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

Bank
Chapter 43
Question 1
Type: MCSA
The nurse is assisting the older adult who is recovering from a cerebral vascular accident to bathe. The client is
performing most of the bath by herself but needs the nurse's help with getting in and out of the tub and washing
the uninvolved side. The nurse sees what time it is and realizes it is almost past time to administer medications to
another client. The nurse's best action is to:
1. Complete the bath for the client and quickly assist her into a chair.
2. Leave the client in the tub and instruct her that you will be back as soon as you administer some medications.
3. Ask an unlicensed assistive personnel to help the client complete the bath.
4. Continue assisting the client and pass the medications a little late.
Correct Answer: 3
Rationale 1: The client's need for independence is important, and should not be taken away because the nurse is
in a hurry. The nurse should ask the unlicensed assistive personnel to assist the client while the nurse gives
medications. Leaving the client alone could result in injury, and failing to administer a medication on time puts
the other clients at risk.
Rationale 2: The client's need for independence is important, and should not be taken away because the nurse is
in a hurry. The nurse should ask the unlicensed assistive personnel to assist the client while the nurse gives
medications. Leaving the client alone could result in injury, and failing to administer a medication on time puts
the other clients at risk.
Rationale 3: The client's need for independence is important, and should not be taken away because the nurse is
in a hurry. The nurse should ask the unlicensed assistive personnel to assist the client while the nurse gives
medications. Leaving the client alone could result in injury, and failing to administer a medication on time puts
the other clients at risk.
Rationale 4: The client's need for independence is important, and should not be taken away because the nurse is
in a hurry. The nurse should ask the unlicensed assistive personnel to assist the client while the nurse gives
medications. Leaving the client alone could result in injury, and failing to administer a medication on time puts
the other clients at risk.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Client Need Sub:


Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Discuss the role of the LPN/LVN in providing nursing care for ill older adults.
Question 2
Type: MCSA
The nurse specializing in geriatric nursing recognizes that caring for older adults with health problems is different
from caring for younger people in that elder care requires:
1. An understanding that the aging process complicates care needs.
2. Assisting the client with all activities of daily living.
3. Thorough assessment of client strengths and weaknesses.
4. Creating an individualized plan of care aimed at meeting client needs.
Correct Answer: 1
Rationale 1: Elder care is different from caring for younger people because the aging process causes
physiological changes that complicate care. The other answer options are required for all clients, not only elders.
Rationale 2: Elder care is different from caring for younger people because the aging process causes
physiological changes that complicate care. The other answer options are required for all clients, not only elders.
Rationale 3: Elder care is different from caring for younger people because the aging process causes
physiological changes that complicate care. The other answer options are required for all clients, not only elders.
Rationale 4: Elder care is different from caring for younger people because the aging process causes
physiological changes that complicate care. The other answer options are required for all clients, not only elders.
Global Rationale:
Cognitive Level: Understanding
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Discuss the role of the LPN/LVN in providing nursing care for ill older adults.
Question 3
Type: MCSA
An older adult client with chronic heart failure is found to have cardiomegaly. The client asks you to explain what
has caused this problem. Which of the following would be most accurate?

