VNSG 1226: Unit 3 Prep U Questions

An older adult client tells a nurse, "I am worried that I'm losing my mind; I have difficulty remembering names as well as I used to, and I missed two health care appointments in the past month because I forgot about them." Which question is the best approach to evaluating the effectiveness of a memory training program?

"How have the memory training techniques helped you? Explanation:The question about how the memory training techniques have helped the client allows the older adult to tell the nurse how memory training has helped and is more open-ended than the other options. It also communicates positive expectations. The question helps identify the techniques that are most effective for the individual.

Which client is at an increased risk for developing respiratory inefficiency as a result of kyphosis?

A 73-year-old retired teacher Explanation:The rib cage and the vertebral musculoskeletal structures are affected by the same kind of age-related changes that affect other musculoskeletal tissue. Because of these age-related processes, kyphosis (i.e., an increased curvature of the spine) occurs. This age-related change compromises chest wall expansion, and older adults need to expend more energy to achieve respiratory efficiency. None of the other client characteristics are significant risks factors for kyphosis.

During a clinic visit, a 72-year-old client tells the nurse that she has inadequate circulation and cannot tolerate walking more than five steps without getting a feeling of heavy, weak legs. The nurses should assess further for what nursing diagnosis?

Activity intolerance related to increased resistance of peripheral vessels Explanation: Activity intolerance can be caused by increased, not decreased, resistance of peripheral vessels. Cardiac or respiratory failure require a need for immediate medical attention.

A nurse discusses common visual disease processes with a group of older adult clients. What information should the nurse provide regarding the risk factors associated with cataract development? Select all that apply.

Aging is a non-modifiable risk factor." "Diabetes increases the risk of developing this vision problem." "Smoking increases one's risk for cataracts." "Wearing sunglasses will decrease the risk from ultraviolet light." Explanation: Cataracts are common in older adults because everyone develops some degree of lens opacity with age. Diabetes, cigarette smoking, and exposure to ultraviolet B light each increase the risk of developing cataracts. Cholesterol is not a known risk factor.

A nurse assesses an older adult Hispanic client. The client states that "my spouse was punished by God." To which illness is the client most likely referring?

Alcohol Abuse Explanation: For some Hispanics, views of mental illness are a punishment by a supreme being for past transgressions; Hispanic older adults define mental health problems as alcohol and other drug abuse. PTSD is relatively common in immigrants. Hallucinations are not related to Hispanic culture. Those of Caribbean descent may attribute the cause of mental illness to voodoo.

The nurse learns that the ovaries of an older female client were not able to be palpated during a pelvic examination. What ovarian issue should the nurse suspect as the reason for this finding?

Atrophied Explanation: A normal age-related change in the female reproductive system is atrophy of the ovaries. Non-palpable ovaries do not indicate disease or cancer. The nurse would see in the medical record if the ovaries were removed.

A nurse in the postoperative unit monitors for hypothermia. Which older adults' assessment finding indicates the onset of hypothermia?

Cool skin on the buttocks Explanation: Cool skin in unexposed areas, such as the abdomen and buttocks, is a distinguishing characteristic of hypothermia. The environmental temperature may be only moderately cool, and the older person will not necessarily shiver or complain of feeling cold. As untreated hypothermia progresses, additional signs may include lethargy, slurred speech, mental changes, impaired gait, puffiness of the face, slowed or irregular pulse, low blood pressure, slowed tendon reflexes, and slow, shallow respirations.

Which consideration should a nurse prioritize when assessing an older adult who has arrhythmias?

Make an assessment in relation to the client's medical history. Explanation: Murmurs and arrhythmias may be caused by cardiac diseases, electrolyte imbalances, or adverse medication effects. It is important to make an assessment of underlying causes in relation to the client's medical history.

An older client has a small amount of protein in the urine. What should the nurse anticipate being prescribed for this client?

No particular diagnostic tests Explanation: Decreased reabsorption from the filtrate makes a proteinuria of 1.0 usually of no diagnostic significance in older adults. The older client most likely will not be prescribed renal x-rays, blood tests, bladder scan, or catheterization for this finding.

Which actions are crucial when assessing visual function in an older adult? (Select all that apply.)

Observing the older adult functioning in his or her normal environment. Asking the older adult whether he or she can drive without difficulties at night. Explanation: The nurse should observe the older adult's usual pattern of activities. These observations occur best in the person's usual environment and address the person's ability to carry out activities. Older adults who report difficulty driving at night may have cataracts or other visual impairments.

The older client has impaired urinary elimination. Which goal is the most important to facilitate physiologic balance?

The client achieves partial or complete restoration of bladder control Explanation: The client achieves partial or complete restoration of bladder control is the most important goal to facilitate physiologic balance. Setting a goal for only partial or only complete bladder control would be an incomplete goal. The client achieves incomplete restoration of bladder control would not facilitate physiologic balance.

