HA Ch. 32 Prep U

d. Delirium

A nurse recognizes that a sudden change in an elderly client's cognition accompanied by a change in the level of alertness may be an indication of what condition? a. Depression b. Infection c. Acute pain d. Delirium

b. Left side-lying

A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum? a. Standing b. Left side-lying c. Lithotomy d. Prone

b. Rales

A 75-year-old client admitted in respiratory failure has been placed on mechanical ventilation. The client develops acute confusion, purulent sputum, low oxygen saturation readings, and dyspnea. What breath sound is the nurse most likely to auscultate on exam? a. Stridor b. Rales c. Wheezing d. Pleural friction rub

c. Loss of firmness in the labia d. Increased dryness in the vagina e. Uterine contractions with orgasm are painful

A 75-year-old female client is discussing with a nurse changes in her body that have affected her sexual life. Which of the following should the nurse expect to hear? Select all that apply. a. Increased elasticity in the vaginal walls b. Decreased sensitivity in the clitoris c. Loss of firmness in the labia d. Increased dryness in the vagina e. Uterine contractions with orgasm are painful

a. Taking warm baths

A 75-year-old female client tells the nurse that she is sexually active but that it causes her pain when she has intercourse. What would the nurse suggest to alleviate this pain? a. Taking warm baths b. Cold application c. Exclusive use of a side-lying position d. Having sex in the morning

d. Poverty

A client is brought to the clinic by his daughter, who tells the nurse that she is concerned because her father appears to be losing weight and she doesn't know why. What would the nurse know is a cause of undernutrition? a. Obsessive/compulsive disorder b. Poor time management c. Acute organ failure d. Poverty

b. diverticulitis.

A gastrointestinal problem that often requires emergency treatment in the frail elder is a. lactose intolerance. b. diverticulitis. c. hiatal hernia. d. Crohn disease.

a. Assist with exercise to strengthen lower extremities c. Remind the client to ask for assistance e. Remove rugs or other loose carpet

A nurse assesses an elderly client and determines that the client is at risk for falls. Which interventions are appropriate to reduce the incidence of actual falls the client incurs? Select all that apply. a. Assist with exercise to strengthen lower extremities b. Limit the amount of activity c. Remind the client to ask for assistance d. Discourage the use of dependence on walkers e. Remove rugs or other loose carpet

d. Bright lighting

A nurse is performing a home safety assessment for an 87-year-old retired farmer who lives alone. Which of the following is not considered an increased risk factor for falls? a. Slippery or irregular surfaces b. Loose electrical cords c. Chairs at awkward angles d. Bright lighting

b. 85

A nurse is working with a client who is considered to be part of the "frail elderly." At which age can is a person typically first considered to be a part of this group? a. 65 b. 85 c. 75 d. 95

a. Knowing the person's baseline functional status and recognizing deviations from it

A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old? a. Knowing the person's baseline functional status and recognizing deviations from it b. Knowing the client's mental status c. Knowing the client's family history d. Knowing the statistical occurrence of the condition among people the same age

b. Solar lentigines

A nurse notes the presence of brown, pigmented patches on an elderly client's hands. What is the proper term for the nurse to use to document this finding? a. Senile purpura b. Solar lentigines c. Seborrheic keratoses d. Actinic keratoses

a. Katz Activities of Daily Living tool

A nurse would like to assess an elderly client's general functional status in performing daily chores. Which of the following should the nurse implement to make this assessment? a. Katz Activities of Daily Living tool b. Activity tolerance testing c. Vision testing d. Get Up and Go test

c. a nasogastric feeding tube.

A risk factor for sinusitis in the frail elderly is a. decreased ability to detect odors. b. an accumulation of ear wax. c. a nasogastric feeding tube. d. conductive hearing loss.

b. Rise from a chair to a standing position

A simple test that a nurse can perform to assess an elderly client's activity tolerance is to ask the client to perform what task while monitoring the heart rate? a. Perform 4 to 5 slow, deep knee bends b. Rise from a chair to a standing position c. Walk around the room and observe gait d. Swing the arms overhead several times

a. Depression

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what? a. Depression b. Malnutrition c. Dementia d. Decreased mobility

d. Shingles

An elderly client visits her community health clinic with an outbreak of vesicles on her skin. She tests positive for the herpes zoster virus. The nurse should recognize this condition as which of the following? a. Senile purpura b. Petechiae c. Actinic keratoses d. Shingles

d. Benign prostatic hypertrophy

An elderly male client presents to the health care clinic with reports of urinary frequency, nocturia, and difficulty starting his stream. A nurse knows that the most common cause of these symptoms is what condition? a. Urinary tract infection b. Sexually transmitted disease c. Renal insufficiency d. Benign prostatic hypertrophy

b. "Notify your healthcare provider about the possibility of cancer."

