Chapter 15 My Nursing Test Banks

Tabloski Gerontological Nursing, 3/e
Chapter 15

Question 1

Type: MCSA

An older female patient is experiencing fatigue, nausea, vague complaint of intermittent chest discomfort, and not sleeping well. How should the nurse interpret these symptoms?

1. Signs of anemia

2. Pancreatic disease

3. Myocardial infarction

4. Normal changes of aging

Correct Answer: 3

Rationale 1: Anemia would present with fatigue but not with nausea or chest discomfort.
Reference: Page 370

Rationale 2: Pancreatic disease would present with pain in the abdominal region.
Reference: Page 370

Rationale 3: Many older women will complain of vague symptoms when having a myocardial infarction, including fatigue, sleep disturbances, and epigastric pain.
Reference: Page 370

Rationale 4: These symptoms are not considered normal changes of aging.
Reference: Page 370

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Relate physiological concepts to the diagnosis and management of common cardiovascular risks and conditions, including hypertension, angina, heart failure, and peripheral vascular disease.

Question 2

Type: MCSA

During a blood pressure screening at a pharmacy an older person experiences a fluttering in the chest. What should the nurse interpret this finding as being?

1. Hypothyroidism

2. Exercise intolerance

3. Nonspecific cardiac changes with aging

4. Underlying illness that requires a medical evaluation

Correct Answer: 4

Rationale 1: Chest fluttering can be a sign of hyperthyroidism, not hypothyroidism.
Reference: Page 370

Rationale 2: Exercise intolerance would include symptoms of shortness of breath, which the older person does not report.
Reference: Page 370

Rationale 3: This symptom does not indicate normal cardiac changes.
Reference: Page 370

Rationale 4: New onset atrial fibrillation and other arrhythmias may signal the onset of a serious underlying illness that requires further medical evaluation.
Reference: Page 370

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Relate physiological concepts to the diagnosis and management of common cardiovascular risks and conditions, including hypertension, angina, heart failure, and peripheral vascular disease.

Question 3

Type: MCSA

An older patient has a blood pressure reading of 150/88. The patient reports no other symptoms or medical history of illness. What should the nurse instruct the patient to do?

1. Have the blood pressure rechecked in a month.

2. Do nothing since this is a normal variant of aging.

3. Go to the emergency department for further evaluation and treatment.

4. Contact the primary care provider for further evaluation and treatment.

Correct Answer: 4

Rationale 1: Waiting for 1 month to recheck the blood pressure is too long of a period of time for evaluation and treatment.
Reference: Page 371

Rationale 2: Blood pressure elevation frequently occurs with aging, although it is not considered a normal variant.
Reference: Page 371

Rationale 3: It is not a symptom of emergent nature because the diastolic is not elevated above 110 mm Hg.
Reference: Page 371

Rationale 4: If left uncontrolled, high systolic pressure can lead to stroke, myocardial infarction, heart failure, kidney damage, blindness, or other conditions. Although it cannot be cured once it has developed, isolated systolic hypertension (ISH) can be controlled.
Reference: Page 371

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Relate physiological concepts to the diagnosis and management of common cardiovascular risks and conditions, including hypertension, angina, heart failure, and peripheral vascular disease.

Question 4

Type: MCSA

During a home visit the nurse learns that an older patient with hypertension takes prescribed medications only when feeling tense. What instruction should the nurse provide to the patient?

1. Contact the physician for a change in blood pressure medication.

2. Continue to administer the blood pressure medication as needed.

3. Teach to take the blood pressure medication as prescribed regardless of feeling tense.

4. Instruct to take a double dose of the medication for one day then resume the normal schedule.

Correct Answer: 3

Rationale 1: The dosage prescribed may be appropriate if taken daily; therefore, it would not need to be changed.
Reference: Pages 372, 376

Rationale 2: The patients current practice is incorrect. The patient needs to be instructed to take the medication as prescribed and not only when feeling tense.
Reference: Pages 372, 376

Rationale 3: Patients sometimes mistakenly take blood pressure medication only on an as-needed basis. This is incorrect and the patient should take the medication as prescribed on a daily basis.
Reference: Pages 372, 376

Rationale 4: To advise the patient to increase the medication without a physician consultation would be out of the scope of nursing practice.
Reference: Pages 372, 376

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify specific nursing interventions used with cardiovascular patients.

Question 5

Type: MCSA

The nurse is planning care for an older patient with hypertension who recently fell in the home. Which assessment would the nurse plan for this patient?