A nurse interviews an older adult client who has several chronic conditions, including type 2 diabetes and heart failure. The client expresses feeling more satisfaction with life now than when younger. Which phenomenon is the client expressing?

The paradox of well-being Explanation: Gerontologists have identified a paradox of well-being among older adults, which describes the phenomenon of older adults suffering significant losses of health, cognition, and social functioning but reporting high levels of well-being and positive emotions. Metamemory, crystallized intelligence, and neuroplasticity are phenomena that are not related to subjective well-being and satisfaction.

An older client asks if stress can cause cancer. Which of the following answers would be most accurate?

There is no clear evidence that food additives are a risk factor for cancer.

The health care provider prescribes a C-reactive protein level to be measured on an older client. What should the nurse instruct the client to prepare for this laboratory test?

There is nothing that needs to be done to prepare for the test Explanation: C-reactive protein (CRP) is a marker of inflammation that is a stronger predictor of cardiovascular events than LDL cholesterol. Because CRP levels are stable over long periods of time, are not affected by food intake, and demonstrate almost no circadian variation, there is no need to obtain fasting blood samples for CRP assessment. The test does not need to be done first thing in the morning. The client does not need to abstain from high fat content foods or eat nothing after midnight the night before the test.

The nurse is assessing an older adult client who is well-known to the nurse. What new assessment finding would suggest a possible new neurological problem?

Uncharacteristic anger toward the nurse Explanation: Personality changes can indicate neurological problems. However, constipation, moist eyes and increased appetite usually have other etiologies.

A nurse determines that a client does not remember current events and has difficulty using technology. The nurse should consider that the client may have difficulty with which activity?

Using a digitally recording blood glucose monitor Explanation: Contextual theories and everyday problem solving emphasize that older adults are able to remember affective and personally relevant information. The client may need to record the blood glucose on paper.

The nurse is educating a 73-year-old client about nutritional supplements for cardiovascular arterial health. Which is the most important supplement to include in the teaching plan?

Vitamin C Explanation:Vitamin C maintains integrity of the arterial walls and would be the most important to include for arterial health of the choices provided. Calcium decreases cholesterol and platelet aggregation and chromium reduces total cholesterol and triglycerides. Iron is not identified as playing a major role in arterial health.

The nurse notes that an older female client has urinary incontinence. For which health problem should the nurse assess this client?

Vulvitis Explanation: Incontinence can be an underlying cause of vulvitis. There is no indication that urinary incontinence is linked to fecal retention, peripheral edema, or hypoactive bowel sounds.

An older adult client is diagnosed with moderate hearing loss. Which assessment questions should the nurse ask to determine how the client's overall wellness is affected by the hearing loss? Select all that apply.

"How much time do you spend each week interacting with friends and family?" "Would you consider yourself to be depressed?" "Are you able to meet your self care needs on a daily basis?" "Do you view yourself as an independent individual?" Explanation:Studies have identified these functional consequences of hearing loss in older adults: functional decline; social isolation; depression; and decreased autonomy. Financial status is not generally associated with hearing loss in the older adult.

What statement made by an older adult client is associated with a problem identifed as the greatest source of concern for that population?

"I don't have much control over my life anymore." Explanation: Life events of older adulthood are often unknown, unexpected, inevitable, and, in fact, unwanted or even feared. Thus, older adults may experience a greater loss of control or fear of losing control over their lives. While the other statements identify real issues for the older population, the sense of having no or little control over life is the primary fear.

A nurse is reviewing the side effects of antidepressants with a group of older adults. Which statement by a member of the group indicates that the nurse's teaching has been effective?

"I need to maintain my fluid intake while on antidepressant medication." Explanation: An increase in fluid intake helps prevent the risk of postural hypotension. Gradually increasing dosages should occur until maximal therapeutic levels are reached, while observing for adverse effects. Fluoxetine is given in the afternoon because of agitation. The length of treatment is usually 6 months for a first-time depression.

An older adult client with a long-standing history of chronic obstructive pulmonary disease was recently placed on warfarin after experiencing atrial fibrillation. Upon discharge from the hospital, which statement by the client indicates a need for further teaching?

"I will continue to use smokeless tobacco since it's a lot better than smoking." Explanation:Smokeless tobacco is associated with mouth cancer, gingivitis, and tooth loss and may be carcinogenic to the pancreas. The other noted actions are appropriate to the maintenance of health.

A nurse notes a 2 mm open shallow ulcer with a red wound bed on the great toe where shoe touched the skin. Which should the nurse document?

