Chapter 14 My Nursing Test Banks

Tabloski Gerontological Nursing, 3/e
Chapter 14

Question 1

Type: MCSA

The nurse learns that an older patient has a decrease in accommodation. What would the nurse assess in this patient?

1. Blurred vision

2. Sensitivity to light

3. Narrowing of field of vision

4. Difficulty reading small print

Correct Answer: 4

Rationale 1: Blurred vision is seen most often with cataracts.
Reference: Page 337

Rationale 2: Sensitivity to light is caused by an inability of the pupil to adapt to varying degrees of light.
Reference: Page 337

Rationale 3: Narrowing of the field of vision describes a change in peripheral vision, which is not associated with accommodation.
Reference: Page 337

Rationale 4: Accommodation is the ability of the lens to change shape and focus images clearly. This loss of pliability in the lens contributes to the decrease in near vision, which generally occurs around the age of 40. This would be demonstrated by the patients difficulty reading small print.
Reference: Page 337

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 2

Type: MCSA

An older patient has sensitivity to light. What should the nurse teach the patient to help with this problem?

1. Dim the lights on sunny days.

2. Place dark patterned rugs on stairs.

3. Use supplementary lamps near work.

4. Remove lampshades to provide more light.

Correct Answer: 3

Rationale 1: Dimming the lights on sunny days is incorrect because more light is needed to eliminate dark and shadowy areas.
Reference: Page 337

Rationale 2: Placing dark patterned rugs on stairs is incorrect because the patterns may overwhelm the eyes and obscure steps and ledges.
Reference: Page 337

Rationale 3: Using supplementary lamps near work is correct because the ability to adapt to varying degrees of light declines with age and there is a need for increased light.
Reference: Page 337

Rationale 4: Removing lampshades to provide more light is incorrect because this may cause glare and obliterate normal vision for a period of time.
Reference: Page 337

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 3

Type: MCMA

The nurse is reviewing an older patients currently prescribed medications. Which medications have side effects that increase visual disturbances?

Standard Text: Select all that apply.

1. Propranolol (Inderal)

2. Warfarin (Coumadin)

3. Tamoxifen (Nolvadex)

4. Amiodarone (Cordarone)

5. Calcium carbonate (Tums)

Correct Answer: 1,3,4

Rationale 1: The side effects of propranolol (Inderal) include blurred vision and dry eyes.
Reference: Page 339

Rationale 2: The side effects of warfarin (Coumadin) do not affect the eyes.
Reference: Page 339

Rationale 3: The side effects of tamoxifen (Nolvadex) include retinopathy and blurred vision.
Reference: Page 339

Rationale 4: The side effects of amiodarone (Cordarone) include blurred vision, corneal changes, optic neuropathy, and halos.
Reference: Page 339

Rationale 5: The side effects of calcium carbonate (Tums) do not affect the eyes.
Reference: Page 339

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify medications that may cause or aggravate sensory dysfunction.

Question 4

Type: MCMA

An older patient has sensorineural hearing loss. Which health problems should the nurse recognize as causing this type of hearing loss?

Standard Text: Select all that apply.

1. Presbycusis

2. Menieres disease

3. Impacted cerumen

4. Otitis media infection

5. Tympanic membrane perforation

Correct Answer: 1,2

Rationale 1: Sensorineural hearing loss can be caused by presbycusis or loss of hearing due to age-related changes in the inner ear.
Reference: Page 348

Rationale 2: Menieres disease causes edema is in the inner ear leading to damage to the nerve.
Reference: Page 348

Rationale 3: Impacted cerumen is in the external ear and causes conductive hearing loss.
Reference: Page 348

Rationale 4: Otitis media infection is in the middle ear and causes conductive hearing loss.
Reference: Page 348

Rationale 5: Tympanic membrane perforation is between the external and middle ear and causes conductive hearing loss.
Reference: Page 348

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 5

Type: MCSA

An otoscopic examination of an older patient reveals a red, bulging membrane with absent distorted light reflex. Which condition would the nurse suspect?

