Chapter 16 My Nursing Test Banks

Tabloski Gerontological Nursing, 3/e
Chapter 16

Question 1

Type: MCSA

Which change in the respiratory system of an older patient does the nurse recognize as an expected finding with aging?

1. Decrease in vital capacity

2. Increase in alveolar surface area

3. Decrease in stiffness of the chest wall

4. Increase in the amount of oxygen carried in the blood

Correct Answer: 1

Rationale 1: The aging process causes a decrease in the vital capacity or amount of air that moves in and out with each breath.
Reference: Page 403

Rationale 2: There is a decrease and not an increase in the alveolar surface area with aging.
Reference: Page 403

Rationale 3: There is an increase and not a decrease in stiffness of the chest wall with aging.
Reference: Page 403

Rationale 4: There is a decrease and not an increase in the amount of oxygen carried in the blood.
Reference: Page 403

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. Define normal changes of aging of the respiratory system.

Question 2

Type: MCSA

Why will the nurse plan interventions to reduce an older patients risk of developing a pulmonary disease?

1. There is an increase in alveolar diameter.

2. The older patient has decreased production of antibodies.

3. The older patient has an improved response to immunizations.

4. The cilia of an older patient is more effective in removing debris from the airway.

Correct Answer: 2

Rationale 1: With aging there is an increased susceptibility to pulmonary diseases because of a decrease in antibody production. Aging causes a change in the shape of the alveoli and an increase in the alveolar diameter but these have no effect on the patients susceptibility to disease.Reference: Page 403

Rationale 2: With aging there is an increased susceptibility to pulmonary diseases because of a decrease in antibody production.Reference: Page 403

Rationale 3: With aging there is an increased susceptibility to pulmonary diseases because of a decrease in antibody production. Even with administration of immunizations, there is less production of antibodies.Reference: Page 403

Rationale 4: With aging there is an increased susceptibility to pulmonary diseases because of a decrease in antibody production. The cilia, which create a constant whipping motion propelling mucus, are less effective in removing foreign matter from the airways.Reference: Page 403

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 1. Define normal changes of aging of the respiratory system.

Question 3

Type: MCSA

An older patient who is having difficulty breathing and is wheezing is scheduled for a test to differentiate the health problem as being asthma or chronic obstructive pulmonary disease (COPD). For which diagnostic test should the nurse prepare the patient?

1. Chest x-ray

2. Electrocardiogram

3. Complete blood count

4. Pulmonary function tests

Correct Answer: 4

Rationale 1: A chest x-ray will give information related to the pulmonary condition but will not differentiate asthma from COPD.
Reference: Page 408

Rationale 2: An electrocardiogram will give information related to the pulmonary condition but will not differentiate asthma from COPD.
Reference: Page 408

Rationale 3: A complete blood count will give information related to the pulmonary condition but will not differentiate asthma and COPD.
Reference: Page 408

Rationale 4: Pulmonary function tests are the most reliable way to diagnose asthma and differentiate it from other illness such as COPD. Measurement of air during expiration is used in the differential diagnosis.
Reference: Page 408

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

Question 4

Type: MCSA

What will the nurse keep in mind when planning care for an older patient diagnosed with asthma?

1. Asthma is not diagnosed as a new condition in older patients.

2. Asthma is treated with the same types of medications in older patients as in younger patients.

3. Older patients will have fewer side effects and drug interactions from asthma medications than younger patients.

4. Asthma can be differentiated from chronic obstructive pulmonary disease (COPD) by changes seen on a series of chest x-rays.

Correct Answer: 2

Rationale 1: Asthma can be a new diagnosis in older patients as well as in younger patients.
Reference: Page 408

Rationale 2: The same types of medications are used to treat asthma in older adults as in younger adults.
Reference: Page 408

Rationale 3: The older adult is likely to experience more side effects from the medications and drug interactions.
Reference: Page 408

Rationale 4: Asthma is differentiated from COPD by examining pulmonary function test results.
Reference: Page 408

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

Question 5

Type: MCMA

An older patient is prescribed an inhaled corticosteroid as part of treatment for asthma. What will the nurse instruct the patient about the use of this medication?

Standard Text: Select all that apply.