1. Check serum sodium levels.

2. Check serum creatinine levels.

3. Check postural blood pressures.

4. Check blood pressure every 2 hours.

Correct Answer: 3

Rationale 1: Serum sodium levels would be used to assess renal function.

Rationale 2: Serum creatinine levels would be used to assess renal function.

Rationale 3: Since baroreceptors are less efficient with aging, postural hypotension is more likely to occur. Also, patients treated for hypertension could have an increase in sensitivity to the medications. Postural blood pressure assessment allows the nurse to prevent postural hypotension and falls.

Rationale 4: Every 2 hours is too frequent for assessments of a noncritical patient.

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Identify specific nursing interventions used with cardiovascular patients.

Question 6

Type: MCMA

The nurse is planning a presentation to a group of senior citizens on lifestyle modifications to manage high blood pressure. What major points will the nurse include in this presentation?

Standard Text: Select all that apply.

1. Keep sodium intake to 2.4 grams per day.

2. Achieve and maintain a normal body mass index.

3. Perform aerobic activity for 30 minutes most days of the week.

4. Limit daily alcohol intake to two drinks for males and one drink for females.

5. Consumption of fruits and whole grains has little impact on blood pressure.

Correct Answer: 1,2,3,4

Rationale 1: One lifestyle modification is to keep sodium intake to 2.4 grams per day.
Reference: Page 374

Rationale 2: One lifestyle modification is to achieve and maintain a normal body mass index.
Reference: Page 374

Rationale 3: One lifestyle modification is to perform aerobic activity for 30 minutes most days of the week.
Reference: Page 374

Rationale 4: One lifestyle modification is to limit daily alcohol intake to two drinks for males and one drink for females.
Reference: Page 374

Rationale 5: Increasing the consumption of fruits, vegetables, and whole grains will lower blood pressure.
Reference: Page 374

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 6. Outline an education plan for cardiovascular patients.

Question 7

Type: MCSA

An older patient who is prescribed doxazosin mesylate (Cardura) has a lying blood pressure of 124/76 mm Hg and a sitting blood pressure of 100/64 mm Hg. What additional observation is needed for this patient?

1. Fall risk

2. Nausea and vomiting

3. Decreased urine output

4. Change in mental status

Correct Answer: 1

Rationale 1: The patients blood pressure values indicate postural hypotension. In addition, the patient is taking a medication that is an alpha blocker, which increases the risk for postural hypotension. Both factors would place the patient at a risk for falls.
Reference: Page 375

Rationale 2: Nausea and vomiting are unrelated to the blood pressure changes.
Reference: Page 375

Rationale 3: Urine output is unrelated to the blood pressure changes.
Reference: Page 375

Rationale 4: Mental status changes are unrelated to the blood pressure changes.
Reference: Page 375

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Identify specific nursing interventions used with cardiovascular patients.

Question 8

Type: MCMA

The nurse is providing discharge instructions for an older patient who is prescribed atorvastatin (Lipitor) for elevated cholesterol. What effects should the nurse advise the patient to report to the healthcare provider?

Standard Text: Select all that apply.

1. Headaches

2. Stomachache

3. Shortness of breath

4. Muscle pain and weakness

5. Bruising and excessive bleeding

Correct Answer: 2,4

Rationale 1: Headaches are not documented side effects of statin medications.
Reference: Page 378

Rationale 2: Gastrointestinal distress is a side effect of statin medication and should be reported to the healthcare provider.
Reference: Page 378

Rationale 3: Shortness of breath is not a documented side effect of statin medications.
Reference: Page 378

Rationale 4: Muscle pain and weakness is a side effect of statin medication and should be reported to the healthcare provider.
Reference: Page 378

Rationale 5: Bruising and excessive bleeding are not documented side effects of statin medications.
Reference: Page 378

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 5. Identify specific nursing interventions used with cardiovascular patients.

Question 9

Type: MCSA

An older patient has an increase in pitting edema of both ankles and is experiencing breathlessness. The patient is not experiencing any pain. What action should the nurse take to help the patient at this time?

