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Ch. 32- Assessing Older Adults

Terms in this set (140)

An older adult client comes to the clinic and reports difficulty with driving at night. What would be the most appropriate response from the nurse to provide when attempting to address the client's concern?

A. "It is nothing to worry about."
B. "It's just something that happens with aging."
C. "With aging, the pupils do not respond to light as quickly, so many people have difficulty driving at night."
D. "This can be serious and needs to be evaluated by the physician immediately."
C
An elderly male client presents to the health care clinic with reports of urinary frequency, nocturia, and difficulty starting his stream. A nurse knows that the most common cause of these symptoms is what condition?

A. Urinary tract infection
B. Sexually transmitted disease
C. Renal insufficiency
D. Benign prostatic hypertrophy
D
A nurse assesses an elderly client and determines that the client is at risk for falls. Which interventions are appropriate to reduce the incidence of actual falls the client incurs? Select all that apply.

A. Limit the amount of activity
B. Remove rugs or other loose carpet
C. Remind the client to ask for assistance
D. Assist with exercise to strengthen lower extremities
E. Discourage the use of dependence on walkers
B,C,D
What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client?

A. Speak loudly to compensate for a hearing deficit
B. Ask the caregiver questions if the client is cognitively impaired
C. Plan for additional time to allow as much independence as possible
D. Address the client by the first name to reduce confusion
C
When using the Romberg test of cerebellar function in an older client, which of the following findings is expected?

A. Slight sway with eyes closed
B. Moderate sway with eyes open
C. Inability to sustain balance with eyes open
D. Inability to sustain balance with eyes closed
A
With a client suspected of suffering from presbycusis, the nurse would expect difficulty hearing:

A. Full range of tones
B. Low-pitched sounds
C. High-pitched sounds
D. Medium-frequency sounds
C
An elderly client visits her community health clinic with an outbreak of vesicles on her skin. She tests positive for the herpes zoster virus. The nurse should recognize this condition as which of the following?

A. Actinic keratoses
B. Petechiae
C. Shingles
D. Senile purpura
C
Which intervention should the nurse suggest to a client to improve the condition of dry skin?

A. Have frequent baths
B. Use lanolin-based products
C. Avoid the use of shampoos
D. Eliminate bathing with soap
B
The nurse observes several patchy white areas on the scalp of an older adult client. What is the nurse's best action?

A. Notify social services.
B. Apply prescribed steroid cream.
C. Apply prescribed antifungal ointment.
D. Stage the area and apply a dressing.
B
A hospitalized client develop thrombocytopenia. Which lab result does the nurse expect in this client?

A. Plasma total bilirubin greater than 2 mg/dL
B. Lactate greater than 2 mmol/L
C. Platelet count less than 100,000
D. Increased creatinine
C
A client is brought to the clinic by his daughter, who tells the nurse that she is concerned because her father appears to be losing weight and she doesn't know why. What would the nurse know is a cause of undernutrition?

A. Poor time management
B. Obsessive/compulsive disorder
C. Acute organ failure
D. Poverty
D
Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?

Weakness.
Confusion.
Falls.
Fever.
D
How do many older adults define their health?

Ability to work
Ability to function independently
Ability to perform activities related to their hobbies
Ability to maintain normal food intake
B
An older client demonstrates mental status changes after being diagnosed with a urinary tract infection. Which finding suggests that this client is experiencing delirium?

refusing to eat
becoming progressively worse
experiencing visual hallucinations
deteriorating performance of self-care activities
C
The nurse notes that it takes an older client 45 seconds to complete the "get up and go" test. Which activities of daily living should the nurse plan to assist the client with completing? Select all that apply.

A. Bathing
B. Climbing stairs
C. Managing finances
D. Using the telephone
E. Getting in and out of bed
A,B,E
The nurse is caring for an older adult who is not eating because "it does not taste like what I eat at home." What would be an appropriate nursing intervention for this client?

Serve 5 to 6 small meals per day
Assess food preferences and obtain favorite foods
Serve in-between-meal snacks
Serve more sweets because the client likes them
B
An elderly client is admitted to the health care facility with an indirect inguinal hernia. Which abnormal data should the nurse expect to find in the client assessment?

