NUR 242 Med/Surg Exam 1 Questions and Verified Answers| 100% Correct
Question 1
A 72-year-old patient is admitted to the orthopedic ward following a hip replacement. According
to the four major subgroups of late adulthood, how should the nurse classify this patient?
A) Elite old
B) Old old
C) Middle old
D) Young old
E) Centenarian
Correct Answer: D) Young old
Rationale: Late adulthood is categorized into four specific subgroups based on age: the
"young old" are those aged 65 to 74 years; the "middle old" are aged 75 to 84 years; the
"old old" are aged 85 to 99 years; and the "elite old" (also known as centenarians) are
those 100 years of age and older. Categorizing patients helps nurses understand age-related
physiological changes and risks associated with specific cohorts of the elderly population.
Question 2
A nurse is providing wellness teaching to a 68-year-old patient. Which recommendation
regarding vaccinations is most appropriate for this patient?
A) Receive the Shingles vaccine only if a prior outbreak occurred.
B) Receive a tetanus booster every 10 years.
C) Obtain the pneumococcal vaccine every 2 years.
D) The flu vaccine is only necessary for those in long-term care.
E) Avoid the flu vaccine if the patient had a cold recently.
Correct Answer: B) Receive a tetanus booster every 10 years.
Rationale: Health promotion for older adults includes maintaining up-to-date
immunizations. Standard guidelines recommend a tetanus-diphtheria (Td or Tdap) booster
every 10 years for all adults. The flu vaccine should be administered yearly, and the
shingles vaccine is recommended regardless of prior outbreaks to prevent post-herpetic
neuralgia. The pneumococcal vaccine schedule varies but is not a biennial requirement for
all.
Question 3
Which lifestyle modification should the nurse emphasize to an older adult to prevent the most
common cause of accidental injury-related morbidity?
A) Wearing hearing aids at all times.
B) Increasing alcohol intake to improve circulation.
C) Avoiding the use of waxed floors and scattered rugs.
D) Using a step stool to reach high cabinets.
E) Reducing socialization to save energy.
, 2
Correct Answer: C) Avoiding the use of waxed floors and scattered rugs.
Rationale: Falls are the most common cause of accidents and injury in the older adult
population. Environmental safety is a priority; therefore, removing trip hazards like
scattered rugs and avoiding slippery surfaces like waxed floors are critical interventions.
Promoting a clutter-free environment significantly reduces the risk of fractures and head
injuries associated with falls.
Question 4
An 88-year-old patient is being evaluated for "Geriatric Failure to Thrive" (GFTT). Which of the
following is a primary component of this complex syndrome?
A) Increased libido
B) Improved cognitive function
C) Impaired mobility
D) Excessive hydration
E) Hypertension
Correct Answer: C) Impaired mobility
Rationale: Geriatric Failure to Thrive (GFTT) is a complex multi-factorial syndrome
characterized by four primary components: under-nutrition, impaired physical mobility,
depression, and cognitive impairment. Recognizing these signs is vital for nurses as GFTT
is associated with increased mortality and a decline in functional status.
Question 5
When assessing a 75-year-old patient using the Geriatric Depression Scale, the nurse understands
that depression in the elderly is:
A) A normal part of the aging process.
B) Always primary and due to neurotransmitter lack.
C) Often manifested through physical and cognitive symptoms.
D) Rare and usually resolves without intervention.
E) Only present in those with a history of mental illness.
Correct Answer: C) Often manifested through physical and cognitive symptoms.
Rationale: Depression is the most common mental health problem among older adults but is
NOT a normal part of aging. It is a mood disorder that presents with cognitive (memory
issues), affective (sadness), and physical (aches, exhaustion) manifestations. It can be
primary (neurotransmitter imbalance) or secondary (situational, such as loss of a spouse or
illness).
Question 6
Which characteristic distinguishes delirium from dementia in an older adult?
A) Delirium is a chronic, slow progression of memory loss.
B) Delirium has an acute and fluctuating onset.
, 3
C) Dementia is always caused by an unfamiliar environment.
D) Delirium does not affect the level of consciousness.
E) Dementia is always reversible with proper hydration.
Correct Answer: B) Delirium has an acute and fluctuating onset.
Rationale: Delirium is characterized by an acute, rapid onset and a fluctuating course, often
triggered by underlying medical issues, medications, or an unfamiliar environment (e.g.,
hospitalization). Symptoms include inattentiveness and altered levels of consciousness.
Dementia, conversely, is a slow, progressive, and generally chronic intellectual impairment
(e.g., Alzheimer’s).
Question 7
The nurse is caring for a patient with multi-infarct dementia. The nurse knows this condition
most commonly results from:
A) Amyloid plaque buildup.
B) Chronic alcohol abuse.
C) A vascular disorder.
D) Vitamin B12 deficiency.
E) Excessive sedative use.
Correct Answer: C) A vascular disorder.
Rationale: Multi-infarct dementia is the second most common form of dementia and results
from vascular disorders, such as multiple small strokes (infarcts) that damage brain tissue.
