Deck 16: Common Clinical Problems: Physiological

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?
1) Urge
2) Stress
3) Overflow
4) Functional

Answer 1

4

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?
1) "As people get older, they need less sleep."
2) "You may be having symptoms of sleep deprivation."
3) "Depression usually changes a person's sleep patterns."
4) "Changes in sleep patterns are a normal aging change."

Answer 2

2

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.
1) Has sleep apnea
2) Is hard of hearing
3) Drinks caffeinated coffee
4) Has osteoarthritis in both hips
5) Takes acetaminophen for pain

Answer 3

1, 2, 4

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?
1) Dehydration
2) Relocation trauma
3) Sundown syndrome
4) Reaction to medications

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?
1) Initiate a toileting program.
2) Place a commode next to the bed.
3) Apply a soft waist restraint at night.
4) Put the side rails down during the night.

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.
1) Influenza
2) Atelectasis
3) Pneumonia
4) Tuberculosis
5) Chronic bronchitis

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?
1) The patient is male.
2) It is caused by a bladder obstruction.
3) It occurs most often in long-term care facilities.
4) It is a sudden loss of small amounts of urine when coughing, laughing, or lifting.

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?
1) Force the patient to participate in the activity program.
2) Refer the patient to the facility social worker for counseling.
3) Walk the patient to the bathroom before and after meals and before bedtime.
4) Change the patient's activity program to activities that can be done in a wheelchair.

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.
1) Prefers to eat alone
2) Poor appetite for breakfast
3) Difficulty swallowing liquids
4) Serum albumin level 2.8 g/dL
5) Frequent episodes of heartburn

Question 10

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

Question 11

The nurse is asked how physical exercise affects the cardiovascular system. Which response should the nurse make?
1) Increases cardiac output
2) Decreases cardiac efficiency
3) Decreases cardiac response to activity
4) Maintains pulse rate in response to activity

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.
1) Sensory
2) Respiratory
3) Genitourinary
4) Cardiovascular
5) Musculoskeletal

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?
1) Increase food choices.
2) Use body restraints for meals.
3) Call the physician for medication to alter his behavior.
4) Provide with sandwiches, small pieces of fruit and cheese, and spill-proof drink containers.

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?
1) Delirium
2) Infection
3) Renal stones
4) Pharmaceutical and psychological

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?
1) Friction
2) Pressure
3) Shearing
4) Moisture