GERO HESI
Which ocular symptom would the nurse expect a client with a diagnosis of dry age-related macular degeneration to report?
*Loss of central vision 2 Attacks of acute pain 3 Constant blurred vision Incorrect4 Decreased peripheral vision
For which clinical manifestations would the nurse assess the client diagnosed with Alzheimer disease? Select all that apply. One, some, or all responses may be correct.
*Loss of recent memory 2 Focused attention span 3 *Perceptual disturbances 4 Willingness to accept change 5 *Difficulty learning something new
Which response would the nurse make to the son who says, "I should never have allowed my father to live alone like he wanted to because he has Alzheimer disease. I'm to blame! He didn't even recognize me"?
"I don't think that anybody can blame you. You did what he wanted. Your being here tells us that you care." 2 "I realize that you're upset now. You can visit again when he is more responsive. I'm sure you'll see a change." 3 "Why do you think your father's condition has deteriorated? His forgetfulness is temporary. You'll help if you don't cry." 4 *"This must be a difficult time for both of you. Please share some of your other observations with us—that will help us plan his care."
Family members received discharge instructions for an older adult male recovering from a urinary tract infection. Which statement indicates family understanding of age-related changes and required care?
"I place a small glass of water at his side to ensure sipping before bedtime." 2 "I respond immediately with the urinal whenever he indicates a need to void." Correct3 *"I provide privacy and standby assistance to help him void." Incorrect4 "I encourage him to use the urinal at least every 2 hours during the day.
An older adult experiencing delirium suffers from a leg fracture caused by a fall. Which interventions would the nurse follow to prevent future falls? Select all that apply. One, some, or all responses may be correct.
*Minimizing sedating medications 2 *Modifying the home environment 3 Teaching clients about the safe use of the Internet 4 *Manage foot and footwear problems 5 Providing information about the effects of using alcohol
To ensure antibody-mediated immunity, which actions would the nurse instruct an older client to implement? Select all that apply. One, some, or all responses may be correct.
*Obtain a shingles vaccination. 2 *Receive a tetanus booster injection. 3 *Obtain the pneumococcal vaccination. 4 Receive annual testing for tuberculosis. 5 *Receive an annual influenza vaccination. 6 Avoid obtaining the pertussis vaccination
The nurse is caring for an older adult client who has constipation. Which independent nursing intervention helps reestablish a normal bowel pattern?
Administer a mineral oil enema. 2 Offer 1 cup of fluid every hour. 3 Manually remove fecal impactions. Correct4 *Offer a cup of prune juice
Which would the nurse assess to determine whether a 75-year-old individual is meeting the developmental tasks associated with aging?
Achievement of a personal philosophy 2 Adaptation to the children leaving home Correct3 *Attainment of a sense of worth as a person 4 Adjustment to life in an assisted-living facility
A married older adult couple lives independently and has three adult children. The husband, who is alert but forgetful, has an enlarged prostate with infrequent urinary incontinence. The wife has diabetes mellitus, rheumatoid arthritis, and walks with difficulty. The nurse identified the couple's need for assistance with bathing, dressing, and meal preparation. Which option would the nurse suggest, which best meets the needs of this couple?
Admit them together to an extended care facility (nursing home). 2 Place them in an apartment together, within an assisted-living facility. 3 *Keep the couple in their home and schedule assistance with a home health aide. 4 Encourage the couple to move in with one of their children for safety reasons
An older adult client who is accustomed to taking enemas periodically to avoid constipation is admitted to a long-term care facility and is bedbound. Which nursing action would be included in the initial plan of care to prevent the client from developing constipation?
Arrange to have enemas prescribed for the client. 2 Obtain a prescription for a daily laxative for the client. 3 Place a commode by the bedside to facilitate defecation. 4 *Offer a large glass of prune juice with warm water each morning
Which age-related finding would the nurse discover when assessing the health of a 69-year-old client?
Big, wide opened eyes 2 Presence of facial hair 3 A bruise on the elbow 4 *Walking with neck bent forward
For which condition is an adult client with a weakened urinary sphincter at risk?