1. Scar tissue

2. Otitis media

3. External otitis

4. Ruptured tympanic membrane

Correct Answer: 2

Rationale 1: Scar tissue is incorrect because it is characterized by dense irregular white patches on the eardrum.
Reference: Page 348

Rationale 2: Otitis media is correct because infected fluid in the middle ear causes the red, bulging membrane and the absent distorted light reflex is caused by the increasing middle ear pressure.
Reference: Page 348

Rationale 3: External otitis (swimmers ear) is incorrect because it is an infection of the outer ear with painful movement of the pinna and tragus, redness and swelling of pinna and canal, scaling, itching, fever, and enlarged tender regional lymph nodes.
Reference: Page 348

Rationale 4: Ruptured tympanic membrane is incorrect because it is characterized by round or oval darkened areas on the drum.
Reference: Page 348

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 6

Type: MCMA

Which interventions should the nurse perform when an older patient reports a change in hearing?

Standard Text: Select all that apply.

1. Perform a Rinne test.

2. Eliminate extraneous noise.

3. Review prescribed medications.

4. Report the change to the physician.

5. Speak in a tone that includes shouting.

Correct Answer: 2,3,4

Rationale 1: A Rinne test is not appropriate at this time because it is a diagnostic test that evaluates air and bone conduction.
Reference: Page 351

Rationale 2: Eliminating extraneous noise helps most older patients because they first lose high-pitch sounds and sounds become distorted with a combination of TV, visitors, and personnel all talking at the same time.
Reference: Page 351

Rationale 3: Medications prescribed must be reviewed because many have side effects that cause hearing loss.
Reference: Page 351

Rationale 4: The physician should be notified of hearing changes to change medications as appropriate and to do referrals as necessary.
Reference: Page 351

Rationale 5: Speaking in tones that include shouting is not correct because in many cases it increases the pitch of the voice, which is difficult for the older patient to hear and is not helpful.
Reference: Page 351

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 7

Type: MCSA

The nurse documents that an older patient has hypogeusia. What is this patient experiencing?

1. Dulled sensitivity to touch

2. Blunting of the sense of taste

3. A downward and outward deviation of the eye

4. Dry mouth occurring with salivary gland dysfunction

Correct Answer: 2

Rationale 1: Dulled sensitivity to touch is hypoesthesia.
Reference: Page 352

Rationale 2: Blunting of the sense of taste is hypogeusia.
Reference: Page 352

Rationale 3: A downward and outward deviation of the eye is hypoexophoria.
Reference: Page 352

Rationale 4: Dry mouth occurring with salivary gland dysfunction is xerostomia.
Reference: Page 352

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 8

Type: MCSA

An older patient with diabetes has an oral infection and is on antibiotics. Which manifestations might the nurse observe in this patient?

1. Increased weight

2. Increased appetite

3. Increased gustatory sensation

4. Increased salt or sugar intake

Correct Answer: 4

Rationale 1: Increased weight is incorrect because loss of taste results in loss of appetite, which leads to loss of weight.
Reference: Page 352

Rationale 2: Increased appetite is incorrect because diabetes, infections, and medications alter sense of taste and, therefore, decrease appetite.
Reference: Page 352

Rationale 3: Increase in gustatory sensation is incorrect because oral infection releases acidic substances that impair saliva production and decreases the ability for food to dissolve and release flavor.
Reference: Page 352

Rationale 4: Increased salt or sugar intake is correct because older people use excessive salt or sugar to compensate for a diminished sense of taste. Sense of taste is affected by diabetes, infections, and medications.
Reference: Page 352

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 9

Type: MCMA

Which interventions should the nurse use to help a patient with xerostomia?

Standard Text: Select all that apply.

1. Use a humidifier.

2. Provide oral fluids after meals.

3. Provide sugar-free hard candies.

4. Reinforce regular dental examinations.

5. Increase medications from once a day to twice a day.

Correct Answer: 1,3,4

Rationale 1: Using a humidifier adds moisture to the air and can help with xerostomia that may interfere with sleep.
Reference: Page 354

Rationale 2: Providing oral fluids after meals is incorrect because fluids should be provided with meals to help relieve symptoms and dysphagia as well as after meals.
Reference: Page 354

Rationale 3: Providing sugar-free hard candies is correct because it helps stimulate salivary secretions without increasing blood sugar.
Reference: Page 354

Rationale 4: Reinforcing regular dental examinations is correct because caries can cause infections and mal-fitting dentures can irritate dry oral mucosa.
Reference: Page 354

Rationale 5: Increasing medications from once a day to twice a day is incorrect because medications will double and symptoms worsen. Also it is not the role of the nurse to increase medications.
Reference: Page 354

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 10

Type: MCSA

Which is a pathophysiological cause that the nurse recognizes in an older patient with hyposmia?

