Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank

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Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank

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Medical Surgical Nursing Single Volume Assessment and Management of Clinical Problems 7th Edition by Sharon L. Lewis -Test Bank

Lewis: Medical-Surgical Nursing, 7th Edition

 

Test Bank

 

Chapter 4: Health History and Physical Examination

 

MULTIPLE CHOICE

 

  1. A patient having difficulty breathing is admitted to the hospital. The best approach for the nurse to use to obtain a complete health history is to
a. use the health care providers medical history to obtain subjective data.
b. obtain subjective data about the patient from family members.
c. delay subjective data collection and focus only on the physical examination.
d. schedule several short sessions with the patient to gather subjective data.

 

Correct Answer: D

Rationale: In an emergency situation, the nurse may need to ask only the most pertinent questions for a specific problem and obtain more information later. A complete health history will include subjective information that is not available in the health care providers medical history. Family members may be able to give some subjective data, but only the patient will be able to give subjective information about the shortness of breath. The physical examination will not provide a complete health history.

 

Cognitive Level: Application                        Text Reference: p. 40

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. When the nurse is gathering information of a personal nature, the question that best communicates acceptance of the patient is,
a. Individuals going through a divorce have many emotional problems. What kind of problems are you having?
b. Many older people have limited financial resources for food and medications. Is this a problem in your case?
c. A lot of people drink alcohol in excessive amounts. How much alcohol do you drink in a day?
d. Many drugs used for hypertension cause sexual dysfunction. What type of problems are you having?

 

Correct Answer: B

 

Rationale: When asking personal or potentially sensitive questions, prefacing the question with phrases such as many people indicates that the patients situation is normal. Therefore, the best response is that where the nurse asks whether the patient actually has the problem of limited resources but does not imply any judgments about the patient in his regard. The response beginning, Individuals going through a divorce have many emotional problems implies that the nurse has already decided the patient must be having emotional problems. The response beginning, A lot of people drink alcohol in excessive amounts indicates that the nurse thinks the patient does drink alcohol daily. And the response beginning, Many drugs used for hypertension cause sexual dysfunction indicates that the nurse is sure that the patient is having problems.

 

Cognitive Level: Application                        Text Reference: p. 41

Nursing Process: Assessment                       NCLEX: Psychosocial Integrity

 

 

  1. A patient is admitted to the orthopedic unit with a fractured right elbow following a skiing accident. During the initial nursing assessment, the subjective information the nurse obtains from the patient about how the injury occurred and what treatments have been implemented is related to the functional health pattern of
a. activity-exercise.
b. cognitive-perceptual.
c. health perception-health maintenance.
d. self-perceptionself-concept.

 

Correct Answer: C

Rationale: In a hospitalized patient, the health perception-health maintenance pattern includes information about the patients understanding of the onset and treatment of the current health problem. The activity-exercise pattern will include questions about how often the patient skis. The cognitive-perceptual pattern question may address how much pain the patient is experiencing. The self-perceptionself-concept pattern may include questions such as how skiing impacts the patients self-concept.

 

Cognitive Level: Application                        Text Reference: pp. 44-45

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. Immediate surgery is planned for a patient with acute abdominal pain. The question used by the nurse that will elicit the most complete information about the patients coping-stress tolerance pattern is
a. What do you think caused this abdominal pain?
b. Are there any other major problems that are a concern right now?
c. How do you feel about yourself and your hospitalization?
d. Can you tell me how intense your pain is now?

 

Correct Answer: B

Rationale: The coping-stress tolerance pattern includes information about other major stressors confronting the patient. The health perception-health management pattern includes information about the patients ideas about risk factors. Feelings about self and the hospitalization are assessed in the self-perceptionself concept pattern. Intensity of pain is part of the cognitive-perceptual pattern.

 

Cognitive Level: Application                        Text Reference: pp. 45-46

Nursing Process: Assessment                       NCLEX: Psychosocial Integrity

 

 

  1. During the health history interview, a patient tells the nurse about periodic fainting spells. In gathering more specific information, the question that will best assist in determining the setting where the fainting spells occur is,
a. Do the spells tend to occur at any special time of day?
b. How frequently do you have the fainting spells?
c. Where are you when you have the fainting spells?
d. Do you have any other symptoms along with the spells?

 

Correct Answer: C

Rationale: Information about the setting is obtained by asking where the patient was and what the patient was doing when the symptom occurred. The other questions from the nurse are appropriate for obtaining information about chronology, frequency, and associated clinical manifestations.

