1. Which patient is most likely to need long-term nursing care management?

a) 72-yr-old who had a hip replacement after a fall at home

b) 64-yr-old who developed sepsis after a ruptured peptic ulcer

c) 76-yr-old who had a cholecystectomy and bile duct drainage

d) 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

ANS: D

Osteoarthritis and obesity are chronic problems that will require planning for

long-term interventions such as physical therapy and nutrition counseling. The

other patients have acute problems that are not likely to require long-term

management.

2. An older adult being admitted is assessed at high risk for falls. Which action

should the nurse take first?

a) Use a bed alarm system on the patient’s bed.

b) Administer the prescribed PRN sedative medication.

c) Ask the health care provider to order a vest restraint.

d) Place the patient in a “geri-chair” near the nurse’s station.

ANS: A

The use of the least restrictive restraint alternative is required. Physical or

chemical restraints may be necessary, but the nurse’s first action should be an

alternative such as a bed alarm.

3. An older adult patient presents with a broken arm and visible scattered

bruises healing at different stages. Which action should the nurse take first?

a) Notify an elder protective services agency about possible abuse.

b) Make a referral for a home assessment visit by the home health nurse.

c) Have the family member stay in the waiting area while the patient is

assessed.

d) Ask the patient how the injury occurred and observe the family member’s

reaction.