1. Increased neurotransmitters

2. Injury of the olfactory mucosa

3. Increased number of sensory cells

4. Lower thresholds for common odors

Correct Answer: 2

Rationale 1: The amount of neurotransmitters decreases with age and cause loss of smell.
Reference: Page 354

Rationale 2: Injury of the olfactory mucosa causes changes in olfactory function.
Reference: Page 354

Rationale 3: With normal age-related changes the number of sensory cells decreases, causing a loss of smell.
Reference: Page 354

Rationale 4: There is no specific information if a threshold for common odors is lowered in the older patient.
Reference: Page 354

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 11

Type: MCMA

An older patient is prescribed antihistamines. What will the nurse assess as side effects of this medication?

Standard Text: Select all that apply.

1. Altered taste

2. Altered smell

3. Altered touch

4. Altered vision

5. Altered hearing

Correct Answer: 1,2,4

Rationale 1: Antihistamines can affect taste.
Reference: Pages 339, 353, 355

Rationale 2: Antihistamines can affect smell.
Reference: Pages 339, 353, 355

Rationale 3: Antihistamines are not known to affect touch.
Reference: Pages 339, 353, 355

Rationale 4: Antihistamines can affect vision.
Reference: Pages 339, 353, 355

Rationale 5: Antihistamines are not known to affect hearing.
Reference: Pages 339, 353, 355

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Identify medications that may cause or aggravate sensory dysfunction.

Question 12

Type: MCMA

The nurse is completing an assessment of an older patients eyes. Which findings does the nurse identify as being normal age-related changes?

Standard Text: Select all that apply.

1. Cataracts

2. Ectropion

3. Entropion

4. Glaucoma

5. Arcus senilis

Correct Answer: 2,3,5

Rationale 1: Cataracts are opacities of the lenses. Cataracts cloud the lens, decrease the amount of light able to reach the retina, and inhibit vision. Development is slow and painless, and may be unilateral or bilateral.
Reference: Page 337

Rationale 2: An ectropion is when the bottom eye lid sags outward and is no longer in contact with the eye.
Reference: Page 337

Rationale 3: An entropion is when the lid turns inward, bringing the eyelashes in contact with the eyeball and causing irritation and abrasion to the cornea.
Reference: Page 337

Rationale 4: Glaucoma is associated with optic nerve damage due to an increase in intraocular pressure, which can ultimately lead to vision loss.
Reference: Page 337

Rationale 5: Arcus senilis are corneal calcium deposits that have cosmetic implications only.
Reference: Page 337

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 13

Type: MCMA

The nurse has identified the diagnosis Self-Care Deficit for an older patient with hyposmia. What should the nurse teach the patient prior to being discharged to home?

Standard Text: Select all that apply.

1. Date and label all foods.

2. Remove kitchen waste weekly.

3. Use colognes as bath substitute.

4. Establish a schedule for house cleaning.

5. Place natural gas detectors near gas heater or stove.

Correct Answer: 1,4,5

Rationale 1: Dating and labeling all foods may prevent a patient who is unable to smell from becoming ill with spoiled food products.
Reference: Page 355

Rationale 2: The removal of kitchen waste should be done every evening to prevent a garbage smell from permeating the house, which may be offensive to visitors and go undetected by the older person with hyposmia.
Reference: Page 355

Rationale 3: Using colognes as substitutes for baths may cause an unpleasant body odor and may result in social isolation.
Reference: Page 355

Rationale 4: Establishing a schedule for house cleaning will prevent malodors from permeating the house and being offensive to visitors when the patient is unable to detect such odors.
Reference: Page 355

Rationale 5: Placing natural gas detectors near gas heater or stove needs to be done because the inability to smell gas increases the potential for fire and explosions.
Reference: Page 355

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 14

Type: MCSA

Which statement should the nurse emphasize when teaching a patient with neuropathy from diabetes?