Bowel sounds heard over scrotum
Edema of the scrotal sac
Masses or bulges in the scrotum
Pain in the inguinal region
A
Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence?

Inspect urethral meatus
Obtain a voiding diary
Ask the client to bear down
Inspect the vaginal opening
B
When looking at a review of systems for an elderly client, which gastrointestinal data should cause the nurse the most concern?

Reports of constipation
Inability to digest dairy products
Early satiety
Decreased production of saliva
A
The nurse suspects an older adult client has congestive heart failure. Which of the following did the nurse most likely assess in the client?

Harsh holosystolic murmur at the apex
S3 heart sound
Carotid bruits
S4 heart sound
B
Which of the following represents an age-related change in the lungs?

Decreased chest wall compliance
Increased speed of expiration
Increased respiratory muscle strength
Increased elastic recoil of lung tissue
A
When inspecting the toenails of an elderly client, an expected finding is:

Painless separated nail plate
Yellowed, thickened, lusterless nails
Thinned, slightly curved free nail edge
Whitish nail plate with reddish band near free edge
B
The client presents to the clinic with complaints of a painful rash under the left breast. The nurse observes a red papular rash and suspects the client is suffering from:

herpes zoster
stasis dermatitis
onychomycosis
seborrhea
A
The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has?

aortic aneurysm
atrial fibrillation
congestive heart failure
holosystolic murmur
A
In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine associated with an abrupt and strong desire to void. What type of incontinence should the nurse document in the client's record?

Stress
Urge
Overflow
Functional
B
In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record?

Stress
Urge
Overflow
Functional
A
A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?

Lithotomy
Standing
Left side-lying
Prone
C
A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old?

A. Knowing the person's baseline functional status and recognizing deviations from it
B. Knowing the statistical occurrence of the condition among people the same age
C. Knowing the client's family history
D. Knowing the client's mental status
A
The nurse has assessed and informed the healthcare provider of a brown-colored lesion on an older client's left cheek. The lesion is diagnosed as solar lentigines. What is the nurse's best action?

Teach the client how to apply topical chemotherapeutic agents.
Prepare the client for a skin biopsy.
Warn the client of the likelihood of metastasis.
Encourage the client to wear sunscreen daily.
D
In order to let an older adult client establish his or her cultural identity, which statement would be most appropriate for the nurse to make first?

"Tell me your beliefs about the illness you are experiencing."
"I will contact your spiritual adviser to help me understand your illness."
"I have read books about your culture to help me understand your illness."
"I will make sure you are the only person I speak to about your illness."
A
A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as what abnormal finding?

Rectocele
Cystocele
Uterine prolapse
Atrophic vaginitis
B
When evaluating the blood pressure of an older adult, the nurse should understand that with aging, the

systolic blood pressure increases
diastolic blood pressure increases
peripheral vascular resistance remains stable
peripheral vascular resistance decreases
A
A 70-year-old retired auto mechanic comes to the office because his neighbor is concerned about the client's memory. The client admits to misplacing his keys more often and forgetting what he is supposed to buy from the grocery store and where he has parked the car. He denies getting lost in familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his three children live in three different provinces; and he has limited his activities because the people he interacted with were "his wife's friends, not his." He drinks a six-pack of beer daily; he does not smoke or use illicit drugs. The nurse performs a mini-mental state examination and obtains a total score of 24 out of 28. Based on this information, what is the most likely diagnosis?

Benign forgetfulness
Dementia
Meningitis
Depression
D
The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?

Kyphosis
Heberden nodes
Hip contracture
Increased ROM
A
A nurse is working with an elderly client with symptoms of urinary tract infection who says she does not like to report health problems and visit the doctor because some of her friends have had negative experiences with clinicians and have even seemed to get worse after doctor's visits. Which of the following interview techniques should the nurse use to encourage the client and build rapport, which will increase the likelihood of her returning for care?

A. Describe the consequences of a urinary tract infection that is left untreated
B. Explain the benefits of modern medicine that have occurred in recent years
C. Acknowledge the client's exercise habits that have kept her trim and healthy for so long
D. Provide the client with nutritional guidelines to reduce her risks of urinary tract infections in the future
C
A nurse would like to assess an elderly client's general functional status in performing daily chores. Which of the following should the nurse implement to make this assessment?

