NUR 109 Exam 3 Questions With Correct
Answers
A nurse is assessing an older adult brought to the emergency department
| | | | | | | | | | | |
following a fall and wrist fracture. She notes that the patient is very thin and
| | | | | | | | | | | | | | |
unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the
| | | | | | | | | | | | | | | |
extremities in addition to her new bruises from the fall. She defers all of the
| | | | | | | | | | | | | | |
questions to her caregiver son who accompanied her to the hospital. The
| | | | | | | | | | | |
nurse’s next step is to:
| | | |
Ask the son to step out of the room so she can complete her assessment.
| | | | | | | | | | | | | |
The assessment leads you to suspect elder mistreatment, but the nurse needs
| | | | | | | | | | | |
more information directly from the patient before calling social services or the
| | | | | | | | | | | |
adult protective services. She will best get this information by asking the son to
| | | | | | | | | | | | | |
leave so she can ask the patient direct questions privately. If the son refuses to
| | | | | | | | | | | | | | |
leave, this will be another indication that elder mistreatment may be occurring.
| | | | | | | | | | | |
Cognitive testing will be important but is not the priority.
| | | | | | | | |
A patient’s family member is considering having her mother placed in a nursing
| | | | | | | | | | | | |
center. The nurse has talked with the family before and knows that this is a
| | | | | | | | | | | | | | |
difficult decision. Which of the following criteria does the nurse recommend in
| | | | | | | | | | | |
choosing a nursing center? | | |
*Adequate staffing is available on all shifts.
| | | | | |
*Social activities are available for all residents.
| | | | | |
*Staff encourage family involvement in care planning and assisting with physical
| | | | | | | | | | |
care.
Adequate staffing, provision of social activities, and active family involvement are
| | | | | | | | | | |
essential. Meals should be high quality with options for what to eat and when it
| | | | | | | | | | | | | | |
is served. A nursing center should be clean, but it should look like a person's
| | | | | | | | | | | | | | |
home rather than a hospital.
| | | |
,A nurse conducted an assessment of a new patient who came to the medical
| | | | | | | | | | | | | |
clinic. The patient is 82 years old and has had osteoarthritis for 10 years and
| | | | | | | | | | | | | | |
diabetes mellitus for 20 years. He is alert but becomes easily distracted during
| | | | | | | | | | | | |
the assessment. He recently moved to a new apartment, and his pet beagle
| | | | | | | | | | | | |
died just 2 months ago. He is most likely experiencing:
| | | | | | | | |
Depression.
Factors that often lead to depression include presence of a chronic disease or a
| | | | | | | | | | | | | |
recent change or life event (such as loss). Patients are alert but easily distracted
| | | | | | | | | | | | | |
in conversation.
|
The nurse is working with an older adult after an acute hospitalization. The goal
| | | | | | | | | | | | |
|is to help this person be more in touch with time, place, and person. Which
| | | | | | | | | | | | | | |
intervention will likely be most effective? | | | | |
Reality orientation |
Reality orientation is a communication technique that can help restore a sense of
| | | | | | | | | | | | |
reality, improve level of awareness, promote socialization, elevate independent
| | | | | | | | |
functioning, and minimize confusion. | | |
A 63-year-old patient is retiring from his job at an accounting firm where he
| | | | | | | | | | | | | |
was in a management role for the past 20 years. He has been with the same
| | | | | | | | | | | | | | | |
company for 42 years and was a dedicated employee. His wife is a homemaker.
| | | | | | | | | | | | | |
She raised their five children, babysits for her grandchildren as needed, and
| | | | | | | | | | | |
belongs to numerous church committees. What are the major concerns for this
| | | | | | | | | | | |
patient?
*The loss of his work role
| | | | |
*How the wife expects household tasks to be divided in the home in retirement
| | | | | | | | | | | | |
The psychosocial stresses of retirement are usually related to role changes with a
| | | | | | | | | | | | |
spouse or within the family and to loss of the work role. Often there are new
| | | | | | | | | | | | | | | |
expectations of the retired person. This patient is not likely to become socially
| | | | | | | | | | | | |
isolated because of the size of the family. Whether the wife will have to work is
| | | | | | | | | | | | | | | |
not a major concern at this time nor is the age of the patient.
