BHA 3

the nurse is caring for a healthy adult client with no history of vision problems. the nurse should tell the client that a thorough eye examination is recommended every

2 years

an objective assessment that is frequently indicated when the subjective assessment reveals a history of falling is

a get up and go test

the physical declines of aging often first become noticeable when

acute or chronic illness places excessive demands on the body

the meibomian glands secrete

an oily substance to lubricate the eyes

orthostatic hypotension is a possible adverse side effect of

anticholinergics, oral corticosteroids, steroidal inhalant

erectile dysfunction is a possible adverse side effect of

anticholinergics, steroidal inhalants

a client visits the clinic and tells the nurse that she has joint pain in her hands, especially in the morning. the nurse should assess the client further for signs and symptoms of

arthritis

while assessing the elbow of an adult client, the client complains of pain and swelling. the nurse should further assess the client for

arthritis

while assessing an older adult client, the client complains of chronic pain and severe limitation of all should movements. the nurse should refer the client to a physician for possible

calcified tendinitis

significant decrease in central vision

cataract

a common sign and symptom of depression in the elderly is

cognitive impairment of pseudodementia

type of rigidity characterized by jerky movements with passive stretching

cogwheel

a sign of infection in the elder that is more common than fever is

confusion

crackling sound or sensation heard or felt with joint movement

crepitus

noticeable loss of vision and distortion of familiar objects and occasional floaters

diabetic retinopathy

a gastrointestinal problem that often requires emergency treatment in the frail elder is

diverticulitis

accumulation of fat around the cervical vertebrae, especially in women, is known as

dowager's

____ increases the risk of choking and aspiration and may contribute to dehydration and malnutrition

dysphagia

____ deprivation leads to atrophy of vaginal and vulvar epithelium

estrogen

movement bringing a limb into or toward a straight condition

extension

a client visits the clinic and tells the nurse that after playing softball yesterday, he thinks his knee is 'locking up'. the nurse should perform McMurray test by asking the client to

flex the knee and hip while in a supine position

an older adult client visits the clinic and tells the nurse that she has had shooting pain for the past several days. the nurse should assess the client for signs and symptoms of

herniated intervertebral disc

an adult client visits the clinic and tells the nurse that he has been experiencing double vision for the past few days. the nurse refers the client to a physician for evaluation of possible

increased intracranial pressure

abnormal convexity of the posterior curve of spine

kyphosis

a benign skin lesion commonly seen in the aged is

lentigines

a client visits the clinic and tells the nurse that he has had lower back pain for the past several days. to perform lasegue test, the nurse should ask the client to

lie flat and raise his legs to the point of pain

blurriness of words in center of the page

macular degeneration

type of flexion associate with foot extension

plantar

loss of elasticity in aorta and arteries

rise in systolic blood pressure

calcification, stiffening, and dilation of the aortic valve

soft systolic murmur at base of heart

the nurse is preparing to draw a genogram of a client's family. the symbol from male members of the family triangle is a

square

a key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is

the degree to which dyspnea affects daily function

(t/f) entropion is a condition that causes the lower eyelashes to touch the cornea and conjunctiva

true

(t/f) loss of intimacy is among one of the greatest losses for many older adults

true

sensory receptors in the ear that help to maintain both static and dynamic equilibrium are located in the semicircular canals and the

vestibule

a client tells the nurse that his grandmother has a diagnosis of osteomalacia. the nurse should instruct the client that to decrease the risk factors for osteomalacia, the clients should have adequate amounts of

vitamin D

to compensate for a stooped posture and less flexible knee, hip, and should joints, the elderly person often walks

with the feet farther apart and the knees slightly bent

by age 90, renal blood flow has usually decreased by approximately

50%

decreased ventricular compliance

S4

while assessing an adult client's jaw, the nurse hears a clicking popping sound, and the client expresses pain in the joint. the nurse should further assess the client for