Vision testing
Katz Activities of Daily Living tool
Activity tolerance testing
Get Up and Go test
B
An older adult with a history of varicose veins presents with lower extremities that are reddish-brown and edematous. What is the nurse's best action?

Stage the affected area and apply an occlusive dressing
Place the legs in a dependent position
Administer antibiotic therapy immediately
Document findings and notify the healthcare provider
D
While the nurse is interviewing a newly admitted older adult client, the client repeats the same story to the nurse several times. What is the nurse's next, best action?

Perform mini mental status exam
Conclude the interview
Request medication for Alzheimer's
Question the client about recent events
A
An objective assessment that is frequently indicated when the subjective assessment reveals a history of falling is

a 24-hour food diary.
a Get Up and Go test.
a tonometry exam.
palpation of the joints for crepitus.
B
When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

postural orthostatic hypotension
decline of pacemaker cells in the sino-atrial node
rise in the systolic blood pressure
stiffening of the large arteries
A
An older client asks why the leg muscles have become flabby over the last few years. What should the nurse respond to this client?

"It means that you have a vitamin deficiency."
"There is nothing that can be done to avoid it."
"It happens because of not enough of protein in the diet."
"It occurs with aging but is encouraged by sitting too much."
D
The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse?

The client has decreased functional ability
The client is being neglected
The client is lazy and appearance no longer matters to him
This client needs to live in a nursing home
A
A nurse obtains an order to check an elderly client for orthostatic hypotension. Which finding alerts the nurse to a positive result for this test?

Systolic pressure increases greater than 10mm Hg
Heart rate increases 20 beats over the baseline rate
Diastolic pressure decreases by less than 10 mm Hg
Pulse pressure widens by 20mmHg over baseline
B
It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause?

Alzheimer's dementia
Stroke
Delirium
Meningitis
C
When using the Romberg test of cerebellar function in an older client, which of the following findings is expected?

Slight sway with eyes closed
Moderate sway with eyes open
Inability to sustain balance with eyes open
Inability to sustain balance with eyes closed
A
A 76-year-old female client's blood pressure is 132/76 in a supine position, 128/71 when dangling at the side of her bed, and 105/58 when she is standing. These assessment findings constitute a risk for which of the following health problems?

Falls
Delirium
Stroke
Peripheral vascular disease
A
The nurse notes that the left arm of an older woman is larger than the right. Which question is best for the nurse to ask to determine the suspected cause of this finding?

"Have you had a mastectomy of the left breast?"
"Have you been diagnosed with an abdominal aneurysm?"
"Do you have problems with atrial fibrillation?"
"Do you suffer from congestive heart failure?"
A
Which question asked by the nurse is appropriate when assessing instrumental activities of daily living (IADLs)?

"Are you able to prepare meals for yourself?"
"Do you need getting up from the chair?"
"Do you need help getting to the bathroom?"
"Do you need assistance to bathe yourself?"
A
An elderly client calls the health care clinic and asks the nurse if it is okay to use an over-the-counter nasal spray to help with sinus congestion. Which question should the nurse ask before assuring the client it is okay to use this medication?

Have you ever been tested for diabetes mellitus?
Do you get up at night to use the bathroom?
Do you have a history of nasal polyps?
Are you taking any drugs for high blood pressure?
D
A 75-year-old female client tells the nurse that she is sexually active but that it causes her pain when she has intercourse. What would the nurse suggest to alleviate this pain?

Taking warm baths
Exclusive use of a side-lying position
Cold application
Having sex in the morning
A
Any new onset of incontinence in the frail elder should be investigated for

prostatitis.
stroke.
fecal impaction.
urinary tract infection.
D
A gastrointestinal problem that often requires emergency treatment in the frail elder is

lactose intolerance.
hiatal hernia.
diverticulitis.
Crohn disease.
C
The nurse wants to ensure that a thorough medication history has been completed with the older adult client. Which checks need to be included? Select all that apply.

A. medication name
B. medication dose
C. medication frequency
D. client's understanding of the need for the medication
E. sleep log
A,B,C,D
An older adult client with type 2 diabetes reports leg pain. Which characteristic will assist the nurse in determining if this is persistent pain?

cramping legs for 3 months
onset after a fall
edema in the lower legs
onset after cardiac catheterization 2 weeks ago
A
When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply.

