Test Bank For Ebersole and Hess' Gerontological Nursing
& Healthy Aging, Canadian Edition, 3rd - 2024 All
Chapters
A nurse is assessing an older client. The nurse understands that in addition to the
collection of physical data and the integration of spiritual and psychosocial issues,
additional assessments commonly utilized for older adults include which of the
following? (Select all that apply.)
a. Functional status assessment
b. Cognitive assessment
c. Caregiver burden assessment
d. Geriatric syndrome assessment
e. Employment assessment - ANS: A, B, C, D
At a minimum, health assessment includes the collection of physical data and the
integration of spiritual and psychosocial, within an individual's cultural context. When
working with older adults, additional assessment areas further include functional and
cognitive status, caregiver stress or burden, patterns of health and health care,
advanced care planning, and the presence or absence of any of the geriatric syndromes
(delirium, falls, dizziness, syncope, and urinary incontinence.
A nurse utilizes the FANCAPES to assess an older adult. Which of the following are
accurate statements about this assessment? (Select all that apply.)
a. The FANCAPES is utilized as guide for the comprehensive assessment of
medically complex older adults.
b. The FANCAPES includes a fall risk assessment of the older adult.
c. The FANCAPES assesses an older adult's activity abilities.
d. The FANCAPES includes the Mini-Cog assessment to assess cognitive abilities.
e. The FANCAPES assesses the older person's current state of hydration. - ANS: A, C,
E
The FANCAPES is a comprehensive physical assessment for the frail and medically
complex older adult. FANCAPES is a mnemonic for Fluids, Aeration, Nutrition,
Communication, Activity, Pain, Elimination, and Socialization. There is no fall risk
assessment and the Mini-Cog is not a part of this assessment.
Which of the following is a true statement about documentation?
,a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete record of the
health status of a client.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS). - ANS: A
Entering clients' expressed wishes in the medical or clinical record helps ensure that the
interdisciplinary team respects these wishes. According to regulations after the
enactment of the Health Insurance Portability and Accountability Act (HIPAA), the client
has access to his or her own medical records and may designate others to have
access. The OASIS is used to measure outcomes for quality improvement purposes; it
does not contain all of the necessary information for care, such as vital signs. The MDS
should be completed jointly by all members of the interdisciplinary team.
Which one of the following is connected with the nursing home reform mandated by a
1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES - ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The
HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an
assessment designed for use in the home health care setting. Fulmer SPICES is an
overall assessment tool developed in 2007.
An older adult client has diabetes mellitus and requires hemodialysis for renal failure.
The client is discharged to home to recover from a sternal wound infection and coronary
artery bypass graft surgery (CABG). A home care nurse will provide wound care. Which
of the following is the major justification for the complete and accurate documentation of
this client's care?
a. Requires complex health care
b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses - ANS: A
The major reason that documentation of this client's health care must be accurate and
complete is that she has complex health care needs in multiple settings and
experiences a high risk for iatrogenic problems and high reimbursement expenses. The
duration of her care is likely to be lengthy; the sternal wound infection after CABG is
serious because of the potential for sternal osteomyelitis. In addition, individuals with
diabetes are at high risk for infection and are slow to heal. The complexity of the care
includes receiving care in multiple settings—at home, at dialysis, and in primary care for
post discharge follow-up care. For an older adult with diabetes, coronary artery disease,
renal failure, and a serious infection, each facet of health care depends on complete
and accurate data on the other aspects of her care to help her achieve optimal health
and wellness. This older adult is at risk for iatrogenic problems because of the
,complexity of care. Each type of care, each illness or condition, and each setting
exposes this older adult to a separate set of risks. In addition, individuals with diabetes
can have peripheral neuropathies that increase the risk for falls and injuries. This older
adult incurs health care expenses dealing with complex health care requirements
including a recent hospital stay for surgery and complicated by an infection, ongoing
needs for hemodialysis, and home care. Because much of the care is nurse driven,
documentation is the basis for which reimbursement is provided.
