8/20/2019 Ramont2e Rev TIF Ch42 http://slidepdf.com/reader/full/ramont2e-rev-tif-ch42 1/33 Ramont, Niedringhous, Comprehensive Nursing Care 2nd Edition Update Test Bank Chapter 42 Question 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$e 2$ 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 happy with how she has lived her life is indicating that she has met the task of integrity Rationa$e 4$ 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 %$o&a$ 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
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Rationa$e 1$ 4erontology is care of clients +2 years old and older
Rationa$e 2$ 4erontology is care of clients +2 years old and older
Rationa$e $ 4erontology is care of clients +2 years old and older
Rationa$e 4$ 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
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
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
(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
could indicate the presence of psoriasis
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
could indicate the presence of psoriasis
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
(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
Rationa$e 2$ =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 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
options are normal results of aging
Rationa$e 4$ =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 remaining
(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
diagnosed medical prolem, and are not related to the normal effects of aging
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
diagnosed medical prolem, and are not related to the normal effects of aging
%$o&a$ Rationa$e:
Cogniti'e (e'e$: Analy&ing
C$ient Need: (hysiological IntegrityC$ient Need )u&:
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
Rationa$e 2$ 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
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
Rationa$e 4$ 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
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$e:
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
(earning ut!ome: Identify ways of maintaining or restoring urinary continence
Question
Type: MCSA
The nurse plans care for the older adult with the understanding that it is most important to$
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
maintaining independence
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
maintaining independence
%$o&a$ Rationa$e:
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
1. =ill use magnifying device 1@ of the time to read prescription instructions
2. =ill wear hearing aid 1@ of the time when receiving instructions
. =ill demonstrate understanding of correct method of stump cleaning
4. =ill identify ways to reduce sugar intake and increase fluid intake
Corre!t "ns#er: .
Rationa$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
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
more acutely ill y the time symptoms do show up
Rationa$e 4$ ;lder clients do not show signs and symptoms of infection and, as a result, are more likely to e
(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$e:
Cogniti'e (e'e$: Applying
C$ient Need: (hysiological Integrity
C$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
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
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
an organi&ation that works to improve the lives of older adults There is no such thing as the %lder Ause
(revention Center
Rationa$e 4$ 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
an organi&ation that works to improve the lives of older adults There is no such thing as the %lder Ause
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
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
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$e 4$ '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 smoking
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
lead to stronger heart, lungs, circulation, metaolism, and elimination
Rationa$e 4$ '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
%$o&a$ Rationa$e:
Cogniti'e (e'e$: /nderstanding
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
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$Select all that applyB
)tandard Te0t: Select all that apply
1. 0ody temperature
2. Fentigo senilis
. 'ydration
4. -idges in nails
-. 'air changes
Corre!t "ns#er: 1,#
Rationa$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
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
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$e:
Cogniti'e (e'e$: Applying
C$ient Need: (hysiological Integrity
-amont, )iedringhous, Comprehensive Nursing Care .nd %dition /pdate Test 0ank
A 3 year5old client is admitted to the emergency room with a recurrence of congestive heart failure, with >J
pitting edema of oth legs =hich of the following psychosocial issues does the nurse need to assess first?
1. 8oint disease
2. Foneliness
. Disual changes
4. inancial changes
Corre!t "ns#er: >
Rationa$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
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
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