NR 509 week 1 Quiz With Complete Solution(Real 2023 updated quiz) week 1 Quiz With Comple, Exams of Nursing

Download NR 509 week 1 Quiz With Complete Solution(Real 2023 updated quiz) week 1 Quiz With Comple and more Exams Nursing in PDF only on Docsity! NR 509 week 1 Quiz With Complete Solution(Real 2023 updated quiz) week 1 Quiz With Complete Solution(Real 2023 updated quiz) 1After completing an initial assessment of a patient, the nurse has charted that his respirations are eupneic and his pulse is 58 beats per minute. These types of data would be. A. Objective B.Reflective C. Subjective D. Introspective 2.A patient tells the nurse that he is very nervous, is nauseated and feels hot. These types of data would be A.Objective B.Reflective C. Subjective D. Introspective 3.The patients record, laboratory studies, objective data, and subjective data combine to form the A. Data base B.Admitting data C. Financial Statement D.Discharge Summary 4. When listening to a patients breath sounds, the nurse is unsure of a sound that is heard. The nurses next action should be to A. Immediately notify the patients physician B.Document the sound exactly as it was heard. C. Validate the data by asking a coworker to listen to breath sounds D.Assess it again in 20 minutes to note whether the sound is still present 5.The nurse is conducting a class for new graduate nurses. During the teaching session, the nurse should keep in mind that novice nurses, without a background of skills and experience from which to draw, are more likely to make their decisions using: A. Intuition B. A set of rules C.Articles in journals D.Advice from supervisors 6. Expert nurses learn to attend to a pattern of assessment data and act without consciously labeling it. These responses are referred to as: A. Intuition B.The nursing process C. Clinical knowledge D.Diagnostic reasoning 7.The nurse is reviewing information about EBP. Which statement best reflects EBP? A.EBP relies on tradition for support of best practices B.EBP is simply the use of best practice techniques for the treatment of patients C. EBP emphasizes the use of best evidence with the clinicians experience D.The patients own preferences are not important with EBP. 8.The nurse is conducting a class on priority setting for a group of new graduate nurses. Which is an example of a first-level priority problem A.Patient with postoperative pain 23. A patient is in the clinic to have her blood pressure checked. She has been coming to the clinic weekly since she changed medications 2 months ago. The nurse should: A. Collect a follow-up data base and then check her blood pressure B. Ask her to read her health record and indicate any changes since her last visit C. Check only her blood pressure because her complete health history was documented 2 months ago D. Obtain a complete health history before checking her blood pressure because much of her history information may have changed 24.A patient is brought by ambulance to the ED with multiple traumas received in an automobile accident. He is alert and cooperative, but his injuries are quite severe. How would the nurse proceed with data collection? A. Collect history information first, then perform a physical examination and institute life- saving measures B. Simultaneously ask history questions while performing the examination and initiating life-saving measures C. Collect all information on the history form, including social support patterns, strengths, and coping patterns D. Perform life-saving measures and delay asking any history questions until the patient is transferred to the ICU. 25.A 42-year-old patient of Asian descent is being seen at the clinic for an initial examination. The nurses knowns that including cultural information in his health assessment is important to: A. Identify the cause of his illness B. Make accurate disease diagnoses C. Provide cultural health rights for the individual D. Provide culturally sensitive and appropriate care 26.In the health promotion model, the focus of the health professional includes: A. Changing the patients perceptions of disease B. Identifying biomedical model interventions C. Identifying negative health acts of the consumer D. Helping the consumer choose a healthier lifestyle 27.The nurse has implemented several planned interventions to address the nurses diagnosis of acute pain. Which would be the next appropriate action? A. Establish priorities B. Identify expected outcomes C. Evaluate the individuals condition, and compare actual outcomes with expected outcomes D. Interpret data, and then identify clusters of cues and make inferences 28.Which statement best describes a proficient nurse? A proficient nurse is one who: A. Has little experience with a specified population and uses rules to guide performance B. Has an intuitive grasp of a clinical situation and quickly identifies the accurate solution C. Sees actions in the context of daily plans for patients D. Understands a patient situation as a whole rather than a list of tasks and recognizes the long-term goals for the patient 29.A nurse is reviewing data collected after an assessment. Of the data listed below, which would be considered related cues that would be clustered together during data analysis? Select all that apply A. Inspiratory wheezes noted in left