Gerontology HESI Practice
An older male client with heart failure (HF) complains of chronic constipation and wants to retrain his bowel. Which information should the registered nurse (RN) offer the client for establishing regular bowel habits?
(A) Add whole grain foods and fibrous vegetables to diet. Rationale: Increasing daily fiber (A) with increasing fluid intake are the best tools to use when retraining bowel habits.
An older male client is seeking counseling about his recent sexual issues with his partner. What issue should the registered nurse (RN) explore in this discussion? A. Certain mediations may impact sexual function B. Normal aging affects sexual function in male clients C. Safe sex is not necessary with older sexually active elders D. Sexual interest usually declines with aging in male clients
(A) Certain medications may impact sexual function Rationale: Certain medications can have a direct influence on sexual function and should be discussed with older clients (A).
The home health registered nurse (RN) is changing an older client's wet to dry dressing. Which observation should the RN evaluate as a therapeutic response with the removal of the dry dressing? A. Debridement and removal of slough and eschar B. Drainage of purulent exudate from the wound C. Moist skin edges around the wound field D. Presence of capillary growth in the wound
(A) Debridement and removal of slough and eschar Rationale: Wet to dry dressings begin with a wet packing inside of the wound, and then a dry gauze is used to cover the wet packing to wick drainage and bacteria away from the wound to promote healing. Removal of dried dressing provides debridement by removing exudate, sloughing tissue, and eschar.
An older female client arrives for an annual visit by the urologist due to a history of changes in serum values related to renal function. What changes should the registered nurse (RN) expect for an older client due to normal aging? A. Decrease in glomerular filtration rate (GFR) B. Hematuria during urinalysis C. Chronic bladder infections
(A) Decrease in glomerular filtration rate (GFR) Rationale: GFR often decreases (A) with normal aging due to a decrease in blood flow through the kidneys, causing renal function test results to vary the clearance of metabolic waste.
The registered nurse (RN) is observing the skin of an older client. Which finding should the RN document as consistent with the normal aging process? A. Decreased elasticity B. Tough and leathery texture C. Shiny and edematous D. Excessive hair growth on the head
(A) Decreased elasticity Rationale: Loss of elasticity is a common finding of the normal aging process (A). The skin of elderly clients becomes thin and fragile with aging, not
The registered nurse (RN) is assigned to the care of an older client with venous stasis ulcers. A primary goal in the client's plan of care is to decrease swelling in the extremities. What action should the RN take to meet this goal? A. Elevate the legs on pillows B. Decrease fluid intake C. Decrease salt intake in diet
(A) Elevate the legs on pillows Rationale: Venous insufficiency is causing intravenous fluids to move into the interstitial spaces, causing edema. To promote gravity drainage, the extremities should be elevated.
An older client with chronic kidney disease (CKD) has an arteriovenous fistula (AV) in the left forearm for for hemodialysis. After palpating the AV fistula, which finding is an indication that the AV fistula is functioning properly? A. Enlarged veins B. Redness around the site C. Decreased pulses below fistula D. Marked ecchymotic areas
(A) Enlarged veins Rationale: The mixing of arterial and venous blood in an AV fistula causes the veins to enlarge (A), which facilitate cancelation for hemodialysis.
After a transurethral resection of the prostate (TURP), an older man returns to the medical surgical floor with a 3-way indwelling urinary catheter. The registered nurse (RN) observes the catheter's tubing for drainage when the client states that he needs to void. What should the RN implement based on this finding?
(A) Irrigate the bladder through the catheter port Rationale: The feeling of urgency can be caused by blood clots that can occlude drainage of the catheter, which is a common occurrence in the first 72 hours after a TURP. The urgency is an indication that the client's bladder is not emptying, and the RN should irrigate catheter (A) to relieve symptoms caused by a clot.
The home health registered nurse (RN) is reinforcing instructions to the family about how to prevent pressure ulcers for their older family member who is bedridden. Which measure should the RN discuss? A. Lift the client when turning instead of sliding B. Massage directly over reddened sites C. Change client's position every 4 hours D. Place pillows under both the knees
(A) Lift the client when turning instead of sliding Rationale: Lifting instead of sliding (A) decreases chances of friction and shearing while moving the client.
The registered nurse (RN) is reinforcing discharge instructions to the family of an older client with failure to thrive. What information should the RN include to promote nutritional intake for the client? (Select all that apply.)
