Pearson Custom For Older Adult Nursing Care By Nancy J.Brown – Test Bank

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Brown Older Adult Nursing Care, 1/E
Chapter 5

Question 1

Type: MCSA

When assessing the integumentary system of an older adult, which of the following observed changes would the nurse consider abnormal?

1. Edema

2. Pale, cool skin

3. Loss of hair

4. Thick toenails

Correct Answer: 1

Rationale 1: Correct. Edema is not considered a normal sign of aging of the integumentary system.

Rationale 2: Pale, cool skin is an expected sign of aging due to thinning of the layers of the skin.

Rationale 3: Loss of hair is an expected sign of aging due to hair follicles becoming inactive.

Rationale 4: Thickening of toenails is an expected sign of aging.

Global Rationale: 

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: 

Learning Outcome: Describe the normal changes of aging in the integumentary system.

Question 2

Type: MCMA

The nurse manager is discussing the rationale for the susceptibility of the older adult client to skin breakdown with a group of nursing assistants. What reasons should the nurse manager include in the teaching? 

Standard Text: Select all that apply.

1. Increase in nerve endings

2. Thinning of layers of skin

3. Increased pain perception

4. Decrease in blood flow

5. Decrease in melanocytes

Correct Answer: 2,4

Rationale 1: Shortening, not increase, of nerve endings occurs with normal aging.

Rationale 2: Correct. Thinning of layers of skin makes the client more susceptible to the development of pressure ulcers because there is less padding at bony prominences.

Rationale 3: Because of the shortening of nerve endings, the older adult client is less, not more, sensitive to pain caused by pressure.

Rationale 4: Correct. Decrease in blood flow occurs.

Rationale 5: Decrease in melanocytes affects coloration of skin, not susceptibility to damage.

Global Rationale: 

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: 

Learning Outcome: Describe the normal changes of aging in the integumentary system.

Question 3

Type: Matching

Match the expected skin change found in an older adult client identified in the left column below with the correct description of the expected skin change found in the right column. 

A. Xerosis

B. Seborrheic keratosis

C. Senile lentigo

D. Actinic keratosis

E. Senile purpura

_____	1. Concentrated areas of melanocytes commonly found on the backs of the hands and on the face, arms, and legs
_____	2. Small, flat, scaly, red, yellow, or brown patch associated with years of sun exposure
_____	3. Dry and scaly skin
_____	4. Slightly elevated brown, gray, or yellow lesion
_____	5. A rashlike collection of bruises and petechiae

Correct Answer: A–3, B-4, C-1, D-2, E-5

Global Rationale: 

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: 

Learning Outcome: Describe the normal changes of aging in the integumentary system.

Question 4

Type: MCSA

To promote daily skin care for the older adult, the nurse would include which of the following suggestions in the teaching?

1. Daily bathing

2. Use of a sunscreen with at least 8 SPF (sun protection factor)

3. Limiting daily sun exposure from 10 AM to 3 PM only

4. Routine moisturizing of the skin

Correct Answer: 4

Rationale 1: Older adult skin tends to be drier, and daily bathing would dry it further. Bathing 2 to 3 times per week is recommended.

Rationale 2: It is recommended that the older adult use a sunscreen with at least 30 SPF.

Rationale 3: The time from 10 AM to 3 PM is the time of day when the sun’s ultraviolet rays are the most dangerous; it is the time the older adult needs to avoid the sun.

Rationale 4: Correct. An older adult’s skin tends to be drier, and regular moisturizing helps alleviate dryness.

Global Rationale: 

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: 

Learning Outcome: Discuss methods of health promotion for the integumentary system.

Question 5

Type: MCSA

An older adult client comes to a long-term care facility with a beginning pressure ulcer developing in the sacral area. Which of the following nursing interventions would be appropriate for tertiary preventive care for this client?

1. Daily inspection of the sacral area

2. Weekly moisturizing of the skin

3. Implementation of a turning schedule

4. Addition of vitamin D to the diet

Correct Answer: 3

Rationale 1: Although daily inspection of wound healing needs to occur, it does not constitute treatment for an existing condition.

Rationale 2: Daily, not weekly, moisturizing of the skin is recommended for care of older adult skin.

Rationale 3: Correct. Implementation of a turning schedule would be appropriate for both primary and tertiary prevention of pressure ulcers.

Rationale 4: Vitamin C and zinc are recommended for healing of wounds in the skin, but vitamin D is recommended to help prevent osteoporosis.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: 

Learning Outcome: Discuss methods of health promotion for the integumentary system.

Question 6

Type: MCSA

A nurse is assessing the feet of an older adult client, paying particular attention to evidence of which potential unexpected issue? 

1. Lunulae

2. Thickening of the toenails

3. Flattening of toenail beds

4. Toenail fungal infection

Correct Answer: 4

Rationale 1: Lunulae are an expected finding in an older adult.