| | | | | | | | | | | | |
,A 71-year-old patient enters the emergency department after falling down stairs
| | | | | | | | | |
in the home. The nurse is conducting a fall history with the patient and his
| | | | | | | | | | | | | | | |
wife. They live in a one-level ranch home. He has had diabetes for over 15 years
| | | | | | | | | | | | | | |
and experiences some numbness in his feet. He wears bifocal glasses. His blood
| | | | | | | | | | | | |
pressure is stable at 130/70. The patient does not exercise regularly and states
| | | | | | | | | | | | | |
that he experiences weakness in his legs when climbing stairs. He is alert,
| | | | | | | | | | | | |
oriented, and able to answer questions clearly. What are the fall risk factors for
| | | | | | | | | | | | | |
this patient?
|
*Impaired vision |
*Leg weakness |
*Exercise history |
Risk factors for falling include sensory changes such as visual loss, musculoskeletal
| | | | | | | | | | |
|conditions affecting mobility (in this case weakness), and deconditioning (from
| | | | | | | | | |
lack of exercise). The mere presence of a chronic disease is not a risk factor
| | | | | | | | | | | | | | |
unless it is a condition such as a neurological disorder that alters mobility or
| | | | | | | | | | | | | |
cognitive function. The patient's blood pressure is stable, and there is no report
| | | | | | | | | | | | |
of orthostatic hypotension. A one-floor residence should not pose risks.
| | | | | | | | |
The nurse is completing a health history with the daughter of a newly admitted
| | | | | | | | | | | | | |
patient who is confused and agitated. The daughter reports that her mother
| | | | | | | | | | | |
was diagnosed with Alzheimer’s disease 1 year ago but became extremely
| | | | | | | | | | |
confused last evening and was hallucinating. She was unable to calm her, and
| | | | | | | | | | | | |
her mother thought she was a stranger. On the basis of this history, the nurse
| | | | | | | | | | | | | | |
suspects that the patient is experiencing:
| | | | |
Delirium
Hallmark characteristics of delirium are acute confusion, hallucinations, and
| | | | | | | | |
agitation. It is not a new onset of dementia since she already has a diagnosis of
| | | | | | | | | | | | | | | |
Alzheimer's disease and, as dementia worsens, we see a gradual rather than
| | | | | | | | | | | |
sudden changes in memory usually not accompanied with hallucinations.
| | | | | | | | |
Depression does not present with acute confusion and agitation.
| | | | | | | |
, The nurse sees a 76-year-old woman in the outpatient clinic. She states that she
| | | | | | | | | | | | |
recently started noticing a glare in the lights at home. Her vision is blurred; and
| | | | | | | | | | | | | | |
she is unable to play cards with her friends, read, or do her needlework. The
| | | | | | | | | | | | | | | |
nurse suspects that the woman may have:
| | | | | |
Cataract(s).
Cataracts normally result in blurred vision, sensitivity to glare, and gradual loss of
| | | | | | | | | | | | |
vision. Presbyopia is a common eye condition resulting in a person having
| | | | | | | | | | | |
difficulty adjusting to near and far vision. The symptoms are not reflective of
| | | | | | | | | | | | |
depression since her vision affects her ability to interact. She has not chosen to
| | | | | | | | | | | | | |
avoid her friends.
| |
A nurse is caring for a patient preparing for discharge from the hospital the next
| | | | | | | | | | | | | |
day. The patient does not read. His family caregiver will be visiting before
| | | | | | | | | | | | | |
discharge. What can the nurse do to facilitate the patient’s understanding of his
| | | | | | | | | | | |
discharge instructions?
| |
*Sit facing the patient so he is able to watch your lip movements and facial
| | | | | | | | | | | | | | |
expressions.
*Present one idea or concept at a time.
| | | | | | |
*Include the family caregiver in the teaching session.
| | | | | | |
Teaching and communication are more effective with older adults when you sit
| | | | | | | | | | | |
and face the patient and present one idea or concept at a time. This requires
| | | | | | | | | | | | | | |
planning. Speaking loudly can distort sound. Speak in a normal tone. Sending
| | | | | | | | | | | |
instructions is helpful but will not directly facilitate the patient's own
| | | | | | | | | | |
understanding. Sharing information with a caregiver provides someone to clarify
| | | | | | | | | |
instructions.
