Adult Care 1 Exam 2 Questions With Complete Solutions
A 76-year-old client lives alone at home. Which of the following
is the highest priority question for his home health nurse to ask
regarding his safety?
A."Do you use soft glow light bulbs in your front room lamps?"
B."At what temperature is your thermostat set?"
C."Why don't you consider selling your two-story home and
buying a house without stairs?"
D."Do any of your medications cause you to be physically
unsteady?" Correct Answers Answer: D
A 79-year-old resident in a long-term care facility is known to
"wander at night" and has fallen in the past. Which of the
following is the most appropriate nursing intervention?
A.A loose abdominal restraint should be placed on the client
during sleeping hours.
B.The caregivers should check the client frequently during the
night.
C.A radio should be left playing at the bedside to assist in reality
orientation.
D.Reassign the client to a room that is close to the nursing
station. Correct Answers Answer: B
A bowel training program includes which of the following?
,A) Using a diet that is low in bulk
B) Decreasing fluid intake to 1000 mL
C) Administering an enema once a day to stimulate peristalsis
D) Allowing ample time for Evacuation Correct Answers
Answer: D
For a bowel training program to be effective, the patient must
have ample time for evacuation usually 20 to 30 minutes. Fluid
intake is increased to 2500 to 3000 mL, food high in bulk is
recommended as part of the program: and a daily enema is not
administered in bowel training program. A cathartic Suppository
maybe use 30 minutes before the patients usually defecation
time to stimulate peristalsis
A client appears upset and tearful, but denies pain and refuses
pain medication, because "my sibling is a drug addict and has
ruined out lives." What is the priority intervention for this
client?
A) Encourage expression of fears on past experiences
B) Provide accurate information about use of pain medication
C) Explain that addiction is unlikely among acute care clients
D) Seek family assistance in resolving this problem Correct
Answers A) Encourage expression of fears on past experiences
Explanation:
This client has strong beliefs and emotions related to the issue of
sibling addiction. First, encourage expression. This indicates to
the client that their feelings are real and valid. It is also an
opportunity to assess beliefs and fears. Giving facts and
information is appropriate at the right time. Family involvement
,is important, bearing in mind that their beliefs about drug
addiction may be similar to those of the client.
A client is being tapered off opioids and the nurse is watchful
for signs of withdrawal. What is one of the first signs of
withdrawal?
A) Fever
B) Nausea
C) Diaphoresis
D) Abdominal cramps Correct Answers C) Diaphoresis
Explanation:
Diaphoresis is one of the early signs that occur between 6 and 12
hours. Fever, nausea, and abdominal cramps are late signs that
occur between 48 and 72 hours.
A family member asks you, "Why can't you give more
medicine? He is still having a lot of pain." What is your best
response?
A) "The doctor ordered the medicine to be given every 4 hours"
B) "If the medication is given too frequently he could suffer ill
effects"
C) "Please tell him that I will be right there to check on him"
D) "Let's wait about 30-40 minutes. If there is no relief I'll call
the doctor" Correct Answers C) "Please tell him that I will be
right there to check on him"
Explanation:
, directly ask the client about the pain and do a complete pain
assessment. This information will determine which action to
take next.
A first day postoperative client on a PCA pump reports that the
pain control is inadequate. What is the first action you should
take?
A) Deliver the bolus dose per standing order
B) Contact the physician to increase the dose
C) Try non-pharmacological comfort measures
D) Assess the pain for location, quality, and intensity Correct
Answers D) Assess the pain for location, quality, and intensity
Explanation:
Assess the pain for changes in location, quality, and intensity, as
well as changes in response to medication. This assessment will
guide the next steps.
A home care nurse is preparing the home for a patient who is
discharged to home following a left-sided stroke. The patient is
cooperative and can ambulate with a quad-cane. Which of the
following must be corrected or removed for the patient's safety?
(Select all that apply.)
A. The rubber mat in the walk-in shower
B. The three-legged stool on wheels in the kitchen
C. The braided throw rugs in the entry hallway and between the
bedroom and bathroom
D. The night-lights in the hallways, bedroom, and bathroom
A 76-year-old client lives alone at home. Which of the following
is the highest priority question for his home health nurse to ask
regarding his safety?