lower lobe B.Hypoactive bowel sounds C. Nonproductive cough D.Edema +2 noted on the left hand E. Patient reports dyspnea upon exertion F. Rate of respirations 16 breaths per minute 30.Put the following situations in order according to the level of priority A. A patient newly diagnosed with type 2 DM does not know how to check his own blood glucose levels with a glucometer B. A teenager who was stung by a bee during soccer match is having trouble breathing C. An older adult with a urinary tract infection is also showing signs of confusion and agitation 1.First-level priority problem (B) 2.Second-level priority problem (C) 3.Third-level priority problem (A) 31.The nurse is conducting an interview what a woman who has recently learned that she is pregnant and who has come to the clinic today to being prenatal care. The woman states that she and her husband are excited about the pregnancy, but have a few questions. She looks nervously at her hands during the interview and sighs loudly. Considering the concept of communication, which statement does the nurse know to be most accurate? The woman is: A. Excited about her pregnancy but nervous about the labor B. exhibiting verbal and nonverbal behaviors that do not match C. Excited about her pregnancy, but her husband is not in this is upsetting to her D. Not excited about her pregnancy but believes the nurse will negatively respond to her if she states this. 32.Receiving is a part of the communication process. which receiver is most likely to misinterpret a message sent by a Health care professional? A. Well-adjusted adolescent who came in B. Recovering alcoholic who came in for a basic physical exam C. Man whose wife has just been diagnosed with lung cancer D. Man with a hearing impairment who uses sign language to communicate and who has an interpreter with him 33.The nurse makes which adjustment in the physical environment to promote success of an interview? A. Reduces noise by turning off televisions and radios B.Reduces the distance between the interviewer and patient to 2 feet or less C. Provides a dim light that makes the room cozy and helps the patient relax D.Arrange is sitting across a desk or table to allow the patient some personal space 34.In an interview, the nurse may find it necessary to take notes to aid his or her memory later. Which statement is true regarding notetaking A. Note taking may impede the nurses observation of the patients 40.When taking a history from a newly admitted patient, the nurse notices that he often pauses and expectantly looks at the nurse. What would be the nurse's best response to this behavior? A. Be silent, and allow him to continue when he is ready B.Smile at him and say, don't worry about all of this. I'm sure we can find out why you are having these pains. C. Lean back in the chair and ask, you are looking at me kinda funny; There isn't anything wrong, is there? D.Stand up and say, I can see this interview is uncomfortable for you. We can continue it another time. 41.A woman is discussing the problems she is having with her 2 year old son. She says, he won't go to sleep at night and during the day he has several fits. I get so upset when that happens. The nurses best verbal response would be: A. Go on, I'm listening B. Fits? Tell me what you mean by this. C. Yes, it can be upsetting when a child has a fit. D. Don't be upset with me has a fit, every 2 year old has fits 42.A 17-year-old single mother is describing how difficult it is to raise a 3 year old child by herself. During the course of the interview she states, I can't believe my boyfriend has left me to do this by myself. What a terrible thing to do to me. Which of these responses by the nurse uses empathy? A. You feel alone. B. You can't believe he left you alone? C. It must be so hard to face this all alone. D. I would be angry too, raising a child alone is no picnic 43.A man has been admitted to the Observation unit for observation after being treated for a large cut on his forehead. As the nurse works through the interview, one of the standard questions has to do with alcohol, tobacco, and drug use. When the nurse asks him about tobacco use, he states, I quit smoking after my wife died 7 years ago. However, the nurse notices an open pack of cigarettes in his shirt pocket. Using confrontation, the nurse could say: A. Mr. K. I know that you are lying B. Mr. K, come on, tell me how much you smoke C. Mr. K, I did not realize your wife had died. It must be difficult for you at this time. Please tell me more about that. D. Mr. K, you have said that you don't smoke, but I see that you have an open pack of cigarettes in your pocket. 