The older adult
The nurse is seeing an older adult client in a wellness screening clinic. The client is discussing their current medications, recent shoulder pain, exercising, and taking a daily one-mile walk. Which statement provided by the nurse is accurate?
"Continue to exercise your joints regularly to your tolerance level."
The nurse is speaking with the daughter of an older adult client (pronouns: she/her/hers) about bringing her mother home to live with her family. Which statement, made by the daughter, presents the greatest concern for the nurse?
"I don't think she will react very well to me making decisions for her."
A college student is having difficulty dealing with being dismissed from college due to poor grades. Which statement made by the student indicates the defense mechanism of denial?
"I don't think the grades are right. I can stay in school."
During a home visit with an 83-year-old client (pronouns: he/him/his) diagnosed with dementia, the nurse notices the client is visibly upset and insists that people are throwing away his medals. The nurse observes the daughter telling her father that he is hiding them in the back of the closet and forgetting where he put them. The nurse notices the client becoming increasingly upset and anxious. The nurse offers to role-play a response with the daughter that could help reduce the client's anxiety. Which statement shared by the nurse would best support the client and his daughter?
"I know those medals are important to you. Tell me more about them."
The nurse is providing education on fall prevention with an older adult client recently discharged home. Which statement made by the client indicates that more teaching is needed to minimize the risk of falls?
"I will limit my activities so I don't fall."
The mother of a 38-year-old client recently died due to complications from surgery that required an unexpected colostomy. After the mother's death, the client exhibits an intellectualized defense mechanism. Which statement represents this type of defense mechanism?
"My mother would have never wanted to live with a colostomy."
A nurse is assessing a client's coping after a recent stressful life event. Which question best assists the nurse in assessing the client's level of coping?
"Are you having difficulty sleeping?"
The nurse is conducting an initial assessment of a client in a crisis. When assessing the client's perception of the precipitating event that led to the crisis, which is the most appropriate question asked by the nurse?
"What leads you to seek help now?"
After a healthcare provider has informed a client that they have colon cancer, the nurse enters the room to find the client gazing out the window in thought. Which is the most appropriate first response provided by the nurse?
"Would you like for me to sit down with you for a few minutes so you can talk about this?"
The nurse provides care for an older adult whose spouse died 8 months ago. Which behaviors indicate that the client is experiencing effective coping? Select all that apply.
Attends religious services on a regular basis. Visits their spouse's grave every 2 weeks. Shows the nurse photographs of their family.
The hospice nurse visits a client who is dying of ovarian cancer. During the visit, the client says, "If I can just live long enough to celebrate my daughter's "Sweet 16" birthday party, I'll be ready to die." Which phase of coping is this client experiencing?
Bargaining
A healthy 78-year-old woman who is considering marriage to a healthy 79-year-old neighbor tells the nurse that she wonders if they will be able to have sexual intercourse. Which is the nurse's most appropriate response?
Both of you may have slower responses to sexual stimulation.
A client expresses to the nurse that they constantly feel irritated and lose their temper. During the course of the interview, the nurse finds that the client is taking care of their mother who is bedridden following a stroke. The client struggles to balance caring for their own family and their mother. Which nursing diagnosis would the nurse most likely identify for this client?
Caregiver role strain
A client has been admitted for restorative care in a long-term care setting following a hip replacement. Which interventions promote independence in activities of daily living (ADL)? Select all that apply.
Collaborate with a physical therapist to promote mobility. Involve the client in the plan of care. Ask the client when they need assistance. Provide the client with a toothbrush.
During a community health fair, nurses teach stress management to the participants. Which belief as a method of coping with stressful life events will the nurses most likely advocate?
Control over one's response to stress is possible.
When assessing the older adult, the nurse should review the client's achievement of developmental tasks. Which outcomes indicate achievement of developmental tasks? Select all that apply.
Coping with the loss of a working role Enjoying more leisure time Redefining relationships with children Accepting themselves as aging
It's 15:00 and the nurse is discharging a client who has just received a diagnosis of pancreatic cancer. The nurse notices the client starting to cry and then the elder, accompanying the client, motions for them to stop crying. The client and their family members have minimal response, hiding their emotions and appearing stoic. Which factor is most likely contributing to the client's response to their diagnosis?
Cultural or ethnic background
A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which changes should the nurse include in the discussion? Select all that apply.
Decreased bladder capacity More difficulty seeing due to a greater sensitivity to glare Decreased cough reflex Dehydration of interveterbal discs
A nurse is observing the skin integrity of an older adult. Which finding will the nurse document as a normal finding?
Decreased elasticity
The nurse is completing a health history with the daughter of a newly admitted client. The daughter reports that the client was diagnosed with Alzheimer's disease 1 year ago. According to the daughter, last night the client became agitated, confused, and was seeing spiders that were not present. The daughter was unable to calm the client and reported that the client did not recognize her. According to the daughter's description of the client, what does the nurse suspect the client is experiencing?