2 mm stage II pressure ulcer Explanation: The wound described is a pressure ulcer. Use of the Pressure Ulcer Scale for Healing staging is required to document all pressure ulcers. Wound documentation should also include size of wound bed. Stage II ulcers are partial thickness loss of dermis presenting as a shallow open ulcer with a red pink wound bed, without slough.

The nurse is caring for an older adult client who has impaired motor function. The nurse should assess for signs of what priority nursing diagnosis?

Activity intolerance Explanation: Activity intolerance is associated with impaired motor function in the older client and has implications for many of the client's functional abilities and his or her quality of life. Pain is less likely, and many clients with diminished activity do not have a disturbed body image or altered self concept.

A nurse in the emergency department cares for an 82-year-old man. The man was found wandering the streets looking for his dog in a snowstorm. Which condition is the priority for the nurse to monitor?

Altered mental status Explanation:As hypothermia progresses, mental functioning becomes clouded. More men than women experience hypothermia. Dehydration exacerbates the effects of hypothermia. Diabetes and hypoglycemia (not hyper) are related to higher risk of hypothermia.

The nurse plans care for an older client recovering from prostate cancer surgery. Which action should the nurse emphasize to prevent an injury and postoperative infection?

Avoid strenuous activities for 3 to 4 weeks Explanation:To prevent an injury and postoperative infection in the client recovering from prostate surgery the nurse should advise the client to avoid strenuous activities for 3 to 4 weeks. Efforts should be taken to prevent constipation which includes high fiber foods and a high fluid intake. The client should report bright red blood in the urine. The Valsalva maneuver should be avoided.

A nurse in an assisted living facility develops interventions that focus on improving cognitive abilities in the residents. Which should the nurse include in the plan of care? (Select all that apply.)

Book Club Letter Writing Explanation: The cognitive reserve model suggests improving cognitive abilities through participation in creative and intellectually stimulating activities, such as art, storytelling, reading, writing, group discussions, and playing musical instruments. Calisthenics, singing traditional tunes, reminiscing, and shopping are not creative and intellectually challenging.

An older adult client expresses frustration to the nurse regarding hearing loss despite a lifetime of being conscientious and avoiding known causes of hearing damage. Which age-related changes may result in hearing loss?

Degeneration of the ear structures Explanation: Age-related changes of the inner ear include loss of hair cells, reduction of blood supply, diminution of endolymph production, decreased basilar membrane flexibility, degeneration of spiral ganglion cells, and loss of neurons in the cochlear nuclei. These inner ear changes result in the degenerative hearing impairment termed presbycusis. Cerumen often becomes more viscous with age, and occlusion of the Eustachian tubes is not a normal, age-related change. Changes to the external ear structures are not a factor in age-related hearing loss.

The nurse is concerned that an older client is at risk for pruritus. What health problems in the client's medical record caused the nurse to have this concern? Select all that apply.

Diabetes Arteriosclerosis Explanation: Diabetes and arteriosclerosis can contribute to the development of pruritus. Heart failure, osteoporosis, and hypothyroidism are not associated with pruritus.

The nurse is caring for an aging client wtih diabetes who has developed peripheral neuropathy. What nursing diagnosis best relates to this complication?

Disturbed sensory perception Explanation: Disturbed sensory perception is associated with the aging client and peripheral neuropathies. Impaired skin integrity may result from injuries that were caused by lack of sensation. Disturbed sleep pattern is associated with the aging client and urinary frequency. Anxiety is associated with the aging client and fear of disease impact.

Which cancer risk factor is associated with non-Hodgkin's lymphoma in the aging client?

Drinking water contaminated with nitrate Explanation: Drinking water contaminated with nitrate is associated with non-Hodgkin's lymphoma in the aging client. X-rays increase risk of thyroid cancer. Radon increases the risk of lung cancer. Alcohol consumption increases the risk for mouth, throat, esophagus, larynx, and liver cancer.

The nurse notes that an older client has never had children. For which sexual health problem should the nurse assess this client?

Dyspareunia Explanation: Dyspareunia is a common problem among older women that accompanies hormonal changes. Nulliparous women experience this problem more frequently than women who have had children. The number of children is not a major risk factor for the development of uterine, ovarian, or cervical cancer.

An older client is diagnosed with an elevated cholesterol level. Which food item should the nurse instruct the client to limit to help reduce body lipid levels?

Egg Yolks Explanation: To help reduce cholesterol level the client should be instructed to reduce the intake of egg yolks. Turkey, olive oil, and skim milk should all be encouraged.

An older client reports having to wake up several times during the night to void. What should the nurse identify as important to instruct this client?

Keep a nightlight on in the room Explanation: Because older adults' increased threshold for light perception makes night vision difficult, nocturia could predispose them to accidents when attempting to walk to the bathroom in the dark. Nightlights should be used to improve visibility during trips to the bathroom, and any clutter or environmental hazards that could cause a fall should be removed. Reducing fluids immediately before bedtime may help, although they should not be significantly restricted. Warm tea may increase the need to void during the night.