A."Do you use soft glow light bulbs in your front room lamps?"
B."At what temperature is your thermostat set?"
C."Why don't you consider selling your two-story home and
buying a house without stairs?"
D."Do any of your medications cause you to be physically
unsteady?" Correct Answers Answer: D
A 79-year-old resident in a long-term care facility is known to
"wander at night" and has fallen in the past. Which of the
following is the most appropriate nursing intervention?
A.A loose abdominal restraint should be placed on the client
during sleeping hours.
B.The caregivers should check the client frequently during the
night.
C.A radio should be left playing at the bedside to assist in reality
orientation.
D.Reassign the client to a room that is close to the nursing
station. Correct Answers Answer: B
A bowel training program includes which of the following?
,A) Using a diet that is low in bulk
B) Decreasing fluid intake to 1000 mL
C) Administering an enema once a day to stimulate peristalsis
D) Allowing ample time for Evacuation Correct Answers
Answer: D
For a bowel training program to be effective, the patient must
have ample time for evacuation usually 20 to 30 minutes. Fluid
intake is increased to 2500 to 3000 mL, food high in bulk is
recommended as part of the program: and a daily enema is not
administered in bowel training program. A cathartic Suppository
maybe use 30 minutes before the patients usually defecation
time to stimulate peristalsis
A client appears upset and tearful, but denies pain and refuses
pain medication, because "my sibling is a drug addict and has
ruined out lives." What is the priority intervention for this
client?
A) Encourage expression of fears on past experiences
B) Provide accurate information about use of pain medication
C) Explain that addiction is unlikely among acute care clients
D) Seek family assistance in resolving this problem Correct
Answers A) Encourage expression of fears on past experiences
Explanation:
This client has strong beliefs and emotions related to the issue of
sibling addiction. First, encourage expression. This indicates to
the client that their feelings are real and valid. It is also an
opportunity to assess beliefs and fears. Giving facts and
information is appropriate at the right time. Family involvement
,is important, bearing in mind that their beliefs about drug
addiction may be similar to those of the client.
A client is being tapered off opioids and the nurse is watchful
for signs of withdrawal. What is one of the first signs of
withdrawal?
A) Fever
B) Nausea
C) Diaphoresis
D) Abdominal cramps Correct Answers C) Diaphoresis
Explanation:
Diaphoresis is one of the early signs that occur between 6 and 12
hours. Fever, nausea, and abdominal cramps are late signs that
occur between 48 and 72 hours.
A family member asks you, "Why can't you give more
medicine? He is still having a lot of pain." What is your best
response?
A) "The doctor ordered the medicine to be given every 4 hours"
B) "If the medication is given too frequently he could suffer ill
effects"
C) "Please tell him that I will be right there to check on him"
D) "Let's wait about 30-40 minutes. If there is no relief I'll call
the doctor" Correct Answers C) "Please tell him that I will be
right there to check on him"
Explanation:
, directly ask the client about the pain and do a complete pain
assessment. This information will determine which action to
take next.
A first day postoperative client on a PCA pump reports that the
pain control is inadequate. What is the first action you should
take?
A) Deliver the bolus dose per standing order
B) Contact the physician to increase the dose
C) Try non-pharmacological comfort measures
D) Assess the pain for location, quality, and intensity Correct
Answers D) Assess the pain for location, quality, and intensity
Explanation:
Assess the pain for changes in location, quality, and intensity, as
well as changes in response to medication. This assessment will
guide the next steps.
A home care nurse is preparing the home for a patient who is
discharged to home following a left-sided stroke. The patient is
cooperative and can ambulate with a quad-cane. Which of the
following must be corrected or removed for the patient's safety?
(Select all that apply.)
A. The rubber mat in the walk-in shower
B. The three-legged stool on wheels in the kitchen
C. The braided throw rugs in the entry hallway and between the
bedroom and bathroom
D. The night-lights in the hallways, bedroom, and bathroom
