
For parents, use parent/guardian, instead of mother/father. Use neutral and inclusive language when talking
with patients (e.g., partner or significant other), listening and reflecting patient’s choice. Remember that some
LGBT patients are also legally married.
13. A nurse is assessing population groups for the risk of suicide requiring medical attention. Which group
should the nurse monitor mostclosely?
Gay, lesbian, and bisexual young people have a significantly increased risk for depression, anxiety, suicide
attempts, and substance use disorders, being 4 times as likely as their straight peers to make suicide attempts
that require medical attention. Caucasian youth, Asian Americans, and African-Americans are not as likely to
attempt suicide resulting in medical attention.
14. A nurse is assessing a patient’s ethnohistory. Which question should the nurse ask?
An ethnohistory question is the following: How different is your life here from back home? Caring beliefs and
practice questions include the following: Which caregivers do you seek when you are sick and How different is
what we do from what your family does when you are sick? The language and communication is the
following: What language do you speak at home?
15. A nurse is teaching patients about health care information. Which patient will the nurse assess closely for
About 9 out of 10 people in the United States experience challenges in using health care information. Patients
who are especially vulnerable are the elderly (age 65+), immigrants, persons with low incomes, persons who
do not have a high-school diploma or GED, and persons with chronic mental and/or physical health conditions.
A 35-year-old patient and patients with high-school and college education are not identified in the vulnerable
b. Use mother rather than father.
c. Use parents rather than guardian.
d. Use wife/husband rather than significant other.
a. Young bisexuals
b. Young caucasians
c. Asian Americans
a. What language do you speak at home?
b. How different is your life here from back home?
c. Which caregivers do you seek when you are sick?
d. How different is what we do from what your family does when you are sick?
a. A patient 35 years old
b. A patient 68 years old
c. A patient with a college degree
d. A patient with a high-school diploma
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16. A nurse works at a hospital that uses equity-focused quality improvement. Which strategy is the hospital
Organizations can implement equity-focused quality improvement by recognizing disparities and committing
to reducing them. Staff diversity is a priority for equity-focused quality improvement, not staff satisfaction.
While the family is important, the focus is on the patients. Organizations should start by implementing a
change on a small scale (pilot testing), learning from each test, and refining the intervention through
performance improvement cycles (e.g., plan, do, study, and act).
17. A nurse is providing care to a culturally diverse population. Which action indicates the nurse is successful
in the role of providing culturally congruent care?
The goal of transcultural nursing is to provide culturally congruent care, or care that fits the person’s life
patterns, values, and system of meaning. Patterns and meanings are generated from people themselves, rather
than from predetermined criteria. Discovering patients’ cultural values, beliefs, and practices as they relate to
nursing and health care requires you to assume the role of learner (not become the leader) and to partner with
your patients and their families to determine what is needed to provide meaningful and beneficial nursing care.
Culturally congruent care is sometimes different from the values and meanings of the professional health care
18. A nurse is assessing the patient’s meaning of illness. Which area of focus by the nurse is priority?
To provide culturally congruent care, you need to understand the difference between disease and illness. Illness
is the way that individuals and families react to disease, whereas disease is a malfunctioning of biological or
psychological processes. The way a patient interacts to family/social interactions is communication processes
and family dynamics.
1. A nurse is using Campinha-Bacote’s model of cultural competency. Which areas will the nurse focus on to
become competent? (Select all that apply.)
a. Document staff satisfaction.
b. Focus on the family.
c. Implement change on a grand scale.
d. Reduce disparities.
a. Provides care that fits the patient’s valued life patterns and set of meanings
b. Provides care that is based on meanings generated by predetermined criteria
c. Provides care that makes the nurse the leader in determining what is needed
d. Provides care that is the same as the values of the professional health care system
a. On the way a patient reacts to disease
b. On the malfunctioning of biological processes
c. On the malfunctioning of psychological processes
d. On the way a patient reacts to family/social interactions
a. Cultural skills
b. Cultural desire
c. Cultural transition
d. Cultural knowledge
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ANS: A, B, D, E
Campinha-Bacote’s model of cultural competency has five interrelated components: cultural awareness;
cultural knowledge; cultural skills; cultural encounters; and cultural desire. Cultural transition is not a
component of this model.