During a community health program a participate asks the nurse to explain the cause Alzheimer disease. Which should the nurse respond to this question?

No one definitive cause Explanation: At present, no one theory can explain Alzheimer disease. There are theories that suggest environmental toxin exposure to mercury and aluminum. There is a theory that suggests an extra chromosome causes the disorder. And, there is a theory about the buildup of free radicals causing the disease. However, not one theory explains the development of tangles and the behavior changes of Alzheimer disease.

After a scheduled trip to the optometrist, an older adult client is informed that the pressure in the client's left eye is 24 mmHg. Which assessment finding should the nurse report?

Peripheral Vision Explanation:Normal eye pressure should range between 10 and 20 mm Hg. Thus, this client may have glaucoma. The term glaucoma refers to a group of eye diseases in which the ganglion cells of the optic nerve become damaged by an abnormal buildup of aqueous humor in the eye. Loss of peripheral vision is a key sign of glaucoma. Eye pain, loss of central vision, and headache are not associated with glaucoma.

A nurse in the long-term care facility assesses an 86-year-old client who has recently become lethargic and difficult to arouse. Vital signs are all stable and within normal limits. Breath sounds are diminished. Which action by the nurse should be the priority?

Send the client to the emergency department Explanation:Atypical presentation is especially common in those who are older than 85 years. Changes in behavior or functioning and increased fatigue are common atypical presentations of infection (e.g., pneumonia or urinary tract infection). In addition, the expected manifestations of an infection, such as elevated temperature or specific complaints of pain or discomfort, may be absent. While the family should be made aware of the update on the condition, the care of the client is the priority. It is not appropriate to delegate this to the certified nursing assistant. Placing the client on fall prevention does not address the assessment data.

The nurse plans care for a client with emphysema. Which interventions should the nurse identify for this client's plan of care? Select all that apply.

Stress reduction Bronchodilators Postural drainage Breathing exercises Explanation: Treatment for the client with emphysema usually includes postural drainage, bronchodilators, the avoidance of stressful situations, and breathing exercises, which are an important part of patient education. Sedatives are contraindicated in the client with emphysema because of the adverse effect on breathing.

When teaching the older client about suspicious skin lesions, which of the following would be the most important information to include about evaluation?

Suspicious skin lesions should be biopsied. Explanation: Suspicious skin lesions should be biopsied is the most important to include. All suspicious skin lesions should be biopsied, not only those that are raised, pigmented, or black in color.

How can the nurse best promote relationship-centered cancer care for the older client?

Taking the time to learn about unique client characteristics Explanation: Taking the time to learn about unique client characteristics is part of relationship-centered cancer care. Understanding and acceptance of clients where they are is part of support and empowerment is part of healing partnerships.

An older client arrives with an adult daughter for a health visit. What should the nurse keep in mind as a priority when assessing this client?

The daughter's role in the client's care' Explanation: The family is the patient, and the capacities and limitations of the total family unit must be evaluated. The daughter's role in the client's care is the priority. It might be unrealistic to expect the client to be totally independent with care. Needs that cannot be fulfilled in the home environment is not a priority issue. It is important for the client to be safe in the home environment however the daughter's role in the client's care needs to be assessed first as a priority.

A nurse evaluates the healing of a full-thickness skin tear on an older adult resident who lives in a long-term care facility. Which finding would support the continuation of the current treatment plan?

The wound showing 50% healing at 16 days. Explanation: About 50% healing at 16 days is acceptable. Full-thickness skin tears take an average of 21 days to heal in older adults. The treatment plan needs to be changed if there is redness at 12 days, pain at 19 days, or draining plasma at 14 days.

An older client asks if beverages that contain caffeine cause cancer. Which of the following statements would be most accurate?

There is no evidence to support a link between coffee and cancer Explanation: There is no evidence to support a link between coffee and cancer. Similarly, green tea is not identified as a carcinogen. Caffeine limitation does not prevent cancer.

A nurse is teaching a group of hearing-impaired nursing home residents about hearing aids. Which point should the nurse emphasize?

While inserting the hearing aid, make sure the volume is off. Explanation: Insert the hearing aid with the volume off and the canal portion pointing into the ear. Use a hearing aid for one-on-one conversation. It is not effective in a dining room where there is background noise. If whistling occurs, the volume should be decreased.

A client with open-angle glaucoma is prescribed pilocarpine eye drops. What should the nurse teach the client about this medication?

vision may be blurred for 1 to 2 hours after use Explanation: The client should be instructed to prepare for side effects from pilocarpine hydrochloride, such as blurring of vision for 1 to 2 hours after administration. Eye pain, eye itchiness, and yellow halo vision are not expected or adverse reactions to the use of pilocarpine eye drops.

