NR 509 week 1 Questions With Complete 100 % Verified Solutions, Exams of Nursing

Download NR 509 week 1 Questions With Complete 100 % Verified Solutions and more Exams Nursing in PDF only on Docsity! NR 509 week 1 Questions With Complete 100 % Verified Solutions After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be. A. Objective B. Reflective C. Subjective D. Introspective A. Objective A patient tells the nurse that he is very nervous, is nauseated and feels hot. These types of data would be A. Objective B. Reflective C. Subjective D. Introspective C. Subjective The patients record, laboratory studies, objective data, and subjective data combine to form the A. Data base B. Admitting data C. Financial Statement D. Discharge Summary A. Data base When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to A. Immediately notify the patients physician B. Document the sound exactly as it was heard. C. Validate the data by asking a coworker to listen to breath sounds D. Assess it again in 20 minutes to note whether the sound is still present C. Validate the data by asking a coworker to listen to breath sounds The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: A. Intuition B. A set of rules C. Articles in journals D. Advice from supervisors b. A set of rules. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: A. Intuition B. The nursing process C. Clinical knowledge D. Diagnostic reasoning A. Intuition The nurse is reviewing information about EBP. Which statement best reflects EBP? A. EBP relies on tradition for support of best practices B. EBP is simply the use of best practice techniques for the treatment of patients C. EBP emphasizes the use of best evidence with the clinicians experience D. The patients own preferences are not important with EBP. C. EBP emphasizes the use of best evidence with the clinicians experience The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first- level priority problem A. Patient with postoperative pain B. Newly diagnosed patient with diabetes who needs diabetic teaching When reviewing the concepts of health, the nurse recalls that the components of holistic health include which of these? A. Disease originates from the external environment B. The individual human is a closed system C. Nurses are responsible for a patients health state D. Holistic health views the mind, body, and spirit as interdependent D. Holistic health views the mind, body, and spirit as interdependent The nurse recognizes that the concept of prevention in describing health is essential because A. Disease can be prevented by treating the external environment B. The majority of deaths among Americans under age 65 years are not preventable C. Prevention places the emphasis on the link between health and personal behavior D. The means to prevention is through treatment provided by primary health care practitioners C. Prevention places the emphasis on the link between health and personal behavior The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the A. Patients history of allergies B. Patients use of medications at home C. Last menstrual period 1 month ago D. 2.5 cm scar on the right lower forearm D. 2.5 cm scar on the right lower forearm A visiting nurse is making an initial home visit for a patient who has many chronic health problems. Which type of data base is most appropriate to collect in this setting? A. A follow-up data base to evaluate changes at appropriate intervals B. An episodic data base because of the continuing, complex medical problems of this patient C. A complete health data base because of the nurses primary responsibility for monitoring the patients health D. An emergency data base because of the need to collect information and make accurate diagnoses rapidly C. A complete health data base because of the nurses primary responsibility for monitoring the patients health Which situation is most appropriate during which the nurse performs a focused or problem-centered history? A. Patient is admitted to a long-term care facility B. Patient has a sudden and severe shortness of breath C. Patient is admitted to the hospital for surgery the following day D. Patient in an outpatient clinic has cold and influenza-like symptoms D. Patient in an outpatient clinic has cold and influenza-like symptoms A patient is in the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: A. Collect a follow-up data base and then check her blood pressure B. Ask her to read her health record and indicate any changes since her last visit C. Check only her blood pressure because her complete health history was documented 2 months ago D. Obtain a complete health history before checking her blood pressure because much of her history information may have changed A. Collect a follow-up data base and then check her blood pressure A patient is brought by ambulance to the ED with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? A. Collect history information first, then perform a physical examination and institute life-saving measures B. Simultaneously ask history questions while performing the examination and initiating life-saving measures C. Collect all information on the history form, including social support patterns, strengths, and coping patterns D. Perform life-saving measures and delay asking any history questions until the patient is transferred to the ICU. B. Simultaneously ask history questions while performing the examination and initiating life-saving measures A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurses knowns that including cultural information in his health assessment is important to: A. Identify the cause of his illness B. Make accurate disease diagnoses C. Provide cultural health rights for the individual D. Provide culturally sensitive and appropriate care D. Provide culturally sensitive and appropriate