Ebersole And Hess Gerontological Nursing And Healthy Aging 4e by Touhy – Jett-Test Bank

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Ebersole And Hess Gerontological Nursing And Healthy Aging 4e by Touhy – Jett-Test Bank

Chapter 2: Gerontological Nursing History, Education, and Roles

Test Bank

 

MULTIPLE CHOICE

 

  1. Identify the best statement about gerontological nursing.
a. Nurses have only recently become involved in the care of the older adult.
b. Gerontological care was the second specialty in which the American Nurses Association (ANA) offered a certification program.
c. Purposes of gerontological nursing include the promotion of health and support for maximal independence.
d. ANA certification is available only for gerontological nurses in research positions.

 

 

ANS:  C

Promoting health and fostering independence are purposes of the practice, as reflected, for example, in the ANA Scope and Standards. Nurses have always cared for older patients. The ANA’s gerontological nursing certification program was the organization’s first and includes a variety of positions, such as nurse practitioners, clinical specialists, researchers, and administrators.

 

PTS:   1                    DIF:    Remember     REF:   8-9

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

  1. Which gerontological nursing organization welcomes nurses from all educational backgrounds?
a. The National Gerontological Nursing Association (NGNA)
b. The National Conference of Gerontological Nurse Practitioners (NCGNP)
c. The National Association of Directors of Nursing Administration in Long-Term Care (NADONA/LTC)
d. The American Society on Aging (ASA)

 

 

ANS:  A

The NGNA was formed specifically for all levels of nursing personnel: registered nurses (RNs), licensed practical nurses (LPNs), licensed vocational nurses (LVNs), and certified nursing assistants (CNAs). The NCGNP is, as its name implies, limited to nurse practitioners. The NADONA/LTC is, as its name implies, limited to directors and assistant directors of nursing. The ASA is an interdisciplinary organization not limited to nurses.

 

PTS:   1                    DIF:    Remember     REF:   15-16

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

  1. Which is an accurate statement regarding gerontological nursing education?
a. Gerontological nursing content has long been integrated into the curriculum of the typical school of nursing.
b. Undergraduate nursing programs extensively cover gerontological nursing in dedicated courses, comparable with the coverage of psychiatric nursing.
c. When content is integrated throughout a curriculum, less than 25% is devoted to geriatric care.
d. Accreditation of a nursing program guarantees that appropriate amounts of gerontological nursing content are included in the curriculum.

 

 

ANS:  C

When content is integrated throughout the curriculum, less than 25% of the content is devoted to geriatric care. Only recently has gerontological nursing content begun to appear in nursing school curricula. Most nursing schools still do not have such courses. At present, no minimum requirements exist for the coverage of care of older adults.

 

PTS:   1                    DIF:    Remember     REF:   6-7                 TOP:   Teaching/Learning

MSC:  Health Promotion and Maintenance

 

  1. Based on current demographic data, which of the following statements identifies a predictive trend regarding the health care needs of society?
a. Most nurses will not need to care for older persons.
b. More nursing services will be required to serve the needs of the population older than 85 years of age.
c. Fewer nurses will be needed to care for older adults.
d. Older adults expect their quality of life to be less than that of earlier generations at their ages.

 

 

ANS:  B

Projections are that 20% of the American population will be older than 65 years of age by 2050, with those older than 85 years showing the greatest increase in numbers. Most nurses can expect to care for older people during the course of their careers. By 2050, the United Nations predicts that more Americans will be over the age of 60 years than those under the age of 15 years. Older people are better educated and more affluent and expect a higher quality of life than their elders had at their age.

 

PTS:   1                    DIF:    Remember     REF:   2

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

  1. A case manager is likely to have how many years of nursing education?
a. 1 to 1.5 c. 4 to 6
b. 2 d. 8 or more

 

 

ANS:  C

A case manager typically has a bachelor’s or master’s degree. This amount of training is typical for an LPN, who typically practices at a nursing home or on a home nursing staff. This amount of training, resulting in an Associate’s Degree in Nursing (ADN), is typical for an associate RN, who is typically found on hospital, home, and nursing home staffs. A nurse with 8 or more years of education, as well as a doctorate, is typically involved in research and teaching.

 

PTS:   1                    DIF:    Remember     REF:   8-14               TOP:   Teaching/Learning

MSC:  Safe, Effective Care Environment

 

  1. Which was the first formal action the ANA took in relation to gerontological nursing?
a. Established a national geriatric nursing group
b. Defined educational standards for gerontology
c. Created the ANA Division of Geriatric Nursing
d. Formed the Council of Long Term Care Nurses

 

 

ANS:  A

The first formal act of the ANA to promote gerontological nursing was to form a national geriatric nursing group in 1962. In 1973, the ANA defined educational standards for geriatric nursing. The ANA Division of Geriatric Nursing was begun in 1966. In 1979, the ANA formed the Council of Long Term Care Nurses.

 

PTS:   1                    DIF:    Understand    REF:   4

TOP:   Communication and Documentation

MSC:  Health Promotion and Maintenance

 

  1. A older man is transferred to a hospice facility with end-stage disease. Which is a suitable nursing intervention for this older adult and his family according to the goals of long-term care?
a. Decrease the analgesic dose to prevent sedation.
b. Provide a basin and towels for morning self-care.
c. Inform family members about strict visiting hours.
d. Facilitate family rituals related to death and dying.

 

 

ANS:  D

To promote comfort and dignity, the nurse facilitates the enactment of family wishes, rituals, or religious practices related to death and dying. To promote comfort, the gerontological nurse administers medications as prescribed and avoids restricting analgesic agents to patients, regardless of the setting or the nurse’s personal views. Although fostering independence is within the scope of the gerontological nursing practice, the nurse should assess the older adult and family before assuming that he will want or be able to perform self-care. Although hospice can have regular visiting hours, the older adult may need his family at the bedside for comfort, strength, or companionship. Thus to provide comfort and promote dignity, the gerontological nurse adapts visiting hours to suit the older adult’s needs.

 

PTS:   1                    DIF:    Apply            REF:   30 Box 2-6

TOP:   Nursing Process: Implementation   MSC:  Safe, Effective Care Environment

 

  1. A nursing home executive interviews RNs to fill a full-time position for direct patient care to maintain the standards of elder care. Which nurse should the nursing home hire?
a. Nurse from a certified college c. Nurse with 15 years of experience
b. Certified gerontological nurse d. Gerontological nurse practitioner

 

 

ANS:  B

A certified gerontological nurse receives education and training to care for older adults, assuring the nursing home and the public that the nurse has mastered the specialized skills and knowledge to care for older adults according to gerontological nursing standards. A nurse educated in a certified college does not necessarily have specialty education and training in gerontology. A nurse with 15-years experience might have no experience with gerontology and offers no proof of specialized knowledge or skills. Although a gerontological nurse practitioner receives specialized education and training in gerontology, these nurses provide primary care in a nursing home.

