Test Bank Ham's Primary Care Geriatrics A Case-Based Approach 6th Edition

Test Bank Ham's Primary Care Geriatrics A Case-Based Approach 6th Edition PREFACE TEST BANK with Complete Questions and Solutions. To clarify, this is the TEST BANK, not the textbook. You get immediate access to download your test bank. You will receive a complete test bank; in other words, all chapters shown in the table of contents in this preview will be there. Test banks come in PDF format; therefore, you do not need specialized software to open them. Chapter 1. Principles of Primary Care of Older Adults MULTIPLE CHOICE 1. In 2010, the revised Standards and Scope of Gerontological Nursing Practice was published. The nurse would use these standards to: a. promote the practice of gerontologic nursing within the acute care setting. b. define the concepts and dimensions of gerontologic nursing practice. c. elevate the practice of gerontologic nursing. d. incorporate suggested interventions from others who practice gerontologic nursing. ANS: D The current publishing of the Standards and Scope of Gerontological Nursing Practice in 2010 incorporates the input of gerontologic nurses from across the United States. It was not intended to promote gerontologic nursing practice within acute care settings, define concepts or dimensions of gerontologic nursing practice, or elevate the practice of gerontologic nursing. DIF: Remembering (Knowledge) REF: msc: 2 OBJ: 1-1 TOP: N/A MSC: Safe and Effective Care Environment 2. When attempting to minimize the effect of ageism on the practice of nursing older adults, a nurse needs to first: a. recognize that nurses must act as advocates for aging patients. b. accept that this population represents a substantial portion of those requiring nursing care. c. self-reflect and formulate ones personal view of aging and the older patient. d. recognize ageism as a form of bigotry shared by many Americans. ANS: C Ageism is an ever-increasing prejudicial view of the effects of the aging process and of the older population as a whole. With nurses being members of a society holding such views, it is critical that the individual nurse self-reflect on personal feelings and determine whether such feelings will affect the nursing care that he or she provides to the aging patient. Acting as an advocate is an important nursing role in all settings. Simply accepting a fact does not help end ageism, nor does recognizing ageism as a form of bigotry. DIF: Applying (Application) REF: N/A OBJ: 1-9 TOP: Teaching-Learning MSC: Safe and Effective Care Environment 3. When discussing factors that have helped to increase the number of healthy, independent older Americans, the nurse includes the importance of: a. increased availability of in-home care services. b. government support of retired citizens. c. effective antibiotic therapies. d. the development of life-extending therapies. ANS: C The health and ultimate autonomy of older Americans has been positively impacted by the development of antibiotics, better sanitation, and vaccines. These public health measures have been more instrumental in increasing the numbers of healthy, independent older Americans than have in-home care services, government programs, or life-extending therapies. DIF: Remembering (Knowledge) REF: msc: 2 OBJ: 3-3 TOP: Nursing Process: Implementation MSC: Health Promotion and Maintenance 14. Based on current data, when presenting an older adults discharge teaching plan, the nurse includes the patients: a. nonrelated caretaker. b. paid caregiver. c. family member. d. intuitional representative. ANS: C Less than 4% of older adults live in a formal health care environment. The majority of the geriatric population lives at home or with family members. DIF: Applying (Application) REF: N/A OBJ: 3-3 TOP: Nursing Process: Planning MSC: Safe and Effective Care Environment 5. The nurse planning care for an older adult who has recently been diagnosed with rheumatoid arthritis views the priority criterion for continued independence to be the patients: a. age. b. financial status. c. gender. d. functional status. ANS: D Maintaining the functional status of older adults may avert the onset of physical frailty and cognitive impairment, two conditions that increase the likelihood of institutionalization. DIF: Remembering (Knowledge) REF: msc: 8 OBJ: 1-6 TOP: Nursing Process: Planning MSC: Physiologic Integrity 6. A nurse working with the older adult population is most likely to assess a need for a financial social services referral for a(n): a. white male. b. black female. c. Hispanic male. d. Asian American female. ANS: B The poverty rate among older black women is substantially higher than that seen among males or females of other ethnic groups. White males had the least poverty. DIF: Applying (Application) REF: N/A OBJ: 1-4 TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment 7. Which of the following statements made by a nurse preparing to complete a health assessment and history on an older patient reflects an understanding of the general health status of this population? a. Ill need to document well regarding the medications the patient is currently prescribed. b. I would like to understand how supportive the patients family members are. c. Most older patients are being treated for a variety of chronic health care issues. d. It will be interesting to see whether this patient sees herself as being healthy. ANS: D It is a misconception that old age is synonymous with disease and illness. The nurse should always determine the patients sense of wellness and independence when conducting a health and history assessment. An assessment of medication use and family support is important for any patient. Many older adults do have chronic health conditions, but their perception is more important than a single number. DIF: Applying (Application) REF: N/A OBJ: 1-4 TOP: Nursing Process: Assessment MSC: Health Promotion 8. The nurse is caring for an older adult who has been admitted to an acute care hospital for treatment of a fractured femur. The family expresses concern about the patients pending transfer to a subacute care facility. What response by the nurse is best? a. Acute care facilities lack the long-term physical therapy support your dad requires. b. Your dad will be much happier in a more serene, private environment. c. The subacute facility will focus on helping your dad maintain his independence. d. Insurance, including Medicare, will cover only a limited amount of time here. ANS: C The transfer of the patient to a subacute facility is based on the need to maintain the patients level of 2function and independence, a task the acute care facility is not prepared to address once the patient is physiologically stable. The patient may or may not be happier in the new setting; the nurse should not make this judgment. It is true that insurance only pays for a limited amount of time in an acute care facility, but this is not the best reason for the patient to transfer. DIF: Applying (Application) REF: N/A OBJ: 1-6 TOP: Communication and Documentation MSC: Health Promotion and Maintenance 9. To best assure both the quality of care and the safety of the older adult patient who requires in home unlicensed assistive personal (UAP) assistance, the geriatric nurse: a. evaluates the competency of the UAP staff. b. assumes the roles of case manager and patient advocate. c. arranges for the needed UAP provided services. d. assesses the patient for functional limitations. ANS: A As more care traditionally provided by professional nurses is being transferred to UAP, the nurse must assume more responsibility for educating, training, and evaluating the competency of