Chapter 09: Meeting Safety Needs of Older Adults My Nursing Test Banks

Wold: Basic Geriatric Nursing, 5th Edition

Chapter 09: Meeting Safety Needs of Older Adults

Test Bank

MULTIPLE CHOICE

1. The nurse cautions the older man who has diminished depth perception that he will have difficulty:

a.

judging the height of steps.

b.

reading small print on food labels.

c.

reading street signs.

d.

seeing in dim light.

ANS: A

Diminished depth perception results in an inability to judge height and depth of steps and judge distance. These deficits result in falls.

DIF: Cognitive Level: Knowledge REF: 167 OBJ: 1

TOP: Diminished Depth Perception KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. The home health nurse helps the family improve the safety of the environment for the 85-year-old male patient with Parkinson disease who is at risk for falls related to:

a.

postural hypotension.

b.

cognitive changes.

c.

altered vision.

d.

altered gait.

ANS: D

The propulsive gait and reduced ability to lift the feet make falls a constant threat to a patient with Parkinson disease.

DIF: Cognitive Level: Application REF: 167-168 OBJ: 3

TOP: Fall Prevention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

3. The nurse reminds the older adult who is taking drugs for hypertension that to prevent falls from orthostatic hypotension, the patient should:

a.

ambulate with a walker.

b.

avoid hot baths.

c.

avoid climbing stairs.

d.

sit on the side of the bed for a moment before ambulation.

ANS: D

Sitting on the side of the bed before ambulation gives the vascular system time to adjust to a positional change.

DIF: Cognitive Level: Application REF: 169, Box 9-2

OBJ: 2 TOP: Fall Prevention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Pharmacological Therapies

4. The nurse is aware that some older adults deny that they have fallen because they fear that they will:

a.

fall again.

b.

be hospitalized for treatment.

c.

be seen as frail and dependent.

d.

be considered clumsy.

ANS: C

Many older adults do not report falls because they fear that they will be seen as frail and dependent.

DIF: Cognitive Level: Application REF: 168 OBJ: 2

TOP: Fall Prevention KEY: Nursing Process Step: Planning

MSC: NCLEX: Psychosocial Integrity: Coping and Adaptation

5. After the 82-year-old female patient fell in her home, the home health nurse interviewed her about the incident because the information will:

a.

be reflected in the home health nurses documentation.

b.

help the patient gain insight into the cause of the fall.

c.

be used to guarantee no further falls.

d.

be collected for research purposes.

ANS: B

Gaining insight into the cause of falls will help the patient and family become aware of factors in the home that are so familiar that they are not seen as hazards. Recognition of hazards will lead to an alteration of the environment for improved safety.

DIF: Cognitive Level: Application REF: 169, Box 9-2

OBJ: 3 TOP: Fall Prevention

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

6. The nurse is aware that a fall prevention exercise program for the residents in a long-term care facility is focused on:

a.

improving balance.

b.

use of assistive devices.

c.

improving circulation.

d.

increase in the knowledge base about falls.

ANS: A

Most exercise programs are focused on improvement of balance to reduce the incidence of falls. Improved balance is seen as an effort to improve the confidence of the older adult.

DIF: Cognitive Level: Comprehension REF: 168 OBJ: 3

TOP: Fall Prevention KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

7. The daughter of an older adult asks the home health nurse for advice in selecting a cane for her 80-year-old mother, who has an unsteady gait. The cane that would be least appropriate would be a:

a.

wooden cane with a rubber tip.

b.

four-footed cane with a rubber grip.

c.

clear acrylic cane with a nonslip tip.

d.

colorful carved cane with a wooden tip.

ANS: D

The lack of a nonskid tip makes the colorful carved canes an inappropriate choice.

DIF: Cognitive Level: Application REF: 169, Box 9-2

OBJ: 3 TOP: Assistive Devices

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

8. A caring home health nurse has given his 90-year-old patient a framed poster that says, Pride goeth before a fall to remind his patient to:

a.

take care not to fall.

b.

ask for assistance when needed.

c.

take pride in his independence.

d.

not attempt any activity without help.

ANS: B

Asking for assistance is good judgment rather than attempting risky acts without help.

DIF: Cognitive Level: Application REF: 169, Box 9-2

OBJ: 3 TOP: Fall Prevention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

9. The nurse in a long-term care facility teaches tai chi for 15 minutes a day to the residents to:

a.

stimulate their intellectual activity.

b.

encourage interaction.

c.

improve coordination.

d.

demonstrate cultural awareness.

ANS: C

Tai chi is a low-impact, nonstressful exercise that develops balance and coordination.

DIF: Cognitive Level: Knowledge REF: 169, Cultural Considerations

OBJ: 3 TOP: Fall Prevention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

10. The home health nurse assesses the home for potential fire hazards and identifies the hazard of:

a.

baking soda near the stovetop.

b.

a smoke detector in the kitchen.

c.

multiple appliances plugged into one outlet.

d.

extension cords coiled up behind furniture.