1. Allow the patient to rest.

2. Measure intake and output.

3. Measure the patients weight.

4. Contact the physician for further evaluation and treatment.

Correct Answer: 4

Rationale 1: Although allowing the patient to rest may reduce the breathlessness, this alone does not provide the appropriate intervention to address the patients underlying problem.
Reference: Page 380

Rationale 2: Measuring intake and output is helpful assessment data but will not help the patients current symptoms.
Reference: Page 380

Rationale 3: Measuring the patients weight is helpful assessment data but will not help the patients current symptoms.
Reference: Page 380

Rationale 4: The absence of chest pain in the older person does not indicate an absence of ischemic heart disease. Older adults can present with fatigue, weakness, shortness of breath, and gastrointestinal complaints. The nurse needs to contact the physician for further evaluation and treatment.
Reference: Page 380

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. Relate physiological concepts to the diagnosis and management of common cardiovascular risks and conditions, including hypertension, angina, heart failure, and peripheral vascular disease.

Question 10

Type: MCMA

An older patient with a history of atrial fibrillation has a fall at home and is diagnosed with a hemorrhagic stroke. What will the nurse assess to help determine the cause of this patients bleeding?

Standard Text: Select all that apply.

1. Current INR

2. Platelet level

3. Liver function studies

4. Hemoglobin and hematocrit

5. Dose of warfarin sodium (Coumadin) taken at home

Correct Answer: 1,5

Rationale 1: The INR is a laboratory test that measures the therapeutic level of anticoagulant medications and could indicate the cause of the patients bleeding.
Reference: Page 387

Rationale 2: The platelet level will not help determine the cause of the patients bleeding.
Reference: Page 387

Rationale 3: Liver function studies are not directly related to this patients problem.
Reference: Page 387

Rationale 4: The hemoglobin and hematocrit levels are not directly related to this patients problem.
Reference: Page 387

Rationale 5: Patients with atrial fibrillation are at risk for development of blood clots. A primary treatment is the use of anticoagulant drugs, such as warfarin sodium (Coumadin). Anticoagulant drugs place the patient at risk for hemorrhage, especially after a fall.
Reference: Page 387

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 3. Relate physiological concepts to the diagnosis and management of common cardiovascular risks and conditions, including hypertension, angina, heart failure, and peripheral vascular disease.

Question 11

Type: MCMA

An older patient asks the nurse what holistic actions can be used to help lower elevated cholesterol and triglyceride levels. What information should the nurse provide to the patient?

Standard Text: Select all that apply.

1. Increase dietary fiber.

2. Eat fatty fish twice a week.

3. Use margarine with phytosterols.

4. Increase the intake of soy products

5. Limit red meat consumption to 6 days a week.

Correct Answer: 1,2,3,4

Rationale 1: The fiber found in oat bran, apples, citrus, and whole-grain products is particularly effective in reducing cholesterol.
Reference: Page 393

Rationale 2: Consumption of fish oil and ingestion of omega-3 fatty acids also have been shown to reduce cholesterol levels prompting the recommendation by the American Heart Association that fatty fish be eaten at least two times a week.
Reference: Page 393

Rationale 3: Phytosterols (plant sterols) are found in whole grains and many fruits and vegetables, and have the ability to interfere with the intestinal absorption of cholesterol. These products have been added to certain margarines and salad dressings, and the FDA has approved statements that consumption of these products may reduce the risk of coronary heart disease.
Reference: Page 393

Rationale 4: Soybeans have been shown to lower LDL blood levels and triglycerides and thus lower the risk of developing coronary heart disease. Soy products can be incorporated into the diet by drinking soy milk, eating tofu, or eating any product made with soybeans. The FDA has allowed the statement that inclusion of soy products in a diet low in saturated fat and cholesterol promotes heart health.
Reference: Page 393

Rationale 5: There is no specific recommendation for the ingestion of red meat to control cholesterol and triglyceride levels.
Reference: Page 393

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Outline an education plan for cardiovascular patients.

Question 12

Type: MCSA

When teaching an older patient about the side effects of furosemide (Lasix), the nurse should instruct the patient to eat foods high in which mineral?

1. Iron

2. Sodium

3. Calcium

4. Potassium

Correct Answer: 4

Rationale 1: Lasix does not affect iron levels.
Reference: Page 375

Rationale 2: Lasix is not documented as altering sodium levels.
Reference: Page 375

Rationale 3: Lasix does not affect calcium levels.
Reference: Page 375

Rationale 4: Lasix is a loop diuretic that depletes the potassium level. Patients who take potassium-depleting diuretics like Lasix should eat foods that replace the electrolyte.
Reference: Page 375

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Outline an education plan for cardiovascular patients.

Question 13

Type: MCSA

An older patient is diagnosed with heart failure. During the health history what will the nurse most likely assess as the patients first symptom of the disorder?

