N128 Week 2 - Adaptive Quizzing #2

Which genitourinary factor contributes to urinary incontinence in older adult clients and needs to be considered by the nurse when planning the care for these clients? Sensory deprivation Urinary tract infection Frequent use of diuretics Inaccessibility ofa bathroom

Urinary tract infection Urinary incontinence in older adults can be a Sign of urinary tract infection. Urinary tract infections affect the genitourinary tract and interfere with voluntary control of micturition. Sensory deprivation is a neurological, not a genitourinary, factor. Frequent use of diuretics is an iatrogenic, not genitourinary, factor. Inaccessibility ofa bathroom is an environmental, not genitourinary, factor.

Which finding by the nurse when assessing a 75-year-old client would be most important to report to the health care provider? Decreased lung sounds at bases Kyphosis with barrel-shaped chest Oxygen saturation at rest 93% Expiratory wheezes bilaterally

Expiratory wheezes bilaterally Expiratory wheezes require further assessment and treatment and are not normal in older clients. Decreased basilar lung sounds may occur with normal aging because of decreased elastic recoil ofthe lungs and less respiratory muscle strength. Kyphosis may occur due to osteoporosis and lead to the chest appearing barrel-shaped, but this is not an acute change and does not require urgent treatment. Oxygen saturation may decrease because of less respiratory muscle strength, fewer alveoli, and more chest wall stiffness, but this is not acute change.

A debilitated older client who has glaucoma places great value on independence. What would the nurse encourage the client to do after discharge from the hospital? Prevent stressful events that can increase symptoms Conserve eyesight by not reading or watching television Perform household chores and shopping without assistance Self-administer eye medications using appropriate technique

Self-administer the eye medications using appropriate technique The responsibility for correctly doing this task will foster independence. Preventing stressful events that increase symptoms is a laudable goal, but it does not relate to independence. Moderate use of the eyes is not contraindicated in clients with glaucoma. Performing household chores and shopping is too ambitious for a debilitated older client.

Which instructions would the nurse give a 60-year-old client who is at an increased risk for corneal damage? Select all that apply. One, some, or all responses may be correct. 'Use saline drops.' 'Increase humidity at home.' 'Wear prescribed lens for best vision.' 'Have corrective lenses solely for reading.'

'Use saline drops.' 'Wear prescribed lens for best vision.' 'Have corrective lenses solely for reading.' A client who has reduced tear production may have an increased risk for corneal damage and eye infection. Using saline eye drops and increasing the humidity may reduce dryness and decrease corneal damage. Flattening ofthe cornea causes blurred vision. The client should be instructed to have regular eye examinations and wear the prescribed lens to prevent corneal damage. All the rest ofthe instructions are associated with the pupil or lens rather than the cornea. A client whose pupils have a decreased ability to dilate has a poor capacity for acclimating to the darkness. These clients are mainly instructed to maintain good lighting to prevent an accident. A client with an inelastic lens is mainly instructed to wear corrective lenses while reading. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

To ensure antibody-mediated immunity, which actions would the nurse instruct an older client to implement? Select all that apply. One, some, or all responses may be correct. Obtain a shingles vaccination. Receive a tetanus booster injection. Obtain the pneumococcal vaccination. Receive annual testing for tuberculosis. Receive an annual influenza vaccination. Avoid obtaining the pertussis vaccination.

Obtain a shingles vaccination Receive a tetanus booster injection Obtain the pneumococcal vaccination Receive an annual influenza vaccination Because older adults are less able to make new antibodies in response to the presence of new antigens, they should receive the shingles vaccination. Because older adults may not have sufficient antibodies present to provide protection when they are reexposed to microorganisms they have already generated antibodies against, booster shots are encouraged. The pneumococcal and influenza vaccinations help create antibodies in response to new antigens. Testing for tuberculosis addresses cell-mediated immunity for the older client. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some of the options may relate My to the situation.

Which nursing intervention would be helpful in meeting the needs of an older adult with Alzheimer disease? Providing nutritious foods that are high in carbohydrates and protein Offering opportunities for choices in the daily schedule to stimulate interest Developing a consistent plan with a fixed time schedule to fulfill emotional needs Simplifying the environment as much as possible by limiting the need for decisions

Simplifying the environment as much as possible by limiting the need for decisions Simplifying the environment as much as possible by limiting the need for decisions is the nursing intervention that would be helpful for a client with Alzheimer disease. Clients with this disorder need a simple environment. Because of brain cell destruction, they are unable to make choices or decisions. A well—balanced diet is important throughout life, notjust during senescence; a diet high in carbohydrates and protein may be lacking in other nutrients such as fat. The client with dementia may be incapable of making choices; providing alternative choices will increase anxiety. Emotional needs must be met on a continuous basis, notjust at fixed times.