care In the health promotion model, the focus of the health professional includes: A. Changing the patients perceptions of disease B. Identifying biomedical model interventions C. Identifying negative health acts of the consumer D. Helping the consumer choose a healthier lifestyle D. Helping the consumer choose a healthier lifestyle The nurse has implemented several planned interventions to address the nurses diagnosis of acute pain. Which would be the next appropriate action? A. Establish priorities B. Identify expected outcomes C. Evaluate the individuals condition, and compare actual outcomes with expected outcomes D. Interpret data, and then identify clusters of cues and make inferences C. Evaluate the individuals condition, and compare actual outcomes with expected outcomes Which statement best describes a proficient nurse? A proficient nurse is one who: A. Has little experience with a specified population and uses rules to guide performance B. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution C. Sees actions in the context of daily plans for patients D. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient D. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient A nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply A. Inspiratory wheezes noted in left lower lobe B. Hypoactive bowel sounds C. Nonproductive cough D. Edema +2 noted on the left hand E. Patient reports dyspnea upon exertion F. Rate of respirations 16 breaths per minute A, C, E, F Put the following situations in order according to the level of priority A. A patient newly diagnosed with type 2 DM does not know how to check his own blood glucose levels with a glucometer B. A teenager who was stung by a bee during soccer match is having trouble breathing C. An older adult with a urinary tract infection is also showing signs of confusion and agitation 1. First-level priority problem C. Mr. Y you mentioned that you have been hospitalized on several occasions. would you tell me more about that? D. Mr. Y, I just need to get some additional information about your past hospitalizations when was the last time you were admitted for chest pain D. Mr. Y, I just need to get some additional information about your past hospitalizations when was the last time you were admitted for chest pain In using verbal responses to assist the patient's narrative, some responses focus on the patients frame of reference and some focus on the health care providers perspective. An example of a verbal response that focuses on the health care providers perspective would be: A. Empathy B. Reflection C. Facilitation D. Confrontation D. Confrontation When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior? A. Be silent, and allow him to continue when he is ready B. Smile at him and say, don't worry about all of this. I'm sure we can find out why you are having these pains. C. Lean back in the chair and ask, you are looking at me kinda funny; There isn't anything wrong, is there? D. Stand up and say, I can see this interview is uncomfortable for you. We can continue it another time. A. Be silent, and allow him to continue when he is ready* A woman is discussing the problems she is having with her 2 year old son. She says, he won't go to sleep at night and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: A. Go on, I'm listening B. Fits? Tell me what you mean by this. C. Yes, it can be upsetting when a child has a fit. D. Don't be upset with me has a fit, every 2 year old has fits B. Fits? Tell me what you mean by this. A 17-year-old single mother is describing how difficult it is to raise a 3 year old child by herself. During the course of the interview she states, I can't believe my boyfriend has left me to do this by myself. What a terrible thing to do to me. Which of these responses by the nurse uses empathy? A. You feel alone. B. You can't believe he left you alone? C. It must be so hard to face this all alone. D. I would be angry too, raising a child alone is no picnic C. It must be so hard to face this all alone.* A man has been admitted to the Observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: A. Mr. K. I know that you are lying B. Mr. K, come on, tell me how much you smoke C. Mr. K, I did not realize your wife had died. It must be difficult for you at this time. Please tell me more about that. D. Mr. K, you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket. D. Mr. K, you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket. The nurse has used interpretation regarding a patient statement or actions. after using this technique, it would be best for the nurse to: A. Apologize, because using interpretation can be demeaning for the patient B. Allow time for the patient to confirm or correct the inference C. Continue with the interview as though nothing has happened D. Immediately restate the nurse's conclusion on the basis of the patients nonverbal response B. Allow time for the patient to confirm or correct the inference During an interview, a woman says, I have decided that I can no longer allow my children to live with their father's violence. But I just can't seem to leave him. Using interpretation, the nurses best response would be A. Are you going to leave him? B. If you are a frayed for your children, then why can't you leave? C. It sounds as if you might be afraid of how your husband will respond. D. It sounds as though you have made your decision. I think it is a good one. C. It sounds as if you might be afraid of how your husband will respond. A pregnant woman states, I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, oh don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was : A. Therapeutic response. By sharing something personal, the nurse gives hope to this woman B. Non-therapeutic response. By Providing false reassurance, the nurse actually cut off further discussion of the woman's fears C. Therapeutic response. By providing information about medications available, the nurse is giving information to the woman. D. Non therapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication. B. Non-therapeutic response. By Providing false reassurance, the nurse actually cut off further discussion of the woman's fear During a visit to the clinic, patient states, the doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I have tried. I just don't know the best way to do it. What should I do? The nurse is most appropriate response in this case would be : A. I'd quit if I were you. The doctor really knows what he is talking about B. Would you like some information about the different ways a person can quit smoking? C. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. D. Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer? B. Would you like some information about the different ways a person can quit smoking? As the nurse enters a patient's room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, I'm so afraid, um, you know. The nurse is most therapeutic response would be to say in a gentle manner: A. You are afraid you might lose your breast? B. No, I'm not sure what you are talking about. C. I'll wait here until you get yourself under control, and then we can talk. D. I can see that you are very upset. Perhaps we should discuss this later period A. You are afraid you might lose your breast? A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, you don't smoke, drink, or take drugs, do you? This question is an example of: A. Talking too much B. Using confrontation C. Using biased or leading questions D. Using blunt language to deal with distasteful topics A female nurse is interviewing a man who has recently immigrated. During the course of the interview he leaned forward and then finally moves his chair close enough that his knees are nearly touching the nurse's knees. The nurse begins to feel uncomfortable with his proximity. Which statement most closely reflects what the nurse should do next A. The nurse should try to relax, these behaviors are culturally appropriate for this person B. Cleaner should discretely move his or her chair back until the distance is more comfortable and then continue with the interview C. These behaviors are indicative of sexual aggression, and the nurse should confront this person about his behaviors D. The nurse should laugh but tell him that he or she is uncomfortable with his proximity and ask him to move away A. The nurse should try to relax, these behaviors are culturally appropriate for this person A female American Indian has come to the clinic for follow up diabetic teaching. During the interview, the nurse notices that she never makes eye contact and speaks mostly to the floor. which statement is true regarding the situation? A. The woman is nervous and embarrassed B. She has something to hide and is ashamed C. The woman is showing inconsistent verbal and nonverbal behaviors D. She is showing that she is carefully listening to what the nurse is saying D. She is showing that she is carefully listening to what the nurse is saying The nurse is performing a health interview on a patient who has a language barrier, and no interpreter is available. Which is the best example of an appropriate question for the nurse to ask in this situation? A. Do you take medicine B. Do you sterilize the bottles? C. Do you have nausea and vomiting? D. You have been taking your medicine, haven't you? A. do you take medicine? A man arrives at the clinic for his annual wellness physical. He is experiencing no acute health problems. Which question or statement by the nurse is most appropriate when beginning the interview? A. How is your family? B. How is your job? C. Tell me about your hypertension. D. How has your health been since your last visit? D. How has your health been since your last visit? The nurse makes this comment to a patient, I know it may be hard, but you should do what the doctor ordered because she is the expert in this field. Which statement is correct about the nurses comment? A. This comment is inappropriate because it shows the nurses blame him B. This comment is appropriate because members of the health care team are experts in their area of patient care C. This type of comments promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation D. Using authority statements when dealing with patients, especially when they are undecided about an issue comment is Necessary at times C. This type of comments promotes dependency and inferiority on the part of the patient and is best avoided in an interview situation A female patient does not speak English well, and the nurse needs to choose an interpreter. Which of the following would be the most appropriate choice? A. Trained interpreter B. Male family member C. Female family member D. Volunteer college student from the foreign language studies Department A. Trained interpreter During a follow up visit, the nurse discovers that a patient has not been taking his insulin on a regular basis. The nurse asked, why haven't you taken your insulin? Which statement is an appropriate evaluation of this question? A. this question may place the patient on the defensive B. this question is an innocent search for Information C. discussing his behavior with his wife would have been better D. A direct question is the best way to discover the reasons for his behavior A. this question may place the patient on the defensive The nurse is nearing the end of an interview. Which statement is appropriate at this time? A. Did we forget something? B. Is there anything else you would like to mention? C. I need to go on to the next patient. I'll be back D. While I'm here, let's talk about your upcoming surgery. B. Is there