Bladder distention Correct2 *Skin irritation 3 Tendency to fall 4 Urinary retention
The nurse listens to and validates the feelings expressed by a confused older adult. Which element(s) would the nurse convey in this situation? Select all that apply. One, some, or all responses may be correct.
Recalling 2 *Respecting 3 *Reassuring 4 Reinforcing 5 *Understanding
Which approach would the nurse use for a client with Alzheimer disease who expresses fear and anxiety upon admission to a long-term care facility?
Exploring the reasons for the concerns 2 *Reassuring the client with the presence of 1 or 2 staff members 3 Providing the client with a written schedule of planned interactions 4 Explaining to the client why the admission to the facility is necessary
The nurse is preparing discharge instructions for a client who has begun to demonstrate signs of early Alzheimer dementia and lives alone, with adult children living nearby. According to the prescribed medication regimen, the client is to take medications six times throughout the day. Which nursing intervention is correct to assist the client with taking the medication?
Contact the client's children and ask them to hire a private-duty aide who will provide round-the-clock care. 2 Develop a chart for the client, listing the times the medication should be taken. 3 *Contact the primary health care provider and discuss the possibility of simplifying the medication regimen. 4 Instruct the client and client's children to put medications in a weekly pill organizer.
The client has a visual impairment. Which technique would the nurse use to communicate?
Face the caregiver while speaking. 2 Provide bright, diffuse, glare lighting. 3 Stand or sit far away from the client while remaining in the client's full view. Correct4 *Encourage the older adult to use assistive devices such as eyeglasses.
An older adult has undergone chemotherapy. Which agent could be administered to decrease the risk of a potentially contagious common viral infection?
Famciclovir 2 Gabapentin 3 *Zoster vaccine 4 Herpes simplex virus type 1 (HSV-1) vaccine
Which priority factor would the nurse consider when planning care for a nursing home client who demonstrates numerous disorganized behaviors related to disorientation and cognitive impairment?
Level of interest in unit activities 2 Orientation to time, place, and person 3 *Ability to perform tasks without becoming frustrated 4 Cognitive impairment, which will increase until adjustment to the home is accomplished
Which immune function change places older clients at risk for bacterial and fungal infections?
Decline in natural antibodies 2 Reduction of neutrophil function 3 *Decrease in circulating T lymphocytes 4 Reduction of colony-forming B lymphocytes
While assessing the skin of an older adult, the nurse observes that the skin has a dry and uneven color. Which change is responsible for this condition?
Decreased subcutaneous fat 2 Decreased extracellular water 3 Decreased proliferation capacity Correct4 *Decreased activity of sebaceous glands
Which change in the joint may result in joint pain for older adults?
Dehydration of discs 2 Loss of muscle mass 3 Decreased elasticity in the ligaments Correct4 *Increased cartilage erosion
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls which expected sensory losses associated with aging? Select all that apply. One, some, or all responses may be correct.
Difficulty in swallowing 2 *Diminished sensation of pain 3 Heightened response to stimuli 4 *Impaired hearing of high frequency sounds 5 Increased ability to tolerate environmental heat
Which age-related change would the nurse consider when formulating a plan of care for an older adult? Select all that apply. One, some, or all responses may be correct.
Difficulty in swallowing 2 Increased sensitivity to heat 3 *Increased sensitivity to glare 4 *Diminished sensation of pain 5 Heightened response to stimuli
Which principles would promote learning in older adults? Select all that apply. One, some, or all responses may be correct.
Emphasize abstract material. 2 *Use past experiences while teaching. 3 Teach by presenting multiple examples at a time. 4 *Keep the environmental distractions to a minimum. 5 *Use audio, visual, and tactile cues to enhance learning.
Which findings in the older adult client are associated with a urinary tract infection (UTI)? Select all that apply. One, some, or all responses may be correct.
Fever 2 Urgency 3 *Confusion 4 *Incontinence 5 *Slight rise in temperature
Which important points would the nurse keep in mind when caring for an older adult to promote health? Select all that apply. One, some, or all responses may be correct.
