Questions → Task Question

Rationale
Answer A: Incorrect - related to urge incontinence.
Answer B: Incorrect - related to total incontinence
Answer C: Incorrect - related to reflex incontinence
Answer D: Correct - stress incontinence is an immediate involuntary loss of urine during
an increase in intra-abdominal pressure. It is due to weak pelvic muscles.
Question
The nurse cares for the client diagnosed with stress incontinence. The nurse identifies
which finding as a major contributing factor to stress incontinence?
A.
Decreased bladder capacity.
B.
Cognitive impairment.
C.
Spinal cord dysfunction.
RIGHT
D.
Weak pelvic muscles.
Questions → Task Question
Rationale
Answer A: Incorrect - occurs when an individual is experiencing or at risk for
deterioration of body systems or altered functioning as a result of prescribed or
unavoidable musculoskeletal inactivity
Answer B: Incorrect - state in which an individual experiences or is at risk for
experiencing dehydration; does not result in fluid deficiency
Answer C: Correct - urine is acidic, irritating to the skin unless removed immediately
Answer D: Incorrect - sufficient knowledge may or may not promote continence
Question
The nurse identifies which nursing diagnosis as appropriate for the client with stress
incontinence?
A.
Disuse syndrome.
B.
Deficient fluid volume.
RIGHT
C.
Impaired skin integrity.
D.
Deficient knowledge.
Questions → Task Question
Rationale
Answer A: Incorrect - older adults often reduce alcohol intake due to concerns with drug
interactions; nurse should be aware of the possibility of dependence on alcohol
Answer B: Incorrect - dysphagia is not a normal process of aging, therefore older adults
should have no more difficulty swallowing than younger persons
Answer C: Correct - risk of potential accumulation of a drug in the body increases
because of decreased liver function and excretion that occurs with aging
Answer D: Incorrect - while it may take older adults longer to process information, they
are generally motivated to follow doctor's prescriptions to remain healthy
Question
The home care nurse makes home visits to the clients living in an assisted care facility.
The nurse identifies which issue is a major concern when administering drugs to older
adults?
A.
Alcohol is often used to cope with the multiple problems of
aging.
B.
Older adults experience an increased difficulty swallowing
tablets.
RIGHT
C.
Risk of overdose is higher due to decreased hepatic
clearance.
D.
Older adults are less motivated to follow the prescribed
regimen.
Questions → Task Question
Rationale
Answer A: Correct - decline in vision, hearing, and tactile sensation, and a slower
response time have the greatest impact on the older adult's ability to maintain safety
Answer B: Incorrect - there is a decline in the respiratory system, but it does not pose a
great threat to the client's safety
Answer C: Incorrect - decline in the cardiovascular system can contribute to decreased
physical activity, endurance, balance, and orthostatic hypertension; changes in the
sensory system have a greater effect on safety
Answer D: Incorrect - does not pose a safety threat
Question
The nurse recognizes the decline of which system most often influences an older adult's
ability to maintain safety?

RIGHT
A.
Sensory.
B.
Respiratory.
C.
Cardiovascular.
D.
Integumentary.
O.S. has a significant Risk for Falls based on multiple criteria. She has visual and
hearing impairments, ambulates with a walker or wheelchair, and reports generalized
weakness. She also has impaired standing due to joint as evidenced by her reports of
stiff joints, use of a walker, and difficulty walking. Malnutrition is a concern, but there is
no indication that this is causing significant health complications at this point. This client
monitors her diet and fluid intake closely, however, she has a reported 10 pound (4.5
kg) weight loss over the past 6 months, so she is at risk for a nutrition imbalance. Social
interaction and processes must be recognized as a concern as she has recently lost her
sister (who was her lifelong companion) and may not be able to cope effectively with the
social void caused by her sister's death. In this case, the nursing diagnosis Impaired
Social Interaction is warranted. On the whole, the client's signs and symptoms support
the diagnosis of Frail Elderly Syndrome, as evidenced by her mobility problems, age,
activity intolerance, and nutrition imbalance.
Client Content V. 3

Nursing Diagnosis Scoring Explanation:

