Gerontology HESI Practice Exam with accurate ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
answers and rationales ||\\//|| ||\\//||
A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
is most important for the registered nurse (RN) to report to the healthcare provider?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Fever and chills
||\\//|| ||\\//|| ||\\//||
B. Confusion and dehydration
||\\//|| ||\\//|| ||\\//||
C. Crackles in the lung fields
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
D. Nausea and vomiting - correct answer✔✔B. Confusion and dehydration
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
perfusion in this frail elderly client. (A), (C) and (D) are all common with pneumonia, but
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the most important finding is confusion and evidence of dehydration, which require
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
treatment for this frail elderly client. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
because food does not taste as good as it used to so they have to season most foods. What
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
information should the RN offer the couple? ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Boredom may influence how the taste of food is perceived, and different seasonings can
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
stimulate taste. ||\\//||
B. With age, an increase in sodium intake is needed to compensate for a decrease in renal
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
function.
C. Short-term memory loss and confusion may be the reason they want to over-season their
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
food.
,D. Taste buds often are dull due to atrophy so older clients should use other seasonings
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
instead of salt. - correct answer✔✔D. Taste buds are often dull due to atrophy so older
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
clients should use other seasonings instead of salt. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: Taste buds atrophy with normal aging, which influences an older client's ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
sensitivity to taste and is often compensated for the use of stronger tasting seasonings. (A), ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
(B), and (C) are not normal aging processes related to taste.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
long history of smoking and still smokes a pack of cigarettes a day. Which finding should
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the registered nurse (RN) report to the healthcare provider?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Barrel chest with increased chest diameter
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
B. Crackles and pulse oximetry level of 88%
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
C. Low hemoglobin and hematocrit levels
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
D. Arterial blood gases indicating respiratory acidosis - correct answer✔✔B. Crackles and
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
pulse oximetry level of 88% ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
adequate oxygenation, which should be reported to the HCP. (A) occurs due to chronic ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
hyperinflation of the lungs and is common in clients with COPD. Anemia (C) is frequently ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
identified in clients with COPD, and respiratory acidosis (D) due to CO2 retention ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
contributes to a lower blood pH. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
An older female client recently moved to an assisted living facility. The family explains to
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the registered nurse (RN) that the client is unmanageable and always confused, disoriented
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
respond?
A. Explain that she is in a new home called an assisted living community
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
B. Question the client about her perception of where she might be now.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
, C. Distract the client with a scenario that she is on an outing with her family.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
D. Reassure the client not to worry because she will meet new friends. - correct
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
answer✔✔A. Explain that she is in a new home called an assisted living community. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: Reality re-orientation (A) is the best response for a client who is confused ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
because the response is consistent and true. (B, C, and D) do not provide the client with ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
feedback that is reality based. ||\\//|| ||\\//|| ||\\//|| ||\\//||
A new resident in an assisted living facility is an older client who is experiencing short-term
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
memory loss and confusion. Which activity should the registered nurse (RN) schedule the
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
client to do during the day? ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Arts and crafts ||\\//|| ||\\//|| ||\\//||
B. Current events discussion group
||\\//|| ||\\//|| ||\\//|| ||\\//||
C. Group sing-along
||\\//|| ||\\//||
D. Daily exercise group - correct answer✔✔D. Daily exercise group
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the client's stress to remember. (A), (C), and a current events discussion group (B) are
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
thought-provoking activities that require attention to detail and short-term memory to ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
participate in the group activity which may be stressful and frustrating to the resident who ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
has difficulty remembering sequence of the details.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
The hospice nurse is completing a focused assessment of an older female client with end
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
stage Alzheimer's disease, who recently fractured her hip. What technique should the
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
registered nurse (RN) use to determine the client's pain? ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Use the FACE pain scale
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
B. Ask the client to rate pain on a scale of 1 to 10
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
C. Observe for facial grimacing
||\\//|| ||\\//|| ||\\//|| ||\\//||
answers and rationales ||\\//|| ||\\//||
A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
is most important for the registered nurse (RN) to report to the healthcare provider?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Fever and chills
||\\//|| ||\\//|| ||\\//||
B. Confusion and dehydration
||\\//|| ||\\//|| ||\\//||
C. Crackles in the lung fields
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
D. Nausea and vomiting - correct answer✔✔B. Confusion and dehydration
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
perfusion in this frail elderly client. (A), (C) and (D) are all common with pneumonia, but
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the most important finding is confusion and evidence of dehydration, which require
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
treatment for this frail elderly client. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
because food does not taste as good as it used to so they have to season most foods. What
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
information should the RN offer the couple? ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Boredom may influence how the taste of food is perceived, and different seasonings can
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
stimulate taste. ||\\//||
B. With age, an increase in sodium intake is needed to compensate for a decrease in renal
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
function.