An older client is to be catheterized for post-void urine residual volume. When should the nurse perform this catheterization?

within 15 minutes of the last void Explanation: If residual urine is a problem, a post-void residual may be ordered in which the client is catheterized within 15 minutes of voiding to determine the volume of urine remaining in the bladder. The client does not need to be catheterized immediately after voiding. Catheterization for post-void residual urine should occur earlier than 1 to 2 hours after the last void. Catheterization for post-void residual urine should not occur immediately before needing to void.

Which of the following are known carcinogens that increase the risk of cancer in the older client?

Radon Fertilizer in drinking water X-rays

A nurse leads a "healthy aging" class at a community health center. Which question should the nurse use to generate discussion among participants in this setting?`

"How did you adjust to your move from your house to the assisted living facility?" Explanation: Healthy aging classes focus on the belief that older adults who are beginning to recognize age-related physical and psychosocial changes or who are already dealing with such changes can benefit from sharing their experiences with their peers. Discussion about these adjustments should be the priority in a healthy aging class.

The nurse notes that an older client has an irregular heart beat and elevated blood pressure. What should the nurse ask the client during the assessment?

"How often do you ingest alcohol?" Explanation: Cardiac disorders can result from alcoholism and can be displayed by hypertension and an irregular heartbeat due to cardiomyopathy. Eating regularly would help assess for depression. Asking about relaxation would be appropriate to assess for an anxiety disorder. Asking about self-harm would be appropriate to assess for suicide risk.

What instructions should the nurse provide regarding skin hygiene and the primary cause of pruritus with a group of older adult clients?

"It is usually sufficient to shower or tub bathe every 3 or 4 days with sponge baths in between." Explanation: Pruritus refers to dry skin. Although skin cleanliness is important, excessive bathing may be hazardous to the skin; daily partial sponge baths and complete baths every third or fourth day are sufficient for the average older person. Deodorant soaps may cause or exacerbate dry skin problems in an older person. Isopropyl alcohol tends to dry the skin and should be avoided by this population of clients. Cool water bathing has no particular benefit when managing dry skin.

A client asks why at age 40 reading glasses are needed when glasses were never required at a younger age. How should the nurse respond to this client?

"The lens muscle fibers stiffen with aging and affects the ability to focus." Explanation: The reduced elasticity and stiffening of the muscle fibers of the lens of the eye that begins in the fourth decade of life interferes with the ability to adequately focus and is the factor responsible for most older people requiring some form of corrective lenses. A reduction in the visual fields affects peripheral vision. Glaring indicates cataract formation. Loss of photoreceptor cells affects visual acuity.

A 65-year-old female client asks when she can stop having mammograms. What should the nurse respond to this client?

"They are recommended every year." Explanation: Mammograms are recommended every year. Some colorectal screening exams are completed every 5 or 10 years. Pap smears are completed every 2 to 3 years.

A nurse assesses older adults at a pulmonary clinic. Which question might best assist in identifying those at risk for pulmonary disorders?

"What type of job did you have?" Explanation:Some job categories are associated with an increased risk of respiratory disease. Having children who smoke does not imply that secondhand smoke occurs. While location does correlate with the percent of smokers, it is not as helpful in identification of those with pulmonary disorders, nor is where a person exercises.

During an 88-year-old client's annual physical, the provider tells the nurse to provide education about neurogenic (reflex) incontinence. Which of the following information is important to include in the education plan? Select all that apply.

"Your condition causes loss of control of voiding. " "Your condition causes an inability to sense the urge to void." "Your condition causes inability to control urine flow." Explanation: The condition causes a loss of control of voiding, an inability to sense the urge to void, and an inability to control urine flow. The condition is not known to cause stabbing pelvic pain or a risk for cancer.

Which mental health nursing diagnosis is most closely associated with the aging client and fatigue?

Activity Intolerance Explanation: Activity intolerance is associated with the aging client and fatigue. Anxiety is associated with threat to self-concept and losses. Fear is associated with new or misperceived environments and losses. Social isolation is associated with anxiety, depression, paranoia, cognitive impairment.

A nurse identifies clients who are at risk for modifiable risk factors for cardiovascular disease. Which client should the nurse prioritize as having modifiable cardiovascular functional consequences?

An older adult client who is obese who has type 2 diabetes Explanation:Modifiable risk factors include obesity and control of blood glucose levels. Hepatitis A is not a risk factor. Prior myocardial infarction and strong family history are not modifiable. However, those clients are at risk and other risk factors in their life may need to be modified.

