NCM 1531L NCLEX Practice Questions

a.

the nurse visits the home of an older person with chronic lung disease. which observation indicates that the person is engaged in health improvement activities?

a. walks a pet twice a day

b. prepares pasta for dinner

c. talks with family once a week

d. sleeps in a recliner in the living room

b.

the nurse visits the home of an older person recovering from an exacerbation of a chronic illness. which observation indicates to the nurse that the person has dispelled the myth that older people cannot learn new things?

a. planning to meet friends for lunch

b. researching medications on the internet

c. scheduling an ophthalmologic examination

d. preparing a shopping list

c.

the nurse prepares an educational program on healthy aging for a community group. which segment of the population should the nurse explain as being the fastest growing in the US?

a. middle-age

b. middle-old

c. old-old

d. young-old

c.

A resident of an assisted-living facility enjoys her new apartment but is disappointed that so many females reside there alone. what does this resident's observation suggest about older men?

a. they are healthy enough to live in their own homes

b. they tend to live with family when they age

c. they do not live as long as women

d. they do not like to live in assisted living facilities

c.

the nurse notes that an older person has difficulty removing clothes in preparation for a physical assessment. on which area should the nurse focus when determining this person's ability to perform activities of daily living?

a. housekeeping

b. laundry

c. bathing

d. walking

d.

the nurse plans an educational wellness program for a group of older adults residing in the community. on which topic should the nurse focus the majority of the information?

a. benefits of treating depression with medications

b. managing alzheimer's disease symptoms

c. benefits of remaining socially active

d. managing heart failure symptoms

c. (in the continuity theory, the pace of activities may be slower and for some, the relief from time pressures and deadlines is a bounty of older age. the activity theory proposes that older adults should stay active and engaged if they are to age successfully. in the theory of individualism, the focus shifts away from the external world toward inner experiences as the older person searches for answers to life's riddles and find the essence of the true self. in the disengagement theory, the pattern of behavior in later life is for the older person to withdraw so that social equilibrium is maintained)

an older person who recently retired expresses delight in not having to get up and go work every morning. which theory of aging does this person's statement demonstrate to the nurse?

a. individualism

b. disengagement

c. continuity

d. activity

c.

an older person states that "it's just a matter of time" before a knee and hip replacement will be needed. which theory of aging is this older person describing to the nurse?

a. endocrine

b. programmed longevity

c. wear and tear

d. immunological

a.

the nurse learns that an older person takes several vitamin and nutritional supplements everyday. which theory of aging is supported by this older person's behavior?

a. free radical

b. somatic DNA damage

c. cross link

d. wear and tear

b.

an adult daughter is concerned about her 85 year old mother's disinterest in activities since retiring from a full-time teaching position. which theory of aging should the nurse use to help explain this older person's behavior?

a. developmental

b. disengagement

c. activity

d. continuity

Answer: 3 Explanation:

1. Many older adults have chronic disease but function well.

2. Often people characterize the elderly in a negative way, believing that after a certain age, things cannot be changed. Older people can learn new things and take up new hobbies they can enjoy and give life meaning and pleasure.

3. Although it may not be possible to reverse all the damage, it is never too late to stop smoking cigarettes. People who quit smoking at an older age enjoy better health outcomes.

4. Older people contribute greatly to society by volunteering, helping with grandchildren, mentoring others, and continue working.

1. The nurse is preparing to discharge an older client with instructions on smoking cessation. The nurse states to a colleague, "This client has been smoking for years and isn't going to stop now." Which negative stereotype of aging does the nurse's statement most reflect?

1. Old people are expected to be sick.

2. Old people are set in their ways.

3. Old people do not value health promotion education.

4. Old people are a drain on societal resources.

Answer: 3 Explanation:

1. A glaucoma screening is recommended annually for those at risk for glaucoma.

2. Nutritional assessment and counseling are encouraged for those with diabetes or renal disease.

3. The nurse will discuss the importance of annual mammograms. Older women are the fastest growing population in the United States.

4. A prostate-specific antigen is recommended yearly for men under the age of 70.

2. The nurse is planning to conduct education for older adult clients regarding preventative health screenings. Which type of screening does the nurse anticipate educating this population on?

1. Glaucoma

2. Nutrition

3. An annual mammogram

4. Prostate-specific antigen

Answer: 4 Explanation:

1. While muscle mass does naturally decline in older adults, there is no indication that she is not physically active.

2. In older adults, adequate nutrition can be a concern, yet there is no indication that she is not adequately nourished.

3. In older adults, depression and social isolation are a risk, yet there is no indication that she is not socially active.

4. Exposure to occupational risk factors has been known to affect life expectancy in men and will have the same effect on women given similar circumstances

3. While completing an admission assessment, the nurse learns that a female adult patient has smoked a pack of cigarettes daily for 20 years and works at a chemical plant. From this information, what is this patient most at risk for?

1. Decline in muscle mass

2. Nutritional deficiencies

3. Depression and social isolation

4. Occupational hazard shortening life expectancy

Answer: 2 Explanation:

1. Assessment of the client's mobility is reflective of secondary prevention.

2. The integration of physical therapy for a client with chronic disease reflects a tertiary intervention to promote restoration and prevent or slow down further debilitation.

3. Discussing injury prevention is health promotion or primary prevention.

4. Obtaining a referral for an occupational therapist reflects a secondary measure of prevention in which there is an early diagnosis and prompt treatment.

4. The nurse is caring for an older adult with a chronic disease. Which is reflective of a tertiary intervention to help slow down the progression of the client's illness?

1. Assess the client's mobility

2. Integrate physical therapy

3. Discuss injury-prevention measures within the home

4. Obtain a referral for occupational therapy

Answer: 3 Explanation:

1. Assistive devices may be necessary to increase the independence of the client. The assessment for an assistive device occurs during the rehabilitation time.

2. Education regarding health screenings focuses on prevention of disease.

3. Rehabilitation after a chronic illness can enhance the quality of life and functional ability of the client. Managing chronic fatigue that occurs with heart disease can require rehabilitation.

4. Techniques of self-management can reduce pain and cost of chronic disease by teaching the client to manage their own chronic condition.

5. The nurse is caring for an older client with heart disease that is experiencing fatigue. Which will the nurse initially implement to enhance the overall quality of life and functional ability of the client?1. Assess the need for assistive devices

2. Provide education on health screenings

3. Reinforce the importance of rehabilitation

4. Instruct the client on techniques for self-management

Answer: 2, 3, 5 Explanation:

1. Even though the arteries stiffen with age, an elevation in blood pressure needs to be investigated and not assumed that it is a normal change related to aging.

2. With aging, bladder capacity declines. Needing to urinate every 3 hours would be evidence of reduced bladder capacity.

3. With aging, difficulty focusing up close would necessitate the need for reading glasses. This would be considered a normal change with aging.

4. Even though the heart muscle thickens with age, a pulse rate of 110 needs to be investigated and not assumed that it is a normal change related to aging.

5. Maximum breathing capacity may decline by about 40% between the ages of 40 and 70. A respiratory rate of 22 per minute after walking a short distance can be considered a normal change related to aging.

6. The nurse is assessing an older female patient admitted to the hospital for generalized weakness and a cough. Which assessment findings indicate normal changes of aging? Select all that apply.

1. Blood pressure of 160/90

2. Needing to urinate every 3 hours

3. Needing to wear eye glasses for reading

4. Pulse rate 110 bpm

5. Respiratory rate 22 per minute after walking a short distance

Answer: 4 Explanation:

1. There is not enough information to determine if the patient has chronic illnesses.

2. This response does not address the issue that body systems return to balance slower after an illness as a part of aging.

3. This response does not address that the patient's age impacts the body's ability to fight an infection and return to homeostasis.

4. The loss of organ reserve that can occur with aging can lead to the concept of homeostenosis or inability of the body to restore homeostasis after even minor environmental challenges, such as trauma or infection. An older person may die from pneumonia, which may have only been a minor illness to a younger person

7. The family of an older male patient asks why the patient needs to be hospitalized for pneumonia when the youngest daughter had the same infection a few months ago and was treated at home. How should the nurse respond to the family?

1. "The patient has chronic illnesses that put him at risk."

2. "I don't think you can compare your grandfather to yourself."

3. "There are some differences between men and women and illness."

4. "Aging decreases the body's ability to restore balance to body systems with an infection."

Answer: 3 Explanation:

1. The cross-link theory states that cross-linked proteins resulting from binding of glucose to proteins causes various problems associated with nutrition.