A. The epidermis thins
B. Nails become thick and brittle with slow growth
C. Wound healing slows as a result of decreased mitotic activity
D. Nails become thin and brittle with increased growth
E. The epidermis thickens
F. The number of sweat and sebaceous glands increases
A,B,C
In the older adult, which changes in the peripheral vascular system can increase blood pressure?

Arterial walls are less elastic and stiffen
Arterial walls are more elastic and compliant
Venous walls are less elastic and stiffen
Venous return slows and increases afterload on the left ventricle
A
A nurse recognizes that a priority goal of assessment in the frail elderly is what outcome?

Focus on disease prevention
Reduction of medication side effects
Minimize disability associated with illness
Identify the need for assistance in activities of daily living
C
Blood pressure abnormalities found more commonly in Western elderly include which of the following?

Isolated elevation of the diastolic BP
Narrow pulse pressure
Elevation of the systolic BP
Elevation of the BP with standing
C
Mrs. Glynn is 90-years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living?

Bathing
Dressing
Preparing food
Transferring from bed to chair
C
An older client admits that she has recently begun wetting her pants. On further questioning by the nurse regarding the cause of the incontinence, the client explains, "I move so slowly these days that I can't always make it to a bathroom in time." The nurse recognizes this as which type of incontinence?

Stress
Urge
Overflow
Functional
D
A sign of infection in the elder that is more common than fever is

pain.
confusion.
diarrhea.
cough.
B
A neurologic change associated with normal aging is

loss of long-term memory.
a decrease in reaction time.
swaying or shuffling gait.
a significant decline in judgment and cognition.
B
Common conditions or problems that accompany aging are often called

conditions of aging
geriatric symptoms
symptoms of aging
geriatric syndromes
D
A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what?

Dementia
Depression
Malnutrition
Decreased mobility
B
An elderly client reports pain in the leg which is not associated with any particular activity but is lessened when the leg is elevated. The nurse recognizes that the client may have which vascular condition?

Arterial insufficiency
Partial obstructed blood flow
Venous insufficiency
Complete obstructed blood flow
C
During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding?

Actinic keratoses
Dermatomycosis
Shingles
Senile purpura
D
An otherwise healthy elderly client develops the sudden onset of confusion, lethargy, anorexia, and nocturia. The nurse should obtain an order for which lab test to assess this sudden change in health status?

Complete blood count for anemia
Live enzymes for acute hepatitis
Urinalysis for the onset of a urinary tract infection
Electrolytes to determine the onset of dehydration
C
An elderly client states that the right eye has better eyesight than the left. A nurse recognizes that this may indicate the onset of what eye condition?

Presbyopia
Macular degeneration
Glaucoma
Arcus senilis
B
A nurse recognizes that a sudden change in an elderly client's cognition accompanied by a change in the level of alertness may be an indication of what condition?

Acute pain
Delirium
Infection
Depression
B
The nurse is assessing an elderly client that has been hospitalized with weakness. The nurse identifies that what disease is most likely to occur in an elderly hospitalized client?

Pressure ulcers
Pneumonia
Sepsis
Bleeding
B
An elderly client is complaining of weakness and fatigue. The nurse suspects the client may be experiencing what?

Anemia
Signs of cancer
Normal aging process
Depression
A
The physical declines of aging often first become noticeable when

approximately 50% of function is lost.
the person is at least 75 years old.
acute or chronic illness places excessive demands on the body.
cognitive declines become significant.
C
The nurse is assessing an elderly client and finds a suspicious lesion on the client's right forearm. The lesion is asymmetrical, has an irregular border, has color variation, and is approximately 8 mm in diameter. What is an appropriate nursing action for this client?

Document findings and refer the client for follow-up
Document findings as a normal age spot
Take no action, because the findings correspond with a normal mole
Call the physician immediately
A
The caretaker of an elderly person tells the nurse that she is worried that the client will choke because of swallowing problems secondary to a recent cerebrovascular accident (CVA). What suggestion should the nurse give the caretaker to minimize the risk of aspiration in the client?