1. Nausea

2. Dyspnea

3. Anorexia

4. Headaches

Correct Answer: 2

Rationale 1: Most heart failure symptoms include breathlessness or dyspnea. Nausea can have many causes and is not usually associated with heart failure.
Reference: Page 385

Rationale 2: Most heart failure symptoms include breathlessness or dyspnea.
Reference: Page 385

Rationale 3: Most heart failure symptoms include breathlessness or dyspnea. Anorexia can have many causes and is not usually associated with heart failure.
Reference: Page 385

Rationale 4: Most heart failure symptoms include breathlessness or dyspnea. Headaches are usually related to hypertension and not heart failure.
Reference: Page 385

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List focus areas of assessment for cardiovascular patients.

Question 14

Type: MCSA

The nurse instructs an older patient with hypertension on ways to avoid the intake of sodium. Which food item should the patient state to avoid as an indication that instruction has been effective?

1. Onions

2. Maple syrup

3. Lemon juice

4. Processed meats

Correct Answer: 4

Rationale 1: Onions are not high in sodium.
Reference: Page 396

Rationale 2: Maple syrup is high in sugar but not in sodium.
Reference: Page 396

Rationale 3: Lemon juice is not high in sodium.
Reference: Page 396

Rationale 4: Processed meats are high in sodium.
Reference: Page 396

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 6. Outline an education plan for cardiovascular patients.

Question 15

Type: MCSA

An older patient being treated for hypertension experiences lightheadedness when getting up in the middle of the night to void and when making sudden movements. How should the nurse instruct this patient?

1. Restrict activity to 10 minutes a day.

2. Increase caffeine intake to help increase blood pressure.

3. Move slowly from a lying to a sitting position and then slowly from sitting to standing.

4. Decrease fluid intake in the evening to prevent the need to get up in the middle of the night.

Correct Answer: 3

Rationale 1: Older adults should be encouraged to have more physical activity to help control blood pressure.
Reference: Page 376

Rationale 2: The patient is being treated for hypertension. Caffeine would counteract the effects of the medication.
Reference: Page 376

Rationale 3: Patients taking antihypertensive medications should be instructed to change positions slowly. Rising too quickly from lying to standing position can result in pooling of blood in the extremities and reduced blood flow to the head. This can cause orthostatic hypotension, which is experienced as light headedness or syncope.
Reference: Page 376

Rationale 4: The nurse should not encourage the patient to restrict fluids since this could potentiate other health problems.
Reference: Page 376

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Outline an education plan for cardiovascular patients.

Question 16

Type: MCMA

An older patient is prescribed a beta blocker to treat hypertension. What effects will the nurse instruct the patient to report to the healthcare professional?

Standard Text: Select all that apply.

1. Fatigue

2. Dry cough

3. Dry mouth

4. Cold extremities

5. Exercise intolerance

Correct Answer: 1,4,5

Rationale 1: Fatigue is a side effect of a beta blocker.
Reference: Page 375

Rationale 2: Dry cough is a side effect of an ACE inhibitor and not a beta blocker.
Reference: Page 375

Rationale 3: Dry mouth is a side effect of a centrally acting alpha2-agonist and not a beta blocker.
Reference: Page 375

Rationale 4: Reduced peripheral circulation which can manifest as cold extremities is a side effect of a beta blocker.
Reference: Page 375

Rationale 5: Exercise intolerance is a side effect of a beta blocker.
Reference: Page 375

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Outline an education plan for cardiovascular patients.

Question 17

Type: MCSA

An older patient with angina complains of prolonged and severe pain that occurs at the same time each day during rest. There are no precipitating factors to the pain. How should the nurse describe this type of angina pain?

1. Stable angina

2. Unstable angina

3. Non-anginal pain

4. Atypical angina (Prinzmetals angina)

Correct Answer: 4

Rationale 1: Stable angina is induced by exercise and is relieved by rest or nitroglycerin.
Reference: Page 381

Rationale 2: Unstable angina is not relieved by rest or nitroglycerin and is less predictable.
Reference: Page 381

Rationale 3: This patient is experiencing anginal pain.
Reference: Page 381

Rationale 4: Atypical or Prinzmetals angina often occurs at the same time each day and typically at rest.
Reference: Page 381

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List focus areas of assessment for cardiovascular patients.

Question 18

Type: MCMA

The nurse anticipates that an older patient with right-sided heart failure would exhibit which symptoms?

Standard Text: Select all that apply.

1. Pallor

2. Edema

3. Wheezing

4. Orthopnea

5. Neck vein distention

Correct Answer: 2,5

Rationale 1: Pallor is not a specific symptom for right-sided heart failure.
Reference: Page 385

Rationale 2: Physical signs of right-sided heart failure include edema in the extremities.
Reference: Page 385

Rationale 3: Wheezing is not a specific symptom of right-sided heart failure.
Reference: Page 385

Rationale 4: Orthopnea is not a specific symptom of right-sided heart failure.
Reference: Page 385

Rationale 5: Physical signs of right-sided heart failure include dilated neck veins.
Reference: Page 385

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List focus areas of assessment for cardiovascular patients.

Question 19

Type: MCMA

The nurse is concerned that an older patient is at risk for metabolic syndrome. What did the nurse assess in this patient?

Standard Text: Select all that apply.

1. Heart rate 88 and regular

2. Respiratory rate 18 and regular

3. Waist circumference 40 inches

4. Blood pressure 148/88 mm Hg

5. Fasting capillary blood glucose 110 mg/dL

Correct Answer: 3,4,5

Rationale 1: Heart rate is not used as a component to diagnose metabolic syndrome.
Reference: Page 379

Rationale 2: Respiratory rate is not used as a component to diagnose metabolic syndrome.
Reference: Page 379

Rationale 3: Womens waist circumference that is equal to or greater than 35 inches is a component to diagnose metabolic syndrome.
Reference: Page 379

Rationale 4: Blood pressure equal to or greater than 130/85 mm Hg is a component to diagnose metabolic syndrome.
Reference: Page 379

Rationale 5: Blood glucose equal to or greater than 100 mg/dL is a component to diagnose metabolic syndrome.
Reference: Page 379

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List focus areas of assessment for cardiovascular patients.

Question 20

Type: MCMA

An older patient is diagnosed with arterial peripheral vascular disease. What will the nurse assess in this patient?

Standard Text: Select all that apply.

1. Leg ulcers

2. Pain with walking

3. 40-year history of smoking

4. Pain relieved when legs dangle

5. History of working as a computer operator

Correct Answer: 2,3,4

Rationale 1: Leg ulcers are associated with venous peripheral vascular disease.
Reference: Page 388

Rationale 2: Pain with walking is a symptom associated with arterial occlusion.
Reference: Page 388

Rationale 3: Smoking is a risk factor for the development of arterial peripheral vascular disease.
Reference: Page 388

Rationale 4: Pain relieved when dangling the legs is an indication of arterial peripheral vascular disease.
Reference: Page 388

Rationale 5: A history of sitting for long periods of time is a risk factor for venous peripheral vascular disease.
Reference: Page 388

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List focus areas of assessment for cardiovascular patients.

Question 21

Type: MCSA

During a home visit an older patient with heart disease tells the nurse of plans to shovel the snow as soon as the visit concludes. How should the nurse instruct the patient at this time?

1. Shovel the steps only.

2. Avoid shoveling at this time.

3. Shovel for 30 minutes at a time.

4. Shovel for 10 minutes and then stop.

Correct Answer: 2

Rationale 1: The older heart cannot respond to stressful stimuli as well as the younger heart. The patient should be cautioned not to engage in stressful activities like vigorous shoveling of snow without engaging in a gradual exercise program to build fitness. Shoveling the steps could be harmful to the patient.
Reference: Page 370

Rationale 2: The older heart cannot respond to stressful stimuli as well as the younger heart. The patient should be cautioned not to engage in stressful activities like vigorous shoveling of snow without engaging in a gradual exercise program to build fitness.
Reference: Page 370

Rationale 3: The older heart cannot respond to stressful stimuli as well as the younger heart. The patient should be cautioned not to engage in stressful activities like vigorous shoveling of snow without engaging in a gradual exercise program to build fitness. Shoveling for 30 minutes could be harmful to the patient.
Reference: Page 370

Rationale 4: The older heart cannot respond to stressful stimuli as well as the younger heart. The patient should be cautioned not to engage in stressful activities like vigorous shoveling of snow without engaging in a gradual exercise program to build fitness. Shoveling for 10 minutes could be harmful to the patient.
Reference: Page 370

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 6. Outline an education plan for cardiovascular patients.

Question 22

Type: MCMA

An older patient diagnosed with pneumonia does not understand why the health problem occurred since respiratory problems have never been experienced. How should the nurse respond to this patient?

Standard Text: Select all that apply.

