N128 WEEK 1 - ADAPTIVE QUIZZING #1 UPDATED
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
Which finding in older adult clients is associated with aging?
Decrease in height Decreased neck rigidity Increased fine-motor dexterity
Increased range of motion (ROM)
Answer:
Decrease in height
Rationale: Loss of height and deformity and shortening of the trunk are
common in older adults because of vertebral compression and degeneration.
Rigidity in the neck, shoulders, back, hips, and knees increases with age
because of loss of elasticity in ligaments, tendons, and cartilage. A decline in
fine-motor dexterity occurs in the older adult because of slow impulse
conduction along motor units. Range of motion (ROM) is limited in the older
adult because of cartilage erosion, increased friction between the bones, and
overgrowth of bone around joint margins.
Question:
Which guideline would the nurse consider when planning care for a
hospitalized older client with Alzheimer disease?
Physical contact will increase dependency needs. Routines provide stability for
clients with neurocognitive disorders. Regressive behavior should be
inter-rupted immediately. Procedures do not have to be explained to clients
with neurocognitive disorders.
Answer:
Routines provide stability for clients with neurocognitive disorders.
Rationale: Routines provide stability for clients with neurocognitive disorders.
Rituals and routines in activities of daily living provide a framework and
structure for clients with Alzheimer disease, adding to their sense of safety
and security. Touch is a universal message that denotes caring; it can be
soothing and will not encourage dependency, and touch may have to be used
judiciously depending upon the stage of Alzheimer disease. Regressive
behavior under stress has a calming effect and should be allowed. Care should
be explained to all clients;
simple declarative statements are usually under-stood by clients with
Alzheimer disease.
Question:
An older client with Alzheimer type dementia, consistently sleeps in a
semi-Fowler position in bed. Which area of the client's body would the nurse
consider a high risk for developing a pressure injury?
Sacrum Scapulae Ischial spine Greater trochanter
Answer:
Sacrum
Rationale: The sacrum is the center of the greatest body mass; an elevated
torso exerts pressure toward this area. Although the scapulae are at risk, they
,do not bear the greatest body weight as when the client is in the semi-Fowler
position. The ischial spine bears the greatest pressure when the client is in an
upright sitting position. Greater trochanter is at risk when the client is in a
side-lying position.
Question:
Which age-related effects on the immune system occur in the older client?
Increased autoantibodies Increased expression of IL-2 receptors Increased
delayed hypersensitivity re-action Increased primary and secondary antibody
responses
Answer:
Increased autoantibodies
Rationale: The effects of aging on the immune system include increased
autoantibodies. Expression of IL-2 re-ceptors, delayed hypersensitivity
reaction, and primary and secondary antibody responses decrease in older
adults because of the effects of aging on the immune system.
Question:
Which type of bone tumor occurs most commonly in elderly clients?
Endochroma Osteosarcoma
Chondrosarcoma Osteochondroma
Answer:
Chondrosarcoma
Rationale: Chondrosarcoma occurs most commonly in cartilage in the arm, leg,
and pelvic bones of older adults in the age group of 50 to 70 years old. En-
dochroma occurs in clients in the age group of 10 to 20 years old.
Osteosarcoma and osteochondroma occur in the age group of 10 to 25 years
old.
Question:
Which action would the nurse take for an older client with Alzheimer disease
who has laid out several outfits on the bed to wear to a recreational session
but is still wearing nightclothes?
Assist the client to dress and explain when residents are expected at the
activity. Prompt the client to dress more quickly to avoid delaying the other
residents. Help the client select appropriate attire and offer to help the client
get dressed. Allow the client time to dress but explain that the client has
missed the opportunity to attend the activity.
Answer:
Help the client select appropriate attire and offer to help the client get dressed.
Rationale: Helping the client select appropriate attire and offering help in
getting dressed is the action the nurse would take. This aids the client in
decision-making; new situations may be stressful and may lead to ambivalent
feelings. Assisting the client to dress and explaining when residents are
expected at the activity is not sharing decision-making; the client may not
remember this explanation in the future. Reminding the client to dress more
quickly to avoid delaying the other residents may make the client more
anxious and frustrated. Because of Alzheimer disease, the client needs help,
not punishment, for getting dressed to attend an activity.