2. A nurse is using the RESPECT mnemonic to establish rapport, the “R” in RESPECT. Which actions should
the nurse take? (Select all that apply.)
ANS: A, C
The “R” in RESPECT stands for rapport and includes the following behaviors: connect on a social level; seek
the patient’s point of view; and consciously attempt to suspend judgment. The “S” stands for support and
includes the behavior of helping the patient overcome barriers. The “P” stands for partnership and includes the
following behaviors: be flexible with regard to issues of control and stress that you will be working together to
address medical problems. The “C” stands for cultural competence and includes the behavior of knowing your
limitations in addressing medical issues across cultures.
3. A nurse is using the explanatory model to determine the etiology of an illness. Which questions should the
nurse ask? (Select all that apply.)
ANS: B, C, E
The questions for etiology include “What do you call your problem?” and “What name does it have?”
Recommended treatment is asked by the question “How should your sickness be treated?” Pathophysiology is
asked by the question “How does this illness work inside your body?” The course of illness is asked by the
question “What do you fear most about your sickness?”
A nurse is using Campinha-Bacote’s model of cultural competency to improve cultural care. Which actions
describe the components the nurse is using?
e. Cultural encounters
a. Connect on a social level.
b. Help the patient overcome barriers.
c. Consciously attempt to suspend judgment.
d. Stress that they will be working together to address problems.
e. Know limitations in addressing medical issues across cultures.
a. How should your sickness be treated?
b. What do you call your problem?
c. How does this illness work inside your body?
d. What do you fear most about your sickness?
e. What name does it have?
a. In-depth self-examination of one’s own background
b. Ability to assess factors that influence treatment and care
c. Sufficient comparative understanding of diverse groups
d. Motivation and commitment to continue learning about cultures
e. Cross-cultural interaction that develops communication skills
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Chapter 14: Older Adult
Potter et al.: Fundamentals of Nursing, 9th Edition
1. A nurse is obtaining a history on an older adult. Which finding will the nurse most typically find?
In 2012, 57% of older adults in non-institutional settings lived with a spouse (45% of older women, 71% of
older men); 28% lived alone (35% of older women, 19% of older men); and only 3.5% of all older adults
resided in institutions such as nursing homes or centers. Most older adults have lost a spouse due to death
rather than divorce.
2. A nurse is developing a plan of care for an older adult. Which information will the nurse consider?
Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care
of older adults poses special challenges because of great variation in their physiological, cognitive, and
psychosocial health. Aging does not automatically lead to disability and dependence. Chronological age often
has little relation to the reality of aging for an older adult.
3. Which information from a co-worker on a gerontological unit will cause the nurse to intervene?
Most older people remain functionally independent despite the increasing prevalence of chronic disease;
therefore, this misconception should be addressed. It is critical for you to respect older adults and actively
involve them in care decisions and activities. You also need to identify an older adult’s strengths and abilities
during the assessment and encourage independence as an integral part of your plan of care.
4. A nurse suspects an older-adult patient is experiencing caregiver neglect. Which assessment findings are
consistent with the nurse’s suspicions?
a. Lives in a nursing home
b. Lives with a spouse
c. Lives divorced
d. Lives alone
Should be standardized because most geriatric patients have the same
b. Needs to be individualized to the patient’s unique needs
c. Focuses on the disabilities that all aging persons face
d. Must be based on chronological age alone
a. Most older people have dependent functioning.
b. Most older people have strengths we should focus on.
c. Most older people should be involved in care decision.
d. Most older people should be encouraged to have independence.
a. Flea bites and lice infestation
b. Left at a grocery store
c. Refuses to take a bath
d. Cuts and bruises
16A&E I Comprehensive Testbank
Caregiver neglect includes unsafe and unclean living conditions, soiled bedding, and animal or insect
infestation. Abandonment includes desertion at a hospital, nursing facility, or public location such as a
shopping center. Self-neglect includes refusal or failure to provide oneself with basic necessities such as food,
water, clothing, shelter, personal hygiene, medication, and safety. Physical abuse includes hitting, beating,
pushing, slapping, kicking, physical restraint, inappropriate use of drugs, fractures, lacerations, rope burns, and
5. A nurse is teaching a group of older-adult patients. Which teaching strategy is best for the nurse to use?
Teaching strategies include the use of past experiences to connect new learning with previous knowledge,
focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond
because older adults’ reaction times are longer than those of younger persons, and keeping the tone of voice
low; older adults are able to hear low sounds better than high-frequency sounds.