1. Back joints are stiffer.

2. Less oxygen is used with aging.

3. Ciliary function decreases with age.

4. Retention of carbon dioxide occurs with aging.

5. Decreased immune function occurs with aging.

Correct Answer: 3,5

Rationale 1: Back joints are stiffer with aging; however, this does not explain the onset of pneumonia in the patient.
Reference: Page 371

Rationale 2: Less oxygen is not used with aging.
Reference: Page 371

Rationale 3: Ciliary function is decreased with aging, which makes the older person more susceptible to pneumonia.
Reference: Page 371

Rationale 4: Retention of carbon dioxide is an indication of pathology and not a normal sign of aging.
Reference: Page 371

Rationale 5: Decreased immune function occurs with aging and makes the older person more susceptible to pneumonia.
Reference: Page 371

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 1. Describe changes in the cardiovascular system that occur with aging.

Question 23

Type: MCSA

An older patient with valvular disease is scheduled for an echocardiogram. What should the nurse teach the patient about this diagnostic test?

1. Determines the risk for metabolic syndrome

2. Analyzes the reasons for high blood pressure

3. Visualizes the heart valves as they open and close

4. Measures the amount of blood flowing through arteries

Correct Answer: 3

Rationale 1: An echocardiogram evaluates all heart valve function. This test allows the visualization of the valves as they open and close. Using this test, one can determine valve area, cardiac output, and any regurgitation. It is not used to determine the risk for metabolic syndrome.
Reference: Page 383

Rationale 2: An echocardiogram evaluates all heart valve function. This test allows the visualization of the valves as they open and close. Using this test, one can determine valve area, cardiac output, and any regurgitation. It is not used to analyze the reasons for high blood pressure.
Reference: Page 383

Rationale 3: An echocardiogram evaluates all heart valve function. This test allows the visualization of the valves as they open and close. Using this test, one can determine valve area, cardiac output, and any regurgitation.
Reference: Page 383

Rationale 4: An echocardiogram evaluates all heart valve function. This test allows the visualization of the valves as they open and close. Using this test, one can determine valve area, cardiac output, and any regurgitation. It is not used to measure the amount of blood flowing through arteries.
Reference: Page 383

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. Relate physiological concepts to the diagnosis and management of common cardiovascular risks and conditions, including hypertension, angina, heart failure, and peripheral vascular disease.

Question 24

Type: MCSA

The nurse is planning care for an older patient with heart failure who is experiencing shortness of breath. Upon assessment the patient stated the inability to purchase medication because of financial limits. Which nursing diagnoses will be of the greatest initial importance when planning care?

1. Fluid Volume Excess

2. Fatigue related to shortness of breath

3. Activity Intolerance related to shortness of breath

4. Ineffective Management of Therapeutic Regime related to inability to purchase medications

Correct Answer: 1

Rationale 1: Although all diagnoses listed are appropriate for this situation, Fluid Volume Excess is the priority diagnosis for this patient.
Reference: Page 392

Rationale 2: Although all diagnoses listed are appropriate for this situation, Fluid Volume Excess is the priority diagnosis for this patient. The patients fatigue will improve once the excess fluid is removed from the body.
Reference: Page 392

Rationale 3: Although all diagnoses listed are appropriate for this situation, Fluid Volume Excess is the priority diagnosis for this patient. The patients tolerance for activity will improve once the excess fluid is removed from the body.
Reference: Page 392

Rationale 4: Although all diagnoses listed are appropriate for this situation, Fluid Volume Excess is the priority diagnosis for this patient. The nurse can work with social services to help the patient with finances so that medications can be purchased in the future.
Reference: Page 392

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 4. Formulate common nursing diagnoses for the cardiovascular patient.

Question 25

Type: MCSA

The nurse is planning to assess an older patients functional health patterns for cardiovascular disease. Which question will the nurse use to assess the patients nutrition/metabolic pattern?

1. Do you sleep through the night?

2. Do you weigh yourself every day?

3. How often do you have a bowel movement?

4. How far can you walk without getting short of breath?

Correct Answer: 2

Rationale 1: The question Do you sleep through the night? would assess the patients sleep/rest pattern.
Reference: Page 391

Rationale 2: The question Do you weigh yourself everyday? would assess the patients nutrition/metabolic pattern.
Reference: Page 391

Rationale 3: The question How often do you have a bowel movement? would assess the patients elimination pattern.
Reference: Page 391

Rationale 4: The question How far can you walk without getting short of breath? would assess the patients activity/exercise pattern.
Reference: Page 391

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 2. List focus areas of assessment for cardiovascular patients.

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