1. It can cause oral thrush or candidiasis.

2. Use a spacer when taking this medication.

3. It has no effect on any other health problems.

4. Rinse the mouth and spit after using this medication.

5. It is the most effective anti-inflammatory treatment for asthma.

Correct Answer: 1,2,4,5

Rationale 1: Inhaled corticosteroids can cause oral thrush (candidiasis).
Reference: Pages 408409

Rationale 2: Patients should be urged to use spacers with their metered-dose inhalers.
Reference: Pages 408409

Rationale 3: Adverse effects of inhaled corticosteroids include electrolyte and fluid imbalances in older patients with cardiac or renal disease, the possibility of hypokalemia when the patient is taking a thiazide diuretic, worsening of hypertension, and elevated blood sugar and blood urea nitrogen readings in patients with diabetes.
Reference: Pages 408409

Rationale 4: Patients should be urged to rinse and spit after use of inhaled corticosteroids.
Reference: Pages 408409

Rationale 5: Inhaled corticosteroid therapy is the most effective anti-inflammatory treatment for asthma.
Reference: Pages 408409

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

Question 6

Type: MCMA

When should the nurse instruct an older patient with asthma to use a peak flow meter?

Standard Text: Select all that apply.

1. After eating dinner in the evening

2. If feeling like cold symptoms are occurring

3. When wheezing or tightness in the chest occurs

4. In the morning after awakening and between noon and 2 p.m.

5. Every day for the first 2 weeks when medication treatment changes

Correct Answer: 2,3,4,5

Rationale 1: The nurse should instruct an older patient with asthma to use a peak flow meter with cold symptoms, chest tightness or wheezing in the morning after awakening, between noon and 2 p.m., and every day for the first 2 weeks when medication treatment changes. It does not need to be used after eating dinner in the evening.
Reference: Page 414

Rationale 2: The nurse should instruct an older patient with asthma to use a peak flow meter with cold symptoms.
Reference: Page 414

Rationale 3: The nurse should instruct an older patient with asthma to use a peak flow meter with chest tightness or wheezing.
Reference: Page 414

Rationale 4: The nurse should instruct an older patient with asthma to use a peak flow meter in the morning after awakening and between noon and 2 p.m.
Reference: Page 414

Rationale 5: The nurse should instruct an older patient with asthma to use a peak flow meter every day for the first 2 weeks when medication treatment changes.
Reference: Page 414

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. Discuss the nurses role in caring for older adults with respiratory problems.

Question 7

Type: MCMA

An older patient with asthma is prescribed rescue inhalers. What should the nurse instruct the patient about this medication?

Standard Text: Select all that apply.

1. Refrigerate unused canisters.

2. Place the canisters near the bed.

3. Label the canisters with bright red tape.

4. Obtain a prescription for extra canisters.

5. Keep several inhalers in different areas in the home.

Correct Answer: 3,4,5

Rationale 1: Unused canisters should not be refrigerated unless directed to do so by the pharmacy.
Reference: Page 409

Rationale 2: The canisters should be placed in different areas in the home and not just at the bedside.
Reference: Page 409

Rationale 3: Patients who require the use of rescue inhalers should label them with bright red tape so they can be easily seen if needed quickly.
Reference: Page 409

Rationale 4: Patients who require the use of rescue inhalers should obtain prescriptions for extra canisters.
Reference: Page 409

Rationale 5: Patients who require the use of rescue inhalers should keep several inhalers in strategic places in the home.
Reference: Page 409

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

Question 8

Type: MCSA

Which manifestation of chronic obstructive pulmonary disease (COPD) that occurs early in the disease will the nurse assess in an older patient?

1. Dysrhythmias

2. Cyanotic nail beds

3. Clubbing of the fingers

4. Cough in the morning producing clear sputum

Correct Answer: 4

Rationale 1: Enlargement and thickening of the right ventricle of the heart often results in dysrhythmias. This occurs later in the disease.
Reference: Page 424

Rationale 2: With the progression of COPD the body compensates by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers leading to the development of cyanotic nail beds.
Reference: Page 424

Rationale 3: With the progression of COPD the body compensates by producing extra red blood cells. These extra blood cells clog the small blood vessels of the fingers leading to the development of clubbing of the fingertips.
Reference: Page 424

Rationale 4: The earliest presenting symptom of COPD is morning cough with clear sputum unless the patient develops an infection. Then the sputum would become yellow or green in color.
Reference: Page 424

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 4. Classify common diseases of the respiratory system.

Question 9

Type: MCSA

Which nursing diagnosis would the nurse select for an older patient with asthma that has a respiratory rate of 28 and audible wheezes on inspiration?

