ANCC Gerontological Nursing 2

Question 1

An 80-year-old patient scores 18/30 on the Mini-Mental State Examination (MMSE). This score indicates:

Accepted Answer

Moderate cognitive impairment

Answer

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:

Accepted Answer

Stage 3

Answer

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?

Accepted Answer

Hourly rounding with toileting and call light within reach

Answer

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?

Accepted Answer

Diphenhydramine (Benadryl)

Answer

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?

Accepted Answer

PAINAD Scale

Answer

The PAINAD (Pain Assessment in Advanced Dementia) scale uses behavioral indicators to assess pain in non-verbal patients.

ANCC - American Nurses Credentialing Center Practice Test

ANCC - American Nurses Credentialing Center Practice Test

ANCC Gerontological Nursing 2