Question 1

A newly admitted resident of a skilled facility has to void, however, a wheelchair and stretcher are blocking the entrance to the bathroom. Which type of incontinence is this patient most likely going to experience?
A) Urge
B) Stress
C) Overflow
D) Functional

Accepted Answer

Functional incontinence occurs when a person recognizes the need to urinate but cannot make it to the bathroom in time due to physical or environmental barriers, such as a blocked path by a wheelchair and stretcher in this scenario.

Question 2

An older person who uses the bathroom three times a night is experiencing eye problems, extreme fatigue, weakness, unsteadiness, and depression. What should the nurse say in response to this patient's symptoms?
A) "As people get older, they need less sleep."
B) "You may be having symptoms of sleep deprivation."
C) "Depression usually changes a person's sleep patterns."
D) "Changes in sleep patterns are a normal aging change."

Accepted Answer

These symptoms suggest sleep deprivation, which can cause or exacerbate issues like fatigue, weakness, unsteadiness, and depression, rather than being normal aging changes or solely due to depression.

Question 3

After an assessment the nurse determines that an older patient is at risk for falling. What assessment findings did the nurse use to make this clinical decision? Select all that apply.
A) Has sleep apnea
B) Is hard of hearing
C) Drinks caffeinated coffee
D) Has osteoarthritis in both hips
E) Takes acetaminophen for pain

Accepted Answer

- Sleep apnea can lead to fatigue and dizziness, increasing fall risk.- Hearing impairment can affect balance and spatial awareness, also increasing fall risk.- Osteoarthritis in the hips can impair mobility and balance, making falls more likely.

Question 4

The nurse notes that an older patient has a behavior change during the evening hours. What should the nurse suspect is occurring with this patient?
A) Dehydration
B) Relocation trauma
C) Sundown syndrome
D) Reaction to medications

Accepted Answer

Sundown syndrome, also known as sundowning, is a condition that can affect individuals with dementia or Alzheimer's disease, characterized by confusion, agitation, and restlessness that begins or worsens as daylight decreases. This is a common phenomenon observed in older patients, especially those with cognitive impairments, making it the most likely cause of behavior change during the evening hours among the options provided.

Question 5

During the night an older patient fell, was incontinent of urine, and complained of not being able to get to the bathroom because the side rails on the bed were raised. What is the most appropriate nursing intervention to prevent this patient from falling again?
A) Initiate a toileting program.
B) Place a commode next to the bed.
C) Apply a soft waist restraint at night.
D) Put the side rails down during the night.

Accepted Answer

Initiating a toileting program addresses the patient's need to use the bathroom regularly, reducing the likelihood of incontinence and the need to climb over side rails, thereby preventing falls.

Question 6

The nurse encourages an older patient to increase activity. Which potential respiratory problem is the nurse helping to prevent? Select all that apply.
A) Influenza
B) Atelectasis
C) Pneumonia
D) Tuberculosis
E) Chronic bronchitis

Accepted Answer

Atelectasis is the collapse of lung tissue, and pneumonia is an infection of the lungs. Both of these conditions can be prevented by increasing activity, which helps to keep the lungs inflated and clear of secretions.

Question 7

The nurse is concerned that a patient is experiencing stress incontinence. What characteristic of this type of incontinence caused the nurse to make this decision?
A) The patient is male.
B) It is caused by a bladder obstruction.
C) It occurs most often in long-term care facilities.
D) It is a sudden loss of small amounts of urine when coughing, laughing, or lifting.

Accepted Answer

Stress incontinence is characterized by the sudden loss of small amounts of urine during activities that increase abdominal pressure, such as coughing, laughing, or lifting, which can cause the bladder sphincter to fail momentarily.

Question 8

An older patient recovering from a stroke has been very depressed and noncompliant with the physical therapy regimen. Which nursing intervention is important to initiate to prevent immobility in this patient?
A) Force the patient to participate in the activity program.
B) Refer the patient to the facility social worker for counseling.
C) Walk the patient to the bathroom before and after meals and before bedtime.
D) Change the patient's activity program to activities that can be done in a wheelchair.

Accepted Answer

Walking the patient to the bathroom before and after meals and before bedtime encourages mobility and helps prevent complications associated with immobility, such as muscle atrophy and joint stiffness, while also being a manageable and routine activity.

Question 9

The nurse is concerned that an older patient is at risk for aspirating. What information did the nurse use to make this clinical determination? Select all that apply.
A) Prefers to eat alone
B) Poor appetite for breakfast
C) Difficulty swallowing liquids
D) Serum albumin level 2.8 g/dL
E) Frequent episodes of heartburn

Accepted Answer

Difficulty swallowing liquids (C) and frequent episodes of heartburn (E) are indicators of potential aspiration risk, as they suggest issues with swallowing and possible reflux, which can lead to aspiration.

