1. While planning morning care, which of the following patients would receive the highest
priority to receive his or her bath first?
a) A patient who just returned to the nursing unit from surgery and is experiencing
pain at a level of 7 on a scale of 0-10
b) A patient who is experiencing frequent incontinent diarrheal stools
c) A patient who prefers a bath in the evening when his wife visits and can help
him
d) A patient who has just returned form diagnostic testing and complains of being
very fatigued
2. Which assessment question should the nurse ask to best understand how visual
alterations are affecting the patient’s self-care ability?
a) “Have you stopped reading books or switched to books on audiotape?”
b) “Are you able to prepare a meal or write a check?”
c) “How do you protect yourself from injury at work?”
d) “How does your vision impairment make you feel?”
3. A home health care nurse has conducted a home safety assessment for an older adult
with impaired vision. There are five concrete steps leading out from the front door.
Which intervention would be most helpful in keeping the older adult safe on the steps?
a) Have the client use a walker or cane on the step
b) Instruct the client to use the garage door instead
c) Install orange color strips at the edge of each step
d) Suggest the client remain indoors indefinitely
4. While completing an admission database, the nurse is interviewing a patient who states
that he’s allergic to latex. The most appropriate nursing action is to first:
a) Ask the patient to describe the type of reaction
b) Leave the room and place the patient in isolation
c) Proceed to the termination phase of the interview
d) Document the latex allergy on the medication administration record
5. The nurse is preparing to position an immobile patient. Before doing so, the nurse must
understand that:
a) Manual lifting is the easier method and should be tried first
b) Following body mechanics principles alone will prevent back injury
c) Body mechanics can be ignored when using patient handling equipment
d) Body mechanics alone are not sufficient to prevent injuries
6. Which of the following gastrointestinal changes are normal with aging?
a) Increased peristalsis
b) Increased liver function
c) Altered intestinal secretions
d) Heightened sense of smell
7. Of the following nursing goals, which is most appropriate for a patient who has had a
total hip replacement?
a) The patient will ambulate by the time of discharge
b) The patient will ambulate briskly on the treadmill by the time of discharge
c) The nurse will assist the patient to ambulate in the hall
, d) The patient will ambulate 750 feet using her walker by the time of
discharge
8. The nurse is caring for a patient with the diagnosis of impaired physical mobility. The
nurse understands that the following interdisciplinary services are needed to ensure the
patient’s best outcome? (SELECT ALL THAT APPLY)
a) Respiratory therapy
b) Physical therapy
c) Cardiac therapy
d) Dental services
e) Occupational therapy
9. A nurse conducted an assessment of a new patient who came to the medical clinic. The
patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for
20 years. He is alert but becomes easily distracted during the assessment. He recently
moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely
experiencing:
a) Depression
b) Dementia
c) Delirium
d) Hypoglycemic reaction
10. The nurse is completing a health history with the daughter of a newly admitted patient
who is confused and agitated. The daughter reports that her mother was diagnosed
with Alzheimer’s disease 1 year ago but became extremely confused last evening and
was hallucinating. On the basis of this history, the nurse suspects that the patient is
experiencing:
a) Depression
b) Delirium
c) New-onset dementia
d) Worsening dementia
11. Sexuality is maintained throughout our lives. Which of the following answers best
explains sexuality in an older adult?
a) When the sexual partner passes away, the survivor no longer feels sexual
b) A decrease in an older adult’s libido occurs
c) Any outward expression of sexuality suggests that the older adult is having a
developmental problem
d) All older adults, whether healthy or frail, need to express sexual feelings
12. A nurse is caring for a patient preparing for discharge from the hospital the next day.
The patient does not read. His family caregiver will be visiting before discharge. What
can the nurse do to facilitate the patient’s understanding of his discharge instructions?