Offer water with meals to clear the throat
Check the mouth frequently for retained food
Keep the client upright for 30 minutes after eating
Prepare foods that are pudding consistency or semisolid
D
On receiving results of some lab work for a client, a nurse learns that the client has a platelet deficiency. Which skin condition related to this finding should the nurse look for in this client?

Actinic keratoses
Petechiae
Shingles
Senile purpura
B
A nurse performs a "Get Up and Go" test on an elderly client. On completion of the test, the nurse documents the test score as 5. What is the gait assessment result as per the score?

Mildly abnormal
Moderately abnormal
Normal
Severely abnormal
D
A simple test that a nurse can perform to assess an elderly client's activity tolerance is to ask the client to perform what task while monitoring the heart rate?

Rise from a chair to a standing position
Walk around the room and observe gait
Perform 4 to 5 slow, deep knee bends
Swing the arms overhead several times
A
A nurse completes an AUDIT-C with a male older adult client who is suspected of having issues with alcohol abuse. The score on the AUDIT-C is 4. Which clue indicates risky drinking?

fasting blood glucose is 108 mg/dl (6 mmol/L)
blood pressure 118/75 mm Hg with antihypertensive medication
reports 7 hours consecutive sleep per night
body mass index (BMI) is 24
A
An older adult client presents with raised yellow lesions on the face. What does this finding most likely suggest to the nurse?

Solar lentigines
Actinic keratoses
Seborrheic keratoses
Cherry angiomas
C
Which statement by an older adult alerts the nurse that health teaching was ineffective?

"Leaking urine is a normal part of aging."
"My hair will get thinner as I get older."
"Getting shorter as I get older is normal."
"It is not normal for my toenails to be yellow and thick."
A
A priority nursing diagnosis for the client experiencing altered perception, extreme agitation, and acute confusion is:

Risk for Injury.
Impaired Verbal Communication.
Altered Role Performance.
Disturbed Sensory Perception.
A
An older client arrives at her primary care provider's office with complaints of irregularly shaped tan, scaly lesions that bleed and are inflamed. The nurse should recognize this condition as which of the following?

Actinic keratoses
Petechiae
Shingles
Senile purpura
A
A nurse is working with a client who is considered to be part of the "frail elderly." At which age can is a person typically first considered to be a part of this group?

65
75
85
95
C
During the assessment of an older client the nurse focuses on household activities and home environment. On which geriatric syndrome is the nurse focusing during this assessment?

fall risk
nutrition
independence
skin breakdown
A
An elderly client is very immobile, sitting in a chair most of the day or spending time in bed. Immobility greatly increases the client's risk for which of the following skin conditions?

Pressure ulcers
Bruising
Fungal infection
Stasis dermatitis
A
During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process?

Retraction of the nipples
Macerated skin under the breasts
Bilateral tenderness
Unilateral nipple discharge
A
Which of the following changes in vision is expected with normal aging?

Cataract
Glaucoma
Macular degeneration
Blurring of near vision
D
The nurse observes the gait and stature of an elderly client entering the room. Which of the following findings is an age-related change?

Gait is wide based.
Arms appear long in proportion to the trunk.
The shoulder of the dominant hand is higher than the shoulder of the non-dominant hand.
Knees are flexed throughout the stance phase.
B
Which of the following statements regarding delirium in older adults is most accurate?

It has a slow, insidious onset that family and clinicians often overlook.
It is associated with a significantly increased risk of suicide.
It often manifests in a daily cycle that includes sundowning.
It typically develops over a short period measured in days, not weeks or months.
D
A nurse notes the presence of brown, pigmented patches on an elderly client's hands. What is the proper term for the nurse to use to document this finding?

Solar lentigines
Actinic keratoses
Seborrheic keratoses
Senile purpura
A
A nurse is inspecting an elderly client's head and neck. Which of the following findings should most prompt the nurse to suspect onset of a chronic condition?

Atrophy of face and neck muscles
Involuntary facial or head movements
Reduced range of motion of head and neck
Development of "buffalo hump" at top of cervical vertebrae
B
The nurse tells the client that she is going to listen to his abdomen for sounds of blood rushing through the blood vessels. The client wants to know why the nurse is specifically listening for this. How would the nurse answer?

