NUR 109 Exam 3 questions 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: - CORRECT ANSWERS ✔✔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? - CORRECT |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔*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: - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔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? - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\
✔✔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? - CORRECT ANSWERS ✔✔*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? - CORRECT ANSWERS ✔✔*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 |\ |\ |\ |\ |\ |\ |\ |\
|\ |\ |\ |\ |\ |\
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: - CORRECT ANSWERS ✔✔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? - CORRECT |\ |\ |\ |\ |\ |\ |\ |\
ANSWERS ✔✔*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: - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\ |\
✔✔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? - CORRECT ANSWERS
|\ |\ |\ |\ |\ |\ |\ |\
✔✔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? - CORRECT ANSWERS ✔✔*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? - CORRECT ANSWERS ✔✔*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 |\ |\ |\ |\ |\ |\ |\ |\