ANS: C

Multiple electrical appliances plugged into one outlet can create an overload and cause a fire.

DIF: Cognitive Level: Analysis REF: 170 OBJ: 3

TOP: Fire Hazard KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

11. When the 80-year-old woman brags about her new deadbolt lock, the home health nurse suggests that while she is inside, she should:

a.

keep the door securely locked.

b.

apply similar locks on the windows.

c.

leave the door unlocked, with the key in place.

d.

replace the lock with a security chain.

ANS: C

Unlocked deadbolts allow rapid access by emergency personnel.

DIF: Cognitive Level: Application REF: 171, Box 9-4

OBJ: 3 TOP: Home Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

12. The home health nurse has evaluated the home of an older adult for factors that could be improved to increase home security and found all the following. Of these, the finding that would least improve home security would be a:

a.

peephole in the door at a convenient height.

b.

brightly lit porch.

c.

large dog with a loud bark.

d.

hook and eye latch on the screen door.

ANS: D

The hook and eye latch on the screen door, although a retardant, would not offer adequate security in the case of a break-in.

DIF: Cognitive Level: Analysis REF: 171, Box 9-4

OBJ: 3 TOP: Home Security

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

13. The home health nurse counsels a family in making rules for their 85-year-old father for driving safety. The rule that would be inappropriate would be to:

a.

limit driving to nearby areas with easy access.

b.

plan ahead and know where you are going.

c.

wear prescribed glasses and hearing aids.

d.

drive below the speed limit to maintain control of the car.

ANS: D

Driving rules are significant when there are no alternatives to driving. Driving slowly causes accidents.

DIF: Cognitive Level: Application REF: 172, Box 9-5

OBJ: 3 TOP: Driving Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

14. The home health nurse points out that older persons may have a thermoregulation disturbance that makes them feel cold related to:

a.

reduced activity.

b.

eating highly spiced foods.

c.

being overweight.

d.

hyperglycemia.

ANS: A

Reduced activity, lower basal metabolism rate, and slowed circulatory rate contribute to the feeling of being cold.

DIF: Cognitive Level: Comprehension REF: 172, Box 9-6

OBJ: 7 TOP: Thermoregulation Disorder

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

15. The nurse confirms that the older adult is suffering from heat exhaustion when the nurse assesses:

a.

excessive perspiration.

b.

bradycardia.

c.

temperature of 100 F.

d.

leg cramps.

ANS: D

Persons with heat exhaustion have leg and abdominal cramps; dry, hot, nonperspiring skin; tachycardia; and a temperature over 102 F.

DIF: Cognitive Level: Application REF: 174 OBJ: 6

TOP: Heat Exhaustion KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

16. The nurse is aware that the older adult is at greater risk for hypothermia than a younger person because the older adult has a diminished ability to:

a.

convert glycogen to glucose.

b.

select appropriate clothing or bed linen.

c.

shiver.

d.

constrict vessels.

ANS: C

Older adults have a diminished ability to shiver. Shivering is a muscular activity that increases metabolism and body heat.

DIF: Cognitive Level: Comprehension REF: 173 OBJ: 4

TOP: Thermoregulation KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

17. The nurse volunteering in a homeless shelter is aware that when a person with severe hypothermia is admitted, interventions should include:

a.

giving the person hot coffee or soup.

b.

placing the person in a warm bath.

c.

briskly rubbing the persons hands.

d.

wrapping the person in blankets.

ANS: D

The hypothermic individual should be moved to a warmer environment, wrapped in blankets or other insulating material, and given warm, not hot, drinks or food. Putting an individual in a warm bath may cause cardiovascular problems or skin damage.

DIF: Cognitive Level: Knowledge REF: 174 OBJ: 4

TOP: Thermoregulation KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. To help prevent a fall while caring for a confused 86-year-old resident in an extended-care facility, the nurses initial choice would be:

a.

use of a vest restraint.

b.

use of an electronic sensor alarm.

c.

placement of a wheelchair between the wall and dining table.

d.

a tray table attached to the arms of the wheelchair.

ANS: B

The alarm is the best initial choice because it does not require a physicians order. The vest restraint requires an order. The tray table and trapping the resident between the wall and a dining table may lead to injuries as the resident attempts to get out of confinement.

DIF: Cognitive Level: Comprehension REF: 176 OBJ: 3

TOP: Restraints KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk

MULTIPLE RESPONSE

1. The home health nurse coaches the older adult about what to do in case of a home fire. The nurse would encourage the older adult to __________. (Select all that apply.)

a.

keep a flashlight at the bedside

b.

use an appropriate fire extinguisher to control fire

c.

keep the doors open for an easy escape route

d.

call 911 before exiting the home

e.

open the windows to decrease smoke

ANS: A

Keep a flashlight for emergency lighting in case of dense smoke or an electrical failure. Do not try to extinguish the fire, close doors and windows to prevent spread of fire, and call 911 after exiting the building.