 

PTS:   1                    DIF:    Apply            REF:   9

TOP:   Nursing Process: Implementation   MSC:  Safe, Effective Care Environment

 

  1. Mezey and Fulmer (2002) justify gerontological nursing research and the work of gerontological advanced practice nurses by concluding the following:
a. Other scientists devalue gerontological nursing research.
b. The research influences outcomes from nursing care in a positive way.
c. Gerontological care is expensive but required in long-term care.
d. Gerontological nursing research is well known to practicing nurses.

 

 

ANS:  B

The practices of advanced practice nurses, who base their practice on nursing research, have resulted in positive older adult outcomes and cost effectiveness. The scientific community widely accepts the research. Advanced practice nurses generate positive outcomes and are cost effective in many settings. Mezey and Fulmer believe the goal of gerontological nursing is to disseminate the knowledge from gerontological nursing research to all nurses and to have the knowledge applied to their practices.

 

PTS:   1                    DIF:    Understand    REF:   16                  TOP:   Nursing Process: Diagnosis

MSC:  Health Promotion and Maintenance

 

  1. The gerontological nurse collaborates with the wound care team about an older patient who has an ulcer. How is this nurse demonstrating leadership in the care of older people?
a. Assessing older adults effectively
b. Facilitating access to elder care programs
c. Coordinating members of the health care team
d. Empowering older adults to manage chronic illness

 

 

ANS:  C

The nurse demonstrates leadership in the care of older adults by initiating and coordinating collaboration with the wound care team to improve the health of an older adult. Screening and assessing are only indirectly related to collaboration. In this case, the nurse’s collaborative efforts are unrelated to facilitating access to a program. Thus far, the nurse has not educated or trained this patient in wound care.

 

PTS:   1                    DIF:    Apply            REF:   8-9                 TOP:   Nursing Process: Evaluation

MSC:  Health Promotion and Maintenance

 

  1. Several organizations collaborated in 2001 to publish Scope and Standards of Gerontological Nursing Practice by the ANA. What is the significance of the collaborative effort to gerontological nurses?
a. Changes the health care delivery to increasing numbers of older adults
b. Mandates gerontological certification for nurses who care for older adults
c. Standardizes gerontological nursing practice among various organizations
d. Ensures minimum gerontological competencies for all graduating students

 

 

ANS:  C

Various gerontological nursing organizations collaborated to define the criteria for gerontological nursing practice, demonstrating an agreement among the various organizations on these standards. The collaboration among multiple organizations potentially improves the quality of gerontological nursing care as the number of older adults grows. This document establishes the criteria for gerontological nursing practice.

To improve the health care to older adults, all graduating students should master minimum competencies in gerontological nursing; however, many students continue to receive little specialty training and education in the care of older adults.

 

PTS:   1                    DIF:    Analyze         REF:   5                    TOP:   Nursing Process: Evaluation

MSC:  Safe, Effective Care Environment

 

  1. Which had a major influence in shifting the care of older adults away from almshouses and public institutions and stimulated the growth of commercial nursing homes?
a. Medicare
b. Social Security Act
c. Hartford Institute for Geriatric Nursing
d. Health maintenance organizations (HMOs)

 

 

ANS:  B

With the passage of the Social Security Act of 1935, federal monies were provided for “old-age” insurance and public assistance for needy older people not covered by insurance. To combat the fear of almshouse placement, Congress stipulated that the Social Security funds could not be used to pay for care in almshouses or other public institutions. This move is thought to have been the genesis of commercial nursing homes. During the next 10 years, many almshouses closed, and the number of private boarding homes providing care to older adults increased. Because retired and widowed nurses often converted their homes into such living quarters and gave care when their boarders became ill, they can be considered the first geriatric nurses and their homes to be the first nursing homes. The Hartford Institute has sponsored significant improvements in gerontological nursing practice, research, and education. HMOs have had a significant impact on the management of care but were virtually nonexistent in the 1930s and 1940s.

 

PTS:   1                    DIF:    Understand    REF:   4

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

  1. Which gerontological organization had a significant influence on the care of older adults?
a. American Association of Retired Persons (AARP)
b. John Hartford Foundation
c. Medicare
d. Mutual of Omaha Insurance

 

 

ANS:  B

The most significant influence in enhancing gerontological nursing has been the work of the Hartford Institute for Geriatric Nursing, funded by the John A. Hartford Foundation. The foundation seeks to shape the quality of the nation’s health care for older Americans by promoting geriatric nursing excellence to both the nursing profession and the larger health care community. Initiatives in nursing education, nursing practice, nursing research, and nursing policy include enhancing geriatrics in nursing education programs through curricular reform and faculty development and the development of nine Centers of Geriatric Nursing Excellence. AARP is a foundation that helps struggling seniors by being a force for change on the most serious issues they face today. Medicare is a national social insurance program, administered by the U.S. federal government since 1965, that guarantees access to health insurance for Americans ages 65 years and older and younger people with disabilities. Mutual of Omaha is a Fortune 500 mutual insurance and financial services company based in Omaha, Nebraska.

 

PTS:   1                    DIF:    Remember     REF:   5

TOP:   Nursing Process: Assessment          MSC:  Safe, Effective Care Environment

 

MULTIPLE RESPONSE

 

  1. In which areas have advanced practice nurses demonstrated their skill in improving? (Select all that apply.)
a. Health outcomes
b. Length of stay
c. Cost effectiveness
d. Reimbursement measures
e. Interprofessional communication

 

 

ANS:  A, C

Advanced practice nurses have demonstrated their skill in improving health outcomes and cost effectiveness. Many of these advanced practice nurses have nursing facility practices managing complex care of frail older adults in collaboration with interprofessional teams. This role is well established, and positive outcomes include increased patient and family satisfaction, decreased costs, less frequent hospitalizations and emergency department visits, and improved quality of care. Reimbursement measures and interprofessional communication have not been identified as areas that advanced practice nurses have demonstrated their skill in improving.

 

PTS:   1                    DIF:    Remember     REF:   10                  TOP:   Nursing Process: Evaluation

MSC:  Safe, Effective Care Environment

 

  1. Identify future directions for gerontological nursing research as suggested by Wykle and Tappen. (Select all that apply.)
a. Interdisciplinary practice models
b. Intergenerational caregiving
c. Health disparities
d. Influence of culture on aging
e. Long-term care initiatives

 

 

ANS:  A, B, C, D

The following have been identified for future directions for gerontological nursing research according to Wykle and Tappen: interdisciplinary practice models, intergenerational caregiving, health disparities, and the influence of culture on aging. Long-term care initiatives have not been identified as a future direction for nursing research.