1. Activity Intolerance

2. Altered Tissue Perfusion

3. Ineffective Airway Clearance

4. Ineffective Breathing Pattern with tachypnea and wheezing.

Correct Answer: 4

Rationale 1: Activity Intolerance would be appropriate if the patient was experiencing fatigue.Reference: Page 417

Rationale 2: Altered Tissue Perfusion would be appropriate if the patient was experiencing hypoxemia.Reference: Page 417

Rationale 3: Ineffective Airway Clearance would be appropriate if the patient has a cough.Reference: Page 417

Rationale 4: Ineffective Breathing Pattern is appropriate since this diagnosis is used if the patient is experiencing wheezing.Reference: Page 417

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Identify the nursing assessment process and formulation of nursing diagnoses relating to the respiratory system.

Question 10

Type: MCSA

An older patient with chronic obstructive pulmonary disease (COPD) develops a dysrhythmia. Which health problem should the nurse consider is occurring with this patient?

1. Anemia

2. Asthma

3. Cor pulmonale

4. Left ventricular hypertrophy

Correct Answer: 3

Rationale 1: Anemia does not occur in COPD.
Reference: Page 423

Rationale 2: Asthma is not associated with dysrhythmias and will not develop in COPD.
Reference: Page 423

Rationale 3: In cor pulmonale the right ventricle enlarges and thickens, which can result in abnormal rhythms. Older patients with cor pulmonale suffer from rhythm disturbances and are at risk for heart failure.
Reference: Page 423

Rationale 4: Left ventricular hypertrophy is not a documented effect of COPD.
Reference: Page 423

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify the nursing assessment process and formulation of nursing diagnoses relating to the respiratory system.

Question 11

Type: MCMA

What steps will the nurse follow when administering a two-step purified protein derivative (PPD) tuberculin skin test to an older patient?

Standard Text: Select all that apply.

1. Repeat the PPD test in 1 to 2 weeks.

2. Measure the area of injection in 48 hours.

3. Measure the area of injection in 72 hours.

4. Administer 5 units of the BCG vaccination serum.

5. Administer an injection of 0.1 mL of 5 TU intradermally.

Correct Answer: 1,3,5

Rationale 1: When administering the two-step PPD tuberculin skin test to an older patient the nurse should administer an injection of 0.1 mL of 5 TU intradermally, measure the area of injection in 72 hours, and repeat the test in 1 to 2 weeks.
Reference: Page 430

Rationale 2: When administering the two-step PPD tuberculin skin test to an older patient the nurse should administer an injection of 0.1 mL of 5 TU intradermally, measure the area of injection in 72 hours, and repeat the test in 1 to 2 weeks. The area of injection should not be read in 48 hours.
Reference: Page 430

Rationale 3: When administering the two-step PPD tuberculin skin test to an older patient the nurse should administer an injection of 0.1 mL of 5 TU intradermally, measure the area of injection in 72 hours, and repeat the test in 1 to 2 weeks.
Reference: Page 430

Rationale 4: When administering the two-step PPD tuberculin skin test to an older patient the nurse should administer an injection of 0.1 mL of 5 TU intradermally, measure the area of injection in 72 hours, and repeat the test in 1 to 2 weeks. The BCG vaccination is an antituberculosis vaccination that is often not used in the United States. It is not injected to test for tuberculosis.
Reference: Page 430

Rationale 5: When administering the two-step PPD tuberculin skin test to an older patient the nurse should administer an injection of 0.1 mL of 5 TU intradermally, measure the area of injection in 72 hours, and repeat the test in 1 to 2 weeks.
Reference: Page 430

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

Question 12

Type: MCMA

What manifestations will the nurse assess in an older patient with active tuberculosis?

Standard Text: Select all that apply.

1. Weight loss

2. Night sweats

3. Ankle edema

4. Bloody sputum

5. Loss of appetite

Correct Answer: 1,2,4,5

Rationale 1: Weight loss is an early symptom of tuberculosis.
Reference: Page 430

Rationale 2: Night sweats are an early symptom of tuberculosis.
Reference: Page 430

Rationale 3: Ankle edema is not a symptom of tuberculosis
Reference: Page 430

Rationale 4: Bloody sputum is a chronic symptom of tuberculosis.
Reference: Page 430

Rationale 5: Loss of appetite is an early symptom of tuberculosis.
Reference: Page 430

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify the nursing assessment process and formulation of nursing diagnoses relating to the respiratory system.

Question 13

Type: MCSA

What should the nurse instruct an older patient who is newly diagnosed with tuberculosis?