2. The wear-and-tear theory sees the human body as a machine and cellular function slows down with time.

3. The free-radical theory states that accumulated damage caused by oxygen radicals causes cells, and eventually organs, to lose function and organ reserve. The use of antioxidants and vitamins is believed to slow this damage.

4. The emerging biological theory states that there are specific genes responsible for human aging.

8. A patient takes herbal and vitamin supplements in order to "slow down" the aging process. The nurse realizes that the patient believes in the use of antioxidants to slow down cell damage. Which is associated with the biological theory of aging?

1. Cross-link

2. Wear-and-tear

3. Free radical

4. Emerging biological

Answer: 1, 3 Explanation:

1. Jung's theory of individualism states that with aging the focus is away from the external world and moves toward the inner experience. This is a psychosocial theory of aging and would be applicable to use for a patient experiencing these emotions.

2. The free-radical theory focuses on aging as a result of accumulated damage caused by oxygen radicals causes cells, and eventually organs, to lose function and organ reserve.

3. Jung's theory of individualism states that with aging the focus is away from the external world and moves towards the inner experience. This is a psychosocial theory of aging and would be applicable to use for a patient experiencing these emotions.

4. The wear-and-tear theory focuses on aging as a result of cells and organs wearing out after years of use. Proponents of this theory see the human body as a machine. They believe that a "master clock" controls all organs and that cellular function slows down with time.

5. The programmed longevity theory focuses on aging as a result of changes in gene function which is a biological theory. This patient is demonstrating psychosocial changes with aging.

9. Jung's theory of individualism focuses on the client's inner psychological state in regards to aging. When assessing an older client, the nurse might find which thoughts? Select all that apply.

1. Signs of sadness and depression

2. Questions about nutrition and vitamins

3. Regrets on not accomplishing more in life

4. A belief that past injuries have altered their abilities

5. Concerns that damaged cells are slowing down their body

Answer: 3 Explanation:

1. The cross-link theory is related to the accumulation of cross-linked proteins causing disease. This theory does not explain the damage done to the patient's joint from playing football.

2. The free-radical theory states that cell damage is a result of accumulation of oxygen radicals. This theory does not explain the damage done to the patient's joint from playing football.

3. Osteoarthritis is characteristic of degeneration that results from joint usage. This disease is characteristic of the aspects of the wear-and-tear theory, which states that there is a "master clock" that controls all organs and cellular functions, which becomes less efficient over time. Abusing one organ or bodily system through repeated injury that occurs with contact sports may result in premature aging and diseases such as osteoarthritis.

4. The somatic DNA damage theory states that genetic mutations occur and accumulate with increasing age. This theory does not explain the damage done to the patient's joint from playing football.

10. A 62-year-old former professional football player is in the hospital for a total knee replacement as a result of wear and tear and a medical diagnosis of osteoarthritis. Which biological theory of aging would help explain this patient's current health problem?

1. Cross-link

2. Free radical

3. Wear-and-tear

4. Somatic DNA damage

Answer: 4 Explanation:

1. Telling the patient that the nurse understands the patient's feelings does not help the patient understand the importance of health promotion activities.

2. Reporting the concerns to the physician does not help the patient understand the importance of health promotion activities.

3. While the patient has an increased likelihood of developing an illness if the vaccines are not taken, stating this does little to meet the patient's voiced concerns.

4. Receiving vaccinations for communicable diseases is a form of health promotion. The patient should be advised that age should not restrict health-saving activities.

11. An older patient is refusing to receive the influenza and pneumococcal vaccinations because he believes he is "too old." How should the nurse respond to this patient?

1. "I understand your feelings."

2. "I will report your concerns to the physician."

3. "You are likely to get sick if you do not take the vaccines."

4. "It is never too late in life to begin health promotion activities."

Answer: 1 Explanation:

1. Heart disease is the leading cause of death in the senior population, even though it has decreased by 2.4% between 2009 and 2010.

2. The death rate increased significantly from 2009 to 2010 for Alzheimer's disease.

3. The rate of heart disease in the senior population has decreased by 2.4% between 2009 and 2010.

4. Cancer is among the top causes of death but is not the number one cause of death.

12. A nursing student is preparing a program to review health concerns for seniors. Which statement should the student include in the presentation?

1. "Heart disease is the leading cause of death for senior citizens."

2. "Decreases have been shown in the rate of Alzheimer's disease."

3. "The rate of heart-disease death for senior citizens is steadily increasing."

4. "Cancer is currently steady within the senior citizen population."

Answer: 1, 3, 4 Explanation:

1. In the Continuity Theory of Aging, the pace of activities may be slowed, so rest periods between activities would be appropriate.

2. In the Continuity Theory of Aging, older age is not viewed as a time for major life readjustments but rather as a time to continue being the same person. Introducing patients to new activities does not support this theory.

3. In the Continuity Theory of Aging, successful aging involves maintaining family ties. Encouraging family members to visit with the patients would be appropriate.

4. In the Continuity Theory of Aging, activities pursued in life that did not bring satisfaction may be dropped. Suggesting that patients avoid activities that do not bring satisfaction would be appropriate.

5. In the Continuity Theory of Aging, successful aging involves maintaining values, habits, and preferences that formed the basic underlying structure of adult life. Reminding patients that withdrawing from activities is expected supports the Disengagement Theory.

13. The nurse provides care to patients in a long-term care facility that embraces the Continuity Theory of Aging. Which actions will the nurse plan to promote this theory? Select all that apply.

1. Plan rest periods between activities.

2. Introduce patients to a wide variety of new activities.

3. Encourage family members to visit with the patients.

4. Suggest participating only in activities that bring satisfaction.

5. Remind patients that withdrawing from activities is expected.

Answer: 1 Explanation:

1. Personality is stable throughout adult life and rarely do healthy older people show signs of personality change during their final years.

2. Personality usually does not change radically even as a result of major lifestyle changes such as the death of a loved one.

3. Personality is stable throughout adult life and rarely do healthy older people show signs of personality change during their final years.

4. Personality usually does not change radically even as a result of major lifestyle changes such as retirement.

14. A graduate nurse is nervous about caring for older adult patients because of the personality changes that occur with aging. How should the nurse's preceptor respond to this statement?

1. "Personality tends to stay stable through life, rarely showing signs of change during final years."

2. "The losses many elderly experience understandably will impact their personality."

3. "The personalities of the elderly do undergo some significant changes after the eighth decade of life."

4. "After retirement, feelings of disuse cause many elderly to begin demonstrating personality changes."

Answer: 1 Explanation:

1. Body fat typically increases until middle age and then stabilizes until late life, when weight tends to decline.

2. Body weight stabilizes after middle age.

3. With aging, fat is redistributed to the deeper organs.

4. With aging, fat is redistributed to the abdomen rather than to the hips. This promotes an apple shape rather than a pear shape.

15. A patient voices concerns about her body weight despite diligently following a healthy diet. Which age-related change would explain this patient's issue with body weight?

1. Body fat increases until middle age.

2. Body weight increases after middle age.

3. Fat is redistributed to the hips after middle age.

4. Body fat promotes a pear-shaped appearance for aging women.

Answer: 1 Explanation:

1. Without exercise muscle mass declines 22% for women and 23% for men between the ages of 30 and 70. Exercise can slow this rate of loss.

2. Calories are burned more slowly during aging, and adding fats can promote fat build-up, not an increase in muscle mass.

3. Without exercise, muscle mass declines 22% for women and 23% for men between the ages of 30 and 70.

4. Without exercise, muscle mass declines 22% for women and 23% for men between the ages of 30 and 70. Exercise can slow this rate of loss.

16. A 60-year-old patient in good health has asked the nurse about what steps can be taken to build muscle mass. What information should be provided to the patient?

1. Exercise can slow the loss of muscle mass.

2. Increasing protein and fat intake will increase muscle mass.

3. Muscle mass declines by 40% between the ages of 30 and 70.

4. There is little that can be done to reduce the loss of muscle mass associated with aging.

Answer: 1, 2, 3, 5 Explanation:

1. Limiting exposure to pathogens can support immune function in the older person.

2. A healthy diet can support immune function in the older person.

3. A healthy, active lifestyle supports immune function in the older person.

4. Declines in immune function can affect the outcomes of illness such as urinary tract infections and pneumonia.

5. Preventive health measures such as a yearly influenza vaccination can support immune function in the older person.

17. The nurse is planning a program about the Immunological Theory of Aging for a group of senior citizens. Which information should the nurse include in this program? Select all that apply.

