1.An older female client recently moved to an assisted living facility. The family explains to the registered nurse (RN) that the client is unmanageable and always confused, disoriented and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond?

A. Explain that she is in a new home called an assisted living community

B. Question the client about her perception of where she might be now.

C. Distract the client with a scenario that she is on an outing with her family.

D. Reassure the client not to worry because she will meet new friends.

A. Explain that she is in a new home called an assisted living community.

Rationale: Reality re-orientation (A) is the best response for a client who is confused because the response is consistent and true. (B, C, and D) do not provide the client with feedback that is reality based.

2.A new resident in an assisted living facility is an older client who is experiencing short-term memory loss and confusion. Which activity should the registered nurse (RN) schedule the client to do during the day?

A. Arts and crafts

B. Current events discussion group

C. Group sing-along

D. Daily exercise group

D. Daily exercise group

Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the client's stress to remember. (A), (C), and a current events discussion group (B) are thought-provoking activities that require attention to detail and short-term memory to participate in the group activity which may be stressful and frustrating to the resident who has difficulty remembering sequence of the details.

3. The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the registered nurse (RN) use to determine the client's pain?

A. Use the FACE pain scale

B. Ask the client to rate pain on a scale of 1 to 10

C. Observe for facial grimacing

D. Review documentation of recent eating habits

C. Observe for facial grimacing

Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a client who cannot communicate due to Alzheimer disease. (A) and (B) may not be understood by a client with end-stage Alzheimer's disease. (D) is not a helpful tool for pain assessment.

4.An older male client arrives at the clinic for an annual physical examination. While the nurse assesses the client, the client states that he is having intimacy problems with his wife. Which information should the nurse provide to elicit more information from the client?

A. Query client to clarify the client's idea of an intimacy problem.

B. Discuss benign prostatic hypertrophy (BPH) and ejaculation.

C. Explore the frequency that he experiences erectile dysfunction (ED)

D. Determine if the client's wife is young enough to get pregnant

A. Query client to clarify the client's idea of an intimacy problem.

Rationale: Clarification of the client's concern is needed to appropriately address the specific concern about intimacy issues (A). (B), (C), and (D) are details that the client should present, not the RN.

5.The registered nurse (RN) is caring for an older female client with a 20 year history of rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated with RA should the RN document?

A. Asymmetrical joint deformity

B. Small joint involvement in fingers

C. Crepitation or grating sensation in joints

D. Weight bearing joint involvement

B. Small joint involvement in fingers.

Rationale: Small joint involvement (B) is common in rheumatoid arthritis. (A), (C) and (D) are findings that different OA from RA.

6.The registered nurse (RN) is re-enforcing discharge instructions with the family of an older client who was recently admitted for an intestinal obstruction. Which statement indicates that the family understands the instructions?

A. Increase protein and carbohydrates in the daily diet

B. Limit activity to bed rest for the first week and increase mobility incrementally each week

C. Report abdominal distention, constipation or any other nausea and vomiting to the healthcare provider

D. Drink liquids 2 hours after meals instead of during meals

C. Report abdominal distention, constipation, or any nausea and vomiting to the healthcare provider.

Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed immediately. (A, B, and D) are not indicated for a client who has been discharged for intestinal obstruction