During a period of cold weather, an older adult is brought to the emergency department with suspected hypothermia. Which assessment should the nurse prioritize with this client?

Assessment of the client's core body temperature Explanation: The most reliable assessment for hypothermia is measurement of core body temperature. Palpation of extremities, interviewing, and assessment of level of consciousness are also relevant assessments, but the measurement of core body temperature is prioritized.

Which of the following statements is most important when evaluating the therapeutic affects of antidepressant medication administration in the older client?

At least one month is needed before therapeutic effects will be noted. Explanation: At least one month is needed before therapeutic effects will be noted is most important. Two months, three months, and one week to note therapeutic effects of antidepressants in older clients are not evidence-based timeframes.

The nurse notes that an older client with diabetes is prescribed rosiglitazone. Which assessment should the nurse complete before providing this medication to the client?

BP Explanation: Rosiglitazone is a thiazolidinedione that can be used alone or in combination with sulfonylureas, metformin, or insulin for the management of type 2 diabetes mellitus. Cardiac function must be assessed in all clients before starting this medication is it can precipitate cardiac failure in clients with cardiac dysfunction. The nurse should assess the client's blood pressure to establish a base line. Bowel sounds, body mass index, and abdominal circumference are not assessments that need to be completed before providing the client with this medication.

The nurse notes that an older client has an area of dark skin above the malleolus of the right ankle. What should the nurse suspect is occurring with this client?

Beginning of a stasis ulcer Explanation: Stasis ulcers often appear on the medial aspect of the tibia above the malleolus and, prior to skin breakdown, present as a dark discoloration of the skin. This finding is not consistent with a deep vein thrombosis, varicose vein, or superficial vein thrombosis.

The nurse identifies the diagnosis of Impaired Physical Mobility for a client recovering from a cerebrovascular accident. Which intervention should the nurse implement to address this client problem? Select all that apply.

Coach in resistance exercises Assist to select menu items high in fiber Maintain proper alignment when in bed Instruct to deep breathe and cough every 2 hours Explanation: Interventions to help with Impaired Physical Mobility include coaching in resistance exercises and maintain proper alignment. High fiber foods help prevent the development of constipation caused by immobility. Deep breathing and coughing every 2 hours helps prevent the development of respiratory problems caused by immobility. Range-of-motion exercises are recommended to be done at least 3 times a day.

During an assessment the nurse feels vibrations when palpating an older client's chest. How should the nurse document this finding?

Fremitus Explanation:Fremitus is a vibration felt during palpation of the chest. Lung consolidation cannot be palpated. Rebound tenderness is a finding when conducting an abdominal assessment. The point of maximum impulse refers to the apical region.

An older client's family asks the nurse to explain causes of dementia. The nurse would include which of the following causes? Select all the apply.

Damage to brain tissue due to Alzheimer's Damage to brain tissue due to degenerative diseases Circulatory conditions Brain infections Explanation: Damage to brain tissue due to Alzheimer's, damage to brain tissue due to degenerative diseases, circulatory conditions, and infection are known causes of dementia in the older adult. Adverse effects of medication can cause delirium, not dementia.

An older adult client who lives alone has been diagnosed with type 1 diabetes. To ensure safe medication use, the nurse should assess the client's:

Dexterity Explanation: The client is likely to need to self-inject, so dexterity is imperative. Weight, strength and vision are valid components of overall assessment, but the client's dexterity relates directly to administration of injection

An older client has recent signs and symptoms that suggest Lewy body dementia. What assessment question best addressing the possible etiology of the disease?

Do you have a history of a family member with dementia? Explanation:Do you have a history of a family member with dementia is the best response because about one fourth of people diagnosed with Lewy body dementia have a history of a family member with dementia. Sundowner syndrome, toxin exposure and vascular disease are not known precursors to Lewy body dementia.

A nurse teaches an older adult about the antidepressant medication recently prescribed. Which should the nurse include in the teaching? (Select all that apply.)

Don't expect immediate improvement; a fair trial may take up to 12 weeks. Antidepressants can interact with alcohol and over-the-counter medications. Explanation: Immediate improvement will not be evident, but the medication administration needs to occur as long as serious adverse effects are not noticed. The fair trial may take as long as 12 weeks, but some positive effects occur within 2 to 4 weeks. Antidepressants can interact with alcohol, nicotine, and other medications, including over-the-counter medications, possibly altering the effects of the medication or increasing the potential for adverse effects. Depression is common in older adults. It's treatable if the client sticks to the treatment plan and takes medication daily. Medication should not be stopped without consulting the primary health care provider.

Which topic is important to teach to caregivers of older adults receiving antidepressant medication? Select all that apply.

Dosage Intended effects Adverse reactions Drug-food interactions Explanation: Dosage, intended effects, adverse reactions, and drug to food interactions are important observations to teach to caregivers of older adults receiving antidepressant medication. The caregiver would not need to know the cyclic compound.

