nclex ch.23 Care of the Older Client

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? 1. Crusting 2. Wrinkling 3. Deepening of expression lines 4. Thinning and loss of elasticity in the skin

1. Crusting

The long-term care nurse is performing assessments on several of the residents. Which are normal age-related physiological changes the nurse should expect to note? Select all that apply. 1. Increased heart rate 2. Decline in visual acuity 3. Decreased respiratory rate 4. Decline in long-term memory 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

2. Decline in visual acuity 5. Increased susceptibility to urinary tract infections 6. Increased incidence of awakening after sleep onset

The home health nurse is visiting a client for the first time. While assessing the client's medication history, it is noted that there are 19 prescriptions and several over-the-counter medications that the client has been taking. Which intervention should the nurse take first? 1. Check for medication interactions. 2. Determine whether there are medication duplications. 3. Call the prescribing health care provider (HCP) and report polypharmacy. 4. Determine whether a family member supervises medication administration.

2. Determine whether there are medication duplications.

The nurse is providing medication instructions to an older client who is taking digoxin daily. The nurse explains to the client that decreased lean body mass and decreased glomerular filtration rate, which are age-related body changes, could place the client at risk for which complication with medication therapy? 1. Decreased absorption of digoxin 2. Increased risk for digoxin toxicity 3. Decreased therapeutic effect of digoxin 4. Increased risk for side effects related to digoxin

2. Increased risk for digoxin toxicity

The home care nurse is visiting an older client whose spouse died 6 months ago. Which behaviors by the client indicates effective coping? Select all that apply. 1. Neglecting personal grooming 2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

2. Looking at old snapshots of family 3. Participating in a senior citizens program 4. Visiting the spouse's grave once a month 5. Decorating a wall with the spouse's pictures and awards received

The nurse is performing an assessment on an older client who is having difficulty sleeping at night. Which statement by the client indicates the need for further teaching regarding measures to improve sleep? 1. "I swim 3 times a week." 2. "I have stopped smoking cigars." 3. "I drink hot chocolate before bedtime." 4. "I read for 40 minutes before bedtime."

3. "I drink hot chocolate before bedtime."

The nurse is providing an educational session to new employees, and the topic is abuse of the older client. The nurse helps the employees to identify which client as most typically a victim of abuse? 1. A man who has moderate hypertension 2. A man who has newly diagnosed cataracts 3. A woman who has advanced Parkinson's disease 4. A woman who has early diagnosed Lyme disease

3. A woman who has advanced Parkinson's disease

The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an older client with hearing loss. What should the nurse tell the UAP about older clients with hearing loss? 1. They are often distracted. 2. They have middle ear changes. 3. They respond to low-pitched tones. 4. They develop moist cerumen production.

3. They respond to low-pitched tones.

The nurse is caring for an older client in a long-term care facility. Which action contributes to encouraging autonomy in the client? 1. Planning meals 2. Decorating the room 3. Scheduling haircut appointments 4. Allowing the client to choose social activities

4. Allowing the client to choose social activities

The visiting nurse observes that the older male client is confined by his daughter-in-law to his room. When the nurse suggests that he walk to the den and join the family, he says, "I'm in everyone's way; my daughter-in-law needs me to stay here." Which is the most important action for the nurse to take? 1. Say to the daughter-in-law, "Confining your father-in-law to his room is inhumane." 2. Suggest to the client and daughter-in-law that they consider a nursing home for the client. 3. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help. 4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.

4. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a senior citizens center.