 

Cognitive Level: Application                        Text Reference: p. 41

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. The nurse records the following general survey of a patient: The patient is a 68-year-old male Asian attended by his wife and two daughters. Alert and oriented. Does not make eye contact with the nurse and responds slowly, but appropriately, to questions. No apparent disabilities or distinguishing features. Additional information that should be added to this general survey includes
a. reasons for contact with the health care system.
b. comments of family members about his condition.
c. nutritional status.
d. intake and output.

 

Correct Answer: C

Rationale: The general survey also describes the patients general nutritional status. The other information will be obtained when doing the complete nursing history and examination but is not obtained through the initial scanning of a patient.

 

Cognitive Level: Application                        Text Reference: p. 46

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. Following knee surgery, the patient has an elastic bandage applied to the surgical site. When assessing the circulation to the lower leg, the first action the nurse will take is to
a. visually inspect the color of the foot.
b. palpate the temperature of the foot.
c. use a stethoscope to auscultate ankle blood pressure.
d. check the patients pedal pulses using the fingertips.

 

Correct Answer: A

Rationale: Inspection is the first of the major techniques used in the physical examination. Palpation and auscultation are used later in the examination.

 

Cognitive Level: Application                        Text Reference: p. 47

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. All the following information is obtained by the nurse while performing a health history and physical examination from a patient with right-sided rib fractures. The pertinent negative finding is that the patient
a. states that there have been no other health problems recently.
b. refuses to take a deep breath because of the associated chest pain.
c. has several bruised and swollen areas on the right anterior chest.
d. denies having pain when the area over the fractures is palpated.

 

Correct Answer: D

Rationale: The nurse expects that a patient with rib fractures will have pain over the fractured area. The first statement is neither a positive nor a negative finding with regard to the rib fractures. The pain with breathing and the bruising and swelling are positive findings.

 

Cognitive Level: Application                        Text Reference: p. 47

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. As the nurse assesses the patients neck, the patient says, My neck is so stiff I can hardly move it. This finding indicates the nurse should perform a(n)
a. specific examination.
b. screening examination.
c. focused examination.
d. extensive examination.

 

Correct Answer: C

Rationale: The focused examination is needed when a patient has clinical manifestations that indicate a problem. The term specific examination is not a commonly used term. The screening examination is a general check to determine any possible problems. Extensive examination is another term that is not generally used and would not be clearly understood by other members of the health care team.

 

Cognitive Level: Comprehension                  Text Reference: p. 47

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. In performing a physical examination, it is most important for the nurse to use
a. the head-to-toe approach.
b. a consistent, systematic approach.
c. the body-systems model.
d. a model based on a nursing theory.

 

Correct Answer: B

Rationale: The nurse is less likely to omit a needed part of the examination if a consistent approach is followed every time. Either a head-to-toe approach or a body-systems approach may be used. Nursing theories do not describe the approach to the physical examination.

 

Cognitive Level: Comprehension                  Text Reference: p. 48

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. The nurse is preparing to perform a screening physical examination for a patient. The assessment technique that will require a stethoscope is
a. inspection.
b. percussion.
c. auscultation.
d. palpation.

 

Correct Answer: C

Rationale: A stethoscope is used to auscultate sounds produced by various parts of the body. Inspection, percussion, and palpation do not require a stethoscope.

 

Cognitive Level: Knowledge                                    Text Reference: p. 48

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. Adaptations used by the nurse when performing a physical examination on an 86-year-old patient will include
a. avoiding the use of touch as much as possible.
b. organizing the sequence to minimize position changes.
c. using slightly more pressure for palpation of the liver.
d. speaking slowly when directing the patient.

 

Correct Answer: B

Rationale: Older patients may have age-related changes in mobility that make it more difficult to change position. There is no need to avoid the use of touch when examining older patients. Less pressure should be used over the liver. There is no indication that the patient has any age-related difficulty in understanding directions from the nurse.

 

Cognitive Level: Application                        Text Reference: p. 50

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. While the nurse is taking the health history, a patient states, My father and grandfather both had heart attacks and were unable to be very active afterwards. This statement is related to the functional health pattern of
a. health perception-health management.
b. activity-exercise.
c. cognitive-perceptual.
d. coping-stress tolerance.

 

Correct Answer: A

Rationale: The information in the patient statement relates to risk factors that may cause cardiovascular problems in the future. Identification of risk factors falls into the health perception-health maintenance pattern.

