1. A nursing student working in an Adult Care for Elders unit learns that frailty in the older population includes
which components? (Select all that appl
... [Show More] y.)
a. Dementia
b. Exhaustion
c. Slowed physical activity
d. Weakness
e. Weight gain
ANS: B, C, D
Frailty is a syndrome consisting of unintentional weight loss, slowed physical activity and exhaustion, and
weakness. Weight gain and dementia are not part of this cluster of manifestations.
DIF: Remembering/Knowledge REF: 29
KEY: Frailty| frail elderly| older adult
MSC: Integrated Process: Nursing Process: Assessment
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NOT: Client Needs Category: Health Promotion and Maintenance
2. A home health care nurse assesses an older client for the intake of nutrients needed in larger amounts than in
younger adults. Which foods found in an older adults kitchen might indicate an adequate intake of these
nutrients? (Select all that apply.)
a. 1% milk
b. Carrots
c. Lean ground beef
d. Oranges
e. Vitamin D supplements
ANS: A, B, D, E
Older adults need increased amounts of calcium; vitamins A, C, and D; and fiber. Milk has calcium; carrots
have vitamin A; the vitamin D supplement has vitamin D; and oranges have vitamin C. Lean ground beef is
healthier than more fatty cuts, but does not contain these needed nutrients.
DIF: Applying/Application REF: 30
KEY: Nutrition| nutritional requirements| older adults
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Basic Care and Comfort
3. A nurse working with older adults assesses them for common potential adverse medication effects. For what
does the nurse assess? (Select all that apply.)
a. Constipation
b. Dehydration
c. Mania
d. Urinary incontinence
e. Weakness
ANS: A, B, E
Common adverse medication effects include constipation/impaction, dehydration, and weakness. Mania and
incontinence are not among the common adverse effects, although urinary retention is.
DIF: Remembering/Knowledge REF: 34
KEY: Medications| adverse effects
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Pharmacological and Parenteral Therapies
4. A nurse manager institutes the Fulmer Spices Framework as part of the routine assessment of older adults in
the hospital. The nursing staff assesses for which factors? (Select all that apply.)
a. Confusion
b. Evidence of abuse
c. Incontinence
d. Problems with behavior
e. Sleep disorders
ANS: A, C, E
SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, and evidence of
falls.
DIF: Remembering/Knowledge REF: 40
KEY: SPICES| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Reduction of Risk Potential
5. A visiting nurse is in the home of an older adult and notes a 7-pound weight loss since last months visit.
What actions should the nurse perform first? (Select all that apply.)
a. Assess the clients ability to drive or transportation alternatives.
b. Determine if the client has dentures that fit appropriately.
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c. Encourage the client to continue the current exercise plan.
d. Have the client complete a 3-day diet recall diary.
e. Teach the client about proper nutrition in the older population.
ANS: A, B, D
Assessment is the first step of the nursing process and should be completed prior to intervening. Asking about
transportation, dentures, and normal food patterns would be part of an appropriate assessment for the client.
There is no information in the question about the older adult needing to lose weight, so encouraging him or her
to continue the current exercise regimen is premature and may not be appropriate. Teaching about proper
nutrition is a good idea, but teaching needs to be tailored to the clients needs, which the nurse does not yet
know.
DIF: Applying/Application REF: 30
KEY: Nutrition| older adult
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Physiological Integrity: Physiological Adaptation
6. A hospitalized older adult has been assessed at high risk for skin breakdown. Which actions does the
registered nurse (RN) delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)
a. Assess skin redness when turning.
b. Document Braden Scale results.
c. Keep the clients skin dry.
d. Obtain a pressure-relieving mattress.
e. Turn the client every 2 hours.
ANS: C, D, E
The nurses aide or UAP can assist in keeping the clients skin dry, order a special mattress on direction of the
RN, and turn the client on a schedule. Assessing the skin is a nursing responsibility, although the aide should
be directed to report any redness noticed. Documenting the Braden Scale results is the RNs responsibility as
the RN is the one who performs that assessment.
DIF: Applying/Application REF: 42
KEY: Skin breakdown| older adult| delegation| unlicensed assistive personnel
MSC: Integrated Process: Communication and Documentation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
7. A nurse admits an older client to the hospital who lives at home with family. The nurse assesses that the
client is malnourished. What actions by the nurse are best? (Select all that apply.)
a. Contact Adult Protective Services or hospital social work.
b. Notify the provider that the client needs a tube feeding.
c. Perform and document results of a Braden Scale assessment.
d. Request a dietary consultation from the health care provider.
e. Suggest a high-protein oral supplement between meals.
ANS: C, D, E
Malnutrition in the older population is multifactorial and has several potential adverse outcomes. Appropriate
actions by the nurse include assessing the clients risk for skin breakdown with the Braden Scale, requesting a
consultation with a dietitian, and suggesting a high-protein meal supplement. There is no evidence that the
client is being abused or needs a feeding tube at this time.
DIF: Applying/Application REF: 40
KEY: Nutrition| malnutrition| older adult| Braden Scale
MSC: Integrated Process: Nursing Process: Implementation
NOT: Client Needs Category: Safe and Effective Care Environment: Management of Care
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Chapter 04: Assessment and Care of Patients with Pain
MULTIPLE CHOICE
1. A student asks the nurse what is the best way to assess a clients pain. Which response by the nurse is best?
a. Numeric pain scale
b. Behavioral assessment
c. Objective observation
d. Clients self-report
ANS: D
Many ways to measure pain are in use, including numeric pain scales, behavioral assessments, and other
objective observations. However, the most accurate way to assess pain is to get a self-report from the client.
DIF: Remembering/Knowledge REF: 46
KEY: Pain| pain assessment
MSC: Integrated Process: Nursing Process: Assessment
NOT: Client Needs Category: Health Promotion and Maintenance [Show Less]