1. Restrict spending time with others who are ill.

2. A healthy diet supports immune function.

3. An active lifestyle supports immune function in the older person.

4. Immune responses increase with aging.

5. Obtaining an annual influenza vaccination supports immune function.

Answer: 3 Explanation:

1. The Continuity Theory of Aging supports the idea that after retirement, activities may slow but are still important to continue for satisfaction and happiness.

2. The Disengagement Theory considers the need of an individual to engage in society and maintain equilibrium.

3. A key focus of Jung's theory is the impact of an inability to accept past accomplishments and failures to promote successful aging. The client is having a hard time regarding the loss of her husband to another person.

4. Despite the loss of a pet/animal, the Continuity Theory of Aging supports that life must go on and routines must continue.

18. Jung's theory focuses on a person's inability to accept past accomplishments and failures. When assessing a client, which statement supports this theory of a patient's belief?

1. "I am having trouble finding the right bowling league since I retired."

2. "I joined a sewing club with my older sister but don't always feel like going."

3. "I lost my husband to a younger, more attractive woman about 4 years ago."

4. "I still get up every morning to go walking, but I miss my dog since she died."

Answer: 1, 4, 5 Explanation:

1. Blood pressure monitoring is a secondary prevention intervention and would be appropriate for the residents at risk for cardiac problems.

2. Demonstrating the use of walkers and canes is a tertiary prevention intervention and would not be appropriate for these residents.

3. Explanation on the avoidance of alcohol would be a primary prevention intervention and would not be appropriate for these residents.

4. Discussion with a dietitian for elevated cholesterol levels is a secondary prevention intervention and would be appropriate for these residents.

5. Discussion with a physical therapist on weight-bearing exercises is a secondary prevention intervention and would be appropriate for these residents.

19. The nurse at an assisted-living facility is planning secondary prevention activities for a group of residents at risk for cardiac problems. Which activities would be appropriate for this level of care? Select all that apply.

1. Blood pressure monitoring

2. Demonstration on the use of walkers and canes

3. Explanation on why the use of alcohol should be avoided

4. Discussion with a dietitian for elevated cholesterol levels

5. Discussion with a physical therapist on weight-bearing activities

Answer: 1, 2, 5 Explanation:

1. Medicare recommends a Pap smear once a year.

2. Medicare recommends a mammogram once a year.

3. Medicare recommends a colonoscopy every 10 years for those with normal risk levels and every 2 years for those at high risk.

4. Medicare recommends fecal occult blood testing once a year.5. Medicare recommends bone mass screening every 2 years for those at risk.

20. A patient who is new to Medicare has been reviewing coverage for health screening tests. Which statements indicate the patient understands the recommendations provided by Medicare? Select all that apply.

1. "I can have a Pap smear once a year."

2. "I can have a mammogram once a year."

3. "I can have a colonoscopy every 15 years."

4. "I can have fecal occult blood testing every 2 years."

5. "I can have bone mass screening every 2 years if I'm at risk."

Answer: 1 Explanation:

1. Currently, colonoscopy screening is recommended every 2 years for those at high risk.

2. Serum cancer markers are not a recommended screening test.

3. The flexible sigmoidoscopy is recommended every 4 years.

4. Fecal occult blood screening is recommended annually.

21. The nurse is preparing a care plan for an older African American patient at risk for colon cancer. What should be included in the plan of care?

1. Colonoscopy every 2 years

2. Serum cancer marker testing every year

3. Flexible sigmoidoscopy testing annually

4. Fecal occult blood screening every 2 years

Answer: 2 Explanation:

1. A growing number of Hispanic and African Americans are reporting diabetes.

2. There is an increasing rate of obesity in the Hispanic population.

3. Nearly 60% of older African Americans report high blood pressure.

4. African Americans are more likely than Caucasians to have limitations in ADLs when chronically ill.

22. The nurse recognizes that clients admitted to the unit are associated with nationwide demographic trends. Which statement supports this observation?

1. Diabetes is most prevalent in the Caucasian community.

2. Hispanic patients have a greater incidence of obesity.

3. African-American patients have a lower incidence of hypertension.

4. Caucasians are more likely than African Americans to have limitations with ADLs when chronically ill.

Answer: 1, 2, 3, 5 Explanation:

1. Cancer is a focus area in Healthy People 2020 that is applicable to older people.

2. Food safety is a focus area in Healthy People 2020 that is applicable to older people.

3. Tobacco use is a focus area in Healthy People 2020 that is applicable to older people.

4. Employment is not a focus area in Healthy People 2020 that is applicable to older people.

5. Heart disease is a focus area in Healthy People 2020 that is applicable to older people.

23. The nurse is planning a program for community members to highlight the Healthy People 2020 areas applicable to older people. Which topics would the nurse include in this program? Select all that apply.

1. The importance of performing monthly breast exams

2. How to cook healthy food safely

3. Tobacco and Smoking Cessation techniques

4. Employment and occupational hazards

5. Heart healthy lifestyle choices

Answer: 2 Explanation:

1. Turning a patient at risk for skin breakdown is an example of a primary prevention goal.

2. Treating a pressure ulcer is an example of a tertiary prevention goal.

3. Assessing a patient at risk for skin breakdown is an example of a primary prevention goal.

4. Teaching a patient how to prevent skin breakdown is an example of a primary prevention goal.

24. The nurse is working on a care area that focuses on tertiary prevention. Which goal is most consistent with this focus?

1. Patients at risk for skin breakdown will be turned every 2 hours.

2. Patients with pressure ulcers will have whirlpool therapy as indicated.

3. Patients will be assessed for factors that place them at risk for skin breakdown.

4. Patients are instructed to change positions in bed every 2 hours to prevent skin breakdown.

Answer: 1, 3, 4 Explanation:

1. Atherosclerosis is considered one of the most common causes of disability in the United States. High blood pressure can be caused by atherosclerotic changes in the arteries.

2. Drinking alcohol on a daily/consistent basis can cause chronic illness; once a week is not consistent with chronic illness later in life.

3. Smoking 1 pack per day for 25 years can lead to a lung or respiratory problem, which is considered as being one of the most common causes of chronic illness in the United States.

4. Degenerative joint disease is considered one of the most common causes of disability in the United States. A history of lower back pain could be an indication of degenerative joint disease in the spine.

5. Employment history such as working as a laboratory technician is not considered a contributing factor to chronic illness later in life.

25. After completing an assessment, the nurse is concerned that a middle-aged patient is at risk for having a chronic illness later in life. What did the nurse assess in this patient? Select all that apply.

1. Has a blood pressure reading of 150/90

2. Goes out with friends for a drink once per week

3. Smokes 1 pack of cigarettes per day for the last 25 years

4. Has a history of lower back pain

5. Works as a laboratory technologist

D. Coordinate time of day to provide hygienic care with the client Rationale: The ethical principle of autonomy is to respect people's needs for self-determination, freedom, and rights. Coordinating the time of day to provide hygienic care with the person supports the principle of autonomy. Assessing for pain, encouraging range of motion, and ambulation supports the ethical principles of beneficence and nonmaleficence.

8.The nurse plans care for an older patient recovering from an exacerbation of a chronic illness. Which intervention best supports this person's autonomy? A. Encourage to perform active range of motion twice a day B. Assess for pain level every 4 hours C. Ambulate down the hall to have meals in the dining room with other clients D. Coordinate time of day to provide hygienic care with the client

C. Offer a tissue and hold the person's hand Rationale: If a person cries, the nurse should offer a tissue, hold their hand if appropriate, and wait a few minutes. Crying can be therapeutic and offers release from persistent feelings of sadness. Asking "what's wrong" in a cheerful tone does not take the person's behavior into consideration. Leaving the person alone may exacerbate the feelings of sadness. Watching television is not an appropriate approach to use for a person who is obviously distressed or sad.

9.An older person is seen sitting in a chair, staring out the window and crying. Which approach should the nurse use to comfort this person? A. Suggest watching television as a distraction B. Cheerfully ask the person "what's wrong?" C. Offer a tissue and hold the person's hand D. Leave the person alone to maintain privacy

C. Repeat the information after making eye contact Rationale: A puzzled look may mean the person cannot hear but is ashamed to interrupt. Because of the puzzled look, the nurse should repeat the information about the activity. Talking louder can be disturbing. There is no reason to lower the lighting in the room. The resident is not demonstrating an emotion issue, so holding the hand is not appropriate at this time.

10.During an activity in the recreation room the nurse notes a resident staring with a puzzled expression after instructions for a group activity are given. What should the nurse do to assist this resident? A. Talk louder in the future B. Lower the room lights C. Repeat the information after making eye contact D. Hold the resident's hand

Answer: 4 Explanation:

1. Palliative care alleviates pain and suffering. There is no information to suggest the client is in need of palliative care.

