ramont2e rev tif ch42

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Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test

Bank

Chapter 42Question 1

Type: MCSA

The nurse interprets which of the following statements as an indication that the elderly client is meeting the

developmental task for this stage of life?

1. "If I could live my life over, I would do a lot of things differently"

2. "It!s een lonely, ut I have found a new sweetheart in the nursing home"

. "I didn!t do everything I wanted to in life, ut I am happy with what I accomplished"

4. "My kids didn!t want my elongings, so I willed them to charity"

Corre!t "ns#er: #

Rationa$e 1$ According to %rikson, the task of the older adult is integrity versus despair, so the client who is

happy with how she has lived her life is indicating that she has met the task of integrity



Rationa$e $ According to %rikson, the task of the older adult is integrity versus despair, so the client who is




%$o&a$ Rationa$e:

Cogniti'e (e'e$: Analy&ing

C$ient Need: 'ealth (romotion and Maintenance

C$ient Need )u&:

Nursing*+ntegrated Con!epts: )ursing (rocess$ Assessment

(earning ut!ome: *escrie psychosocial challenges confronting older adults

Question 2

Type: MCSA

The nurse speciali&ing in gerontology cares for clients$

1. + years old or older

-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank

Copyright .1. y (earson %ducation, Inc



2. +2 years old or older

. 3 years old or older

4. #2 years old or older

Corre!t "ns#er: .

Rationa$e 1$ 4erontology is care of clients +2 years old and older


Rationa$e $ 4erontology is care of clients +2 years old and older


%$o&a$ Rationa$e:

Cogniti'e (e'e$: -ememering

C$ient Need:

C$ient Need )u&:

Nursing*+ntegrated Con!epts:

(earning ut!ome: *efine the term gerontology and discuss its importance as a specialty

Question

Type: MCSA

The nurse, when admitting a new client to the long5term care facility, assesses the client!s family history ecause$

1. 'eredity and genetics play a role in longevity and types of health concerns the client might face

2. It is important to know the person to notify in case of emergency

. 6nowing more aout the client will allow more of the client!s needs to e met

4. The admission form dictates that this information e collected

Corre!t "ns#er: 1

Rationa$e 1$ 'eredity and genetics play an important role in determining what types of health concerns the clientmight face, as does to life e7pectancy

Rationa$e 2$ 'eredity and genetics play an important role in determining what types of health concerns the client

might face, as does to life e7pectancy

Rationa$e $ 'eredity and genetics play an important role in determining what types of health concerns the client

might face, as does to life e7pectancy





Rationa$e 4$ 'eredity and genetics play an important role in determining what types of health concerns the clientmight face, as does to life e7pectancy

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: Identify factors that affect the aging process

Question 4

Type: MCSA

The nurse assesses the skin of a resident in the assisted5living facility and determines that which of the following

is a normal physiological change related to aging?

1. 8aundiced skin color

2. Cyanotic undertones to skin color

. Appearance of rown pigmentation on the hands

4. (la9ue formations on the elows and knees

Corre!t "ns#er: 1

Rationa$e 1$ As part of the aging process, lentigo senilis, or rown spots:often referred to as age spots:can

appear on the client!s e7posed parts, such as the hands, face, and arms 8aundice and cyanosis are anormalfindings re9uiring further assessment, and should e reported to the provider (la9ue formation on the elows

could indicate the presence of psoriasis

Rationa$e 2$ As part of the aging process, lentigo senilis, or rown spots:often referred to as age spots:can

appear on the client!s e7posed parts, such as the hands, face, and arms 8aundice and cyanosis are anormalfindings re9uiring further assessment, and should e reported to the provider (la9ue formation on the elows


Rationa$e $ As part of the aging process, lentigo senilis, or rown spots:often referred to as age spots:can

appear on the client!s e7posed parts, such as the hands, face, and arms 8aundice and cyanosis are anormal

findings re9uiring further assessment, and should e reported to the provider (la9ue formation on the elowscould indicate the presence of psoriasis

Rationa$e 4$ As part of the aging process, lentigo senilis, or rown spots:often referred to as age spots:canappear on the client!s e7posed parts, such as the hands, face, and arms 8aundice and cyanosis are anormal

findings re9uiring further assessment, and should e reported to the provider (la9ue formation on the elows






%$o&a$ Rationa$e:

Cogniti'e (e'e$: Applying


C$ient Need )u&:


(earning ut!ome: *iscuss normal physiologic changes of older adults y ody system, including sensory

changes and adaptations

Question -

Type: MCSA

The nurse assesses the musculoskeletal system of a client admitted to the rehailitation facility and determines

that which of the following is not a normal result of aging?

