Health Assessment Chapter 32: Assessing Older Adults 5-8

Rales

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 Stridor Wheezing Pleural friction rub

fasting blood glucose is 108 mg/dl (6 mmol/L)

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) body mass index (BMI) is 24 reports 7 hours consecutive sleep per night blood pressure 118/75 mm Hg with antihypertensive medication

Solar lentigines

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? Actinic keratoses Solar lentigines Senile purpura Seborrheic keratoses

Cystocele

A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as what abnormal finding? Rectocele Atrophic vaginitis Uterine prolapse Cystocele

Delirium

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? Infection Delirium Acute pain Depression

Katz Activities of Daily Living tool

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? Activity tolerance testing Katz Activities of Daily Living tool Vision testing Get Up and Go test

Risk for Injury.

A priority nursing diagnosis for the client experiencing altered perception, extreme agitation, and acute confusion is: Altered Role Performance. Disturbed Sensory Perception. Risk for Injury. Impaired Verbal Communication.

Are you taking any drugs for high blood pressure?

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? 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? Have you ever been tested for diabetes mellitus?

Venous insufficiency

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? Partial obstructed blood flow Venous insufficiency Complete obstructed blood flow Arterial insufficiency

"It occurs with aging but is encouraged by sitting too much."

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 occurs with aging but is encouraged by sitting too much." "There is nothing that can be done to avoid it." "It means that you have a vitamin deficiency." "It happens because of not enough of protein in the diet."

Water

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? Vitamin B1 Water Protein Vitamin C

geriatric syndromes

Common conditions or problems that accompany aging are often called conditions of aging symptoms of aging geriatric syndromes geriatric symptoms

fall risk

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? independence skin breakdown fall risk nutrition

Senile purpura

During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding? Senile purpura Dermatomycosis Shingles Actinic keratoses

"Tell me your beliefs about the illness you are experiencing."

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? "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." "Tell me your beliefs about the illness you are experiencing."

Petechiae

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? Shingles Actinic keratoses Petechiae Senile purpura

Tenting of the skin when pinched.

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. A furrowed tongue. Dry warm skin. Sunken eyes.

Prepare foods that are pudding consistency or semisolid

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? Check the mouth frequently for retained food Prepare foods that are pudding consistency or semisolid Offer water with meals to clear the throat Keep the client upright for 30 minutes after eating

Document findings and refer the client for follow-up

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 Take no action, because the findings correspond with a normal mole Document findings as a normal age spot Call the physician immediately

Pneumonia

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? Sepsis Bleeding Pneumonia Pressure ulcers

Address the family member if the client hesitates when answering a question

The nurse is assessing an older adult with intact cognition. A younger family member is present. The client is slightly hearing impaired, so the nurse must speak up. What should the nurse never do in relation to the client in this situation? Direct all questions to the client, not the family member Address the family member if the client cannot provide information Address the family member if the client hesitates when answering a question Wait for an answer from the client even if the client is slow to recall information

"Do you have any thoughts of wanting to harm or kill yourself?"

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 struggle with completing activities of daily living?" "Do you feel sad, hopeless, and powerless every day?" "Do you have any thoughts of wanting to harm or kill yourself?" "Do you ever feel like life is mentally too much to handle?"

"As a person gets older, the kidneys do not work as well in removing waste materials."

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." "An elevated creatinine suggests increased reabsorption of this substance by the kidneys." "The kidneys filter waste materials at an increased rate as a person get older." "Creatinine is an indicator of how well the kidneys are functioning in removing wastes."

seborrheic keratosis

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: squamous cell carcinoma basal cell carcinoma malignant carcinoma seborrheic keratosis

Arms appear long in proportion to the trunk.

The nurse observes the gait and stature of an elderly client entering the room. Which of the following findings is an age-related change? Knees are flexed throughout the stance phase. Arms appear long in proportion to the trunk. The shoulder of the dominant hand is higher than the shoulder of the non-dominant hand. Gait is wide based.

medication dose medication name medication frequency client's understanding of the need for the medication

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. medication dose medication name sleep log medication frequency client's understanding of the need for the medication

Reports of constipation

When looking at a review of systems for an elderly client, which gastrointestinal data should cause the nurse the most concern? Reports of constipation Decreased production of saliva Inability to digest dairy products Early satiety

Blurring of near vision

Which of the following changes in vision is expected with normal aging? Cataract Glaucoma Macular degeneration Blurring of near vision

"Leaking urine is a normal part of aging."

Which statement by an older adult alerts the nurse that health teaching was ineffective? "Getting shorter as I get older is normal." "Leaking urine is a normal part of aging." "It is not normal for my toenails to be yellow and thick." "My hair will get thinner as I get older."