6. An older patient has fallen and suffered a hip fracture. As a consequence, the patient’s family is concerned
about the patient’s ability to care for self, especially during this convalescence. What should the nurse do?
Nurses help older adults and their families by providing information and answering questions as they make
choices among care options. Some older adults deny functional declines and refuse to ask for assistance with
tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing
center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life
varies and is unique for each person.
7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing
Provide several topics of discussion at once to promote independence
and making choices.
Avoid uncomfortable silences after questions by helping patients
complete their statements.
Ask patients to recall past experiences that correspond with their
d. Speak in a high pitch to help patients hear better.
a. Stress that older patients usually ask for help when needed.
Inform the family that placement in a nursing center is a permanent
Tell the family to enroll the patient in a ceramics class to maintain
quality of life.
Provide information and answer questions as family members make
choices among care options.
Have the family members evaluate nursing home staff according to
their ability to get tasks done efficiently and safely.
Make sure that nursing home staff members get patients out of bed
and dressed according to staff’s preferences.
Explain that it is important for the family to visit the center and
inspect it personally.
Suggest a nursing center that has standards as close to hospital
standards as possible.
17A&E I Comprehensive Testbank
An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home
should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff
should focus on the person, not the task. Residents should be out of bed and dressed according to their
preferences, not staff preferences.
8. A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. The nurse is
discussing health care services and possible long-term living arrangements with the patient’s only son. What
will the nurse suggest?
Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult
or when convalescence from hospitalization requires more assistance than the family is able to provide. An
apartment setting and the use of home health visits are not appropriate because living at home is unsafe.
Dementia is not a time of inactivity but an impairment of intellectual functioning.
9. A nurse is caring for an older adult. Which goal is priority?
Adjusting to retirement is one of the developmental tasks for an older person. A young or middle-aged adult
has to adjust to career and/or divorce. A middle-aged adult has to adjust to grandchildren.
10. A nurse is observing for the universal loss in an older-adult patient. What is the nurse assessing?
The universal loss for older adults usually revolves around the loss of relationships through death. Life
transitions, of which loss is a major component, include retirement and the associated financial changes,
changes in roles and relationships, alterations in health and functional ability, changes in one’s social network,
and relocation. However, these are not the universal loss.
11. A nurse is discussing sexuality with an older adult. Which action will the nurse take?
a. An apartment setting with neighbors close by
b. Having the patient utilize weekly home health visits
c. A nursing center because home care is no longer safe
That placement is irrelevant because the patient is retreating to a place
a. Adjusting to career
b. Adjusting to divorce
c. Adjusting to retirement
d. Adjusting to grandchildren
a. Loss of finances through changes in income
b. Loss of relationships through death
c. Loss of career through retirement
d. Loss of home through relocation
Ask closed-ended questions about specific symptoms the patient may
Provide information about the prevention of sexually transmitted
c. Discuss the issues of sexuality in a group in a private room.
d. Explain that sexuality is not necessary as one ages.
18A&E I Comprehensive Testbank
Include information about the prevention of sexually transmitted infections when appropriate. Open-ended
questions inviting an older adult to explain sexual activities or concerns elicit more information than a list of
closed-ended questions about specific activities or symptoms. You need to provide privacy for any discussion
of sexuality and maintain a nonjudgmental attitude. Sexuality and the need to express sexual feelings remain
throughout the human life span.
12. A nurse is teaching a health promotion class for older adults. In which order will the nurse list the most
common to least common conditions that can lead to death in older adults?
1. Chronic obstructive lung disease
2. Cerebrovascular accidents
3. Heart disease
Heart disease is the leading cause of death in older adults followed by cancer, chronic lung disease, and stroke
13. A nurse is observing skin integrity of an older adult. Which finding will the nurse document as a normal
Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation
changes, glandular atrophy (oil, moisture, and sweat glands), thinning hair (facial hair: decreased in men,
increased in women), slower nail growth, and atrophy of epidermal arterioles.