 

PTS:   1                    DIF:    Remember     REF:   27 Box 2-3     TOP:   Nursing Process: Planning

MSC:  Safe, Effective Care Environment

Chapter 10: Elimination

Test Bank

 

MULTIPLE CHOICE

 

  1. Which of the following is a true statement about elimination in older adults?
a. Defecation less than once each day is not necessarily constipation.
b. Mineral oil is recommended as a laxative for the older adult.
c. Excessive sleep can be a symptom of constipation.
d. Leaking liquid feces should be treated as diarrhea.

 

 

ANS:  A

Constipation is present when fewer than three bowel movements occur per week or when the frequency decreases. Mineral oil and saline laxatives can be harmful. Fiber, fruit, and fluids are the first recommendations; stimulant laxatives such as senna and cascara can be used on a short-term basis. Altered cognitive status, increased agitation, and unexplained falls can be symptoms of constipation; these behaviors may be the only clinical symptom of constipation in cognitively impaired older persons. Excessive sleep has not been identified as a symptom. Liquid feces may be leaking around a fecal impaction, and antidiarrheal treatment can aggravate the impaction.

 

PTS:   1                    DIF:    Remember     REF:   13-21

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. Which action should be included in all bladder-retraining programs?
a. Toileting at bedtime c. Toileting every hour
b. Using adult incontinence pads d. Providing 1000 ml of fluids daily

 

 

ANS:  A

Toileting at bedtime should be incorporated for all patients. This intervention decreases the amount of urine in the bladder during the night. Incontinence pads are not encouraged during the retraining process. Toileting is not automatically scheduled every hour but is based on the individual’s needs. The volume of scheduled fluid intake is also based on the individual’s needs.

 

PTS:   1                    DIF:    Apply            REF:   13-21             TOP:   Nursing Process: Planning

MSC:  Physiological Integrity

 

  1. The nurse understands that stress incontinence occurs:
a. With a urinary tract infection (UTI)
b. Because of emotional strain
c. As a result of increased intraabdominal pressure
d. With a specific amount of urine in the bladder

 

 

ANS:  C

If intraabdominal pressure increases, then the patient can have dribbling. A UTI causes frequency as a result of irritation in the bladder. Emotional strain can cause frequency. Specific volume of urine in the bladder triggers reflex incontinence.

 

PTS:   1                    DIF:    Understand    REF:   5-7

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

  1. What is the most important aspect of care for the nurse to maintain when assisting an older patient with urinary incontinence?
a. Availability of protective rubber garments
b. Using indwelling urinary catheters
c. Using smooth muscle relaxants
d. Maintaining an attitude that is respectful and positive about resolving the problem

 

 

ANS:  D

The nurse recognizes that incontinence is a sign of an underlying problem and not an inevitable result of aging. In addition, the nurse offers dignity, hope, and understanding by maintaining a positive and respectful manner and by communicating that effective treatments are available. Rubber garments, in particular, are hot and can cause skin irritation. Internal catheters should be used only for a short time and under limited circumstances. Using a smooth muscle relaxant is indicated only for urge incontinence and for an overactive bladder.

 

PTS:   1                    DIF:    Understand    REF:   32 Box 10-3

TOP:   Nursing Process: Implementation   MSC:  Health Promotion and Maintenance

 

  1. Which option is part of a program that addresses bowel incontinence in an older adult patient?
a. Ensuring that a toilet or commode is readily accessible to the patient
b. Encouraging the intake of 1 liter of water each day
c. Expecting a rapid and full recovery
d. Toileting the patient 10 to 15 minutes after meals

 

 

ANS:  A

Difficult access to facilities within the time available is a factor in bowel incontinence and bladder incontinence. The intake of 1 L of fluid is less than the recommended amount to protect against dehydration and constipation. Realistic expectations and goals should be discussed with the patient. Toileting should occur 20 to 40 minutes after regularly scheduled meals when the gastrocolic reflex is active.

 

PTS:   1                    DIF:    Remember     REF:   38 Box 10-7   TOP:   Nursing Process: Planning

MSC:  Health Promotion and Maintenance

 

  1. An older adult who is on bed rest after surgery is prescribed morphine for pain. Which of the following is the nurse’s priority for preventive care?
a. Constipation c. Poor solid food intake
b. Diarrhea d. Poor liquid intake

 

 

ANS:  A

This older adult is at high risk for developing constipation as a result of being on bed rest and being prescribed an opiate for pain. A decrease in activity, combined with the use of an opiate, often leads to constipation, not diarrhea. Appetite can be poor for the first few days after surgery, but it often returns without incidence. Decreased fluid intake is often supplemented with intravenous fluids for the first few days after surgery.

 

PTS:   1                    DIF:    Apply            REF:   35-36 Box 10-5

TOP:   Nursing Process: Planning              MSC:  Health Promotion and Maintenance

 

  1. The nurse is caring for a patient who has recently had an indwelling catheter placed. The nurse should assess the patient for:
a. An increase in oral fluid intake c. Upper back pain
b. A change in mental status d. A decrease in activity

 

 

ANS:  B

The nurse assesses the older adult’s mental status. Changes in mental status, character of urine, decreased appetite, abdominal pain, chills, low back pain, urethral discharge in men, new onset of incontinence, or even respiratory distress may signal a possible UTI in older people. An indwelling catheter does not often cause a decrease in activity.

 

PTS:   1                    DIF:    Apply            REF:   11

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. The nurse assesses a male resident in a nursing home for urinary incontinence and determines that he is unaware of the problem. Which recommendation should the nurse implement?
a. Limit oral fluid intake. c. Apply absorbent undergarment.
b. Provide regular toileting. d. Encourage frequent rest periods.

 

 

ANS:  B

The nurse provides regular toileting to promote voiding and to prevent incontinence for a resident with a potential cognitive impairment. The nurse avoids limiting oral fluid intake; older adults, especially those living in residential facilities, are at higher risk for dehydration than younger people. Using absorbent undergarments may be unnecessary if the incontinence can be controlled with regular toileting. Nursing research supports the claim that ambulatory residents are less likely to be incontinent. This resident may have dementia, but maintaining mobility will have a greater impact in preventing incontinence.