TMJ dysfunction

a neurologic change associated with normal aging is

a decrease in reaction time

constipation is a possible adverse side effect of

anticholinergics, oral corticosteroids

the transmission of sound waves through the external ear and the middle ear is known as

conductive hearing

while assessing the eye of an adult client, the nurse observes an inward turning of the client's left eye. the nurse should document the client's

esotropia

movement that brings a limb into or toward a bent condition

flexion

a diagram of the family tree showing genetics, generational information, and relationships of family members

genogram

an adult client tells the nurse that her peripheral vision is not what it used to be and she has a blind spot in her left eye. the nurse should refer the client for evaluation of possible

glaucoma

an adult client tells the nurse that he eats sardines every day. the nurse should instruct the client that a diet high in purines can contribute to

gouty arthritis

a broad definition of the family includes two or more persons who

have mutual decision making

an adult client visits the clinic and tells the nurse that she has had a sudden change in her vision. the nurse should explain to the client that sudden changes in vision are often associated with

head trauma

while examining the spine of an adult client, the nurse notes that the client has a flattened lumbar curvature. the nurse should refer the client to a physician for possible

herniated disc

articulation between the head of the femur and the acetabulum is in the

hip joint

while reviewing a client's charts before seeing the client for the first time, the nurse notes that the client has a diagnosis of dupuytren contracture. the nurse anticipates that the client will exhibit

inability to extend the ring and little finger

___ are brown pigmented areas caused by hyperpigmentation of the skin due to exposure to sunlight

lentigines

the nurse is preparing to inspect the nose of an adult client with an otoscope. the nurse plans to

position the handle of the otoscope to one side

diminished vibratory sensations and slowed motor responses in advanced age result in

postural instability

hearing loss associated with aging is called

presbycusis

one of the functions of a bone is to

produce blood cells

the bony orbit and fat cushion of the eye serves as a

protector

the position of the children within a family based on age and gender

rank order

straight movements of the eye are controlled by the

rectus muscles

floaters associated with flashes of light

retinal detachment

a client visits the clinic and tells the nurse that she has painful cracking in the corners of her lips. the nurse should assess the client's diet for a deficiency of

riboflavin

any new onset of incontinence in the frail elderly should be investigated for

urinary tract infection

when the nurse moves the client's arm away from the midline of the body, the nurse is performing

abduction

the functional reflex that allows the eyes to focus on near objects is termed

accomodation

after examining the client's tympanic membranes, the nurse documents "right tympanic membrane red and bulging with no light reflex." the nurse recognizes that these are signs of

acute otitis media

moving limbs toward median plane of the body

adduction

an adult client tells the nurse that she frequently experiences burning and itching of both eyes. the nurse should assess the client for

allergies

the nurse has assessed the nose of an adult client and has explained to the client about her thick yellowish nasal discharge. the nurse determines that the client understand the instruction when the client says that the yellowish discharge is most likely due to

an upper respiratory infection

an adult client visits the clinic complaining of recurrent ulcers in the mouth. the nurse assess the client's mouth and observes a painful ulcer. the nurse should document the presence of

aphthous stomatitis

the nurse is assessing an adult client's oral cavity for possible oral cancer. the nurse should explain to the client that the most common site of oral cancer is the

area underneath the tongue

the nurse is assessing the mouth of an older adult and observes that the client appears to have poorly fitting dentures. the nurse should instruct the client that she may be at greater risk for

aspiration

the conjunctiva of the eye is divided into the palpebral portion and the

bulbar portion

inflammation of the bursa

bursitis

an adult client tells the nurse that he has been experiencing gradual vision loss. the nurse should

check the client's blood pressure

the middle layer of the eye is known as the

choroid layer

the nurse has performed the rinne test on an older adult client. after the test, the client reports that her bone conduction sound was heard longer than the air conduction sound. the nurse determines that the client is most likely experiencing

conductive hearing loss

the nurse has tested an adult client's visual fields and determined that the temporal field is 90 degrees in both eyes. the nurse should

document the findings in the client's records

backward bending or flexion of a joint

dorsiflexion

diagram of the family's contact with larger systems

ecomap

the cone of light is located in the

external ear

bones contain yellow marrow that is composed mainly of

fat

the nurse is preparing the examine the ears of an adult client with an otoscope. the nurse should plan to

firmly pull the auricl, out, up, and back

in the hearing pathway, hair cells of the spiral organ of corti are stimulated by movement of

fluid

behaviors expected of family members based on their sex and family beliefs about masculinity and feminity

gender role

cybernetics, as applied to families, combines communication with

general systems theory

while assessing the ears of an adult client, the nurse observes that the tympanic membrane is completely immobile. the nurse should further assess the client for signs and symptoms of

infection

the ability of a family to carry out activities of daily living is a family function termed