Which response would the nurse make to a client's daughter who asks when it would be best to visit her mother who has Alzheimer disease? 'Around 2:30 in the afternoon would be a good time to visit.' 'Whenever is most convenient tor you. She'll be glad to see you.' 'Come at noon. You'll be able to go to the dining room and visit while she eats.' 'The longest uninterrupted time begins after supper and extends until bedtime, at 8:30 PM.'

'Around 2:30 in the afternoon would be a good time to visit.' The nurse would say, 'Around 2:30 in the afternoon would be a good time to visit.'A client with Alzheimer disease will be most alert in the midatternoon because ofthe presence of sunlight and decreased activity in the environment. Telling the daughter to come whenever it is most convenient for her does not take into consideration the client's circadian rhythms and stressors within the environment that may affect the client. As environmental stimuli increase, the client is at risk for increased contusion, restlessness, agitation, and combative behavior. Thus, coming at noon is inadvisable. Also, talking while eating can be confusing for the client with Alzheimer disease. The evening (after supper and continuing until bedtime, at 8:30 PM) is when the sundown syndrome occurs; clients with Alzheimer disease exhibit increased contusion, restlessness, agitation, wandering, and combative behavior because of misinterpretation otthe environment, lower tolerance for stress at the end ofthe day, or overstimulation resulting from increased environmental activity in the evening.

Which points require correction regarding wellness promotion in the older adult? Select all that apply. One, some, or all responses may be correct. 'Older adults need to prevent injuries when promoting wellness.' 'Curing diseases or other illnesses completely is essential i to promote wellness in the older adult.' 'It is important to assess the level of fear of falling and provide support accordingly when caring for older adults.' 'It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries.' 'An older adult should live in social isolation to prevent stress.'

'Curing diseases or other illnesses completely is essential i to promote wellness in the older adult.' 'It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries.' 'An older adult should live in social isolation to prevent stress.' When promoting health in older adults, the nurse must focus on achieving the highest level of health in the presence ofa disease instead of curing the disease completely. When providing care, the nurse would take the social environment into consideration and strengthen support as a means of promoting health and ensuring access to health care resources. To promote health and extend the years of independent active life, the nurse would encourage older adults to engage in physical activities. When caring for older adults, the nurse would remember that preventing injuries is the key mechanism in promoting and improving health. The nurse would understand that older adults refrain from taking up physical activities because they fear falling. The nurse would assess the fear and provide support to reduce the risk offalls.

Which points require correction regarding wellness promotion in the older adult? Select all that apply. One, some, or all responses may be correct. 'Older adults need to prevent injuries when promoting wellness.' 'Curing diseases or other illnesses completely is essential i to promote wellness in the older adult.' 'It is important to assess the level of fear of falling and provide support accordingly when caring for older adults.' 'It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries.' 'An older adult should live in social isolation to prevent stress.'

'Curing diseases or other illnesses completely is essential i to promote wellness in the older adult.' 'It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries.' 'An older adult should live in social isolation to prevent stress.' When promoting health in older adults, the nurse must focus on achieving the highest level of health in the presence ofa disease instead of curing the disease completely. When providing care, the nurse would take the social environment into consideration and strengthen support as a means of promoting health and ensuring access to health care resources. To promote health and extend the years of independent active life, the nurse would encourage older adults to engage in physical activities. When caring for older adults, the nurse would remember that preventing injuries is the key mechanism in promoting and improving health. The nurse would understand that older adults refrain from taking up physical activities because they fear falling. The nurse would assess the fear and provide support to reduce the risk of falls.

While assessing the skin of an older client, the nurse finds skin transparency and fragility. Which nursing instructions will benefit the client? 'Do not place tape on the skin.' 'Take multiple vitamins on a daily basis.' 'Refrain from exposure to skin irritants.' 'Keep an eye on any pigmented lesions.'

'Do not place tape on the skin.' The client should avoid taping the skin, because it is transparent and fragile and can injure easily. This condition may be due to a decrease in epidermal thickness. The older client should take daily multiple vitamins when there is increased risk of osteomalacia (softening of bone). Avoiding exposure to skin irritants is important ifthe client shows increased epidermal permeability. In the event hyperplasia of melanocyte activity becomes apparent, the client should keep track of changes in pigmented lesions when exposed to sun for these require evaluation for malignancy.

Which instructions would the nurse give to an older adult with decreased perception of touch? Select all that apply. One, some, or all responses may be correct. 'Use a cane for support when walking.' 'Hold on to handrails while ambulating.' 'Look where your feet are placed while walking.' 'Wear shoes that give good support while walking.' 'lf you are unable to change your position frequently, request assistance.'

