Gerontology ATI Review

1. A nurse is assessing a client who has a wrist restraint applied. For which of the following
findings should the nurse loosen the restraint?

A. The client has a full range of motion in her wrist.

B. The client’s hand is cool and pale.
C. The client has a capillary refill of less than 2 seconds.
D. The client is attempting to remove restraint.

2. A nurse is caring for a 4-year old child who is resistant to taking medication. Which of
the following strategies should the nurse use to elicit the child's cooperation?

A. Offer the child a choice of taking the medication with juice or water
B. Tell the child it is candy
C. Hide the medication in large dish of ice cream.
D. Tell the child he will have to have a shot instead.

3. A nurse is caring for a client who has late-stage Alzheimer's disease and is hospitalized
for treatment of pneumonia. During the night shift, the client is found climbing into the
bed of another client who becomes upset and frightened. Which of the following actions
should the nurse take?

A. assist the client to the correct room.

B. Place the client in restraints
C. reorient the client to time and place
D. move the client to a room at the end of the hall.

4. A nurse is caring for a client in the emergency department who had a traumatic
amputation of his left arm in an industrial accident 1 hr ago. The nurse should expect the
client to be in which of the following stages of grief?

A. Acceptance
B. Denial
C. Bargaining
D. Depression
5. A nurse is assessing a client who is experiencing complications due to immobility. Which
of the following findings should the nurse expect? Select all that Apply.
A. Contractors of the extremities
B. Polyuria
C. Diarrhea
D. Crackles in the lungs
E. Pressure ulcers

6. A nurse in a drug and alcohol detoxification center is planning care for a client who has
alcohol use disorder. Which of the following interventions should the nurse identify as
the priority?
A. Providing adequate hydration and rest
B. Confronting the use of denial and other defense mechanisms
C. Helping the client identify positive personality traits.
D. Educating the client about the consequences of alcohol misuse

7. A nurse is caring for an older adult client who had a cerebrovascular accident and has
right-sided paralysis and aphasia. The client's son tells the nurse it is his fault because he
did not insist that his mother live with him. Which of the following responses should the
nurse make?
A. You are not responsible for your mother’s stroke.
B. So, it seems that you feel responsible for what happened to your mother.
C. Why do you blame yourself? You could not have prevented the stroke.
D. Your mother will be fine. You shouldn’t worry too much.

8. A nurse in a long-term care facility is caring for an older adult client who had a stroke 4
weeks ago and who is unable to move independently. The nurse should monitor for which
of the following complications of immobility?
A. A reddened area over the sacrum
B. Stiffness in the lower extremities
C. Difficulty moving the upper extremities.
D. Difficulty hearing some types of sounds.

9. A nurse is planning to discharge a client who has quadriplegia to his home. The nurse
suggests that the family might need respite care services. When a family member asks
how respite care can help, which response should the nurse provide?
A. Respite care provides holistic support and care for a client who is terminally ill.
B. Respite care relieves pain and promotes comfort.
C. Respite care allows the primary caregiver time away from day-to-day care
responsibilities.
D. Respite care is a continuation of psychological support after a family member dies.
10. A client who has major depressive disorder states to the nurse that he and his family
would be better off if he were gone. Which is the nurse’s priority response?
A. When did you first start feeling this way?
B. Tell me what is happening right now.
C. Do you really think your family would be better off without you?
D. Are you thinking of harming yourself?

11. A nurse is caring for a client whose partner is requesting to bring the client food from
home that is not allowed in the client's dietary plan. Which of the following responses
shou nurse make?

A "Let's try to find ways to incorporate your partner's favorite food into the diet plan:"
B "Why would you want to put your partner's health at further risk?"
C "Everyone likes food from home, but it can delay your partner's recovery."
D "You will need to discuss your concerns about your partner's diet with your primary
health care provider."

12. A nurse is caring for a client who has dementia. When performing a mental status
examination, the nurse should include which of the following data?
A. Ability to perform calculations.
B. Recall ability.
C. Long-term memory
D. Level of orientation
E. Coping skills

13. A nurse is preparing to perform hand hygiene, which of the following actions should the
nurse take?
A. Hold the hands higher than the elbows.
B. Rub hands and arms to dry.
C. Adjust the water temperature to feel hot.
D. Appy 4-5 ml of liquid soap to hands

14. A nurse is caring for a client who is dying. The client says, "My mother died in the
hospital, but I did not get there before she died." Which of the following statements
should the nurse make?
A. I will make sure a staff member is always in your room.
B. I wonder if you are fearful of dying alone.
C. We will call your family in time for them to get here.
D. I will tell your family of your concern so that they can be here.
15. A nurse is administering a tap water enema to a client who is constipated. During the
administration of the enema, the client states he is having abdominal cramps. Which of
the following actions should the nurse take to relieve the client's discomfort?
A. Lower the height of the solution container.
B. Encourage the client to bear down.
C. Allow the client to expel some fluid before continuing.
D. Stop the enema and document that the client did not tolerate the procedure.