Question 10

An older male patient is complaining of leaking urine and constipation. Which health problem is this patient most likely experiencing?
A) Diabetes
B) Heart failure
C) Alzheimer's disease
D) A fecal impaction, causing overflow incontinence

Accepted Answer

A fecal impaction can cause pressure on the bladder, leading to overflow incontinence, and can also cause constipation, matching the symptoms described.

Question 11

The nurse is asked how physical exercise affects the cardiovascular system. Which response should the nurse make?
A) Increases cardiac output
B) Decreases cardiac efficiency
C) Decreases cardiac response to activity
D) Maintains pulse rate in response to activity

Accepted Answer

Physical exercise increases cardiac output by enhancing the heart's efficiency and ability to pump blood throughout the body, which is crucial for improving overall cardiovascular health.

Question 12

The nurse is assessing an older patient. Which body system would contribute to an alteration in mobility in this patient? Select all that apply.
A) Sensory
B) Respiratory
C) Genitourinary
D) Cardiovascular
E) Musculoskeletal

Accepted Answer

The answer of The nurse is assessing an older patient....

Question 13

An older patient who is losing weight refuses to come to meals and when he does he cannot sit down long enough to eat. What should the nurse do to improve this patient's nutritional status?
A) Increase food choices.
B) Use body restraints for meals.
C) Call the physician for medication to alter his behavior.
D) Provide with sandwiches, small pieces of fruit and cheese, and spill-proof drink containers.

Accepted Answer

Providing the patient with easy-to-consume foods like sandwiches, small pieces of fruit and cheese, along with spill-proof drink containers, can help improve nutritional intake for someone who has difficulty sitting through meals. This approach is practical and respects the patient's autonomy and comfort.

Question 14

The mnemonic DRIP is used to help remember the possible causes of acute incontinence. According to this mnemonic, which is a least likely cause of acute incontinence?
A) Delirium
B) Infection
C) Renal stones
D) Pharmaceutical and psychological

Accepted Answer

Renal stones, while they can cause pain and discomfort, are less likely to cause acute incontinence compared to the other options. Delirium, infection, and certain pharmaceuticals or psychological factors can more directly impact bladder control.

Question 15

An older patient is sitting in a wheelchair for 3 hours. When changing position the nurse notes an area of redness over the coccyx. Which risk factor caused this patient's area of erythema?
A) Friction
B) Pressure
C) Shearing
D) Moisture

Accepted Answer

The area of redness over the coccyx in a patient who has been sitting in a wheelchair for an extended period is most likely caused by pressure. This is because prolonged pressure on the skin, especially over bony areas like the coccyx, can impair blood flow and lead to erythema or redness.

Quiz 16: Common Clinical Problems: Physiological

A newly admitted resident of a skilled facility has to void, however, a wheelchair and stretcher are blocking the entrance to the bathroom. Which type of incontinence is this patient most likely going to experience?

An older person who uses the bathroom three times a night is experiencing eye problems, extreme fatigue, weakness, unsteadiness, and depression. What should the nurse say in response to this patient's symptoms?

After an assessment the nurse determines that an older patient is at risk for falling. What assessment findings did the nurse use to make this clinical decision? Select all that apply.

The nurse notes that an older patient has a behavior change during the evening hours. What should the nurse suspect is occurring with this patient?

During the night an older patient fell, was incontinent of urine, and complained of not being able to get to the bathroom because the side rails on the bed were raised. What is the most appropriate nursing intervention to prevent this patient from falling again?

The nurse encourages an older patient to increase activity. Which potential respiratory problem is the nurse helping to prevent? Select all that apply.

The nurse is concerned that a patient is experiencing stress incontinence. What characteristic of this type of incontinence caused the nurse to make this decision?

An older patient recovering from a stroke has been very depressed and noncompliant with the physical therapy regimen. Which nursing intervention is important to initiate to prevent immobility in this patient?

The nurse is concerned that an older patient is at risk for aspirating. What information did the nurse use to make this clinical determination? Select all that apply.

An older male patient is complaining of leaking urine and constipation. Which health problem is this patient most likely experiencing?

The nurse is asked how physical exercise affects the cardiovascular system. Which response should the nurse make?

The nurse is assessing an older patient. Which body system would contribute to an alteration in mobility in this patient? Select all that apply.

An older patient who is losing weight refuses to come to meals and when he does he cannot sit down long enough to eat. What should the nurse do to improve this patient's nutritional status?

The mnemonic DRIP is used to help remember the possible causes of acute incontinence. According to this mnemonic, which is a least likely cause of acute incontinence?

An older patient is sitting in a wheelchair for 3 hours. When changing position the nurse notes an area of redness over the coccyx. Which risk factor caused this patient's area of erythema?