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

1. Damage from bacteria collecting on heart valves


2. Being too sedentary or immobile for years
3. Decreased elasticity of the arteries and veins
4. Elevated cholesterol and triglyceride levels
Correct Answer: 3
Rationale 1: As the client ages, the elasticity of the arteries and veins declines, resulting in loss of flexibility,
leading to hypertension and poor venous return to the heart. The end result is heart failure with Cardiomegaly, as
the heart works harder to maintain adequate cardiac output.
Rationale 2: As the client ages, the elasticity of the arteries and veins declines, resulting in loss of flexibility,
leading to hypertension and poor venous return to the heart. The end result is heart failure with Cardiomegaly, as
the heart works harder to maintain adequate cardiac output.
Rationale 3: As the client ages, the elasticity of the arteries and veins declines, resulting in loss of flexibility,
leading to hypertension and poor venous return to the heart. The end result is heart failure with Cardiomegaly, as
the heart works harder to maintain adequate cardiac output.
Rationale 4: As the client ages, the elasticity of the arteries and veins declines, resulting in loss of flexibility,
leading to hypertension and poor venous return to the heart. The end result is heart failure with Cardiomegaly, as
the heart works harder to maintain adequate cardiac output.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: Describe common disorders of older adults by body system.
Question 4
Type: MCSA
The nurse teaches the client interventions to reduce folic acid-deficiency anemia and determines the teaching was
understood a few weeks later when the client states:
1. "I've stopped drinking alcohol."
2. "I am eating a banana every day."
3. "I will agree to take the B12 injection."
4. "I am taking my vitamins with iron."
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Correct Answer: 1
Rationale 1: Alcohol interferes with folic acid absorption and metabolism, so the client who stopped drinking
alcohol understood the nurse's teaching. The other options would not relate to folic acid deficiency.
Rationale 2: Alcohol interferes with folic acid absorption and metabolism, so the client who stopped drinking
alcohol understood the nurse's teaching. The other options would not relate to folic acid deficiency.
Rationale 3: Alcohol interferes with folic acid absorption and metabolism, so the client who stopped drinking
alcohol understood the nurse's teaching. The other options would not relate to folic acid deficiency.
Rationale 4: Alcohol interferes with folic acid absorption and metabolism, so the client who stopped drinking
alcohol understood the nurse's teaching. The other options would not relate to folic acid deficiency.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: Describe common disorders of older adults by body system.
Question 5
Type: MCSA
The nurse caring for a client diagnosed with dehydration best assesses hydration by:
1. Checking tenting on both of the arms.
2. Checking tenting on the top of the hand.
3. Measuring the client's head circumference.
4. Checking skin tenting on the upper chest.
Correct Answer: 4
Rationale 1: The best way to check skin turgor is to check skin tenting on the upper chest in older adults, because
the skin on their hands will have reduced elasticity and will not recoil promptly, even when normally hydrated.
Rationale 2: The best way to check skin turgor is to check skin tenting on the upper chest in older adults, because
the skin on their hands will have reduced elasticity and will not recoil promptly, even when normally hydrated.
Rationale 3: The best way to check skin turgor is to check skin tenting on the upper chest in older adults, because
the skin on their hands will have reduced elasticity and will not recoil promptly, even when normally hydrated.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Rationale 4: The best way to check skin turgor is to check skin tenting on the upper chest in older adults, because
the skin on their hands will have reduced elasticity and will not recoil promptly, even when normally hydrated.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Identify specific needs and appropriate nursing interventions for the ill older client with an
acute illness.
Question 6
Type: MCSA
When caring for the hospitalized older adult, the nurse amends the standardized care plan to include:
1. Monitoring vital signs more frequently.
2. Handwashing before and after delivering care.
3. Increased attention to maintaining skin integrity.
4. Administration of extra sedatives.
Correct Answer: 3
Rationale 1: The plan of care must consider the increased fragility of the older adult's skin, and special care must
be taken to prevent loss of skin integrity. More frequent vital signs would be determined by status, not age.
Handwashing should be performed for all clients. The older adult normally will need lower dosages of sedatives,
not higher dosages.
Rationale 2: The plan of care must consider the increased fragility of the older adult's skin, and special care must
be taken to prevent loss of skin integrity. More frequent vital signs would be determined by status, not age.
Handwashing should be performed for all clients. The older adult normally will need lower dosages of sedatives,
not higher dosages.
Rationale 3: The plan of care must consider the increased fragility of the older adult's skin, and special care must
be taken to prevent loss of skin integrity. More frequent vital signs would be determined by status, not age.
Handwashing should be performed for all clients. The older adult normally will need lower dosages of sedatives,
not higher dosages.
Rationale 4: The plan of care must consider the increased fragility of the older adult's skin, and special care must
be taken to prevent loss of skin integrity. More frequent vital signs would be determined by status, not age.
Handwashing should be performed for all clients. The older adult normally will need lower dosages of sedatives,
not higher dosages.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Global Rationale:
Cognitive Level: Analyzing
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Identify specific needs and appropriate nursing interventions for the ill older client with an
acute illness.
Question 7
Type: MCSA
The nurse admits an elderly client to the physician's office and learns the client has been seeing a cardiologist,
nephrologist, hematologist, and pulmonologist for differing medical diagnoses. When collecting data on this
client, the nurse carefully questions:
1. Current diagnoses.
2. Results of recent laboratory findings.
3. Current symptoms.
4. Current medications.
Correct Answer: 4
Rationale 1: The client who is under the care of multiple providers risks polypharmacy, and the nurse must
carefully assess the client's current medications. Another concern for this client is that one provider might order a
drug that interacts with another prescribed medication due to inaccurate understanding of all of the client's
medications.
Rationale 2: The client who is under the care of multiple providers risks polypharmacy, and the nurse must
carefully assess the client's current medications. Another concern for this client is that one provider might order a
drug that interacts with another prescribed medication due to inaccurate understanding of all of the client's
medications.
Rationale 3: The client who is under the care of multiple providers risks polypharmacy, and the nurse must
carefully assess the client's current medications. Another concern for this client is that one provider might order a
drug that interacts with another prescribed medication due to inaccurate understanding of all of the client's
medications.
Rationale 4: The client who is under the care of multiple providers risks polypharmacy, and the nurse must
carefully assess the client's current medications. Another concern for this client is that one provider might order a
drug that interacts with another prescribed medication due to inaccurate understanding of all of the client's
medications.
Global Rationale:
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Cognitive Level: Analyzing


Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Discuss specific issues related to medication administration for older clients.
Question 8
Type: MCSA
The nurse admits an older adult client and reviews orders from the physician. What order would the nurse
question?
Bedrest with bathroom privileges
Acetaminophen (Tylenol) 650 mg p.o. every 4 hours p.r.n. pain
Meperidine (Demerol) 100 mg IM every 6 hours p.r.n. pain
Zolpidem tartrate (Ambien) 5 mg p.o. p.r.n. HS
1. Bedrest
2. Acetaminophen
3. Meperidine
4. Zolpidem tartrate
Correct Answer: 3
Rationale 1: The dosage of meperidine is at the upper limit for a healthy younger adult, but is a very high dosage
for an elderly client, and the nurse should question the order. The other orders are appropriate for the older adult.
Rationale 2: The dosage of meperidine is at the upper limit for a healthy younger adult, but is a very high dosage
for an elderly client, and the nurse should question the order. The other orders are appropriate for the older adult.
Rationale 3: The dosage of meperidine is at the upper limit for a healthy younger adult, but is a very high dosage
for an elderly client, and the nurse should question the order. The other orders are appropriate for the older adult.
Rationale 4: The dosage of meperidine is at the upper limit for a healthy younger adult, but is a very high dosage
for an elderly client, and the nurse should question the order. The other orders are appropriate for the older adult.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: Discuss specific issues related to medication administration for older clients.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

Question 9
Type: MCSA
The nurse assesses the client for depression using the geriatric depression scale. The client scores a 7, which
indicates to the nurse that the client has:
1. An altered level of consciousness.
2. Depression.
3. Alzheimer's disease.
4. A normal result.
Correct Answer: 2
Rationale 1: A score of 5 or higher indicates that the client is depressed. This scale would not be used for
diagnosis of Alzheimer's disease or an altered level of consciousness.
Rationale 2: A score of 5 or higher indicates that the client is depressed. This scale would not be used for
diagnosis of Alzheimer's disease or an altered level of consciousness.
Rationale 3: A score of 5 or higher indicates that the client is depressed. This scale would not be used for
diagnosis of Alzheimer's disease or an altered level of consciousness.
Rationale 4: A score of 5 or higher indicates that the client is depressed. This scale would not be used for
diagnosis of Alzheimer's disease or an altered level of consciousness.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: Describe common disorders of older adults by body system.
Question 10
Type: MCSA
The nurse receives report on the assigned client and learns the client has sundowner's syndrome. Which of the
following findings would be consistent with this syndrome?
1. The client falls asleep after sundown.
2. The eyes are held so that only the top halves are visible above the lower lids.
Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.

3. The client becomes confused after sundown.


4. The client becomes increasingly hard of hearing after age 70.
Correct Answer: 3
Rationale 1: Sundowner's syndrome is diagnosed when the client is alert and oriented during the day but becomes
confused after sundown.
Rationale 2: Sundowner's syndrome is diagnosed when the client is alert and oriented during the day but becomes
confused after sundown.
Rationale 3: Sundowner's syndrome is diagnosed when the client is alert and oriented during the day but becomes
confused after sundown.
Rationale 4: Sundowner's syndrome is diagnosed when the client is alert and oriented during the day but becomes
confused after sundown.
Global Rationale:
Cognitive Level: Applying
Client Need: Psychosocial Integrity
Client Need Sub:
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: Describe common disorders of older adults by body system.

Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank
Copyright 2012 by Pearson Education, Inc.