GERI FINAL EXAM WITH PRECISE |! |! |! |! |!
ANSWERS & RATIONALES |! |!
The nurse is performing an assessment on an older adult client. Which
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assessment data would indicate a potential complication associated with the
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skin?
A. Crusting
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B. Wrinkling
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C. Deepening of expression lines
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D. Thinning and loss of elasticity in the skin - Correct answer ✔A. Crusting
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Wrinkling, deepening of expression lines, and thinning and loss of elasticity
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in the skin are are considered normal changes of aging. Crusting is
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concerning for a pathological condition. |! |! |! |!
A patient's documentation indicates he has a stage III pressure ulcer on his
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right hip. What should the nurse expect to find on assessment of the patient's
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right hip? |!
A. Exposed bone, tendon, or muscle
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B. An abrasion, blister, or shallow crater
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C. Deep crater through subcutaneous tissue to fascia
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D. Persistent redness (or bluish color in darker skin tones) - Correct answer
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✔C. Deep crater through subcutaneous tissue to fascia
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,A stage III pressure injury involves full thickness skin loss or necrosis of the
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subcutaneous tissue that may extend down to but not through the underlying |! |! |! |! |! |! |! |! |! |! |! |!
fascia
A. Stage IV
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B. Stage II
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C. Stage III
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D. Stage I
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Which patient is at the greatest risk for developing pressure ulcers?
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A. A 42-year old obese woman with type 2 diabetes
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B. A 78-year old man who is confused and malnourished
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C. An 80-year old man who is comatose following a head injury
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D. A 65-year old woman who has urge and stress incontinence - Correct
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answer ✔C. An 80-year old man who is comatose following a head injury
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Although diabetes, malnutrition, and incontinence can increase risk of
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pressure injuries, an elderly patient, immobilized in an intensive care unit is
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at the highest risk.
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The patient is transferring from another facility with the description of a sore
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on her sacrum that is deep enough to see the muscle. What stage of pressure
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ulcers does the nurse expect to see on admission?
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A. Stage I
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B. Stage II
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, C. Stage III
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D. Stage IV - Correct answer ✔D. Stage IV
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A stage IV pressure injury involves full-tissue skin loss with destruction
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extending to muscle, bone, or supporting structures
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The nurse reviews information collected after completing a comprehensive
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assessment with an older person. For which reason should the nurse
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recommend lipid-disorder screening for this patient? |! |! |! |! |!
A. Over the age of 65
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B. Body mass index 28.5
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C. Blood pressure 140/90 mm Hg
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D. Diagnosed with peripheral-artery disease - Correct answer ✔D. Diagnosed
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with peripheral-artery disease
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The nurse notes that an older patient has a blood pressure of 150/90 mm Hg.
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Which health screening should the nurse recommend for this patient?
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A. Arthritis
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B. Diabetes
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C. Depression
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D. Cognitive function - Correct answer ✔B. Diabetes
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The nurse notes that laboratory data for a person who is not a resident of the
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skilled facility was accidentally faxed to the care area. What should the nurse
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do with this information?
|! |! |!
ANSWERS & RATIONALES |! |!
The nurse is performing an assessment on an older adult client. Which
|! |! |! |! |! |! |! |! |! |! |! |!
assessment data would indicate a potential complication associated with the
|! |! |! |! |! |! |! |! |! |!
skin?
A. Crusting
|!
B. Wrinkling
|!
C. Deepening of expression lines
|! |! |! |!
D. Thinning and loss of elasticity in the skin - Correct answer ✔A. Crusting
|! |! |! |! |! |! |! |! |! |! |! |! |!
Wrinkling, deepening of expression lines, and thinning and loss of elasticity
|! |! |! |! |! |! |! |! |! |! |!
in the skin are are considered normal changes of aging. Crusting is
|! |! |! |! |! |! |! |! |! |! |! |!
concerning for a pathological condition. |! |! |! |!
