QUESTIONS, CORRECT ANSWERS (VERIFIED ANSWERS) &
RATIONALES
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
C) Cold Climates
Rationale: Can cause prolonged painful vasoconstriction of the peripheral
extremities (especially hands) in clients with Raynaud's phenomenon.
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
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
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?
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
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.
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
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.
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
D) Provide a foot board
Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot
drop throughout the recovery.
,An older client is transferred to a telemetry unit after placement of a pacemaker.
What action should the registered nurse (RN) taken first?
a) View the incision site
b) Obtain a blood pressure
c) Establish telemetry monitoring
d) Evaluate client for pain
C) Establish telemetry monitoring
Rationale: The first action is to establish continuous telemetry monitoring to ensure
the pacemaker is functioning properly.
An older male client with Parkinson's disease (PD) is discharged home with
levodopa-carbidopa (Sinemet) and instructions to his wife for his care. Which
statement best indicates to the registered nurse (RN) that the wife understands her
husband's needs?
a) "It is important to keep my husband in a chair or in bed as much as possible and
prevent him from falling."
b) "I will notify the healthcare provider if my husband has increasing involuntary
movements of his extremities."
c) "Since it is difficult for my husband to eat, we should stay in the house instead
of going out to dine."
d) "I should expect that my husband will be incontinent of bowel and bladder as
his disease advances."
B) "I will notify the healthcare provider if my husband has increasing involuntary
movements of his extremities."
Rationale: Increasing involuntary movements should be reported during the use of
levodopa; it is an indicator that the body is failing to readjust to the changes in the
level of the intracerebral neurotransmitter dopamine.
The home health registered nurse (RN) visits an older woman with heart failure
(HF) who is on complete bed rest. Which intervention is most important for the RN
to suggest to the client to prevent complications related to immobility?
a) Get as much sleep as possible
b) Perform leg exercises while in bed
, c) Increase protein intake to combat fatigue
d) Invite friends to visit to decrease risk for depression
B) Perform leg exercises while in bed
Rationale: The client is at risk for complications related to immobility. Active leg
exercises should be performed frequently to decrease the risk for thrombophlebitis.
The home health registered nurse (RN) is reinforcing instructions to the family
about how to prevent pressure ulcers for their older family member who is
bedridden. Which measure should the RN discuss?
a) Lift the client when turning instead of sliding
b) Massage directly over reddened sites
c) Change client's position every 4 hours
d) Place pillows under both the knees
A) Lift the client when turning instead of sliding
Rationale: Lifting instead of sliding decreases chances of friction and shearing
while moving the client.
An older male client is seeking counseling about his recent sexual issues with his
partner. What issue should the registered nurse (RN) explore in this discussion?
a) Certain medications may impact sexual function
b) Normal aging affects sexual function in male clients
c) Safe sex is not necessary with older sexually active elders
d) Sexual interest usually declines with aging in male clients
A) Certain medications may impact sexual function
Rationale: Certain medications can have a direct influence on sexual function and
should be discussed with older clients.
An older male client returns to the hospital after discharge 4 days ago for a
transurethral resection of the prostate (TURP). The registered nurse (RN) evaluates
the function of the 3-way indwelling urinary catheter and the continuous bladder
irrigation system. Which finding should the RN report to the healthcare provider?