Which documentation tool does the nurse use to achieve optimal functional status for a
nursing home resident?
a. Narrative client progress notes
b. Problem-oriented documentation
c. Resource Utilization Group (RUG)
d. Resident Assessment Instrument (RAI) - ANS: D
Mandated by the federal government to improve the quality of care for nursing home
residents, the nurse uses the RAI to help residents in nursing homes achieve optimal
functional status. The RAI includes identification of issues with the MDS, a
comprehensive assessment from Resident Assessment Protocols (RAPs), and the
foundation for reimbursement using the RUG. Narrative progress notes are used in
nursing homes to describe events that are unsuitable for other forms of documentation
in the medical record. Problem-oriented documentation identifies resident problems, the
plan of care to resolve the problem, and the outcome of the problem or response to
treatment. The RUG is the reimbursement tool in the RAI.
Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger for a
male nursing home resident who requires an indwelling urinary catheter from the
Minimum Data Set (MDS). Which should the nurse do next?
a. Develop an individualized care plan.
b. Assign suitable nursing interventions.
c. Refer to the appropriate quality measures.
d. Institute agency-approved catheter care. - ANS: C
The nurse uses the RAPs to assess triggers identified from the MDS. To help the
resident achieve optimal functional status by determining his strengths, needs, and
preferences, quality measures provide an organized framework used by the health care
team for additional assessment of the trigger. The nurse develops the care plan after
completing the RAPs. The nurse assigns suitable nursing interventions to the plan of
care. The nurse uses agency-approved policies to provide care as assigned in the plan
of care.
The federal government requires the use of a specific standardized documentation tool
for home nursing care. Which information must a home nurse add to the approved
documentation tool?
a. Activity
, b. Vital signs
c. Functional
d. Demographic - ANS: B
The nurse must add the vital signs and information about the older adult's health care
beliefs to the OASIS. The nurse does not need to add information about the older
adult's activity level. The nurse does not need to add information about the older adult's
functional status. The nurse does not need to add demographic information about the
older adult to the documentation tool.
The nurse must inform an older adult client who does not speak English about client
rights. In addition, the nurse must have the adult sign the document about information
access. Which intervention should the nurse use to maintain the confidentiality of this
older adult?
a. Present the client with a Spanish version of the information access document.
b. Have an English-speaking family member explain the document to the client.
c. Explain the document to the client using an interpreter to ensure understanding.
d. Instruct an interpreter to read the information access document to the resident
privately - ANS: C
To ensure client understanding, the nurse explains a client's rights about information
access to the client with the assistance of an interpreter. The nurse is responsible for
client understanding and thus cannot relinquish this task to another person. When
understanding is reached concerning the rights associated with access to information,
the client can then make an informed decision about releasing health care information
and thus maintain privacy. The nurse cannot ensure client understanding without
discussing the document with the client using an interpreter. The nurse cannot delegate
a nursing responsibility to a family member; the nurse does not have the right to release
the health information to anyone. In private or public, the nurse cannot delegate this
task to another person.
A nurse conducts a comprehensive assessment of an older adult client. The nurse
utilizes the Mini-Cog, a valid and reliable assessment tool to assess the individual's
mental status. The nurse understands that the benefit of utilizing a standard
assessment tool is what?
a. A standard assessment tool is required by Medicare and Medicaid.
b. A standard assessment tool will increase likelihood of obtaining accurate data.
c. A standard assessment tool will increase reimbursement by Medicare and
Medicaid.
d. A standard assessment tool will increase the client's confidence in the nurse. - ANS:
B
The appropriate and accurate use of assessment and documentation instruments will
increase the likelihood of obtaining reliable, useful data; especially that which can be
used to monitor changes over time. Medicare and Medicaid do not mandate the use of
standardized tools, and reimbursement rates are not linked to specific assessment
tools. Assessment tools are not likely to impact the nurse-client relationship.