2. Educating the clients on healthcare services is important, but the nurse is not educating in this role, they are supporting a discussion with the family.

3. Collaboration with the interdisciplinary team would include the nurse working with other professionals to provide client care. The nurse is not collaborating with other professionals regarding the client's desire to complete advance directives.

4. The nurse is advocating for the family and client regarding end-of-life decisions. This is included in the knowledge and skills of gerontological nurses.

1. The nurse supports an older client's desire to discuss advance directives with the client's family. What action is the nurse performing with this client?

1. Facilitating palliative care

2. Educating the family on healthcare services

3. Collaborating with the interdisciplinary team

4. Advocating for client's rights and autonomy

Answer: 2 Explanation:

1. Justice involves fairness and equal distribution of resources to all in need.

2. Autonomy is the respect for a client's self-determination, freedom, and rights including the right to refuse treatment.

3. Beneficence is the principle of doing "good" and not doing harm to clients.

4. Nondisclosure is an ethical issue when persons who care about a client, such as family, do not want a client to be told the entire facts of a negative prognosis in order to protect the client from anxiety and fear.

2. The nurse supports an older client's autonomy; which decision supports this ethical principle?

1. Client wants to see case management for Medicaid resources.

2. Client decides to stop further chemotherapy treatments.

3. Client is given more education regarding medication side effects.

4. Client treatment information is kept from client because of family request.

Answer: 1, 2, 4 Explanation:

1. Care must always be based on current evidence. Nurses must be knowledgeable about using informatics to access the best evidence for care provision.

2. Teamwork is a knowledge, skill, or attitude that will improve the quality of care of the facility's residents by fostering open communication, mutual respect, and shared decision making to achieve better quality.

3. Staff incentives are not a knowledge, skill, or attitude that will improve the quality of care of the facility's residents.

4. For a team to function well, respectful communication is an essential skill.

5. QSEN does emphasize valuing everyone's beliefs, values, and needs. The nursing director would include information on how to be respectful of all cultures and individuals, but presenting information specific to the local area does not fully meet this criteria.

9. The director of nursing at a skilled facility is implementing the Quality and Safety Education for Nurses (QSEN) project to improve the quality of care of the older residents. Which topics will the director include in staff teaching? Select all that apply.

1. Directions on accessing evidence-based practice resources

2. Methods for ensuring effective team collaboration

3. A plan for staff incentives for meeting care goals

4. Examples of respectful team communication5. Information on the most prevalent cultures in the region

d.

an organization intends to improve cultural-competent care throughout the healthcare system. which action indicates that the Transcultural Nursing Society's care standards are being implemented?

a. cultural-minority applicants are encouraged to seek employment at the university hospital b. non english-speaking persons referred to a local hospital who employs interpreters c. cultural-assessment forms located on each computer station d. continuing-education sessions scheduled every three months for all nursing staff

d.

a healthcare organization placed posters printed in english and spanish throughout the organization to direct patients and family to various parts of the facility. which culturally and linguistically appropriate services in healthcare (CLAS) standard does this demonstrate?

a. principle b. engagement, continuous improvement, and accountability c. governance, leadership, and workforce d. communication and language assistance

b.

the nurse prepares to complete a cultural assessment with an older patient newly admitted to the care area for treatment of an acute illness. which action should the nurse take first before beginning this assessment?

a. review the patient's current health problem b. identify the patient's primary language c. select an appropriate culture-assessment tool d. determine if family are available to answer questions

c.

a new certified nursing assistant has recently relocated to the US from an eastern european country. which facility practice might cause the assistant to provide less-than-competent cultural care?

a. meals are provided in the dining hall or in the residents' rooms b. residents are scheduled for routine baths and showers c. residents' family members visit once or twice a month d. staff attend report at the beginning and end of every shift

a.

the nurse notes that an older female patient refuses care offered by a male nursing assistant. for which outcome should the nurse assess the person as a result of this situation?

a. anxiety b. dehydration c. weight loss d. anger

d.

the nurse reviews the care needs for assigned patients. which person should the nurse identify as having the highest heritage consistency?

a. 70 year old who reads the daily newspaper b. 65 year old who swims at the local health facility twice a week c. 60 year old who occasionally attends culture based family gatherings d. 75 year old who visits the country of origin 4x a year

d.

an older person relates being widowed as a young woman and how it was an expectation to wait at least 5 years before dating. which question should the nurse ask to understand this person's cultural-life trajectory?

a. "what did you do for 5 years?" b. "did you want to date sooner?" c. "where did you live during this time?" d. "why was it an expectation?"

d.

an older person will not eat breakfast or take medication until the parish priest arrives. what action should the nurse take that demonstrates cultural sensitivity for the person's delay in eating this meal?

a. remove the breakfast tray and mark "refused" on the appetite record b. discuss that the priest understands the person is ill and will understand if a meal is eaten c. explain that the meal must be eaten before medication can be provided d. keep the tray in the room until the parish priest arrives

d.

an older person who relocated to the US a few months ago has a limited understanding of english and has no living family members for support. which action should the nurse take to reduce the amount of cultural marginality that this person experiences?

a. find an interpreter to help with completing the assignment b. suggest returning to the home country for ongoing care and support c. provide information on english as a second language classes d. locate a community organization that is the same culture as the person

d.

an older person expresses the desire to get better and return to home. which aspect of ethnogeriatric care is important to this patient?

a. respect b. modesty c. manners d. independence

Answer: 1 Explanation:

1. Limited understanding of ethnic, cultural, religious heritages and life trajectories of each other results in difficulty with cultural literacy.

2. The perspective of a person's heritage reflects the consistency with their own heritage.

3. Feeling disconnected from one's own culture and not being able to acculturate to a prevailing culture is a personal experience known as cultural marginality.

4. There is not specifically a lack of healthcare policies that have contributed to cultural illiteracy. However, nurses should recognize the effect of healthcare policies, delivery systems, and resources on the older adult populations and continue to advocate for their inclusion.

1. The charge nurse has provided a staff inservice on the cultural triad and nursing care. Which statement, made by a staff nurse, best indicates an understanding of a healthcare team's difficulty with cultural literacy?

1. "Our healthcare team has limited knowledge of each others' backgrounds."

2. "Each of our perspectives of our own heritage interferes with cultural literacy."

3. "A feeling of being disconnected from our own culture has resulted in cultural illiteracy."

4. "The lack of healthcare policies have contributed to the current state of cultural illiteracy."

Answer: 1 Explanation:

1. A common cultural conflict is misunderstanding a cultural practice of modesty and the need for gender-specific care. The nurse should recognize this as a legitimate request and make every attempt to honor the request.

2. Stating that the request is unreasonable shows insensitivity to the patient's cultural need.

3. Although both male and female staff have professional and ethical responsibilities to respect a patient's privacy, the nurse must still make efforts to meet the request of the patient.

4. The response of covering the patient shows insensitivity to the patient's cultural need.

2. The husband of a female patient of the Islamic culture asks that only a female doctor examine his wife. How should the nurse respond to the husband?

1. A female doctor will be provided.

2. The request is unreasonable and cannot be honored.

3. Both male and female doctors respect the patient's privacy.

4. The patient's body will be covered during any examinations.

Answer: 2 Explanation:

1. Researching the client's practices will help the nurse become culturally competent, but this does not support the client in practicing his or her beliefs.

2. Obtaining a consult with a dietician will assist the client in adhering to religious practices that center around dietary intake.

3. Documenting the client's preferences on a form is important for communication but does not address the actual dietary requirements associated with the clients practiced beliefs.

4. Communicating the client's preferences to the healthcare team is important for communication but does not address the actual dietary requirements associated with the client's practiced beliefs.

3. The nurse learns that a client of the Jewish faith does not eat certain types of foods and fasts on religious holidays. Which intervention would help support the client's cultural practice?

1. Research the client's practices.

2. Obtain a consult with the dietician.

3. Document the client's preferences on the assessment form.

4. Communicate the client's practices to the healthcare team.

Answer: 2 Explanation:

1. Instructing the mother to stop using the paste demonstrates cultural insensitivity by the nurse and should not be done.

2. To recognize cultural practices, the nurse must acknowledge that use of folk and home remedies are part of caregiving practices. Asking the mother what ingredients are in the paste allows the nurse to best evaluate what the mother is using, and then a determination of the benefit or detriment to the infant can be made in a nonjudgmental manner.