(A) Minimize stress level by providing the client with a quiet environment during meals (B) Provide food variations that the client can manage without assistance Rationale: (A and B) are correct and continue to promote independence and decreased stress for the client, which will increase the opportunity for nutritional intake.
The registered nurse (RN) is caring for an elderly client with functional incontinence who lives in an assisted living community. The client is alert and mildly confused and can self-ambulate. Which nursing intervention should the RN implement?
(A) Offer assistance with toileting q2 hours Rationale: Maintaining independence and self-esteem is important for an older client with incontinence. (A) decreases the client's chances of accidents and embarrassment by introducing a toilet training program.
An older woman asks the registered nurse (RN) how she can decrease her chances of getting cystitis. What information should the RN provide? A. Void and empty the bladder completely every 2 to 3 hours B. Take warm sits baths with bubble bath to cleanse the vulva C. Decrease fluid volume intake to reduce urgency
(A) Void and empty the bladder completely every 2 to 3 hours Rationale: (A) minimizes over distention, which can compromise blood supply to the bladder wall and cause irritation to the bladder.
An older client who is unconscious is admitted after experiencing a head injury from a fall. Glasgow Coma Scale (GCS) is prescribed to evaluate the client. Which focused assessments should the registered nurse (RN) use to determine the client's GCS score? (Select all that apply.) A. Verbal response B. Motor response C. Eye opening D. Pupillary reaction E. Hearing
(A), (B), (C) Rationale: (A, B, and C) are correct. The Glasgow Coma Scale evaluates verbal response (A), motor response (B), and eye opening (C)
An older resident is newly admitted to an assisted living community. Which actions should the registered nurse (RN) implement to provide the resident ways to maintain safe medication administration? (Select all that apply.) A. Locked medication storage in the client's room B. Medication administration record (MAR) C. Payment forms for prescribed medications D. Delivery of adequate supply of medication E. List of findings indicating medication effectiveness
(A), (B), (D), (E) Rationale: (A, B, D and E) are correct. For safe self-medication in an assisted living community, the resident should be provided a locked storage box, create a medication administration record to monitor medication, establish adequate medication supply; and a reference to evaluate the effectiveness of medications.
An older male client asks the registered nurse (RN) how he can reduce his incidents of hemorrhoidal flare ups. What information should the RN offer the client about how to prevent rectal discomfort? (Select all that apply.) A. Increase fiber and liquids in the diet to help prevent constipation and straining B. Change exercise program to reflect less cardio-exercise and more weight training C. Use a therapeutic cushion or frequent repositioning for periods of prolonged sitting D. Take frequent warm sits baths and do not use abrasive paper that can traumatize tissues E. Establish bowel habits by scheduling daily time to defecate when the client is not rushed
(A), (C), (D) and (E) Rationale: (A, C, D and E) are correct. Fluids, comfort measures, and establishment of a regular bowel pattern help reduce incidents of hemorrhoid inflammation. Weight training can aggravate hemorrhoids and is not effective in reducing hemorrhoid irritation.
An older male client with Parkinson's disease (PD) is discharged home with levodopa-carbidopa (Sinemet) and instructions to his wife for his care. What statement best indicates to the registered nurse (RN) that the wife understands her husband's needs? A. "It is important to keep my husband in a chair or in bed as much as possible and prevent him from falling." B. "I will notify the healthcare provider if my husband has increasing involuntary movements of his extremities." C. "Since it is difficult for my husband to eat, we should stay in the house instead of going out to dine."
(B) "I will notify the healthcare provider if my husband has increasing involuntary movements of his extremities." Rationale: Increasing involuntary movements (B) should be reported during the use of levodopa; it is an indicator that the body is failing to readjust to the changes in the level of the intracerebral neurotransmitter dopamine. The client should be encouraged to engage in exercise and regular daily activities. Socialization and activities as tolerated help to prevent the client from becoming depressed.
Osteoporosis increases the risk for a hip fracture in older adults, and women are more likely to have osteoporosis than men. Women of which ethnic group have the highest risk for a hip fracture? (Arrange with the highest risk first and the lowest risk last.)
(B) Caucasian (C) Asian (D) Hispanic (A) African American Rationale: Caucasian women have the highest risk for hip fractures secondary to osteoporosis. Women of Asian descent have the second highest risk, followed by Hispanic women and African American women.