1. In the early stage, it causes weight gain and shortness of breath.

2. It is caused by a virus related to human immunodeficiency virus (HIV).

3. It can be spread by persons who have positive skin tests and no symptoms.

4. It presents a higher risk for patients who take immunosuppressant medications.

Correct Answer: 4

Rationale 1: Early symptoms include weight loss, night sweats, and loss of appetite.
Reference: Page 429

Rationale 2: Tuberculosis is caused by mycobacterium tuberculosis, which is an acid-fast, aerobic bacterium. Patients with HIV are at greater risk for tuberculosis because of altered immune status.
Reference: Page 429

Rationale 3: Tuberculosis is spread by droplet infection by persons with active disease. Persons with positive skin tests have been exposed to the infection and have sustained an immune response to the exposure. They usually are given an antibiotic prophylactically.
Reference: Page 429

Rationale 4: A risk factor for developing tuberculosis is the use of medications that suppress the immune system, such as corticosteroids or anticancer medications.
Reference: Page 429

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. Discuss the nurses role in caring for older adults with respiratory problems.

Question 14

Type: MCSA

What should the nurse keep in mind when teaching an older patient about smoking cessation?

1. Most people quit smoking several times before they are successful.

2. Bupropion (Zyban) taken orally is safe for patients with seizure disorders.

3. A piece of nicotine gum should be chewed for 5 minutes of every waking hour.

4. There is no adverse risk if the patient chooses to smoke while wearing a nicotine patch.

Correct Answer: 1

Rationale 1: Nurses should be persistent in educating and urging older patients to quit. The smoking addiction is difficult to beat. Many older people try to quit several times before they are ultimately successful.
Reference: Page 428

Rationale 2: Bupropion is contraindicated in people with seizure disorder.
Reference: Page 428

Rationale 3: For patients choosing Nicorette gum, it is recommended that 9 to 12 pieces be used daily. The nurse should instruct patients to chew one piece at a time when they get the urge to smoke. After chewing the gum a few times to soften it, it should be held in the buccal cavity for at least one-half hour to release all the medication.
Reference: Page 428

Rationale 4: A patient wearing a nicotine patch must not smoke because of increased risk for cardiovascular problems including myocardial infarction.
Reference: Page 428

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. Describe appropriate health promotion and disease prevention guidelines relating to the respiratory system.

Question 15

Type: MCMA

Which manifestations should the nurse investigate as indicating possible pneumonia in an older patient?

Standard Text: Select all that apply.

1. Fever

2. Dyspnea

3. Tachycardia

4. Behavior changes

5. Substernal chest pain

Correct Answer: 2,3,4,5

Rationale 1: Fever may be absent in the older patient because many older people have a lower basal temperature and will not exhibit a fever response in the face of infection.
Reference: Page 435

Rationale 2: Nonbacterial pneumonia may be accompanied by dyspnea.
Reference: Page 435

Rationale 3: New-onset of tachycardia is an important clue to an illness with both viral and bacterial pneumonia.
Reference: Page 435

Rationale 4: Subtle changes in behavior can indicate pneumonia in an older patient.
Reference: Page 435

Rationale 5: Nonbacterial pneumonia may be accompanied by substernal chest pain.
Reference: Page 435

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify the nursing assessment process and formulation of nursing diagnoses relating to the respiratory system.

Question 16

Type: MCMA

The nurse is caring for an older patient with chronic obstructive pulmonary disease (COPD) who is having difficulty clearing secretions from the respiratory tract. Which actions can the nurse take to help this patient?

Standard Text: Select all that apply.

1. Restrict oral fluids.

2. Use postural drainage.

3. Apply chest percussion.

4. Teach controlled coughing.

5. Perform tracheal suctioning.

Correct Answer: 2,3,4,5

Rationale 1: Oral fluids help to thin respiratory secretions and should not be limited in the patient with COPD.
Reference: Page 426

Rationale 2: Postural drainage uses gravity to force secretion upward and stimulates a cough reflex.
Reference: Page 426

Rationale 3: Chest percussion loosens secretions.
Reference: Page 426

Rationale 4: Controlled coughing contracts the diaphragm to maximize the cough response.
Reference: Page 426

Rationale 5: Tracheal suctioning is used to remove secretions in those who are too frail or near end of life.
Reference: Page 426

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. Discuss the nurses role in caring for older adults with respiratory problems.

Question 17

Type: MCMA

The nurse is preparing to use a peak flow meter for an older patient with asthma. For which reasons will the nurse use this device?

Standard Text: Select all that apply.