Focus on achieving the highest level of health and absence of disease. Correct2 *Encourage regular physical activity and the use of stress-management strategies. 3 Encourage the client to accept help for carrying out activities of daily living (ADLs). Correct4 *Consider the client's social environment, and strengthen social support to promote health. *Correct5 Assess the client for fear of falling, and provide support by making environmental changes
Which action would be used to decrease risk for postoperative respiratory complications in an older client with decreased vital capacity?
Give prescribed intravenous antibiotic. 2 Administer oxygen per nonrebreather mask. 3 *Teach the client coughing and deep-breathing exercises. 4 Keep the client on the mechanical ventilation for several days
Which information, if reported by a client within 4 hours after repair of a retinal detachment, would the nurse plan to communicate to the primary health care provider?
Has not voided 2 Cannot open the eye 3 Cannot remember the date 4 *Has sharp pain in the eye
"My vision is best when I dim the lights." 2 "I always see halos around lights, especially at night." 3 "I can't see objects in my periphery vision." Correct4 "I can't see objects in the center of my vision field."
Industry versus inferiority 2 Identity versus role confusion Correct3 *Generativity versus stagnation 4 Autonomy versus shame/doubt
Which approach would the nurse use for a nursing home client with Alzheimer disease who is confused, agitated, and at times unaware of the presence of others?
Initiating a program of unplanned interaction 2 Explaining the nature and routines of the unit 3 Exploring in depth the reasons for the admission 4 *Arranging for the constant presence of a staff member
Which principle of teaching would the nurse consider when providing instructions to an older client recently diagnosed with diabetes mellitus?
Knowledge reduces general anxiety. 2 Capacity to learn decreases with age. Correct3 *Continued reinforcement is advantageous. 4 Readiness of the learner precedes instruction
The registered nurse is teaching isometric exercises to an 80-year-old client. Which change as a result of aging requires this intervention?
Kyphotic posture 2 *Muscular atrophy 3 Decreased bone density 4 Cartilaginous degeneration
A 78-year-old client who has hypertension is beginning treatment with furosemide. Considering the client's age, which would the nurse teach the client to do?
Limit fluids at bedtime. 2 *Change positions slowly. 3 Take the medication between meals. 4 Assess the skin for breakdown daily.
A client with dementia is having trouble with person, place, and time. Which action by the nurse would be appropriate in this situation?
Minimize environmental stress to reduce confusion. 2 *Let the client continue to think in his or her own way. 3 Prompt the client to recognize the correct date and time. 4 Ask the client to recall the past to understand the present situation
Which conclusion would the home care nurse make regarding an older adult client with mild Alzheimer disease?
Must be supervised closely at all times 2 Needs a live-in home health aide to assist with activities of daily living Correct3 *Should be allowed to function independently if therapeutically possible 4 Ought to be responsible for carrying out daily self-care activities without assistance
A 60-year-old client with gastric cancer has a shiny tongue, paresthesias of the limbs, and ataxia. The laboratory results show cobalamin levels of 125 pg/mL. Which medication would the nurse expect to be prescribed for the client?
Oral hydroxyurea Correct2 *Vitamin B12 injections 3 Oral iron supplements 4 Erythropoietin injections
Which priority parameter would the nurse assess when caring for an older adult client with a neurocognitive disorder who demonstrates disorientation and numerous unmanageable behaviors?
Orientation to time, place, and person 2 Ability to perform daily activities without assistance from others 3 *Stressors that appear to precipitate the client's disruptive behavior 4 Cognitive impairments until complete adjustments are accomplished
Based upon the information in the chart, which action would be priority when an older adult presents to the clinic with reports of nausea, headache, and episodes of double vision during the past few days?
Perform an in-depth cardiac assessment. 2 Arrange for an ophthalmic consultation immediately. 3 Initiate a conversation about the son's cancer diagnosis. Correct4 *Inquire when the client began therapy for hypertension.
Which actions would be considered in the collaborative plan of care for a client with increased lens density? Select all that apply. One, some, or all responses may be correct.
