ANCC Gerontological Nursing 2 — Questions and Answers
Question 1: An 80-year-old patient scores 18/30 on the Mini-Mental State Examination (MMSE). This score indicates:
- Normal cognition
- Mild cognitive impairment
- Moderate cognitive impairment (Correct answer)
- Severe cognitive impairment
Correct answer: Moderate cognitive impairment
MMSE scores of 10–18 indicate moderate cognitive impairment; scores ≥24 are considered normal.
Question 2: A 78-year-old has a pressure injury with full-thickness skin loss exposing subcutaneous tissue without exposed bone, tendon, or muscle. This is classified as:
- Stage 1
- Stage 2
- Stage 3 (Correct answer)
- Stage 4
Correct answer: Stage 3
Stage 3 pressure injuries involve full-thickness skin loss with visible subcutaneous tissue but no exposed bone, tendon, or muscle.
Question 3: Which intervention is most effective for preventing falls in hospitalized older adults?
- Bed restraints to prevent getting up unsupervised
- Hourly rounding with toileting and call light within reach (Correct answer)
- Sedating medications at night
- Keeping all side rails up at all times
Correct answer: Hourly rounding with toileting and call light within reach
Regular rounding with scheduled toileting and ensuring call lights are accessible are evidence-based fall prevention strategies.
Question 4: Which of the following medications is considered high-risk in older adults due to anticholinergic effects?
- Metformin
- Amlodipine
- Diphenhydramine (Benadryl) (Correct answer)
- Lisinopril
Correct answer: Diphenhydramine (Benadryl)
Diphenhydramine has strong anticholinergic effects causing confusion, urinary retention, constipation, and fall risk in older adults.
Question 5: When assessing pain in a non-verbal older adult with dementia, which scale is most appropriate?
- Numeric Rating Scale (NRS 0–10)
- Visual Analog Scale (VAS)
- PAINAD Scale (Correct answer)
- Wong-Baker FACES Scale
Correct answer: PAINAD Scale
The PAINAD (Pain Assessment in Advanced Dementia) scale uses behavioral indicators to assess pain in non-verbal patients.
Question 6: Elder mistreatment screening should be performed using which validated tool in outpatient settings?
- CAGE questionnaire
- Elder Abuse Suspicion Index (EASI) (Correct answer)
- PHQ-9
- AUDIT-C
Correct answer: Elder Abuse Suspicion Index (EASI)
The Elder Abuse Suspicion Index (EASI) is a validated 6-item tool used by clinicians to identify elder mistreatment.
ANCC Gerontological Nursing 2
An 80-year-old patient scores 18/30 on the Mini-Mental State Examination (MMSE).
This score indicates: