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Nursing 166 NCLEX Qs (1).
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Nursing 166 NCLEX Qs1. The nurse is performing an assessment on an older client who is having difficulty sleeping at
night. Which statement by the client indicates the need for further teaching regarding measures to
improve sleep?
a) "I swim three times a week."
b) "I have stopped smoking cigars."
c) "I drink hot chocolate before bedtime."
d) "I read for 40 minutes before bedtime." - CORRECT ANSWER-1) C
- Rationale: Many nonpharmacological sleep aids can be used to influence sleep. However, the
client should avoid caffeinated beverages and stimulants such as tea, cola, and chocolate. The
client should exercise regularly, because exercise promotes sleep by burning off tension that
accumulates during the day. A 20-to 30-minute walk, swim, or bicycle ride three times a week is
helpful. The client should sleep on a bed with a firm mattress. Smoking and alcohol should be
avoided. The client should avoid large meals; peanuts, beans, fruit, raw vegetables, and other
foods that produce gas; and snacks that are high in fat because they are difficult to digest.
- Test-Taking Strategy: Note the strategic words need for further teaching . These words indicate a
negative event query and ask you to select an option that is an incorrect statement. Options A, B,
and D are positive statements indicating that the client understands the methods of improving
sleep.
2. Geriatric Nursing Exam Questions about a visiting nurse who observes that the older male client
is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den
and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here."
Which is the most important action for the nurse to take?
a) Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane."
b) Suggest to the client and daughter-in-law that they consider a nursing home for the client.
c) Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help.
d) Suggest appropriate resources to the client and daughter-in-law, such as respite care and a
senior citizens' center. - CORRECT ANSWER-2) D
- Geriatric Nursing Exam Questions Rationale: Assisting clients and families to become aware of
available community support systems is a role and responsibility of the nurse. Observing that the
client has begun to be confined to his room makes it necessary for the nurse to intervene legally
and ethically, so option C is not appropriate and is passive in terms of advocacy. Option B
suggests committing the client to a nursing home and is a premature action on the nurse's part.
Although the data provided tell the nurse that this client requires nursing care, the nurse does not
know the extent of the nursing care required. Option A is incorrect and judgmental.
- Test-Taking Strategy: Note the strategic words most important. Using principles related to the
ethical and legal responsibility of the nurse and knowledge of the nurse's role will direct you to the
correct option. Option A is a nontherapeutic statement, option B is a premature action, and option
C avoids the situation.
3. The nurse is performing an assessment on an older adult client. Which assessment data would
indicate a potential complication associated with the skin?
a) Crusting
b) Wrinkling
, c) Deepening of expression lines
d) Thinning and loss of elasticity in the skin - CORRECT ANSWER-3) A
- Rationale: The normal physiological changes that occur in the skin of older adults include
thinning of the skin, loss of elasticity, deepening of expression lines, and wrinkling. Crusting noted
on the skin would indicate a potential complication.
- Geriatric Nursing Exam Questions Test-Taking Strategy: Note the subject , a potential
complication. Think about the normal physiological changes that occur in the aging process to
direct you to the correct option.
4. The home health nurse is visiting a client for the first time. While assessing the client's
medication history, it is noted that there are 19 prescriptions and several over-the-counter
medications that the client has been taking. Which intervention should the nurse take first?
a) Check for medication interactions.
b) Determine whether there are medication duplications.
c) Call the prescribing health care provider (HCP) and report polypharmacy.
d) Determine whether a family member supervises medication administration. - CORRECT
ANSWER-4) B
- Rationale: Polypharmacy is a concern in the older client. Duplication of medications needs to be
identified before medication interactions can be determined because the nurse needs to know
what the client is taking. Asking about medication administration supervision may be part of the
assessment but is not a first action. The phone call to the HCP is the intervention after all other
information has been collected.
- Test-Taking Strategy: Note the strategic word first . Also note that the nurse is visiting the client
for the first time. Options A, C, and D should be done after possible medication duplication has
been identified.
5. The long-term care nurse is performing assessments on several of the residents. Which are
normal age-related physiological change(s) the nurse expects to note? Select all that apply.
a) Increased heart rate
b) Decline in visual acuity
c) Decreased respiratory rate
d) Decline in long-term memory
e) Increased susceptibility to urinary tract infections
f) Increased incidence of awakening after sleep onset - CORRECT ANSWER-5) B, E, F
- Geriatric Nursing Exam Questions Rationale: Anatomical changes to the eye affect the
individual's visual ability, leading to potential problems with activities of daily living. Light
adaptation and visual fields are reduced. Although lung function may decrease, the respiratory
rate usually remains unchanged. Heart rate decreases and heart valves thicken. Age-related
changes that affect the urinary tract increase an older client's susceptibility to urinary tract
infections. Short-term memory may decline with age, but long-term memory usually is maintained.
Change in sleep patterns is a consistent, age-related change. Older persons experience an
increased incidence of awakening after sleep onset.
- Test-Taking Strategy: Focus on the subject , normal age-related changes. Read each
characteristic carefully and think about the physiological changes that occur with aging to select
the correct items.
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