ATI Older Adults Post Assignment

A nurse is performing an eye assessment of an older adult client and identifies a corneal ulceration. Which of the following conditions most likely contributes to this finding?

Entropion rationale: entropion is an inversion of the lower eyelid that can lead to corneal ulceration from the friction of eyelashes.

A nurse is providing an in-service educational session on nutritional assessment of older adult clients for a group of newly licensed nurses. Which of the following should the nurse include when discussing physical changes that affect adequate nutrition?

Decreased dexterity rationale: arthritic changes affecting dexterity in the hands can cause difficulty in preparing and eating food which can interfere with adequate caloric intake.

A nurse is assessing an older adult client. The nurse recognizes that which of the following findings can affect the client's ability to perform activities of daily living (ADLs)? Select all that apply

Arthritic changes in upper extremities stumbled when walking into examination room hesitancy to shower difficulty risking from a seated position rationale: the loss of independence can affect the client's mood as it is viewed as a reduction in the overall quality of life.

A nurse is educating an older adult client about home safety. Which of the following information should the nurse include?

Older adults are more susceptible in injury from external stimuli rationale: Promoting independence of older adult involves awareness of safety risks in the home, as well as the client's mobility, cognitive issues, and functional impairment. Risk factors include reduced neurological responses to stimuli, such as pain or heat, and slowed psychomotor responses.

A nurse is performing a skin assessment of an older adult client and identifies an area of tissue sloughing, eschar, and exposed muscle on the sacrum. Which of the following terms will the nurse use to document this pressure injury?

Stage IV (4) rationale: A stage IV (4) pressure injury is characterized by full-thickness breakdown into the dermal layer of skin exposing bone, muscle, and/or tendons. Dead tissues (slough or eschar) may be visible. The wound may tunnel deeper than the surface level.

A nurse is obtaining a health history from an older adult client. Which of the following actions by the nurse promotes the establishment of trust and rapport?

The nurse avoids interrupting the client. rationale: Allow the client to tell their story, avoiding interrupting whenever possible. Interruptions can make the client feel rushed or cause them to leave out vital parts of their history. Research has shown clients who have a good rapport and relationship with their medical team are more likely to follow recommended treatment, leading to improved health outcomes.

A nurse is assessing an older adult client who is experiencing constipation. Which of the following actions by the client requires further education?

Uses a laxative every 3 days. rationale: the nurse should provide further education regarding the frequency use of laxative or enemas. Frequent use of either can cause the body to become dependent of their use and prevent normal bowel habits.

A nurse is teaching an older adult client about strategies to prevent bone loss. Which of the following information should be included?

Vitamin D supplements may be required rationale: older adults may have difficulty absorbing or obtaining adequate amounts of vitamin D from sunlight and should have blood testing to monitor their levels

A nurse is visiting an older adult client who is recovering from a total hip replacement at home. The client is extremely restless, crying, and indicates they are experiencing incision site pain rated as 9 on scale of 1 to 10. Their caregiver, who was sleeping on the couch when the nurse arrived, yells, "Hey, I gave you your pill an hour ago. Quit complaining." Which of the following nursing actions is the priority?

assess for potential medication misuse rationale: Assess for potential medication misuse is correct. The first action the nurse should take when using the nursing process is to assess the client's current condition and situation. By gathering data privately from the client, assessing vital signs, talking to the caretaker, and verifying the number of pills remaining in the client's bottle, the nurse can then follow up with the provider if abuse is suspected. The nurse should recognize that a form of physical abuse is medication misuse. Clients may appear, especially with the use of analgesics, as undermedicated and in pain, or overly-medicated and extremely sedated.

A nurse is assessing an older adult client following a head injury with loss of consciousness. Which of the following findings should the nurse address?

clear nasal drainage rationale: Clear nasal drainage is correct. Clear nasal drainage following a head injury could indicate leakage of spinal fluid and warrants further investigation.

A nurse is assessing breath sounds on an older adult client and auscultates intermittent course bubbling sounds that do not clear with coughing, Which of the following terms should the nurse use to document the findings?

crackle rationale: Crackle is the correct term used to describe intermittent, crackling, or bubbling sounds that can be either high-pitched and fine, or low-pitched and coarse. These sounds are commonly auscultated in clients with pneumonia, congestive heart failure, bronchitis, pulmonary edema, or consolidation, and do not clear with coughing.

A nurse is assessing an older adult client diagnosed with osteopenia 2 years ago. Which of the following current findings indicates this condition has deteriorated?

kyphosis rationale: Kyphosis is correct and suggests the client has developed weakness, compression, or fractures of the spine, indicating the condition has likely evolved due to increased bone thinning and deterioration.

A nurse is caring for an older adult client in the emergency department who is experiencing nausea and indigestion. Which of the following assessment findings requires an immediate intervention?

left shoulder pain rationale: Common manifestations of a heart attack are nausea, sweating, pain that radiates to the left arm or shoulder, and shortness of breath. In an older adult experiencing a heart attack, epigastric discomfort, confusion, and weakness may occur without any chest discomfort.

A nurse is documenting skin assessment findings that reveal skin lesions that are less than 10 mm in diameter, flat, and brown in color. Which of the following terms should be used?

macule rationale: Macules are flat, discolored lesions less than 10 mm in diameter and include freckles and flat moles. It is important to note these spots and track them for changes.

a nurse is performing an assessment of an older adult client who reports eye pain and floaters. which of the following nursing actions is appropriate?

recommend referral to an eye specialist. rationale: this should be performed as the manifestations being reported indicate a serious eye disorder, such as retinal detachment, which is considered a medical emergency

A nurse is performing an abdominal assessment. Which of the following quadrants of the abdomen should the nurse auscultate first?

right lower quadrant (RLQ) rationale: The nurse should begin auscultation in the right lower quadrant and continue for the remaining three quadrants, moving in a clockwise manner. Bowel sounds are normally always present in the right lower quadrant, and by beginning in the right lower quadrant, it helps to track the natural movement through the colon.