1. ;steoporosis

2. Shrinking of interverteral disks

. *ecreased fle7iility of <oints

4. Appearance of an unsteady gait

Corre!t "ns#er: 1

Rationa$e 1$ =hile a gradual loss of calcium in the ones egins in the #s and >s, the occurrence of

osteoporosis is not a normal result of aging, and can e prevented y increasing calcium intake The remainingoptions are normal results of aging


osteoporosis is not a normal result of aging, and can e prevented y increasing calcium intake The remaining

options are normal results of aging

Rationa$e $ =hile a gradual loss of calcium in the ones egins in the #s and >s, the occurrence ofosteoporosis is not a normal result of aging, and can e prevented y increasing calcium intake The remaining



osteoporosis is not a normal result of aging, and can e prevented y increasing calcium intake The remaining


%$o&a$ Rationa$e:


C$ient Need: (hysiological Integrity

C$ient Need )u&:






(earning ut!ome: *iscuss normal physiologic changes of older adults y ody system, including sensorychanges and adaptations

Question

Type: MCSA

The nurse admits an 25year5old client to the acute care facility and contriutes which of the following goals

related to the normal results of aging?

1. The client will remain infection5free at time of discharge

2. The client will reduce weight y 12 pounds within the ne7t two months

. The client will demonstrate improved e7ercise tolerance as pneumonia resolves

4. The client will improve cardiac output y 1@ after maintaining a low5sodium diet and reducing fluid volume

e7cess

Corre!t "ns#er: 1

Rationa$e 1$ Aging clients have reduced immune response, and are more susceptile to infection, so an importannursing goal is to prevent a nosocomial infection The other goals would e more appropriate for a client with a

diagnosed medical prolem, and are not related to the normal effects of aging

Rationa$e 2$ Aging clients have reduced immune response, and are more susceptile to infection, so an importan

nursing goal is to prevent a nosocomial infection The other goals would e more appropriate for a client with adiagnosed medical prolem, and are not related to the normal effects of aging

Rationa$e $ Aging clients have reduced immune response, and are more susceptile to infection, so an importannursing goal is to prevent a nosocomial infection The other goals would e more appropriate for a client with a


Rationa$e 4$ Aging clients have reduced immune response, and are more susceptile to infection, so an importan

nursing goal is to prevent a nosocomial infection The other goals would e more appropriate for a client with a


%$o&a$ Rationa$e:


C$ient Need: (hysiological IntegrityC$ient Need )u&:

Nursing*+ntegrated Con!epts: )ursing (rocess$ (lanning

(earning ut!ome: *iscuss normal physiologic changes of older adults y ody system, including sensorychanges and adaptations

Question /

Type: MCMA





The nurse is developing a plan to help the client restore urinary continence, and includes$ Select all that applyB

)tandard Te0t: Select all that apply

1. (rompted voiding

2. (elvic muscle e7ercises

. )egative reinforcement

4. Insertion of an indwelling catheter

-. Skin care

Corre!t "ns#er: 1,.,2

Rationa$e 1$ The client who e7periences urinary incontinence will enefit from eing reminded to void regularly

performing 6egel e7ercises, and meticulous skin care to prevent damage from urine remaining on the skin

(ositive, not negative, reinforcement should e used to reward successes Insertion of an indwelling cathetere7poses the client to the risk of urinary tract infection, and might worsen, rather than improve, urinary

incontinence


performing 6egel e7ercises, and meticulous skin care to prevent damage from urine remaining on the skin(ositive, not negative, reinforcement should e used to reward successes Insertion of an indwelling catheter

e7poses the client to the risk of urinary tract infection, and might worsen, rather than improve, urinary

incontinence

Rationa$e $ The client who e7periences urinary incontinence will enefit from eing reminded to void regularly

performing 6egel e7ercises, and meticulous skin care to prevent damage from urine remaining on the skin(ositive, not negative, reinforcement should e used to reward successes Insertion of an indwelling catheter

e7poses the client to the risk of urinary tract infection, and might worsen, rather than improve, urinaryincontinence


performing 6egel e7ercises, and meticulous skin care to prevent damage from urine remaining on the skin

(ositive, not negative, reinforcement should e used to reward successes Insertion of an indwelling cathetere7poses the client to the risk of urinary tract infection, and might worsen, rather than improve, urinary

incontinence

Rationa$e -$ The client who e7periences urinary incontinence will enefit from eing reminded to void regularly performing 6egel e7ercises, and meticulous skin care to prevent damage from urine remaining on the skin(ositive, not negative, reinforcement should e used to reward successes Insertion of an indwelling catheter

e7poses the client to the risk of urinary tract infection, and might worsen, rather than improve, urinary

incontinence

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome: Identify ways of maintaining or restoring urinary continence

Question

Type: MCSA

The nurse plans care for the older adult with the understanding that it is most important to$

1. ;tain a Social Services consult to help him deal with difficult financial situations

2. Include him in care planning to promote their independence as much as possile

. 'elp him prepare for his upcoming death in order to e ale to achieve acceptance

4. Arrange for multiple opportunities to interact with others

Corre!t "ns#er: .