1. Set water heater at 120F.

2. Avoid hand and foot massages.

3. Use a mirror to inspect feet daily.

4. Increase medication for pain as necessary.

Correct Answer: 3

Rationale 1: Water temperature at 120F is too hot and the patient may become scalded because of the lack of sensation.
Reference: Page 356

Rationale 2: Hand and foot massages might be relaxing to the patient, increase circulation, reduce the need for medication, and increase the psychological benefits of touch.
Reference: Page 356

Rationale 3: Older patients with diabetes mellitus should place a mirror on the wall close to the floor, remove their shoes, and examine the bottoms of their feet daily for blisters, redness, or ulcerations.
Reference: Page 356

Rationale 4: Increasing medication for pain as necessary can further decrease touch sensation by clouding the sensorium and inducing lethargy, which requires additional supervision and monitoring to ensure safety.
Reference: Page 356

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 15

Type: MCMA

Which interventions should the nurse suggest an older patient use to reduce safety issues in the home?

Standard Text: Select all that apply.

1. Use lampshades to prevent glare.

2. Recommend designed rug patterns.

3. Increase lighting in high-traffic areas.

4. Add extra lighting in areas that are dark.

5. Paint the edges of stairs to identify steps.

Correct Answer: 1,3,4,5

Rationale 1: One intervention to improve safety issues in the home is to use lampshades to prevent glare.
Reference: Page 338

Rationale 2: The patient should be instructed to avoid complicated rug patterns that may overwhelm the eye and obscure steps and ledges.
Reference: Page 338

Rationale 3: One intervention to improve safety issues in the home is to increase lighting in high-traffic areas.
Reference: Page 338

Rationale 4: One intervention to improve safety issues in the home is to add extra lighting in areas that are dark.
Reference: Page 338

Rationale 5: One intervention to improve safety issues in the home is to paint the edges of stairs to identify steps.
Reference: Page 338

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 16

Type: MCSA

An older patient who wears glasses is being admitted to a long-term care facility. Which action should the nurse take when assessing the patients visual acuity?

1. Ask the patient to wear the glasses.

2. Ask the patient to remove the glasses.

3. Allow the patient to choose whether or not to remove the glasses.

4. If the patient wears glasses to eat then glasses should be removed.

Correct Answer: 1

Rationale 1: The older person with glasses should wear them during the vision assessment.
Reference: Page 335

Rationale 2: The assessment findings will not be accurate if the patient removes the glasses during the assessment.
Reference: Page 335

Rationale 3: If the patient removes the glasses the assessment findings will not be accurate.
Reference: Page 335

Rationale 4: If the patient is wearing the glasses they should be worn for the assessment, regardless if the patient wears glasses to eat.
Reference: Page 335

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List common nursing diagnoses of older adults related to sensory problems.

Question 17

Type: MCSA

A 75-year-old patient complains that his vision continues to get worse every year. How should the nurse respond to this patients complaint?

1. I certainly understand your frustration.

2. The problems you are experiencing are likely the early stages of glaucoma.

3. The visual problems you are reporting become increasingly common after age 70.

4. Maybe you have a medical problem that may be causing these drastic visual problems.

Correct Answer: 3

Rationale 1: Telling the patient that you understand does not foster empathy or provide adequate information.
Reference: Page 337

Rationale 2: Glaucoma results when there is an increase in ocular pressure as a result of buildup of aqueous humor.
Reference: Page 337

Rationale 3: Visual acuity tends to diminish gradually after the age of 50 and then more rapidly after the age of 70.
Reference: Page 337

Rationale 4: There are no indications that the patient has a medical problem from the information provided.
Reference: Page 337

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Explain normal changes associated with the aging process on the five senses: vision, hearing, taste, smell, and touch.

Question 18

Type: MCSA

A family is making home modifications for a visually impaired older family member. Which recommendation should the home care nurse make to the family?