A. "Bruits over the aorta or renal or femoral artery are found in cardiovascular disease."
B. "Bruits over the aorta or renal or femoral artery are found in atherosclerotic disease."
C. "Bruits over the aorta or renal or femoral artery are found in chronic pulmonary disease."
D. "Bruits over the aorta or renal or femoral artery are found in rheumatoid arthritis disease."
B
The nurse is doing a shift assessment on an older adult client with diabetes who has had a 2 pack/day smoking habit for 22 years. The nurse cannot palpate a dorsalis pedis pulse even with a Doppler. When reviewing previous assessment findings, they show that pulses were weakly palpable. What would be the first nursing action?

Notify the primary provider
Reevaluate the pulse again in 30 minutes
Reevaluate the pulse again in 15 minutes
Ask the client how the extremity feels
A
The nurse is assessing the older adult for depression. The older adult scores 10 on the short-form of the Geriatric Depression Scale. Which is the best question for the nurse to ask first?

"Do you have any thoughts of wanting to harm or kill yourself?"
"Do you struggle with completing activities of daily living?"
"Do you feel sad, hopeless, and powerless every day?"
"Do you ever feel like life is mentally too much to handle?"
A
During the assessment of an older client, the nurse notes a cloudy ring around the iris of the client's eye. The nurse recognizes this condition as which of the following?

Presbyopia
Macular degeneration
Glaucoma
Arcus senilis
D
A nurse is working with an 86-year-old man who has developed pneumonia. The nurse is aware that this client, due to his age, is living with how much less cellular function in his organ systems throughout his body than a younger person?

10%
25%
50%
75%
C
An older client exhibits a strong dorsalis pedis pulse in the right foot and a weak dorsalis pedis pulse in the left foot. How should the nurse document these findings?

Dorsalis pedis pulses are 4+ left and 1+ right.
Dorsalis pedis pulses are 3+ left and 1+ right.
Dorsalis pedis pulses are 1+ left and 4+ right.
Dorsalis pedis pulses are 1+ left and 2+ right.
D
To compensate for a stooped posture and less flexible knee, hip, and shoulder joints, the elderly person often walks

with a waddling type of gait.
with one leg slightly dragging behind the other.
with the feet farther apart and the knees slightly bent.
with a slight swaying side-to-side motion.
C
A common sign or symptom of depression in the elderly is

rambling or incoherent speech.
illusion or hallucinations.
insomnia.
cognitive impairment or pseudodementia.
D
A characteristic sign of delirium is

a significant decline in memory.
a chronic low mood.
a rapid decline in level of alertness.
disorientation to self.
C
Some symptoms of dehydration are common to younger and older adults. Which one of the following cannot be used to determine dehydration in older adults?

A furrowed tongue.
Tenting of the skin when pinched.
Dry warm skin.
Sunken eyes.
B
A client comes to the client for examination of red patches on his forearms which have been present for several months. They remain for several weeks. He denies a history of trauma. Which of the following is likely?

Actinic keratoses
Pseudoscars
Actinic purpura
Cherry angiomas
A
The nurse is reviewing the results of laboratory blood tests with the older adult. The client asks, "Why is my creatinine elevated?" Which is the best response by the nurse?

"As a person gets older, the kidneys do not work as well in removing waste materials."
"The kidneys filter waste materials at an increased rate as a person get older."
"An elevated creatinine suggests increased reabsorption of this substance by the kidneys."
"Creatinine is an indicator of how well the kidneys are functioning in removing wastes."
A
The nurse observes a dark brown, pigmented waxy lesion 2-mm in size on the right forearm of an older adult. The nurse recognizes this lesion as:

seborrheic keratosis
squamous cell carcinoma
malignant carcinoma
basal cell carcinoma
A
While assessing an elderly client, the nurse finds the client to be confused, hypotensive, with an increased respiratory rate. Upon further review, the nurse identifies the nurse has not been eating in the last 48 hours. What does the nurse suspect?

Pneumonia
Deep vein thrombosis
Compartment syndrome
Pneumothorax
A
The nurse is assessing a new client, age 68 years, for orthostatic hypotension. The nurse would know that this means a drop in systolic blood pressure of 20 mm Hg or more or diastolic blood pressure of 10 mm Hg or more within how many minutes of standing?