A nurse is participating in a health and wellness event at the local community
| | | | | | | | | | | | | |
center. A woman approaches and relates that she is worried that her widowed
| | | | | | | | | | | | |
father is becoming more functionally impaired and may need to move in with
| | | | | | | | | | | | |
her. The nurse inquires about his ability to complete activities of daily living
| | | | | | | | | | | | |
(ADLs). ADLs include independence with:
| | | |
Answers
A nurse is assessing an older adult brought to the emergency department
| | | | | | | | | | | |
following a fall and wrist fracture. She notes that the patient is very thin and
| | | | | | | | | | | | | | |
unkempt, has a stage 3 pressure ulcer to her coccyx, and has old bruising to the
| | | | | | | | | | | | | | | |
extremities in addition to her new bruises from the fall. She defers all of the
| | | | | | | | | | | | | | |
questions to her caregiver son who accompanied her to the hospital. The
| | | | | | | | | | | |
nurse’s next step is to:
| | | |
Ask the son to step out of the room so she can complete her assessment.
| | | | | | | | | | | | | |
The assessment leads you to suspect elder mistreatment, but the nurse needs
| | | | | | | | | | | |
more information directly from the patient before calling social services or the
| | | | | | | | | | | |
adult protective services. She will best get this information by asking the son to
| | | | | | | | | | | | | |
leave so she can ask the patient direct questions privately. If the son refuses to
| | | | | | | | | | | | | | |
leave, this will be another indication that elder mistreatment may be occurring.
| | | | | | | | | | | |
Cognitive testing will be important but is not the priority.
| | | | | | | | |
A patient’s family member is considering having her mother placed in a nursing
| | | | | | | | | | | | |
center. The nurse has talked with the family before and knows that this is a
| | | | | | | | | | | | | | |
difficult decision. Which of the following criteria does the nurse recommend in
| | | | | | | | | | | |
choosing a nursing center? | | |
*Adequate staffing is available on all shifts.
| | | | | |
*Social activities are available for all residents.
| | | | | |
*Staff encourage family involvement in care planning and assisting with physical
| | | | | | | | | | |
care.
Adequate staffing, provision of social activities, and active family involvement are
| | | | | | | | | | |
essential. Meals should be high quality with options for what to eat and when it
| | | | | | | | | | | | | | |
is served. A nursing center should be clean, but it should look like a person's
| | | | | | | | | | | | | | |
home rather than a hospital.
| | | |
,A nurse conducted an assessment of a new patient who came to the medical
| | | | | | | | | | | | | |
clinic. The patient is 82 years old and has had osteoarthritis for 10 years and
| | | | | | | | | | | | | | |
diabetes mellitus for 20 years. He is alert but becomes easily distracted during
| | | | | | | | | | | | |
the assessment. He recently moved to a new apartment, and his pet beagle
| | | | | | | | | | | | |
died just 2 months ago. He is most likely experiencing:
| | | | | | | | |
Depression.
Factors that often lead to depression include presence of a chronic disease or a
| | | | | | | | | | | | | |
recent change or life event (such as loss). Patients are alert but easily distracted
| | | | | | | | | | | | | |
in conversation.
|
The nurse is working with an older adult after an acute hospitalization. The goal
| | | | | | | | | | | | |
|is to help this person be more in touch with time, place, and person. Which
| | | | | | | | | | | | | | |
intervention will likely be most effective? | | | | |
Reality orientation |
Reality orientation is a communication technique that can help restore a sense of
| | | | | | | | | | | | |
reality, improve level of awareness, promote socialization, elevate independent
| | | | | | | | |
functioning, and minimize confusion. | | |
A 63-year-old patient is retiring from his job at an accounting firm where he
| | | | | | | | | | | | | |
was in a management role for the past 20 years. He has been with the same
| | | | | | | | | | | | | | | |
company for 42 years and was a dedicated employee. His wife is a homemaker.
| | | | | | | | | | | | | |
She raised their five children, babysits for her grandchildren as needed, and
| | | | | | | | | | | |
belongs to numerous church committees. What are the major concerns for this
| | | | | | | | | | | |
patient?
*The loss of his work role
| | | | |
*How the wife expects household tasks to be divided in the home in retirement
| | | | | | | | | | | | |
The psychosocial stresses of retirement are usually related to role changes with a
| | | | | | | | | | | | |
spouse or within the family and to loss of the work role. Often there are new
| | | | | | | | | | | | | | | |
expectations of the retired person. This patient is not likely to become socially
| | | | | | | | | | | | |
isolated because of the size of the family. Whether the wife will have to work is
| | | | | | | | | | | | | | | |
not a major concern at this time nor is the age of the patient.