'Hold on to handrails while ambulating.' 'Look where your feet are placed while walking.' 'Wear shoes that give good support while walking.' 'If you are unable to change your position frequently, request assistance.' Decreased perception oftouch is a physiological change ofthe nervous system associated with aging. The client may experience decreased sensory perception that may cause the client to fall. Holding onto the handrails for directional guidance and support may help allow time for careful foot placement. The client should be instructed to look carefully where feet are placed while walking to prevent falling. Good support from wearing shoes while walking may reduce the risk of falling in clients with decreased perception oftouch. If the client is unable to change position frequently, the caretaker should change the position ofthe client every hour while the client is in bed or in a chair. A cane may be useful for a client with a musculoskeletal condition or injury but will not help with decreased sensory perception. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or client. All options likely relate to the situation, but only some ofthe options may relate directly to the situation.

Family members received discharge instructions for an older adult male recovering from a urinary tract infection. Which statement indicates family understanding of age-related changes and required care? 'I place a small glass of water at his side to ensure sipping before bedtime.' 'I respond immediately with the urinal whenever he indicates a need to void.' 'I provide privacy and standby assistance to help him void.' 'I encourage him to use the urinal at least every 2 hours during the day.'

'I provide privacy and standby assistance to help him void.' The family must help the client while he voids and provide privacy to encourage voiding without embarrassment. These measures will promote voiding and prevent urinary retention in the client. Giving the client water to drink just before bed can increase the risk of nocturia. Immediate response to the client when he needs to void reduces the risk of urinary incontinence. Encouraging the client to use the urinal at least every 2 hours helps the client empty the bladder. Voiding at regular intervals reduces the risk of overflow urinary incontinence.

The registered nurse (RN) is teaching a nursing student about how to educate clients based on their developmental capacity. Which statements made by the nursing student are applicable for older adults? Select all that apply. One, some, or all responses may be correct. 'I would encourage independent learning.' 'I would keep the teaching sessions short.' 'I would involve the client in any discussion or activity.' 'I would encourage learning through pictures and short stories.' 'I would teach the client psychomotor skills to maintain his or her health.'

'I would keep the teaching sessions short.' 'I would involve the client in any discussion or activity.' The nurse would keep teaching sessions short to help the older adult learn easily. Older clients should also be involved in discussions or activities to further engage them. Younger or middle-aged adults are more receptive to being encouraged to learn independently. Teaching psychomotor skills and encouraging learning via pictures and short stories are more applicable to school-aged children. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem ofthe item that are the same as or similar in nature to those in one or two ofthe options .

A registered nurse (RN) is supervising a student nurse while assessing a 70—year-old client who is receiving aminoglycoside therapy. Which statement about the client's condition is incorrect? 'The client may have deterioration of the cochlea.' 'The client may have thinning of the tympanic membrane.' 'The client may have an inability to hear high-frequency sounds.' 'The client may have an inability to differentiate between consonants.'

'The client may have thinning of the tympanic membrane.' An older adult who is on aminoglycoside antibiotic therapy is at a high risk of developing ototoxicity. The client with ototoxicity may have thickening of the tympanic membrane but not thinning of the tympanic membrane. Deterioration of the cochlea may cause older adults to gradually lose hearing. They may experience an inability to hear high-frequency sounds and differentiate between consonants. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer.

An older adult client is brought to the hospital by a family member because of deep partial-thickness burns on the arms and hands. The client protests being hospitalized and asks, 'Why can't I just go home and have my spouse care for me?' Which is the best response by the nurse? 'You sound upset, but your primary health care provider knows best. You should do what is prescribed.' 'Your spouse is very capable, but if your burns get infected, a family member can't give you the injections you will need.' 'Your burns are more serious than you think, and we have specially trained people here just to take care of you.' 'You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital.'

'You may heal more slowly because of your age, and you may need the special care and equipment available in the hospital.' Many older clients have multiple health problems and are at a higher risk for infection because ofa depressed immune system; the response lYou may heal more slowly because ofyour age, and you may need the special care and equipment available in the hospitalI provides information and addresses the fact that special care and equipment may not be available in the home. Although the response 1You sound upset, but your primary health care provider knows best. You should do what is prescribed' addresses feelings, it does not provide information and promotes dependency and feelings of powerlessness and helplessness. The response lYour spouse is very capable, but if your burns get infected, a family member can't give you the injections you will needl is inaccurate; family members may be trained on how to give injections. The statement produces anxiety about an unpredictable future. In addition, the competency of the spouse has not been assessed. The response 'Your burns are more serious than you think, and we have specially trained people here just to take care of you' may increase anxiety and precipitate feelings of guilt regarding expectations being placed on the spouse.

An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls which expected sensory losses associated with aging? Select all that apply. One, some, or all responses may be correct. Difficulty in swallowing Diminished sensation of pain Heightened response to stimuli Impaired hearing of high frequency sounds Increased ability to tolerate environmental heat

Diminished sensation of pain Impaired hearing of high frequency sounds Because of aging ofthe nervous system, an older adult has a diminished sensation of pain and may be unaware ofa serious illness, thermal extremes, or excessive pressure. As people age, they experience atrophy ofthe organ of Corti and cochlear neurons, loss ofthe sensory hair cells, and degeneration ofthe stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.