(SELECT ALL THAT APPLY.)
a) Yell so the patient can hear you
b) Sit facing the patient so he is able to watch your lip movements and facial
expressions
c) Present one idea or concept at a time
d) Send a written copy of the instructions home with him and tell him to have the
family review them
e) Include the family caregiver in the teaching session
priority to receive his or her bath first?
a) A patient who just returned to the nursing unit from surgery and is experiencing
pain at a level of 7 on a scale of 0-10
b) A patient who is experiencing frequent incontinent diarrheal stools
c) A patient who prefers a bath in the evening when his wife visits and can help
him
d) A patient who has just returned form diagnostic testing and complains of being
very fatigued
2. Which assessment question should the nurse ask to best understand how visual
alterations are affecting the patient’s self-care ability?
a) “Have you stopped reading books or switched to books on audiotape?”
b) “Are you able to prepare a meal or write a check?”
c) “How do you protect yourself from injury at work?”
d) “How does your vision impairment make you feel?”
3. A home health care nurse has conducted a home safety assessment for an older adult
with impaired vision. There are five concrete steps leading out from the front door.
Which intervention would be most helpful in keeping the older adult safe on the steps?
a) Have the client use a walker or cane on the step
b) Instruct the client to use the garage door instead
c) Install orange color strips at the edge of each step
d) Suggest the client remain indoors indefinitely
4. While completing an admission database, the nurse is interviewing a patient who states
that he’s allergic to latex. The most appropriate nursing action is to first:
a) Ask the patient to describe the type of reaction
b) Leave the room and place the patient in isolation
c) Proceed to the termination phase of the interview
d) Document the latex allergy on the medication administration record
5. The nurse is preparing to position an immobile patient. Before doing so, the nurse must
understand that:
a) Manual lifting is the easier method and should be tried first
b) Following body mechanics principles alone will prevent back injury
c) Body mechanics can be ignored when using patient handling equipment
d) Body mechanics alone are not sufficient to prevent injuries
6. Which of the following gastrointestinal changes are normal with aging?
a) Increased peristalsis
b) Increased liver function
c) Altered intestinal secretions
d) Heightened sense of smell
7. Of the following nursing goals, which is most appropriate for a patient who has had a
total hip replacement?
a) The patient will ambulate by the time of discharge
b) The patient will ambulate briskly on the treadmill by the time of discharge
c) The nurse will assist the patient to ambulate in the hall
, d) The patient will ambulate 750 feet using her walker by the time of
discharge
8. The nurse is caring for a patient with the diagnosis of impaired physical mobility. The
nurse understands that the following interdisciplinary services are needed to ensure the
patient’s best outcome? (SELECT ALL THAT APPLY)
a) Respiratory therapy
b) Physical therapy
c) Cardiac therapy
d) Dental services
e) Occupational therapy
9. A nurse conducted an assessment of a new patient who came to the medical clinic. The
patient is 82 years old and has had osteoarthritis for 10 years and diabetes mellitus for
20 years. He is alert but becomes easily distracted during the assessment. He recently
moved to a new apartment, and his pet beagle died just 2 months ago. He is most likely
experiencing:
a) Depression
b) Dementia
c) Delirium
d) Hypoglycemic reaction
10. The nurse is completing a health history with the daughter of a newly admitted patient
who is confused and agitated. The daughter reports that her mother was diagnosed
with Alzheimer’s disease 1 year ago but became extremely confused last evening and
was hallucinating. On the basis of this history, the nurse suspects that the patient is
experiencing:
a) Depression
b) Delirium
c) New-onset dementia
d) Worsening dementia
11. Sexuality is maintained throughout our lives. Which of the following answers best
explains sexuality in an older adult?
a) When the sexual partner passes away, the survivor no longer feels sexual
b) A decrease in an older adult’s libido occurs
c) Any outward expression of sexuality suggests that the older adult is having a
developmental problem
d) All older adults, whether healthy or frail, need to express sexual feelings
12. A nurse is caring for a patient preparing for discharge from the hospital the next day.
The patient does not read. His family caregiver will be visiting before discharge. What
can the nurse do to facilitate the patient’s understanding of his discharge instructions?
(SELECT ALL THAT APPLY.)
a) Yell so the patient can hear you
b) Sit facing the patient so he is able to watch your lip movements and facial
expressions
c) Present one idea or concept at a time
d) Send a written copy of the instructions home with him and tell him to have the
family review them
e) Include the family caregiver in the teaching session