4 minutes
3 minutes
2 minutes
1 minute
B
Diminished vibratory sensations and slowed motor responses in advanced age result in

stiffness and rigidity.
paresthesia.
postural instability.
tremors.
C
The nurse is assessing a female older adult client with hyperthyroidism. For which related health problem should the nurse assess the client?

bone loss
cold intolerance
constipation
dry skin
A
Which sign can the nurse include in the general survey of the older adult client during the physical exam?

odor
blood pressure
pressure ulcers
visual acuity
A
The nurse notes that an older client has a systolic murmur. What should this finding suggest to the nurse?

onset of heart failure
calcification of the aortic cusps
hypertrophy of the left ventricle
malfunction of the right atrium
B
What does the nurse use to formulate a nursing care plan?

Objective data
Subjective data
Assessment data
A preprinted care plan
C
A 72-year-old retired truck driver comes with his wife to the clinic for evaluation of hearing loss. He has noticed some decreased ability to hear what his wife and grandchildren say to him. He admits to lip-reading more. He has a history of noise exposure in his young adult years: he worked as a sound engineer at a local arena and had to attend many concerts. Based on this information, what is the most likely finding regarding his hearing acuity?

Loss of acuity for middle-range sounds
Increased acuity for low-range sounds
Loss of acuity for high-range sounds
Increased acuity for high-range sounds
A
An elderly client presents to the emergency department with reports of a productive cough of blood-tinged sputum, fatigue, weight loss, and shortness of breath. The nurse recognizes that these are symptoms associated with which respiratory disease process?

Tuberculosis (TB)
Chronic obstructive pulmonary disease (COPD)
Pneumonia
Lung cancer
D
A nurse recognizes that a slight barrel-shaped chest in an elderly client is due to what physiologic change in the thorax as a result of the aging process?

Decreased vital capacity
Increased residual volume
Loss of skeletal muscle strength
Use of accessory muscles
C
A benign skin lesion commonly seen in the aged is

squamous cell carcinoma.
shingles.
actinic keratosis.
lentigines.
D
To reduce the risk for late recognition of cognitive impairment in the older adult client, which actions should the nurse take? Select all that apply.

A. Adopt more direct questions.
B. Use geriatric screening tools.
C. Consult family members or caregivers.
D. Normalize occasional loss of memory.
E. Provide teaching about sexual health.
A,B,C
The nurse is concerned about an older client's ability to live independently in the home. For which activities should the nurse assess this client? Select all that apply.

A. Does own laundry
B. Watches television
C. Shops for groceries
D. Balances check book
E. Dials telephone numbers
A,C,D,E
When assessing an elderly client's ability to return to the community following discharge, it is important for the nurse to measure the client's abilities in relation to instrumental activities of daily living. Which of the following options is the most important area that must included in the assessment?

Family involvement
Church involvement
Finance management
Living status
C
The nurse is caring for an older adult client whose steps are uneven and shorter than most adults. How would the nurse explain this phenomenon?

The client has a narrower base of support.
The client walks bent forward.
The client's age makes this a normal characteristic.
The client has loss of balance.
C
The nurse assesses an older adult using the short from of the Geriatric Depression Scale. The total score obtained is 11. Which interpretation by the nurse is correct?

The client is most likely depressed.
Further evaluation is needed to make a diagnosis.
The score suggests depression may be a problem.
The client is not depressed.
A
An older adult has experienced two falls in the past week. Which test would be most appropriate for the nurse to administer?

Timed Get Up and Go Test
Functional Independence Measure
Direct Assessment of Functional Abilities
Lawton's Instrumental Activities of Daily Living
A
An older adult client is admitted to the hospital with obstruction of the portal vein. Which abnormal data should the nurse expect to find in the client assessment?

Bowel sounds heard over scrotum
Edema of the scrotal sac
Masses or bulges in the scrotum
Pain in the inguinal region
B
A nurse inspects an elderly client's abdomen and notices the presence of a mass. What is an appropriate action by the nurse in regards to this finding?

Measure the mass to determine the diameter
Auscultate for the presence of a bruit
Ask if the client needs to empty the bladder
Palpate the mass to determine if it is solid or fluid filled
B
A nurse is interviewing a 79-year-old client regarding her present health concern. Under which of the following conditions should the nurse consult a family member of the client to compare the client's current cognition and behavior with a prior level of function? Select all that apply.