A married older adult couple lives independently and has three adult children. The husband, who is alert but forgetful, has an enlarged prostate with infrequent urinary incontinence. The wife has diabetes mellitus, rheumatoid arthritis, and walks with difficulty. The nurse identified the couple's need for assistance with bathing, dressing, and meal preparation. Which option would the nurse suggest, which best meets the needs ofthis couple? Admit them together to an extended care facility (nursing home). Place them in an apartment together, within an assisted-living facility. Keep the couple in their home and schedule assistance with a home health aide. Encourage the couple to move in with one of their children for safety reasons.

Keep the couple in their home and schedule assistance with a home health aide. Care provided in the home is more efficient and cost-effective; this couple can manage with assistance from community resources. There is nothing in the history to demonstrate that skilled nursing care provided by a nursing home is necessary. Because the couple appears able to function with assistance at home, it is not necessary to move them to another setting at this time. Test-Taking Tip: Anxiety leading to an exam is normal. Reduce your stress by studying often, not long. Spend at least 15 minutes every day reviewing the Ioldl material. This action alone will greatly reduce anxiety. The more time you devote to reviewing past material, the more confident you will feel about your knowledge ofthe topics. Start this review process on the first day ofthe semester. Don't wait until the middle to end of the semester to try to cram information.

Which characteristic would the nurse consider when attempting to assess the defense mechanisms of an older adult client with neurocognitive disorder due to vascular impairment? Avoids use of any defense mechanisms Uses one method of defense for every situation Makes exaggerated use of old, familiar mechanisms Attempts to develop new defense mechanisms for the current situation

Makes exaggerated use of old, familiar mechanisms The guideline to remember is that clients will make exaggerated use of old, familiar mechanisms. Clients with neurocognitive disorders try to use defense mechanisms that have worked in the past but use them in an exaggerated manner. The client will use defense mechanisms, but they may not be effective. The client with neurocognitive disorder is not capable of focusing on one defense mechanism all the time because of short-term memory loss. Because of brain cell destruction, clients are unable to develop new defense mechanisms. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques, such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

For which physiological condition would the nurse teach an older adult client about the use of isometric exercises? Kyphosis Muscle atrophy Decreased bone density Decreased range of motion (ROM)

Muscle atrophy Muscle atrophy occurs due to muscular weakness; isometric exercises can help increase muscular strength. Introducing the client to proper body mechanics and instructing the client to sit in supportive chairs with arms reduces kyphosis. Teaching safety tips to prevent falls and reinforcing the need to exercise reduces complications associated with decreased bone density. The nurse should assess the client's ability to perform activities of daily living and mobility in a client with a decreased ROM. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words; (2) Read each answer thoroughly and see if it completely covers the material asked by the question; (3) Narrow the choices by immediately eliminating answers you know are incorrect.

The nurse is caring for a community-dwelling older adult who is suffering from confusion. Which are the correct nursing interventions in this situation? Select all that apply. One, some, or all responses may be correct. Provide a protective environment. Assist with personal hygiene. Educate the client about correct body mechanics. Promote activities that reinforce reality. Teach the client's caregiver proper feeding techniques.

Provide a protective environment. Assist with personal hygiene. Promote activities that reinforce reality. When caring for an older adult who is in a confused state, the nurse would provide a protective environment, assist with personal hygiene, and promote activities that reinforce reality. If a client is suffering from arthritis, the nurse would educate him or her about correct body mechanics. If the nurse is caring for a client with dementia, then he or she should teach the family caregiver proper feeding techniques. Test-Taking Tip: Avoid looking for an answer pattern or code. There may be times when four or five consecutive questions have the same letter or number for the correct answer.

An older adult is having urinary incontinence. Which nursing interventions would help the client? Select all that apply. One, some, or all responses may be correct. Provide nutritional support. Provide voiding opportunities. Avoid indwelling catheterization. Provide beverages and snacks frequently. Promote measures to prevent skin breakdown.

Provide voiding opportunities. Avoid indwelling catheterization. Promote measures to prevent skin breakdown. An older adult should be provided voiding opportunities to minimize urinary incontinence. Indwelling catheterization should be avoided because this action increases the risk of infection, weakens bladder tone, and may cause discomfort. Measures to prevent skin breakdown should be taken because the client may develop skin problems due to incontinence. Nutritional support and frequent beverages and snacks should be provided to a client with malnutrition.

