Basic Geriatric nursing

MULTIPLE CHOICE 1. The admitting nurse gives the new long-term care facility resident a score of 20 on the Braden Scale for Predicting Pressure Sore Risk. These scores indicate that the resident has which risk for pressure injury? a. A high probability of developing a pressure injury b. A moderate risk of developing a pressure injury c. A low risk of developing a pressure injury d. At least one pressure injury at the time of admission ANS: C Scores of 20 on the Braden Scale ind...

MULTIPLE CHOICE 1. What statement by a 65-year-old man who had a myocardial infarction 6 months ago would indicate a need for further teaching? a. “I’m enjoying the same sexual activities now as I did before my heart attack.” b. “I’m still pretty cautious, but our sex lives are very satisfactory.” c. “I’ve been told that I’m at risk for another heart attack if we have sex.” d. “My heart medications have caused erectile dysfunction, but we’ve found other method...

MULTIPLE CHOICE 1. Which statement by a patient’s spouse would indicate that the patient is experiencing myoclonus? a. “His loud snoring and jerking awake wakes me up, too.” b. “I am black and blue from his kicking me every night.” c. “He wakes up at 2 AM every morning and walks around the house.” d. “His constant leg movements tear up the covers and keep me awake.” ANS: B Myoclonus is a periodic kicking movement of the lower extremities, which can be severe. ...

MULTIPLE CHOICE 1. An older adult is performing isometric and isotonic exercises. Which action should the nurse suggest in order to prevent an accidental Valsalva maneuver? a. Hold the breath during an exercise cycle. b. Breathe through the mouth. c. Breathe deeply and rhythmically during an exercise cycle. d. Breathe in through the nose and out through the mouth. ANS: B Breathing through the mouth makes it impossible to hold the breath, and bearing down cannot be performed. Th...

MULTIPLE CHOICE 1. Which nursing action would be effective when assisting an 85-year-old adult with weak abdominal muscles to defecate? a. Encourage the use of a bedpan before getting up in the morning. b. Place a footstool under the feet of the patient when seated on the toilet. c. Insert a finger in the patient’s rectum to stimulate the urge to defecate. d. Instruct the patient to do isometric exercises to strengthen the abdominal muscles. ANS: B Placement of a stool under...

MULTIPLE CHOICE 1. Which method will the nurse use to help a grieving widow begin the grief resolution process? a. Distract her with social conversation. b. Encourage her to verbalize her grief. c. Point out behaviors that are not helpful to grief resolution. d. Focus on her loneliness and loss. ANS: B Verbalization, acknowledgment, and confrontation of grief initiate problem solving for grief resolution. Encouraging the widow to focus on the negative aspects of loss and loneli...

MULTIPLE CHOICE 1. The long-term care facility nurse is aware that the resident most at risk for suicide related to depression is which resident? a. 70-year-old man with diabetes b. 75-year-old woman with chronic obstructive pulmonary disease c. 80-year-old woman with a bipolar disorder d. 85-year-old man with schizophrenia ANS: C Persons with affective disorders are most at risk for suicide related to depression. DIF: 7 REF: p. 218 OBJ: 5 TOP: Suicide Risk KEY: Nur...

MULTIPLE CHOICE 1. The distraught wife of a terminally ill patient reports to the nurse, “My husband has not been shaved, and he has that miserable gown on instead of his own pajamas. Don’t you people care about things like that?” What would be the best response of the nurse? a. “I delayed his morning care because he was sleeping comfortably. I’ll complete his care now that he’s awake.” b. “We’re running late today and I have six other patients to care for. What do you ...

MULTIPLE CHOICE 1. A nurse wants to demonstrate cultural understanding. Which way is effective to develop an appreciation and understanding of diverse beliefs and values? a. Interact with persons of another culture. b. Increase personal knowledge of another culture. c. Remain open-minded. d. Travel to diverse regions. ANS: B Open-mindedness and understanding of other cultures assist the nurse to work effectively with persons from a variety of cultures. DIF: 3 REF: p. 256 ...

MULTIPLE CHOICE 1. An 80-year-old patient recently became widowed, moved into a long-term care facility, and had to quit driving. The patient reports fatigue and is irritable when questioned about current health conditions. The nurse will take which appropriate action? a. Suggest a daytime nap and going to bed early. b. Report the symptoms as expected adjustments to relocation. c. Approach the patient to talk about perceptions related to his relocation. d. Suggest that the patient fi...