The home health registered nurse (RN) is assessing an older client for a pressure ulcer. Which finding should the RN observe the area for a Stage I pressure ulcer? A. Superficial skin breakdown and flaking B. Deep pink, red or mottle skin C. Subcutaneous damage or necrosis D. Skin that blanches pink when pressed
(B) Deep pink, red or mottled skin Rationale: Temporary blanching of an area can last for over a minute due to poor circulation. Deep pink, red or mottle skin (B) is a finding consistent with Stage I pressure ulcer.
An older client who recently moved into an assisted living community refuses to eat or join any activities. When evaluating the client further, what should the registered nurse (RN) focus on during the next examination? A. Anxiety B. Depression C. Exhaustion D. Confusion
(B) Depression Rationale: Depression is a symptom that an older client is likely to experience with a sudden change in living accommodations when a loss of personal identity can create low self-esteem, (B) is most likely and most important for the RN to focus on.
The healthcare provider prescribes a new medication, atorvastatin (Lipitor), for an older client who arrives at the clinic for an annual physical examination. What common side effect should the registered nurse (RN) advise the client to observe with this medication?
(B) Headaches Rationale: Headaches (B) are the most common side effect with this medication, which the RN should direct the client to report.
An older client is admitted with a preliminary diagnosis of Addison's disease. Which skin finding should the registered nurse (RN) document that is typical with Addison's disease? A. Moon face B. Hyperpigmentation C. Excessive acne D. Multiple skin tags
(B) Hyperpigmentation Rationale: Addision's disease is characterized by a deficiency in the production of adrenal cortex hormones, which results in anterior pituitary feedback to secrete stimulating hormones, such as melanocyte stimulating hormone (MSH) that increases melanin production. (B) is seen in clients with Addison's disease.
An older male client is admitted for emergency treatment of acute closed-angle glaucoma. The registered nurse (RN) begins administering the prescribed miotic medications and glycerin (Glycol) therapy. Which intervention is most important for the RN to maintain during the client's therapy?
(B) Monitor intake and output q2 hours for 24 hours Rationale: Monitoring intake and output (B) is most important during the administration of glycerin (Glycol) due to the rapid acting osmotic diuretic effect of glycerin therapy.
The home health registered nurse (RN) visits an older woman with heart failure (HF) who is on complete bed rest. Which intervention is most important for the RN to suggest to the client to prevent complications related to immobility? A. Get as much sleep as possible B. Perform leg exercises while in bed C. increase protein intake to combat fatigue D. Invite friends to visit to decrease risk for depression
(B) Perform leg exercises while in bed. Rationale: The client is at risk for complications related to immobility. (B) should be performed frequently to decrease the risk for thrombophlebitis.
The registered nurse (RN) is assigned the care of an older client who returns to the unit after surgery for closed angle glaucoma. What intervention in the plan of care should the RN bring to the attention of the healthcare team?
(C) Administer morphine 4 mg IM q2 hour PRN pain Rationale: Morphine side effects include nausea, vomiting and constipation, causing straining on stool, all of which can increase intraocular pressure and cause intraocular bleeding during the postoperative period. Administration of morphine 0.4 mg IM q2 hours PRN pain (C) should be discussed with the healthcare team to determine the risk of the side effects for the client.
The home health registered nurse (RN) visits an older female client with an ideal conduit who has been experiencing chronic urinary tract infections (UTI). Which intervention should the RN recommend to the client to manage the frequency of UTIs?
(C) Attach a larger drainage bag while sleeping Rationale: (C) can prevent urinary reflux if the bag fills to near capacity or greater, which can contribute to UTIs. Forcing fluids is encouraged and should exceed urinary output, which commonly should be greater than 1,000 ml
The nursing assessment of an older female elicits information that the client is diagnosed with Raynaud's phenomenon. Which exposure should the nurse instruct the client to avoid? A. Alcohol consumption B. Warm climates C. Cold climates D. Active exercise
(C) Cold climates Rationale: Exposure to cold environments (C) can cause prolonged painful vasoconstriction of the peripheral extremities (especially in hands) in client's with Raynaud's phenomenon.
A frail elderly woman visits the healthcare provider because she has been getting out of breath easily when walking long distances. Which pulmonary function change should the registered nurse (RN) expect to commonly occur with aging?
(C) Reduced vital capacity Rationale: With aging, a frail elder is likely to have a reduced vital capacity (C) due to the loss of elasticity of the lung tissue. With reduced elasticity, residual volume increases.