After reviewing the medical record the nurse is concerned that an older client is at risk for developing hyperlipidemia. What information did the nurse use to make this clinical determination? Select all that apply

Explanation: Hypothyroidism Uncontrolled diabetes Takes prescribed steroids Takes a prescribed thiazide diuretic

The nurse prepares to assess an older client's urinary status. Which problem should the nurse make a focus during this assessment?

Frequency Explanation: One of the greatest annoyances is urinary frequency, caused by hypertrophy of the bladder muscle and thickening of the bladder, which decreases the ability of the bladder to expand and reduces storage capacity. In addition to frequency during the day, nighttime urinary frequency (nocturia) can be a problem. Infection could be caused by urinary retention however this is not a major problem identified in the older client. Hematuria and stone formation are not identified as health problems of the aging client.

The nurse reviews goals established for a client with diabetes. Which laboratory finding suggests that the goal to control blood glucose level has been achieved?

Hemoglobin A1c 5.8% Explanation: Although the glycemic goals need to be individualized for the patient, the general recommendations are for the client to achieve a hemoglobin A1c of less than 6.5%, postprandial glucose of less than 180 mg/dL, a random blood glucose of less than 200 mg/dL, and a fasting plasma glucose of 70 to 130 mg/dL. A hemoglobin A1c level of 5.8% indicates that the goal was achieved.

The nurse is planning care for an older client with urinary incontinence. What should the nurse identify as the initial goal for this client's care?

Identify the cause Explanation: The initial goal for incontinent individuals is to identify the cause of incontinence. Acidifying the urine would be helpful to prevent the development of urinary tract infections. Training on bladder control would depend upon the cause for the incontinence. Preventing skin breakdown is important however would not be needed to plan care to address the type of incontinence the client is experiencing.

The nurse is caring for an older adult client who has visual deficits and who wishes to live independently. When planning this client's care, what nursing diagnosis should the nurse most likely identify?

Impaired Home Maintenance Explanation: Impaired home maintenance is likely for an aging client with visual deficits, especially if the individual wishes to live independently. Pain and infection are not normally related to visual deficits. The nurse must assess how the client's nutritional needs will be met, but lack of vision does not necessarily preclude cooking or eating.

Which nursing diagnosis is associated with unreliable urine specimen findings due to resorption of glucose and less concentrated urine in the older client?

Ineffective health maintenance Explanation: Ineffective health maintenance is associated with unreliable urine specimen findings due to resorption of glucose and less concentrated urine in the older client. Toileting self-care deficit is associated with immobility, dementia, and weakness. Pain and body image are less likely to be affected by unreliable urine specimens.

When asked to cough with a full bladder an older female client experiences urinary incontinence. Which action should the nurse take first to help this client?

Instruct to keep a log of all episodes of incontinence Explanation:If incontinence is present, it can prove useful to maintain a record or have the client maintain a diary of each occurrence of incontinence and factors associated with these incidents. Wearing perineal protection materials will not help solve the problem. Reducing fluid intake will adversely affect the client's health status. Avoiding activities because of the risk of incontinence may severely hamper this client's activity level and should not be recommended.

An older client tells the nurse that his depression has gotten worse after starting prescribed antihypertensives to address his high blood pressure. The nurse would include what information in an explanation?

It's possible that the medication may aggravate his depression Explanation: Medications like antihypertensives can have an effect and aggravate depression. There is a known relationship between drug use causing depression.

Which statement best captures the typical character of health problems in the lives of older adults?

Most older adults experience an interplay between a number of chronic conditions and occasional acute health problems. Explanation: The interplay between chronic and occasional acute conditions is typical of the health trajectory of many older adults. The most salient factor is not acute problems alone nor are health problems necessarily attributable to age-related changes. Changes in health status are rarely consistent and do not exclude chronic conditions or acute problems.

A nurse teaches a client and care partner about cholinesterase inhibitors. Which statement should the nurse include in the teaching?

Nausea, vomiting, diarrhea, and loss of appetite can be prevented or reduced by starting with a low dose. Explanation:When administering medications to older adults, it is imperative to start with lower doses and increase the doses slowly. Rivastigmine is less likely to interact with other drugs and may be safer and better tolerated in people. The effectiveness of cholinesterase inhibitors diminishes significantly if it is stopped and then restarted.

An older client is unable to clearly say the word "ga" repeatedly. Which body area should the nurse expect further testing to be prescribed?

Pharynx Explanation: With dysarthria, words are used correctly, but speech may be slurred or distorted as a result of poor motor control. Subtle dysarthrias can be disclosed by asking the client to pronounce ga, ga, ga (to test the pharynx), me, me, me (to test the lips), or la, la, la (to test the tongue). The integrity of the trachea is not assessed by asking the client to pronounce words or syllables.