Rationa$e 1$ It is very important to elderly clients to maintain their independence and they should e included in

all care planning to help them achieve this goal )ot all elderly clients have difficult financial situations(reparation for death would not e planned unless there were a reason to anticipate that this is impending Social

opportunities are more important for the adolescent than for the elderly client, and not nearly as important as

maintaining independence

Rationa$e 2$ It is very important to elderly clients to maintain their independence and they should e included in

all care planning to help them achieve this goal )ot all elderly clients have difficult financial situations(reparation for death would not e planned unless there were a reason to anticipate that this is impending Social

opportunities are more important for the adolescent than for the elderly client, and not nearly as important asmaintaining independence

Rationa$e $ It is very important to elderly clients to maintain their independence and they should e included in

all care planning to help them achieve this goal )ot all elderly clients have difficult financial situations

(reparation for death would not e planned unless there were a reason to anticipate that this is impending Socialopportunities are more important for the adolescent than for the elderly client, and not nearly as important as


Rationa$e 4$ It is very important to elderly clients to maintain their independence and they should e included inall care planning to help them achieve this goal )ot all elderly clients have difficult financial situations(reparation for death would not e planned unless there were a reason to anticipate that this is impending Social

opportunities are more important for the adolescent than for the elderly client, and not nearly as important as


%$o&a$ Rationa$e:






C$ient Need: (sychosocial Integrity

C$ient Need )u&:


(earning ut!ome: *escrie psychosocial challenges confronting older adults

Question

Type: MCSA

A healthy client in the si7th decade of life comes to the physician!s office for a routine physical e7amination The

client asks the nurse for general nutritional advice The nurse will ase this general nutrition advice on which of

the following facts?

1. As people age, they need to take in more calories

2. The older adult cannot digest fatty foods properly

. ;lder adults have more difficulty digesting carohydrates than they do other food groups

4. Taking antacids efore each meal prevents most gastric prolems in the elderly

Corre!t "ns#er: .

Rationa$e 1$ at is not easily digested y the older client, who is more prone to diarrhea after eating fatty foods


Rationa$e $ at is not easily digested y the older client, who is more prone to diarrhea after eating fatty foods


%$o&a$ Rationa$e:



C$ient Need )u&:

Nursing*+ntegrated Con!epts: )ursing (rocess$ Implementation



Question 13

Type: MCSA

The nurse has gathered data on an older client who has presycusis The nurse is setting goals with this client

=hich of the following goals would the nurse and client likely make to deal with this prolem?





1. =ill use magnifying device 1@ of the time to read prescription instructions

2. =ill wear hearing aid 1@ of the time when receiving instructions

. =ill demonstrate understanding of correct method of stump cleaning

4. =ill identify ways to reduce sugar intake and increase fluid intake

Corre!t "ns#er: .

Rationa$e 1$ It is important to make sure the client can hear instructions provided y the nurse, and the use of the

hearing aid will increase the likelihood of hearing what the nurse says

Rationa$e 2$ It is important to make sure the client can hear instructions provided y the nurse, and the use of thehearing aid will increase the likelihood of hearing what the nurse says

Rationa$e $ It is important to make sure the client can hear instructions provided y the nurse, and the use of the

hearing aid will increase the likelihood of hearing what the nurse says

Rationa$e 4$ It is important to make sure the client can hear instructions provided y the nurse, and the use of thehearing aid will increase the likelihood of hearing what the nurse says

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: Identify special health concerns of older adults

Question 11

Type: MCSA

=hen working with an older adult client, the nurse would e especially alert to the fact that this client is likely$

1. To sense pain more 9uickly than younger clients do

2. )ot to show signs and symptoms of infection as early as younger clients do

. To have a larger percentage of ody fluids compared with young adults

4. To have increased production of erythrocytes

Corre!t "ns#er: .

Rationa$e 1$ ;lder clients do not show signs and symptoms of infection and, as a result, are more likely to e

more acutely ill y the time symptoms do show up





Rationa$e 2$ ;lder clients do not show signs and symptoms of infection and, as a result, are more likely to emore acutely ill y the time symptoms do show up

Rationa$e $ ;lder clients do not show signs and symptoms of infection and, as a result, are more likely to e


Rationa$e 4$ ;lder clients do not show signs and symptoms of infection and, as a result, are more likely to e


%$o&a$ Rationa$e:



C$ient Need )u&:




Question 12

Type: MCSA

=hen preparing to teach the elderly client, it would e important to assess which of the following first?

1. 'air and scalp condition

2. =eight loss or weight gain

. Dision and hearing

4. Mental status

Corre!t "ns#er: #

Rationa$e 1$ The nurse should assess vision and hearing in order to customi&e the teaching plan to optimi&e the

client!s understanding



Rationa$e $ The nurse should assess vision and hearing in order to customi&e the teaching plan to optimi&e theclient!s understanding



%$o&a$ Rationa$e:






C$ient Need: Safe %ffective Care %nvironment

C$ient Need )u&:


(earning ut!ome: Identify special health concerns of older adults

Question 1

Type: MCSA

An older adult client in the long5term care facility is incontinent of urine during the day and night =hat message

would e est for the nurse to convey to the client, the client!s family, and the nursing assistants caring for this

client?