 

PTS:   1                    DIF:    Apply            REF:   32-35 Boxes 3 & 4

TOP:   Nursing Process: Planning              MSC:  Health Promotion and Maintenance

 

  1. A large residual urine volume characterizes what type of incontinence?
a. Urge c. Overflow
b. Stress d. Functional

 

 

ANS:  C

Dribbling, hesitancy, and a large residual urine volume characterize overflow incontinence. Both urge incontinence and stress incontinence are associated with a small residual urine volume. Functional incontinence is not associated with residual urine volume.

 

PTS:   1                    DIF:    Remember     REF:   5-7

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. An older adult is in the hospital because of heart failure and has become incontinent of urine. Which evidence-based resource should the nurse use to guide continence care for this patient?
a. Nursing Standard Practice Protocol
b. The Borun Center training modules
c. Toolkit from the American Geriatrics Society
d. The Centers for Medicare and Medicaid Services

 

 

ANS:  A

The Nursing Standard Practice Protocol is a resource for urinary incontinence in older adults admitted to acute care. The Borun Center provides training modules suitable for nurses managing incontinence in residents in long-term care facilities. The American Geriatrics Society helps with managing urinary incontinence in primary care settings. The Centers for Medicare and Medicaid Services supply guidelines for managing urinary incontinence in long-term care facilities.

 

PTS:   1                    DIF:    Understand    REF:   5-10               TOP:   Nursing Process: Planning

MSC:  Health Promotion and Maintenance

 

  1. The nurse wants to begin helping a resident who is overweight and has urinary incontinence with healthy bladder behavior skills. Which intervention should the nurse implement?
a. Begin a low-calorie diet for weight management.
b. Schedule voiding at 2- to 4-hour intervals.
c. Instruct the resident to practice abdominal exercises.
d. Reduce the time between an urge to void and voiding.

 

 

ANS:  B

Healthy bladder behavior skills include scheduling voiding at 2- to 4-hour intervals for residents either independently or with prompting. Beginning a low-calorie diet can be a reasonable approach to urinary incontinence, but the nurse first applies low-cost behavioral techniques. Pelvic floor exercises will help control urinary incontinence. Bladder training involves increasing the time between the urge to void and voiding.

 

PTS:   1                    DIF:    Apply            REF:   32-35 Boxes

TOP:   Nursing Process: Implementation   MSC:  Health Promotion and Maintenance

 

  1. An older woman tells the nurse practitioner that she fears her family will place her in a nursing home because she developed stress incontinence. Which recommendation should the nurse implement?
a. Tell her to eliminate the use of caffeinated beverages.
b. Coordinate a family conference with the older adult.
c. Recommend exercises to strengthen the pelvic floor.
d. Schedule voiding for every 2 hours around the clock.

 

 

ANS:  C

The nurse practitioner recommends pelvic floor exercises to strengthen the pelvic floor and the muscles that surround the urethra, vagina, and rectum to decrease the incidence of stress incontinence. Stress incontinence is usually due to weakened pelvic floor muscles; therefore eliminating caffeinated beverages can be an ineffective treatment. Arranging a family conference is premature and potentially embarrassing for the older adult. Many therapies are available to decrease this older adult’s incontinence. Scheduled voiding is recommended at 2- to 4-hour intervals during the day and at 4-hour intervals at night.

 

PTS:   1                    DIF:    Apply            REF:   32-35 Boxes

TOP:   Nursing Process: Implementation   MSC:  Health Promotion and Maintenance

 

MULTIPLE RESPONSE

 

  1. Which signs and symptoms are characteristic of a urinary tract infection (UTI) in an older adult? (Select all that apply.)
a. Fever
b. Uremia
c. Dysuria
d. Anorexia
e. Flank pain
f. Turbid urine

 

 

ANS:  D, F

Anorexia is a more reliable indicator of a UTI in an older adult. In addition, individuals, including older adults, are likely to void cloudy urine when a UTI is present. Fever, uremia, dysuria, and flank pain are all unreliable indicators of a UTI in the older adult.

 

PTS:   1                    DIF:    Remember     REF:   11-13

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

  1. Long-term use of external catheters can lead to which complication(s)? (Select all that apply.)
a. Fungal skin infections
b. Penile skin maceration
c. Atrophy
d. Edema
e. Phimosis

 

 

ANS:  A, B, D, E

Long-term use of external catheters can lead to fungal skin infections, penile skin maceration, edema, fissures, contact burns from urea, phimosis, UTIs, and septicemia. The catheter should be removed and replaced daily and the penis cleaned, dried, and aired to prevent irritation, maceration, and the development of pressure ulcers and skin breakdown. If the catheter is not sized appropriately and applied and monitored correctly, then strangulation of the penile shaft can occur. Atrophy has not been identified as a complication.

 

PTS:   1                    DIF:    Remember     REF:   11

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

  1. Continuous indwelling catheter use is indicated for which condition(s)? (Select all that apply.)
a. Urethral obstruction c. Stress incontinence
b. Urinary retention d. Severely impaired skin integrity

 

 

ANS:  A, B, D

Continuous indwelling catheter use is indicated for those with urethral obstruction or urinary retention because these patients are unable to empty their bladder without this device. Stress incontinence is not a condition that warrants a continuous indwelling catheter. Continuous indwelling catheter use is indicated for patients with severely impaired skin integrity to decrease the risk of further deterioration of skin integrity.

 

PTS:   1                    DIF:    Remember     REF:   10

TOP:   Nursing Process: Assessment          MSC:  Health Promotion and Maintenance

 

OTHER

 

  1. The nurse evaluates the urinalysis (UA) of a female patient with an indwelling urinary catheter. The UA report shows gross contamination of the urine. Rank the nursing interventions in order, beginning with the first intervention the nurse should implement.
  2. Provide perineal hygiene.
  3. Provide urinary catheter care.
  4. Check the duration of catheterization.
  5. Obtain a urine specimen from a sterile port.

 

ANS:

C, B, A, D

Gross contamination of a urine specimen is a costly error because contaminated urine is unsuitable for evaluation. The nurse responds to the report of contamination by determining how long the catheter has been in place; increased duration increases the risk of a UTI from fecal contamination and can affect subsequent nursing interventions. The second intervention is providing catheter care. Regardless of the cause of the specimen contamination, catheter care is a suitable nursing intervention because it decreases the colony count on the catheter. Third, the nurse progresses to perineal care. This intervention follows catheter care because of the principle of asepsis regarding working from the least contaminated to the most contaminated area. Finally, the nurse obtains another urine specimen from a sterile port. Although the catheter has been washed, the nurse rubs the port with alcohol and withdraws urine with a sterile needle and syringe to prevent the introduction of contaminants into the specimen.