Your Selecting Diagnoses (Dx) score reflects the number of correct Nursing Diagnoses
you selected, compared to the number of criteria nursing diagnoses designated by the
case author. It is expressed both in raw numbers and as a percentage.
Your Selecting Confirming Items score reflects the number of correct data items that
you selected to help support or confirm each CORRECT nursing diagnosis. Confirming
items may also have equivalents for which you may be credited if you do not select the
primary confirming item. Your Selecting Confirming Items score is expressed both in
raw numbers and as a percentage.
Your Questions score reflects the number of questions that you got correct, compared
to the total number of questions in this section. It is expressed both in raw numbers and
as a percentage.
Your Module Total reflects your total score for Selecting Diagnoses, Confirming
Data and Questions. It is expressed both in raw numbers and as a percentage.
Omitted Selections are criteria identified by the case author that you omitted. Non-
Criteria Selections are incorrect items that you selected, or they are duplicates to criteria
items.
 Social Interaction, Impaired

Equivalents:

 Social Interaction, Impaired

 Correct Selections (1)

 Non-criteria Selections (0)

 All Selections (1)

 Omitted Selections (1)

RIGHT
Initial Assessment → Psychosocial → Client is Feeling: → Sad

 Sad — Sister, Dorothy, died 17 days ago after being in adjoining long term care
facility. Patient and sister had lived together all of their lives. "I miss Dorothy a lot. It's
bad, but at least she is no longer suffering. It was really hard watching her this last
year."
Equivalents:

Initial Assessment → Psychosocial → Recent Stress:

Sister died 17 days ago, moved from home one year ago to place sister in long term
care. Hospitalized night of funeral with pneumonia

RIGHT

Mobility, Impaired: Physical

Equivalents:

 Mobility, Impaired: Physical

 Correct Selections (2)

 Non-criteria Selections (0)

 All Selections (2)

 Omitted Selections (1)

RIGHT
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → Impaired Mobility

 Impaired Mobility

RIGHT
Initial Assessment → Musculoskeletal → Balance/Gait: → Unsteady
  Unsteady — very unsteady without walker
Equivalents:

Physical Assessment → Maneuvers → Gait & Station

The patient stands by holding onto walker. Kyphosis is noted. When walking, patient
moves walker approximately 6 inches (15 cm), moves right leg forward and then left leg.
The patient bears weight on arms bilaterally. Stance is approximately shoulder width.
Frail Elderly Syndrome

Equivalents:

 Frail Elderly Syndrome

 Omitted Selections (3)
Initial Assessment → Nutritional → Usual Food Intake:
"I watch my diet very closely. I have cereal for breakfast and one cup of coffee. For
lunch I normally have some soup. For dinner I eat with the other residents. I don't like
meat much, but I eat a lot of fruits and vegetables. My doctor told me to watch my
cholesterol."
Equivalents:

Initial Assessment → Nutritional → Usual Food Intake:

"I watch my diet very closely. I have cereal for breakfast and one cup of coffee. For
lunch I normally have some soup. For dinner I eat with the other residents. I don't like
meat much, but I eat a lot of fruits and vegetables. My doctor told me to watch my
cholesterol."
Initial Assessment → Musculoskeletal → Balance/Gait: → Unsteady

 Unsteady — very unsteady without walker

Equivalents:

Initial Assessment → Musculoskeletal → Symptoms: → Weakness

 Weakness — uses walker

Initial Assessment → Musculoskeletal → Activity Devices: → Walker

 Walker — whenever up
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → General Weakness

 General Weakness
Physical Assessment → Maneuvers → Gait & Station
The patient stands by holding onto walker. Kyphosis is noted. When walking, patient
moves walker approximately 6 inches (15 cm), moves right leg forward and then left leg.
The patient bears weight on arms bilaterally. Stance is approximately shoulder width.
Initial Assessment → Psychosocial → Client is Feeling: → Sad
  Sad — Sister, Dorothy, died 17 days ago after being in adjoining long term care
facility. Patient and sister had lived together all of their lives. "I miss Dorothy a lot. It's
bad, but at least she is no longer suffering. It was really hard watching her this last
year."
Equivalents:

Initial Assessment → Psychosocial → Recent Stress:

Sister died 17 days ago, moved from home one year ago to place sister in long term
care. Hospitalized night of funeral with pneumonia
Nutrition, Imbalanced: Less Than Body Requirements

Equivalents:

 Nutrition, Imbalanced: Less Than Body Requirements

 Omitted Selections (3)
Physical Assessment → Vital Signs → Height & Weight
Height: 62 inches (157.5 cm); Weight: 100 lbs. (45.4 kg); BMI=18.3
Equivalents:

Physical Assessment → Observations → Height & Weight

Height: 62 inches (157.5 cm); Weight: 100 lbs. (45.4 kg); BMI=18.3
Initial Assessment → Nutritional → Usual Food Intake:
"I watch my diet very closely. I have cereal for breakfast and one cup of coffee. For
lunch I normally have some soup. For dinner I eat with the other residents. I don't like
meat much, but I eat a lot of fruits and vegetables. My doctor told me to watch my
cholesterol."
Initial Assessment → Nutritional → Weight Loss Last 6 Mo.:
10 pounds (4.5 kg)
Equivalents:

Initial Assessment → Nutritional → Usual Fluid Intake:

"I don't drink much. It just makes me go to the bathroom more. I have my coffee with
breakfast and a glass of water with meals."
Falls, Risk for

Equivalents:

 Falls, Risk for

 Omitted Selections (5)
Initial Assessment → Neurological → Symptoms → Sight

 Sight — Wears glasses

Equivalents:

Initial Assessment → Admission Data → Assistive Devices: → Glasses

  Glasses
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → Impaired Senses (i.e. Vision)

 Impaired Senses (i.e. Vision)

Initial Assessment → Medical History → Major Medical Problems → Eye Problems

 Eye Problems — near sighted, cataracts bilaterally

Physical Assessment → Maneuvers → Visual Acuity
While wearing glasses, a Snellen chart at 20 ft. (6 meters) revealed visual acuity of
20/40 (6/12) in right eye and 20/60 (6/18) in left eye. The patient can read 20/40 (6/12)
on a reading card held at 14 inches (35 cm).
Initial Assessment → Medical History → Major Medical Problems → Seizures

 Seizures — for last 7 years - controlled with depakote

Equivalents:

Initial Assessment → Neurological → Symptoms → Seizures

 Seizures — "I haven't had a seizure in 3 years. I take my pill every day."
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → Impaired Mobility

 Impaired Mobility
Physical Assessment → Maneuvers → Gait & Station
The patient stands by holding onto walker. Kyphosis is noted. When walking, patient
moves walker approximately 6 inches (15 cm), moves right leg forward and then left leg.
The patient bears weight on arms bilaterally. Stance is approximately shoulder width.
Equivalents:

Initial Assessment → Psychosocial → General Appearance:

Well-groomed older adult woman, neat appearance, stooped, walks with a limp using
walker
Initial Assessment → Medical History → Major Medical Problems → Arthritis

 Arthritis — bilateral hands and hips

Fluid Volume, Risk for Deficient

Equivalents:

 Fluid Volume, Risk for Deficient

 Omitted Selections (1)
Initial Assessment → Nutritional → Usual Fluid Intake:
"I don't drink much. It just makes me go to the bathroom more. I have my coffee with
breakfast and a glass of water with meals."
Standing, Impaired
 Equivalents:

 Standing, Impaired
 Omitted Selections (1)
Initial Assessment → Musculoskeletal → Balance/Gait: → Unsteady

 Unsteady — very unsteady without walker

Equivalents:

Initial Assessment → Musculoskeletal → Symptoms: → Weakness

 Weakness — uses walker

Initial Assessment → Musculoskeletal → Activity Devices: → Walker

 Walker — whenever up
Physical Assessment → Maneuvers → Gait & Station
The patient stands by holding onto walker. Kyphosis is noted. When walking, patient
moves walker approximately 6 inches (15 cm), moves right leg forward and then left leg.
The patient bears weight on arms bilaterally. Stance is approximately shoulder width