1. "Clients who are incontinent at night need to e npo in the evening"

2. "An indwelling catheter can e a long5term answer to this prolem"

. "Incontinence is not a normal part of aging, and often is treatale"

4. "%liminating all caffeine drinks from the diet will help eliminate this prolem"

Corre!t "ns#er: #

Rationa$e 1$ It is important for the nurse to inform the client and family that the staff will help the clientovercome the prolem of incontinence, and that it is treatale

Rationa$e 2$ It is important for the nurse to inform the client and family that the staff will help the client

overcome the prolem of incontinence, and that it is treatale

Rationa$e $ It is important for the nurse to inform the client and family that the staff will help the clientovercome the prolem of incontinence, and that it is treatale

Rationa$e 4$ It is important for the nurse to inform the client and family that the staff will help the client

overcome the prolem of incontinence, and that it is treatale

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing (rocess$ Implementation

(earning ut!ome: Identify ways of maintaining or restoring urinary continence

Question 14

Type: MCSA





The nurse identifies which of the following organi&ations as an important resource when dealing with elder

ause?

1. Administration on Aging

2. American Association of -etired (ersons

. )ational Center on %lder Ause

4. %lder Ause (revention Center

Corre!t "ns#er: #

Rationa$e 1$ The )ational Center on %lder Ause was estalished y the Administration on Aging to act as a

resource to reduce the numer of older adults e7periencing ause The American Association of -etired (ersons ian organi&ation that works to improve the lives of older adults There is no such thing as the %lder Ause

(revention Center

Rationa$e 2$ The )ational Center on %lder Ause was estalished y the Administration on Aging to act as aresource to reduce the numer of older adults e7periencing ause The American Association of -etired (ersons i

an organi&ation that works to improve the lives of older adults There is no such thing as the %lder Ause

(revention Center

Rationa$e $ The )ational Center on %lder Ause was estalished y the Administration on Aging to act as aresource to reduce the numer of older adults e7periencing ause The American Association of -etired (ersons i


(revention Center

Rationa$e 4$ The )ational Center on %lder Ause was estalished y the Administration on Aging to act as aresource to reduce the numer of older adults e7periencing ause The American Association of -etired (ersons i


(revention Center

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: Identify important safety issues of older clients

Question 1-

Type: MCSA

The nurse is addressing a group of older adults who are learning to use computers in a class for senior citi&ens

The nurse promotes safety y encouraging the group to$





1. *ownload instant messaging so they can keep in touch with others

2. Avoid social networking sites such as aceook

. 4uard their personal information

4. Avoid living alone to reduce stranger danger

Corre!t "ns#er: #

Rationa$e 1$ ;lder clients are at increased risk for identity theft and scams, so it is important, when teaching the

elder to use the computer, to also discuss the risks inherent with sharing personal information

Rationa$e 2$ ;lder clients are at increased risk for identity theft and scams, so it is important, when teaching theelder to use the computer, to also discuss the risks inherent with sharing personal information

Rationa$e $ ;lder clients are at increased risk for identity theft and scams, so it is important, when teaching the

elder to use the computer, to also discuss the risks inherent with sharing personal information

Rationa$e 4$ ;lder clients are at increased risk for identity theft and scams, so it is important, when teaching theelder to use the computer, to also discuss the risks inherent with sharing personal information

%$o&a$ Rationa$e:


C$ient Need: Safe %ffective Care %nvironment

C$ient Need )u&:


(earning ut!ome: Identify important safety issues of older clients

Question 1

Type: MCSA

The nurse working in a geriatrician!s office is admitting a client diagnosed with Al&heimer!s disease when the

client!s daughter says, "I love my Mom, ut she is driving me cra&y I have to watch her constantly ecause she

tends to wander, and I am only getting aout four hours of interrupted sleep a night I don!t know how much

longer I can stand this" The nurse interprets this comment as an indication of$

1. %7haustion of the caregiver

2. Caregiver role strain with potential for elder ause

. The need to place the client in a nursing home

4. A sign that the client is in the end stage of Al&heimer!s disease

Corre!t "ns#er: .





Rationa$e 1$ The e7hausted caregiver daughter is e7hiiting signs that could indicate the potential for ause, andthe nurse should e7plore options for the family that would allow the caregiver time to sleep and meet her own

needs The caregiver is plainly indicating that she is e7hausted, and this doesn!t re9uire interpretation It is

uncertain if this family desires placement in a nursing home or whether other options might work etter for themThis client is not in late5stage Al&heimer!s if she is still ale to wander

Rationa$e 2$ The e7hausted caregiver daughter is e7hiiting signs that could indicate the potential for ause, and

the nurse should e7plore options for the family that would allow the caregiver time to sleep and meet her ownneeds The caregiver is plainly indicating that she is e7hausted, and this doesn!t re9uire interpretation It isuncertain if this family desires placement in a nursing home or whether other options might work etter for them

This client is not in late5stage Al&heimer!s if she is still ale to wander

Rationa$e $ The e7hausted caregiver daughter is e7hiiting signs that could indicate the potential for ause, and

the nurse should e7plore options for the family that would allow the caregiver time to sleep and meet her ownneeds The caregiver is plainly indicating that she is e7hausted, and this doesn!t re9uire interpretation It is

uncertain if this family desires placement in a nursing home or whether other options might work etter for them