Alzheimer's is the most common form and is associated with plaques and tangles, while
multi-infarct dementia is specifically tied to impaired blood flow to the brain.
Question 8
A nurse is acting as a rehab advocate for a patient. Which action best exemplifies the nurse's role
in the rehabilitation milieu?
A) Performing all ADLs for the patient to prevent fatigue.
B) Creating a therapeutic environment and providing patient-centered care.
C) Limiting communication with the family to reduce patient stress.
D) Deciding the care plan without consulting the healthcare team.
E) Discouraging the use of adaptive equipment to promote natural strength.
Correct Answer: B) Creating a therapeutic environment and providing patient-centered
care.
Rationale: In a rehabilitation setting, the nurse acts as an advocate, collaborator, and
coordinator. The nurse’s role is to create a therapeutic milieu, provide "whole-person"
patient-centered care, and collaborate with the interdisciplinary team to develop and
evaluate an effective care plan that promotes independence.
, 4
Question 9
The nurse is assessing a patient’s risk for skin breakdown. Which tool is most appropriate for this
assessment?
A) Glasgow Coma Scale
B) Geriatric Depression Scale
C) Braden Scale
D) Morse Fall Scale
E) ABCDE tool
Correct Answer: C) Braden Scale
Rationale: The Braden Scale is a validated tool used to assess a patient's risk for developing
pressure injuries. It evaluates six categories: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear. A lower score indicates a higher risk for skin
breakdown, allowing the nurse to implement preventative measures early.
Question 10
According to Safe Patient Handling and Mobility (SPHM) guidelines, what is the correct bed
height when the nurse is providing direct bedside care?
A) Hip level
B) Knee level
C) Waist level
D) Chest level
E) At the lowest possible setting
Correct Answer: C) Waist level
Rationale: To prevent musculoskeletal injury to the nurse, the bed should be adjusted to
waist level when providing direct patient care. When moving or transferring patients, the
bed should be at hip level to utilize better leverage and body mechanics. These practices
prevent spinal rotation and strain.
Question 11
When teaching a patient how to use a walker, which instruction is correct?
A) Move the walker about 5 feet forward before stepping.
B) Lift the walker and set it down on all four legs simultaneously.
C) Keep the walker as far from the body as possible.
D) Walk while the walker is still in the air.
E) Use the walker to pull yourself up from a seated position.
Correct Answer: B) Lift the walker and set it down on all four legs simultaneously.
Rationale: Proper walker technique involves lifting the walker, moving it approximately 2
feet forward, and ensuring all four legs are set down firmly before taking steps. The patient
Question 1
A 72-year-old patient is admitted to the orthopedic ward following a hip replacement. According
to the four major subgroups of late adulthood, how should the nurse classify this patient?
A) Elite old
B) Old old
C) Middle old
D) Young old
E) Centenarian
Correct Answer: D) Young old
Rationale: Late adulthood is categorized into four specific subgroups based on age: the
"young old" are those aged 65 to 74 years; the "middle old" are aged 75 to 84 years; the
"old old" are aged 85 to 99 years; and the "elite old" (also known as centenarians) are
those 100 years of age and older. Categorizing patients helps nurses understand age-related
physiological changes and risks associated with specific cohorts of the elderly population.
Question 2
A nurse is providing wellness teaching to a 68-year-old patient. Which recommendation
regarding vaccinations is most appropriate for this patient?
A) Receive the Shingles vaccine only if a prior outbreak occurred.
B) Receive a tetanus booster every 10 years.
C) Obtain the pneumococcal vaccine every 2 years.
D) The flu vaccine is only necessary for those in long-term care.
E) Avoid the flu vaccine if the patient had a cold recently.
Correct Answer: B) Receive a tetanus booster every 10 years.
Rationale: Health promotion for older adults includes maintaining up-to-date
immunizations. Standard guidelines recommend a tetanus-diphtheria (Td or Tdap) booster
every 10 years for all adults. The flu vaccine should be administered yearly, and the
shingles vaccine is recommended regardless of prior outbreaks to prevent post-herpetic
neuralgia. The pneumococcal vaccine schedule varies but is not a biennial requirement for
all.
Question 3
Which lifestyle modification should the nurse emphasize to an older adult to prevent the most
common cause of accidental injury-related morbidity?
A) Wearing hearing aids at all times.
B) Increasing alcohol intake to improve circulation.
C) Avoiding the use of waxed floors and scattered rugs.
D) Using a step stool to reach high cabinets.
E) Reducing socialization to save energy.
, 2
Correct Answer: C) Avoiding the use of waxed floors and scattered rugs.
Rationale: Falls are the most common cause of accidents and injury in the older adult
population. Environmental safety is a priority; therefore, removing trip hazards like
scattered rugs and avoiding slippery surfaces like waxed floors are critical interventions.
Promoting a clutter-free environment significantly reduces the risk of fractures and head
injuries associated with falls.
Question 4
An 88-year-old patient is being evaluated for "Geriatric Failure to Thrive" (GFTT). Which of the
following is a primary component of this complex syndrome?