| | | | | | | | | | | | |
,A 71-year-old patient enters the emergency department after falling down stairs
| | | | | | | | | |
in the home. The nurse is conducting a fall history with the patient and his
| | | | | | | | | | | | | | | |
wife. They live in a one-level ranch home. He has had diabetes for over 15 years
| | | | | | | | | | | | | | |
and experiences some numbness in his feet. He wears bifocal glasses. His blood
| | | | | | | | | | | | |
pressure is stable at 130/70. The patient does not exercise regularly and states
| | | | | | | | | | | | | |
that he experiences weakness in his legs when climbing stairs. He is alert,
| | | | | | | | | | | | |
oriented, and able to answer questions clearly. What are the fall risk factors for
| | | | | | | | | | | | | |
this patient?
|
*Impaired vision |
*Leg weakness |
*Exercise history |
Risk factors for falling include sensory changes such as visual loss, musculoskeletal
| | | | | | | | | | |
|conditions affecting mobility (in this case weakness), and deconditioning (from
| | | | | | | | | |
lack of exercise). The mere presence of a chronic disease is not a risk factor
| | | | | | | | | | | | | | |
unless it is a condition such as a neurological disorder that alters mobility or
| | | | | | | | | | | | | |
cognitive function. The patient's blood pressure is stable, and there is no report
| | | | | | | | | | | | |
of orthostatic hypotension. A one-floor residence should not pose risks.
| | | | | | | | |
The nurse is completing a health history with the daughter of a newly admitted
| | | | | | | | | | | | | |
patient who is confused and agitated. The daughter reports that her mother
| | | | | | | | | | | |
was diagnosed with Alzheimer’s disease 1 year ago but became extremely
| | | | | | | | | | |
confused last evening and was hallucinating. She was unable to calm her, and
| | | | | | | | | | | | |
her mother thought she was a stranger. On the basis of this history, the nurse
| | | | | | | | | | | | | | |
suspects that the patient is experiencing:
| | | | |
Delirium
Hallmark characteristics of delirium are acute confusion, hallucinations, and
| | | | | | | | |
agitation. It is not a new onset of dementia since she already has a diagnosis of
| | | | | | | | | | | | | | | |
Alzheimer's disease and, as dementia worsens, we see a gradual rather than
| | | | | | | | | | | |
sudden changes in memory usually not accompanied with hallucinations.
| | | | | | | | |
Depression does not present with acute confusion and agitation.
| | | | | | | |
, The nurse sees a 76-year-old woman in the outpatient clinic. She states that she
| | | | | | | | | | | | |
recently started noticing a glare in the lights at home. Her vision is blurred; and
| | | | | | | | | | | | | | |
she is unable to play cards with her friends, read, or do her needlework. The
| | | | | | | | | | | | | | | |
nurse suspects that the woman may have:
| | | | | |
Cataract(s).
Cataracts normally result in blurred vision, sensitivity to glare, and gradual loss of
| | | | | | | | | | | | |
vision. Presbyopia is a common eye condition resulting in a person having
| | | | | | | | | | | |
difficulty adjusting to near and far vision. The symptoms are not reflective of
| | | | | | | | | | | | |
depression since her vision affects her ability to interact. She has not chosen to
| | | | | | | | | | | | | |
avoid her friends.
| |
A nurse is caring for a patient preparing for discharge from the hospital the next
| | | | | | | | | | | | | |
day. The patient does not read. His family caregiver will be visiting before
| | | | | | | | | | | | | |
discharge. What can the nurse do to facilitate the patient’s understanding of his
| | | | | | | | | | | |
discharge instructions?
| |
*Sit facing the patient so he is able to watch your lip movements and facial
| | | | | | | | | | | | | | |
expressions.
*Present one idea or concept at a time.
| | | | | | |
*Include the family caregiver in the teaching session.
| | | | | | |
Teaching and communication are more effective with older adults when you sit
| | | | | | | | | | | |
and face the patient and present one idea or concept at a time. This requires
| | | | | | | | | | | | | | |
planning. Speaking loudly can distort sound. Speak in a normal tone. Sending
| | | | | | | | | | | |
instructions is helpful but will not directly facilitate the patient's own
| | | | | | | | | | |
understanding. Sharing information with a caregiver provides someone to clarify
| | | | | | | | | |
instructions.
A nurse is participating in a health and wellness event at the local community
| | | | | | | | | | | | | |
center. A woman approaches and relates that she is worried that her widowed
| | | | | | | | | | | | |
father is becoming more functionally impaired and may need to move in with
| | | | | | | | | | | | |
her. The nurse inquires about his ability to complete activities of daily living
| | | | | | | | | | | | |
(ADLs). ADLs include independence with:
| | | |