1. Remove lamp shades to increase lighting.

2. Use soft blue, gray, and light green tones.

3. Install motion-sensor lights when possible.

4. Install reflective floors to provide increased lighting to the environment.

Correct Answer: 3

Rationale 1: The removal of lamp shades will promote a glare.
Reference: Page 338

Rationale 2: There is an inadequate contrast between soft blue, gray, and light green tones. This will not provide the distinction needed by the visually impaired individual. Red, orange, and yellow are recommended.
Reference: Page 338

Rationale 3: The use of motion-sensor lights will provide illumination when the visually impaired man walks into the room.
Reference: Page 338

Rationale 4: Reflective floors are not recommended.
Reference: Page 338

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 19

Type: MCSA

The daughter of an older patient is concerned that the patient continues to drive at age 81. What should the nurse share with the daughter and patient about motor vehicle accidents and older people?

1. The elderly have few wrecks, as they are more cautious drivers.

2. There are few studies available looking at this particular concern.

3. The risks of seniors over age 80 are similar to those of teen drivers.

4. Accidents are the result of cognitive changes not related to sensory problems.

Correct Answer: 3

Rationale 1: While the elderly may be cautious behind the wheel, this does not entirely compensate for the potential changes in sensory and the neurological system.
Reference: Page 338

Rationale 2: There are numerous studies highlighting the safety of older people driving.
Reference: Page 338

Rationale 3: It is estimated that drivers over the age of 80 have a crash rate per mile driven that is equivalent to that of teenage motorists.
Reference: Page 338

Rationale 4: It is estimated that drivers over the age of 80 have a crash rate per mile driven that is equivalent to that of teenage motorists. It is very important for older adults to have their vision and driving ability screened regularly.
Reference: Page 338

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 20

Type: MCSA

An older patient wants to use holistic ways to reduce the risk of age-related macular degeneration. What should the nurse instruct the patient to consume to promote eye health?

1. Cabbage, eggs, and orange juice

2. Whole-wheat bread, eggs, and milk

3. Sweet potatoes, spinach, and broccoli

4. Lean meats, whole-wheat breads, and blueberries

Correct Answer: 3

Rationale 1: The Age-Related Eye Disease Study (AREDS) conducted by the National Eye Institute found a 25% risk reduction in the development of age-related macular degeneration by consuming high doses of antioxidants (vitamins C and E and beta-carotene) and zinc. Orange juice is the only food item that contains antioxidants.
Reference: Page 340

Rationale 2: The Age-Related Eye Disease Study (AREDS) conducted by the National Eye Institute found a 25% risk reduction in the development of age-related macular degeneration by consuming high doses of antioxidants (vitamins C and E and beta-carotene) and zinc. These food items do not contain antioxidants.
Reference: Page 340

Rationale 3: The Age-Related Eye Disease Study (AREDS) conducted by the National Eye Institute found a 25% risk reduction in the development of age-related macular degeneration by consuming high doses of antioxidants (vitamins C and E and beta-carotene) and zinc. Sweet potatoes, spinach, and broccoli are excellent sources of beta-carotene. Broccoli is also a good source of vitamin C.
Reference: Page 340

Rationale 4: The Age-Related Eye Disease Study (AREDS) conducted by the National Eye Institute found a 25% risk reduction in the development of age-related macular degeneration by consuming high doses of antioxidants (vitamins C and E and beta-carotene) and zinc. Blueberries are the only food item that contains antioxidants.
Reference: Page 340

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 21

Type: MCSA

An older patient is being treated for glaucoma with Timoptic. Which assessment finding indicates an adverse effect associated with the medication?

1. Diarrhea

2. Slow heat rate

3. Excessive salivation

4. Reduced urinary output

Correct Answer: 2

Rationale 1: Diarrhea is associated with the use of miotic medications.
Reference: Page 343

Rationale 2: A slow heart rate is called bradycardia, and must be evaluated because Timoptic is a beta blocker and is associated with bradycardia in some patients.
Reference: Page 343

Rationale 3: Excessive salivation is associated with the use of miotic medications.
Reference: Page 343

Rationale 4: Reduced urinary output, which could indicate renal failure, is associated with the use of carbonic anhydrase inhibitors.
Reference: Page 343

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 4. Identify medications that may cause or aggravate sensory dysfunction.