3. Providing the mother with another cream to use for the diaper rash demonstrates cultural insensitivity by the nurse and should not be done.

4. Explaining to the mother that herbal ingredients are harmful to the baby demonstrates cultural insensitivity by the nurse and should not be done

4. An infant of African origin is being cared for by parents who immigrated to the United States 6 months prior. The mother is using an herbal paste to treat the baby's diaper rash. What should the nurse do to ensure cultural competence?

1. Instruct the mother to stop using the paste.

2. Ask the mother to explain the ingredients in the paste.

3. Provide the mother with another cream to use for the diaper rash.

4. Explain to the mother that herbal ingredients are harmful to the baby.

Answer: 4 Explanation:

1. Loss of trust occurs when there are missed cues with the client. It may not be culturally acceptable for a client that is in pain to show any indication of it.

2. The nurse should become familiar with the client's culture; however, this does not address how to appropriately assess the client's pain level, and the nurse should not assume the client has pain.

3. This would not help implement culturally competent care and does not help the nurse accurately assess the client's pain level.

4. Using an interpreter to accurately assess the client for pain and explain the use of the faces pain scale to assess the client's pain level in the future would be culturally appropriate.

5. The nurse is developing a plan of care for a client with a language barrier that is recovering from surgery and has not requested any pain medication. Which of the following interventions should the nurse include in the care plan?

1. Assess the client for non-verbal signs of pain and medicate the client if signs are noted.

2. Become familiar with the client's culture and how the culture typically demonstrates signs of pain.

3. Obtain a prescription for the client to have a patient-controlled analgesic pump so the client can be in control of their own pain management.

4. Utilize an interpreter to explain the faces pain scale for assessing and evaluating the client's pain level now and throughout the hospitalization.

Answer: 2 Explanation:

1. The nurse needs to respect the decisions of the family and the culture even when they are different from the nurse's beliefs.

2. Assisting with the exploration of resources to meet the client's needs supports the traditions and culture of the client and family.

3. The nurse should include the family in discussions about care and respect the client's support systems.

4. The healthcare team is available to provide support to the client and family, not completely direct the clients care.

6. The family of an older adult, requiring end of life care, is planning on caring for the client in the home. Which intervention should the nurse implement to meet the cultural needs of the client?

1. Encourage the family to allow a hospice nurse in the home to care for the client.

2. Explore the resources available to the family to meet the client's needs in the home.

3. Ask the client when the family is not present if the client wants to stay in the hospital.

4. Explain to the family the importance of allowing the healthcare team to direct the client's care.

Answer: 2, 3, 4, 5 Explanation:

1. When meeting a person for the first time, introduce yourself by your full name, and then explain your role. This helps establish a respectful relationship between the nurse, family and client and prevent conflict.

2. Many of the CNAs may be new immigrants and have difficulty speaking and understanding English. Both native and foreign-born CNAs may have limited understanding of the ethnic, cultural, and religious heritages and life trajectories of the older persons and nurses who, in turn, have a limited understanding of the backgrounds of these nursing assistants. This lack of understanding may lead to difficulties with cultural literacy for both older persons and caregivers and negatively impact access to culturally competent nursing care.

3. There is a demarcation in the older adult population's technological savvy where the middle-old (75—84) and oldest-old (85+) may not possess the needed technologic ability and comfort.

4. Worldviews tend to differ greatly between generations. Those who have high heritage consistency tend to have difficulty accepting perspectives of generations different from their own. This can be a source of conflict.

5. There is a significant disparity between the number of foreign-born U.S. residents who need a nurse who speaks their language vs. the number of nurses available who actually speak their language.

7. The nurse is planning care for a client who is 82 years old, male and Hispanic. Which of the following should the nurse identify as potential conflicts when considering the cultural-care triad? Select all that apply.

1. Appropriate introductions between the nurse and client

2. Cultural differences in education among the caregivers

3. Difficulty accessing electronic health information by the client

4. Generational differences among the client, caregiver, and nurse

5. Language barriers between the nurse and the caregiver and client

Answer: 1, 2, 5 Explanation:

1. To meet the national standards for culturally and linguistically appropriate services, the nurse needs to offer language assistance services to the patient.

2. To meet the national standards for culturally and linguistically appropriate services, the nurse needs to post signage in the patient's native language.

3. Family should not be used to provide interpretive services except upon request by the patient.

4. Healthcare organizations must offer and provide language assistance services at no cost to each patient.

5. To meet the national standards for culturally and linguistically appropriate services, the nurse needs to provide the patient with a written notice in the patient's language, informing the patient of the right to receive language assistance services.

8. The nurse is caring for an older patient who only speaks Spanish. To meet the national standards for culturally and linguistically appropriate services in healthcare, what will the nurse do? Select all that apply.

1. Offer language assistance services to the patient.

2. Post signs in the patient's room written in Spanish.

3. Encourage the patient's family members to serve as interpreters.

4. Explain the cost to employ an interpreter to help the patient with language needs.

5. Provide a written notice in the patient's language informing of the right to receive language assistance services.

Answer: 1 Explanation:

1. Nodal key events in a person's life are considered life trajectories. Events in a person's life, school, military service, marriage, divorces, children, moves, major illnesses, surgeries, and deaths of significant others are life trajectories.

2. Asking the client about how they feel about their treatment plan is not directly associated with a life trajectory.

3. Inquiring about the need for a hospital chaplain is not directly associated with a life trajectory.

4. Inquiring about a living will or durable power of attorney is not directly associated with a life trajectory.

9. The nurse is assessing life trajectory of an older client admitted to the unit. Which of the following would be the best question by the nurse to obtain information about life trajectory?

1. "Tell me about your spouse and children?"

2. "How do you feel about your treatment plan?"

3. "Would you like me to contact a chaplain for you?"

4. "Do you have an advanced directive or living will?"

Answer: 1 Explanation:

1. Heritage consistency includes the enjoyment of regular contact with their extended family.

2. A generation difference is a challenge to heritage consistency.

3. Marrying someone from the same culture is not an example of heritage consistency.

4. An older adult demonstrates ties to their ethnicity through dress, language, preferred foods, family celebrations, and holidays.

10. The nurse is caring for an older adult in a long-term care facility. Which statement made by the client best indicates that the client practices heritage consistency?

1. "I look forward to my family visits every Sunday."

2. "The younger generation does not understand me."

3. "My parents were so happy that my spouse shares our culture."

4. "I was so excited to learn English when I came to this country."

Answer: 1 Explanation:

1. The best use for a nurse learning to speak Spanish is the ability to communicate with their clients and their families effectively.

2. Learning a second language can help facilitate the professional growth of the nurse but will be of best use when communicating with the clients and their families.

3. A second language will help facilitate communication with others in the community but will be of best use for communicating with the clients and their families.

4. The nurse can derive a great deal of personal satisfaction from learning a second language, but the language will be of best use when communicating with the clients and their families.

11. The nurse that lives in a predominantly Spanish-speaking community is learning to speak Spanish. Which describes the best use of learning Spanish?

1. The nurse will be able to communicate better with the clients' families.

2. Speaking a second language will facilitate the professional growth of the nurse.

3. A second language will help when communicating with others in the community.

4. The nurse can gain a great deal of personal accomplishment after learning a second language.

Answer: 2, 5 Explanation:

1. The nurse should offer the services instead of requesting a chaplain. Requesting a chaplain is an assumption the client would like their services.

2. The nurse that is practicing cultural competence will defer scheduled activities for the client to pray.

3. The nurse should offer privacy to the client for prayer.

4. Encouraging a client to pray when family are visiting does not address the client's immediate spiritual needs.

5. Show a sincere interest in learning about their culture. When you do not understand a person's actions, politely and respectfully seek information.

12. The nurse is caring for an older client that has requested time to pray. Which interventions are most appropriate to facilitate the client's ability to perform the ritual? Select all that apply.

1. Request a chaplain

2. Defer scheduled activities

3. Remain with the client during prayer

4. Encourage the client to pray when family are visiting

5. Ask questions about the client's beliefs

Answer: 1 Explanation:

1. Using the hospital-approved interpreter program is the intervention of choice when communicating with any patient who is deaf or has limited English proficiency.

2. Using family members can interfere with confidentiality and also does not ensure that the information is being communicated correctly.

3. Asking the patient to read assessment questions off of the computer screen does not ensure that the patient will understand the questions that are being asked.

4. Using other coworkers can interfere with confidentiality and also does not ensure that the information is being communicated correctly.

13. The nurse is preparing to admit an elderly patient who is deaf. What should the nurse do to ensure effective communication with the patient?