anything else you would like to mention? During the interview portion of data collection, the nurse collects the ______ data. A. Physical B. Historical C. Objective D. Subjective D. Subjective During an interview, the nurse would expect that most of the interview will take place at what distance? A. Intimate zone B. Personal distance C. Social distance D. Public distance C. Social distance A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overly sexual comment. The nurses best reaction would be A. Stop that immediately! B. Oh, you are too funny. let's keep going with the interview. C. Do you really think I would be interested? D. It makes me uncomfortable when you talk that way. please stop. D. It makes me uncomfortable when you talk that way. please stop. The nurse is conducting an interview. Which of these statements is true regarding open ended questions? Select all that apply. A. Open ended questions elicit cold facts B. They allow for self-expression C. Open ended questions build an enhance rapport D. They leave interactions neutral E. Open ended questions call for short 1-2 word answers F. They are used when narrative information is needed Answer B, C, F When assessing the quality of a patient's pain, the nurse should ask which question? A. When did the pain start? B. Is the pain a stabbing pain? C. Is it a sharp pain or a dull pain? D. What does your pain feel like? D. What does your pain feel like? With assessing a patient's pain, the nurse knows that an example of visceral pain would be; A. Hip fracture B. Cholecystitis C. Second-degree burns D. Pain after a leg amputation B. Cholecystitis The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? A. Perception B. Modulation C. Transduction D. Transmission A. Perception* When assessing the intensity of a patient's pain, which question by the nurse is appropriate? A. What makes your pain better or worse? B. How much pain do you have now? C. How does pain limit your activities? D. What does your pain feel like? B. How much pain do you have now? A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? A. Completing the physical examination first and then giving pain medication B. Telling the patient that the pain medication must wait until after the x-ray images are completed C. Evaluating the full range of motion of the knee and then medicating for pain D. Administering pain medication and then proceeding with the assessment. D. Administering pain medication and then proceeding with the assessment. The nurse knows that which statement is true regarding the pain experienced by infants? A. Pain in infants can only be assessed by physiologic changes, such as increased heart rate B. THE FPS-R can be used to assess pain in infants C. A procedure that induces pain in adults will also induce pain in the infant D. Infants feel pain less than do adults C. A procedure that induces pain in adults will also induce pain in the infant A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as A. Referred B. Cutaneous C. Visceral D. Deep somatic D. Deep somatic During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? A. Sleeping B. Moaning C. Diaphoresis D. Bracing E. Restlessness F. Rubbing Ans A, D, F During an admission assessment of patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply A. Ask the patient, do you have pain? B. Assess the patients breathing independent of vocalization C. Note whether the patient is calling out, groaning or crying D. Have the pain rate pain on a 1-10 scale. E. Observe the patients body language for pacing and agitation Ans B,C,E An 85 year old man has come in for a physical examination, in the nurse notices that he uses a cane. when documenting general appearance, the nurse should document this information under the section that covers: A. Posture B. Mobility C. Mood and affect D. Physical deformity B. Mobility The nurse is performing a vision examination. Which of these charts is most widely used for vision examinations? A. Snellen B. Sheltlen C. Smoollen D. Schwellon A. Snellen After the health history has been obtained and before beginning the physical examination, the nurse should first ask the patient to: A. Empty the bladder B. Completely disrobe C. lie on the exam table D. Walk around the room A. Empty the bladder During a complete health assessment, how would the nurse test the patient's hearing? A. Observing how the patient participates in normal conversation B. Using the whispered voice test C. Using the Weber and Rinne tests D. Testing with an audiometer B. Using the whispered voice test A patient states, whenever I open my mouth real wide, I feel this popping sensation in front of my ears. To further examine this, the nurse would; A. Place the stethoscope over the temporomandibular joint and listen for bruits B. Place the hands over his ears, and ask him to open his mouth really wide C. Palpation of the mouth and tongue The nurse should use which location for eliciting deep tendon reflexes? A. Achilles B. Femoral C. Scapular D. Abdominal A. Achilles During an inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicated which cranial nerve is intact? A. VII B. IX C. XI D. XII A. VII During inspection of the posterior chest, the nurse should assess for: A. Symmetric expansion B. Symmetry of shoulders and muscles C. Tactile fremitus D. Diaphragmatic excursion B. Symmetry of shoulders and muscles During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: A. Vertigo B. Tinnitus C. Syncope D. Dizziness A. Vertigo A patient tells the nurse, sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath. When documenting this information, the nurse would note A. Orthopnea B. Acute emphysema C. Paroxysmal nocturnal dyspnea D. Acute shortness of breath episode C. Paroxysmal nocturnal dyspnea During an examination of a patient, the nurse notices that she has