14. An older-adult patient in no acute distress reports being less able to taste and smell. What is the
nurse’s best response to this information?
Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell
and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is
unnecessary at this time as per the information provided.
15. A nurse is assessing an older adult for cognitive changes. Which symptom will the nurse report as normal?
a. 4, 1, 2, 3
b. 3, 4, 1, 2
c. 2, 3, 4, 1
d. 1, 2, 3, 4
a. Oily skin
b. Faster nail growth
c. Decreased elasticity
d. Increased facial hair in men
Notify the health care provider immediately to rule out cranial nerve
Schedule the patient for an appointment at a smell and taste disorders
c. Perform testing on the vestibulocochlear nerve and a hearing test.
d. Explain to the patient that diminished senses are normal findings.
19A&E I Comprehensive Testbank
Slower reaction time is a common change in the older adult. Symptoms of cognitive impairment, such as
disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging
changes and require further investigation of underlying causes.
16. An older patient with dementia and confusion is admitted to the nursing unit after hip replacement surgery.
Which action will the nurse include in the plan of care?
Patients with dementia need a routine. Continuing to reorient a patient with dementia is nonproductive and not
advised. Patients with dementia need limited choices. Social interaction based on the patient’s abilities is to be
17. A nurse is helping an older-adult patient with instrumental activities of daily living. The nurse will be
assisting the patient with which activity?
Instrumental activities of daily living or IADLs (such as the ability to write a check, shop, prepare meals, or
make phone calls) and activities of daily living or ADLs (such as bathing, dressing, and toileting) are essential
to independent living.
18. A male older-adult patient expresses concern and anxiety about decreased penile firmness during an
erection. What is the nurse’s best response?
Aging men typically experience an erection that is less firm and shorter acting and have a less forceful
ejaculation. Testosterone lessens with age and sometimes (not always) leads to a loss of libido. However, for
both men and women sexual desires, thoughts, and actions continue throughout all decades of life. Sexuality
involves love, warmth, sharing, and touching, not just the act of intercourse. Touch complements traditional
sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or
b. Poor judgment
c. Slower reaction time
d. Loss of language skills
a. Keep a routine.
b. Continue to reorient.
c. Allow several choices.
d. Socially isolate patient.
a. Taking a bath
b. Getting dressed
c. Making a phone call
d. Going to the bathroom
Tell the patient that libido will always decrease, as well as the sexual
Tell the patient that touching should be avoided unless intercourse is
c. Tell the patient that heterosexuality will help maintain stronger libido.
d. Tell the patient that this change is expected in aging adults.
20A&E I Comprehensive Testbank
possible. Clearly not all older adults are heterosexual, and there is emerging research on older adult, lesbian,
gay, bisexual, and transgender individuals and their health care needs.
19. A patient asks the nurse what the term polypharmacy means. Which information should the nurse share
with the patient?
Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with side
effects, adverse drug effects, or risks of medication use due to aging.
20. An outcome for an older-adult patient living alone is to be free from falls. Which statement indicates the
patient correctly understands the teaching on safety concerns?
Postural hypotension is an intrinsic factor that can cause falls. Changing positions slowly indicates a correct
understanding of this concept. Environmental hazards outside and within the home such as poor lighting,
slippery or wet flooring, and items on floor that are easy to trip over such as throw rugs are other factors that
can lead to falls. Impaired vision and poor lighting are other risk factors for falls and should be avoided (dim
lighting). Inappropriate footwear such as smooth bottom socks also contributes to falls.
21. A nurse’s goal for an older adult is to reduce the risk of adverse medication effects. Which action will the
Strategies for reducing the risk for adverse medication effects include reviewing the medications with older
adults at each visit; examining for potential interactions with food or other medications; simplifying and
individualizing medication regimens; taking every opportunity to inform older adults and their families about
all aspects of medication use; and encouraging older adults to question their health care providers about all
prescribed and over-the-counter medications. Although polypharmacy often reflects inappropriate prescribing,
the concurrent use of multiple medications is often necessary when an older adult has multiple acute and
chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the
absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to
ensure safe and appropriate use of all medications—both prescribed medications and over-the-counter
medications and herbal options.