DIF: Cognitive Level: Application REF: 170 OBJ: 3

TOP: Fire Safety KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

2. The nurse clarifies internal factors that threaten the safety of the older adult, which include __________. (Select all that apply.)

a.

decrease in flexibility

b.

slowed reaction time

c.

gait changes

d.

thermal hazards

e.

postural changes

ANS: A, B, C, E

Thermal hazards are not internal risk factors. All other options listed are internal risk factors.

DIF: Cognitive Level: Comprehension REF: 168-169 OBJ: 2

TOP: Internal Hazards KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

3. The nurse in a long-term care facility awards Fall Guy stickers to certified nursing assistants who consistently __________. (Select all that apply.)

a.

report broken tiles in the shower room and bathrooms

b.

mop up spills

c.

assist residents to hurry

d.

remind residents to use walkers

e.

retie residents shoelaces

ANS: A, B, D, E

Hurrying the older adult increases the risk for falls. All other options promote safety for the older adult.

DIF: Cognitive Level: Application REF: 169 OBJ: 3

TOP: Fall Prevention KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

4. The home health nurse identifies environmental hazards and personal practices of the 80-year-old woman that need to be modified to decrease the risk of falls, which are __________. (Select all that apply.)

a.

brightly lit rooms

b.

pantry food at an accessible level

c.

colorful scatter rugs marking doorways and steps

d.

wearing comfortable laced tennis shoes

e.

attractive, low, magazine rack beside a chair

ANS: C, E

Scatter rugs and low items placed near the bed or chairs are fall hazards. All the other options listed promote safety at home.

DIF: Cognitive Level: Application REF: 170, Box 9-3

OBJ: 3 TOP: Fall Prevention

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

5. The nurse lists external risk factors that may be a threat to the older adult, including __________. (Select all that apply.)

a.

fire hazards

b.

lack of home security

c.

vehicular accidents

d.

thermal hazards

e.

sensory deficit

ANS: A, B, C, D

Sensory deficits are not external risk factors. All other options listed are.

DIF: Cognitive Level: Knowledge REF: 170, Box 9-3

OBJ: 2 TOP: External Risk Factors

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

6. The home health nurse suggests telephone modifications to increase the safety of older adults, which are __________. (Select all that apply.)

a.

placement of phones at bedside and next to a favorite chair

b.

programming an auto dial function for quick dialing

c.

using an answering machine with a male voice

d.

replacing the phone cord with a 15-foot cord for ease in carrying around the phone

e.

selecting a phone with large numbers

ANS: A, B, C, E

Long cords are a fall hazard. All other options increase safety of the older adult.

DIF: Cognitive Level: Application REF: 171, Box 9-4

OBJ: 3 TOP: Phone Safety

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

7. The home health nurse has evaluated the community for measures that support pedestrian safety and identifies pedestrian safety measures, including __________. (Select all that apply.)

a.

pedestrian-controlled crosswalks

b.

safety islands on wide street intersections

c.

free vehicular turning at all intersections

d.

clearly marked crosswalks at intersections

e.

overhead crossings over busy streets

ANS: A, B, D, E

Free vehicular turning at intersections is a hazard for the older adult pedestrian. All other options listed promote pedestrian safety.

DIF: Cognitive Level: Application REF: 171 OBJ: 3

TOP: Prevention of Vehicular Accidents KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

8. The nurse lists factors that increase the risk of vehicular accidents for the older driver, which are __________. (Select all that apply.)

a.

safety islands in the street

b.

cognitive disorders

c.

altered depth perception

d.

changes in night vision

e.

reduced flexibility

ANS: B, C, D, E

Safety islands in the street are a safeguard against accidents. All other options listed put the older adult at risk for accidents.

DIF: Cognitive Level: Knowledge REF: 171 OBJ: 2

TOP: Vehicular Hazards KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

9. The distraught daughter of a 92-year-old man who still drives shares observations with the home health nurse indicative of his deteriorated driving skills, which are __________. (Select all that apply.)

a.

paint scrapes on the mailbox at the curb

b.

friends calling him to get rides to the grocery store

c.

choosing not to drive at night because of night blindness

d.

difficulty turning his head

e.

carefully planning routes to avoid heavy traffic

ANS: A, D

Paint scrapes suggest depth perception difficulty, and inability to turn the head makes backing up and checking for cross traffic difficult.

DIF: Cognitive Level: Comprehension REF: 172 OBJ: 3

TOP: Driving Safety KEY: Nursing Process Step: Assessment

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

COMPLETION

1. The nurse takes into consideration that the most common injuries to the older adult are the result of __________.

ANS: falls

DIF: Cognitive Level: Knowledge REF: 167 OBJ: 1

TOP: Falls KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

Copyright 2012 by Mosby, Inc., an affiliate of Elsevier Inc.

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