 

PTS:   1                    DIF:    Analyze         REF:   10-13| 29 Box 10-1

TOP:   Nursing Process: Planning              MSC:  Health Promotion and Maintenance

Chapter 20: Neurological Disorders

Test Bank

 

MULTIPLE CHOICE

 

  1. Which of the following statements is true about Parkinson disease (PD)?
a. Drinking large amounts of alcohol can relieve symptoms of essential tremor.
b. Motor tremors and slow movement accompany severe cognitive impairment.
c. Lewy body dementia (LBD) is the most common form of dementia.
d. Older adults taking rasagiline (Azilect) must avoid eating foods containing tyramine.

 

 

ANS:  D

Older adults taking rasagiline (Azilect) must avoid eating foods containing tyramine; interactions of rasagiline with tyramine can cause sudden, severe hypertension.

Drinking small amounts of alcohol can relieve symptoms of essential tremor, although heavy drinking should be avoided. The majority of persons with PD remain alert and intelligent, but motor difficulties in facial expression and speech can give a false impression of cognitive impairment. LBD, which can occur in some patients with PD symptoms, is the second most common form of dementia. It accounts for 15% to 20% of all dementias.

 

PTS:   1                    DIF:    Remember     REF:   10-11

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. An older man comes to the emergency department after falling at home, and he reports that he cannot walk without losing his balance. Which steps should the nurse implement for this patient?
a. Arrange to transfer him immediately to the radiology department.
b. Determine symptom onset or when he fell at home.
c. Organize the reperfusion tissue plasminogen activator (tPA) infusion.
d. Perform a comprehensive neurologic assessment.

 

 

ANS:  B

The nurse determines when the symptoms first appeared or the time of the fall to determine whether sufficient time is left to administer reperfusion tPA; if indicated, tPA must be administered within 3 hours of symptom onset. A patient with clinical indicators of a stroke will need a computed tomographic (CT) scan to differentiate between a thrombotic stroke and a hemorrhagic stroke; the type of stroke will determine the therapeutic course. The time of symptom onset is a vital piece of information that must be determined before the patient is referred to the radiology department because tPA is usually administered in the radiology suite. Administering tPA can be contraindicated for this patient; therefore the preparation of this infusion is delayed until the type of stroke and the plan of care are determined. The nurse will not have enough time to complete a comprehensive assessment and thus will perform a focused assessment in preparation for the trip to radiology.

 

PTS:   1                    DIF:    Application    REF:   22

TOP:   Nursing Process: Implementation   MSC:  Physiological Integrity

 

  1. Which of the following statements is true about dysarthria?
a. Does not affect intelligence.
b. Stems from severe rheumatoid arthritis.
c. Physical therapy can be beneficial.
d. Can affect the balance.

 

 

ANS:  A

Dysarthria is a speech disorder caused by a weakness or incoordination of the speech muscles. It occurs as a result of central or peripheral neuromuscular disorders that interfere with the clarity of speech and pronunciation; it does not affect intelligence. It does not stem from rheumatoid arthritis. Occupational therapy can help. Dysarthria does not affect balance.

 

PTS:   1                    DIF:    Understand    REF:   16-17| 33-34

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. A new nurse in a long-term care facility is caring for a patient with PD. The nurse should note which one of the following actions related to PD that is observed during the assessment?
a. Tremors during sleep c. Frequent blinking
b. Cogwheel rigidity d. Fast movements

 

 

ANS:  B

Patients with PD display slow movement, infrequent blinking, masked facies, and cogwheel rigidity. Patients with PD exhibit tremors at rest in their hands, arms, legs, feet, and jaw.

 

PTS:   1                    DIF:    Understand    REF:   32

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. An older adult arrives at the emergency department with a probable diagnosis of a hemorrhagic stroke. The nurse understands, based on the patient’s age, that the most likely cause is which one of the following?
a. Intracranial hemorrhage c. Thrombosis
b. Decreased cardiac output d. Uncontrolled hypertension

 

 

ANS:  D

Hemorrhagic strokes are primarily caused by uncontrolled hypertension and less often by malformations of the blood vessels (e.g., aneurysms). Although the exact mechanism is not fully understood, it appears that chronic hypertension causes a thickening of the vessel wall, microaneurysms, and necrosis. When enough damage to the vessel accumulates, it is at risk for rupture. The spontaneous rupture may be large and acute or small with a slow leak of blood into the adjacent brain tissue. In many cases, blood ruptures or seeps into the ventricular system of the brain with damage to the affected tissue through necrosis or death of brain tissue.

Hemorrhagic strokes are more life threatening but occur less frequently than ischemic strokes. Decreased cardiac output does not cause this type of hemorrhage. A thrombosis is not related to this type of hemorrhage.

 

PTS:   1                    DIF:    Understand    REF:   3

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. After completing an admission assessment on a patient who recently suffered a stroke, the nurse should choose which of the following nursing diagnoses as a priority?
a. Risk for inury c. Altered cerebral perfusion
b. Altered thought process d. Decreased mobility

 

 

ANS:  C

Altered cerebral perfusion is the priority diagnosis. Altered cerebral perfusion may be caused by an interruption in blood flow such as occlusive disorder, hemorrhage, cerebral vasospasm, or cerebral edema. It is important for the nurse to monitor cognitive status and vitals for patients experiencing altered cerebral perfusion. The patient is at risk for injury due to the effects of the stroke, however it is not the priority diagnosis. This patient may suffer from altered thought processes due to cerebral damage from the stroke; however, this is not the priority diagnosis. This patient may experience a decrease in mobility such as hemiparesis; however, it is not the priority diagnosis.

 

PTS:   1                    DIF:    Analyze         REF:   2-5

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. A home health nurse is completing an admission on a patient who recently experienced a transient ischemic attack (TIA). During the assessment, the patient begins to complain of a severe headache and numbness in his left arm. Which action should the nurse take next?
a. Instruct the patient to take Tylenol.
b. Ask whether patient suffers from migraine headaches.
c. Reschedule the visit.
d. Call 9-1-1.

 

 

ANS:  D

The home health nurse should immediately call 9-1-1. Approximately 24% to 29% of those who have a TIA will have a stroke within 5 years after the event (Goldstein, 2011). Tylenol would not be advised. The nurse should not leave the patient until the patient is en route to the emergency department.

 

PTS:   1                    DIF:    Analyze         REF:   2-5| 29

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. The nurse in a rehabilitation center is caring for a patient who has new-onset stroke with right-side hemiparesis. Which intervention should the nurse implement when caring for this patient?
a. Orders a two-person assist with a transfer.
b. May need to incorporate repetition.
c. Gives the patient a dry erase board.
d. Raises all four side rails.