44.The nurse has used interpretation regarding a patient statement or actions. after using this technique, it would be best for the nurse to: A. Apologize, because using interpretation can be demeaning for the patient B. Allow time for the patient to confirm or correct the inference C. Continue with the interview as though nothing has happened D. Immediately restate the nurse's conclusion on the basis of the patients nonverbal response 45.During an interview, a woman says, I have decided that I can no longer allow my children to live with their father's violence. But I just can't seem to leave him. Using interpretation, the nurses best response would be A. Are you going to leave him? B. If you are a frayed for your children, then why can't you leave? C. It sounds as if you might be afraid of how your husband will respond. D. It sounds as though you have made your decision. I think it is a good one. 46.A pregnant woman states, I just know labor will be so painful that I won't be able to stand it. I know it sounds awful, but I really dread going into labor. The nurse responds by stating, oh don't worry about labor so much. I have been through it, and although it is painful, many good medications are available to decrease the pain. Which statement is true regarding this response? The nurses reply was : A. Therapeutic response. By sharing something personal, the nurse gives hope to this woman B. Non-therapeutic response. By Providing false reassurance, the nurse actually cut off further discussion of the woman's fears C. Therapeutic response. By providing information about medications available, the nurse is giving information to the woman. D. Non therapeutic response. The nurse is essentially giving the message to the woman that labor cannot be tolerated without medication. 47.During a visit to the clinic, patient states, the doctor just told me he thought I ought to stop smoking. He doesn't understand how hard I have tried. I just don't know the best way to do it. What should I do? The nurse is most appropriate response in this case would be : A. I'd quit if I were you. The doctor really knows what he is talking about B. Would you like some information about the different ways a person can quit smoking? C. Stopping your dependence on cigarettes can be very difficult. I understand how you feel. D. Why are you confused? Didn't the doctor give you the information about the smoking cessation program we offer? 48.As the nurse enters a patient's room, the nurse finds her crying. The patient states that she has just found out that the lump in her breast is cancer and says, I'm so afraid, um, you know. The nurse is most therapeutic response would be to say in a gentle manner: A. You are afraid you might lose your breast? B.No, I'm not sure what you are talking about. C. I'll wait here until you get yourself under control, and then we can talk. D. I can see that you are very upset. Perhaps we should discuss this later period 49.A nurse is taking complete health histories on all of the patients attending a wellness workshop. On the history form, one of the written questions asks, you don't smoke, drink, or take drugs, do you? This question is an example of: A. Talking too much B. Using confrontation C. Using biased or leading questions D. Using blunt language to deal with distasteful topics 50.When observing a patient verbal and nonverbal communication, the nurse notices a discrepancy. Which statement is true regarding this situation? The nurse should : A. Ask someone who knows the patient well to help interpret this discrepancy B. Focus on the patient's verbal message and try to ignore the nonverbal behaviors C. Try to integrate the verbal and nonverbal messages and then interpret them as an average D. Focus on the patient's nonverbal behaviors, because these are often more reflective of a patients true feelings 51.During an interview, a parent of a hospitalised child is sitting in an open position. And the interviewer begins to discuss his son's treatment, suddenly crosses his arms against his chest and crosses his legs. This changed posture would suggest that the parent is: A. Simply changing positions B. More comfortable in this position C. Tired and need a break from the interview. D. Uncomfortable talking about his son's treatment 52.A mother brings her 28-month-old daughter into the clinic for a well child visit. At the beginning of the visit the nurse focuses attention away from the toddler, but as the interview progresses, the toddler begins to warm up and a smiling shyly at the nurse. The nurse will be most successful and interacting with the toddler if which is done next? A. Tickle the toddler get her to laugh B. Stoop down to her level and ask her about the toys she is holding. C. Continue to ignore her until it is time for the physical examination D.Ask the mother to leave during the examination of the toddler, because toddlers often fuss less if their parent is not in view 53.During an examination of a 3 year old child, the nurse will need to take her blood pressure. What might think nurse do to try to gain the child's full cooperation? A. Tell the child that the blood pressure cuff is going to give her arm a big hug B. Tell the child that the blood pressure cuff is asleep and cannot wake up C. Give the blood pressure cuff a name and refer to it by this name during the assessment D. Tell the child that by using the blood pressure cuff we can see how strong her muscles are. 54.A 16 year old boy has just been admitted to the unit for overnight observation after being in an automobile accident. What is the nurses best approach to communicating with him? A. use periods of silence to communicate respect B. Be totally honest with him even if the information is unpleasant C. Tell him that everything that is discussed will be kept totally confidential D. Use slang language when possible to help him open up 55.A 75-year-old woman is at the office for a pre-op interview. The nurse is aware that