This client is not in late5stage Al&heimer!s if she is still ale to wander

Rationa$e 4$ The e7hausted caregiver daughter is e7hiiting signs that could indicate the potential for ause, andthe nurse should e7plore options for the family that would allow the caregiver time to sleep and meet her own

needs The caregiver is plainly indicating that she is e7hausted, and this doesn!t re9uire interpretation It is

uncertain if this family desires placement in a nursing home or whether other options might work etter for themThis client is not in late5stage Al&heimer!s if she is still ale to wander

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome: *iscuss caregiver stress, factors that contriute to elder ause, and client teaching to preven

elder ause

Question 1/

Type: MCSA

The nurse e7plains to a group of nursing students that gerontology is$

1. A health specialty that focuses on the care of older adults

2. The study of adults from >2 to +2

. The study of older adults

4. 'ealth promotion of older adults

Corre!t "ns#er: #





Rationa$e 1$ 4eriatrics is a health specialty that focuses on care of older adults


Rationa$e $ 4eriatrics is a health specialty that focuses on care of older adults


%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

The nurse understands that the field of geriatrics is growing due to the following$Select all that applyB


1. The numer of older adults is growing

2. Many of the older adults are coming into old age in poor health

. The effects of aging are cumulative

4. There are 32 million ay oomers

-. ;lder adults are seeking healthcare, and are interested in promoting good health

Corre!t "ns#er: 1,#,>,2

Rationa$e 1$ The numer of older adults is increasing and are coming into old age more active


Rationa$e $ The numer of older adults is increasing and are coming into old age more active


Rationa$e -$ The numer of older adults is increasing and are coming into old age more active

%$o&a$ Rationa$e:







C$ient Need )u&:


(earning ut!ome:

Question 1

Type: MCMA

The nurse is presenting a workshop for a group of clients at a senior center =hich of the following actions y the

clients will decrease the older personEs chances of ecoming disaled?Select all that applyB


1. Disit the doctor

2. Stop smoking

. Maintain weight

4. %7ercise once or twice a week

-. Stretch, and use sound lifting techni9ues


Rationa$e 1$ ;lder adults should get regular checkups and screenings


Rationa$e $ ;lder adults should get regular checkups and screenings


Rationa$e -$ ;lder adults should get regular checkups and screenings

%$o&a$ Rationa$e:




(earning ut!ome:

Question 23

Type: MCMA





The nurse is reviewing the nutritional needs of the older adult =hich of the following is true aout the nutrition

needs of the elderly?Select all that applyB


1. ;lder people are more likely to e affected y loss of appetite

2. There is no difference in the My(yramid recommendations for older adults

. Caloric needs increase as people age

4. %conomic factors affect the diet of the older adult

-. It is difficult for the frail elderly to reuild lost muscle mass

Corre!t "ns#er: 1,>,2

Rationa$e 1$ Many seniors e7perience a decrease in appetite, which can adversely affect their protein intake


Rationa$e $ Many seniors e7perience a decrease in appetite, which can adversely affect their protein intake


Rationa$e -$ Many seniors e7perience a decrease in appetite, which can adversely affect their protein intake

%$o&a$ Rationa$e:

Cogniti'e (e'e$: /nderstanding


C$ient Need )u&:


(earning ut!ome:

Question 21

Type: MCSA

The nurse counsels the 3+ year old client to$

1. %at even when not hungry

2. Fisten to and take cues from oneEs ody

. *onEt try to keep up with the grandchildren

4. -educe contact with others as you age





Corre!t "ns#er: .

Rationa$e 1$ The client should eat when hungry, making sure that the 9uality of the food will meet nutritionalneeds

Rationa$e 2$ The client should eat when hungry, making sure that the 9uality of the food will meet nutritional

needs

Rationa$e $ The client should eat when hungry, making sure that the 9uality of the food will meet nutritionalneeds

Rationa$e 4$ The client should eat when hungry, making sure that the 9uality of the food will meet nutritional

needs

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 22

Type: MCMA

A family is voicing concern to the nurse regarding their 35year5old motherEs recovery from a roken hip The

nurse e7plains to the family that$Select all that applyB


1. ;lder people re9uire more time to recover from illness and in<ury

2. Fonger recovery periods are normal for older clients

. ;lder adults will recover more 9uickly if they have een e7ercising regularly

4. They donEt need to worryG most older people heal more slowly ecause of poor nutrition

-. If the older adult did not care for herself during her younger years, there may e serious health issues in older

adulthood

Corre!t "ns#er: 1,.,#,2

Rationa$e 1$ ;lder people re9uire more time to recover from illness, in<ury, or surgery than they did when they

were younger





Rationa$e 2$ ;lder people re9uire more time to recover from illness, in<ury, or surgery than they did when theywere younger

Rationa$e $ ;lder people re9uire more time to recover from illness, in<ury, or surgery than they did when they

were younger

Rationa$e 4$ ;lder people re9uire more time to recover from illness, in<ury, or surgery than they did when they

were younger

Rationa$e -$ ;lder people re9uire more time to recover from illness, in<ury, or surgery than they did when they

were younger

%$o&a$ Rationa$e:



C$ient Need )u&:


(earning ut!ome:

Question 2

Type: MCMA

The nurse is reviewing the odily changes that occur with aging with a group of family memers of older adults

actors that affect the aging process include$Select all that applyB


1. 'ealth conditions

2. 'eredity

. %nvironment

4. 4ender

-. Marital status

Corre!t "ns#er: 1,.,#,>

Rationa$e 1$ 'ealth conditions refers to the way a person has taken care of his or her odyG activity and smoking

haits have profound effects on the aging process







Rationa$e $ 'ealth conditions refers to the way a person has taken care of his or her odyG activity and smokinghaits have profound effects on the aging process



Rationa$e -$ 'ealth conditions refers to the way a person has taken care of his or her odyG activity and smoking


%$o&a$ Rationa$e:



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Question 24

Type: MCSA

The nurse is evaluating a +5year5old client 'ealth conditions that may affect the aging process include$

1. *iet

2. 4enetics

. Fiving in the city

4. Fiving in a cold climate

Corre!t "ns#er: 1

Rationa$e 1$ 'ealth conditions refers to the way a person has taken care of his or her ody healthy dietary haitslead to stronger heart, lungs, circulation, metaolism, and elimination

Rationa$e 2$ 'ealth conditions refers to the way a person has taken care of his or her ody healthy dietary haits

lead to stronger heart, lungs, circulation, metaolism, and elimination

Rationa$e $ 'ealth conditions refers to the way a person has taken care of his or her ody healthy dietary haits


Rationa$e 4$ 'ealth conditions refers to the way a person has taken care of his or her ody healthy dietary haits


%$o&a$ Rationa$e:







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Question 2-

Type: MCMA

The nurse is taking a family history of a new client =hich of the following health disorders may have a genetic

link that can help the nurse to affect lifestyle changes that may lead to positive outcomes?Select all that applyB


1. Smoking

2. 'eart disease

. *iaetes

4. ;esity

-. Multiparity

Corre!t "ns#er: .,#

Rationa$e 1$ Smoking is a choice that a client makes that is not related to genetics


Rationa$e $ Smoking is a choice that a client makes that is not related to genetics


Rationa$e -$ Smoking is a choice that a client makes that is not related to genetics

%$o&a$ Rationa$e:



C$ient Need )u&:Nursing*+ntegrated Con!epts: )ursing (rocess$ Implementation

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Question 2

Type: MCSA

A nurse is evaluating a clientEs environment %nvironmental factors to incorporate in the client history include$





1. 'istory of smoking

2. 'istory of hypertension

. 'istory of divorce

4. 'istory of daily e7ercise

Corre!t "ns#er: #

Rationa$e 1$ A clientEs history of smoking is considered an element of health conditions


Rationa$e $ A clientEs history of smoking is considered an element of health conditions


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Question 2/

Type: MCMA

The nurse is reviewing general guidelines aout the older adult and ody changes Important aspects to rememer

in order to customi&e client care include$Select all that apply


1. There are many predictale changes

2. Timing of physiologic changes happens at the same rate in identical twins

. (romoting physical health among older adults is a role for nurses

4. (hysical changes stop once the older adult moves to a health care facility, such as a nursing home, where

ade9uate health care is provided

-. The only system unaffected y aging is the endocrine system

Corre!t "ns#er: 1,#





Rationa$e 1$ Many predictale changes can e oserved in older adultsE physiology and structure


Rationa$e $ Many predictale changes can e oserved in older adultsE physiology and structure


Rationa$e -$ Many predictale changes can e oserved in older adultsE physiology and structure

%$o&a$ Rationa$e:



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Question 2

Type: MCMA

The nurse can e7pect to note several changes in the skin of the older adult =hich of the following are particularl

important to assess as potential effects of these changes$Select all that applyB


1. 0ody temperature

2. Fentigo senilis

. 'ydration

4. -idges in nails

-. 'air changes

Corre!t "ns#er: 1,#

Rationa$e 1$ ;lder adults are at risk for heat stroke and heat e7haustion ecause they have fewer and fewer active

sweat glandsG in addition, due to the loss of sucutaneous fat and reduced thickness and vascularity of the dermisolder people are more susceptile to hypothermia

Rationa$e 2$ Fentigo senilis, or Hage spots are areas of rown pigmentation that have no dangerous effects

Rationa$e $ 'ydration is difficult to assess in the older clients, due to reductions in skin elasticity, fluid content,and sucutaneous fatG nurses have to e innovative and assess areas that are not affected y wrinkling when

checking skin turgor





Rationa$e 4$ -idges in the nails are cause y an increase in calcium deposits, which are not dangerous to theclientEs health

Rationa$e -$ 'air changes as pigment cells are lost from hair uls, and hair turns gray or white and ecomes

thinnerG this is not dangerous to the client

%$o&a$ Rationa$e:



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Question 2

Type: MCSA

The nurse is caring for a client who is 25years5old =hich of the following musculoskeletal system issues is notlikely to e noted?