UAP staff to provide safe, effective care for the older adult patient. DIF: Applying (Application) REF: N/A OBJ: 1-2 TOP: Communication and Documentation MSC: Safe and Effective Care Environment 10. The nurse working with older adults understands what information about certification in gerontologic nursing? a. It is mandatory for those in long-term care settings. b. It is voluntary and shows clinical expertise in an area. c. It allows nurses to be paid by third-party payers. d. It allows nurses to advance their careers in a job. ANS: B Certification is voluntary and shows that a nurse has additional knowledge and expertise in a certain area of practice. It is not mandatory in specific care settings. It does not allow for third party reimbursement. It may be part of a career ladder program, but that is not true of all work settings. DIF: Remembering (Knowledge) REF: msc: 2 OBJ: 1-2 TOP: Teaching-Learning MSC: Safe Effective Care Environment 11. A nurse works in a gerontologic clinic. What action by the nurse takes highest priority? a. Serving as a patient advocate b. Educating patients about diseases c. Helping patients remain independent d. Referring patients to home health care ANS: C One of the challenges and priorities of the gerontologic nurse is helping patients maintain their independence. DIF: Remembering (Knowledge) REF: msc: 10 OBJ: 1-2 TOP: Nursing Process: Implementation MSC: Health Promotion 12. A nurse is caring for an older patient in the emergency department. What information about the patient will be most helpful in creating a plan of care? a. Baseline physical and cognitive functioning b. Living conditions and family support c. Medications and current medical problems d. Results of the Mini Mental State examination ANS: A The nurse is encouraged to view older patients as individuals and consider their baseline physical and cognitive functional status as a standard by which to compare the patients current status. The other information is also important, but the basis of individualized care begins with the patients strengths and weaknesses. DIF: Applying (Application) REF: N/A OBJ: 1-6 3TOP: Nursing Process: Assessment MSC: Health Promotion 13. The faculty member explains to students that many older Americans continue to work past the retirement age. What best explains this trend? a. Feeling healthier longer b. Changing financial outlook c. Becoming bored in retirement d. A desire to give back ANS: B As financial situations may have declined as a result of many economic factors, more older adults work past their retirement age. The other options may be reasons for some to continue working, but financial necessity is the reason the majority continue to do so. DIF: Remembering (Knowledge) REF: msc: 7 OBJ: 1-3 TOP: Teaching-Learning MSC: Health Promotion 14. What information does the faculty member teach students about Medicare? a. Covers anyone with end stage renal disease b. Part A covers some prescription costs c. Part B covers inpatient hospital costs d. Part D eliminates the drug donut hole ANS: A Although Medicare is primarily for those over the age of 65, it does cover people of any age with end-stage kidney disease. Part A covers hospital costs. Part B is medical insurance. The donut hole was fixed by the Affordable Care Act. DIF: Understanding (Comprehension) REF: msc: 9 OBJ: 1-3 TOP: Teaching-Learning MSC: Health Promotion 15. A nursing manager notes that many older patients are admitted to the nursing unit for acute problems. What action can the manager take to most benefit this population? a. Provide mandatory education on the needs of the older patient. b. Provide restorative therapy programs designed for this group. c. Ensure staffing numbers are adequate for dependent patients. d. Encourage all nurses to obtain gerontologic certification. ANS: B Many older adults need acute care for sudden illness and injury but live in a state of functional decline, which could possibly be prevented by establishing a restorative therapy program. The other actions will help the older patients cared for in the unit, but only to limited degrees. DIF: Applying (Application) REF: N/A OBJ: 1-4 TOP: Nursing Process: Implementation MSC: Physiologic Integrity: Reduction of Risk Potential 16. The dean of a new nursing program wishes to ensure graduates are prepared to care for older patients. What document should guide the dean in designing the curriculum? a. The Nurse Practice Act for that state b. The American Nurses Association (ANA) code of ethics for nurses c. Healthy People 2020 d. The Recommended Baccalaureate Competencies and Curricular Guidelines ANS: D The Recommended Baccalaureate Competencies and Curricular Guidelines for the Nursing Care of Older Adults is an updated version of The Essentials of Baccalaureate Education for Professional Nursing Practice. This document was first published by the American Association of Colleges of Nursing (AACN) in 2008 and was updated in 2010. The other three documents do not have information about curricular requirements to prepare students to care for the older population. DIF: Applying (Application) REF: N/A OBJ: 1-2 TOP: Teaching-Learning MSC: Health Promotion 17. A nurse wants to plan a community event at a retirement center. What topic would most likely be 4best received? a. Heart healthy living b. Financial planning c. Avoiding scams d. Ethnic cooking classes ANS: A Older adults are demanding more programs and services aimed at health maintenance and promotion and disease and disability prevention. Based on this information, the heart healthy living presentation would be best received. DIF: Applying (Application) REF: N/A OBJ: 1-3 TOP: Teaching-Learning MSC: Health Promotion 18. What does the bedside nurse understand about his or her role in nursing research? a. Research is only done by doctorally prepared nurses. b. All nurses have a role in delivering research-based care. c. A bedside nurse can be part of a hospital research team. d. The bedside nurse can collect data if the nurse has been properly trained. ANS: B All nurses are charged to deliver patient-centered care based on evidence-based practice, research, quality improvement, and informatics. The bedside nurse is part of an interdisciplinary team that is responsible for redesigning the health care structure of the future. DIF: Understanding (Comprehension) REF: msc: 13 TOP: Teaching-Learning MSC: Safe Effective Care Environment: Management of Care MULTIPLE RESPONSE 1. The clinic nurse caring for an older diabetic patient with a sixth grade education anticipates that the patient may experience difficulty (Select all that apply.) a. recognizing the importance of keeping clinic appointments. b. following a low-carbohydrate diet. c. paying for insulin and syringes. d. deciding on a primary health care provider. e. naming a health care surrogate. ANS: A, B, C Even though the educational level of the older population has steadily increased, as a population they are less educated than the general population. This deficiency can account for a lack of understanding regarding the need for medical care and the importance of following a treatment plan. These patients may also have fewer financial resources to devote to health care issues. DIF: Analyzing (Analysis) REF: N/A OBJ: 1-4 TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment 2. The nurse studying the history of gerontologic nursing learns which information about the specialty? (Select all that apply.) a. The number of older Americans is diminishing. b. The geriatric nursing conference group was established in 1962. c. The gerontologic clinical nurse specialist certification was offered in 1989. d. There were no writings