Question 22

Type: MCSA

An older patient, experiencing a significant loss of hearing after being involved in an explosion, wants to know how long the loss will last. Which response by the nurse is most appropriate at this time?

1. Surgery will help restore the hearing you have lost.

2. Hearing loss attributed to loud noises is normally reversible.

3. Loud noises can cause immediate, permanent losses of hearing.

4. The most common cause of hearing impairments is the result of exposure to loud noises.

Correct Answer: 3

Rationale 1: Promising that surgery will restore the patients hearing is inappropriate and may not be correct.
Reference: Page 346

Rationale 2: Very loud sounds of short duration, such as an explosion or gunfire, can cause immediate, severe, and permanent loss of hearing.
Reference: Page 346

Rationale 3: Very loud sounds of short duration, such as an explosion or gunfire, can cause immediate, severe, and permanent loss of hearing.
Reference: Page 346

Rationale 4: About one-third of all hearing impairments are at least partially attributable to damage from exposure to loud sounds.
Reference: Page 346

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. List common nursing diagnoses of older adults related to sensory problems.

Question 23

Type: MCSA

The home care nurse observes a buildup of cerumen in both ears of an older patient. What should the nurse do to help this patient?

1. Instruct the patient to use a curate to remove the cerumen.

2. Show the patient how to use a bulb syringe to remove the cerumen.

3. Advise the patient to seek medical attention to remove the cerumen.

4. Teach the patient to use a cotton-tipped swab to remove the cerumen.

Correct Answer: 3

Rationale 1: The use of a curette is beneficial in the removal of cerumen, but should only be used by a skilled user.
Reference: Pages 347348

Rationale 2: The use of a bulb syringe is beneficial in the removal of cerumen but should only be used by a skilled user.
Reference: Pages 347348

Rationale 3: Cerumen buildup is a common problem in the elderly. The removal of it from the elderly is best performed by a trained professional.
Reference: Pages 347348

Rationale 4: The use of cotton-tipped swabs may push the cerumen further into the ear canal.
Reference: Pages 347348

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

Question 24

Type: MCSA

When assessing the tympanic membrane of an older patient, the nurse notes the presence of two jagged white lines. What does this finding indicate to the nurse?

1. The tympanic membrane appears to be ruptured.

2. This is a sign of chronic infection of the tympanic membrane.

3. The white lines are consistent with a past history of a tympanic rupture.

4. The presence of these markings is consistent with the presence of an infection.

Correct Answer: 3

Rationale 1: White lines along the tympanic membrane do not indicate that the membrane is ruptured.
Reference: Page 348

Rationale 2: A red, bulging membrane is a sign of a middle ear infection.
Reference: Page 348

Rationale 3: Some older adults have jagged white scars across the tympanic membrane as a result of ruptured eardrums from infections when they were children before the widespread use of antibiotics.
Reference: Page 348

Rationale 4: A red, bulging membrane is a sign of a middle ear infection.
Reference: Page 348

Global Rationale:

Cognitive Level: Analyzing

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List common nursing diagnoses of older adults related to sensory problems.

Question 25

Type: MCMA

The nurse is planning a teaching session for nursing assistants regarding effective communication with hearing-impaired patients. Which principles should be included in the program?

Standard Text: Select all that apply.

1. Use gestures if appropriate.

2. Raise voice pitch when talking.

3. Pause at the end of each sentence.

4. Stand 1 to 2 feet away from the patient.

5. Speak in a normal tone of voice during the interaction.

Correct Answer: 1,3,5

Rationale 1: Nursing interventions to use when speaking to an individual with a hearing impairment include using gestures when appropriate.
Reference: Page 351

Rationale 2: The pitch of the voice should be lowered.
Reference: Page 351

Rationale 3: Pausing at the end of the sentence will allow the patient the opportunity to respond to the conversation and take in the information being relayed.
Reference: Page 351

Rationale 4: It is recommended that the caregiver stand 2 to 3 feet from the patient during the interaction.
Reference: Page 351

Rationale 5: Speaking in a normal tone of voice is helpful. Shouting is not helpful.
Reference: Page 351

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Recognize nursing interventions that can be implemented to assist the aging patient with sensory changes.

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