 

Cognitive Level: Application                        Text Reference: p. 44

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. The nurse is admitting a patient who has just arrived on the medical-surgical unit with severe abdominal pain. The action by the nurse that will be most effective in obtaining complete and accurate data from the patient is
a. to complete only basic demographic data before addressing the patients abdominal pain.
b. to inform the patient that the abdominal pain will be treated as soon as the health history is completed.
c. to take the initial vital signs and then deal with the abdominal pain prior to completing the health history.
d. to medicate the patient for the abdominal pain before attending to the health history and examination.

 

Correct Answer: C

Rationale: The patient priority in this situation will be to decrease the pain level, so the patient will be unlikely to cooperate in providing demographic data or the health history until the nurse addresses the pain. However, obtaining information about vital signs is essential before using either pharmacologic or nonpharmacologic therapies for pain control. The vital signs may indicate hemodynamic instability which would need to be addressed immediately.

 

Cognitive Level: Application                        Text Reference: p. 41

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

  1. A patient is seen in the emergency department with acute nausea and vomiting. The nurse obtains information about the length of time that the patient has been nauseated, the approximate amount of the emesis, and performs a physical assessment of the patients abdomen. This will be described as a/an
a. comprehensive database.
b. episodic assessment.
c. follow-up database.
d. subjective assessment.

 

Correct Answer: B

Rationale: An assessment that is focused on a problem of limited scope is called an episodic (or problem-focused) assessment and is used when the intention is to identify and treat a specific patient problem. A comprehensive database includes all detailed information about multidimensional aspects of the patients health. A follow-up database is used to evaluate the status of a previously identified problem. Subjective assessments are an important aspect of all types of databases.

 

Cognitive Level: Comprehension                  Text Reference: p. 40

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

Lewis: Medical-Surgical Nursing, 7th Edition

 

Test Bank

 

Chapter 6: Older Adults

 

MULTIPLE CHOICE

 

  1. While obtaining a health history from a 68-year-old patient, the nurse learns that the patient takes daily supplements of antioxidants beta carotene, selenium, and vitamin E. The nurse recognizes that the use of these substances in slowing the aging process is related to the biologic aging theory of
a. telomere-telomerase decrease.
b. free radicals.
c. somatic mutation.
d. programmed cell death.

 

Correct Answer: B

Rationale:  Research has focused on the use of antioxidants to slow the oxidative process caused by free radicals. Use of antioxidants is not proposed as a treatment for telomere-telomerase decreases, somatic mutation, or programmed cell death.

 

Cognitive Level:  Application                       Text Reference: p. 69

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. Which question will provide the most useful information when the nurse is performing a comprehensive geriatric assessment of an older adult who is being assessed for admission to an assisted-living facility?
a. Do you have a history of heart disease?
b. Are you able to prepare your own meals?
c. Have you had any recent infections?
d. How frequently do you see a doctor?

 

Correct Answer: B

Rationale:  The patients functional abilities, rather than the presence of acute or chronic illness, are more useful in determining how well the patient might adapt to the assisted-living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

 

Cognitive Level:  Application                       Text Reference: pp. 71, 77

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

 

  1. As the home health nurse is teaching a 72-year-old patient who lives alone about a new medication, the patient replies I just dont learn new information like I used to. The nurse will plan to
a. schedule the patient for daily visits for medication administration.
b. teach the patients family members to give the medications.
c. spend more time discussing the medications with the patient.
d. tell the patient it is not safe to take medications independently.

 

Correct Answer: C

Rationale:  The process of learning new information is slower in older adults, but there is no indication that the patient will be unable to learn about the new medications. Because the patient is living independently, there is no indication that medication administration needs to be done by the nurse or by family members. There are no data to indicate that self-management of medications by this patient is not safe.

 

Cognitive Level:  Application                       Text Reference: p. 79

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

 

 

  1. The home health nurse is developing a care plan for an alert and active 85-year-old patient who takes multiple medications for chronic cardiac and respiratory disease. The patient lives with family members who work during the day. An appropriate nursing diagnosis is
a. social isolation related to weakness and fatigue.
b. caregiver role strain related to need to adjust family employment schedule.
c. risk for injury related to drug-drug interactions.
d. compromised family coping related to the patients many care needs.

 

Correct Answer: C

Rationale:  The patients age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Because the patient is alert and active, the diagnoses in responses 1 and 4 are not appropriate for the patient or family. There is no indication that the familys employment schedule should be changed to accommodate the needs of this patient.