about the care of older persons until World War II. e. The first Standards of Practice for Geriatric Nursing was written in 1969. ANS: B, C, E The geriatric nursing conference group was established in 1962, the gerontologic clinical nurse specialist certification was first offered in 1989, and the first Standards of Practice for Geriatric Nursing was written in 1969. The population of older Americans is the fastest-growing subset of the population. Writings about care of the aged can be found from as early as 1900. DIF: Remembering (Knowledge) REF: msc: 2-3 OBJ: 1-2 TOP: Teaching-Learning MSC: Nursing Process: Assessment 3. The student asks the gerontologic clinic nurse why so many older people are women. What information does the nurse provide? (Select all that apply.) a. Reduced maternal mortality b. Decreased deaths from infectious diseases 5c. More deaths from chronic disease in men d. More deaths in war occur in men e. Women tend to smoke and drink less than men ANS: A, C, D A decrease in maternal mortality, decreased deaths from infectious diseases, and more chronic illness in men account for the disparity in genders as people age. DIF: Understanding (Comprehension) REF: msc: 6 OBJ: 1-5 TOP: Teaching-Learning MSC: Health Promotion 4. The gerontologic nurse plans community programming for older women, noting what facts about this population subgroup? (Select all that apply.) a. More likely to live alone b. Increased chance of living in poverty c. Taking care of a spouse d. Suffering many chronic diseases e. Living with extended families ANS: A, B, D Older women have a greater chance than men of living alone and in poverty. They also have a greater degree of functional impairment and chronic disease. DIF: Remembering (Knowledge) REF: msc: 6 OBJ: 1-5 TOP: Nursing Process: Analysis MSC: Health Promotion 5. The nurse knows that the most common causes of death in the older population result from which diseases? (Select all that apply.) a. Cerebrovascular disease b. End-stage kidney disease c. Heart disease d. Cancer e. Diabetes ANS: A, C, D The most common causes of death in the older population are cerebrovascular disease, heart conditions, and cancer. End-stage renal disease and diabetes are not among the top three causes of death Chapter 4. Wellness and Prevention MULTIPLE CHOICE 1. When the home health nurse assists the older adult patient with rearranging furniture within the home to prevent the patient from falling, the nurse is demonstrating: a. health promotion. b. health protection. c. health prevention. d. disease prevention. ANS: B The overarching goals are to attain high-quality, long lives free of preventable disease, disability, and injury; to eliminate disparities; create social and physical environments that promote health; and optimize quality of life across the life span. Health protection targets five areas including unintentional injury. Rearranging furniture to prevent falls is a health protection activity. DIF: Applying (Application) REF: N/A OBJ: 8-1 TOP: Nursing Process: Implementation MSC: Safe Effective Care Environment 2. The primary focus of the health belief model of health promotion is addressed when the nurse: a. accompanies the assisted living residents on a walk before dinner. b. asks a senior citizens group what health screening they want to have. c. plans a program on cooking diabetic-friendly meals in cooperation with a dietician. d. asks the patient if he believes smoking puts him at risk for lung cancer. ANS: D The health belief model, which was developed to determine the likelihood of an individuals participation in health promotion, health protection, and disease prevention services, includes assessing an 6individuals perception of his or her susceptibility to developing an illness. Asking the patient about beliefs related to tobacco use and health is an activity that falls within this model. The other activities do not. DIF: Understanding (Comprehension) REF: msc: 141 OBJ: 8-2 TOP: Nursing Process: Assessment MSC: Health Promotion 3. Financial considerations are a major barrier to the older adults participation in health promotion because: a. most older adults have accepted poor health as a part of growing older. b. Medicare often does not cover the cost of preventive services. c. many already have been diagnosed with chronic illnesses. d. they generally place more value on saving their disposable income. ANS: B Older adults must incur the cost of many preventive services because Medicare does not cover them all. This can be hard on the fixed, limited income of many older adults. It is not true that older adults accept poor health as inevitable. Health promotion activities can occur in the presence of chronic illnesses. Some older adults do place high value on saving money, but not all older adults are influenced by this desire. DIF: Understanding (Comprehension) REF: msc: 148 OBJ: 8-4 TOP: Nursing Process: Assessment MSC: Health Promotion 4. To engage the older adults who frequently attend a senior citizens center in primary disease prevention, the nurse: a. immunizes those attending a weekly luncheon against the H1N1 virus. b. arranges for a colorectal cancer screening at the center. c. schedules a speaker to discuss cooking for diabetic patients. d. surveys the members to identify health issues of interest to them. ANS: A Primary prevention refers to specific action taken to optimize the health of the older individual by helping him or her to become more resistant to disease or to ensure that the environment will be less harmful. Providing immunizations would be included in this level of prevention. Colorectal cancer screening is secondary prevention. Cooking for diabetic patients is tertiary prevention. Surveying patients does not fall into any level of prevention. DIF: Applying (Application) REF: N/A OBJ: 8-5 TOP: Nursing Process: Implementation MSC: Health Promotion 5. The nurse has the greatest impact on a patients health promotion when: a. evaluating a diabetic patients ability to administer his insulin injections. b. encouraging an obese patient to limit both fat and carbohydrate intake. c. volunteering to take blood pressures at a community health fair. d. educating the patient about vitamin D and calcium to prevent bone loss. ANS: D Health promotion includes interventions that help prevent disease and disability in a patient. Education regarding health promotion issues has the greatest impact on the health of a patient. The other patients already have established diseases. DIF: Applying (Application) REF: N/A OBJ: 8-1 TOP: Teaching-Learning MSC: Health Promotion 6. A nurse is assessing a patients ability to manage existing health problems. What question by the nurse is most helpful? a. Can you tell me why its important to test your blood glucose level at least daily? b. What were the results of your most recent A1C blood test? c. Which pharmacy do you use when your prescription needs to be refilled? d. Have you been experiencing pain in your feet? ANS: B The results of a laboratory test used to monitor glucose control will show how well the patient has been managing the various aspects of his or her treatment plan. This information is collected in the health perception/health management functional health pattern. The other questions do not demonstrate the patients knowledge level. DIF: Applying (Application) REF: N/A OBJ: 8-5 TOP: Nursing Process: Assessment MSC: Health Promotion 77. During a home visit, a nurse is assessing the nutritional awareness of an older adult patient who lives alone. The nurse is most effective in obtaining objective information when: a. asking to see what types of foods the patient keeps readily