A) Increased libido
B) Improved cognitive function
C) Impaired mobility
D) Excessive hydration
E) Hypertension
Correct Answer: C) Impaired mobility
Rationale: Geriatric Failure to Thrive (GFTT) is a complex multi-factorial syndrome
characterized by four primary components: under-nutrition, impaired physical mobility,
depression, and cognitive impairment. Recognizing these signs is vital for nurses as GFTT
is associated with increased mortality and a decline in functional status.
Question 5
When assessing a 75-year-old patient using the Geriatric Depression Scale, the nurse understands
that depression in the elderly is:
A) A normal part of the aging process.
B) Always primary and due to neurotransmitter lack.
C) Often manifested through physical and cognitive symptoms.
D) Rare and usually resolves without intervention.
E) Only present in those with a history of mental illness.
Correct Answer: C) Often manifested through physical and cognitive symptoms.
Rationale: Depression is the most common mental health problem among older adults but is
NOT a normal part of aging. It is a mood disorder that presents with cognitive (memory
issues), affective (sadness), and physical (aches, exhaustion) manifestations. It can be
primary (neurotransmitter imbalance) or secondary (situational, such as loss of a spouse or
illness).
Question 6
Which characteristic distinguishes delirium from dementia in an older adult?
A) Delirium is a chronic, slow progression of memory loss.
B) Delirium has an acute and fluctuating onset.
, 3
C) Dementia is always caused by an unfamiliar environment.
D) Delirium does not affect the level of consciousness.
E) Dementia is always reversible with proper hydration.
Correct Answer: B) Delirium has an acute and fluctuating onset.
Rationale: Delirium is characterized by an acute, rapid onset and a fluctuating course, often
triggered by underlying medical issues, medications, or an unfamiliar environment (e.g.,
hospitalization). Symptoms include inattentiveness and altered levels of consciousness.
Dementia, conversely, is a slow, progressive, and generally chronic intellectual impairment
(e.g., Alzheimer’s).
Question 7
The nurse is caring for a patient with multi-infarct dementia. The nurse knows this condition
most commonly results from:
A) Amyloid plaque buildup.
B) Chronic alcohol abuse.
C) A vascular disorder.
D) Vitamin B12 deficiency.
E) Excessive sedative use.
Correct Answer: C) A vascular disorder.
Rationale: Multi-infarct dementia is the second most common form of dementia and results
from vascular disorders, such as multiple small strokes (infarcts) that damage brain tissue.
Alzheimer's is the most common form and is associated with plaques and tangles, while
multi-infarct dementia is specifically tied to impaired blood flow to the brain.
Question 8
A nurse is acting as a rehab advocate for a patient. Which action best exemplifies the nurse's role
in the rehabilitation milieu?
A) Performing all ADLs for the patient to prevent fatigue.
B) Creating a therapeutic environment and providing patient-centered care.
C) Limiting communication with the family to reduce patient stress.
D) Deciding the care plan without consulting the healthcare team.
E) Discouraging the use of adaptive equipment to promote natural strength.
Correct Answer: B) Creating a therapeutic environment and providing patient-centered
care.
Rationale: In a rehabilitation setting, the nurse acts as an advocate, collaborator, and
coordinator. The nurse’s role is to create a therapeutic milieu, provide "whole-person"
patient-centered care, and collaborate with the interdisciplinary team to develop and
evaluate an effective care plan that promotes independence.
, 4
Question 9
The nurse is assessing a patient’s risk for skin breakdown. Which tool is most appropriate for this
assessment?
A) Glasgow Coma Scale
B) Geriatric Depression Scale
C) Braden Scale
D) Morse Fall Scale
E) ABCDE tool
Correct Answer: C) Braden Scale
Rationale: The Braden Scale is a validated tool used to assess a patient's risk for developing
pressure injuries. It evaluates six categories: sensory perception, moisture, activity,
mobility, nutrition, and friction/shear. A lower score indicates a higher risk for skin
breakdown, allowing the nurse to implement preventative measures early.
Question 10
According to Safe Patient Handling and Mobility (SPHM) guidelines, what is the correct bed
height when the nurse is providing direct bedside care?
A) Hip level
B) Knee level
C) Waist level
D) Chest level
E) At the lowest possible setting
Correct Answer: C) Waist level
Rationale: To prevent musculoskeletal injury to the nurse, the bed should be adjusted to
waist level when providing direct patient care. When moving or transferring patients, the
bed should be at hip level to utilize better leverage and body mechanics. These practices
prevent spinal rotation and strain.
Question 11
When teaching a patient how to use a walker, which instruction is correct?
A) Move the walker about 5 feet forward before stepping.
B) Lift the walker and set it down on all four legs simultaneously.
C) Keep the walker as far from the body as possible.
D) Walk while the walker is still in the air.
E) Use the walker to pull yourself up from a seated position.
Correct Answer: B) Lift the walker and set it down on all four legs simultaneously.
Rationale: Proper walker technique involves lifting the walker, moving it approximately 2
feet forward, and ensuring all four legs are set down firmly before taking steps. The patient
