Adult 2 Exam 1 Evolve
The RN has delegated nursing actions to experienced unlicensed assistive personnel (UAP)
working in a long-term care facility. Which actions require direct supervision by the RN?
Select all that apply.
A) Assisting a 70-year-old client who has new-onset leg pain when ambulating
B) Feeding an 82-year-old client who has severe joint disease in both hands
C) Helping a 66-year-old client complete her personal hygiene
D) Repositioning a 69-year-old client who has recently become unconscious
E) Assisting a 72-year-old client who has chronic arthritis of the knee to the restroom - CORRECT
ANSWER-A) Assisting a 70-year-old client who has new-onset leg pain when ambulating
D) Repositioning a 69-year-old client who has recently become unconscious
The RN manager of a skilled nursing facility wants to assign a staff member to assess the
nutritional needs of an emaciated client with pressure ulcers. Which of these team members is
appropriate?
A) The LPN/LVN treatment nurse responsible for the client's wound care
B) The LPN/LVN medication nurse for this client
C) The nursing assistant caring for this client for the past 2 weeks
D) The RN team leader responsible for care planning - CORRECT ANSWER-D) The RN team
leader responsible for care planning
The nurse is conducting a medication assessment on an older adult client who is being admitted to
a long-term care facility for rehabilitation following a hip replacement. With Beers Criteria used as
a resource, which drug poses a potential risk for this client?
A) Acetaminophen (Tylenol)
B) Celecoxib (Celebrex)
C) Digoxin (Lanoxin)
D) Mesalamine (Asacol) - CORRECT ANSWER-C) Digoxin (Lanoxin)
The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants.
Which of these nursing actions does the RN delegate to a nursing assistant?
A) Admitting a new client with multiple bruises over the upper thighs
,B) Assisting a client with chronic joint stiffness to ambulate
C) Making hourly assessments on a client with delirium and dementia
D) Monitoring a confused client who has been placed in a jacket restraint - CORRECT
ANSWER-B) Assisting a client with chronic joint stiffness to ambulate
The nurse is assessing an older adult client's alcohol use. Which client statement warrants a
follow-up collection of more data?
A) "I am a 'teetotaler'; I never drink anything alcoholic."
B) "I had three glasses of champagne at my granddaughter's wedding last month."
C) "I like to have a glass of wine every once in a while."
D) "I usually drink two vodkas to help me get to sleep each night." - CORRECT ANSWER-D) "I
usually drink two vodkas to help me get to sleep each night."
What is the fastest-growing subgroup of older adults?
A) Young old
B) Middle old
C) Old old
D) Elite old - CORRECT ANSWER-C) Old old
A 70-year-old client whose spouse died the previous year says to the nurse, "Life is not fun
anymore." How does the nurse respond?
A) "Are you getting enough sleep? That makes me feel better!"
B) "Tell me about your support network, such as friends or family."
C) "How are you feeling about the death of your spouse after this length of time?"
D) "Why don't you go on a vacation? A change of scenery will do you good." - CORRECT
ANSWER-B) "Tell me about your support network, such as friends or family."
The nurse is assessing the nutritional status of an older adult client. Which statement made by the
client needs to be explored further?
,a) "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods."
b) "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at
least three times a week."
c) "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day."
d) "With less activity and exercise in my life these days, I should reduce my total calorie intake." -
CORRECT ANSWER-b) "For protein in my diet, I like to get the fish sandwich and fries at the
fast-food drive-through at least three times a week."
An older adult client who lives with her daughter is admitted to the hospital. During the admission
assessment, the nurse notes strong body odor, several large pressure ulcers, and limb
contractures. What does the nurse do first?
a) Asks the daughter about the ulcers and contractures
b) Contacts the hospital social worker
c) Gives the client a bath
d) Notifies the health care provider - CORRECT ANSWER-b) Contacts the hospital social worker
The nurse is teaching a class of older adults about ways to promote their cognitive health. Which
collaborative interventions will be most helpful for them?
Select all that apply.
a) Allowing for increased rest and relaxation time
b) Having solitary times to reminisce about life experiences
c) Joining a peer group with a common learning goal
d) Learning a new skill
e) Meditating for 30 minutes every day
f) Starting a new physical activity - CORRECT ANSWER-c) Joining a peer group with a common
learning goal
d) Learning a new skill
f) Starting a new physical activity
The nurse is talking to a group of active senior citizens about making healthy lifestyle choices.