available. b. reviewing the components of a healthy diet with the patient. c. asking the patient to describe what he or she ate for all three meals yesterday. d. observing the patient eat a meal that he or she has prepared. ANS: D Objective information is best obtained when observing general appearance and various body system indicators of nutritional status. Note height, weight, and fit of clothes. If possible, observe the older adult eating a meal. Food available in the home does not indicate the patients knowledge, as someone else may have bought the food. Asking the patient for information is requesting subjective data. Reviewing a healthy diet does not allow the patient to demonstrate knowledge. DIF: Applying (Application) REF: N/A OBJ: 8-5 TOP: Nursing Process: Assessment MSC: Physiologic Integrity 8. The nurse is discussing an older adults past marital history during the admission assessment. The nurse can best determine that the patient has a healthy ability to cope with emotional stressors when the patient states: a. After my husband died, I managed to raise and educate our two children by myself. b. Since my husbands death, Ive grown even closer to my sisters. c. Its been hard since my husband died, but you manage to go on somehow. d. After my husband died, I married a good man who was there for me and my children. ANS: A This pattern encompasses the patients reserve and capacity to resist challenges to self-integrity and his or her ability to manage difficult situations. The ability to view herself as a success in fulfilling her responsibilities as a mother is evidence of healthy stress coping skills. DIF: Evaluating (Evaluation) REF: N/A OBJ: 8-5 TOP: Nursing Process: Evaluation MSC: Psychosocial Integrity 9. An older adult patient has recently experienced some difficulty sustaining an erection as a result of medication he has been prescribed. The nurse best assesses the patients perception of his own sexuality by asking: a. How are you and your wife coping with your sexual dysfunction? b. What problems has your sexual dysfunction caused between you and your wife? c. What impact has this dysfunction had on your ability to be intimate with your wife? d. Are you and your wife prepared to deal with this dysfunction over the long term? ANS: C Asking about the impact of the dysfunction directly assesses the patients satisfaction or dissatisfaction with current circumstances related to sexual function and intimacy, thus providing the best evaluation of his self- perception of the issue. DIF: Applying (Application) REF: N/A OBJ: 8-5 TOP: Nursing Process: Assessment MSC: Psychosocial Integrity 10. The nurse admitting an 89-year-old patient to an assisted living facility notes that the patient is currently taking numerous prescribed and over-the-counter medications. The nurses initial intervention is to: a. confirm with the physician that all the medications are required. b. evaluate the patients understanding of why he is taking each medication. c. explain to the patient the dangers of taking so many different medications. d. review the listed medications for possible interactions. ANS: D The first nursing action is to determine if the patients health is at risk from possible drug interactions. The other actions might be warranted, but patient safety comes first. DIF: Understanding (Comprehension) REF: msc: 143 OBJ: 8-6 TOP: Nursing Process: Assessment MSC: Physiologic Integrity 11. When assessing the older adult for bowel health, the nurse is most effective in obtaining subjective data when asking: 8a. Would you describe your bowel movements as usually normal? b. Do you have a problem with constipation? c. How often do you usually have a bowel movement? d. Have your bowel movements changed recently? ANS: C Subjective data can be obtained through the health history. Asking the patient to identify how often the bowels move would establish the fundamental baseline of the patients elimination patterns. Normal is a vague term that should not be used. Asking if there are problems with constipation or if bowel habits have changed are yes/no questions, which are generally avoided. DIF: Applying (Application) REF: N/A OBJ: 8- 5 TOP: Nursing Process: Assessment MSC: Physiologic Integrity 12. Using social cognitive theory, which action by the nurse will have the most impact on older adults participation in health promotion behaviors? a. Creating a walking club in the community b. Offering private nutritional counseling c. Providing meals at the senior center d. Handing out educational materials ANS: A According to this theory, self-efficacy and outcome expectations are influenced by successful performance of the behavior, verbal encouragement, seeing similar people do the behavior, decreasing unpleasant aspects of the behavior, caring approaches to facilitate the behavior, and education about benefits. A local walking club with other seniors fulfills many of these criteria. Private nutritional counseling does not allow the participant to see others engaged in this activity. Meals may or may not be healthy or palatable. Educational materials on their own may not have great benefit. DIF: Applying (Application) REF: N/A OBJ: 8-2 TOP: Nursing Process: Implementation MSC: Health Promotion 13. The nurse wishes to participate in a community secondary prevention activity. Which activity does the nurse choose? a. Administering blood pressure screening at a mall b. Dispensing free flu vaccinations at a clinic c. Fitting impoverished older adults with glasses d. Teaching about the risks of sun exposure ANS: A Secondary prevention is screening and early diagnosis. It aims to find people with clinical conditions that have not yet become apparent to them. Blood pressure screening would fit this description. Flu vaccinations and teaching about sun exposure are examples of primary prevention. Fitting older adults with glasses is a tertiary prevention. DIF: Applying (Application) REF: N/A OBJ: 8-5 TOP: Nursing Process: Implementation MSC: Health Promotion 14. A patient who is homeless has not followed through with getting an influenza vaccination. What response by the nurse to a student is most appropriate? a. Its hard to be proactive when you are hungry. b. If the patient would just come in, we have the shot. c. These patients never follow through on directions. d. Too bad we cant take the shot to him where he is. ANS: A Competing priorities often cause patients to seem uninterested or noncompliant with health recommendations. According to Maslow, basic needs such as food, water, shelter, and safety take priority over other matters. Perhaps it is a good idea to take shots into the community, but that is not the best response by the nurse, as it does not help the student understand the situation. The other two statements are biased and show disregard for the patients circumstances. DIF: Applying (Application) REF: N/A OBJ: 8-4 TOP: Communication and Documentation MSC: Health Promotion 915. The nurse is seeing a 68-year old woman for a physical exam in the family practice clinic. The woman complains about having another pelvic exam. What response by the nurse is best? a. I know its uncomfortable, but its important to do it. b. You are past the age where this exam is recommended. c. Why dont you want to have your pelvic exam? d. This will be the last time you need this exam. ANS: B According to the U.S. Preventative Task Force, pelvic exams and pap smears can be discontinued after age 65 if prior testing was normal and the patient is not at high risk for cervical cancer. The other statements are incorrect. DIF: Understanding (Comprehension) REF: msc: 143 OBJ: 8-5 TOP: Teaching-Learning MSC: Health Promotion 16. A male