Which approach would the nurse use for an older adult client with Alzheimer disease who frequently switches from being pleasant and happy to being hostile and unhappy without apparent external cause? Pointing out reality to the client Providing nursing care when the client is receptive Encouraging the client to talk about personal feelings Restraining the client when hostility is being exhibited

Providing nursing care when the client is receptive The nurse would provide nursing care when the client is receptive. Because clients with Alzheimer disease experience lability of mood, it is best to attempt to establish a relationship and give care when they are feeling receptive. Although the mood swings may be pointed out to the client, the client with Alzheimer disease may not remember what happened previously. Also, repeated attempts to reorient the client may increase the hostile outbursts. Encouraging the client to talk about personal feelings may be of limited help; the client with Alzheimer disease may be unable to do this, the loss of recent recall may limit the benefit ofthis intervention. Restraining the client when hostility is being exhibited is the last resort. Clients with Alzheimer disease can be redirected or distracted more easily than restraining the client, which will increase agitation and hostility.

Which intervention would the home health nurse perform when conducting an initial visit to an older depressed client who lives alone and performs all tasks of daily living? Supporting the client's usual routine Helping the client in setting new goals Assisting the client in focusing on the future Arranging for the client to have help in the home

Supporting the client's usual routine On an initial visit, the nurse would support the client's usual routine. A routine is important to older adults, because it promotes a sense of control and security. Assisting the client in setting new goals is an important strategy for future planning, but it is not the intervention for the client at this time. During an initial visit, an older adult may need to focus on the past first. Older people may need to focus on the past as much as they do on the future; a life review is often conducted during this stage of development. Arranging for the client to have help in the home may be helpful for future visits but on an initial visit may not be welcomed by the client who performs all tasks of daily living. Test-Taking Tip: Practicing a few relaxation techniques may prove helpful on the day of an examination. Relaxation techniques such as deep breathing, imagery, head rolling, shoulder shrugging, rotating and stretching of the neck, leg lifts, and heel lifts with feet flat on the floor can effectively reduce tension while causing little or no distraction to those around you. It is recommended that you practice one or two of these techniques intermittently to avoid becoming tense. The more anxious and tense you become, the longer it will take you to relax.

Which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the intravenous fluid infusion for an older client with an infection? Pruritus Erythema Acute confusion General malaise

Acute confusion The nurse would consider the development of dehydration if acute confusion occurs in an older client with an infection. Additional fluids would not be helpful if pruritus, erythema, or general malaise develop in a client with an infection.

The nurse assists in the care off our older clients whose clinical features are shown in the accompanying chart. Which client may have dementia? Client 1 Client 2 Client 3 Client 4

Client 1 Client 1 has normal psychomotor behavior. The attention otthe client is also indicated to be normal. Moreover, misperceptions are absent. Client 1 may likely have dementia. Hypokinetic psychomotor behavior, impaired attention, and difficulty in distinguishing between reality and perceptions may signify delirium. Hyperkinetic behavior and inattention with hallucinations may also signify delirium. Psychomotor retardation, easily distractible attention, and illusions may be caused by depression.

Which age-related change would the nurse consider when formulating a plan of care for an older adult? Select all that apply. One, some, or all responses may be correct. Difficulty in swallowing Increased sensitivity to heat Increased sensitivity to glare Diminished sensation of pain Heightened response to stimuli

Increased sensitivity to glare Diminished sensation of pain Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older adult unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older adults. Older adults tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in older adults.

An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions would the nurse follow to prevent future falls? Select all that apply. One, some, or all responses may be correct. Minimizing sedating medications Modifying the home environment Teaching clients about the safe use of the Internet Manage foot and footwear problems Providing information about the effects of using alcohol

Minimizing sedating medications Modifying the home environment Manage foot and footwear problems The nursing interventions followed to prevent falls are minimizing medications, modifying the home environment, and managing foot and footwear problems. Teaching clients about the safe use of the Internet may be an effective intervention for preventing delirium. Providing information about the effects of using alcohol is not an intervention for older adults; this action is more beneficial for adolescents.

The nurse assists in the care offour older clients whose clinical features are shown in the accompanying chart. Which client may have dementia? Client 1 Psychomotor behavior: Normal Attention: Normal Perception: Misperceptions absence Client 2 Psychomotor behavior: Hypokinetic Attention: Impaired attention Perception: Difficult to distinguish between reality and perceptions Client 3 Psychomotor behavior: Hyperkinetic Attention: Inattentive Perception: Hallucinations Client 4 Psychomotor behavior: Psychomotor retardation Attention: Easily distractible Perception: Illusions present

Client 1 Client 1 has normal psychomotor behavior. The attention ofthe client is also indicated to be normal. Moreover, misperceptions are absent. Client 1 may likely have dementia. Hypokinetic psychomotor behavior, impaired attention, and difficulty in distinguishing between reality and perceptions may signify delirium. Hyperkinetic behavior and inattention with hallucinations may also signify delirium. Psychomotor retardation, easily distractible attention, and illusions may be caused by depression.

