Question 1

Incontinence in older adults,which is related to the inability to get to the bathroom in time,is classified as:

Accepted Answer

A)  Stress incontinence 
B)  Urge incontinence 
C)  Functional incontinence 
D)  Sporadic incontinence 
A)  Stress incontinence 
B)  Urge incontinence 
C)  Functional incontinence 
D)  Sporadic incontinence

Question 2

A nurse caring for a patient who has been prescribed bedrest for 1 week notices a reddened area on the patient's left hip.The skin is intact but,when the nurse presses on the area,the redness does not fade.The nurse recognizes this pressure ulcer as:

Accepted Answer

A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV 
A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV

Question 3

When preparing a plan care for an older adult patient,the nurse should consider the common problems associated with immobility.These problems may be classified as:

Accepted Answer

A)  Environmental and intellectual 
B)  Internal and external 
C)  Mental and medical 
D)  Physical and psychosocial 
A)  Environmental and intellectual 
B)  Internal and external 
C)  Mental and medical 
D)  Physical and psychosocial

Question 4

To prevent respiratory complications resulting from immobility,the best nursing interventions would be to:

Accepted Answer

A)  Suction every 4 to 6 hours. 
B)  Administer pain medications as frequently as possible. 
C)  Teach the patient the technique of pursed lip breathing. 
D)  Reposition the patient, and encourage him or her to cough and deep-breathe at least every 2 hours. 
A)  Suction every 4 to 6 hours. 
B)  Administer pain medications as frequently as possible. 
C)  Teach the patient the technique of pursed lip breathing. 
D)  Reposition the patient, and encourage him or her to cough and deep-breathe at least every 2 hours.

Question 5

During the shift report,the nurse is told that the patient she will be caring for has a stage II pressure ulcer.During the dressing change,the nurse would expect to see a(n):

Accepted Answer

A)  Ulcer that appears black with possible signs of infection 
B)  Shallow ulcer that appears blistered, cracked, or abraded 
C)  Craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base 
D)  Redness of skin with no ulceration 
A)  Ulcer that appears black with possible signs of infection 
B)  Shallow ulcer that appears blistered, cracked, or abraded 
C)  Craterlike sore with a distinct outer margin formed as the epidermis thickens and rolls over the edge toward the ulcer base 
D)  Redness of skin with no ulceration

Question 6

The patient complains that his "bottom" is sore.The nurse assesses the area and finds an open area on the sacrum that appears blistered.The nurse should:

Accepted Answer

A)  Document the cause of the burn. 
B)  Clean with alcohol, apply moisturizer, and cover with a set dressing. 
C)  Massage the area to promote circulation. 
D)  Clean with mild soap, dry, and apply a light dressing. 
A)  Document the cause of the burn. 
B)  Clean with alcohol, apply moisturizer, and cover with a set dressing. 
C)  Massage the area to promote circulation. 
D)  Clean with mild soap, dry, and apply a light dressing.

Question 7

The nurse is talking with a patient who recently became paraplegic as a result of a cervical spinal cord injury.When some home equipment is discussed,the patient becomes angry and says,"I don't need to worry about any kind of home equipment." The best response by the nurse would be:

Accepted Answer

A)  "I know you will be walking soon, but you may need some equipment until then." 
B)  "There is very little chance that you will ever walk." 
C)  "Tell me what it is about this equipment that bothers you." 
D)  "Let me call the physician to come explain your injuries to you." 
A)  "I know you will be walking soon, but you may need some equipment until then." 
B)  "There is very little chance that you will ever walk." 
C)  "Tell me what it is about this equipment that bothers you." 
D)  "Let me call the physician to come explain your injuries to you."

Question 8

The nurse evaluates the effectiveness of the treatment for a stage III pressure ulcer as satisfactory when the bed of the ulcer is pink,indicating the presence of _________________________,which is an indicator of tissue perfusion.

