The nursing assessment of an older female elicits information that the client is diagnosed
with Raynaud's phenomenon. Which exposure should the nurse instruct the client to avoid?
a) Alcohol consumption
b) Warm climates
c) Cold climates
d) Active exercise - ANSWER C) Cold Climates
Rationale: Can cause prolonged painful vasoconstriction of the peripheral extremities (espe-
cially hands) in client's with Raynaud's phenomenon.
A family member brings their aging father to the clinic because he has been alert and ori-
ented during the day but agitated and disoriented in the evening. The registered nurse (RN)
reviews the client's list of current medications with the client and family. Which action taken
by the RN is most important?
a) Medication review with family caregivers is the PN's responsibility
b) Multiple medications can contribute to sundowner like symptoms
c) Medication recall is the best way to evaluate the client's memory
d) Reviewing medication actions is a component of effective client care - ANSWER B)
Multiple medications can contribute to sundowner like symptoms
Rationale: Older clients may see a variety of healthcare providers which can increase the
change of polypharmacy that compounds the workload of metabolic pathways that may be
less efficient due to the aging process. Multiple medication interactions may contribute to
sundowner like symptoms.
1
,An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the left
forearm for hemodialysis. After palpating the AV fistula, which finding is an indication that
the AV fistula is functioning properly?
a) Enlarged veins
b) Redness around the site
c) Decreased pulses below the fistula
d) Marked ecchymotic areas - ANSWER A) Enlarged Veins
Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to en-
large, which facilitate cannulation for hemodialysis
The home health registered nurse (RN) is changing an older client's wet to dry dressing.
Which observation should the RN evaluate as a therapeutic response with the removal of
the dry dressing?
a) Debridement and removal of slough and eschar
b) Drainage of purulent exudate from the wound
c) Moist skin edges around the wound field
d) Presence of capillary growth in the wound - ANSWER A) Debridement and removal of
slough and eschar
Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a dry
gauze is used to cover the wet packing to wick drainage and bacteria away from the wound
to promote healing. Removal of dried dressing provides debridement by removing exudate,
sloughing tissue, and eschar.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that
apply)
2
,a) Needs are greater than the caretaker's ability
b) Client's declining strength
c) Fixed income
d) Longer life expectancy
e) Lack of exposure to technology and trends - ANSWER A, B
Rationale: When needs are not being met due to lack of ability of the caretaker, stress and
feelings of failure of the care provider may be expressed through neglect and abuse. Decline
in strength increases the older client's vulnerability to resist or respond to elder abuse.
A 64-year-old client is admitted to the hospital with a fractured right hip. One of the con-
cerns following surgical repair is to promote dorsiflexion. Which intervention would a nurse
implement?
a) Begin early ambulation
b) Monitor pain level
c) Provide PCA instructions
d) Provide a foot board - ANSWER D) Provide a foot board
Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop
throughout the recovery.
During the quarterly evaluations of the clients in the assisted living community, the regis-
tered nurse (RN) assesses for findings of failure to thrive in the older population. Which find-
ings should the RN document and report as manifestations related to failure to thrive? (Se-
lect all that apply).
a) Unintentional weight loss
b) Increased weakness
c) Increased amounts of sleep
3
, d) Irritation and agitation
e) Seeking constant attention for caregiver - ANSWER A, B, C
Rationale: Symptoms of failure to thrive in the older population include weight loss, weak-
ness, and excessive sleep, which should be documented and evaluated by a healthcare pro-
vider immediately.
An older male client is admitted to the hospital with left-sided heart failure (HF). Which find-
ing should the registered nurse (RN) document that is consistent with HF?
a) Ascites
b) Pitting edema
c) Jugular distention
d) Coarse and fine crackles - ANSWER D) Coarse and fine crackles
Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta causes
blood to back up into the pulmonary capillaries; this pushes intravascular fluid into the alve-
oli, which is manifested as crackles or rales.
The registered nurse (RN) is reinforcing discharge instructions to the family of an older client
with failure to thrive. What information should the RN include to promote nutritional intake
for the client? (Select all that apply).
a) Minimize stress level by providing the client with a quiet environment during meals
b) Provide food variations that the client can manage without assistance
c) Assist the client with eating meals in bed in a semi Fowler's position
d) Encourage fluid intake before meals to decrease dehydration
e) Offer any type of food to the client as long as calories are consumed - ANSWER A, B
4
with Raynaud's phenomenon. Which exposure should the nurse instruct the client to avoid?
a) Alcohol consumption
b) Warm climates
c) Cold climates
d) Active exercise - ANSWER C) Cold Climates
Rationale: Can cause prolonged painful vasoconstriction of the peripheral extremities (espe-
cially hands) in client's with Raynaud's phenomenon.