1. Evaluate effects of stress.

2. Measure response to medications.

3. Recognize the need for emergency care.

4. Determine if medications need changed.

5. Establish the presence of medication side effects.

Correct Answer: 1,2,3,4

Rationale 1: The peak flow meter can alert the patient and the healthcare provider by evaluating the effects of stress.
Reference: Page 414

Rationale 2: The peak flow meter can alert the patient and the healthcare provider by measuring the patients response to medications.
Reference: Page 414

Rationale 3: The peak flow meter can alert the patient and the healthcare provider by recognizing the need for emergency care.
Reference: Page 414

Rationale 4: The peak flow meter can alert the patient and the healthcare provider by determining if medications need to be changed.
Reference: Page 414

Rationale 5: The peak flow meter is not used to establish the presence of medication side effects.
Reference: Page 414

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 2. Describe appropriate health promotion and disease prevention guidelines relating to the respiratory system.

Question 18

Type: MCMA

An older patient asks the nurse what can be done to prevent a respiratory infection during the winter months. How should the nurse respond to this patient?

Standard Text: Select all that apply.

1. Stay active with daily exercise.

2. Dont smoke and avoid secondhand smoke.

3. Wash the hands often and get a flu vaccination.

4. Eat a healthy diet and maintain a normal weight.

5. Visit with a variety of people to build up immunity.

Correct Answer: 1,2,3,4

Rationale 1: Tips to keep a healthy respiratory system include staying active with daily exercise.
Reference: Page 405

Rationale 2: Tips to keep a healthy respiratory system include not smoking and avoiding secondhand smoke.
Reference: Page 405

Rationale 3: Tips to keep a healthy respiratory system include frequent hand washing and getting a flu vaccination.
Reference: Page 405

Rationale 4: Tips to keep a healthy respiratory system include eating a healthy diet and maintaining a normal weight.
Reference: Page 405

Rationale 5: Visiting a variety of people to build up immunity is not a strategy to keep a healthy respiratory system.
Reference: Page 405

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 2. Describe appropriate health promotion and disease prevention guidelines relating to the respiratory system.

Question 19

Type: MCSA

The nurse is preparing a care plan for an older patient with asthma. The patient is receiving oxygen and has a respiratory rate of 28, heart rate of 86, and blood pressure of 108/52. Which nursing diagnosis would be the priority for this patient?

1. Risk for Injury

2. Risk for Infection

3. Activity Intolerance

4. Ineffective Peripheral Tissue Perfusion

Correct Answer: 4

Rationale 1: There is no evidence that the patient is at risk for injury.
Reference: Page 417

Rationale 2: The patient may or may not be at risk for infection.
Reference: Page 417

Rationale 3: The patient may or may not have activity intolerance.
Reference: Page 417

Rationale 4: Ineffective Peripheral Tissue Perfusion is the appropriate diagnosis for the patient with hypoxemia.
Reference: Page 417

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 5. Identify the nursing assessment process and formulation of nursing diagnoses relating to the respiratory system.

Question 20

Type: MCSA

When assessing an older patient with chronic obstructive lung disease (COPD) the nurse sees calluses on both of the patients elbows. What does this finding indicate to the nurse?

1. The patient lifts weights.

2. Use of the tripod position.

3. An allergy to a medication.

4. The patient falls frequently.

Correct Answer: 2

Rationale 1: Older patients with COPD often have calluses on their elbows as a result of leaning over tables to stretch out their torsos so that more air can enter and exit during respiration. It is often referred to as the tripod position. This does not mean that the patient lifts weights.
Reference: Page 424

Rationale 2: Older patients with COPD often have calluses on their elbows as a result of leaning over tables to stretch out their torsos so that more air can enter and exit during respiration. It is often referred to as the tripod position.
Reference: Page 424

Rationale 3: Older patients with COPD often have calluses on their elbows as a result of leaning over tables to stretch out their torsos so that more air can enter and exit during respiration. It is often referred to as the tripod position. This does not indicate an allergy to a medication.
Reference: Page 424

Rationale 4: Older patients with COPD often have calluses on their elbows as a result of leaning over tables to stretch out their torsos so that more air can enter and exit during respiration. It is often referred to as the tripod position. This does not mean the patient falls frequently.
Reference: Page 424

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 5. Identify the nursing assessment process and formulation of nursing diagnoses relating to the respiratory system.

Question 21

Type: MCMA

What will the nurse instruct an older patient with asthma to do to control house dust?

Standard Text: Select all that apply.

