QUESTIONS AND VERIFIED ANSWERS|BRAND NEW
Question 1
The nursing assessment of an older female elicits information that the client is diagnosed
with Raynaud's phenomenon. Which exposure should the nurse instruct the client to
avoid?
a) Alcohol consumption
b) Warm climates
c) Cold climates
d) Active exercise
CORRECT ANSWER
C) Cold Climates
Rationale: Can cause prolonged painful vasoconstriction of the peripheral extremities
(especially hands) in client's with Raynaud's phenomenon.
Question 2
A family member brings their aging father to the clinic because he has been alert and
oriented during the day but agitated and disoriented in the evening. The registered nurse
(RN) reviews the client's list of current medications with the client and family. Which
action taken by the RN is most important?
a) Medication review with family caregivers is the PN's responsibility
b) Multiple medications can contribute to sundowner like symptoms
c) Medication recall is the best way to evaluate the client's memory
1
,d) Reviewing medication actions is a component of effective client care
CORRECT ANSWER
B) Multiple medications can contribute to sundowner like symptoms
Rationale: Older clients may see a variety of healthcare providers which can increase the
change of polypharmacy that compounds the workload of metabolic pathways that may
be less efficient due to the aging process. Multiple medication interactions may
contribute to sundowner like symptoms.
Question 3
An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the
left forearm for hemodialysis. After palpating the AV fistula, which finding is an indication
that the AV fistula is functioning properly?
a) Enlarged veins
b) Redness around the site
c) Decreased pulses below the fistula
d) Marked ecchymotic areas
CORRECT ANSWER
A) Enlarged Veins
Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to
enlarge, which facilitate cannulation for hemodialysis
Question 4
The home health registered nurse (RN) is changing an older client's wet to dry dressing.
Which observation should the RN evaluate as a therapeutic response with the removal of
the dry dressing?
2
,a) Debridement and removal of slough and eschar
b) Drainage of purulent exudate from the wound
c) Moist skin edges around the wound field
d) Presence of capillary growth in the wound
CORRECT ANSWER
A) Debridement and removal of slough and eschar
Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a
dry gauze is used to cover the wet packing to wick drainage and bacteria away from the
wound to promote healing. Removal of dried dressing provides debridement by
removing exudate, sloughing tissue, and eschar.
Question 5
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 ability
b) Client's declining strength
c) Fixed income
d) Longer life expectancy
e) Lack of exposure to technology and trends
CORRECT ANSWER
A, B
Rationale: When needs are not being met due to lack of ability of the caretaker, stress
and feelings of failure of the care provider may be expressed through neglect and abuse.
Decline in strength increases the older client's vulnerability to resist or respond to elder
abuse.
3
, Question 6
A 64-year-old client is admitted to the hospital with a fractured right hip. One of the
concerns following surgical repair is to promote dorsiflexion. Which intervention would a
nurse implement?
a) Begin early ambulation
b) Monitor pain level
c) Provide PCA instructions
d) Provide a foot board
CORRECT ANSWER
D) Provide a foot board
Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop
throughout the recovery.
Question 7
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.
Which 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 for caregiver
4
Question 1
The nursing assessment of an older female elicits information that the client is diagnosed
with Raynaud's phenomenon. Which exposure should the nurse instruct the client to
avoid?
a) Alcohol consumption
b) Warm climates
c) Cold climates
d) Active exercise
CORRECT ANSWER
C) Cold Climates
Rationale: Can cause prolonged painful vasoconstriction of the peripheral extremities
(especially hands) in client's with Raynaud's phenomenon.
Question 2
A family member brings their aging father to the clinic because he has been alert and
oriented during the day but agitated and disoriented in the evening. The registered nurse
(RN) reviews the client's list of current medications with the client and family. Which
action taken by the RN is most important?
a) Medication review with family caregivers is the PN's responsibility
b) Multiple medications can contribute to sundowner like symptoms
c) Medication recall is the best way to evaluate the client's memory
1
,d) Reviewing medication actions is a component of effective client care
CORRECT ANSWER
B) Multiple medications can contribute to sundowner like symptoms
Rationale: Older clients may see a variety of healthcare providers which can increase the
change of polypharmacy that compounds the workload of metabolic pathways that may
be less efficient due to the aging process. Multiple medication interactions may
contribute to sundowner like symptoms.
Question 3
An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the
left forearm for hemodialysis. After palpating the AV fistula, which finding is an indication
that the AV fistula is functioning properly?
a) Enlarged veins
b) Redness around the site
c) Decreased pulses below the fistula
d) Marked ecchymotic areas
CORRECT ANSWER
A) Enlarged Veins
Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to
enlarge, which facilitate cannulation for hemodialysis
Question 4
The home health registered nurse (RN) is changing an older client's wet to dry dressing.
Which observation should the RN evaluate as a therapeutic response with the removal of
the dry dressing?
2
,a) Debridement and removal of slough and eschar
b) Drainage of purulent exudate from the wound
c) Moist skin edges around the wound field
d) Presence of capillary growth in the wound
CORRECT ANSWER
A) Debridement and removal of slough and eschar
Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a
dry gauze is used to cover the wet packing to wick drainage and bacteria away from the
wound to promote healing. Removal of dried dressing provides debridement by
removing exudate, sloughing tissue, and eschar.
Question 5
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 ability
b) Client's declining strength
c) Fixed income
d) Longer life expectancy
e) Lack of exposure to technology and trends
CORRECT ANSWER
A, B
Rationale: When needs are not being met due to lack of ability of the caretaker, stress
and feelings of failure of the care provider may be expressed through neglect and abuse.
Decline in strength increases the older client's vulnerability to resist or respond to elder
abuse.
3
, Question 6
A 64-year-old client is admitted to the hospital with a fractured right hip. One of the
concerns following surgical repair is to promote dorsiflexion. Which intervention would a
nurse implement?
a) Begin early ambulation
b) Monitor pain level
c) Provide PCA instructions
d) Provide a foot board
CORRECT ANSWER
D) Provide a foot board
Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop
throughout the recovery.
Question 7
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.
Which 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 for caregiver
4