patient complains about the digital rectal prostate exam and blood work for prostate specific antigen (PSA) and asks, How long am I expected to do this? What response by the nurse is best? a. Every year for the rest of your life. b. Until you turn 75 years of age. c. You can quit when you turn 80. d. There are no guidelines on this. ANS: B According to the U.S. Preventative Task Force, there is no evidence that continuing routine PSA screening past the age of 75 has any benefit, so the patient can forgo the blood test after he turns 75. DIF: Understanding (Comprehension) REF: msc: 143 OBJ: 8-5 TOP: Teaching-Learning MSC: Health Promotion 17. A nurse routinely assesses patients for alcohol use. What principle guides this assessment? a. The older adult must balance risks to benefits of use. b. Alcohol causes older adults to fall and should not be consumed. c. There are no data on risks or benefits after the age of 75. d. Alcohol-related diseases are more severe in older people. ANS: A There are both benefits and risks to drinking alcohol. The nurse must help the older patient determine which predominates when assessing and possibly counseling patients on their alcohol use. DIF: Applying (Application) REF: N/A OBJ: 8-6 TOP: Nursing Process: Assessment MSC: Safe Effective Care Environment 18. An 80-year-old woman has found a lump in her breast and is in the clinic. What question by the nurse is most appropriate? a. How long have you had this lump? b. If its cancer, are you willing to treat it? c. Do you have cancer in your family? d. Are you having any pain right now? ANS: B All questions are appropriate; however, for a woman this age, further testing is not recommended unless the patient is willing to go through with treatment for cancer. Tumors in older women tend to be slow growing and quality of life is a bigger priority. DIF: Applying (Application) REF: N/A OBJ: 8-6 TOP: Nursing Process: Assessment MSC: Physiologic Integrity 19. A nurse wishes to volunteer in a tertiary health care activity. What activity would the nurse choose? a. Teaching about safer sexual behaviors b. Greeting women at an emergency pregnancy clinic c. Assisting women who are having radiation therapy d. Finding home health safety resources ANS: C Tertiary prevention aims to care for established disease. Helping women having radiation therapy for 10cancer would fall into this realm. Teaching is primary prevention. The emergency pregnancy clinic is secondary prevention. Home safety is primary prevention. DIF: Applying (Application) REF: N/A OBJ: 8-5 TOP: Nursing Process: Implementation MSC: Health Promotion 20. A nurse is working with a woman who has been reluctant to start a walking program for her osteoporosis. What assessment by the nurse is most important? a. Fear of falling b. Lack of time c. Lack of energy d. Pain with movement ANS: A Fear of falling is a common fear in older adults and has special significance to those with osteoporosis. The nurse should first assess for this factor. All other factors can be possible contributors, but people usually attend to safety first. DIF: Applying (Application) REF: N/A OBJ: 8-4 TOP: Nursing Process: Assessment MSC: Psychosocial Integrity MULTIPLE RESPONSE 1. A nurse planning primary disease prevention interventions for a 64-year-old patient includes which of the following? (Select all that apply.) a. Giving an influenza vaccination in early autumn of each year. b. Suggesting the patient attend Cooking to Manage Hypertension classes taught by a registered dic. Giving a pneumococcal vaccination to celebrate the patients 65th birthday. d. Identifying several local smoking cessation support groups. e. Providing the patient with a take-home occult stool screening kit. ANS: A, C, D Primary prevention refers to specific action taken to optimize the health of the older individual by helping him or her become more resistant to disease or to ensure that the environment will be less harmful. DIF: Application (Apply) REF: N/A TOP: Nursing Process: Planning MSC: Health Promotion and Maintenance 2. A patient has not followed up with recommendations made by the nurse to participate in cardiac rehabilitation after a myocardial infarction. What factors are most important for the nurse to assess in determining the cause of this behavior? (Select all that apply.) a. Out-of-pocket costs b. Transportation problems c. Beliefs about the benefits d. Location of the clinic e. Ethnicity of providers ANS: A, B, C, D Many factors affect the ability and willingness of patients to engage in health promotion behaviors, including cost, transportation, beliefs, and location of the services. Ethnicity of the providers may be a consideration for some, but that is not a high priority for assessment in most patients. DIF: Applying (Application) REF: N/A OBJ: 8-2 TOP: Nursing Process: Assessment MSC: Health Promotion 3. The student learns the Medicare guidelines for preventive health and reimbursement policies. Which statement follows the guidelines? (Select all that apply.) a. Medicare pays for an annual pneumococcal vaccination. b. Medicare covers annual influenza vaccinations. c. Pap smears and pelvic exams are covered once every 2 years. d. Annual fecal occult blood tests are covered for those who are from 50 to 85 years of age. e. A bone density scan is covered every 2 years (a co-payment is required). ANS: B, D, E Medicare guidelines provide reimbursement for pneumococcal vaccination once and every 5 years as recommended, an annual flu vaccination, pap smears and pelvic exams every 3 years, an annual fecal occult blood test for those who are from 50 to 85 years of age, and a bone density scan every 2 years 11(however, a co-payment is required) Chapter 5. Advanced Cultural Competency in Caring for Geriatric Patients MULTIPLE CHOICE 1. A postmenopausal black woman who has been experiencing uterine bleeding tells the nurse, I expect Ill need a total hysterectomy because when my sister had this problem thats what she had done. The nurse recognizes that this woman belongs to a cultural subgroup whose health care beliefs are most influenced by the: a. biomedical model. b. magico-religious model. c. balance/harmony model. d. personal experience. ANS: A The patient shows a tendency to identify with the biomedical model, which views the body as a functioning machine. When a part gives out or is functioning abnormally, traditional Western medical treatment is sought and expected. The magico-religious models believe that health is a reward from a higher power. The balance/harmony models state that illness is the result of a state of imbalance in body energies. Personal experience influences all of these models. DIF: Understanding (Comprehension) REF: msc: 91 OBJ: 5-5 TOP: Nursing Process: Assessment MSC: Psychosocial Integrity 2. A Hispanic patient explains that the Hispanic culture believes that dietary management would be just as effective in managing her problems as medication, so the patients prescription has not been filled. Which action by the nurse illustrates cultural accommodation? a. Asking the patient to give more details regarding this belief b. Discussing how to add dietary preferences into the treatment plan c. Offering to have a registered nutritionist discuss the situation with the patient d. Researching the patients proposed dietary beliefs ANS: B Cultural care accommodation or negotiation refers to those assistive, supportive, facilitative, or enabling creative professional actions and decisions that help people of a designated culture adapt to or negotiate with others for a beneficial or satisfying health outcome. The nurse can ask the patient to share more about beliefs, offer a consultation