Performing keratoplasty 2 *Performing phacoemulsification 3 Monitoring for pain and eye redness 4 *Monitoring the client's blood glucose levels 5 *Assessing if the client is on antiplatelet medication
Which action would the nurse take for an older client with Alzheimer disease who has intermittent episodes of urinary incontinence?
Point out the behavior to the client. 2 Obtain incontinence pads for the client. Correct3 *Take the client to the bathroom at regular intervals. 4 Encourage the client to call for help when there is an urge to urinate.
The nurse instructs a 70-year-old client to dress warmly in cold weather. Which physical changes seen in the client necessitate this instruction? Select all that apply. One, some, or all responses may be correct.
Reduced sebum production 2 Degeneration of elastic fibers 3 Decreased dermal blood flow 4 *Thinning of the subcutaneous layer 5 *Decreased vasomotor responsiveness
Which findings are expected when assessing the skin of an older adult? Select all that apply. One, some, or all responses may be correct.
Scaly skin 2 *Tenting of skin 3 *Transparent skin 4 *Increased wrinkles 5 *Pigmented lesions
Which genitourinary factor contributes to urinary incontinence in older adult clients and needs to be considered by the nurse when planning the care for these clients?
Sensory deprivation 2 *Urinary tract infection 3 Frequent use of diuretics 4 Inaccessibility of a bathroom
Which nursing intervention is indicated for an aging client with decreased bone density?
Teaching the client isometric exercises 2 Advising the client to take a warm shower 3 Providing supportive armchairs to the client 4 *Demonstrating weight-bearing exercises to the client
Which intervention would the nurse implement with a healthy older adult client who has decreased bone density?
Teaching the client to do isometric exercises Correct2 *Encouraging the client to do weight-bearing exercise 3 Instructing the client to sit in supportive chairs with arms 4 Providing moist heat such as a shower or moist compresses
The nurse leans toward the client while talking. Which would this posture convey?
The nurse is relaxed and comfortable with the client. 2 *The nurse is involved and interested in the interaction. 3 The nurse is there to listen and is interested in what the client is saying. 4 The nurse is involved and has a willingness to listen to what the client is saying
The nurse is advising an older adult client to apply moisturizer when the skin is moist. Which physical change in the client is associated with this advice?
Thinning subcutaneous layer 2 Degeneration of elastic fibers 3 *Decreased dermal blood flow 4 Benign proliferation of capillaries
Which therapeutic communication strategy is involved when the older client is recalling the past?
Touch 2 *Reminiscence 3 Reality orientation 4 Validation therapy
An older adult with a history of small cell lung carcinoma reports muscle cramping, thirst, and fatigue. The primary health care provider diagnoses the client with a pituitary disorder and is treating the client accordingly. Which is an effective outcome of the treatment?
Urine output of 10 L/day 2 *Urine specific gravity less than 1.025 3 Urine osmolarity of 80 mOsm/kg (80 mmol/kg) 4 Serum osmolarity of 600 mOsm/kg (600 mmol/kg)
An older adult who has an endocrine disorder is scheduled for a diagnostic study with contrast medium. The nurse identifies that it is essential for which laboratory test to be performed before the procedure?
Urine pH 2 *Serum creatinine 3 Serum albumin 4 Creatinine clearance
Which factor would the nurse consider when planning activities for an older resident in a long-term care facility with a diagnosis of neurocognitive disorder?
Varied activities that will keep the resident occupied Correct2 *Familiar activities that the resident can complete successfully 3 Challenging activities to maintain the resident's contact with reality 4 Unit activities to ensure that the resident actively participates daily
The nurse recognizes that a common conflict experienced by older adults is the conflict between which?
Youth and old age 2 Retirement and work 3 *Independence and dependence 4 Wishing to die and wishing to live
The nursing student counsels an older 70-year-old female client about changes caused by aging. Which statement made by the client indicates effective learning?
"I should reduce my calcium intake." 2 "I should limit my Kegel exercises." 3 *"I should have regular breast examinations." 4 "I should avoid eating protein."