1. Use the hospital-approved interpreter program.

2. Use the patient's family members to communicate with the patient.

3. Ask the patient to read assessment questions off of the computer screen.

4. Ask if anyone who is currently working could help communicate with the patient.

Answer: 4 Explanation:

1. Understanding the client's background is a component of providing culturally appropriate care.

2. Considering the context of a client's situation is a component of providing culturally appropriate care.

3. Familiarization with cultural health practices is reflective of culturally appropriate care.

4. A plan of care should incorporate the assessment findings regarding the client's cultural preferences, not nursing considerations.

14. The nurse overhears a student nurse discussing the three areas of focus of cultural care nursing. Which statement by the student best indicates a lack of understanding of cultural care nursing?

1. "The nurse must understand the client's background."

2. "A nurse must acknowledge the total context of the client's situation.

3. "When caring for clients, the nurse should be familiar with the client's cultural health practices."

4. "Nursing considerations regarding the client's culture should be incorporated into the care plan."

Answer: 3 Explanation:

1. The client attending secular religious services has no identification with a specific religion.

2. A client that is well versed in many different cultures is not demonstrating the practice of heritage consistency.

3. A client planning to visit a childhood neighborhood is practicing heritage consistency.

4. A client that occasionally contacts extended family members is not necessarily practicing heritage consistency.

15. The nurse is caring for an older client. Which assessment finding best indicates that the client is practicing heritage consistency?

1. The client attends secular religious services.

2. The client is very well versed in many cultures.

3. The client plans to visit their childhood neighborhood.

4. The client occasionally contacts extended family members.

Answer: 1 Explanation:

1. A ritual of prayer is associated with many cultures and religions. Respecting the client's prayer ritual contributes to the delivery of culturally competent care.

2. Asking a client how they would like to be addressed demonstrates professionalism and respect to all clients regardless of their cultural communication practices. This statement has more to do with professionalism than culturally competent care.

3. Providing the client with uninterrupted time to visit their family is professional and conveys respect to all clients regardless of their cultural beliefs. This statement corresponds more with respect than culturally competent care.

4. All clients should be asked if they would like to participate in general or special activities. There may be a special activity that is culturally related that the client would like to participate in; however, this would not be the most correct comment about culturally competent care.

16. The nurse has provided education for a nursing assistant on culturally competent care. Which statement made by a nursing assistant is the most correct about culturally competent care?

1. "I will respect my client's daily prayer ritual."

2. "I will ask my clients how they would like to be addressed."

3. "I will provide my client uninterrupted time to visit their family."

4. "I will ask my client if they would like to participate in any activities."

Answer: 2, 5 Explanation:

1. Minimally responding to an assessment question does not indicate that the client does not understand what is being asked or cannot communicate using the English language.

2. The client's family member answering the questions is indicative of a language barrier. The nurse's observation may be indicative of a pattern of the family communicating for the client.

3. A lack of eye contact with verbal communication may be cultural, not a language barrier.

4. The client that moves away from the nurse when approached may be modest, prefer minimal touch, or require greater personal space.

5. When a client understands minimal English or none at all and is embarrassed or does not know how to communicate that they cannot speak English, they often just nod and agree while the nurse is speaking.

17. The nurse is assessing a client's ability to speak and understand the English language. Which assessment findings are indicative of a language barrier? Select all that apply.

1. The client answers with a minimal response.

2. The client's family member answers the questions.

3. The client does not make eye contact when spoken to.

4. The client moves away from the nurse when approached.

5. The client nods the head in agreement with everything the nurse says.

Answer: 3 Explanation:

1. Both life and cultural perspectives affect the triad.

2. The cultural care triad consists of the nurse, caregiver, and patient.

3. Cultural diversity of nursing does impact the accessibility to culturally competent care.

4. Demographic disparities between the client and the triad affect the client's care.

5. There is a demarcation in the older adult population's technological savvy with many of the young-old (55—75 years old) easily utilizing computers and other electronic devices while the middle-old (75—84) and oldest-old (85+) may not possess that technologic ability and comfort. This can affect older adults' access to health information and services.

18. The staff development instructor is preparing a presentation on the cultural-care triad. Which information should the instructor include?

1. Life perspective solely impacts the triad.

2. The triad consists of the nurse, patient, and family.

3. The cultural diversity of nursing impacts the accessibility to care.

4. Demographic disparities between the client and the triad minimally impact care.

5. The increased use of technology can negatively impact the client's ability to access health information.

Answer: 4 Explanation:

1. The client that cannot acculturate is not displaying ethnocultural heritage. Acculturation is a blending of the old and new cultures. Ethnocultural heritage is the extent to which a person's lifestyle and belief systems align with the culture of their tribal culture.

2. A person can value characteristics that are both heritage consistent (traditional) and heritage inconsistent (modern). These values exist on a continuum.

3. Ethnocultural heritage is not a loss of culture through the process of becoming Americanized. Ethnocultural heritage is the extent to which a person's lifestyle and belief systems align with the culture of their tribal culture.

4. Feeling disconnected from one's culture is a component of cultural marginality. Cultural marginality occurs when one feels disconnected from their native culture and is unable to acculturate.

19. The preceptor taught a new nurse about the concepts of ethnocultural heritage. Which statement made by the new nurse indicates an understanding?

1. "A client that cannot acculturate is displaying ethnocultural heritage."

2. "A person can only value characteristics that are heritage consistent."

3. "As the client becomes Americanized, their cultural beliefs will change."

4. "Feeling disconnected from one's culture is a loss of ethnocultural heritage."

Answer: 3 Explanation:

1. The question "Where was your mother born?" is a question asked when completing a heritage assessment.

2. The question "Did you live in an extended family?" is a question asked when completing a heritage assessment.

3. The question "Where did your father go to school?" is not a question asked when completing a heritage assessment.

4. The question "Do you belong to a religious institution?" is a question asked when completing a heritage assessment.

20. The nurse is completing a heritage assessment with an older patient from a non-English-speaking culture. Which question would not be a part of this assessment?

1. Where was your mother born?

2. Did you live in an extended family?

3. Where did your father go to school?

4. Do you belong to a religious institution?

Answer: 3 Explanation:

1. Asking a client about a prior occupation has no relation to a heritage assessment.

2. An advanced directive does not specifically address the client's cultural practices of death and dying. It is a legal document that is encouraged for all clients to have.

3. Asking the client about a specific dietary practice addresses the client's cultural and religious practices.

4. Assessing independence from a cultural perspective includes engaging in activities and staying active in their healthcare and living arrangements. The client should be encouraged to independently complete their morning cares and any other activity of daily living.

21. The nurse is conducting a heritage assessment with an older client and wants to understand the client's beliefs on expectations for healthcare. Which question is most appropriate during the assessment?

1. "What was your prior occupation?"

2. "Do you have an advanced directive?"

3. "Do you have a specific dietary practice?"

4. "Would you like to participate in your morning care?"

Answer: 2 Explanation:

1. Assessing the level of pain in the client does not specifically address culture competency.

2. One step to develop cultural competency is becoming aware of the patients' life trajectories. This supports mutual respect between the patient, caregiver, and nurse.

3. The plan of care should include the input of the client. A missed cue can result in a power struggle if there is a cultural conflict.

4. Permission must be obtained from the client prior to involving family members in the client's care.

22. The nurse is admitting an older client to the unit. Which of the following should the nurse include in the admission process to provide culturally competent care?

1. Assess the client's level of pain

2. Identify the client's life trajectories

3. Allow the client to see the prescribed plan of care

4. Encourage family involvement in as much of the client's care as possible

Answer: 3 Explanation:

1. Family members should not be used as interpreters.

2. Writing questions does not help improve communication with the patient.

3. Using a competent interpreter is the most appropriate intervention.

4. Speaking loudly and slowly does not help improve communication with the patient.

23. The nurse has identified the diagnosis of Risk for Impaired Verbal Communication for a patient with limited English skills. Which intervention would be appropriate for this diagnosis?

1. Asking a family member to act as an interpreter

2. Writing questions on a clipboard for the patient to read

3. Using an interpreter when communicating with the patient

4. Speaking loudly and slowly when attempting to communicate with the patient

Answer: 1, 2, 3, 4 Explanation:

1. One question to ask when becoming aware of personal ethnocultural heritage is "Do you value stoic behavior?"

2. One question to ask when becoming aware of personal ethnocultural heritage is "Where were your parents and grandparents born?"

3. One question to ask when becoming aware of personal ethnocultural heritage is "What are examples of your ethnocultural life trajectories?"