& Healthy Aging, Canadian Edition, 3rd - 2024 All
Chapters
A nurse is assessing an older client. The nurse understands that in addition to the
collection of physical data and the integration of spiritual and psychosocial issues,
additional assessments commonly utilized for older adults include which of the
following? (Select all that apply.)
a. Functional status assessment
b. Cognitive assessment
c. Caregiver burden assessment
d. Geriatric syndrome assessment
e. Employment assessment - ANS: A, B, C, D
At a minimum, health assessment includes the collection of physical data and the
integration of spiritual and psychosocial, within an individual's cultural context. When
working with older adults, additional assessment areas further include functional and
cognitive status, caregiver stress or burden, patterns of health and health care,
advanced care planning, and the presence or absence of any of the geriatric syndromes
(delirium, falls, dizziness, syncope, and urinary incontinence.
A nurse utilizes the FANCAPES to assess an older adult. Which of the following are
accurate statements about this assessment? (Select all that apply.)
a. The FANCAPES is utilized as guide for the comprehensive assessment of
medically complex older adults.
b. The FANCAPES includes a fall risk assessment of the older adult.
c. The FANCAPES assesses an older adult's activity abilities.
d. The FANCAPES includes the Mini-Cog assessment to assess cognitive abilities.
e. The FANCAPES assesses the older person's current state of hydration. - ANS: A, C,
E
The FANCAPES is a comprehensive physical assessment for the frail and medically
complex older adult. FANCAPES is a mnemonic for Fluids, Aeration, Nutrition,
Communication, Activity, Pain, Elimination, and Socialization. There is no fall risk
assessment and the Mini-Cog is not a part of this assessment.
Which of the following is a true statement about documentation?
,a. Nurses should keep records of clients' wishes.
b. Clients do not have access to their own medical records.
c. The Outcomes and Assessment Information Set (OASIS) is a complete record of the
health status of a client.
d. The nurse is responsible for completing all of the Minimum Data Set (MDS). - ANS: A
Entering clients' expressed wishes in the medical or clinical record helps ensure that the
interdisciplinary team respects these wishes. According to regulations after the
enactment of the Health Insurance Portability and Accountability Act (HIPAA), the client
has access to his or her own medical records and may designate others to have
access. The OASIS is used to measure outcomes for quality improvement purposes; it
does not contain all of the necessary information for care, such as vital signs. The MDS
should be completed jointly by all members of the interdisciplinary team.
Which one of the following is connected with the nursing home reform mandated by a
1987 law?
a. Resident Assessment Instrument (RAI)
b. HIPAA
c. OASIS
d. Fulmer SPICES - ANS: A
The RAI must be completed for all residents receiving Medicare or Medicaid. The
HIPAA was passed in 1996 and mandates privacy practices. The OASIS is an
assessment designed for use in the home health care setting. Fulmer SPICES is an
overall assessment tool developed in 2007.
An older adult client has diabetes mellitus and requires hemodialysis for renal failure.
The client is discharged to home to recover from a sternal wound infection and coronary
artery bypass graft surgery (CABG). A home care nurse will provide wound care. Which
of the following is the major justification for the complete and accurate documentation of
this client's care?
a. Requires complex health care
b. Has needs in multiple settings
c. Is at risk for iatrogenic problems
d. Has significant health care expenses - ANS: A
The major reason that documentation of this client's health care must be accurate and
complete is that she has complex health care needs in multiple settings and
experiences a high risk for iatrogenic problems and high reimbursement expenses. The
duration of her care is likely to be lengthy; the sternal wound infection after CABG is
serious because of the potential for sternal osteomyelitis. In addition, individuals with
diabetes are at high risk for infection and are slow to heal. The complexity of the care
includes receiving care in multiple settings—at home, at dialysis, and in primary care for
post discharge follow-up care. For an older adult with diabetes, coronary artery disease,
renal failure, and a serious infection, each facet of health care depends on complete
and accurate data on the other aspects of her care to help her achieve optimal health
and wellness. This older adult is at risk for iatrogenic problems because of the
,complexity of care. Each type of care, each illness or condition, and each setting
exposes this older adult to a separate set of risks. In addition, individuals with diabetes
can have peripheral neuropathies that increase the risk for falls and injuries. This older
adult incurs health care expenses dealing with complex health care requirements
including a recent hospital stay for surgery and complicated by an infection, ongoing
needs for hemodialysis, and home care. Because much of the care is nurse driven,
documentation is the basis for which reimbursement is provided.