, Question:
Which action would the nurse take for an older client with Alzheimer disease
who sleeps very little and becomes more disoriented from sleep deprivation?
Shut the client's door during the night. Apply a vest restraint when the client
is in bed. Leave a dim light on in the client's room at night. Administer the
client's prescribed as-needed sedative medication.
Answer:
Leave a dim light on in the client's room at night.
Rationale: The nurse would leave a dim light on in the client's room at night. A
small light in the room may prevent misinterpretation of shadows, which can
heighten fear and alter the client's perception of the environment. A
disoriented and confused client should be closely observed, not isolated by
closing the door.
Restraints are a last resort; less restrictive inter-ventions should be used first.
Sedatives should be used sparingly in older adults, because they may cause
further confusion and agitation.
Question:
Which activity would the nurse ask the older adult client to do when testing
short-term memory?
Subtract serial sevens from 100. Copy one simple geometric figure. State three
random words mentioned earlier in the examination. Name two common
objects when the nurse points to them.
Answer:
State three random words mentioned earlier in the examination.
Rationale: Stating three random words mentioned earlier in the examination
is a test of the client's ability to recall from short-term memory. Subtracting
serial sevens from 100 is a test of the ability to calculate and pay attention.
Copying one simple geometric figure is a test of visual comprehension.
Naming two common objects when the nurse points to them is a test of verbal
skills, not short-term memory.
Question:
Which characteristic of a therapeutic milieu would the nurse consider
important for a confused older adult with socially aggressive behavior?
Sets limits Has variety Is group oriented Allows freedom of expression
Answer:
Sets limits
Rationale: The therapeutic milieu characteristic would be to set limits. Because
clients with socially aggressive behavior have poor control, these individuals
re-quire a therapeutic environment in which appropriate limits for behavior
are set for them. Variety will increase anxiety. The daily routine should be
structured and repetitive. A group-oriented environment is too stimulating for
a person with socially aggressive behavior. Freedom of expression may
result in injury to the client or others, because the client may be unable to
control impulses.
Question:
Which intervention would the nurse include when developing a plan of care
for an older client with dementia?
ACTUAL QUESTIONS AND CORRECT ANSWERS
Question:
Which finding in older adult clients is associated with aging?
Decrease in height Decreased neck rigidity Increased fine-motor dexterity
Increased range of motion (ROM)
Answer:
Decrease in height
Rationale: Loss of height and deformity and shortening of the trunk are
common in older adults because of vertebral compression and degeneration.
Rigidity in the neck, shoulders, back, hips, and knees increases with age
because of loss of elasticity in ligaments, tendons, and cartilage. A decline in
fine-motor dexterity occurs in the older adult because of slow impulse
conduction along motor units. Range of motion (ROM) is limited in the older
adult because of cartilage erosion, increased friction between the bones, and
overgrowth of bone around joint margins.
Question:
Which guideline would the nurse consider when planning care for a
hospitalized older client with Alzheimer disease?
Physical contact will increase dependency needs. Routines provide stability for
clients with neurocognitive disorders. Regressive behavior should be
inter-rupted immediately. Procedures do not have to be explained to clients
with neurocognitive disorders.
Answer:
Routines provide stability for clients with neurocognitive disorders.
Rationale: Routines provide stability for clients with neurocognitive disorders.
Rituals and routines in activities of daily living provide a framework and
structure for clients with Alzheimer disease, adding to their sense of safety
and security. Touch is a universal message that denotes caring; it can be
soothing and will not encourage dependency, and touch may have to be used
judiciously depending upon the stage of Alzheimer disease. Regressive
behavior under stress has a calming effect and should be allowed. Care should
be explained to all clients;
simple declarative statements are usually under-stood by clients with
Alzheimer disease.
Question:
An older client with Alzheimer type dementia, consistently sleeps in a
semi-Fowler position in bed. Which area of the client's body would the nurse
consider a high risk for developing a pressure injury?
Sacrum Scapulae Ischial spine Greater trochanter
Answer:
Sacrum
Rationale: The sacrum is the center of the greatest body mass; an elevated
torso exerts pressure toward this area. Although the scapulae are at risk, they
,do not bear the greatest body weight as when the client is in the semi-Fowler
position. The ischial spine bears the greatest pressure when the client is in an
upright sitting position. Greater trochanter is at risk when the client is in a
side-lying position.