C. Short-term memory loss and confusion may be the reason they want to over-season their
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
food.
,D. Taste buds often are dull due to atrophy so older clients should use other seasonings
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
instead of salt. - correct answer✔✔D. Taste buds are often dull due to atrophy so older
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
clients should use other seasonings instead of salt. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: Taste buds atrophy with normal aging, which influences an older client's ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
sensitivity to taste and is often compensated for the use of stronger tasting seasonings. (A), ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
(B), and (C) are not normal aging processes related to taste.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
long history of smoking and still smokes a pack of cigarettes a day. Which finding should
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the registered nurse (RN) report to the healthcare provider?
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Barrel chest with increased chest diameter
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
B. Crackles and pulse oximetry level of 88%
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
C. Low hemoglobin and hematocrit levels
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
D. Arterial blood gases indicating respiratory acidosis - correct answer✔✔B. Crackles and
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
pulse oximetry level of 88% ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
adequate oxygenation, which should be reported to the HCP. (A) occurs due to chronic ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
hyperinflation of the lungs and is common in clients with COPD. Anemia (C) is frequently ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
identified in clients with COPD, and respiratory acidosis (D) due to CO2 retention ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
contributes to a lower blood pH. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
An older female client recently moved to an assisted living facility. The family explains to
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the registered nurse (RN) that the client is unmanageable and always confused, disoriented
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
respond?
A. Explain that she is in a new home called an assisted living community
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
B. Question the client about her perception of where she might be now.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
, C. Distract the client with a scenario that she is on an outing with her family.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
D. Reassure the client not to worry because she will meet new friends. - correct
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
answer✔✔A. Explain that she is in a new home called an assisted living community. ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: Reality re-orientation (A) is the best response for a client who is confused ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
because the response is consistent and true. (B, C, and D) do not provide the client with ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
feedback that is reality based. ||\\//|| ||\\//|| ||\\//|| ||\\//||
A new resident in an assisted living facility is an older client who is experiencing short-term
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
memory loss and confusion. Which activity should the registered nurse (RN) schedule the
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
client to do during the day? ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Arts and crafts ||\\//|| ||\\//|| ||\\//||
B. Current events discussion group
||\\//|| ||\\//|| ||\\//|| ||\\//||
C. Group sing-along
||\\//|| ||\\//||
D. Daily exercise group - correct answer✔✔D. Daily exercise group
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
the client's stress to remember. (A), (C), and a current events discussion group (B) are
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
thought-provoking activities that require attention to detail and short-term memory to ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
participate in the group activity which may be stressful and frustrating to the resident who ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
has difficulty remembering sequence of the details.
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
The hospice nurse is completing a focused assessment of an older female client with end
||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
stage Alzheimer's disease, who recently fractured her hip. What technique should the
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registered nurse (RN) use to determine the client's pain? ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//|| ||\\//||
A. Use the FACE pain scale
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B. Ask the client to rate pain on a scale of 1 to 10
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C. Observe for facial grimacing
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