the interview may take longer then interviews with younger persons. What is the reason for this? A. An aged person has a longer story to tell B.An aged person is usually lonely and likes to have someone with whom to talk C.Aged persons lose much of their mental abilities and require longer time to complete an interview C. Social distance D. Public distance 68.A female nurse is interviewing a male patient who is near the same age as the nurse. During the interview, the patient makes an overly sexual comment. The nurses best reaction would be A. Stop that immediately! B. Oh, you are too funny. let's keep going with the interview. C. Do you really think I would be interested? D. It makes me uncomfortable when you talk that way. please stop. 69.The nurse is conducting an interview. Which of these statements is true regarding open ended questions? Select all that apply. A. Open ended questions elicit cold facts B. They allow for self-expression C. Open ended questions build an enhance rapport D. They leave interactions neutral E. Open ended questions call for short 1-2 word answers F. They are used when narrative information is needed 70.The nurse is conducting an interview in an outpatient clinic and is using a computer to record data. Which are the best uses of the computer in this Situation? select all that apply. A. Collect the patience data and a direct face to face manner B.Enter all the data as the patient states them C.Ask the patient to wait as a nurse enters the data D. Type the data into the computer after the narrative is fully explored E. Allow the patient to see the monitor during typing 71.When evaluating a patient's pain, the nurse knows that an example of acute pain would be A. Arthritic pain B. Fibromyalgia C. Kidney stones D. Low back pain 72.Which statement indicates that the nurse understands the pain experienced by an older adult? A. Older adults must learn to tolerate pain B. Pain is a normal process of aging and is to be expected C. Pain indicates a pathologic condition or injury and is not a normal process of aging D. Older individuals perceive pain to a lesser degree than the younger individuals 73.A 4-year-old boy is brought to the emergency Department by his mother. She says he points to his stomach and says it hurts so bad. Which pain assessment tool would be the best choice when assessing the child's pain? A. Descriptor scale B. Numeric rating scale C. Brief pain inventory D. Faces pain scale revised (FPS-R) 74.A patient states that the pain medication is not working and rates his post-operative pain at a 10 on a 1-10 scale. Which of these assessment findings indicates an acute pain response to poorly controlled pain? A. Confusion B. Hyperventilation C. Increased blood pressure and pulse D. Depression 75.A 60 year old woman has developed reflexive sympathetic dystrophy after arthroscopic repair of her shoulder. A key feature of this condition is that the : A. Affected extremity will eventually regain its function B. Pain is felt at one site but originates from another location C. patients pain will be Associated with nausea, pallor, and diaphoresis D. Slightest touch, such as sleep brushing against her arm, causes severe and intense pain 76.The nurse is assessing a patients pain. The nurse knows that the most reliable indicator of pain would be the A. Patients vital signs B. Physical examination C. Results of a computerized axial tomographic scan D. Subjective report 77.A patient has had arthritic pain in her hips for several years since a hip fracture. She is able to move around in her room and has not offered any complaints so far this morning. However, when asked, she states that her pain is bad this morning and rates it at in 8 on a 1-10 scale. What does the nurse suspect? The patient: A. Is addicted to her pain medications and cannot obtain pain relief B. Does not want to trouble the nursing staff with her complaints C. Is not in pain but Ray said hi to receive pain medication D. Has experienced chronic pain for years and has adapted to it 78.The nurse is reviewing the principles of pain. Which type of pain is due to an abnormal processing of the paint impulse do the peripheral or central nervous system? A. Visceral B. Referred C. Cutaneous D. Neuropathic 79.When assessing the quality of a patient's pain, the nurse should ask which question? A. When did the pain start? B. Is the pain a stabbing pain? C. Is it a sharp pain or a dull pain? D. What does your pain feel like? 80.With assessing a patient's pain, the nurse knows that an example of visceral pain would be; A. Hip fracture B. Cholecystitis C. Second-degree burns D. Pain after a leg amputation 81.The nurse is reviewing the principles of nociception. During which phase of nociception does the conscious awareness of a painful sensation occur? A. Perception B.Modulation C. Transduction D.Transmission 82.When assessing the intensity of a patient's pain, which question by the nurse is appropriate? A. What makes your pain better or worse? B. How much pain do you have now? C. How does pain limit your activities? D. What does your pain feel like? 83.A patient is complaining of severe knee pain after twisting it during a basketball game and is requesting pain medication. Which action by the nurse is appropriate? A. Completing the physical examination first and then giving pain medication B. Telling the patient that the pain medication must wait until after the x- ray images are completed C. Evaluating the full range of motion of the knee and then medicating for pain D. Administering pain medication and then proceeding with the assessment. 