The nurse is caring for an older adult with a hearing loss secondary to aging. Which would the nurse expect to identify when assessing this client? Select all that apply. One, some, or all responses may be correct. Dry cerumen Tears in the tympanic membrane Difficulty hearing high pitched voices Decrease of hair in the auditory canal Overgrowth of the epithelial auditory lining

Dry cerumen Difficulty hearing high pitched voices Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. There is no greater incidence tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.

Which instructions would the nurse give a 60—year-old client who is at an increased risk for corneal damage? Select all that apply. One, some, or all responses may be correct. 'Use saline drops.' 'Increase humidity at home.' 'Wear prescribed lens for best vision.' 'Have corrective lenses solely for reading.'

'Use saline drops.' 'Wear prescribed lens for best vision.' 'Have corrective lenses solely for reading.' A client who has reduced tear production may have an increased risk for corneal damage and eye infection. Using saline eye drops and increasing the humidity may reduce dryness and decrease corneal damage. Flattening ofthe cornea causes blurred vision. The client should be instructed to have regular eye examinations and wear the prescribed lens to prevent corneal damage. All the rest of the instructions are associated with the pupil or lens rather than the cornea. A client whose pupils have a decreased ability to dilate has a poor capacity for acclimating to the darkness. These clients are mainly instructed to maintain good lighting to prevent an accident. A client with an inelastic lens is mainly instructed to wear corrective lenses while reading. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation.

The nurse finds that an older adult has a new onset of decreased consciousness, fatigue, and hallucinations. Which condition would the nurse suspect in the client? Delirium Dementia Depression Alzheimer disease

Delirium is an acute confusion state in which the client has reduced or disturbed consciousness, fatigue, and distorted perceptions accompanied by delusions, hallucinations, and misperceptions. Clear consciousness exists and misconceptions are usually absent in clients with dementia. Clear consciousness exists and distortions and hallucinations are observed only in severe cases of depression. Alzheimer disease is a progressive cerebral deterioration that can occur in middle-aged or advanced age adults. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words. (2) Read each answer thoroughly and see if it completely covers the material asked by the question. (3) Narrow the choices by immediately eliminating answers you know are incorrect.

The registered nurse (RN) is teaching a nursing student about how to educate clients based on their developmental capacity. Which statements made by the nursing student are applicable for older adults? Select all that apply. One, some, or all responses may be correct. 'I would encourage independent learning.' 'I would keep the teaching sessions short.' 'I would involve the client in any discussion or activity.' 'I would encourage learning through pictures and short stories.' '1 would teach the client psychomotor skills to maintain his or her health.'

'I would keep the teaching sessions short.' 'I would involve the client in any discussion or activity.' The nurse would keep teaching sessions short to help the older adult learn easily. Older clients should also be involved in discussions or activities to further engage them. Younger or middle-aged adults are more receptive to being encouraged to learn independently. Teaching psychomotor skills and encouraging learning via pictures and short stories are more applicable to school—aged children. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem ofthe item that are the same as or similar in nature to those in one or two ofthe options .

The nurse instructs an older client's adult child about age-related immune system changes and associated care measures. Which statement indicates a need for further instruction? 'My parent has a private room at home.' 'My parent has received the pneumococcal vaccination recently.' 'My parent comes in for checkups only when experiencing a fever.' 'My parent has been given a second dose of the pertussis vaccination.'

'My parent comes in for checkups only when experiencing a fever.' Older clients should have regular checkups even in the absence offever. Because aging causes reduced neutrophil function, some infections may not show fever symptoms. Older adults should have a private room at home to avoid other adults who may have viral infections. Because older adults have a decreased production of antibodies against new antigens, the caretaker should ensure that the older client has received updated vaccinations against infectious diseases such as pneumococcus and pertussis.

Which priority factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment? Level of interest in unit activities Orientation to time, place, and person Ability to perform tasks without becoming frustrated Cognitive impairment, which will increase until adjustment to the home is accomplished

Ability to perform tasks without becoming frustrated The nurse would consider ability to perform tasks without becoming frustrated. When the client is unable to perform a task, frustration occurs and results in more disorganized behavior. Clients with disorientation and cognitive impairment may show little interest in unit activities but should be included to the best of their ability. However, this does not address the client's disorganized behaviors. Although orientation is important, the client's disorientation is already documented; more important is the assessment ofthe client's ability to function. Although cognitive impairment is important, adjusting to the nursing home may never be fully achieved.

In the older adult client with decreased cell division in the epidermal layer of the skin, which interventions would the nurse include in the client's plan of care? Select all that apply. One, some, or all responses may be correct. Advise the client to prevent exposure to skin trauma. Advise the client to protect open areas of skin. Advise nonalcohol-based lotions for excessive dryness or moisture. Handle the client carefully to reduce skin friction. Advise the client to change positions every 2 hours.