 

Cognitive Level:  Application                       Text Reference: pp. 80-81

Nursing Process: Diagnosis

NCLEX: Health Promotion and Maintenance

 

 

  1. To obtain the most complete information when doing an assessment for an 81-year-old patient, the nurse will
a. review the patients chart for the history of medical problems.
b. interview both the patient and the primary patient caregiver.
c. use a geriatric assessment instrument to evaluate the patient.
d. ask the patient to write down medical problems and medications.

 

Correct Answer: C

Rationale:  The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which will include information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the chart, interviews of the patient and caregiver, and written information by the patient will all be included in a comprehensive geriatric assessment.

 

Cognitive Level:  Application                       Text Reference: p. 77

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. When developing the plan of care for an older adult who is hospitalized for an acute illness, the nurse should
a. use a standardized geriatric nursing care plan.
b. plan for likely long-term-care transfer to allow additional time for recovery.
c. consider the preadmission functional abilities when setting patient goals.
d. minimize activity level during hospitalization.

 

Correct Answer: C

Rationale:  The plan of care for older adults should be individualized and based on the patients current functional abilities. A standardized geriatric nursing care plan is unlikely to address individual patient needs and strengths. A patients need for discharge to a long-term-care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

 

Cognitive Level:  Application                       Text Reference: pp. 78-80

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

  1. When caring for an older adult who lives in a rural area, the nurse will plan to
a. assess the patient for chronic diseases that are unique to rural areas.
b. ensure that the patient has transportation to appointments with the health care provider.
c. obtain adequate medications for the patient to last for 4 to 6 months.
d. suggest that the patient move to an urban area for better health care.

 

Correct Answer: B

Rationale:  Transportation can be a barrier to accessing health services in rural areas. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area.

 

Cognitive Level:  Application                       Text Reference: p. 70

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

  1. To help prevent drug-drug interactions in an older adult patient taking many medications, the most appropriate instruction by the nurse is,
a. Do not take any over-the-counter (OTC) drugs with your prescription drugs.
b. Be sure to have all of your prescriptions filled at the same pharmacy.
c. Bring all the medications, supplements, and herbs that you use to every health care appointment.
d. Use a medication reminder system so that you wont forget to take your medications as scheduled.

 

Correct Answer: C

Rationale:  The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy, but these interventions alone will not prevent drug-drug interactions between prescribed drugs, OTC drugs, and any herbal supplements. Use of a medication reminder system will help the patient take medications as scheduled but will not prevent drug-drug interactions.

 

Cognitive Level:  Application                       Text Reference: p. 80

Nursing Process: Implementation

NCLEX: Physiological Integrity

 

 

  1. The home health nurse is making an 8:00 AM visit to a confused older patient who lives with a daughter. Which information most indicates a need for further action by the nurse?
a. The patient is unable to remember the nurses name.
b. The patient has not yet taken the daily medications.
c. The patient is weaker than on the previous visit.
d. The patients daughter asks about respite services.

 

Correct Answer: C

Rationale:  A change in physical status may indicate an acute medical problem such as infection or elder abuse or neglect. Inability to remember caregiver names is not unusual in confused patients and simply indicates a need for reintroduction by the nurse. Because it is early in the day, the patient may take the medications later. The question about respite services does indicate a need for further action, but this would not be as urgent as the need to assess the patient for physiologic changes.

 

Cognitive Level:  Application                       Text Reference: pp. 71, 73

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. Ageism is an important concept for the nurse to understand because it
a. provides statistical information regarding the older population.
b. promotes consideration of the diversity of the older population.
c. may lead to poorer health care for older individuals.
d. increases social awareness of the needs of older people.

 

Correct Answer: C

Rationale:  Negative attitudes about aging may lead to disparities in the way older patients are treated. The concept does not describe statistics about older individuals; consider the diversity of the older population, or increase the awareness of the needs of the older population.

 

Cognitive Level:  Comprehension                 Text Reference: p. 67

Nursing Process: Assessment                       NCLEX: Psychosocial Integrity

 

 

  1. An alert and well-oriented 78-year-old patient with multiple health problems rarely gets out of bed and complains of having no energy and feeling increasingly weak. The patient has had an 11-pound weight loss over the last year. The nurse should initially
a. ask the patient about daily dietary intake.
b. schedule regular range-of-motion exercise.
c. discuss long-term care placement with the patient.
d. describe normal changes with aging to the patient.