A. Client is lethargic and agitated
B. Client speaks slowly and softly
C. Client requires assistance standing and walking
D. Client appears agitated
E. Client appears excessively distracted
F. Client offers inconsistencies in her responses
A,D,E,F
An older adult client, who is a retired construction worker, presents with an ulcerated lesion on his left auricle. What teaching should the nurse provide to this client?

"Notify your healthcare provider about the possibility of cancer."
"Apply over the counter steroid cream twice daily."
"Over the counter antibiotic ointment should be applied once daily."
"Make an appointment right away with an audiologist to prevent hearing loss."
A
A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is

nutritional deficiency.
dysphagia.
the degree to which dyspnea affects daily function.
a possible history of immunosuppression.
C
The nursing student asks the instructor why older adults develop wrinkles. Which information should the nurse omit when responding?

A decrease in goblet cells causes the skin to dry.
The loss of facial subcutaneous fat leads to wrinkles.
Wrinkling occurs primarily in sun-exposed areas.
A reduction in dermal fibers occurs with long-term smoking.
A
The nurse is assessing the client's risk for falls. What data identifies the client as having a fall risk? Select all that apply.

A. Antihypertensive medications
B. Stiffness
C. Wide gait
D. Urinary frequency
E. Abnormal heart sounds
A,B,C
The nurse is assessing an cognitively impaired older adult that is experiencing sleep disturbances and agitation. The nurse suspects the client is experiencing what?

Pain
Dementia
Delirium
Fear
A
A 75-year-old client admitted in respiratory failure has been placed on mechanical ventilation. The client develops acute confusion, purulent sputum, low oxygen saturation readings, and dyspnea. What breath sound is the nurse most likely to auscultate on exam?

Rales
Wheezing
Stridor
Pleural friction rub
A
The nurse suspects that an older client has undiagnosed Parkinson's disease. What finding caused the nurse to make this clinical determination?

bradykinesia
muscle atrophy
wide-based gait
tremor of the head
A
The nurse is concerned that an older client is developing delirium. What findings caused the nurse to make this clinical determination? Select all that apply.

A. Rambling speech
B. Sleep disturbances
C. Combative behavior
D. Inability to recall recent events
E. Easily distracted by unimportant things
A,B,C,E
The nurse familiar with the National Center for Health Statistics identifies which of the following as causes of adult mortality in people 65 years and older? (Select all that apply.)

A. diseases of the heart
B. malignant neoplasms
C. chronic lower respiratory diseases
D. suicide
E. Alzheimer's disease
A,B,C,E
An older client presents to the clinic with a painful tongue fissure. The nurse should encourage the client to increase the intake of which nutrient?

Water
Vitamin C
Vitamin B1
Protein
A
During a health history, which of the following can the nurse ask to determine an older adult client's abilities to conduct instrumental activities of daily living? (Select all that apply.)

"Do you shop for groceries?"
"Are you able to feed yourself?"
"Do you do your own laundry?"
"Do you manage your own money?"
"Who prepares your meals?"
A,C,D,E
The nurse is assessing the eyes of an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?

arcus senilis
senile ptosis
small pupil size
sluggish accommodation
A
Identify the priorities of nursing care for clients diagnosed with a cognitive disorder. Select all that apply.

Managing agitation
Maintaining safety
Communication
Support the family
Financial stability
A,B,C,D
The nurse is admitting an older male client diagnosed with congestive heart failure. Several risk factors for falls have been identified on the admission database. What is the nurse's best action to prevent falls?

Use two client identifiers, such as name and date of birth.
Scan the client's armband before medication administration.
Use SBAR and medical terminology for verbal communication.
Utilize safety alarms that are available on the unit.
D
The nurse is assessing risk for falls. What data should be included in the fall risk assessment? Select all that apply.

Medical diagnosis
History of falls
IV/heparin lock
Nutritional status
Friction
A,B,C
When assessing an older adult, the nurse finds the client has a history of falls, shortness breath and fatigue. The nurse would suspect the client is experiencing what?

Cardiac dysrhythmias
Chronic lung disease
Normal aging process
Muscle atrophy
A
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