1. Thinner one density

2. 6yphosis

. Increased muscle fatigue

4. Steady gait

Corre!t "ns#er: >

Rationa$e 1$ A gradual loss of calcium in the one starts in the third to fourth decade of lifeG the ones ecome

thinner and weaker with each decade

Rationa$e 2$ Interverteral disk shrinkage in the thoracic disks can give older adults a stooped5over appearance,

called kyphosis

Rationa$e $ Anemia and respiratory prolems can restrict availale o7ygen and lead to a uildup of cellularwaste products such as lactic acid and caron dio7ideG these uildups can cause painful muscle spasms and

muscle fatigue, even with minimal e7ertion

Rationa$e 4$ *ecreased muscle tone and control can give older adults the appearance of having a staggering or

unsteady gaitG maintaining the clientEs safety is an important nursing intervention

%$o&a$ Rationa$e:







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Question 3

Type: MCMA

The older adult is at increased risk for respiratory tract infections due to a comination of respiratory system

changes that include$Select all that applyB


1. Foss of vocal cord elasticity

2. Increased respiratory effort

. *ecreased tissue elasticity in the airway

4. Increased physical activity

-. *ecreased Ciliary movement

Corre!t "ns#er: #,2

Rationa$e 1$ Foss of vocal cord elasticity can cause changes in vocal pitch and 9uality, which do not affect the

risk for respiratory infections



Rationa$e $ Foss of vocal cord elasticity can cause changes in vocal pitch and 9uality, which do not affect the




Rationa$e -$ Foss of vocal cord elasticity can cause changes in vocal pitch and 9uality, which do not affect the


%$o&a$ Rationa$e:



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Question 1

Type: MCSA

The nurse is doing an admission physical e7am on an older adult The client is concerned aout his lood

pressure The nurse e7plains$

1. The heart gets smaller with age

2. The left ventricular chamer wall gets thinner

. The arteries are less elastic, and less sensitive

4. The odyEs circulation responds 9uickly to postural or positional changes

Corre!t "ns#er: #

Rationa$e 1$ The heart does not get smaller or atrophy with aging

Rationa$e 2$ The left ventricular chamer wall gets thicker with age

Rationa$e $ The arteries are less elastic, and aroreceptors ecome less sensitiveG as a result diastolic and systoli

lood pressures tend to increase

Rationa$e 4$ The odyEs circulation is slower and does not respond as 9uickly to postural or positional changes

%$o&a$ Rationa$e:




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Question 2

Type: MCMA

The nurse is caring for an older adult client who is concerned aout her driving Appropriate responses y the

nurse include$ Select all that applyB


1. atty deposits in the rain cause a decrease in cereral metaolism that slows thought processes

2. (hysiologic neurologic changes cause a decrease in motor responses

. Tasks that re9uire 9uick response are harder for young adults as well





4. The si&e and weight of the rain decreases with aging

-. The immune system ecomes less effective

Corre!t "ns#er: 1,.,>

Rationa$e 1$ atty deposits in the rain are a normal effect of aging on the rain

Rationa$e 2$ (hysiologic changes can cause a decrease in motor responsesG refle7es ecome sluggish and slow

Rationa$e $ Tasks that re9uire 9uick responses are harder for older adults to do safely

Rationa$e 4$ The si&e and the weight of the rain decreases as aging takes placeG shrinkage of rain tissue is

linked to a decrease in circulating functional cortical neurons

Rationa$e -$ The immune system ecomes less effective, however this is not an appropriate response regarding

neurosensory changes

%$o&a$ Rationa$e:



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Question

Type: MCMA

=hen caring for elderly clients, appropriate nursing interventions to facilitate maintenance of normal voiding

haits include$Select all that applyB


1. Assisting the client to lie down to void

2. (roviding running water within hearing distance of the client may stimulate voiding refle7

. ;ffer toileting assistance at the clientEs usual voiding times

4. Teach 6egel e7ercises

-. -egulate fluid intake

Corre!t "ns#er: .,#





Rationa$e 1$ Assist the client to a normal position for voidingG these positions allow gravity to enhance tomovement of urine

Rationa$e 2$ Assist the client to a normal position for voidingG these positions allow gravity to enhance to

movement of urine

Rationa$e $ Assist the client to a normal position for voidingG these positions allow gravity to enhance to

movement of urine

Rationa$e 4$ Assist the client to a normal position for voidingG these positions allow gravity to enhance to

movement of urine

Rationa$e -$ Assist the client to a normal position for voidingG these positions allow gravity to enhance to

movement of urine

%$o&a$ Rationa$e:




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Question 4

Type: MCSA

The nurse is caring for a +35year5old couple who report wanting to remain se7ually active, and want information

on changes to e7pect in the reproductive system -eproductive system changes the nurse should discuss with this

couple include$

1. Men can father children well into their s

2. The penis may take less time to ecome erect

. Menopause may cause flushing

4. Daginal secretions decrease

Corre!t "ns#er: >

Rationa$e 1$ =ith this couple oth eing +3 years old, the fertility of either individual is not an issue

Rationa$e 2$ In the older man, the penis may take more time to ecome erect

Rationa$e $ The +3 year old woman is well past menopause, and unlikely to e having hot flashes





Rationa$e 4$ *ue to the decrease in hormones, vaginal secretions decrease and the resultant dryness may causevulvar soreness and painful intercourse

%$o&a$ Rationa$e:



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Question -

Type: MCSA

A 3 year5old client is admitted to the emergency room with a recurrence of congestive heart failure, with >J

pitting edema of oth legs =hich of the following psychosocial issues does the nurse need to assess first?