with a nutritionist, or research the beliefs, but these actions do not show accommodation. DIF: Applying (Application) REF: N/A OBJ: 5-9 TOP: Caring MSC: Psychosocial Integrity 3. A geriatric nurse practitioner working with a tribe of Native Americans makes the decision to acculturate in an attempt to provide culturally appropriate care. The nurse does this best by: a. living the values of the tribe. b. researching the tribes belief systems. c. learning the language of the tribe. d. residing among the tribe members. ANS: A Acculturation is a process that occurs when a member of one cultural group adopts the values, beliefs, expectations, and behaviors of another group, usually in an attempt to become recognized as a member of the group. The other actions might be helpful in acculturating. DIF: Applying (Application) REF: N/A OBJ: 5-3 TOP: Nursing process: Implementation MSC: Psychosocial Integrity 4. The nurse in an assisted living facility is practicing a form of cultural bias called ethnocentrism when: a. requesting the bridge group only use the game room for 2 hours at a time. b. encouraging Christian residents to attend mass or church services. c. repeatedly confiscating herbs and food products used in healing. 12d. telling potential patients who are Jewish that the facility does not have a kosher kitchen, ANS: C Ethnocentrism is a belief that ones own cultural group is superior to that of anothers. In nursing we have a unique culture and expect our patients to adapt to us rather than attempting to adapt to the culture of the patient. Confiscating items used in healing rituals shows ethnocentrism and disrespect to the resident. Limiting activities in a group room, encouraging people to attend church services of their religion, and letting prospective Jewish residents know that the facility does not have a kosher kitchen are not examples of ethnocentrism. DIF: Applying (Application) REF: N/A OBJ: 5-6 TOP: Nursing Process: Implementation MSC: Psychosocial Integrity 5. While caring for an older Korean patient, the nurse notes that the patient answers questions regarding health history when asked but is otherwise silent and does not maintain eye contact. Being culturally sensitive, the nurse recognizes that the patients actions are most likely a(n): a. sign of respect for the wisdom and expertise of the nurse. b. indication that he has no questions regarding the care he is receiving. c. expression of discomfort discussing personal matters. d. means of communicating his dissatisfaction with his care. ANS: A Asian cultures generally view eye contact as rude and are often passive in their care. The patient may or may not have further questions. It is not a sign of discomfort or dissatisfaction. DIF: Remembering (Knowledge) REF: msc: 93 OBJ: 5-7 TOP: Caring MSC: Psychosocial Integrity 6. The culturally sensitive nurse will recognize that an older adult patient with a high-context ethnic background will appreciate: a. not having a treatment scheduled during a favorite television program. b. both a written and verbal explanation describing how to monitor her blood sugar levels. c. a concise explanation as to why her physical therapy appointment has been canceled. d. having a conversation about her grandchildren while her dressing is changed. ANS: D The interactional patterns of high-context (universalism) patients refer to the characteristics of relationships and behaviors toward others. When a person from a high-context culture interacts with the nurse, a more personal relationship is expected. This is not related to television shows, teaching materials, or appointment cancellations. DIF: Understanding (Comprehension) REF: msc: 92 OBJ: 5-7 TOP: Caring MSC: Psychosocial Integrity 7. In an attempt to be sensitive to varying cultural responses to touch, before shaking a patients hand, the nurse will: a. offer the patient his or her upturned palm. b. wait until the patient extends his or her hand. c. establish eye contact with the patient first. d. address the patient by his or her full name. ANS: B The best way to show respect and implement the appropriate response is to follow the lead of the patient by waiting for the patient to extend a hand. DIF: Applying (Application) REF: N/A OBJ: 5-7 TOP: Caring MSC: Psychosocial Integrity 8. A older Asian patient receiving physical therapy after hip surgery has developed a low-grade fever. The patient explains that the fever will lessen if the treatment includes the principles of yin/yang. The nurse expects to support the patient by: a. providing privacy when his shaman visits. b. arranging for his diet to include cold foods and liquids. c. planning his physical therapy so it does not conflict with meditation. d. keeping a magical amulet under his pillow. ANS: B The yin/yang theory proposes that health is a result of balance within the body. A principle of this theory is 13that an illness is either hot or cold and must be treated by elements of the opposite state in order to put the system back into balance. It is not related to shaman visits, meditation, or amulets. DIF: Applying (Application) REF: N/A OBJ: 5-9 TOP: Caring MSC: Psychosocial Integrity 9. The nurse in an assisted living facility is preparing to admit an older adult patient who speaks very little English. The nurse decides that it is most important that an interpreter be present when the patient: a. indicates a desire to talk with the physician. b. is being oriented to the facility. c. is required to sign official documents. d. begins crying and is inconsolable. ANS: C The more complex the decision making, the more important it is to have an interpreter present. Although all situations would benefit from an interpreter, the most important time is when the patient is signing official documents that have legal implications. DIF: Applying (Application) REF: N/A OBJ: 5-8 TOP: Communication and Documentation MSC: Psychosocial Integrity 10. When attempting to provide culturally sensitive care according to the explanatory model, the nurse asks the patient: a. Who will be able to help you when you go home? b. Do you think the treatment is helping? c. When did you first notice the problem? d. Has this illness changed your life? ANS: D The gerontologic nurse uses this model to explore the meaning of the health problem from the patients perspective. DIF: Applying (Application) REF: N/A OBJ: 5-7 TOP: Caring MSC: Psychosocial Integrity 11. The nurse is caring for an older adult patient in need of hospitalization. The nurse is aware this patient is a member of an ethnic group that holds a collectivist perspective on community. The nurse best addresses the patients medical needs by: a. calling an interpreter to assure the patient is making an informed decision. b. assuring the patient that his spiritual advisor will meet him at the hospital. c. arranging for admission to a hospital that is familiar with this patients culture. d. offering to phone the patients family and ask them to come in and discuss the hospitalization. ANS: D People with a collectivist perspective derive their identity from affiliation with and participation in a social group such as a family or clan. The needs of the group are more important than those of the individual, and decisions are made with consideration of the effect on the whole. Health care decisions may be made by a group (such as the tribal elders) or a group leader (such as the oldest son). The other options may or may not be needed depending on the specifics of the patients case. DIF: Applying (Application) REF: N/A OBJ: 5-9 TOP: Caring MSC: Psychosocial Integrity 12. The nurse is most effectively using the concept of future time orientation when: a. promising