1. Wash the hands frequently.

2. Remove carpets from the bedroom.

3. Reduce indoor humidity to less than 50%.

4. Stay out of a room that is being vacuumed.

5. Do not sleep or lie on upholstered furniture.

Correct Answer: 2,3,4,5

Rationale 1: Frequent hand washing would be more appropriate if the patient has pets.
Reference: Page 421

Rationale 2: Removing carpets from the bedroom is an action to control house dust.
Reference: Page 421

Rationale 3: Reducing indoor humidity is an action to control house dust.
Reference: Page 421

Rationale 4: Staying out of a room that is being vacuumed is an action to control asthma symptoms caused by house dust.
Reference: Page 421

Rationale 5: Avoiding upholstered furniture is an action to control house dust.
Reference: Page 421

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. Describe appropriate health promotion and disease prevention guidelines relating to the respiratory system.

Question 22

Type: MCSA

The nurse is reviewing new medication orders for an older patient with asthma. Which medication should the nurse question before providing it to the patient?

1. Aspirin

2. Antibiotic

3. Anticoagulant

4. Calcium channel blocker

Correct Answer: 1

Rationale 1: Certain medications should be avoided when treating patients with asthma because adverse reactions can exacerbate asthmatic problems. Sudden, potentially life-threatening bronchospasm has been associated with aspirin use in older patients.
Reference: Page 414

Rationale 2: Antibiotics can be safely provided to an older patient with asthma.
Reference: Page 414

Rationale 3: Anticoagulants can be safely provided to an older patient with asthma.
Reference: Page 414

Rationale 4: Calcium channel blockers can be safely provided to an older patient with asthma.
Reference: Page 414

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

Question 23

Type: MCSA

An older patient is prescribed isoniazid (INH) for 6 months. What should the nurse instruct the patient about this medication?

1. Avoid vitamin supplements.

2. Use alcohol in small amounts.

3. Report yellow eyes or skin immediately.

4. Expect the finger and toe tingling to occur.

Correct Answer: 3

Rationale 1: There is no reason to avoid vitamin supplements while taking this medication.
Reference: Page 431

Rationale 2: Patients taking isoniazid are urged not to drink alcoholic beverages, including wine, beer, and liquor.
Reference: Page 431

Rationale 3: Serious side effects of isoniazid include jaundice. The patient should report yellow eyes or skin immediately.
Reference: Page 431

Rationale 4: Serious side effects of isoniazid include tingling in the fingers and toes and should be reported immediately.
Reference: Page 431

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Pharmacological and Parenteral Therapies

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

Question 24

Type: MCSA

The nurse has identified the diagnosis of Ineffective Airway Clearance for an older patient with pneumonia. Which intervention should the nurse include when planning care for this patient?

1. Chest percussion

2. Limiting fluid intake

3. Smoking cessation education

4. Administering the pneumococcal vaccine

Correct Answer: 1

Rationale 1: Chest percussion can help clear secretions.
Reference: Page 436

Rationale 2: Patients with pneumonia are encouraged to increase fluid intake.
Reference: Page 436

Rationale 3: Smoking cessation will not help with the immediate need of ineffective airway clearance.
Reference: Page 436

Rationale 4: Administering the pneumococcal vaccine will not help with the immediate need of ineffective airway clearance.
Reference: Page 436

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 5. Identify the nursing assessment process and formulation of nursing diagnoses relating to the respiratory system.

Question 25

Type: MCSA

The nurse has instructed an older patient on ways to prevent the development of pneumonia. Which patient statement indicates further instruction is needed?

1. I will get the influenza vaccine every year.

2. I will get the pneumococcal vaccine every fall.

3. I cant get the influenza vaccine due to my allergy to eggs.

4. I will get the pneumococcal vaccine as soon as I recover from this pneumonia.

Correct Answer: 2

Rationale 1: The influenza vaccine should also be received yearly in people who are at risk for pneumonia.
Reference: Page 436

Rationale 2: The pneumococcal vaccine is administered once. Revaccination is only recommended in persons with renal failure, those who have had a splenectomy, those with malignancies, and those with HIV/AIDS.
Reference: Page 436

Rationale 3: The flu shot is contraindicated in those with egg allergies.
Reference: Page 436

Rationale 4: The patient should receive the pneumococcal vaccination as soon as the current illness has subsided.
Reference: Page 436

Global Rationale:

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Reduction of Risk Potential

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 3. Discuss the nurses role in caring for older adults with respiratory problems.

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