The nursing assessment of an older female C) Cold Climates
elicits information that the client is
diagnosed with Raynaud's phenomenon. Rationale: Can cause prolonged painful vasoconstriction of the peripheral
Which exposure should the nurse instruct extremities (especially hands) in client's with Raynaud's phenomenon.
the client to avoid?
a) Alcohol consumption
b) Warm climates
c) Cold climates
d) Active exercise
A family member brings their aging father B) Multiple medications can contribute to sundowner like symptoms
to the clinic because he has been alert and
oriented during the day but agitated and Rationale: Older clients may see a variety of healthcare providers which can increase
disoriented in the evening. The registered the change of polypharmacy that compounds the workload of metabolic pathways
nurse (RN) reviews the client's list of that may be less efficient due to the aging process. Multiple medication interactions
current medications with the client and may contribute to sundowner like symptoms.
family. Which action taken by the RN is
most important?
a) Medication review with family caregivers
is the PN's responsibility
b) Multiple medications can contribute to
sundowner like symptoms
c) Medication recall is the best way to
evaluate the client's memory
d) Reviewing medication actions is a
component of effective client care
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,10/18/24, 3:58 PM
An older client with chronic kidney disease A) Enlarged Veins
(CKD) has an arteriovenous fistula (AV) in
the left forearm for hemodialysis. After Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to
palpating the AV fistula, which finding is an enlarge, which facilitate cannulation for hemodialysis
indication that the AV fistula is functioning
properly?
a) Enlarged veins
b) Redness around the site
c) Decreased pulses below the fistula
d) Marked ecchymotic areas
The home health registered nurse (RN) is A) Debridement and removal of slough and eschar
changing an older client's wet to dry
dressing. Which observation should the RN Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and
evaluate as a therapeutic response with the then a dry gauze is used to cover the wet packing to wick drainage and bacteria
removal of the dry dressing? away from the wound to promote healing. Removal of dried dressing provides
debridement by removing exudate, sloughing tissue, and eschar.
a) Debridement and removal of slough and
eschar
b) Drainage of purulent exudate from the
wound
c) Moist skin edges around the wound field
d) Presence of capillary growth in the
wound
Older clients are at highest risk for abuse A, B
and neglect due to which factors? (Select
all that apply) Rationale: When needs are not being met due to lack of ability of the caretaker,
stress and feelings of failure of the care provider may be expressed through neglect
a) Needs are greater than the caretaker's and abuse. Decline in strength increases the older client's vulnerability to resist or
ability respond to elder abuse.
b) Client's declining strength
c) Fixed income
d) Longer life expectancy
e) Lack of exposure to technology and
trends
A 64-year-old client is admitted to the D) Provide a foot board
hospital with a fractured right hip. One of
the concerns following surgical repair is to Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop
promote dorsiflexion. Which intervention throughout the recovery.
would a nurse implement?
a) Begin early ambulation
b) Monitor pain level
c) Provide PCA instructions
d) Provide a foot board
2/30
, 10/18/24, 3:58 PM
During the quarterly evaluations of the A, B, C
clients in the assisted living community, the
registered nurse (RN) assesses for findings Rationale: Symptoms of failure to thrive in the older population include weight loss,
of failure to thrive in the older population. weakness, and excessive sleep, which should be documented and evaluated by a
Which findings should the RN document healthcare provider immediately.
and report as manifestations related to
failure to thrive? (Select all that apply).
a) Unintentional weight loss
b) Increased weakness
c) Increased amounts of sleep
d) Irritation and agitation
e) Seeking constant attention for caregiver
An older male client is admitted to the D) Coarse and fine crackles
hospital with left-sided heart failure (HF).
Which finding should the registered nurse Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta
(RN) document that is consistent with HF? causes blood to back up into the pulmonary capillaries; this pushes intravascular
fluid into the alveoli, which is manifested as crackles or rales.
a) Ascites
b) Pitting edema
c) Jugular distention
d) Coarse and fine crackles
The registered nurse (RN) is reinforcing A, B
discharge instructions to the family of an
older client with failure to thrive. What Rationale: These continue to promote independence and decrease stress for the
information should the RN include to client, which will increase the opportunity for nutritional intake.
promote nutritional intake for the client?
(Select all that apply).
a) Minimize stress level by providing the
client with a quiet environment during
meals
b) Provide food variations that the client
can manage without assistance
c) Assist the client with eating meals in bed
in a semi Fowler's position
d) Encourage fluid intake before meals to
decrease dehydration
e) Offer any type of food to the client as
long as calories are consumed
3/30
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