An older female client who is a new resident at an assisted living facility cannot remember how to get to her room. What action should the registered nurse (RN) implement? A. Schedule therapy and social activities in her room B. Ask another resident to help the client C. Show client how to follow hallway signs to her room D. Move client to a room close to nurses station
(C) Show client how to follow hallway signs to her room Rationale: Teaching the client how to follow hallway signs to her room
When assessing an older client, which age-related changes in the cardiovascular system should the registered nurse (RN) document? (Select all that apply.) A. Dyspnea B. Chest pain C. Cardiac murmurs D. Widening pulse pressure E. Irregular heart rate
(C), (D) Rationale: For older clients, the expected age-related changes in the cardiovascular system include murmurs (C) and widening pulse pressure (D). (A, B and E) are not normal findings and require further evaluation.
An older male client is admitted to the hospital with left-sided heart failure (HF). Which finding should the registered nurse (RN) document that is consistent with HF? A. Ascites B. Pitting edema C. Jugular distention D. Coarse and fine crackles
(D) Coarse and fine crackles Rationale: In left-sided heart failure, the inadequacy of pumping blood into the aorta causes blood to back up into the pulmonary capillaries; this pushes intravascular fluid into the alveoli, which is manifested as crackles or rales.
After a recent total hip replacement, an older female client, who transferred to a rehabilitation facility placement, asks the registered nurse (RN) if she broke her hip because she is old. How should the RN best respond?
(D) Older women commonly lose bone calcium which increases the risk of fracture. Rationale: The best response is to provide the client with an explanation based on aging and demineralization of the bone (D) in older females, especially after menopause.
A 64-year-old client is admitted to the hospital with a fractured right hip. One of the concerns following surgical repair is to promote dorsiflexion. Which intervention would a nurse implement? A. Begin early ambulation B. Monitor pain level C. Provide PCA instructions D. Provide a foot board
(D) Provide a foot board Rationale: A footboard supports the feet in dorsiflexion and helps prevent foot drop throughout recovery .
An older male client returns to the hospital after discharge 4 days ago for a TURP. The registered nurse (RN) evaluates the function of the 3-way indwelling urinary catheter and the continuous bladder irrigation system. Which finding should the RN report to the healthcare provider?
(D) The tubing that drains the urinary bladder has bright red urine with clots. Rationale: The presence of bright red urine with clots in the tubing draining the bladder (D) is an abnormal finding indicating active bleeding, which should have resolved 36-72 hours postoperatively and should be reported.
The home health registered nurse (RN) is visiting an older client with chronic hypertension. What evaluation is most important for the RN to complete with each visit? A. Effectiveness of medication B. Ability to ambulate C. Signs of dehydration D. Familial support
A. Effectiveness of medication Rationale: The highest priority in the care of an older client with chronic hypertension is evaluation of the effectiveness of blood pressure medication (A) and the client's compliance in order to prevent complications related to chronic disease.
An older female client recently moved to an assisted living facility. The family explains to the registered nurse (RN) that the client is unmanageable and always confused, disoriented and depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond?
A. Explain that she is in a new home called an assisted living community. Rationale: Reality re-orientation (A) is the best response for a client who is confused because the response is consistent and true.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that apply.) A. Needs are greater than the caretaker's abilities B. Client's declining strength C. Fixed income D. Longer life expectancy E. Lack of exposure to technology and trends
A. Needs regretter than the caretaker's abilities B. Client's declining strength Rationale: When needs are not being met due to lack of ability of the caretaker (A), stress and feelings of failure may be expressed through neglect and abuse. Decline in strength (B) increases the older client's vulnerability to resist or respond to elder abuse.
An older male client arrives at the clinic for an annual physical examination. While the nurse assesses the client, the client states that he is having intimacy problems with his wife. Which information should the nurse provide to elicit more information from the client?
A. Query client to clarify the client's idea of an intimacy problem. Rationale: Clarification of the client's concern is needed to appropriately address the specific concern about intimacy issues (A).
An older client who is a resident in a long-term care facility is receiving medications through a gastric tube (GT). After interrupting the continuous GT feeding in which sequence should the nurse implement these actions for administration of crushed medications? (Arrange in order from first to last step.) A. Flush the feeding tube of feeding solution B. Crush the medication into a powder or fine granules C. Administer each medication separately D. Dissolve each crushed medication in a medicine cup E. Flush GT to clear the medication from the tubing F. Reconnect the gastric feeding tube
B - D - A - C - E - F Rationale: The sequence begins with crushing and dissolving the medications. Then flushing the GT of feeding formula and giving each medication separately. When all medications have been given, the feeding tubing should be flushed to clear the medication, and the GT should be reconnected. If the medications are compatible with food, the continuous GT formula can be restarted.