 

 

ANS:  C

Right-side hemiparesis involves a left-side brain injury. The left side of the brain controls speaking and language. By giving the patient a dry erase board, he or she can communicate easier initially after the stroke. People who have this type of hemiparesis experience difficulty talking.

With only one side affected; the nurse should be able to transfer the patient alone. Patients with left-side hemiparesis have with short term memory, often repetition must be incorporated into patient care. The raising of all four side rails up would be considered a restraint.

 

PTS:   1                    DIF:    Analyze         REF:   4-5

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. The nurse is caring for a patient who has had a stroke. The nurse is concerned the patient will develop contractures. Which intervention should the nurse implement?
a. Use tennis shoes while in bed.
b. Turn the patient onto the affected side, resting on the shoulder.
c. Use paraffin wax for hand soaks.
d. Conduct passive range-of-motion movements to the affected extremities.

 

 

ANS:  D

Conducting passive range-of-motion movements will help decrease the risk of contractures. Using tennis shoes in bed helps decrease foot drop. Turning the patient on the affected side, resting on the shoulder, can cause pain. Paraffin wax soaks are often used for sufferers of arthritis.

 

PTS:   1                    DIF:    Analyze         REF:   4-5

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. The nurse is caring for a patient diagnosed with PD. Which tool should the nurse use to gather information from the patient’s perspective?
a. The Geriatric Depression Tool
b. The Sickness Impact Profile (SIP)
c. The Mini-Mental State Examination–2nd edition (MMSE-2)
d. The Montreal Cognitive Assessment Tool

 

 

ANS:  B

The SIP is a useful tool that can be used by nurses to determine problems most troublesome from the patient’s perspective. The Geriatric Depression Tool measures depression, and the MMSE-2 and the Montreal Cognitive Assessment Tool measures cognitive ability.

 

PTS:   1                    DIF:    Analyze         REF:   13

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

MULTIPLE RESPONSE

 

  1. Which of the following behavior modifications should the nurse instruct a patient to accomplish to help reduce the risk factors for an occurrence of a stroke. (Select all that apply.)
a. Increase the intake of green, leafy vegetables.
b. Stop smoking.
c. Control blood pressure.
d. Increase physical activity.

 

 

ANS:  B, C, D

Stopping smoking, keeping blood pressure under control, and incorporating physical activities are all modifiable risk factors. Increasing the intake of green leafy vegetables does not, in itself, decrease the risk of stroke; however, they are part of a healthy diet if the patient is not taking an anticoagulant medication.

 

PTS:   1                    DIF:    Apply            REF:   31                  TOP:   Nursing Process: Planning

MSC:  Physiological Integrity

 

  1. Which of the following are common side effects of PD and the medications used to treat it? (Select all that apply.)
a. Skin irritation c. Dystonia
b. Dyskinesias d. Nausea

 

 

ANS:  B, C

Medication therapy is complicated and must be closely supervised. Hypotension, dyskinesias (involuntary movements), dystonia (lack of control of movement), hallucinations, sleep disorders, and depression are common side effects of both the disease and the medications used to treat it. Nausea is not a side effect of PD.

 

PTS:   1                    DIF:    Understand    REF:   11

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

SHORT ANSWER

 

  1. _____________   _____________ is the result of a lesion in the part of the brain adjacent to the primary auditory cortex (Wernicke area).

 

ANS:

Fluent aphasia

Fluent aphasia is also known as sensory, posterior, or Wernicke aphasia. The person speaks easily with many long runs of words, but the content does not make sense. He or she has problems finding the correct word and often substitutes an incorrect word. The speech sounds are similar to what is sometimes referred to as jabberwocky, with unrelated words strung together or syllables repeated.

 

PTS:   1                    DIF:    Understand    REF:   14

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. Persons with _____________   _______________ usually understand others but speak very slowly and use a minimal number of words.

 

ANS:

Nonfluent aphasia

Patients often struggle to articulate a word and seem to have lost the ability to voluntarily control the movements of speech. Difficulties are experienced in communicating orally and in writing.

 

PTS:   1                    DIF:    Understand    REF:   14

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

 

  1. _______________  __________________ is a motor speech disorder that affects the ability to plan and sequence voluntary muscle movements.

 

ANS:

Verbal apraxia

The muscles of speech are not paralyzed; rather, a disruption occurs in the brain’s transmission of signals to the muscles. When thinking about what to say, the person may be unable to speak at all or may struggle to say any words. In contrast, the person may be able to say many words or sentences correctly when not thinking about the words. Apraxia frequently occurs with aphasia.

 

PTS:   1                    DIF:    Understand    REF:   14

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

Chapter 24: Relationships, Roles, and Transitions

Test Bank

 

MULTIPLE CHOICE

 

  1. Which of the following statements is not true of older adult relationships?
a. After 50 years of marriage, a couple can face new and severe challenges to their relationship.
b. Older adults often hold their families together by arranging get-togethers and documenting the family’s history and rituals.
c. Losing a brother or sister brings an older adult face-to-face with his or her own death.
d. For older adults, friends can never take the place of family.

 

 

ANS:  D

Friendships can provide the commitment and support that is sometimes lacking in family relationships.

Physical and psychosocial changes related to aging, such as declining health, reduced income, and mismatched needs, may cause a severe strain even for a couple who has been together for 50 years or more. A person who holds his or her family together by arranging get-togethers and documenting the family’s history and rituals is known as a kin-keeper. The impact of the loss of a brother or sister, not only at the time of the death but also when a younger survivor reaches the age at which the lost sibling died, can be quite disruptive.

 

PTS:   1                    DIF:    Understand    REF:   8

TOP:   Nursing Process: Assessment          MSC:  Psychosocial Integrity

 

  1. Which of the following statements is true about the role of grandparents?
a. The usefulness of grandparents declined with the advent of the industrial age.
b. Today, many grandparents are the primary caregivers of their grandchildren.
c. The value of grandparents is to provide gifts to younger family members.
d. Traditionally, parents are subordinate to the grandparents in caregiving.

 

 

ANS:  B

Grandparents have always had an important role to play and have become more important than ever in recent decades. An increasing number of parents have been unable to provide necessary care for their children as a result of personal problems; often, grandparents fill the gaps. Grandparents provide continuity, family tradition, and accumulated wisdom. Parents are still expected to be the primary caregivers.