4. One question to ask when becoming aware of personal ethnocultural heritage is "What do you see as seminal cultural events of your lifetime?"

5. One question that is not asked when becoming aware of personal ethnocultural heritage is "Which life experience stands out as an event in your heritage?" since there must be a cumulative effort to learn from each experience.

24. A student nurse is preparing a presentation to explain the steps in developing cultural competency. What questions should the student ask to become more aware of personal ethnocultural heritage? Select all that apply.

1. "Do you value stoic behavior?"

2. "Where were your parents and grandparents born?"

3. "What are examples of your ethnocultural life trajectories?"

4. "What do you see as seminal cultural events of your lifetime?"

5. "Which life experience stands out as an event in your heritage?"

Answer: 2 Explanation:

1. Telling the client this information does not help protect the client's privacy and beliefs.

2. The nurse should have care arranged by a person of the same sex as much as possible and protect the person's personal privacy at all times.

3. Telling the client that they may have to be transferred to another floor may increase their anxiety and instill fear and shame.

4. Placing a sign outside the patient's door is inappropriate. The communication between the healthcare team should take place verbally and be documented. Arrangements should be made to have the care by a person of the same sex and to protect the person's personal privacy at all times.

25. The nurse is admitting a client to the unit who states, "I am very uncomfortable with males. My religion does not permit me to have physical contact with them." Which statement made by the nurse would be most appropriate?

1. "We have many male assistants on this unit."

2. The nurse should have care arranged by a person of the same sex as much as possible and protect the person's personal privacy at all times.

3. "I can see if we can transfer you to another floor."

4. "I will put a sign on your door so that no males enter your room."

d.

(??? but the answer is b.)

the nurse notes that an older person lives alone and has been losing weight despite the absence of chronic illness that affect metabolism. which member of the interdisciplinary team should the nurse contact to discuss this person's situation?

a. geriatric physician b. dentist c. physical therapist d. social worker

c.

the nurse schedules an interdisciplinary team meeting for an older person with new pressure injuries on the sacrum and left heel. which team member should the nurse ensure is present before the meeting begins?

a. social worker b. dietitian c. geriatric physician d. PT

b.

the nurse completes a comprehensive geriatric assessment on an older person. on which area should the nurse focus when identifying this person's level of independence?

a. medical diagnoses b. functional ability c. living arrangements d. socioeconomic status

a.

during a comprehensive geriatric assessment the nurse learns that an older person has not been taking prescribed medications for several months. which aspect of the assessment should the nurse focus to identify the reason for medication nonadherence?

a. socioeconomic status b. functional ability c. medical diagnoses d. nutritional status

a.

the nurse reviews information collected after completing a comprehensive assessment with an older person. for which reason should the nurse recommend lipiddisorder screening?

a. diagnosed with peripheral artery disease b. over the age of 65 c. BP 140/90 d. BMI 28.5

b.

the nurse notes that an older person has a BP of 150/90. which health screening should the nurse recommend?

a. depression b. diabetes c. cognitive function d. arthritis

c.

a cognitively intact resident of a long-term care facility asks for assistance getting dressed. shortly thereafter a taxicab driver comes to the desk to pick up the resident as requested. what action should the nurse take?

a. send the driver away since the resident is not permitted to leave the facility b. obtain the name, license #, and telephone # of the taxicab service c. locate the resident for the taxicab driver d. ask the resident to sign an "AMA" form before leaving

a.

the nurse notes that laboratory data for a person who is not a resident of the skilled facility was accidentally faxed to the care area. what should the nurse do with this information?

a. destroy it with a paper shredder b. file in the reusable paper file c. place it in a biohazard trash d. throw it in the trash

c.

an adult daughter says that the parent has been asked repeatedly to complete an advance directive; however, he has neglected to do so. what should the nurse do first to facilitate this person completing an advance directive?

a. ascertain the person's religious belief surrounding death and dying b. obtain a copy of the person's last will and testament c. assess the older adult's attitudes about advance directives d. determine if an attorney has been identified

b.

an older adult without an advance directive requests no interventions should be stop breathing during the night. which type of order should the nurse discuss with the person and healthcare provider?

a. no extraordinary measures b. allow natural death c. all but CPR d. permit to die

Answer: 4 Explanation:

1. Patients should have a minimum of 1-hour appointments scheduled. Shorter appointments will result in a hurried interview with missed information.

2. The reference states to be sure there are bathrooms available during the interview.

3. The ID and insurance card are unrelated to gathering data for a health history.

4. To make the older patient comfortable, adequate lighting and seating should be available.

1. The nurse is preparing to conduct a health history with an older client. Which action should the nurse take to ensure the accuracy and efficiency of the client's health history?

1. Scheduling one-half hour for the medical history interview.

2. Requesting the client use the bathroom before starting the interview.

3. Ensuring the client has their identification and insurance card with them upon arrival.

4. Conducting the history in an environment with comfortable seating and proper lighting.

Answer: 4 Explanation:

1. It is unrealistic to expect that the nurse will speak the patient's primary language if it is not English.

2. Many of the clinical assessment instruments have not been validated for use with ethnic minorities.

3. To avoid stereotypical thinking, the nurse must approach each patient as a unique individual.

4. Knowing the prevalence, incidence, and risk factors for diseases specific to different ethnic groups is a component of cultural competence in healthcare.

2. Which nursing intervention will ensure that the nurse will provide culturally competent healthcare to an older patient?

1. Speak the patient's primary language.

2. Use standardized assessment instruments in health evaluations.

3. Approach patients of a particular ethnic group in the same manner.

4. Know prevalence, incidence, and risk factors for diseases specific to different ethnic groups.

Answer: 3, 5Explanation:

1. Medication information is needed since this may impact the patient's ability to function.

2. The MDS is a standardized assessment tool that forms the foundation for all residents of long-term care facilities certified to participate in Medicare or Medicaid.

3. The items in the MDS give a multidimensional view of the patient's functional capacities.

4. The MDS is used for validating the need for long-term care, reimbursement, ongoing assessment of clinical problems, and assessment of and need to alter the current plan of care.

5. The MDS includes categories that measure physical, psychological, and psychosocial functioning of the patient.

3. The nurse is completing the minimal data set (MDS) for an older patient. What are characteristics of this assessment? Select all that apply.

1. Eliminates listing the patient's prescribed medications

2. Identifies health insurance coverage that is not Medicare or Medicaid

3. Provides a multidimensional view of the patient's functional capacities

4. Used primarily to determine the amount of funding the patient has for long-term care

5. Includes a core set of screening, clinical, and functional measures used in patient assessment

Answer: 3, 4 Explanation:

1. This statement indicates the health belief based on the perceived control of health outcome.

2. This statement is based on the health belief of perceived internal control of action.

3. This statement indicates the client's health beliefs are based on the perceived importance of taking action.

4. This statement indicates the client's health beliefs are based on the perceived importance of taking action.

5. This statement indicates the client's health beliefs are based on the perceived reduction of threat from action.

4. The nurse is assessing an older client's health status. Which comments, made by the client, would indicate that the client's health beliefs are based on the perceived importance of taking action to promote health? Select all that apply.

1. "I should get a physical every year so I can stay healthy."

2. "I know that choosing to eat healthy or not will affect my health now and later on."

3. "I know if I go for walks on a regular basis, I am less likely to have a health problem."

4. "I understand if I continue to go to church and spend time with friends, I will feel less lonely."

5. "I understand if I stop drinking alcohol, I will decrease my chance of liver disease and other health issues."

Answer: 2 Explanation:

1. Evaluating the client for long-term care would not improve the client's overall health.

2. Research shows that comprehensive geriatric evaluations can help improve mental status and reduce hospital readmissions.

3. Collecting an accurate and thorough health history should always be the standard of care, but this would not help improve the client's overall health status.

4. This action only helps with the client's ADLs.

5. The nurse is talking with an older client who has a history of multiple hospitalizations and a recent decline in mental status. Which of the following interventions should the nurse implement to improve the client's overall health?

1. Have the client evaluated for long-term care.

2. Obtain a referral for a comprehensive evaluation.

3. Collect an accurate and thorough health history.

4. Provide the appropriate amount of help for normal activities.

Answer: 1, 2, 3, 5 Explanation:

1. SPICES is an overall assessment tool used to plan, promote, and maintain optimal function in older adults.

2. PULSES is a tool that measures general functional performance in mobility and self-care, medical status, and psychosocial factors.

3. Identifying and using the client's strengths to help maximize independence is one role of the nurse when assessing the function of an older adult.