Accepted Answer

Granulation tissue
The appeara

Question 9

The nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer.The nurse understands that the purpose of this type of dressing is to:

Accepted Answer

A)  Keep the wound moist. 
B)  Prevent infection. 
C)  Débride necrotic tissue. 
D)  Increase circulation to the tissue. 
A)  Keep the wound moist. 
B)  Prevent infection. 
C)  Débride necrotic tissue. 
D)  Increase circulation to the tissue.

Question 10

When positioning an immobile patient,the nurse should:

Accepted Answer

A)  Ensure that the patient's knees and hips are flexed. 
B)  Visualize how a person looks while standing, and try to have the patient achieve that position while lying down. 
C)  Reposition the patient no more often than every 4 hours. 
D)  Always position the patient on his or her back with the head raised to prevent aspiration. 
A)  Ensure that the patient's knees and hips are flexed. 
B)  Visualize how a person looks while standing, and try to have the patient achieve that position while lying down. 
C)  Reposition the patient no more often than every 4 hours. 
D)  Always position the patient on his or her back with the head raised to prevent aspiration.

Question 11

The home health nurse instructs a family about boosting the patient in bed so that a ____________________ type of skin injury will not occur.

Accepted Answer

Shearing force
Shearing force

Question 12

During the skin integrity assessment,the nurse notices an area on the right heel that is black and draining purulent,foul-smelling exudate.The nurse should document this as a pressure ulcer in:

Accepted Answer

A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV 
A)  Stage I 
B)  Stage II 
C)  Stage III 
D)  Stage IV

Question 13

The most effective intervention to prevent constipation in a patient who recently suffered a fractured femur and is currently in traction is to:

Accepted Answer

A)  Get the patient up and to the bathroom at least twice each day. 
B)  Administer enemas each day until the patient has a bowel movement. 
C)  Administer pain medication to prevent pain during defecation. 
D)  Encourage a high-fiber diet and increased amounts of fluids. 
A)  Get the patient up and to the bathroom at least twice each day. 
B)  Administer enemas each day until the patient has a bowel movement. 
C)  Administer pain medication to prevent pain during defecation. 
D)  Encourage a high-fiber diet and increased amounts of fluids.

Exam 21: Immobility

Incontinence in older adults,which is related to the inability to get to the bathroom in time,is classified as:

A nurse caring for a patient who has been prescribed bedrest for 1 week notices a reddened area on the patient's left hip.The skin is intact but,when the nurse presses on the area,the redness does not fade.The nurse recognizes this pressure ulcer as:

When preparing a plan care for an older adult patient,the nurse should consider the common problems associated with immobility.These problems may be classified as:

To prevent respiratory complications resulting from immobility,the best nursing interventions would be to:

During the shift report,the nurse is told that the patient she will be caring for has a stage II pressure ulcer.During the dressing change,the nurse would expect to see a(n):

The patient complains that his "bottom" is sore.The nurse assesses the area and finds an open area on the sacrum that appears blistered.The nurse should:

The nurse is talking with a patient who recently became paraplegic as a result of a cervical spinal cord injury.When some home equipment is discussed,the patient becomes angry and says,"I don't need to worry about any kind of home equipment." The best response by the nurse would be:

The nurse evaluates the effectiveness of the treatment for a stage III pressure ulcer as satisfactory when the bed of the ulcer is pink,indicating the presence of _________________________,which is an indicator of tissue perfusion.

The nurse is performing a wet-to-dry dressing change on a stage IV pressure ulcer.The nurse understands that the purpose of this type of dressing is to:

When positioning an immobile patient,the nurse should:

The home health nurse instructs a family about boosting the patient in bed so that a ____________________ type of skin injury will not occur.

During the skin integrity assessment,the nurse notices an area on the right heel that is black and draining purulent,foul-smelling exudate.The nurse should document this as a pressure ulcer in:

The most effective intervention to prevent constipation in a patient who recently suffered a fractured femur and is currently in traction is to:

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