Question:
Which age-related effects on the immune system occur in the older client?
Increased autoantibodies Increased expression of IL-2 receptors Increased
delayed hypersensitivity re-action Increased primary and secondary antibody
responses
Answer:
Increased autoantibodies
Rationale: The effects of aging on the immune system include increased
autoantibodies. Expression of IL-2 re-ceptors, delayed hypersensitivity
reaction, and primary and secondary antibody responses decrease in older
adults because of the effects of aging on the immune system.
Question:
Which type of bone tumor occurs most commonly in elderly clients?
Endochroma Osteosarcoma
Chondrosarcoma Osteochondroma
Answer:
Chondrosarcoma
Rationale: Chondrosarcoma occurs most commonly in cartilage in the arm, leg,
and pelvic bones of older adults in the age group of 50 to 70 years old. En-
dochroma occurs in clients in the age group of 10 to 20 years old.
Osteosarcoma and osteochondroma occur in the age group of 10 to 25 years
old.
Question:
Which action would the nurse take for an older client with Alzheimer disease
who has laid out several outfits on the bed to wear to a recreational session
but is still wearing nightclothes?
Assist the client to dress and explain when residents are expected at the
activity. Prompt the client to dress more quickly to avoid delaying the other
residents. Help the client select appropriate attire and offer to help the client
get dressed. Allow the client time to dress but explain that the client has
missed the opportunity to attend the activity.
Answer:
Help the client select appropriate attire and offer to help the client get dressed.
Rationale: Helping the client select appropriate attire and offering help in
getting dressed is the action the nurse would take. This aids the client in
decision-making; new situations may be stressful and may lead to ambivalent
feelings. Assisting the client to dress and explaining when residents are
expected at the activity is not sharing decision-making; the client may not
remember this explanation in the future. Reminding the client to dress more
quickly to avoid delaying the other residents may make the client more
anxious and frustrated. Because of Alzheimer disease, the client needs help,
not punishment, for getting dressed to attend an activity.
, Question:
Which action would the nurse take for an older client with Alzheimer disease
who sleeps very little and becomes more disoriented from sleep deprivation?
Shut the client's door during the night. Apply a vest restraint when the client
is in bed. Leave a dim light on in the client's room at night. Administer the
client's prescribed as-needed sedative medication.
Answer:
Leave a dim light on in the client's room at night.
Rationale: The nurse would leave a dim light on in the client's room at night. A
small light in the room may prevent misinterpretation of shadows, which can
heighten fear and alter the client's perception of the environment. A
disoriented and confused client should be closely observed, not isolated by
closing the door.
Restraints are a last resort; less restrictive inter-ventions should be used first.
Sedatives should be used sparingly in older adults, because they may cause
further confusion and agitation.
Question:
Which activity would the nurse ask the older adult client to do when testing
short-term memory?
Subtract serial sevens from 100. Copy one simple geometric figure. State three
random words mentioned earlier in the examination. Name two common
objects when the nurse points to them.
Answer:
State three random words mentioned earlier in the examination.
Rationale: Stating three random words mentioned earlier in the examination
is a test of the client's ability to recall from short-term memory. Subtracting
serial sevens from 100 is a test of the ability to calculate and pay attention.
Copying one simple geometric figure is a test of visual comprehension.
Naming two common objects when the nurse points to them is a test of verbal
skills, not short-term memory.
Question:
Which characteristic of a therapeutic milieu would the nurse consider
important for a confused older adult with socially aggressive behavior?
Sets limits Has variety Is group oriented Allows freedom of expression
Answer:
Sets limits
Rationale: The therapeutic milieu characteristic would be to set limits. Because
clients with socially aggressive behavior have poor control, these individuals
re-quire a therapeutic environment in which appropriate limits for behavior
are set for them. Variety will increase anxiety. The daily routine should be
structured and repetitive. A group-oriented environment is too stimulating for
a person with socially aggressive behavior. Freedom of expression may
result in injury to the client or others, because the client may be unable to
control impulses.
Question:
Which intervention would the nurse include when developing a plan of care
for an older client with dementia?