The registered nurse teaches a 70-year-old client with kyphosis about self-care measures. Which statement made by the client indicates effective learning?
"I should take warm baths." 2 "I should do isometric exercises." 3 *"I should sit in supportive armchairs." 4 "I should position myself quickly.
The nurse is teaching an older client about proper medication use. Which statement made by the client indicates the need for further education?
"I will ask the pharmacist to give generic medications." Correct2 *"I will use over-the-counter medicines along with prescribed medications." Incorrect3 "I will continue my treatment by consulting a single health care provider." 4 "I will know the names and times of administration of the medications I am taking."
The registered nurse (RN) is teaching a nursing student about how to educate clients based on their developmental capacity. Which statements made by the nursing student are applicable for older adults? Select all that apply. One, some, or all responses may be correct.
"I would encourage independent learning." 2 *"I would keep the teaching sessions short." 3 *"I would involve the client in any discussion or activity." 4 "I would encourage learning through pictures and short stories." 5 "I would teach the client psychomotor skills to maintain his or her health."
The nurse instructs an older client's adult child about age-related immune system changes and associated care measures. Which statement indicates a need for further instruction?
"My parent has a private room at home." 2 "My parent has received the pneumococcal vaccination recently." 3 *"My parent comes in for checkups only when experiencing a fever." 4 "My parent has been given a second dose of the pertussis vaccination.
Which response reported by an older adult client would the nurse identify as consistent with the diagnosis of macular degeneration?
"My vision is best when I dim the lights." 2 "I always see halos around lights, especially at night." 3 "I can't see objects in my periphery vision." Correct4 *"I can't see objects in the center of my vision field."
Which points require correction regarding wellness promotion in the older adult? Select all that apply. One, some, or all responses may be correct.
"Older adults need to prevent injuries when promoting wellness." 2 *"Curing diseases or other illnesses completely is essential i to promote wellness in the older adult." 3 "It is important to assess the level of fear of falling and provide support accordingly when caring for older adults." 4 *"It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." 5 *"An older adult should live in social isolation to prevent stress.
Which instructions would the nurse give to an older adult with decreased perception of touch? Select all that apply. One, some, or all responses may be correct.
"Use a cane for support when walking." Correct2 *"Hold on to handrails while ambulating." Correct3 *"Look where your feet are placed while walking." Correct4 *"Wear shoes that give good support while walking." Correct5 *"If you are unable to change your position frequently, request assistance."
Which response would the nurse make to a depressed older client who has not been eating well since admission to the hospital and repeatedly states, "No one cares"?
"We all care about you; now please eat." 2 "We all care about you; you have to eat to stay alive." 3 *"I care about you. What are some foods you especially like?" 4 "I care about you. Will you please eat some of this food for me?"
Which response would the nurse make to a client's daughter who asks when it would be best to visit her mother who has Alzheimer disease?
*"Around 2:30 in the afternoon would be a good time to visit." 2 "Whenever is most convenient for you. She'll be glad to see you." 3 "Come at noon. You'll be able to go to the dining room and visit while she eats." 4 "The longest uninterrupted time begins after supper and extends until bedtime, at 8:30 PM."
An older client asks, "How do I know that the medications that I take are safe?" Which response by the nurse is correct? Select all that apply. One, some, or all responses may be correct.
*"Ask your health care provider how and when you should be taking your medications." 2 "Stop taking a prescribed medication if you are not feeling better in a few days." 3 "Discard medications into the toilet that have exceeded the expiration date on the bottle." 4 *"Check the name, dose, and instructions about administration of medications each time before leaving the pharmacy." 5 *"Inform your health care provider of the over-the-counter medications, recreational drugs, and amount of alcohol you ingest."
While assessing the skin of an older client, the nurse finds skin transparency and fragility. Which nursing instructions will benefit the client?
*"Do not place tape on the skin." 2 "Take multiple vitamins on a daily basis." 3 "Refrain from exposure to skin irritants." 4 "Keep an eye on any pigmented lesions.
Which instruction would the nurse give an older adult to promote wellness and reduce the risk of disability?
