Medical Surgical Nursing II (NURS223)Detailed Answer Key Gerontology Exam 1(Gray)
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Medical Surgical Nursing II
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Medical Surgical Nursing II
Medical Surgical Nursing II (NURS223)Detailed Answer Key
Gerontology Exam 1(Gray)1. A nurse is caring for an older adult client who reports constipation. Which of the following recommendations should
the nurse make?
A. Bear down hard when defecating.
Rationale: The client should avoid bearing d...
Medical Surgical Nursing I (LaGuardia Community College)
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Detailed Answer Key
Gerontology Exam 1(Gray)
1. A nurse is caring for an older adult client who reports constipation. Which of the following recommendations should
the nurse make?
A. Bear down hard when defecating.
Rationale: The client should avoid bearing down when defecating, because straining can result in
hemorrhoids.
B. Limit fluid intake to 1,000 mL daily.
Rationale: The client should drink 2 to 3 L fluid each day to help keep the stool soft and prevent
constipation.
C. Eat raw vegetables.
Rationale: The client should eat raw vegetables to help provide fiber in the diet to increase stool bulk, move
the stool through the colon, and prevent constipation.
D. Reduce activity.
Rationale: Increasing activity increases peristalsis and helps prevent constipation.
2. A nurse is collecting data for a client who has malnutrition resulting from a chronic illness. Which of the following
manifestations should the nurse expect to find?
A. Non-palpable spleen
Rationale: The client who is malnourished due to chronic disease is most likely to have liver or spleen
enlargement.
B. Slightly moist skin
Rationale: The client who is malnourished due to chronic disease is most likely to have rough, dry, scaly
skin.
C. Presence of surface papillae on tongue
Rationale: The client who is malnourished due to chronic disease is most likely to have atrophic papillae on
the surface of the tongue.
D. Depigmented hair
Rationale: The client who is malnourished due to chronic disease is most likely to have depigmented hair.
Other indications of malnutrition include hair that is stringy, dull, brittle, dry, thin, sparse, and
easily plucked.
3. A nurse is caring for an older adult client in a long-term care facility. Which of the following measures should the
nurse take first when assisting with planning the client's care?
Created on:05/26/2023 Page 1
Downloaded by DANIEL NDAMBIRI (ndambiridaniel20@gmail.com)
, lOMoARcPSD|16995810
Detailed Answer Key
Gerontology Exam 1(Gray)
A. Explaining the roles of the RN, licensed practical nurse, and assistive personnel
Rationale: The client is at risk for confusion and frustration from not understanding the roles of the staff
members he will encounter; however, another action is the priority.
B. Understanding the client's routine for his own care at home
Rationale: The client is at risk for confusion and frustration if his caregivers do not understand and respect
his usual routines; however, another action is the priority.
C. Determining the client's mobility
Rationale: The greatest risk to this client is injury from moving without assistance if he has impaired
mobility; therefore, the priority action is to collect data about the client’s mobility and need for
assistance with transferring and ambulating.
D. Introducing health care team members to the client
Rationale: The client is at risk for fear and anxiety from perceiving various staff members as strangers who
might harm him; however, another action is the priority.
4. A home health nurse is caring for a client who has emphysema and has difficulty with mobility. The client spends
most of his day in a reclining chair. Which of the following physiological responses to prolonged immobility should
the nurse expect?
A. Increased insulin production
Rationale: Prolonged immobility does not affect insulin production. It does, however, reduce metabolic rate.
B. Decreased RBC production
Rationale: Prolonged immobility does not affect RBC production. It does, however, increase the risk of
thrombus formation.
C. Decreased sodium excretion
Rationale: Prolonged immobility does not affect sodium excretion. It does, however, cause other electrolyte
imbalances.
D. Increased calcium excretion
Rationale: Prolonged immobility leads to the breakdown of bone tissue. This results in increased calcium
excretion.
5. What is probably the most significant issue to impact the older adult and their family?
A. Decrease Financial resources
Rationale: This is not expected to be the most significant issue
B. Change in physical appearance
Rationale:
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