ATI Older Adults 3.0
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
A nurse is performing an eye assessment of an older adult client and identifies a corneal ulceration. Which of the following conditions most likely contributed to this finding?
Entropion
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
A nurse is assessing breath sounds on an older adult client and auscultates intermittent coarse bubbling sounds that do not clear with coughing. Which of the following terms should the nurse use to document the findings?
Crackle
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
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
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 rising from a seated position
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 a 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
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
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 to injury from external stimuli.
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.
A nurse is performing an abdominal assessment. Which of the following quadrants of the abdomen should the nurse auscultate first?
Right lower quadrant
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 4
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.
A nurse is assessing an older adult client who is experiencing constipation. Which of the following actions by the client requires further education?
Use a laxative every 3 day
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.