to help the patient call his daughter each weekend. b. offering to complete the health assessment history after the patient eats dinner. c. encouraging an older patient to keep a follow-up clinic appointment. d. arranging for a colorectal cancer screen for senior citizens. ANS: D In the concept of future orientation, people accept the idea that what is done now affects future health. This means that health screenings will help detect a problem today for potentially better health at a later time, days, weeks, or years ahead; it means that prevention may be worth pursuing. The other actions do not show a future orientation. DIF: Applying (Application) REF: N/A OBJ: 5-9 TOP: Caring MSC: Psychosocial Integrity 1413. The student learns that which of the following is the best definition of culture? a. A group of similarly appearing individuals b. Shared beliefs, behaviors, and expectations of groups c. Group beliefs about what is right and wrong d. Groups that come from the same part of the world ANS: B A culture is a set of shared and learned beliefs, behaviors, and expectations among a group of people. The individuals in different cultures may or may not look similar. Group beliefs about what is right or wrong are known as values. Cultural members may come from many different parts of the world. DIF: Remembering (Knowledge) REF: msc: 87 OBJ: 5-3 TOP: Teaching-Learning MSC: Psychosocial Integrity 14. A student nurse expresses frustration to the faculty member regarding an ethnic older adult who appears to be noncompliant. The student states, Why cant the patient just do what we teach her to do? What response by the nurse is best? a. Yes, I realize how frustrating this must be for you. b. People from her culture are never compliant. c. Maybe you can find a different way to get through. d. Culture dictates how people respond to others. ANS: D Culture is a blueprint for responding to individuals, family, and the community. Persons from strong cultural backgrounds cannot just change their behavior when instructed to do so. The nurse explains this to the student. Stating that the nurse understands the frustration is helpful but does not give the student any information that could help him or her work with this patient. Stating that people from a certain culture are never compliant is biased and prejudicial. Getting through to the patient implies ethnocentrism and bias. DIF: Applying (Application) REF: N/A OBJ: 5-7 TOP: Caring MSC: Psychosocial Integrity 15. A patient from a culture that differs from that of the nurse is hospitalized and near death. What action by the nurse best demonstrates cultural care preservation? a. Allowing the family to remain at the bedside b. Pinning a healing amulet to the patients gown c. Offering the family food and drink in the room d. Giving the family time to be alone with the patient ANS: B Cultural care preservation refers to those assistive, supportive, facilitative, or enabling professional actions and decisions that help people of a particular culture to retain and maintain their well-being, to recover from illness, or to face handicaps or death. Allowing the patient to have healing artifacts important in his or her culture nearby best demonstrates this concept. The other actions are caring but do not demonstrate this principle. DIF: Applying (Application) REF: N/A OBJ: 5-9 TOP: Caring MSC: Psychosocial Integrity 16. The nurse uses the LEARN model when providing care. What event best demonstrates that this model has been successful? a. The nurse learns about the patients culture and how it impacts care. b. The patient and nurse agree on a mutually acceptable plan of action. c. The nurse listens carefully to the patients concerns and beliefs. d. The patient understands how medical care will be beneficial. ANS: B The LEARN model includes listening to the patient, explaining your own perspectives, acknowledging the similarities and differences in both viewpoints, recommending a plan of action, and negotiating a final plan. If the patient and nurse have come to an agreement on a plan of action, this model has been successful. DIF: Evaluating (Evaluation) REF: N/A OBJ: 5-7 TOP: Caring MSC: Psychosocial Integrity 1517. A new nurse is caring for a patient from Appalachia. The patient seems guarded and secretive, which frustrates the new nurse. What advice from the mentor is most appropriate? a. Maybe you should ask to change your assignment. b. This is a normal behavior for this patients cultural group. c. You could try to apologize for anything you may have done. d. Ask the patient why she is acting so strangely around you. ANS: B Patients from the Appalachian culture are typically wary and guarded around strangers and view the hospital as a place to go and die. The nurse explains this to the new nurse. Changing assignments will not help the new nurse become culturally competent. The new nurse could ask the patient if there has been some offense, but this is probably not the case. Why questions put people on the defensive and are not considered examples of therapeutic communication. DIF: Understanding (Comprehension) REF: msc: 87 OBJ: 5-6 TOP: Caring MSC: Psychosocial Integrity 18. A nurse is caring for an Arab American patient in the hospital. The patient has many visitors who seem to be tiring the patient. What action by the nurse is best? a. Limit the number of visitors the patient can have. b. Only allow family members to visit the patient. c. Suggest shorter visits to the patients visitors. d. Require visitors to check in at the front desk. ANS: C In Arab American Muslim culture, visiting the sick is a cultural value and expectation. Although the visits may be tiring, they may also be important to the patient. The nurse can suggest shorter visits so the patient can have both the visitors and more rest. Limiting the number of visitors would violate this cultural norm as would limiting visits to family only. Checking in at the front desk serves no useful purpose. DIF: Applying (Application) REF: N/A OBJ: 5-6 TOP: Caring MSC: Psychosocial Integrity 19. A director of nursing works in a hospital that serves many Jehovahs Witness patients. What action by the nurse would best facilitate culturally appropriate health care? a. Establish a bloodless surgery program. b. Create an immunization clinic for children. c. Employ spiritual leaders from this faith. d. Allow faith healing ceremonies. ANS: A Jehovahs Witnesses generally are opposed to receiving all blood products. A bloodless surgery program would be a culturally competent way to improve the health care of this population. DIF: Applying (Application) REF: N/A OBJ: 5-5 TOP: Caring MSC: Psychosocial Integrity 20. An incapacitated older adult with dementia is brought to the emergency department by a rescue squad after falling and breaking an arm. When the patients children arrive, they are adamantly against the patient having any medical care and insist that prayer will heal the broken arm. What action by the nurse is most appropriate? a. Allow the family to pray with the patient then escort them to the waiting room. b. Call security to keep the family from interfering with medical care. c. Check facility policies and contact the hospital social worker. d. Call the police who can force the family to accept medical care. ANS: C This family may be Christian Scientists, who do not believe in medical care. Health crises are thought to be errors of the mind that can be altered by prayer. The nurse should check the facility policies for treating vulnerable adults and possibly notify social work, who can assist with ensuring adequate treatment occurs as allowed by policy. Allowing the family to pray with the patient is a