84.The nurse knows that which statement is true regarding the pain experienced by infants? A. Pain in infants can only be assessed by physiologic changes, such as increased heart rate B. THE FPS-R can be used to assess pain in infants C. A procedure that induces pain in adults will also induce pain in the infant D. Infants feel pain less than do adults 85.A patient has been admitted to the hospital with vertebral fractures related to osteoporosis. She is in extreme pain. This type of pain would be classified as A. Referred B. Cutaneous C. Visceral D. Deep somatic 86.During assessment of a patient's pain, the nurse is aware that certain nonverbal behaviors are associated with chronic pain. Which of these behaviors are associated with chronic pain? A. Sleeping B.Moaning C.Diaphoresis D. Bracing E.Restlessness F. Rubbing 87.During an admission assessment of patient with dementia, the nurse assesses for pain because the patient has recently had several falls. Which of these are appropriate for the nurse to assess in a patient with dementia? Select all that apply A. Ask the patient, do you have pain? B. IX, and XII C. X and XII D.XI and XII 95.During an examination the nurse notices that a patient is unable to stick out his tongue. Which cranial nerve is involved with successful performance of this action? A. I B. V C. XI D. XII 96.A patient is unable to shrug her shoulders against the nurses resistant hands. What cranial nerve is involved with successful shoulder shrugging? A. VII B. IX C. XI D. XII 97.During an examination, a patient has successfully completed the finger to nose and rapid alternating movements tests and is able to run each heel down the opposite shin. The nurse will conclude that the patient's function is intact. A. Occipital B. Cerebral C. Temporal D. Cerebellar 98.When the nurse performs the confrontation test, the nurse has assessed: A. Extraocular eye muscles (EOMs) B. Pupils (PERRLA) C. Near Vision D. Visual fields 99.Which statement is true regarding the complete physical assessment? A. The male genitalia should be examined in the supine position B. The patient should be in the sitting position for the examination of the head and neck C. The vital signs, height and weight should be obtained at the end of the examination D. To promote consistency between patients, the examiner should not vary the order of the assessment 100.Which of these is included in an assessment of general appearance ? A. Height B. Weight C. Skin color D. Vital signs 101. The nurse should wear gloves for which of these examinations? A. Measuring vital signs B. Palpation of the sinuses C. Palpation of the mouth and tongue D. Inspection of the eye with ophthalmoscope 102. The nurse should use which location for eliciting deep tendon reflexes? A. Achilles B.Femoral C. Scapular D.Abdominal 103.During an inspection of a patient's face, the nurse notices that the facial features are symmetric. This finding indicated which cranial nerve is intact? A. VII B. IX C. XI D.XII 104.During inspection of the posterior chest, the nurse should assess for: A. Symmetric expansion B. Symmetry of shoulders and muscles C. Tactile fremitus D. Diaphragmatic excursion 105.During an examination, the patient tells the nurse that she sometimes feels as if objects are spinning around her. The nurse would document that she occasionally experiences: A. Vertigo B.Tinnitus C. Syncope D.Dizziness 106. A patient tells the nurse, sometimes I wake up at night and I have real trouble breathing. I have to sit up in bed to get a good breath. When documenting this information, the nurse would note A. Orthopnea B. Acute emphysema C. Paroxysmal nocturnal dyspnea D.Acute shortness of breath episode 107.During an examination of a patient, the nurse notices that she has several small, flat macules on the posterior portion of her thorax. The macules are less than 1 cm wide. Another name for these macules is A. Warts B. Bullae C. Freckles D. Papules 108.During an examination, the nurse notices that a patient's legs turn white when they are raised above the patient's head. The nurse should suspect: A. Lymphedema B. Raynaud disease C. Chronic arterial insufficiency D. Chronic venous insufficiency 109. The nurse documents that a patient has coarse, thickened skin and brown discoloration over the lower legs. Pulses are present. This finding is probably the result of; A. Lymphedema B. Raynaud Disease C. Chronic arterial insufficiency D. Chronic venous insufficiency 110. The nurse notices that a patient has ulcerations on the tips of the toes and on the lateral aspect of the ankles. This finding indicates: A. Lymphedema B. Raynaud disease C. Arterial insufficiency D. Venous insufficiency 111. The nurse has just recorded a positive iliopsoas test on a patient who has abdominal pain. This test is used to confirm A. Inflamed liver B. Perforated spleen C. Perforated appendix D. Enlarged gallbladder 112. The nurse will measure a patient's near vision with which tool? A. Snellen eye chart with letters B. Snellen