Rationale 2: Thickening of toenails is an expected finding in an older adult.

Rationale 3: Flattening of toenail beds is an expected finding in an older adult.

Rationale 4: Older adults are more susceptible to development of fungal infections, but this would be an unexpected finding.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: 

Learning Outcome: Discuss methods of health promotion for the integumentary system.

Question 7

Type: MCSA

An older adult client presents to the emergency room with what is diagnosed by the physician as herpes zoster. Which of the following infection control precautions should the nurse implement in caring for this client?

1. Use of N-95 Respirator

2. No particular precautions

3. Wearing gloves with direct contact

4. Use of mask, gloves, shoe covers, and gown

Correct Answer: 3

Rationale 1: Guidelines indicate use of gloves with direct contact, but no other precautions are necessary.

Rationale 2: Guidelines indicate use of gloves with direct contact.

Rationale 3: Correct. Wearing gloves is the recommended isolation technique for herpes zoster.

Rationale 4: Guidelines indicate only use of gloves with direct contact.

Global Rationale: 

Cognitive Level: Applying

Client Need: Safe Effective Care Environment

Client Need Sub: Safety and Infection Control

Nursing/Integrated Concepts: 

Learning Outcome: Discuss common skin conditions that occur in older adults.

Question 8

Type: MCSA

An older adult client comes to a walk-in clinic complaining of pain coming from an open ulcer on the ventral aspect of the left foot. The client states that there is also intermittent pain in the left calf when walking. The nurse assesses the client’s left foot, which is a bluish-whitish color with a faint pedal pulse. The nurse suspects that the client is suffering from which of the following disorders?

1. Cellulitis of the left foot

2. An ischemic ulcer of the left foot

3. A pressure ulcer of the left foot

4. Basal cell carcinoma of the left foot

Correct Answer: 2

Rationale 1: The signs and symptoms of cellulitis include redness/edema of the affected area (usually the legs), along with possible blistering, streaking, and systemic signs; signs in this client indicate ischemic ulcer.

Rationale 2: Correct. The client is exhibiting signs of arterial insufficiency in the left foot, along with intermittent claudication. These, along with the blue-white color, are signs/symptoms of an arterial or ischemic ulcer.

Rationale 3: The signs and symptoms of a pressure ulcer are associated with immobility and would be determined by the stage; signs in this client indicate ischemic ulcer.

Rationale 4: The signs and symptoms of basal cell carcinoma involve the presence of a pearly papule found most commonly on the head, neck, or back of the hands; signs in this client indicate ischemic ulcer.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: 

Learning Outcome: Discuss common skin conditions that occur in older adults.

Question 9

Type: MCSA

The nurse manager is explaining the importance of good perineal care for older adult clients with diabetes to a group of nursing assistants. The nurse bases the teaching on the knowledge that these clients would be at high risk of developing which of the following integumentary system disorders?

1. Cellulitis

2. Psoriasis

3. Herpes zoster

4. Candida fungal Infection

Correct Answer: 4

Rationale 1: Clients with diabetes are prone to developing cellulitis, but good perineal care would not be associated with its prevention.

Rationale 2: Psoriasis is an autoimmune skin disorder found on knees, elbows, scalp, and buttocks and is not associated with diabetes.

Rationale 3: Herpes zoster is a red, papular rash caused by a virus, not diabetes.

Rationale 4: Correct. Candida fungal Infection is often found in the genital area; it grows best in a moist, high-sugar environment and so is more likely in clients with diabetes.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: 

Learning Outcome: Discuss common skin conditions that occur in older adults.

Question 10

Type: HOTSPOT

The nurse reads in an older adult client’s chart a description of a stage II pressure ulcer on the client’s skin. Place an “X” by the photo below which best depicts a stage II pressure ulcer. 

Standard Text: Click on the correct area on the image.

Correct Answer: 

Rationale : The lower right photo depicts a stage I pressure ulcer that shows intact skin with nonblanchable redness.

Global Rationale: 

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: 

Learning Outcome: Describe the appropriate assessment techniques for the skin.

Question 11

Type: MCSA

The nurse is palpating the edematous ankles of an older adult client. The nurse is able to depress the tissue to a depth of 6 mm. The nurse identifies this as what type of pitting edema on the client’s record?

1. 4+

2. 3+

3. 2+

4. 1+

Correct Answer: 2

Rationale 1: In 4+ pitting edema, the tissue can be depressed 8 mm deep.

Rationale 2: Correct. In 3+ pitting edema, the tissue can be depressed 6 mm deep.

Rationale 3: In 2+ pitting edema, the tissue can be depressed 4 mm deep.

Rationale 4: In 1+ pitting edema, the tissue can be depressed just a trace amount.