caring action, but this complex situation requires more intervention. Calling security or the police will antagonize the family even more and demonstrates an adversarial relationship. DIF: Applying (Application) REF: N/A OBJ: 5-6 TOP: Communication and Documentation MSC: Safe Effective Care Environment MULTIPLE RESPONSE 161. When attempting to reflect about personal cultural awareness, the nurse asks himself or herself which of the following quetions? (Select all that apply.) a. What image do I want to project to members of other cultures? b. What makes a culture worthy of biased treatment? c. Have my life experiences contributed to any biases regarding other cultures? d. Am I uncomfortable when interacting with members of other cultures? e. Does the patients culture rely on solid science to direct health care? ANS: A, C, D Self-reflection implies thinking that regards how I, the individual, perceives/believes/behaves. Awareness of ones thoughts and feelings about others who are culturally different from oneself is necessary to become culturally aware. No culture is worthy of biased treatment. Solid science is an ethnocentric principle. DIF: Applying (Application) REF: N/A OBJ: 5-4 TOP: Caring MSC: Psychosocial Integrity 2. What does the nurse working with older adults from many different cultures know about the demographics of culture in the United States? (Select all that apply.) a. Hispanics will become the largest minority group by 2030. b. Many persons of color are not counted in the census. c. The percentage of Native Americans/Native Alaskans will decrease. d. The number of refugees and immigrants is expected to decrease. e. Some Native Americans want to identify as specific tribal members. ANS: A, B, C Hispanics are expected to be the largest minority group in the United States by 2030. Many persons of color are not represented in the census, and this underestimates their presence. The percentage of Native Alaskans and Native Americans will rise, as will the number of immigrants/refugees. Some Native Americans may not view themselves as part of this larger group, preferring to identify as a member of a specific tribe. DIF: Remembering (Knowledge) REF: msc: 83 OBJ: 5-1 TOP: Communication and Documentation MSC: Psychosocial Integrity 3. A nurse working in the emergency department is seeing an older patient who does not speak English well. The nurse calls for an interpreter. The student wants to know why the patients minor child, who speaks English, cannot interpret. What response by the nurse is best? (Select all that apply.) a. The child may not accurately translate. b. The child and older adult may be embarrassed. c. The patient has the right to interpretation. d. Having a child interpret takes too much time. e. Privacy laws prohibit this practice. ANS: A, B, C Although in a true emergency the nurse may have to use a child interpreter, this practice is not recommended. The child may not have the vocabulary to translate, the child may edit the comments, the child or older adult may be embarrassed by the medical condition, and patients have a legal right to professional interpretation. Using an interpreter always takes more time and privacy laws do not prohibit this practice. Chapter 7. Ethics MULTIPLE CHOICE 1. A nurse caring for older adult patients shows an understanding of the implementation of standards of care when: a. dialing the telephone when the patient wants to call his daughter. b. requesting the patients favorite dessert on his birthday. c. closing the patients door when he is praying. d. reminding the patient to call for assistance before getting out of bed. ANS: D A standard of care is a guideline for nursing practice and establishes an expectation for the nurse to 17provide safe and appropriate care, such as reminding the patient to call for assistance before getting out of bed. Standards of care may be established on national or regional levels. Dialing the phone for the patient, closing the patients door, and requesting a special dessert are not actions that conform to standards of care. DIF: Applying (Application) REF: N/A OBJ: 3-1 TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment 2. A nurse new to geriatric nursing asks the nurse manager to clarify how to handle a patients claim that she has been physically abused. The nurse manager responds most appropriately when stating: a. Ill show you where you can find this states reporting requirements. b. As a nurse you are considered a mandated reporter of elder abuse. c. As long as you are reasonably sure abuse has occurred, report it. d. You need to report any such claims directly to me. ANS: A To be responsive to the legal obligation to report reasonably suspicious acts of abuse and because there is great variation among the states, nurses should determine the specific reporting requirements of their jurisdictions, including where reports and complaints are received and in what form they must be made. The statements that the nurse is a mandatory reporter and that abuse should be reported if suspected are true, but they do not help the nurse learn to handle the complaint. The manager may want to know about claims of abuse and it may be facility policy to report up the chain of command, but the nurse is responsible for filing the formal complaint. DIF: Applying (Application) REF: N/A OBJ: 3-8 TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment 3. The nurse recognizes that a nursing aide likely to abuse an older patient is one who has: a. ineffective verbal communication skills. b. little experience working with the older population. c. poor stress management skills. d. been a victim of abuse. ANS: C It has been shown that the primary abusers of nursing facility residents are nurse aides and orderlies who have never received training in stress management. DIF: Remembering (Knowledge) REF: msc: 32 OBJ: 3-8 TOP: Nursing Process: Assessment MSC: Safe and Effective Care Environment 4. An older adult resident of a long-term care nursing facility frequently attempts to get out of bed and is at risk of sustaining an injury. The nurses planned intervention to minimize the patients risk for injury is guided by: a. the patients right to self-determination and to be free to get out of bed. b. an understanding that nondrug interventions must be tried before medications. c. the knowledge that application of a vest restraint requires a physicians order. d. the patients cognitive ability to understand and follow directions. ANS: B The drug use guidelines are based on the principles that certain problems can be handled with nondrug interventions and that such forms of treatment must be ruled out before drug therapy is initiated. The patient does have the right to self-determination, but the staff must ensure the patients safety. Vest restraints do require an order, but environmental measures must be tried before chemical or physical restraints. The patients cognitive abilities do not allow for unjustified physical or chemical restraints. DIF: Remembering (Knowledge) REF: msc: 35-6 OBJ: 3-7 TOP: Nursing Process: Implementation MSC: Safe and Effective Care Environment 5. During the state inspection of a skilled nursing facility, a surveyor notes suspicion that a particular nurse may not be providing the proper standard of care. The nurse manager informs the nurse to expect: a. a review of the situation by the state board of nursing. b. termination of employment from the facility. c. mandatory remediation related to the suspect care issues. d. unannounced reevaluation of performance within the next 3 months. ANS: A In such cases, the surveyor may forward the record showing the relevant findings to the appropriate state 18