Which suggestion is most important in promoting health and safety?
a) "Continue to eat healthy foods, especially protein."
b) "Seek counseling for depression, because it is not a normal part of aging."
, d) "Enroll in a safe driving refresher course and avoid risky driving situations."
e) "Walk 30 minutes three to five times a week." - CORRECT ANSWER-d) "Enroll in a safe driving
refresher course and avoid risky driving situations."
At a follow-up home-care visit after repair of a fractured radial bone, an older adult client states, "I
am not sleeping at all during the night." The client's partner reports that the client is sleeping all
day. Which intervention does the nurse suggest?
a) Increasing the client's daytime activities
b) Placing a "Do not disturb" sign on the door at night
c) Taking additional pain medication (analgesic) during the day
d) Taking herbal sleep remedies to enhance the effects of prescribed medications - CORRECT
ANSWER-a) Increasing the client's daytime activities
A client with end-stage lung cancer and metastasis to the brain has been admitted to the
medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is
required to apply restraints. Which nursing intervention is required for this client?
a) Checking the restraints every 1 to 2 hours
b) Releasing the restraints at least every 2 hours
c) Using chemical sedation instead of restraints
d) Using the most restrictive devices to prevent falls - CORRECT ANSWER-b) Releasing the
restraints at least every 2 hours
An 80-year-old client is being relocated from a home setting to a long-term care facility. Which
nursing intervention best minimizes the effects of relocation stress syndrome?
a) Explaining all procedures and routines to the client's family at the time of relocation
b) Keeping the room clear of personal belongings to reduce the risk of falling
c) Providing the client with limited decision making to avoid stressful situations
d) Reorienting the client frequently to his or her new location - CORRECT ANSWER-d)
Reorienting the client frequently to his or her new location
The RN has delegated nursing actions to experienced unlicensed assistive personnel (UAP)
working in a long-term care facility. Which actions require direct supervision by the RN?
Select all that apply.
A) Assisting a 70-year-old client who has new-onset leg pain when ambulating
B) Feeding an 82-year-old client who has severe joint disease in both hands
C) Helping a 66-year-old client complete her personal hygiene
D) Repositioning a 69-year-old client who has recently become unconscious
E) Assisting a 72-year-old client who has chronic arthritis of the knee to the restroom - CORRECT
ANSWER-A) Assisting a 70-year-old client who has new-onset leg pain when ambulating
D) Repositioning a 69-year-old client who has recently become unconscious
The RN manager of a skilled nursing facility wants to assign a staff member to assess the
nutritional needs of an emaciated client with pressure ulcers. Which of these team members is
appropriate?
A) The LPN/LVN treatment nurse responsible for the client's wound care
B) The LPN/LVN medication nurse for this client
C) The nursing assistant caring for this client for the past 2 weeks
D) The RN team leader responsible for care planning - CORRECT ANSWER-D) The RN team
leader responsible for care planning
The nurse is conducting a medication assessment on an older adult client who is being admitted to
a long-term care facility for rehabilitation following a hip replacement. With Beers Criteria used as
a resource, which drug poses a potential risk for this client?
A) Acetaminophen (Tylenol)
B) Celecoxib (Celebrex)
C) Digoxin (Lanoxin)
D) Mesalamine (Asacol) - CORRECT ANSWER-C) Digoxin (Lanoxin)
The RN at a skilled nursing facility is supervising a staff of LPN/LVNs and nursing assistants.
Which of these nursing actions does the RN delegate to a nursing assistant?
A) Admitting a new client with multiple bruises over the upper thighs
,B) Assisting a client with chronic joint stiffness to ambulate
C) Making hourly assessments on a client with delirium and dementia
D) Monitoring a confused client who has been placed in a jacket restraint - CORRECT
ANSWER-B) Assisting a client with chronic joint stiffness to ambulate
The nurse is assessing an older adult client's alcohol use. Which client statement warrants a
follow-up collection of more data?
A) "I am a 'teetotaler'; I never drink anything alcoholic."
B) "I had three glasses of champagne at my granddaughter's wedding last month."