*"Engage in physical activities to stay fit." 2 "Don't exhaust yourself by engaging in physical activities." 3 "Pay no heed to your financial problems if you want to stay healthy." 4 "Stay away from people so as to prevent anxiety and stress disorders."
The nurse suspects that a client has diabetes mellitus. Which statements made by the client helped the nurse reach this conclusion? Select all that apply. One, some, or all responses may be correct.
*"I am 65 years old." 2 *"I quite often feel thirsty." 3 *"I eat food every 2 hours." 4 "I have excessive sweating." 5 "I sometimes experience shortness of breath."
Which initial response would the nurse make during a routine yearly physical to an older adult who says, "I haven't had sex lately because I can't get an erection anymore"?
*"Let's discuss this concern a little more." 2 "Be sure to tell your primary health care provider about this problem." 3 "There is medication available for erectile dysfunction." 4 "This is an expected physiological response to getting older."
Which instructions would the nurse give a 60-year-old client who is at an increased risk for corneal damage? Select all that apply. One, some, or all responses may be correct.
*"Use saline drops." 2 "Increase humidity at home." 3 *"Wear prescribed lens for best vision." 4 *"Have corrective lenses solely for reading.
The nurse was assessing an older adult client and recorded the pulse rate as 85. After assessment the nurse determined the cardiac output as 5950. Which would be the approximate stroke volume?
*70 mL 2 60 mL 3 50 mL 4 40 mL
Which age-related changes would the nurse expect to find when assessing the reproductive health of an older female client? Select all that apply. One, some, or all responses may be correct.
*Smaller clitoris 2 *Shrunken vulva 3 Dimpled breasts 4 *Narrowed vaginal opening 5 Green vaginal discharge
In the older adult client with decreased cell division in the epidermal layer of the skin, which interventions would the nurse include in the client's plan of care? Select all that apply. One, some, or all responses may be correct.
*Advise the client to prevent exposure to skin trauma. 2 *Advise the client to protect open areas of skin. 3 Advise nonalcohol-based lotions for excessive dryness or moisture. 4 Handle the client carefully to reduce skin friction. 5 Advise the client to change positions every 2 hours
The home health care nurse visits an older adult couple living independently. The wife cares for the husband, who has dementia. Which interventions would the nurse implement for them? Select all that apply. One, some, or all responses may be correct.
*Assess the wife for caregiver burden. 2 Arrange hospice care for the husband. 3 Make health care decisions for the couple. 4 *Assess the husband for signs of physical abuse. 5 *Identify social support within the community.
An older adult client who is receiving chemotherapy for cancer has severe nausea and vomiting and becomes dehydrated. The client is admitted to the hospital for rehydration therapy. Which nursing actions have specific gerontological implications the nurse must consider? Select all that apply. One, some, or all responses may be correct.
*Assessment of skin turgor 2 Documentation of vital signs 3 Assessment of intake and output 4 *Administration of antiemetic medications 5 *Replacement of fluid and electrolytes
A client with Parkinson disease is admitted to the hospital. Which medication is prescribed to improve the physical manifestations of Parkinson disease?
*Carbidopa-levodopa 2 Isocarboxazid 3 Dopamine 4 Pyridoxine (vitamin B6)
Which precaution would the nurse teach a client prescribed selegiline for the treatment of Parkinson disease?
*Change to a standing position slowly. 2 Take the medication between meals. 3 Perform self-blood glucose monitoring. 4 Withhold the next dose if nausea occurs.
The nurse finds that an older adult has a new onset of decreased consciousness, fatigue, and hallucinations. Which condition would the nurse suspect in the client?
*Delirium 2 Dementia 3 Depression 4 Alzheimer disease
The nurse is caring for an older adult with a hearing loss secondary to aging. Which would the nurse expect to identify when assessing this client? Select all that apply. One, some, or all responses may be correct.
*Dry cerumen 2 Tears in the tympanic membrane 3 *Difficulty hearing high pitched voices 4 Decrease of hair in the auditory canal 5 Overgrowth of the epithelial auditory lining
Which age-related changes are associated with the female genitalia? Select all that apply. One, some, or all responses may be correct.