Delirium
An older adult client that has been separating themselves from others has now stopped participating in their favorite social activities at the nursing home. They share that their family has been visiting less frequently. What should the nurse consider as a possible cause for this change in behavior?
Depression
The nurse is planning client education for an older adult being prepared for discharge home after hospitalization with a new cardiac diagnosis. Which nursing action addresses a priority need for this client?
Encourage the client to use a compartmentalized pill storage container for their daily medications.
A nurse is developing a care plan for a client who is lacking confidence and experiencing stress at home. What should the nurse do initially?
Encourage the client to verbalize thoughts and feelings.
A 40-year-old client is alarmed at their recent diagnosis of type 2 diabetes. Which action taken by the client best indicates a problem-focused coping strategy?
Exercising three times weekly
An older-adult client with no acute distress reports being less able to taste and smell. What is the nurse's best response to this information?
Explain to the client that diminished senses are normal.
Which statements should be included when teaching a group of active older adults about skin care? Select all that apply.
Generous use of moisturizers and minimal use of soap prevent skin drying. Sunscreens are recommended to reduce the risk of skin cancer Generalized itching may be a symptom of a serious illness.
When assessing an older adult, the nurse knows which change is a normal and physiological change related to aging?
Increased time for the heart rate to return to baseline after exercise
When a nurse conducts an assessment about how a client is coping, from which sources does the data often come? Select all that apply.
Information that the client shares verbally An observation of how a client reacts non-verbally to instructions Input from a neighbor who visits the client daily
A client is going through a divorce and trying to juggle work and moving. They are extremely sad and worried about their family. Which behaviors demonstrate that they are experiencing a conversion response? Select all that apply.
Lack of appetite Roaming the house in the middle of the night because they can't sleep
A nurse is discussing medication safety with a group of older adults. Which information, when discussed with clients, will increase medication safety? Select all that apply.
Names of the medications Question the healthcare provider about new prescribed medications When to take the medications Undesirable effects of the medications Ask the healthcare provider before taking over-the-counter medication
What is the best resource for identifying information regarding an older adult's current functional ability?
Neighbor who visits daily and helps the client to the store weekly
What should the nurse consider when developing the plan of care for an older adult who is hospitalized for an acute illness?
Preadmission functional abilities
The nurse is providing client teaching for an 85-year-old client who will be going home on anticoagulant therapy. Which strategy reflects considerations of aging changes that may affect this client?
Provide large-print handouts that reflect the verbal information presented.
A client who was sexually assaulted a month ago presents to the emergency room. The provider suspects that the client is experiencing post-traumatic stress response. Which signs and symptoms recognized by the nurse best support this suspicion?
Recurrent nightmares and flashbacks
In reviewing changes in the older adult, the nurse recognizes which statement related to cognitive functioning in the older client as true?
Reversible systemic disorders are often a cause of delirium.
An 89-year-old client is confused and disoriented. Which of these interventions promotes reminiscence?
Showing the client a picture of when they baked cookies with their grandchildren
What are normal physiological changes associated with aging?
Smooth, brown, irregularly shaped spots on the backs of hands and forearms
A nurse in a long-term care facility is caring for several older adults with noticeable hearing loss. Which is the best way for the nurse to communicate with these clients?
Speak in a low and distinct voice tones.
Which are developmental stressors for clients? Select all that apply.
Starting a family Starting retirement Turning 50 years old
When assessing an older adult, the nurse knows which is a normal and physiological change related to aging?
Taking longer for the heart rate to return to baseline after exercise
During a home health visit, a nurse talks with a client and their family caregiver about the client's medications. The client has a history of hypertension and renal disease. Which client findings place the client at risk of an adverse drug event? Select all that apply.
Taking two medications for hypertension Taking a total of eight different medications during the day Client's health history of renal disease
A home health nurse is caring for an older couple living in their home. The clients have children and grandchildren that live far away who typically visit once or twice a year. The husband is beginning to show signs of Alzheimer's disease and mobility issues. The wife has had some difficulty managing her diabetes. She is willing to help her husband and maintain his safety. What kind of support should the nurse give the wife regarding caring for her husband?
Teach the wife about this progressive disease and the need to promote as much independence as possible.
The nurse is providing support for a caregiver who is feeling burntout. Which are appropriate suggestions for coping? Select all that apply.
Tell the caregiver to set aside time for themselves. Encourage the caregiver to participate in a support group. Listen to the caregiver's concerns and feelings. Introduce stress-reducing methods to the caregiver.
Tell the client that they need to reposition or get out of bed as much as possible.
Tell the client that they need to reposition or get out of bed as much as possible.
A 68-year-old client who is hospitalized with pneumonia became disoriented and confused 3 days after admission. Which information indicates that the client is experiencing delirium rather than dementia?
The client was oriented and alert when admitted.
When is the risk of abuse of an older adult family member the greatest?
The older adult has more than one chronic illness.
When caring for an older adult, which information is important to consider?
Treat the client as an individual with a unique history of their own.