Since his arrival in an assisted living community, an older male client is having difficulty going to sleep. Which intervention should the registered nurse (RN) implement first? A. Encourage client to take a warm bath at night B. Ask the client what has helped him in the past C. Recommend that the client not take daytime naps D. Offer the client a glass of warm milk before bedtime
B. Ask the client what has helped him in the past. Rationale: Asking the client (B) about his sleeping habits involves the client in his own care and preserves his autonomy as he adapts to living in a new community.
A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding is most important for the registered nurse (RN) to report to the healthcare provider? A. Fever and chills B. Confusion and dehydration C. Crackles in the lung fields D. Nausea and vomiting
B. Confusion and dehydration Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and perfusion in this frail elderly client. (are all common with pneumonia, but the most important finding is confusion and evidence of dehydration, which require treatment for this frail elderly client.
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a long history of smoking and still smokes a pack of cigarettes a day. Which finding should the registered nurse (RN) report to the healthcare provider?
B. Crackles and pulse oximetry level of 88% Rationale: With pneumonia, crackles in the lungs and low O2 saturation, can impact adequate oxygenation, which should be reported to the Health Care Provider.
A family member brings their aging father to the clinic because he has been alert and oriented during the day but agitated and disoriented in the evening. The registered nurse (RN) reviews the client's list of current medications with the client and family. Which action taken by the RN is most important?
B. Multiple medications can contribute to sundowner like symptoms. Rationale: Older clients may see a variety of HCP which can increase the chance of polypharmacy that compounds the workload of metabolic pathways that may be less efficient due to the aging process. Multiple medication interactions may contribute to sundowner like symptoms; reviewing medication actions and interactions provides the information that may indicate polypharmacy leading to sundowner syndromes.
An older female client who has been taking hydrocodone/acetaminophen (Lortab) q4 hours for chronic back pain for the past 5 years tells the registered nurse (RN) that she cannot live without her pain pills. When asked if she is addicted, the client states that she is not an addict because the healthcare provider prescribed the pain pills. Which coping mechanism should the RN determine the client is using about her addiction?
B. Rationalization to support narcotic use. Rationale: The client is using rationalization to maintain self-esteem when she is questioned by stating that she is not addicted because she is taking medication prescribed by a healthcare provider.
The registered nurse (RN) is caring for an older female client with a 20 year history of rheumatoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated with RA should the RN document?
B. Small joint involvement in fingers. Rationale: Small joint involvement (B) is common in rheumatoid arthritis.
An older client is transferred to a telemetry unit after placement of a pacemaker. What action should the registered nurse (RN) take first? A. View incision site B. Obtain a blood pressure C. Establish telemetry monitoring D. Evaluate client for pain
C. Establish telemetry monitoring. Rationale: The first action is to establish continuous telemetry monitoring (C) to ensure the pacemaker is functioning properly.
The hospice nurse is completing a focused assessment of an older female client with end stage Alzheimer's disease, who recently fractured her hip. What technique should the registered nurse (RN) use to determine the client's pain?
C. Observe for facial grimacing Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a client who cannot communicate due to Alzheimer disease.
The registered nurse (RN) is re-enforcing discharge instructions with the family of an older client who was recently admitted for an intestinal obstruction. Which statement indicates that the family understands the instructions?
C. Report abdominal distention, constipation, or any nausea and vomiting to the healthcare provider. Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed immediately.
A new resident in an assisted living facility is an older client who is experiencing short-term memory loss and confusion. Which activity should the registered nurse (RN) schedule the client to do during the day?
D. Daily exercise group Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the client's stress to remember.
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake because food does not taste as good as it used to so they have to season most foods. What information should the RN offer the couple?
D. Taste buds are often dull due to atrophy so older clients should use other seasonings instead of salt. Rationale: Taste buds atrophy with normal aging, which influences an older client's sensitivity to taste and is often compensated for the use of stronger tasting seasonings. (
During the quarterly evaluations of the clients in the assisted living community, the registered nurse (RN) assesses for findings of failure to thrive in the older population. What findings should the RN document and report as manifestations related to failure to thrive? (Select all that apply.)
Unintentional weight loss Increased weakness Increased amounts of sleep Rationale: Symptoms of failure to thrive in the older population include weight loss, weakness and excessive sleep, which should be documented and evaluated by a healthcare provider immediately.