instrumental

in the most functional families, parents have power that

is shared by both parents

an adult client tells the nurse that his 80-year-old father is almost completely deaf. after an explanation to the client about risk factors for hearing loss, the nurse determines the client needs further instruction when the client says

it is difficult to prevent hearing loss or worsening hearing

bones in synovial joints are joined together by

ligaments

the nurse is preparing to examine the sinuses of an adult client. after examining the frontal sinuses, the nurse should proceed to examine the

maxillary sinuses

the tarsal plates of the upper eyelid contain

meibomian glands

an example of a subsystem of a family is

mother-son

in the assessment of the family's home environment, and important characteristic for the nurse to assess is the

neighborhood's safety

one example of a complementary birth order of spouses is

oldest son marries youngest daughter

the optic nerves from each eyeball cross as the

optic chiasma

transmission of sound waves in the inner ear is known as

perceptive hearing

the nurse is preparing to examine an adult client's eyes using a snellen chart. the nurse should

position the client 20 feet away from the chart

a nurse assesses the mouth of an adult male client and observes a rough, crusty, eroded area. the nurse should

refer the client for further evaluation

an adult client visits the clinic and tells the nurse that she has been experiencing frequent nosebleeds for the past month. the nurse should

refer the client for further evaluation

while assessing the ears of an adult client. the nurse observes bloody drainage in the client's ear. the nurse should

refer the client to a physician

photoreceptors of the eye are located in the eye's

retina

according to the theory by Minuchin, disengaged families have boundaries that are

rigid

families with poorly differentiated members will exhibit

rigid patterns of interactions

young adult's shift toward separation from the family of origin

self-differentiation

while assessing the family, the nurse determines that the family's parental practices are based on control, coercion, and punishment. these parenting practices discourage

socialization

the ossicles contained in the middle ear include the malleus, the incus, and the

stapes

an adolescent client tells the nurse that her mother says she grinds her teeth when she sleeps. the nurse should explain to the client that grinding the teeth may be a sign of

stress and anxiety

the nurse is planning to conduct the weber test on an adult male client. to perform this test, the nurse should plan to

strike a tuning fork and place it on the center of the client's head or forehead

when the nurse moves a client's leg upward, the nurse is performing

supination

an adult client visits the clinic and complains of tinnitus. the nurse should ask the client if she has been

taking antibiotics

the internal structure of a family includes

the gender of the members

an adult client tells the nurse that his father had cataracts. he asks the nurse about risk for cataracts. the nurse should instruct the client that a potential risk factor is

ultraviolet light exposure

a client tells the nurse that she has difficulty seeing while driving at night. the nurse should explain to the client that night blindness is associated with

vitamin A deficiency

a characteristic sign of delirium is

a rapid decline in level of alertness

the chambers of the eye contain aqueous humor, which helps to maintain intraocular pressure and

cleanse the cornea and the lens

while assessing the eyes of an adult client, the nurse uses a wisp of cotton to stimulate the client's

corneal reflexes

the nurse is planning to inspect an adult client's mouth, using a tongue depressor. the nurse should plan to

depress the tongue blade slightly off center

before examining the mouth of an adult client, the nurse should first

don clean gloves for the procedure

(t/f) a swollen, red, and painful tongue may indicate vitamin E deficiency

false

some symptoms are common in elderly clients. which of the following is less likely to be a common problem in old age?

fever

an adult client visits the clinic and tells the nurse that he has had excessive tearing in his left eye. the nurse should assess the client's eye for

lacrimal obstrcution

the nurse is planning a presentation on osteoporosis to a group of high school students. which of the following should the nurse plan to include in the presentation?

moderate strenuous exercise tends to increase bone density

tenderness or pain in the muscle

myalgia

usually considered to include father, mother, and children

nuclear family

decreased baroreceptor sensitivity

orthostatic hypotension

the subacromial bursae are contained in the

shoulder joint

a 45-year-old client tells the nurse that he occasionally sees spots in front of his eyes. the nurse should

tell the client that these often occur with aging

an adult client visits the clinic complaining of a sore throat. after assessing the throat, the nurse documents the client's tonsils as 4+. the nurse should explain to the client that 4+ tonsils are present when the nurse observes tonsils that are

touching each other

an adult client visits the outpatient clinic and tells the nurse that he has a throbbing aching pain in his right eye. the nurse should assess the client for