1. 8oint disease

2. Foneliness

. Disual changes

4. inancial changes

Corre!t "ns#er: >

Rationa$e 1$ The symptoms of osteoarthritis appear in almost everyone y the age of 3G this is not a psychosocia

issue for the older adult, ut a physiologic concern

Rationa$e 2$ =hile the 35year old may e a widow or widower, and feel loss and loneliness, it is not a primary

assessment in the emergency situation

Rationa$e $ Disual changes are common in the over52 population, ut are not of primary importance in this

emergency situation

Rationa$e 4$ The financial aility of a client to care for him ore herself, including the aility to afford medicationand appropriate food is an area that needs to e assessedG this client may not e taking appropriate medications as

ordered due to inaility to afford them

%$o&a$ Rationa$e:



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Question

Type: MCMA

A client is admitted from a long5term care facility to the acute care setting The nurse notes the clientEs condition

in the admission assessment (otential indicators of elder ause include$


1. *ry, cracked lips

2. Tenting of skin when skin turgor assessed

. Signs of kyphosis

4. (resycusis

-. *epression


Rationa$e 1$ *ry and cracked lips may indicate dehydration or overmedication, and should e reported to the uni

supervisor


supervisor

Rationa$e $ *ry and cracked lips may indicate dehydration or overmedication, and should e reported to the uni

supervisor


supervisor

Rationa$e -$ *ry and cracked lips may indicate dehydration or overmedication, and should e reported to the unisupervisor

%$o&a$ Rationa$e:




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Question /

Type: MCMA





The nurse is coordinating the discharge planning for a family with a frail elderly mother who will e living with

her daughter and son5in5law and their teenage son Appropriate teaching for the family includes$Select all that

applyB


1. Ask for help

2. %ncourage the family to discuss advance directives prior to acute events

. -eview the common physiologic and psychosocial changes in the older adult

4. -efer the family to counseling

-. %ncourage respite care

Corre!t "ns#er: 1,.,#,2

Rationa$e 1$ %ncouraging caregivers to make use of groups, home5delivered meal, and adult day care reduces the

risk of stress, and caregiver role strain, and therefore the risk of elder ause

Rationa$e 2$ Careful planning, using advance directives, trusts and wills can reduce uncertainty, preserveresources and prevent crises

Rationa$e $ Assisting the family to identify common stressors, and recogni&e the and understand the causes of

difficult ehavior can help them learn techni9ues to deal with these more effectively

Rationa$e 4$ =hile counseling may e appropriate in some situations, it is not indicated with the information

given at this time

Rationa$e -$ %ncouraging the family to take reaks, including respite care, will reduce stress, and reduce the risk

of elder ause

%$o&a$ Rationa$e:



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Question

Type: MCMA

=hat important personal safety issues can the nurse alert older adults and their families to?Select all that applyB






1. 6eep ank ooks and credit cards in a secure place

2. Maintain an active cell phone

. (rogram emergency contacts into home and cell phones

4. *o a home safety inspection

-. (rovide referrals for at home services

Corre!t "ns#er: .,#,>,2

Rationa$e 1$ 6eeping financial assets in a secure place is an element of financial safety for older adults

Rationa$e 2$ Cell phones can e used in case of an emergency, as well as convenience

Rationa$e $ (rogramming Hin case of emergency IC%B numers in the cell phone enales first responder personnel to reach the appropriate contact more 9uickly and efficiently

Rationa$e 4$ *oing a home safety inspection, looking for loose rugs, e7tension cords, access to commonly used

items will decrease the likelihood of falls related to slower movements, reactions and diminished alance in the

older adult

Rationa$e -$ -eferrals for at home services can decrease the travel or driving the older adult needs to do to meet

shopping and other needsG this can support the clientEs independence, as well as meeting safety needs

%$o&a$ Rationa$e:



C$ient Need )u&:


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Question

Type: MCSA

The nurse is caring for a client who is scheduled for chest 75ray The client is re9uesting that he e allowed to

wear his religious amulet An appropriate response for the nurse includes$

1. HKou must take the amulet off for the 75ray

2. H*o you think something ad will happen if you take it off?

. H*o you want to wear it around your wrist until after the test??

4. HI will call security so it will e safe





Corre!t "ns#er: #

Rationa$e 1$ The nurse needs to teach and promote wellness while addressing the clientEs view non<udgmentallyin addition, re9uiring the client to remove the amulet may cause him untoward stress and an7iety

Rationa$e 2$ It is important for the nurse to address cultural health practices in a non<udgmental manner

Rationa$e $ Allowing the client to make a choice aout where to have the amulet retains autonomy and respectsthe clients cultural values

Rationa$e 4$ This response does not allow the client to make a decision, and does not respect the clientEs culturalvalues

%$o&a$ Rationa$e:



C$ient Need )u&:


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