with Correct Answers
The nursing assessmentof an olderfemaleelicitsinformationthattheclientis diagnosedwith R aynaud'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 -Cold Climates
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Can causeprolongedpainfulvasoconstrictionof theperipheralextremities(especiallyhands)in client's with
Raynaud's phenomenon.
A family memberbrings their aging fatherto theclinic becausehe has beenalertand orientedd uring the
day but agitatedand disorientedin the evening.The registerednurse (RN) reviewsthe client's list of
current medicationswith the clientand family. Which actiontaken by theRN is m ost important?
a) Medicationreviewwith family caregiversis thePN's responsibility
b) Multiplemedicationscan contributeto sundownerlike symptoms
c) Medicationrecallis thebestwayto evaluatetheclient'smemory
d) Reviewingmedicationactionsis a componentof effectiveclientcare- CORRECT ANSWER -
Multiple medications can contribute to sundowner like symptoms
-
Older clients maysee avarietyof healthcareproviders which canincrease the change of
polyph armacy
that compounds the workload of metabolic
Rpathways that may be
less efficientdue to t heaging process.
Multiplemedicationinteractionsmay contributeto sundownerlike symptoms.
An older client with chronickidney disease(CKD) has an arteriovenousfistula (AV) in the left for earm
for hemodialysis.After palpating the AV fistula, which finding is an indication that the AV fi stula is
functioning properly?
,a) Enlargedveins
b) Rednessaroundthesite
c) Decreasedpulsesbelowthefistula
d) Markedecchymoticareas- CORRECT ANSWER -EnlargedVeins
-
The mixing of arterialand venousbloodin an AV fistulacausestheveinsto enlarge,which facilit ate
cannulation for hemodialysis
When assessingan olderclient,which age-
relatedchangesin thecardiovascularsystemshouldtheregisterednurse(RN) document?(Selec t all that
apply).
a) Dyspnea
b) Chestpain
c) Cardiac murmurs
d) WideningRpulsepressure
e) Irregularheartrate- CORRECT ANSWER --Cardiac murmurs
-Wideningpulsepressure
The homehealthregisterednurse(RN) is changingan olderclient'swetto dry dressing.Which o
bservation should the RN evaluateaastherapeutic response with the removal of the dry dressi
ng?
a) Debridementand removalof sloughand eschar
b) Drainageof purulentexudatefrom thewound
c) Moistskin edgesaroundthewoundfield
d) Presenceof capillarygrowthin thewound- CORRECT ANSWER -
Debridement and removal of slough and eschar
-
Wet to dry dressingsbeginwith a wetpacking inside of thewound,and thena dry gauzeis used to cover
thewetpacking to wickdrainage andbacteria awayfrom thewoundto promote heali
, ng. Removalof drieddressingprovidesdebridementby removingexudate,sloughingtissue,and eschar.
Older clientsareat highestriskRfor abuseand neglectdueto which factors?(Selectall thatapply
)
a) Needsaregreaterthanthecaretaker'sability
b) Client'sdecliningstrength
c) Fixed income
d) Longer life expectancy
e) Lack of exposureto technologyand trends- CORRECT ANSWER --
Needsaregreaterthanthecaretaker'sabilities(whenneedsarenot beingmetdueto lack of ab ilityof the
caretaker,stressand feelingsof failureof thecareprovidermay be expressedthroug h neglect and abuse).
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Client'sdecliningstrength(declinein strengthincreasestheolderclient'svulnerabilityto resisto r
respond to elder abuse).
A 64-year-
old clientis admittedto thehospitalwith a fracturedright hip. One of theconcernsfollowingsu rgical repair
is to promote dorsiflexion. Which intervention would a nurse implement?
a) Begin earlyambulation
b) Monitorpain level
c) ProvidePCA instructions
d) Providea footboard- CORRECT ANSWER -Providea footboard
-
A footboardsupportsthefeetin dorsiflexionand helpspreventfootdrop throughouttherecovery.
During thequarterlyevaluationsof theclientsin theassistedliving community,theregisteredn urse
(RN) assessesfor findings of failureto thrivein theolderpopulation.Which findings should