E chart C. Jaeger card D. Ophthalmoscope 113.If the nurse records the results to the Hirschberg test, the nurse has: A. Tested the patellar reflex B. Assessed for appendicitis C. Tested the corneal light reflex D.Assessed for thrombophlebitis 114.During the examination of the patient's mouth, the nurse observes a nodular bony ridge down the middle of the hard palate. The nurse would chart this finding as: A. Cheilosis B. Leukoplakia C. Ankyloglossia D. Torus palatinus 115.During examination, the nurse finds that a patient is unable to distinguish objects placed in his hand. The nurse would document: A. Stereognosis B. Astereognosis C. Graphesthesia D.Agraphesthesia 116. After examination of the an infant, the nurse documents opisthotonos. The nurse recognizes that this finding often occurs with A. Cerebral palsy B. Meningeal irritation C. Lower motor neuron lesion D. Upper motor neuron lesion 117. After assessing a female patient, the nurse notices flesh-colored, soft, pointed, moist papules in a cauliflower like patch around her introitus. This finding is most likely: A. Urethral caruncle B. Syphilitic chancre C. Hypoactive bowel sounds D. Hyperactive bowel sounds 125.Which of these is most appropriate to perform on a 9 month old infant at a well child checkup? A. Testing for the Ortolani sign B.Assessment for stereognosis C. Blood pressure measurement D.Assessment for the presence of the startle reflex 126.The nurse is assessing an older adult's functional ability. which definition correctly describes one's functional abilities? Functional ability: A. Is the measure of the expected changes of aging that one is experiencing? B. Refers to the individual's motivation to live independently C. Refers to the level of cognition present in the older person D. Refers to one's ability to perform activities necessary to live in modern society 127.The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: A. Observe the patient's ability to perform the tasks B.Ask the patients wife how he does when performing tasks C. Review the medical record for information on the patient's abilities D.Ask the patients physician for information on the patient's abilities 128.The nurse needs to assess a patient's ability to perform ADLs and should choose which tool for this assessment? A. Direct assessment of functional abilities (DAFA) B.Lawton Instrumental Activities of Daily Living (IADL) scale C. Barthel Index D.Older American Resources and Services Multidimensional Functional Assessment Questionnaire IADL (OMFAQ-IADL) 129.The nurse is preparing to use the Lawton IADL Instrument as part of an assessment. Which statement about the Lawton IADL assessment is true? A. The nurse uses direct observation to implement this tool B. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability C. This instrument is not useful in the acute hospital setting D. This tool is best used for those residing in an institutional setting 130. The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include: A. Recreational activities B.Meal preparation C. Balancing the checkbook D.Self-grooming activities 131.When using the various instruments to assess and older persons ADLs, the nurse needs to remember that a disadvantage of these instruments includes: A. Reliability of the tools B. Self or proxy reporting of functional activities C. Lack of confidentiality during the assessment D. Insufficient details concerning the deficiencies identified 132.A patient will be ready to be discharged from the hospital soon and the patient's family members are concerned about whether the patient is able to walk safely outside alone. The nurse will perform which test to assess this? A. Get Up and Go Test B.Performance ADLs C. Physical Performance Test D.Tinetti Gait and Balance Evaluation 133. The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? A. Local senior center B. Patients Medicare check C. Meals on Wheels meal delivery service D. Patients neighbor, who visits with her daily 134.An 85-year-old man has been hospitalized after a fall at home, and his 86 year old wife is at his bedside. She told the nurse that she is his primary care giver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: A. Depression B.Weight gain C.Hypertension D.Social phobias 135.During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? A. Geriatric Depression Scale, short form B. Rapid Disability Rating Scale-2 C. Mini-Cog D. Get Up and Go Test 136.An older patient has been admitted to the intensive care unit after falling at home. Within 8 hours, his condition has stabilized, and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? A. Lawton IADL instrument B. Hospital Admission Risk Profile (HARP) C. Mini-Cog D. NEECHAM Confusion Scale 137.During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding Common environmental hazards? A. Please slow toilet seats are safe because they are nearer to the ground in case of falls. B. Do you have a relative or friend who can help install grab bars in your shower? C. These small rugs are ideal for preventing you from sleeping on the hard floor D. it would be safer to keep the writing low in this room to avoid glare in your eyes 138.When beginning to assess a person spirituality, Which question by the nurse would be most appropriate? A. Do you believe in God?