a foreign body in the eye

a risk factor for sinusitis in the frail elderly is

a nasogastric feeding tube

whitish or yellow-tinged patched in mouth are possible adverse side effects of

antidepressants, anticoagulants

GI bleeding is a possible adverse side effect of

antihypertensives

while assessing muscle strength in an older adult client, the nurse determines that the client's knee joint has a rating of 3 and exhibits active motion against gravity. the nurse should document the client's muscle strength as being/having

average weakness

the nurse is assessing a client who has been taking antibiotics for an infection for 10 days. the nurse observes whitish curd-like patches in the client's mouth. the nurse should explain to the client that these spots are most likely

candida albicans infection

feedback system of reciprocal communication between people

circular communication

an adult client tells the nurse that his eyes are painful because he left his contact lenses in too long the day before yesterday. the nurse should instruct the client that prolonged wearing of contact lenses can lead to

corneal damage

the nurse has tested the near visual acuity of a 45-year-old client. the nurse explains to the client that the client has impaired near vision and discusses a possible reason for the condition. the nurse determines that the client understood the instrcutions when the client says that presbyopia is usually due to

decreased accomodation

according to bowen's family theory, differentiation of self is assessed by

determining the boundaries of the subsystems in the family structure

the nurse is planning a presentation to a group of high school students about the risk factors for oral caner. which of the following should be included in the nurse's plan

diets low in fruits and vegetables are a possible risk factor for oral cancer

the range and types of feelings that are openly expressed or acceptable to be communicated within a family

emotional communication

one element of the context of a family's structure is

ethnicity

(t/f) atrophy of the eccrine glands decreases the risk of hyperthermia in elder clients

false

(t/f) systolic and diastolic pressure falls with age due to loss of elasticity of the aorta and arteries

false

joints may be classified as cartilaginous, synovial, or

fibrous

similarity of illness or behaviors that run through the family from one generation to the next

multigenerational patterns

messages sent through body position, eye contact, touch, gestures, tone of voice, crying, stammering, etc

nonverbal communication

the nurse is planning to perform an ear examination on an adult client. after explaining the procedures to the client, the nurse should

observe the client's response to the explanations

while assessing the musculoskeletal system of an adult client, the nurse observes hard painless nodules over the distal interphalanged joints. the nurse should document the presense of

osteoarthritis

a client with insulin-dependent diabetes visits the clinic and complains of painful hip joints. the nurse should asses the client carefully for signs and symptoms of

osteomyelitis

a female client visits the clinic and tells the nurse that she began menarche at the age of 16 years. the nurse should instruct the client that she is at a higher risk for

osteoporosis

the external covering of the bone that contains osteoblasts and blood vessels is termed the

periosteum

a client visits the local clinic after experiencing head trauma. the client tells the nurse that he has a consistent blind spot in his right eye. the nurse should

refer the client to an ophthalmologist

a client has tested 20/40 on the distant visual acuity test using a snellen chart. the nurse should

refer the client to an optometrist

the nurse is examining an adult client's eyes. the nurse has explained the positions test to the client, the nurse determines that the client needs further instructions when the client says that the positions test

required the covering of each eye seperately

the nurse visits a family at home after the 16-year-old son was injured severely in an automobile accident. the client is in a wheelchair and requires 24-hour care. the client's mother is the sole caregiver, and she tells the nurse that she is saddened because "my son was such a wonderful basketball player." a priority family nursing diagnoses is

risk for dysfunctional grieving related to loss of health status of youthful family member

while assessing the range of motion in an adult client's shoulders, the client expresses pain and exhibits limited abduction and muscle weakness. the nurse plans to refer the client to a physician for possible

rotator cuff tear

the nurse is assessing the spine of an adult client and detects lateral curvature of the thoracic spine with an increase in convexity on the left curved side. the nurse suspects that the client is experiencing

scoliosis

skeletal muscles are attached to bones by

tendons

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

tenting of the skin when pinched

the nurse is caring for an adult client who is in a cast because of a fractured arm. to promote healing of the bone and tissue, the nurse should instruct the client to eat a diet that is high in

vitamin C

the nurse is preparing to perform a musculoskeletal examination on an adult client. the nurse has explained the examination procedure to the client. the nurse determines that the client needs further instructions when the client says

you'll continue with range of motion even if i have discomfort