22. An older-adult patient has developed acute confusion. The patient has been on tranquilizers for the past
week. The patient’s vital signs are normal. What should the nurse do?
a. This is multiple side effects experienced when taking medications.
b. This is many adverse drug effects reported to the pharmacy.
c. This is the multiple risks of medication effects due to aging.
d. This is concurrent use of many medications.
a. “I’ll take my time getting up from the bed or chair.”
b. “I should dim the lighting outside to decrease the glare in my eyes.”
“I’ll leave my throw rugs in place so that my feet won’t touch the cold
“I should wear my favorite smooth bottom socks to protect my feet
when walking around.”
a. Review the patient’s list of medications at each visit.
b. Teach that polypharmacy is to be avoided at all cost.
c. Avoid information about adverse effects.
d. Focus only on prescribed medications.
21A&E I Comprehensive Testbank
Some sedatives and tranquilizers prescribed for acutely confused older adults sometimes cause or exacerbate
confusion. Carefully administer drugs used to manage confused behaviors, taking into account age-related
changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such
as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time
of day or is related to environmental factors, nonpharmacological measures such as making the environment
more meaningful, providing adequate light, etc., should be used. Making phone calls to friends or family
members allows older adults to hear reassuring voices, which may be beneficial.
23. Which assessment finding of an older adult, who has a urinary tract infection, requires an immediate
Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires
further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the
older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an
expected finding in an older adult. Older adults tend to have lower core temperatures. Coping with the death of
a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case.
24. Which patient statement is the most reliable indicator that an older adult has the correct understanding of
health promotion activities?
General preventive measures for the nurse to recommend to older adults include keeping regular dental
appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and
maintaining immunizations for seasonal influenza, tetanus, diphtheria and pertussis, shingles, and
25. A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been
retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public
transportation. Which psychosocial change does the nurse focus on as a priority?
Take into account age-related changes in body systems that affect
Increase the dose of tranquilizer if the cause of the confusion is an
c. Note when the confusion occurs and medicate before that time.
d. Restrict phone calls to prevent further confusion.
c. Temperature of 97.9° F
d. Death of a spouse 2 months ago
a. “I need to increase my fat intake and limit protein.”
“I still keep my dentist appointments even though I have partials
c. “I should discontinue my fitness club membership for safety reasons.”
“I’m up-to-date on my immunizations, but at my age, I don’t need the
22A&E I Comprehensive Testbank
The highest priority at this time is the potential for social isolation. This woman does not know how to drive
and lives in a rural community that does not have public transportation. All of these factors contribute to her
social isolation. Other possible changes she may be going through right now include sexuality related to her
advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired
for 5 years, so this is also not an immediate need. She may eventually experience needs related to environment,
but the data do not support this as an issue at this time.
1. A recently widowed older-adult patient is dehydrated and is admitted to the hospital for intravenous fluid
replacement. During the evening shift, the patient becomes acutely confused. Which possible reversible causes
will the nurse consider when assessing this patient? (Select all that apply.)
ANS: A, B, C, D
Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due to a
physiological event. Physiological causes include electrolyte imbalances, untreated pain, infection, cerebral
anoxia, hypoglycemia, medication effects, tumors, subdural hematomas, and cerebrovascular infarction or
hemorrhage. Sometimes it is also caused by environmental factors such as sensory deprivation or
overstimulation, unfamiliar surroundings, or sleep deprivation or psychosocial factors such as emotional
distress. Dementia is a gradual, progressive, and irreversible cerebral dysfunction.
A nurse is using different strategies to meet older patients’ psychosocial needs. Match the strategy the nurse is
using to its description.