An older client's apical pulse is 120 beats per minute after completing physical therapy exercises. What action should the nurse take?

Reassess in two hours Explanation: Older hearts take longer to recover from stress. Tachycardia may be detected as a result of a stress that occurred several hours earlier. If tachycardia is discovered in an older person, reassess in several hours. It is not necessary for the nurse to place the client on bed rest, notify the health care provider, or assess the client for orthostatic blood pressure changes.

Which endocrine function nursing diagnosis is associated with the aging client who has vaginitis as a result of diabetes?

Sexual Dysfunction Explanation: Sexual dysfunction is associated with the aging client and peripheral neuropathy-vaginitis. This problem does not result in frequency or hypoglycemia. Dehydration is unlikely.

An 85-year-old client broke two teeth after hitting them on the siderail of her bed. The nurse has confirmed that she is not bleeding. Which of the following would be most crucial for the nurse to assess next?

Signs and Symptoms of Respiratory Compromise Explanation:T he most crucial focus is respiratory compromise because pieces of brittle teeth can break off in the aging population and be aspirated, causing respiratory problems. Nutrition would not be affected at this early stage and there is no reason to anticipate cardiac effects. Swallowing assessment may be performed later but it is not an immediate priority.

The older client has risk of injury related to urinary incontinence. Which goal is the most important to facilitate physiologic balance?

The client is free from falls related to escaped urine. Explanation: The client is free from falls related to escaped urine is the most important to facilitate physiologic balance. Physical therapy, role performance and freedom from infection are secondary to immediate safety concerns.

Which characteristic of an older adult woman most likely increases her risk for breast cancer?

The client is obese Explanation: Obesity is associated with breast cancer in the aging client. Diets high in animal fats and second hand smoke exposure is associated with stomach cancer. Alcohol consumption is associated with mouth, throat, esophagus, larynx, and liver cancer.

An older African American client expresses stress to the nurse about dark areas that look like bruises on his skin. Which is the most important information to describe that would alleviate the client's stress? Select all that apply.

The condition is more prevalent in persons of African American backgrounds. Mongolian spots may or may not need to be treated. Mongolian spots are birth marks. Explanation: Mongolian spots are birth marks, may or may not need to be treated, and are more prevalent in persons of African American backgrounds. Mongolian spots are not cancer.

An older client is diagnosed with a toxic multinodular thyroid goiter. What teaching should the nurse prepare for this client?

Thyroidectomy Explanation: If toxic multinodular goiter is the underlying cause of hyperthyroidism, surgery may be preferred due to the delayed and incomplete response to medications. Medication teaching may be delayed until after surgery. Dietary changes are not a part of the plan to treat hyperthyroidism. Radioactive iodine may not be sufficient to treat the symptoms associated with hyperthyroidism.

An older client with diabetes has foul-smelling concentrated urine. What should the nurse realize that this finding indicates?

UTI Explanation: An older client with diabetes has a higher incidence of urinary tract infections. The findings of foul-smelling concentrated urine should cause the nurse to suspect an infection. Concentrated urine would occur with dehydration. A change in urine would not occur with inadequate caloric intake or excessive glucose in the urine.

A nurse monitors older adults in a long-term care facility. Which symptom would require follow-up by the nurse to assess for depression in the older adult?

anorexia Explanation: Appetite disturbances, particularly anorexia, are among the most common physical complaints of depressed older adults. Individuals with dementia have the following symptoms: vague fatigue, labile affect, and easily forgotten physical complaints.

An older client is suspected as having urosepsis. Which treatment should the nurse anticipate being prescribed first for this client?

discontinue indwelling urinary catheter Explanation:Urosepsis is a common complication of persons with indwelling catheters, so selective use of catheters is important. Oral fluids, antibiotics, and cranberry juice may all be prescribed to treat the client with urosepsis however these treatments can all be started after the indwelling urinary catheter is discontinued.

An older adult client is admitted to the hospital. A nurse assesses the client for frailty. Which signs or symptoms indicate frailty? (Select all that apply.)

slow walking speed self-reported exhaustion diminished handgrip strength Explanation: Clients are considered frail when they have three or more of the following conditions: low level of physical activity, slow walking speed, unintentional weight loss (i.e., 10 lb [4.5 kg] or more during the past year), weakness (measured by diminished handgrip strength), and self-reported exhaustion.

An older adult has developed hallucinations. For which conditions should the nurse assess? (Select all that apply.)

stroke infection digoxin toxicity Explanation:Infection, digoxin toxicity, and a stroke can all lead to hallucinations. Hyperglycemia and myocardial infarction generally do not.