Global Rationale: 

Cognitive Level: Remembering

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: 

Learning Outcome: Describe the appropriate assessment techniques for the skin.

Question 12

Type: MCSA

The nurse is assessing the respiratory status of an African American client with a diagnosis of end-stage pulmonary fibrosis. In order to correctly assess for cyanosis in this client, the nurse would need to observe the color of what part of this client’s integumentary system?

1. Sclera of the eyes

2. Earlobes

3. Nail beds

4. Oral mucous membranes

Correct Answer: 4

Rationale 1: One would check for jaundice, not cyanosis, at the sclera of the eyes.

Rationale 2: The earlobes are a darker pigment in African American people, so they would not be the area to assess.

Rationale 3: Although nail beds are a typical place to check in lighter-skinned people, cyanosis may not be evident here due to darker pigment color of the skin and nails in African Americans.

Rationale 4: Correct. Oral mucous membranes are an appropriate area to assess for cyanosis, jaundice, and pallor in a darker-skinned client.

Global Rationale: 

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub: 

Nursing/Integrated Concepts: 

Learning Outcome: Describe the appropriate assessment techniques for the skin.

Question 13

Type: MCSA

The nurse in a long-term care facility is teaching a group of nursing assistants the proper interventions to use to promote skin integrity in older adult residents. Which information should the nurse include?

1. “Be sure to elevate the head of the bed at least 45 degrees when feeding the resident or providing oral care.”

2. “Massage all bony prominences during the resident’s bed bath in order to increase circulation to these areas.”

3. “Be certain that the resident’s bed, bedside chair, and wheelchair are free of wrinkles, crumbs, and any kind of debris.”

4. “Establish a turning schedule for each resident, making certain to turn each resident every four hours.”

Correct Answer: 3

Rationale 1: The head of the bed should be elevated no more than 30 degrees to prevent shearing injuries.

Rationale 2: Massaging bony prominences can increase the chance for skin breakdown.

Rationale 3: Correct. Wrinkles, crumbs, and debris in the client’s bed or chair can cause formation of a pressure ulcer.

Rationale 4: Older adult clients should be turned at least every two hours or less, depending on the fragility of the client and existence of any pressure ulcers.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: 

Learning Outcome: Use the nursing process to guide you in caring for a client with a skin disorder.

Question 14

Type: MCMA

The nurse formulates the following nursing diagnosis for an older adult client recovering from surgery: Risk for Disturbed Body Image related to altered physical appearance associated with surgery to remove large basal cell carcinoma of the face. Which of the following nursing interventions would be appropriate for the nurse to include for this diagnosis? 

Standard Text: Select all that apply.

1. Discuss client’s feelings about the surgery.

2. Do not allow the client to view the surgical site.

3. Manage all of the aspects of the surgical wound care.

4. Contact a social worker for referral to support groups.

5. Perform treatments in a matter-of-fact manner.

Correct Answer: 1,4,5

Rationale 1: Correct. Allowing the client to share feelings about the surgery will help the client comes to terms with the situation.

Rationale 2: Allowing, even encouraging, the client to view the site assists in the client’s self-acceptance.

Rationale 3: Clients should be encouraged to assist in their own wound care to help them gain some control of the situation.

Rationale 4: Correct. A support group provides empathy and encouragement for the client.

Rationale 5: Correct. Performing the care with a matter-of-fact manner facilitates a positive attitude in the client.

Global Rationale: 

Cognitive Level: Understanding

Client Need: Psychosocial Integrity

Client Need Sub: 

Nursing/Integrated Concepts: 

Learning Outcome: Use the nursing process to guide you in caring for a client with a skin disorder.

Question 15

Type: MCSA

The nurse consults a dietician for assistance in promoting wound healing in a client with a stage II pressure ulcer. Which of the following groups of nutrients would the nurse expect the dietician to suggest?

1. Calcium, vitamin D, and protein

2. Protein, vitamin C, and zinc

3. Zinc, calcium, and vitamin B

4. Vitamin B, protein, and calcium

Correct Answer: 2

Rationale 1: Protein aids in tissue repair, but calcium and vitamin D assist in strengthening of bone tissue.

Rationale 2: Correct. Protein, vitamin C, and zinc all aid in tissue repair.

Rationale 3: In this option, only zinc aids specifically in tissue repair.

Rationale 4: In this option, only protein specifically aids in tissue repair.

Global Rationale: 

Cognitive Level: Remembering

Client Need: Physiological Integrity

Client Need Sub: Basic Care and Comfort

Nursing/Integrated Concepts: 

Learning Outcome: Use the nursing process to guide you in caring for a client with a skin disorder.

Brown, Older Adult Nursing Care, 1/E Test Bank

Copyright 2013 by Pearson Education, Inc.