Advise the client to prevent exposure to skin trauma. Advise the client to protect open areas of skin. A client with decreased cell division in the epidermal layer of the skin is at risk of delayed wound healing. The nurse would advise the client to avoid skin trauma and to protect open areas. Nurses would assess the older client with decreased epidermal thickness for excessive dryness or moisture and handle these clients carefully to reduce skin friction. Nurses would advise clients with a flattened dermal-epidermal junction to change their positions every 2 hours.

An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontological implications the nurse must consider? Select all that apply. One, some, or all responses may be correct. Assessment of skin turgor Documentation of vital signs Assessment of intake and output Administration of antiemetic medications Replacement of fluid and electrolytes

Assessment of skin turgor Administration of antiemetic medications Replacement of fluid and electrolytes When skin turgor is assessed, the presence oftenting may be related to loss of subcutaneous tissue associated with aging rather than to dehydration; skin over the sternum should be used instead of skin on the arm for checking turgor. Older adults are susceptible to central nervous system side effects, such as confusion, associated with antiemetic medications; dosages must be reduced, and responses must be evaluated closely. Because many older adults have delicate fluid balance and may have cardiac and renal disease, replacement of fluid and electrolytes may result in adverse consequences, such as hypervolemia, pulmonary edema, and electrolyte imbalance. Vital signs can be obtained as with any other adult. Intake and output can be measured accurately in older adults.

Which immune function change places older clients at risk for bacterial and fungal infections? Decline in natural antibodies Reduction of neutrophil function Decrease in circulating T lymphocytes Reduction of colony-forming B lymphocytes

Decrease in circulating T lymphocytes A decrease in circulating T lymphocytes occurs with cell-mediated immunity, resulting in an increased risk of bacterial and fungal infections. A client would need booster shots for old vaccinations and immunizations when there is a decline in natural antibodies. A reduced neutrophil function may be an implication when neutrophil function is decreased. The older adult should receive immunizations, such as flu shots, when the number of colony-forming B lymphocytes is diminished.

The nurse provides discharge teaching to an older adult about care associated with activities of daily living. Which factor is the priority that the nurse would consider when counseling the client on how often to take a tub bath? Condition of the skin Ability of the client to provide self-care Degree of orientation to the environment Type of allergic reactions experienced by the client

Condition of the skin The condition ofthe skin is priority for the frequency of bathing. Aging causes reduction in skin lubrication, which results in dry skin. The ability ofthe client to provide self-care influences how much assistance is necessary, not the frequency of bathing. The degree ofthe client's orientation influences safety factors applicable during the bath, not the frequency of bathing. A history of allergic reactions experienced by the client influences which bath products may be used, not the frequency of bathing. Test-Taking Tip: The presence of absolute words and phrases can also help you determine the correct answer to a multiple-choice item. If answer choices contain an absolute (e.g., none, never, must, cannot), be very cautious. Remember that there are not many things in the world that are absolute, and in an area as complex as nursing, an absolute may be a reason to eliminate it from consideration as the best choice. This is only a guideline and should not be taken to be true 100% ofthe time; however, it can help you reduce the number of choices.

Which conclusion would the home care nurse make regarding an older adult client with mild Alzheimer disease? Must be supervised closely at all times Needs a live-in home health aide to assist with activities of daily living Should be allowed to function independently if therapeutically possible Ought to be responsible for carrying out daily self-care activities without assistance

Should be allowed to function independently if therapeutically possible The nurse would allow the client to function independently iftherapeutically possible. Priority should be given to providing nursing care to maintain an optimal level of safe function for as long as possible. Close supervision is usually not necessary during the early stages of dementia. Constant supervision can be destructive to self-esteem. A live- in home health aide is usually not necessary during the early stages of dementia. The client may or may not be capable of performing all daily self-care activities without assistance.

In the older adult client with decreased cell division in the epidermal layer ofthe skin, which interventions would the nurse include in the client's plan of care? Select all that apply. One, some, or all responses may be correct. Advise the client to prevent exposure to skin trauma. Advise the client to protect open areas of skin. Advise nonalcohol—based lotions for excessive dryness or moisture. Handle the client carefully to reduce skin friction. Advise the client to change positions every 2 hours.

Advise the client to prevent exposure to skin trauma. Advise the client to protect open areas of skin. A client with decreased cell division in the epidermal layer of the skin is at risk of delayed wound healing. The nurse would advise the client to avoid skin trauma and to protect open areas. Nurses would assess the older client with decreased epidermal thickness for excessive dryness or moisture and handle these clients carefully to reduce skin friction. Nurses would advise clients with a flattened dermal-epidermal junction to change their positions every 2 hours.