C) "I like to have a glass of wine every once in a while."
D) "I usually drink two vodkas to help me get to sleep each night." - CORRECT ANSWER-D) "I
usually drink two vodkas to help me get to sleep each night."
What is the fastest-growing subgroup of older adults?
A) Young old
B) Middle old
C) Old old
D) Elite old - CORRECT ANSWER-C) Old old
A 70-year-old client whose spouse died the previous year says to the nurse, "Life is not fun
anymore." How does the nurse respond?
A) "Are you getting enough sleep? That makes me feel better!"
B) "Tell me about your support network, such as friends or family."
C) "How are you feeling about the death of your spouse after this length of time?"
D) "Why don't you go on a vacation? A change of scenery will do you good." - CORRECT
ANSWER-B) "Tell me about your support network, such as friends or family."
The nurse is assessing the nutritional status of an older adult client. Which statement made by the
client needs to be explored further?
,a) "Although I enjoy eating sweets and desserts, I need to balance them with healthier foods."
b) "For protein in my diet, I like to get the fish sandwich and fries at the fast-food drive-through at
least three times a week."
c) "To keep my bowel movements regular, I try to eat some fresh fruits or vegetables each day."
d) "With less activity and exercise in my life these days, I should reduce my total calorie intake." -
CORRECT ANSWER-b) "For protein in my diet, I like to get the fish sandwich and fries at the
fast-food drive-through at least three times a week."
An older adult client who lives with her daughter is admitted to the hospital. During the admission
assessment, the nurse notes strong body odor, several large pressure ulcers, and limb
contractures. What does the nurse do first?
a) Asks the daughter about the ulcers and contractures
b) Contacts the hospital social worker
c) Gives the client a bath
d) Notifies the health care provider - CORRECT ANSWER-b) Contacts the hospital social worker
The nurse is teaching a class of older adults about ways to promote their cognitive health. Which
collaborative interventions will be most helpful for them?
Select all that apply.
a) Allowing for increased rest and relaxation time
b) Having solitary times to reminisce about life experiences
c) Joining a peer group with a common learning goal
d) Learning a new skill
e) Meditating for 30 minutes every day
f) Starting a new physical activity - CORRECT ANSWER-c) Joining a peer group with a common
learning goal
d) Learning a new skill
f) Starting a new physical activity
The nurse is talking to a group of active senior citizens about making healthy lifestyle choices.
Which suggestion is most important in promoting health and safety?
a) "Continue to eat healthy foods, especially protein."
b) "Seek counseling for depression, because it is not a normal part of aging."
, d) "Enroll in a safe driving refresher course and avoid risky driving situations."
e) "Walk 30 minutes three to five times a week." - CORRECT ANSWER-d) "Enroll in a safe driving
refresher course and avoid risky driving situations."
At a follow-up home-care visit after repair of a fractured radial bone, an older adult client states, "I
am not sleeping at all during the night." The client's partner reports that the client is sleeping all
day. Which intervention does the nurse suggest?
a) Increasing the client's daytime activities
b) Placing a "Do not disturb" sign on the door at night
c) Taking additional pain medication (analgesic) during the day
d) Taking herbal sleep remedies to enhance the effects of prescribed medications - CORRECT
ANSWER-a) Increasing the client's daytime activities
A client with end-stage lung cancer and metastasis to the brain has been admitted to the
medical-surgical unit. After trying all options to provide a safe environment, the nursing staff is
required to apply restraints. Which nursing intervention is required for this client?
a) Checking the restraints every 1 to 2 hours
b) Releasing the restraints at least every 2 hours
c) Using chemical sedation instead of restraints
d) Using the most restrictive devices to prevent falls - CORRECT ANSWER-b) Releasing the
restraints at least every 2 hours
An 80-year-old client is being relocated from a home setting to a long-term care facility. Which
nursing intervention best minimizes the effects of relocation stress syndrome?
a) Explaining all procedures and routines to the client's family at the time of relocation
b) Keeping the room clear of personal belongings to reduce the risk of falling
c) Providing the client with limited decision making to avoid stressful situations
d) Reorienting the client frequently to his or her new location - CORRECT ANSWER-d)
Reorienting the client frequently to his or her new location