 

PTS:   1                    DIF:    Understand    REF:   17-18

TOP:   Nursing Process: Assessment          MSC:  Psychosocial Integrity

 

  1. An older man is being abused by his daughter, a single working mother of four children, with whom he lives. The nurse investigates and learns that the abuse is due to situational stress. Which of the following interventions should the nurse implement to address the short-term crisis?
a. Immediately remove him from his daughter’s home.
b. Encourage the daughter to work with social services.
c. Arrange respite care or day care for the patient.
d. Place the patient in a long-term care facility.

 

 

ANS:  C

By relieving the daughter of some responsibilities, respite care is likely to be beneficial for the older adult and his daughter; it can help reduce tension.

Unlike children, abused older adults cannot be removed from their situations without their permission. Helping the daughter manage the situational stress would be more effective. Encouraging the daughter to work with social services can help teach her more effective and harmless ways of solving problems, but it does not address the short-term crisis. Placing the patient in a long-term care facility may eventually be necessary, but improving the living situation within the patient’s family would be better.

 

PTS:   1                    DIF:    Apply            REF:   21-22

TOP:   Nursing Process: Implementation   MSC:  Safe, Effective Care Environment

 

  1. Which of the following statements is true about caregiving?
a. Dementia in an older adult can cause grief in the caregiver, comparable with the grief from the older adult’s death.
b. Middle-aged adults and older parents reverse life-long caregiving roles with increasing age.
c. Older adults should relocate to the caregiver’s home when long distances separate the two.
d. Increasing numbers of adult children who are developmentally disabled become caregivers for their older parents.

 

 

ANS:  A

As the dementia progresses, the patient may cease to recognize a spouse or child. The parent still remains the parent, and the idea that the parent somehow becomes a child again is demeaning. The older person may have significant support in the community where he or she lives. Older parents often remain the caregivers for disabled children, which is a serious burden.

 

PTS:   1                    DIF:    Understand    REF:   13-24| 51-55

TOP:   Nursing Process: Assessment          MSC:  Psychosocial Integrity

 

  1. Which disease has become known as the “great imitator?”
a. Human immunodeficiency virus (HIV)
b. Acquired immunodeficiency syndrome (AIDS)
c. Alzheimer disease
d. Schizophrenia

 

 

ANS:  A

The compromised immune system of an older individual makes him or her more susceptible to HIV or AIDS than a younger person. AIDS in older adults has been called the “great imitator”; many of the symptoms, such as fatigue, weakness, weight loss, and anorexia, are common to other disease conditions and may be attributed to normal aging. Alzheimer disease and schizophrenia are not known as the “great imitator.”

 

PTS:   1                    DIF:    Understand    REF:   31-32

TOP:   Nursing Process: Assessment          MSC:  Psychosocial Integrity

 

  1. Which is the most important element for older adults to have for enhancing the transition into retirement?
a. Good health c. 401k retirement plan
b. Private pension d. Preretirement planning

 

 

ANS:  D

Good health is always a desirable state; however, if an older adult in poor health plans for retirement, then the transition to the changes of retirement can be smoother if the planning accounts for health challenges. With preretirement planning, private pensions are not obligatory. With preretirement planning, 401k retirement plans are not obligatory; however, these plans are effective saving plans for retirement; they allow employees to save pretax dollars. Preretirement planning is the most important aspect of a smooth transition into retirement because it affords the individual a chance to prepare for losses associated with retirement such as income, interpersonal communication, health insurance, status, influence, and other issues. Health, social, and financial planning help the older adult adapt to expected or sudden retirement.

 

PTS:   1                    DIF:    Understand    REF:   9-13| 47-48

TOP:   Nursing Process: Assessment          MSC:  Safe, Effective Care Environment

 

  1. Which one of the following older adults is most likely to need preretirement counseling to avoid significant concerns in retirement?
a. African-American woman who is a certified public accountant
b. Mexican-American woman who receives cash for cleaning services
c. Middle-aged man who has a history of type 1 diabetes mellitus
d. Older male clerk who works for the Department of Homeland Security

 

 

ANS:  B

Older adults with the most need for retirement planning are usually the same people who are least likely to receive it. The Mexican-American woman will most likely need preretirement counseling to avoid significant problems in retirement. She has three characteristics indicating a need for retirement planning: (1) her sex is female, (2) her job implies a lack of education or training, and (3) she does not pay into Social Security or federal taxes. Thus she can potentially fail to pay into the federal system for a sufficient length of time to be eligible for Social Security and Medicare benefits in retirement. In addition, her job is unlikely to offer a 401k plan.

Although the African-American woman is a member of a minority group, she is a professional and likely to earn a significant income in a finance-related business. Her occupation and education places her well to receive significant retirement planning. The middle-aged man has one factor potentially associated with the need for retirement planning—poor health. The older clerk has one factor potentially associated with the need for retirement planning—he is likely to be a low-level employee.

 

PTS:   1                    DIF:    Understand    REF:   9-13| 47-48

TOP:   Nursing Process: Assessment          MSC:  Safe, Effective Care Environment

 

  1. The community health nurse delivers a program to middle-aged adults about retirement planning and wants to them to choose the year of their retirement. Which is the most important area on which the participants should focus to ease the transition to retirement?
a. Kind of legacy they want to leave behind
b. Type of setting for their personal residence
c. Location of convenient health care services
d. Ability to maintain a stable standard of living

 

 

ANS:  D

The most significant factors contributing to a smooth transition into retirement are health, income, and social involvement; therefore the nurse helps the participants focus on financial issues to begin retirement planning, thereby establishing the future retiree’s ability to maintain health, income, and social involvement. By choosing a year for retirement, individuals can estimate their retirement income and consult specialists in retirement planning, such as the employee’s human resources department, to determine retirement benefits.

Defining the kind of legacy is a secondary factor and less likely to contribute to a smooth transition into retirement. The location of retirement and the location of health care services are also less likely to contribute to a smooth transition into retirement.

 

PTS:   1                    DIF:    Analyze         REF:   9-13| 47-48

TOP:   Nursing Process: Implementation   MSC:  Safe, Effective Care Environment

 

  1. Which one of the following older adults has the highest economic risk in retirement at the beginning of retirement?
a. Divorced woman who has lived in this country for 3 years
b. Male veteran who is an above-the-knee amputee and was a teacher
c. Female widow who is a primary care nurse practitioner
d. Man who immigrated from China and designs computer software

 

 

ANS:  A

The older divorced woman who has lived in this country for 3 years has three factors associated with economic risk in retirement: (1) female sex, (2) divorced, and (3) immigrant with inadequate time to be eligible for government-sponsored retirement benefits.

The older male veteran, an above-the-knee amputee, was a teacher and has one risk factor—disability. The older female widow and primary care nurse practitioner has two risk factors: (1) female gender and (2) widowhood. The older man who emigrated from China and designs computer software has one risk factor—immigrant.