A patient's documentation indicates he has a stage III pressure ulcer on his
|! |! |! |! |! |! |! |! |! |! |! |! |!
right hip. What should the nurse expect to find on assessment of the patient's
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
right hip? |!
A. Exposed bone, tendon, or muscle
|! |! |! |! |!
B. An abrasion, blister, or shallow crater
|! |! |! |! |! |!
C. Deep crater through subcutaneous tissue to fascia
|! |! |! |! |! |! |!
D. Persistent redness (or bluish color in darker skin tones) - Correct answer
|! |! |! |! |! |! |! |! |! |! |! |! |!
✔C. Deep crater through subcutaneous tissue to fascia
|! |! |! |! |! |! |!
,A stage III pressure injury involves full thickness skin loss or necrosis of the
|! |! |! |! |! |! |! |! |! |! |! |! |! |!
subcutaneous tissue that may extend down to but not through the underlying |! |! |! |! |! |! |! |! |! |! |! |!
fascia
A. Stage IV
|! |!
B. Stage II
|! |!
C. Stage III
|! |!
D. Stage I
|! |!
Which patient is at the greatest risk for developing pressure ulcers?
|! |! |! |! |! |! |! |! |! |!
A. A 42-year old obese woman with type 2 diabetes
|! |! |! |! |! |! |! |! |!
B. A 78-year old man who is confused and malnourished
|! |! |! |! |! |! |! |! |!
C. An 80-year old man who is comatose following a head injury
|! |! |! |! |! |! |! |! |! |! |!
D. A 65-year old woman who has urge and stress incontinence - Correct
|! |! |! |! |! |! |! |! |! |! |! |! |!
answer ✔C. An 80-year old man who is comatose following a head injury
|! |! |! |! |! |! |! |! |! |! |! |!
Although diabetes, malnutrition, and incontinence can increase risk of
|! |! |! |! |! |! |! |! |!
pressure injuries, an elderly patient, immobilized in an intensive care unit is
|! |! |! |! |! |! |! |! |! |! |! |!
at the highest risk.
|! |! |!
The patient is transferring from another facility with the description of a sore
|! |! |! |! |! |! |! |! |! |! |! |! |!
on her sacrum that is deep enough to see the muscle. What stage of pressure
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
ulcers does the nurse expect to see on admission?
|! |! |! |! |! |! |! |!
A. Stage I
|! |!
B. Stage II
|! |!
, C. Stage III
|! |!
D. Stage IV - Correct answer ✔D. Stage IV
|! |! |! |! |! |! |! |!
A stage IV pressure injury involves full-tissue skin loss with destruction
|! |! |! |! |! |! |! |! |! |! |!
extending to muscle, bone, or supporting structures
|! |! |! |! |! |!
The nurse reviews information collected after completing a comprehensive
|! |! |! |! |! |! |! |! |!
assessment with an older person. For which reason should the nurse
|! |! |! |! |! |! |! |! |! |! |!
recommend lipid-disorder screening for this patient? |! |! |! |! |!
A. Over the age of 65
|! |! |! |! |!
B. Body mass index 28.5
|! |! |! |!
C. Blood pressure 140/90 mm Hg
|! |! |! |! |!
D. Diagnosed with peripheral-artery disease - Correct answer ✔D. Diagnosed
|! |! |! |! |! |! |! |! |! |!
with peripheral-artery disease
|! |!
The nurse notes that an older patient has a blood pressure of 150/90 mm Hg.
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
Which health screening should the nurse recommend for this patient?
|! |! |! |! |! |! |! |! |!
A. Arthritis
|!
B. Diabetes
|!
C. Depression
|!
D. Cognitive function - Correct answer ✔B. Diabetes
|! |! |! |! |! |! |!
The nurse notes that laboratory data for a person who is not a resident of the
|! |! |! |! |! |! |! |! |! |! |! |! |! |! |! |!
skilled facility was accidentally faxed to the care area. What should the nurse
|! |! |! |! |! |! |! |! |! |! |! |! |!
do with this information?
|! |! |!