Which documentation tool does the nurse use to achieve optimal functional status for a
nursing home resident?
a. Narrative client progress notes
b. Problem-oriented documentation
c. Resource Utilization Group (RUG)
d. Resident Assessment Instrument (RAI) - ANS: D
Mandated by the federal government to improve the quality of care for nursing home
residents, the nurse uses the RAI to help residents in nursing homes achieve optimal
functional status. The RAI includes identification of issues with the MDS, a
comprehensive assessment from Resident Assessment Protocols (RAPs), and the
foundation for reimbursement using the RUG. Narrative progress notes are used in
nursing homes to describe events that are unsuitable for other forms of documentation
in the medical record. Problem-oriented documentation identifies resident problems, the
plan of care to resolve the problem, and the outcome of the problem or response to
treatment. The RUG is the reimbursement tool in the RAI.
Using the Resident Assessment Instrument (RAI), the nurse identifies a trigger for a
male nursing home resident who requires an indwelling urinary catheter from the
Minimum Data Set (MDS). Which should the nurse do next?
a. Develop an individualized care plan.
b. Assign suitable nursing interventions.
c. Refer to the appropriate quality measures.
d. Institute agency-approved catheter care. - ANS: C
The nurse uses the RAPs to assess triggers identified from the MDS. To help the
resident achieve optimal functional status by determining his strengths, needs, and
preferences, quality measures provide an organized framework used by the health care
team for additional assessment of the trigger. The nurse develops the care plan after
completing the RAPs. The nurse assigns suitable nursing interventions to the plan of
care. The nurse uses agency-approved policies to provide care as assigned in the plan
of care.
The federal government requires the use of a specific standardized documentation tool
for home nursing care. Which information must a home nurse add to the approved
documentation tool?
a. Activity
, b. Vital signs
c. Functional
d. Demographic - ANS: B
The nurse must add the vital signs and information about the older adult's health care
beliefs to the OASIS. The nurse does not need to add information about the older
adult's activity level. The nurse does not need to add information about the older adult's
functional status. The nurse does not need to add demographic information about the
older adult to the documentation tool.
The nurse must inform an older adult client who does not speak English about client
rights. In addition, the nurse must have the adult sign the document about information
access. Which intervention should the nurse use to maintain the confidentiality of this
older adult?
a. Present the client with a Spanish version of the information access document.
b. Have an English-speaking family member explain the document to the client.
c. Explain the document to the client using an interpreter to ensure understanding.
d. Instruct an interpreter to read the information access document to the resident
privately - ANS: C
To ensure client understanding, the nurse explains a client's rights about information
access to the client with the assistance of an interpreter. The nurse is responsible for
client understanding and thus cannot relinquish this task to another person. When
understanding is reached concerning the rights associated with access to information,
the client can then make an informed decision about releasing health care information
and thus maintain privacy. The nurse cannot ensure client understanding without
discussing the document with the client using an interpreter. The nurse cannot delegate
a nursing responsibility to a family member; the nurse does not have the right to release
the health information to anyone. In private or public, the nurse cannot delegate this
task to another person.
A nurse conducts a comprehensive assessment of an older adult client. The nurse
utilizes the Mini-Cog, a valid and reliable assessment tool to assess the individual's
mental status. The nurse understands that the benefit of utilizing a standard
assessment tool is what?
a. A standard assessment tool is required by Medicare and Medicaid.
b. A standard assessment tool will increase likelihood of obtaining accurate data.
c. A standard assessment tool will increase reimbursement by Medicare and
Medicaid.
d. A standard assessment tool will increase the client's confidence in the nurse. - ANS:
B
The appropriate and accurate use of assessment and documentation instruments will
increase the likelihood of obtaining reliable, useful data; especially that which can be
used to monitor changes over time. Medicare and Medicaid do not mandate the use of
standardized tools, and reimbursement rates are not linked to specific assessment
tools. Assessment tools are not likely to impact the nurse-client relationship.