 

PTS:   1                    DIF:    Understand    REF:   9-13| 47-48

TOP:   Nursing Process: Assessment          MSC:  Safe, Effective Care Environment

 

  1. As the wife of a university president, an older woman met exciting people and traveled extensively until her husband died. Besides losing an intimate partner, the nurse identifies that this woman is most likely to grieve for the loss of which area of her life?
a. Self-confidence c. Status in community
b. Economic security d. Intellectual stimulation

 

 

ANS:  C

After the loss of her husband, this older adult will most likely mourn the loss of her status in the community; no longer is she a wife or the wife of a community leader. After her husband’s death, the opportunities for university-related travel and social occasions will most likely disappear from her life.

After extensive travel and sophisticated social stimulation, this older adult is likely to be self-confident and to have acquired life skills from her experiences. The president of a university is likely to have planned for retirement and is likely to have left his survivors with an adequate estate. This woman will most likely to be able to provide intellectual stimulation in her own life, although the stimulation from the university-related activities will likely decrease.

 

PTS:   1                    DIF:    Apply            REF:   9-13| 47-48

TOP:   Nursing Process: Assessment          MSC:  Psychosocial Integrity

 

  1. The children of an older woman ask the nurse for advice about helping their mother heal after her husband’s (their father’s) death. Which strategy should the nurse share with the family?
a. Appoint one family member to take her on outings.
b. Coordinate family expressions of care and concern.
c. Have each child plan a long trip with her assistance.
d. Take her to community events to meet other people.

 

 

ANS:  B

The nurse suggests that the family work together to provide extended expressions of caring and concern for their mother; many small expressions of concern and caring from several sources help the bereaved gain the strength and confidence needed to survive a huge loss. Multiple small gestures are more likely to help build strength and confidence than a few large gestures.

One person is unlikely to provide enough support for the bereaved, and this strategy can potentially imply that only one person is concerned. Helping a widow meet new people can be unsuitable; she may be uninterested or unwilling to attend events for meeting new people. In addition, she may feel that the family is trying to find a replacement for the deceased to ease the family’s burden. However, the family can offer to accompany her to such events.

 

PTS:   1                    DIF:    Apply            REF:   12-16             TOP:   Nursing Process: Planning

MSC:  Psychosocial Integrity

 

  1. What makes nursing support of caregivers so important for health care in the United States?
a. Family members providing care in the home are the best caregivers.
b. Eighty percent of caregiving takes place in the home of the older adult.
c. The health care system reimburses families for caregiving from Medicare.
d. Informal caregiving saves the health care system enormous sums of money.

 

 

ANS:  D

The value of caregiving is estimated at $257 billion; therefore informal caregiving is a huge savings for the health care system that it might potentially be unable to provide in the event that it was called to do so.

Although family members can be the most convenient and are the least expensive, they do not necessarily make the best caregivers. Family members provide 80% of the caregiving for older adults. Caregiving is not an expense for which Medicare reimburses the family.

 

PTS:   1                    DIF:    Understand    REF:   13-24| 51-55

TOP:   Nursing Process: Assessment          MSC:  Safe, Effective Care Environment

 

  1. Which of the following statements is true about relationships of older adults?
a. Loneliness is evidence of self-centeredness and an unwillingness to love.
b. A person may be lonely even when surrounded by other people.
c. Hostile behavior indicates that a person prefers to be left alone.
d. A pet cannot substitute for human attention.

 

 

ANS:  B

The mere presence of other people, without significant personal exchange, does not prevent or alleviate loneliness.

Loneliness is evidence of the capacity to love. Hostile behavior can be a sign of loneliness. Pets can provide comfort, touch, affection, and an opportunity to care for another being.

 

PTS:   1                    DIF:    Understand    REF:   12-57

TOP:   Nursing Process: Assessment          MSC:  Psychosocial Integrity

 

MULTIPLE RESPONSE

 

  1. In a retirement planning program, the community health nurse wants to help participants avoid disappointment in retirement. The nurse’s program emphasizes which of the following elements that must be adequate to meet postretirement expectations? (Select all that apply.)
a. Financial planning
b. Company-sponsored benefits
c. Company-sponsored health care
d. Government-sponsored benefits
e. Ability to maintain a personal residence
f. Safety and security of a personal residence

 

 

ANS:  A, B, C, D

Overall financial planning is important to provide a stable source of income for retirement if individuals want to fulfill their retirement expectations. Company-sponsored benefits must be sufficient in retirement to avoid large, unplanned expenses. Health care expenses in retirement are more likely to be significant; therefore retirement health care must be adequate to avoid huge, unexpected expenses. If government-sponsored benefits are inadequate for retirement, then the individual must plan to fill the gaps with preretirement planning.

The ability to maintain a residence is not essential to fulfill retirement expectations. Safety and security of the personal residence is also not essential to fulfill retirement expectations.

 

PTS:   1                    DIF:    Remember     REF:   9-13| 47-48    TOP:   Nursing Process: Planning

MSC:  Safe, Effective Care Environment

 

  1. The nurse should suggest which of the following to a spouse of a patient with dementia who has displayed inappropriate sexual behavior to decrease the occurrence? (Select all that apply.)
a. Intimate relations c. Kiss
b. Hug d. Touch

 

 

ANS:  B, C, D

Inappropriate sexual behavior may be triggered by unmet intimacy needs or may be symptoms of an underlying physical problem, such as a urinary tract or vaginal infection. Encouraging family and friends to touch, hug, kiss, and hold hands when visiting may help meet the patient’s touch and intimacy needs and decrease inappropriate sexual behavior.

 

PTS:   1                    DIF:    Understand    REF:   31                  TOP:   Nursing Process: Planning

MSC:  Psychosocial Integrity

 

  1. Which population(s) is(are) most at risk for developing HIV? (Select all that apply.)
a. Those over the age of 50 years
b. Women
c. Those who are cognitively impaired
d. Those who are sexually active

 

 

ANS:  A, B, D

Older adults who are sexually active are at risk for HIV, AIDS, and other sexually transmitted diseases. People older than 50 years of age are approximately one sixth as likely to use condoms during sex. Older women who are sexually active are at high risk for HIV, AIDS, and other sexually transmitted infections from an infected partner, resulting, in part, from normal age changes of the vaginal tissue—a thinner, drier, friable vaginal lining that makes viral entry more efficient. Being cognitively impaired does not put one at high risk.

 

PTS:   1                    DIF:    Understand    REF:   31-33

TOP:   Nursing Process: Assessment          MSC:  Physiological Integrity

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