The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice? Thinning subcutaneous layer Degeneration of elastic fibers Decreased dermal blood flow Benign proliferation of capillaries

Decreased dermal blood flow With decreased dermal blood flow the client is susceptible to dry skin; the nurse would advise the client to apply moisturizer when the skin is moist. lfa client is found to have a thinning subcutaneous layer, the nurse would teach the client to dress warmly in cold weather. lfa client presents with degenerated elastic fibers, the nurse would check the skin turgor on the forehead or chest ofthe client. lfa client has benign proliferation of the capillaries, this indicates cherry hemangiomas; the nurse would teach the client that these are benign.

Which finding by the nurse when assessing a 75-year-old client would be most important to report to the health care provider? Decreased lung sounds at bases Kyphosis with barrel—shaped chest Oxygen saturation at rest 93% Expiratory wheezes bilaterally

Expiratory wheezes bilaterally Expiratory wheezes require further assessment and treatment and are not normal in older clients. Decreased basilar lung sounds may occur with normal aging because of decreased elastic recoil ofthe lungs and less respiratory muscle strength. Kyphosis may occur due to osteoporosis and lead to the chest appearing barrel- shaped, but this is not an acute change and does not require urgent treatment. Oxygen saturation may decrease because of less respiratory muscle strength, fewer alveoli, and more chest wall stiffness, but this is not acute change.

Which physiological change occurs in older adults and warrants the nurse teaching the client about safety tips to prevent falls? Slowed movement Cartilage degeneration Decreased bone density Decreased range of motion (ROM)

Teaching safety tips to prevent falls would best help a client with decreased bone density. If a client experiences slow movements, the nurse should not rush the client because the client may become frustrated if hurried. Providing a client with cartilage degeneration with a moist heat source such as a shower or a warm compress is beneficial because this action may increase blood flow to the area. The nurse should assess a client's ability to perform activities of daily living and mobility to help improve the self-care skills of clients with a decreased range of motion.

Which instruction from the nurse to an 80-year-old client with thinning of a subcutaneous layer would be beneficial? Dress warmly in cold weather. Use soaps with high fat content. Change the position of bed once every 5 hours. Apply moisturizer 2 hours after bathing.

Dress warmly in cold weather. Older clients should be advised to dress warmly in cold weather because they are at an increased risk of hypothermia due to thinning of the subcutaneous layer. Use of soaps with high fat content is recommended for clients with decreased eccrine and apocrine gland activity because this helps avoid dry skin. Bed position should be changed once every 2 hours in clients with thinning ofthe subcutaneous layer to prevent the occurrence of pressure injuries. Moisturizer should be applied immediately after bathing to avoid drying of skin.

The community nurse is assessing an older adult client who lives alone at home. The nurse finds that the client refrains from physical activity for fear of falling when walking. Which intervention(s) by the nurse are beneficial to promote a healthy lifestyle? Select all that apply. One, some, or all responses may be correct. Instruct the client to apply bedside rails. Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Ask the client to install handrails in the bathroom. Help the client rearrange furniture in the house.

Encourage the client to wear nonskid shoes. Suggest that the client use an assistive device. Help the client rearrange furniture in the house. The nurse would encourage the client to wear nonskid shoes that provide a firm grip while walking and help reduce the chance offalls. The nurse would suggest that the client use an assistive device such as a cane or walker for support while walking. The nurse would make environmental changes by helping the client rearrange the furniture in the house. This will help reduce the incidence offalls within the house. These interventions reduce the fear of falling and encourage the client to participate in physical activity indoors and outdoors. The bedside rails protect the client from falling from the bed. The handrails in the bathroom assist provide support while using the bathroom. Test-Taking Tip: Be alert for details. Details provided in the stem ofthe item, such as behavioral changes or clinical changes (or both) within a certain time period, can provide a clue to the most appropriate response or, in some cases, responses.

The nurse is caring for an older adult client with dementia. Which client need would the nurse prioritize while providing care? Safety Self-esteem Self-actualization Love and belonging

Safety An older adult client with dementia has impaired cognition. The nurse would make arrangements such as applying bedside rails to ensure that the client's safety needs are met first. At this stage, self—esteem or factors that enhance confidence and self—worth are not as important as safety. Self-actualization is the ability to solve problems and being able to cope realistically, which is beyond the capacity of the client with dementia. All clients need to feel love and belonging; however, safety is the first priority for this client. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.

Which conclusion would the home care nurse make regarding an older adult client with mild Alzheimer disease? Must be supervised closely at all times Needs a live-in home health aide to assist with activities of daily living Should be allowed to function independently if therapeutically possible Ought to be responsible for carrying out daily self-care activities without assistance

Should be allowed to function independently if therapeutically possible The nurse would allow the client to function independently iftherapeutically possible. Priority should be given to providing nursing care to maintain an optimal level ofsafe function for as long as possible. Close supervision is usually not necessary during the early stages of dementia. Constant supervision can be destructive to self-esteem. A live-in home health aide is usually not necessary during the early stages of dementia. The client may or may not be capable of performing all daily self-care activities without assistance.