A family member brings their aging father to the clinic because he has been alert and ori-
ented during the day but agitated and disoriented in the evening. The registered nurse (RN)
reviews the client's list of current medications with the client and family. Which action taken
by the RN is most important?
a) Medication review with family caregivers is the PN's responsibility
b) Multiple medications can contribute to sundowner like symptoms
c) Medication recall is the best way to evaluate the client's memory
d) Reviewing medication actions is a component of effective client care - ANSWER B)
Multiple medications can contribute to sundowner like symptoms
Rationale: Older clients may see a variety of healthcare providers which can increase the
change of polypharmacy that compounds the workload of metabolic pathways that may be
less efficient due to the aging process. Multiple medication interactions may contribute to
sundowner like symptoms.
1
,An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the left
forearm for hemodialysis. After palpating the AV fistula, which finding is an indication that
the AV fistula is functioning properly?
a) Enlarged veins
b) Redness around the site
c) Decreased pulses below the fistula
d) Marked ecchymotic areas - ANSWER A) Enlarged Veins
Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to en-
large, which facilitate cannulation for hemodialysis
The home health registered nurse (RN) is changing an older client's wet to dry dressing.
Which observation should the RN evaluate as a therapeutic response with the removal of
the dry dressing?
a) Debridement and removal of slough and eschar
b) Drainage of purulent exudate from the wound
c) Moist skin edges around the wound field
d) Presence of capillary growth in the wound - ANSWER A) Debridement and removal of
slough and eschar
Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a dry
gauze is used to cover the wet packing to wick drainage and bacteria away from the wound
to promote healing. Removal of dried dressing provides debridement by removing exudate,
sloughing tissue, and eschar.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that
apply)
2
,a) Needs are greater than the caretaker's ability
b) Client's declining strength
c) Fixed income
d) Longer life expectancy
e) Lack of exposure to technology and trends - ANSWER A, B
Rationale: When needs are not being met due to lack of ability of the caretaker, stress and
feelings of failure of the care provider may be expressed through neglect and abuse. Decline
in strength increases the older client's vulnerability to resist or respond to elder abuse.
A 64-year-old client is admitted to the hospital with a fractured right hip. One of the con-
cerns following surgical repair is to promote dorsiflexion. Which intervention would a nurse
implement?
a) Begin early ambulation
b) Monitor pain level
c) Provide PCA instructions
d) Provide a foot board - ANSWER D) Provide a foot board
Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop
throughout the recovery.
During the quarterly evaluations of the clients in the assisted living community, the regis-
tered nurse (RN) assesses for findings of failure to thrive in the older population. Which find-
ings should the RN document and report as manifestations related to failure to thrive? (Se-
lect all that apply).
a) Unintentional weight loss
b) Increased weakness
c) Increased amounts of sleep
3
, d) Irritation and agitation
e) Seeking constant attention for caregiver - ANSWER A, B, C
Rationale: Symptoms of failure to thrive in the older population include weight loss, weak-
ness, and excessive sleep, which should be documented and evaluated by a healthcare pro-
vider immediately.
An older male client is admitted to the hospital with left-sided heart failure (HF). Which find-
ing should the registered nurse (RN) document that is consistent with HF?
a) Ascites
b) Pitting edema
c) Jugular distention
d) Coarse and fine crackles - ANSWER D) Coarse and fine crackles
Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta causes
blood to back up into the pulmonary capillaries; this pushes intravascular fluid into the alve-
oli, which is manifested as crackles or rales.
The registered nurse (RN) is reinforcing discharge instructions to the family of an older client
with failure to thrive. What information should the RN include to promote nutritional intake
for the client? (Select all that apply).
a) Minimize stress level by providing the client with a quiet environment during meals
b) Provide food variations that the client can manage without assistance
c) Assist the client with eating meals in bed in a semi Fowler's position
d) Encourage fluid intake before meals to decrease dehydration
e) Offer any type of food to the client as long as calories are consumed - ANSWER A, B
4