several small, flat macules on the posterior portion of her thorax. The macules are less than 1 cm wide. Another name for these macules is A. Warts B. Bullae C. Freckles D. Papules C. Freckles During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: A. Lymphedema B. Raynaud disease C. Chronic arterial insufficiency D. Chronic venous insufficiency C. Chronic arterial insufficiency The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of; A. Lymphedema B. Raynaud Disease C. Chronic arterial insufficiency D. Chronic venous insufficiency D. Chronic venous insufficiency The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: A. Lymphedema B. Raynaud disease C. Arterial insufficiency D. Venous insufficiency C. Arterial insufficiency The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This test is used to confirm A. Inflamed liver B. Perforated spleen C. Perforated appendix D. Enlarged gallbladder C. Perforated appendix The nurse will measure a patient's near vision with which tool? A. Snellen eye chart with letters B. Snellen E chart C. Jaeger card D. Ophthalmoscope C. Jaeger card If the nurse records the results to the Hirschberg test, the nurse has: A. Tested the patellar reflex B. Assessed for appendicitis C. Tested the corneal light reflex D. Assessed for thrombophlebitis C. Tested the corneal light reflex During the examination of the patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as: A. Cheilosis B. Leukoplakia C. Ankyloglossia D. Torus palatinus D. Torus palatinus During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: A. Stereognosis B. Astereognosis C. Hypoactive bowel sounds D. Hyperactive bowel sounds D. Hyperactive bowel sounds Which of these is most appropriate to perform on a 9 month old infant at a well child checkup? A. Testing for the Ortolani sign B. Assessment for stereognosis C. Blood pressure measurement D. Assessment for the presence of the startle reflex A. Testing for the Ortolani sign The nurse is assessing an older adult's functional ability. which definition correctly describes one's functional abilities? Functional ability: A. Is the measure of the expected changes of aging that one is experiencing? B. Refers to the individual's motivation to live independently C. Refers to the level of cognition present in the older person D. Refers to one's ability to perform activities necessary to live in modern society D. Refers to one's ability to perform activities necessary to live in modern society The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: A. Observe the patient's ability to perform the tasks B. Ask the patients wife how he does when performing tasks C. Review the medical record for information on the patient's abilities D. Ask the patients physician for information on the patient's abilities A. Observe the patient's ability to perform the tasks The nurse needs to assess a patient's ability to perform ADLs and should choose which tool for this assessment? A. Direct assessment of functional abilities (DAFA) B. Lawton Instrumental Activities of Daily Living (IADL) scale C. Barthel Index D. Older American Resources and Services Multidimensional Functional Assessment Questionnaire IADL (OMFAQ- IADL) A. Direct assessment of functional abilities (DAFA) The nurse is preparing to use the Lawton IADL Instrument as part of an assessment. Which statement about the Lawton IADL assessment is true? A. The nurse uses direct observation to implement this tool B. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability C. This instrument is not useful in the acute hospital setting D. This tool is best used for those residing in an institutional setting B. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include: A. Recreational activities B. Meal preparation C. Balancing the checkbook D. Self-grooming activities A. Recreational activities When using the various instruments to assess and older persons ADLs, the nurse needs to remember that a disadvantage of these instruments includes: A. Reliability of the tools B. Self or proxy reporting of functional activities C. Lack of confidentiality during the assessment D. Insufficient details concerning the deficiencies identified B. Self or proxy reporting of functional activities A patient will be ready to be discharged from the hospital soon and the patient's family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this? A. Get Up and Go Test B. Performance ADLs C. Physical Performance Test D. Tinetti Gait and Balance Evaluation A. Get Up and Go Test The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? A. Local senior center B. Patients Medicare check C. Meals on Wheels meal delivery service D. Patients neighbor, who visits with her daily D. Patients neighbor, who visits with her daily An 85-year-old man has been hospitalized after a fall at home, and his 86 year old wife is at his bedside. She told the nurse that she is his primary care giver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: A. Depression B. Weight gain C. Hypertension D. Social phobias A. Depression During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? A. Geriatric Depression Scale, short form B. Rapid Disability Rating Scale-2 C. Mini-Cog D. Get Up and Go Test C. Mini-Cog An older patient has been admitted to the intensive care unit after falling at home. Within 8 hours, his condition has stabilized, and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? A. Lawton IADL instrument B. Hospital Admission Risk Profile (HARP) C. Mini-Cog D. NEECHAM Confusion Scale B. Hospital Admission Risk Profile (HARP) During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding Common environmental hazards? A. Please slow toilet seats are safe because they are nearer to the ground in case of falls. B. Do you have a relative or friend who can help install grab bars in your shower?