1. Body image
2. Validation therapy
3. Therapeutic communication
4. Reality orientation
Chapter 24: Communication
Potter et al.: Fundamentals of Nursing, 9th Edition
1. Which types of nurses make the best communicators with patients?
d. Social isolation
a. Electrolyte imbalance
b. Sensory deprivation
d. Drug effects
a. Respecting the older adult’s uniqueness
b. Improving level of awareness
c. Listening to the patient’s past recollections
d. Accepting describing of patient’s perspective
e. Offering help with grooming and hygiene
a. Those who learn effective psychomotor skills
b. Those who develop critical thinking skills
23A&E I Comprehensive Testbank
Nurses who develop critical thinking skills make the best communicators. Just liking people does not make an
effective communicator because it is important to apply critical thinking standards to ensure sound effective
communication. Just learning psychomotor skills does not ensure that the nurse will use those techniques, and
communication involves more than psychomotor skills.Critical thinking helps the nurse overcome perceptual
biases or human tendencies that interfere with accurately perceiving and interpreting messages from others.
Nurses who maintain perceptual biases do not make good communicators.
2. A nurse believes that the nurse-patient relationship is a partnership and that both are equal participants.
Which term should the nurse use to describe this belief?
Effective interpersonal communication requires a sense of mutuality, a belief that the nurse-patient relationship
is a partnership and that both are equal participants. Critical thinking in nursing, based on established standards
of nursing care and ethical standards, promotes effective communication and uses standards such as humility,
self-confidence, independent attitude, and fairness. To be authentic (one’s self) and to respond appropriately to
the other person are important for interpersonal relationships but do not mean mutuality. Attending is giving all
of your attention to the patient.
3. A nurse wants to present information about flu immunizations to the older adults in the community. Which
type of communication should the nurse use?
Public communication is interaction with an audience. Nurses have opportunities to speak with groups of
consumers about health-related topics, present scholarly work to colleagues at conferences, or lead classroom
discussions with peers or students. When nurses work on committees or participate in patient care conferences,
they use a small group communication process. Interpersonal communication is one-on-one interaction
between a nurse and another person that often occurs face to face. Intrapersonal communication is a powerful
form of communication that you use as a professional nurse. This level of communication is also called selftalk.
4. A nurse is using therapeutic communication with a patient. Which technique will the nurse use to ensure
c. Those who like different kinds of people
d. Those who maintain perceptual biases
a. Critical thinking
b. Small group
Interpersonal communication to change negative self-talk to positive
b. Small group communication to present information to an audience
c. Electronic communication to assess a patient in another city
d. Intrapersonal communication to build strong teams
24A&E I Comprehensive Testbank
Electronic communication is the use of technology to create ongoing relationships with patients and their
health care team. Intrapersonal communication is self-talk. Interpersonal communication is one-on-one
interaction between a nurse and another person that often occurs face to face. Public communication is used to
present information to an audience. Small group communication is interaction that occurs when a small
number of persons meet. When nurses work on committees or participate in patient care conferences, they use
a small group communication process.
5. A nurse is standing beside the patient’s bed.
Nurse: How are you doing?
Patient: I don’t feel good.
Which element will the nurse identify as feedback?
“I don’t feel good” is the feedback because the feedback is the message the receiver returns. The sender is the
person who encodes and delivers the message, and the receiver is the person who receives and decodes the
message. The nurse is the sender. The patient is the receiver. “How are you doing?” is the message.
6. A nurse is sitting at the patient’s bedside taking a nursing history. Which zone of personal space is the nurse
Personal space is 18 inches to 4 feet and involves things such as sitting at a patient’s bedside, taking a patient’s
nursing history, or teaching an individual patient. Intimate space is 0 to 18 inches and involves things such as
performing a physical assessment, bathing, grooming, dressing, feeding, and toileting a patient. The socioconsultative zone is 9 to 12 feet and involves things such as giving directions to visitors in the hallway and
giving verbal report to a group of nurses. The public zone is 12 feet and greater and involves things such as
speaking at a community forum, testifying at a legislative hearing, or lecturing.
7. A smiling patient angrily states, “I will not cough and deep breathe.” How will the nurse interpret this
An inappropriate affect is a facial expression that does not match the content of a verbal message (e.g., smiling
when describing a sad situation). The patient is smiling but is angry, which indicates an inappropriate affect.
The patient’s personal space was not violated. The patient’s vocabulary is not poor. Individuals who use a
common language share denotative meaning: baseball has the same meaning for everyone who speaks English,
but code denotes cardiac arrest primarily to health care