EXAM QUESTIONS AND ANSWERS | 100% RATED CORRECT | 100% VERFIED |
ALREADY GRADED A+
1. The nursing assessment of an older female elicits information that the client is diagnosed with
Raynaud's phenomenon. Which exposure should the nurse instruct the client to avoid?
a) Alcohol consumption
b) Warm climates
c) Cold climates
d) Active exercise: C) Cold Climates
Rationale: Can cause prolonged painful vasoconstriction of the peripheral extremities (especially hands)
in client's with Raynaud's phenomenon.
2. A family member brings their aging father to the clinic because he has been alert and oriented
during the day but agitated and disoriented in the evening. The registered nurse (RN) reviews the
client's list of current medications with the client and family. Which action taken by the RN is most
important?
a) Medication review with family caregivers is the PN's responsibility
b) Multiple medications can contribute to sundowner like symptoms
,c) Medication recall is the best way to evaluate the client's memory
d) Reviewing medication actions is a component of effective client care: B) Multiple medications
can contribute to sundowner like symptoms
Rationale: Older clients may see a variety of healthcare providers which can increase the change of
polypharmacy that compounds the workload of metabolic pathways that may be less efficient due to the
aging process. Multiple medication interactions may contribute to sundowner like symptoms.
3. An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the left
forearm for hemodialysis. After palpating the AV fistula, which finding is an indication that the
AV fistula is functioning properly? a) Enlarged veins
b) Redness around the site
c) Decreased pulses below the fistula
d) Marked ecchymotic areas: A) Enlarged Veins
Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to enlarge, which
facilitate cannulation for hemodialysis
4. The home health registered nurse (RN) is changing an older client's wet to dry dressing. Which
observation should the RN evaluate as a therapeutic response with the removal of the dry
dressing?
a) Debridement and removal of slough and eschar
b) Drainage of purulent exudate from the wound
,c) Moist skin edges around the wound field
d) Presence of capillary growth in the wound: A) Debridement and removal of slough and eschar
Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a dry gauze is
used to cover the wet packing to wick drainage and bacteria away from the wound to promote healing.
Removal of dried dressing provides debridement by removing exudate, sloughing tissue, and eschar.
5. Older clients are at highest risk for abuse and neglect due to which factors?
(Select all that apply)
a) Needs are greater than the caretaker's ability
b) Client's declining strength
c) Fixed income
d) Longer life expectancy
e) Lack of exposure to technology and trends: A, B
Rationale: When needs are not being met due to lack of ability of the caretaker, stress and feelings of
failure of the care provider may be expressed through neglect and abuse. Decline in strength increases
the older client's vulnerability to resist or respond to elder abuse.
6. A 64-year-old client is admitted to the hospital with a fractured right hip. One of the concerns
following surgical repair is to promote dorsiflexion. Which intervention would a nurse implement?
a) Begin early ambulation
, b) Monitor pain level
c) Provide PCA instructions
d) Provide a foot board: D) Provide a foot board
Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop throughout the
recovery.
7. During the quarterly evaluations of the clients in the assisted living community, the registered
nurse (RN) assesses for findings of failure to thrive in the older population. Which findings should
the RN document and report as manifestations related to failure to thrive? (Select all that apply).
a) Unintentional weight loss
b) Increased weakness
c) Increased amounts of sleep
d) Irritation and agitation
e) Seeking constant attention for caregiver: A, B, C
Rationale: Symptoms of failure to thrive in the older population include weight loss, weakness, and
excessive sleep, which should be documented and evaluated by a healthcare provider immediately.
8. An older male client is admitted to the hospital with left-sided heart failure (HF). Which finding
should the registered nurse (RN) document that is consistent with HF?
a) Ascites