 

Correct Answer: A

Rationale:  In the frail elderly patient, nutrition is frequently compromised, and the nurses initial action should be to assess the patients nutritional status. Active range-of-motion may be helpful in improving the patients strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term-care placement, but more assessment is needed before this can be determined. The patients assessment data are not consistent with normal changes associated with aging.

 

Cognitive Level:  Application                       Text Reference: p. 71

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. When admitting an 88-year-old patient to the hospital, the nurse should plan to
a. interview the patient before the physical assessment.
b. speak slowly and loudly while facing the patient.
c. determine whether the patient uses glasses or hearing aids.
d. obtain a detailed medical history from the patient.

 

Correct Answer: C

Rationale:  Assistive devices should be in place before assessing the patient to minimize anxiety and confusion. When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records.

 

Cognitive Level:  Application                       Text Reference: p. 77

Nursing Process: Planning

NCLEX: Health Promotion and Maintenance

 

 

  1. The nurse is planning discharge for an alert, homeless 70-year-old with a chronic foot infection and poorly controlled diabetes. The most appropriate intervention by the nurse is to
a. teach the patient how to assess and care for the foot infection.
b. refer to social services for placement in a low-income assisted living facility.
c. give the patient written information about shelters and meal sites.
d. schedule the patient to return to outpatient services for foot and diabetes care.

 

Correct Answer: B

Rationale:  A common reason for homelessness in older adults is the lack of affordable housing. Assisted-living facilities provide both housing and health care assistance for older adults. Even with appropriate education, a homeless individual may not be able to maintain adequate foot and diabetes care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of lack of transportation or inability to keep track of dates or times.

 

Cognitive Level:  Application                       Text Reference: pp. 70-71

Nursing Process: Implementation                NCLEX: Physiological Integrity

 

  1. The home health nurse is caring for a 71-year-old patient who lives alone and is taking seven different prescribed medications for chronic health problems. The nurse will plan to
a. use a marked pillbox to set up the patients medications.
b. discuss the option of moving to an assisted-living facility.
c. call the health care provider about stopping some of the medications.
d. visit the patient daily to administer the medications.

 

Correct Answer: A

Rationale:  The use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living. Because the average 70-year-old takes seven medications and the medications have been prescribed for the patients health problems, discontinuing the medications is not appropriate. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).

 

Cognitive Level:  Application                       Text Reference: p. 81

Nursing Process: Planning                            NCLEX: Physiological Integrity

 

 

  1. When assessing a 68-year-old Latina patient who has diabetes, which question will the nurse ask in determining the impact of ethnicity on the patients health care choices?
a. Who helps you with your care at home?
b. How do you pay your medical bills?
c. What do you think helps people get better?
d. Which type of insulin do you use?

 

Correct Answer: C

Rationale:  This question encourages the patient to discuss any special ethnic beliefs about practices, medications, foods, etc., that might be used to maintain or improve health. The information about who cares for the patient does not address the patients health care choices. Ethnicity does not have an impact on how the patient pays health care bills. The type of insulin used is not impacted by ethnicity.

 

Cognitive Level:  Application                       Text Reference: p. 72

Nursing Process: Assessment                       NCLEX: Psychosocial Integrity

 

 

  1. A 42-year-old who is providing home care for a parent tells the nurse, I dont feel comfortable giving Mom her medications yet, but I think I will be able to do it with a little more practice. Which nursing diagnosis is most appropriate?
a. Caregiver role strain related to inability to safely give medications
b. Anxiety related to lack of confidence
c. Risk for situational low self-esteem
d. Readiness for enhanced therapeutic regimen management

 

Correct Answer: D

Rationale:  The caregivers statement indicates an interest in learning the new skill and confidence that it can be learned, consistent with the diagnosis of readiness of enhanced therapeutic management. There is no indication of caregiver role strain, anxiety related to lack of confidence, or low self-esteem.

 

Cognitive Level:  Application                       Text Reference: p. 73

Nursing Process: Diagnosis                          NCLEX: Psychosocial Integrity

 

 

  1. Which information obtained by the home health nurse when making a visit to an 88-year-old with mild forgetfulness is of concern?
a. The patients son uses a marked pillbox to set up the patients medications weekly.
b. The patient has lost 10 pounds (4.5 kg) during the last month.
c. The patient is cared for by a daughter during the day and stays with a son at night.
d. The patient tells the nurse that a close friend recently died.