4. Interviewing a family member is not necessary for assessing the older adults' functional status.

5. An interdisciplinary approach should be utilized to consult and evaluate the older adult.

6. The nurse is assessing the function of an older adult. Which of the following actions should the nurse take? Select all that apply.

1. Utilize the SPICES tool.

2. Utilize the PULSES tool.

3. Identify the client's strengths.

4. Interview the client's closest family member.

5. Use an interdisciplinary assessment approach.

Answer: 2 Explanation:

1. Removing the client from the facility may be unnecessary and can be difficult on the older adult. The client can become more confused and if the client already has established relationships with other residents in the nursing home, removing the client may not be the best action.

2. All states are to operate long-term care ombudsmen programs. These programs provide trained people to investigate complaints made by residents and families about care received in the facility.

3. Since all states are required to provide ombudsmen programs, it would not be in the family's best interest to hire a lawyer first. They should call the ombudsmen first.

4. Unless the family is trained in the medical field, they would not necessarily know what to look for in the medical records to know if appropriate care has been given. This would not be the best choice over calling the ombudsmen.

7. The family of an older client in a nursing home feels that the client has not been treated fairly and that the client's rights have been violated. Which of the following would be the best action for the family to take?

1. Remove the client from the facility.

2. Call the local ombudsman and report the information.

3. Hire a lawyer to obtain information about the client's care.

4. Request a copy of the client's medical record and determine if appropriate care has been given.

Answer: 2 Explanation:

1. The nurse has a duty to advocate for clients and that includes questioning any orders that seem unsafe or inappropriate. The nurse should not just follow the physician's orders without using clinical judgement about the order.

2. Careful documentation of nursing care is the best way for the nurse to defend himself or herself should a legal suit be filed.

3. It is not necessary to avoid using this type of technology to share or transmit client information, but it is the nurse's responsibility to ensure that client confidentiality is upheld when using email or fax.

4. Providing friendly and respectful care should be practiced by every nurse, but this would not prevent the nurse from being involved in a legal suit.

8. Which action should the nurse take to avoid becoming involved in a legal suit with client care?

1. Consistently follow the physician's orders.

2. Document carefully all nursing care provided.

3. Avoid using emails and fax machines to send client information.

4. Always provide friendly and respectful care to the client and families.

Answer: 3, 4, 5 Explanation:

1. The right to leave the facility and gamble is in the Patient's Bill of Rights. As long as the client signs out, the client is allowed to leave and participate in legal activities.

2. The right to raise grievances and make complaints is in the Patient's Bill of Rights. Every client and family member should be shown where the information is posted about the ombudsmen.

3. The right to be free from chemical and physical restraints is in the Patient's Bill of Rights, and sedating a resident because they are making noise or calling out is not an appropriate use of restraints.

4. The right to privacy and marry is in the Patient's Bill of Rights and clients who are both residents and married have the right to sexual activity or just private time together with the door closed.

5. The right to practice religion is in the Patient's Bill of Rights, and the client should not be forced to participate in an activity that is not part of the client's religious beliefs.

9. Which of the following would violate client's rights according to the Patient's Bill of Rights? Select all that apply.

1. The client signed out and left the facility for the day to go to a casino.

2. The nurse showed the adult daughter of a client the notice posted about the ombudsman.

3. The nurse gave a prescribed prn sedative to a client who continuously yelled out, "Hello!".

4. The nurse refused to allow clients, who are husband and wife, to have private time with the door closed.

5. The nurse told the client, who is a practicing Jew, that the client had to participate in the facilities Christmas party.

Answer: 1 Explanation:

1. Questioning a medication dosage outside the normal range is a situation in which a reasonable nurse would pursue a similar action and would be considered the standard of care.

2. Medicating a client with aspirin for severe chest pain without a prescription and then notifying the physician would not be considered standard care.

3. The nurse should have withheld the breakfast tray from a client who is nauseated and vomiting or at least left it outside the client's room so the client would not smell the food and possibly exacerbate the symptoms.

4. Assisting a patient who has fallen is a situation in which a reasonable nurse would pursue a similar action and would be considered the standard of care. The nurse would then need to fill out the incident report at the time of the incident, not on the next shift.

10. Which of the following actions by the nurse would meet the standard of care?

1. The nurse questioned a physician about a prescription where the dose was higher than the recommended dose.

2. The nurse medicated a client who reported severe chest pain with aspirin and then called the physician to get a prescription.

3. The nurse brings a breakfast tray into the client's room and puts in on the counter away from the client who is vomiting and nauseous.

4. A nurse leaving the facility at the end of the shift witnesses a client fall. The nurse calls for help and tells the other nurse that during the next shift he or she will fill out the incident report.

Answer: 1, 4 Explanation:

1. Restraints are now limited to short-term use of 2 hours or less.

2. Restraints may be necessary in other situations other than just in emergency situations.

3. Waist restraints are not proven to be the best approach to prevent client falls. Nurses are urged to develop alternatives to physical restraints such as addressing client and environmental factors.

4. Restraints are used only with a physician's order.

5. The nurse should ensure the client is wearing eyeglasses, which would reduce the need to use a restraint.

11. What actions will the nurse follow when using restraints for an older client in a long-term care facility? Select all that apply.

1. Use restraints for 2 hours or less.

2. Use restraints for emergency situations only.

3. Utilize waist restraints to prevent client falls.

4. Obtain a physician's order before using restraints.

5. Remove the client's eyeglasses when applying restraints.

Answer: 2, 4, 5 Explanation:

1. Health promotion for the older adult is not focused on disease or disability. Type 2 diabetes would not be a focus when planning health promotion.

2. Health promotion for the older adult is focused on individual strengths, abilities, and values. Walking for 30 minutes 3 times a week would be taken into consideration for the patient.

3. Health promotion for the older adult is not focused on disease or disability. Using a BIPAP machine for sleep apnea would not be a focus when planning health promotion.

4. Health promotion for the older adult is focused on individual strengths, abilities, and values. Attending religious services every Sunday would be taken into consideration for the patient.

5. Health promotion for the older adult is focused on individual strengths, abilities, and values. Living alone and volunteering at the local library most afternoons would be taken into consideration for the patient.

12. The gerontological nurse is planning health promotion actions for an older client. Which of the following information should the nurse focus on when planning these actions? Select all that apply.

1. Client has type 2 diabetes mellitus.

2. Client walks for 30 minutes 3 times a week.

3. Client uses BIPAP machine for sleep apnea.

4. Client attends religious services every Sunday morning.

5. Client lives alone and volunteers at the local library most afternoons.

Answer: 3 Explanation:

1. The nurse would not be violating confidentiality if the client and physician are both caring for the client.

2. Clients must sign a release form when they want copies of their medical records.

3. Nurses should never ask another nurse to look up client information if that nurse is not involved in the client's care. This would require the charge nurse to intervene.

4. Faxing client information via fax machine is legal as long as the information is kept private and an authorized person is there to receive the information.

13. Which of the following actions, if observed by the charge nurse, would require the charge nurse to intervene?

1. The nurse looks over the physician's shoulder to see the results of an assigned client's labs.

2. The nurse requires a client to fill out a release of information form when the client requests a copy of his or her medical record.

3. The nurse asks another nurse to quickly look up the results of an x-ray of a client since the other nurse is already signed on the computer.

4. The nurse faxed reports of client tests to a machine that is in the office of the client's primary care physician, and a nurse is expecting the report.

Answer: 1 Explanation:

1. A breach in patient privacy is the nurse discussing the client's condition with a relative without the client's permission, and if the nurse gives the results, there is no way to undo that information and to protect the client's privacy. This should be the charge nurse's priority.

2. Copies of patient records must be rendered unreadable before being discarded. This would be a violation of HIPAA but not an immediate threat to the client's privacy, so it would not be the priority.

3. The physician should not be asking another physician to look at records unless a formal consult has been ordered; however, this would not be a priority since all doctors should protect client information, so there is no immediate threat of client information being unprotected.

4. Patient records must be secure, especially when used in departments other than the nursing unit. However, this would not be the priority unless the charge nurse saw that someone without authorization was trying to look at the medical record.

14. Which of the following situations would be a priority for the nurse to intervene?

1. A client's spouse asks the nurse for the results of an HIV test.

2. Copies of the patient's diagnostic test results are found in the regular trash behind the nurse's station.

3. The charge nurse overhears a physician asking another physician not involved in the client's care to look at a test result.

4. A client's medical record is left unattended on a stretcher outside the radiology department while the client receives an x-ray.