16. An older adult client is scheduled to have an elective surgical procedure and informs the
nurse that she wants to be designated as a "do not resuscitate" (DNR) case. Which of the
following responses should the nurse provide?
A. This is a minor procedure; there is no need for this request.
B. You need to discuss your request with the hospital chaplain.
C. Your provider needs to talk to you concerning your request.
D. You need to let our provider know your wishes after the procedure.

17. A nurse is teaching a class about expected changes to the skin in older adults. Which of
the following information should the nurse include?

A. increase in skin thinning?

B. increase in skin elasticity.
C. decrease in subcutaneous tissue.
D. increase in blood supply to skin.
E. decrease in skin hydration.

18. A nurse in an acute care facility is admitting an older adult client who has dementia due
to Alzheimer's disease. The nurse notes that the client's partner appears exhausted. He
states that he is finding it more and more difficult to care for his wife. Which of the
following interventions is the nurse's priority?

a. Recommend that the partner place the client in a long-term care facility.
b. Suggest that the partner see a counselor to help him cope with his exhaustion.
c. Ask the partner to talk about his difficulties in caring for the client.
d. Tell the partner to call a family meeting to get help.

A nurse is assessing an older adult client who has experienced some loss of bone density.
The nurse observes a "hunchback" curvature of the client's spine. The nurse should
expect the provider to document which of the following disorders?
 A. Kyphosis
B. Scoliosis
C. Lordosis
D. Ankylosis

19. A nurse is caring for a client who has major depressive disorder and is scheduled for
electroconvulsive therapy (ECT). The client's spouse asks the nurse about the possible
side effects of the ECT. Which of the following responses should the nurse make?

A. The main side effects are temporary and may include mild confusion, a headache, and
short-term memory loss.
B. Most clients have no adverse effects to this treatment, but muscle cramping may
result from the induced seizure.
C. Some clients have been known to have a myocardial infarction, but we will monitor
your spouse closely to be certain this does not happen.
D. The most common side effects are directly related to anesthesia.

20. A nurse on a long-term care unit is creating a plan of care for a client who has
Alzheimer's disease. Which of the following interventions should the nurse include in the
plan?
A. Provide an activity schedule that changes from day to day.
B. Rotate assignment of daily caregivers.
C. Limit time for the client to perform activities.
D. Talk the client through tasks one step at a time.

21. A nurse is an emergency department caring for a client who has been taking haloperidol
(Haldol) for the past 3 months. The client has a temperature of 38.9 C (102 F), a blood
pressure of 150/110 mm Hg, and tachycardia. The nurse should know that these
manifestations indicate a diagnosis of:
A. Neuroleptics malignant syndrome
B. Tardive dyskinesia
C. Akathisia
D. Agranulocytosis

22. A nurse is admitting an older adult client who has a suspected cognitive disorder. Which
of the following inventories should be included as part of the admission assessment?
A. Brief Patient Health Questionnaire (Brief PHQ)

B. Abnormal Involuntary Movements Scale (AIMS)

C. Mental status examination (MSE)

D. Scale for Assessment of Negative Symptoms (SANS)

23. A nurse enters an older adult client's room to insert a saline lock. the client asks the nurse,
"Why do i need that? I am drinking plenty of fluids." Which of the following responses
should the nurse provide.

A. it's quicker to admin meds IV in the hospital

B. clients over the age of 65 must have a saline lock according to facility policy
C. we administer all meds IV to clients in this unit
D. your provider has prescribed antibiotic therapy to be administered IV every 6 hr

A nurse is caring for a client who has been hospitalized for treatment of bipolar disorder
and will be discharged with a prescription of lithium. The nurse's discharge teaching
should include information cautioning against which of the following factors that may
cause lithium toxicity?
A. Experiencing diarrhea
B. Exercising moderately
C. Increasing sodium intake
D. Drinking green tea

24. A nurse is preparing an in-service presentation for a group of newly licensed nurses about
the use of restraints. What should nurse include as a criterion for applying restraints?
A. The nurse has already considered alternatives to the restraints.
B. The client must understand the need for restraints.
C. The provider must renew a restraint prescription every 8hr.
D. The restraints should promote the client’s safety and prevent injuries.

25. A nurse is participating in a disaster simulation in which a toxic substance has been
release into a crowded stadium. Multiple clients are transported to the facility. Which of
the following actions should the nurse take first?
A. Prevent cross-contamination of clients
B. Complete a thorough client assessment
C. Treat clients arriving at the facility who have yellow triage tags
D. Maintain a client tracking system
26. A nurse is planning care for a client who has become increasingly anxious and confused.
Which of the following actions should the nurse include to avoid the use of physical
restraints?
A. Ensure effective pain management.
B. Attend to the client's needs for toileting.
C. Assign the client to a room near the nurses' station.
D. Orient client frequently to the environment.
E. Elevate all side rails on the bed.

27.A public health nurse is assessing an older adult client who lives with a family member.
The nurse identifies several bruises in various stages of healing. The client and family
member explain that the bruises are a result of clumsiness. However, based on the
distribution of the bruises, the nurse suspects abuse. Which of the following actions should
the nurse take first?
a. Document the bruises in the client's chart.
b. Report the findings to a supervisor.
c. Provide the client with a crisis hotline number.
d. Discuss respite care with the client's family.