 

Correct Answer: B

Rationale:  A 10-pound weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an 88-year-old would have friends who have died.

 

Cognitive Level:  Application                       Text Reference: pp. 71, 73-74

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

  1. A confused and agitated 76-year-old patient with a broken arm is brought to the emergency department by a family member. To determine whether elder abuse is the cause of the patients injury, the nurse should
a. have the family member stay in the waiting area while the patient is assessed.
b. ask the patient how the injury occurred and observe the family members reaction.
c. make a referral for a home assessment visit by the home health nurse.
d. notify an elder protective services agency about the possible abuse.

 

Correct Answer: A

Rationale:  The patient should be assessed for clinical manifestations of other injuries, such as bruising and pressure ulcers and these should be documented and photographed. In addition, the patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document physiologic data before notifying the elder protective services agency.

 

Cognitive Level:  Application                       Text Reference: p. 74

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

  1. The family of an 85-year-old with chronic health problems and increasing weakness is considering placing the patient in a long-term care facility. Which action by the nurse will be most helpful in assisting the patient to make the transition?
a. Have the family select a LTC facility that is relatively new.
b. Obtain the patients input about the choice of LTC facility.
c. Ask that the patient be placed in a private room at the facility.
d. Explain the reasons for the need to live in LTC to the patient.

 

Correct Answer: B

Rationale:  The stress of relocation is likely to be less when the patient has input into the choice of facility. The age of the long-term-care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and choice of facility.

 

Cognitive Level:  Application                       Text Reference: p. 76

Nursing Process: Implementation                NCLEX: Psychosocial Integrity

 

 

  1. Which information about a 77-year-old patient who is being assessed by the nurse is of most concern?
a. The patient takes two or three naps during the day and sleeps about 6 hours at night.
b. The patient uses five different medications for chronic heart and joint problems.
c. The patient says, I dont go on my daily walks since I had pneumonia 3 months ago.
d. The patient organizes medications in a marked pillbox so I dont forget them.

 

Correct Answer: C

Rationale:  Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. A pattern of taking frequent naps during the day to compensate for shorter nighttime sleep periods is normal in older adults. On average, a 70-year-old takes seven different medications; the use of five medications is not unusual for a 78-year-old. The use of memory devices to assist with safe medication administration is recommended for older adults.

 

Cognitive Level:  Application                       Text Reference: p. 80

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. When admitting a 79-year-old patient who has urinary urgency and a possible urinary tract infection (UTI), the nurse should first
a. assess the patients orientation.
b. inspect for abdominal distension.
c. question the patient about hematuria.
d. invite the patient to use the bathroom.

 

Correct Answer: D

Rationale:  Before beginning the assessment of an older patient with a UTI and urgency, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patients ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.

 

Cognitive Level:  Application                       Text Reference: p. 77

Nursing Process: Assessment                       NCLEX: Physiological Integrity

 

 

MULTIPLE RESPONSE

 

  1. Which nursing actions will the nurse take to assess for possible malnutrition in a 69-year-old patient? (Select all that apply.)
a. Review laboratory results.
b. Ask about transportation needs.
c. Determine food likes and dislikes.
d. Observe for depression.
e. Assess teeth and oral mucosa.
f. Question about salt use.

 

Correct Answer: A, B, D, E

Rationale:  The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat/cholesterol intake. Transportation impacts patients ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition. Salt intake does not impact nutritional status.

 

Cognitive Level:  Application                       Text Reference: p. 71

Nursing Process: Assessment

NCLEX: Health Promotion and Maintenance

 

 

  1. Appropriate approaches used by the long-term care nurse to provide teaching to a 73-year-old who has just been diagnosed with diabetes include which of the following? (Select all that apply.)
a. Schedule a visit by another resident who is diabetic.
b. Demonstrate food choices using food photographs.
c. Avoid discussion of the patients favorite foods.
d. Remind the patient that a lot of damage has already occurred.
e. Encourage the patients family to participate in teaching sessions.
f. Ask the patient about past experiences with lifestyle changes.

 

Correct Answer: A, B, E, F

Rationale:  Strategies to promote learning in older adults include peer teaching, visual aids, family participation, and relating new learning to past experiences. Discussion of the patients favorite foods is needed to determine how old favorites can be adapted to the new diet. Reminders about the damage already done will indicate that the changes are not worth the effort.

 

Cognitive Level:  Application                       Text Reference: p. 79

Nursing Process: Implementation

NCLEX: Health Promotion and Maintenance

 

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