An older adult client, who is a retired construction worker, presents with an ulcerated lesion on his left auricle. What teaching should the nurse provide to this client? a. "Apply over the counter steroid cream twice daily." b. "Notify your healthcare provider about the possibility of cancer." c. "Make an appointment right away with an audiologist to prevent hearing loss." d. "Over the counter antibiotic ointment should be applied once daily."

d. Document findings and notify the healthcare provider

An older adult with a history of varicose veins presents with lower extremities that are reddish-brown and edematous. What is the nurse's best action? a. Administer antibiotic therapy immediately b. Stage the affected area and apply an occlusive dressing c. Place the legs in a dependent position d. Document findings and notify the healthcare provider

d. Functional

An older client admits that she has recently begun wetting her pants. On further questioning by the nurse regarding the cause of the incontinence, the client explains, "I move so slowly these days that I can't always make it to a bathroom in time." The nurse recognizes this as which type of incontinence? a. Stress b. Urge c. Overflow d. Functional

d. 152 lbs.

An older client who typically weights 160 lbs. appears withdrawn and disheveled and causes the nurse to be concerned since the last visit a month ago. For which body weight should the nurse conduct a complete nutritional assessment? a. 162 lbs. b. 158 lbs. c. 155 lbs. d. 152 lbs.

b. Urinalysis for the onset of a urinary tract infection

An otherwise healthy elderly client develops the sudden onset of confusion, lethargy, anorexia, and nocturia. The nurse should obtain an order for which lab test to assess this sudden change in health status? a. Complete blood count for anemia b. Urinalysis for the onset of a urinary tract infection c. Electrolytes to determine the onset of dehydration d. Live enzymes for acute hepatitis

c. urinary tract infection.

Any new onset of incontinence in the frail elder should be investigated for a. fecal impaction. b. stroke. c. urinary tract infection. d. prostatitis.

a. urinary tract infection.

Any new onset of incontinence in the frail elder should be investigated for a. urinary tract infection. b. stroke. c. fecal impaction. d. prostatitis.

b. Elevation of the systolic BP

Blood pressure abnormalities found more commonly in Western elderly include which of the following? a. Elevation of the BP with standing b. Elevation of the systolic BP c. Isolated elevation of the diastolic BP d. Narrow pulse pressure

c. geriatric syndromes

Common conditions or problems that accompany aging are often called a. geriatric symptoms b. conditions of aging c. geriatric syndromes d. symptoms of aging

b. fall risk

During the assessment of an older client the nurse focuses on household activities and home environment. On which geriatric syndrome is the nurse focusing during this assessment? a. independence b. fall risk c. skin breakdown d. nutrition

a. Retraction of the nipples

During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process? a. Retraction of the nipples b. Macerated skin under the breasts c. Unilateral nipple discharge d. Bilateral tenderness

d. Senile purpura

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

d. Ability to function independently

How do many older adults define their health? a. Ability to maintain normal food intake b. Ability to perform activities related to their hobbies c. Ability to work d. Ability to function independently

c. Urge

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine associated with an abrupt and strong desire to void. What type of incontinence should the nurse document in the client's record? a. Overflow b. Functional c. Urge d. Stress

a. Stress

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record? a. Stress b. Overflow c. Urge d. Functional

a. Delirium

It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause? a. Delirium b. Meningitis c. Stroke d. Alzheimer's dementia

c. Elder abuse

Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar aspects of her forearms and on her abdomen. She otherwise has no complaints, and her diabetes and hypertension are well managed. Her son from out of state accompanies her today and has recently moved in to help her. What should the nurse suspect? a. Overuse of aspirin b. Depression c. Elder abuse d. Frequent falls

d. Preparing food

Mrs. Glynn is 90-years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living? a. Dressing b. Bathing c. Transferring from bed to chair d. Preparing food

d. Fever.

Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age? a. Falls. b. Weakness. c. Confusion. d. Fever.

d. Prepare foods that are pudding consistency or semisolid

The caretaker of an elderly person tells the nurse that she is worried that the client will choke because of swallowing problems secondary to a recent cerebrovascular accident (CVA). What suggestion should the nurse give the caretaker to minimize the risk of aspiration in the client? a. Keep the client upright for 30 minutes after eating b. Offer water with meals to clear the throat c. Check the mouth frequently for retained food d. Prepare foods that are pudding consistency or semisolid

d. aortic aneurysm

The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has? a. atrial fibrillation b. holosystolic murmur c. congestive heart failure d. aortic aneurysm

d. Encourage the client to wear sunscreen daily.

The nurse has assessed and informed the healthcare provider of a brown-colored lesion on an older client's left cheek. The lesion is diagnosed as solar lentigines. What is the nurse's best action? a. Prepare the client for a skin biopsy. b. Teach the client how to apply topical chemotherapeutic agents. c. Warn the client of the likelihood of metastasis. d. Encourage the client to wear sunscreen daily.

d. Document findings and refer the client for follow-up

The nurse is assessing an elderly client and finds a suspicious lesion on the client's right forearm. The lesion is asymmetrical, has an irregular border, has color variation, and is approximately 8 mm in diameter. What is an appropriate nursing action for this client? a. Call the physician immediately b. Take no action, because the findings correspond with a normal mole c. Document findings as a normal age spot d. Document findings and refer the client for follow-up

d. The client has decreased functional ability

The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse? a. The client is being neglected b. This client needs to live in a nursing home c. The client is lazy and appearance no longer matters to him d. The client has decreased functional ability

d. seborrheic keratosis

The nurse observes a dark brown, pigmented waxy lesion 2-mm in size on the right forearm of an older adult. The nurse recognizes this lesion as: a. malignant carcinoma b. basal cell carcinoma c. squamous cell carcinoma d. seborrheic keratosis

d. acute or chronic illness places excessive demands on the body.

The physical declines of aging often first become noticeable when a. the person is at least 75 years old. b. approximately 50% of function is lost. c. cognitive declines become significant. d. acute or chronic illness places excessive demands on the body.

d. Plan for additional time to allow as much independence as possible

What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client? a. Address the client by the first name to reduce confusion b. Ask the caregiver questions if the client is cognitively impaired c. Speak loudly to compensate for a hearing deficit d. Plan for additional time to allow as much independence as possible

c. Plan for additional time to allow as much independence as possible

What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client? a. Ask the caregiver questions if the client is cognitively impaired b. Address the client by the first name to reduce confusion c. Plan for additional time to allow as much independence as possible d. Speak loudly to compensate for a hearing deficit

a. Wound healing slows as a result of decreased mitotic activity d. Nails become thick and brittle with slow growth e. The epidermis thins

When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply. a. Wound healing slows as a result of decreased mitotic activity b. Nails become thin and brittle with increased growth c. The epidermis thickens d. Nails become thick and brittle with slow growth e. The epidermis thins f. The number of sweat and sebaceous glands increases

b. Slight sway with eyes closed

When using the Romberg test of cerebellar function in an older client, which of the following findings is expected? a. Inability to sustain balance with eyes open b. Slight sway with eyes closed c. Moderate sway with eyes open d. Inability to sustain balance with eyes closed

a. Obtain a voiding diary

Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence? a. Obtain a voiding diary b. Inspect urethral meatus c. Ask the client to bear down d. Inspect the vaginal opening

b. Blurring of near vision

Which of the following changes in vision is expected with normal aging? a. Cataract b. Blurring of near vision c. Glaucoma d. Macular degeneration

b. Medications are used to counteract side effects of other prescribed medications.

Which of the following indicates that an elderly client has been affected by polypharmacy? a. Medications that might promote health of the older adult are not prescribed. b. Medications are used to counteract side effects of other prescribed medications. c. The older adult's condition does not improve after a medication is discontinued. d. Medications that are contraindicated are not prescribed for the older adult.

d. It typically develops over a short period measured in days, not weeks or months.

Which of the following statements regarding delirium in older adults is most accurate? a. It is associated with a significantly increased risk of suicide. b. It often manifests in a daily cycle that includes sundowning. c. It has a slow, insidious onset that family and clinicians often overlook. d. It typically develops over a short period measured in days, not weeks or months.

d. "Leaking urine is a normal part of aging."

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

c. High-pitched sounds

With a client suspected of suffering from presbycusis, the nurse would expect difficulty hearing: a. Full range of tones b. Low-pitched sounds c. High-pitched sounds d. Medium-frequency sounds