*Dry vagina 2 Firm breasts 3 Erect nipples 4 *Graying pubic hair 5 *Shrinking of the labia majora
Which action would the nurse take for a daughter who states that she gives sleeping pills to her live-in mother who has dementia to stop wandering at night?
*Explore hiring a home health aide to stay with the client at night. 2 Discuss the possibility of having the client placed in a nursing home. 3 Suggest moving the client among family members on a monthly basis. 4 Empathize with the daughter but suggest that wrist restraints would be preferable
Which observation by the nurse indicates a client's decrease in hearing acuity? Select all that apply. One, some, or all responses may be correct.
*Frequent use of words such as "what" 2 *Postural changes while listening to the speaker 3 *Bending toward the other person while talking 4 *Mismatch between the questions asked and the responses given 5 Startled expression to any unexpected sound in the environment
The nurse is communicating with a deaf client. Which intervention by the nurse is beneficial to promote communication? Select all that apply. One, some, or all responses may be correct.
*Giving the client a chance to speak 2 Assuming the client is being uncooperative 3 Chewing gum while talking to the client 4 *Making sure that the client knows you are speaking 5 *Keeping the communication concise
An 82-year-old client is scheduled for physical therapy after a fracture of the arm. Considering the older population, the nurse recalls that mild exercise is likely to have which effect on the client's respirations?
*Increase to 24 breaths per minute 2 Become progressively more difficult 3 Decrease in rate as their depth increases 4 Become irregular but remain within normal rates
While assessing an older adult client before noon, the nurse smells alcohol on the client's breath. Which additional signs and symptoms would the nurse then monitor for? Select all that apply. One, some, or all responses may be correct.
*Irritability Correct2 *Poor hygiene Correct3 *Family conflict Incorrect4 Good nutritional habits Correct5 *Excessive mood swings 6 Strong cognitive skills
Which intrinsic factors may contribute to falls in older adults? Select all that apply. One, some, or all responses may be correct.
*Lack of exercise 2 *Impaired vision 3 Inappropriate footwear 4 Improper use of assistive devices 5 Unfamiliar environment of hospital room
Which statement is true about older adults and type 2 diabetes?
*Older adults seldom develop ketoacidosis. 2 Older adults secrete no endogenous insulin. 3 Older adults have a lower risk of complications. 4 Older adults develop a sudden onset of symptoms
A client who has type 1 diabetes and chronic bronchitis is prescribed atenolol for the management of angina pectoris. Which clinical manifestation will alert the nurse to the fact that the client may be developing a life-threatening response to the medication?
*Paroxysmal nocturnal dyspnea 2 Supraventricular tachycardia 3 Malignant hypertension 4 Hyperglycemia
An older adult in acute care has a risk of skin breakdown. Which intervention(s) is/are beneficial to the client? Select all that apply. One, some, or all responses may be correct.
*Providing thorough skin care Correct2 *Reducing shear forces and friction 3 Providing beverages and snacks frequently Incorrect4 Using a support surface base all the time Correct5 *Avoiding pressure with proper positioning
The nurse is assessing an older adult male client. Which clinical finding(s) are expected response(s) to the aging process? Select all that apply. One, some, or all responses may be correct.
*Slowed neurological responses Lowered intelligence quotient Long-term memory impairment *Forgetfulness about recent events *Reduced ability to maintain an erection
Which intervention would the home health nurse perform when conducting an initial visit to an older depressed client who lives alone and performs all tasks of daily living?
*Supporting the client's usual routine 2 Helping the client in setting new goals 3 Assisting the client in focusing on the future 4 Arranging for the client to have help in the home
An emaciated older adult with dementia develops a large pressure ulcer after refusing to change position for extended periods. The family blames the nurses and threatens to sue. Which is considered when determining the source of blame for the pressure ulcer?
*The client should have been turned regularly. 2 Older clients frequently develop pressure ulcers. 3 The nurse is not responsible to the client's family. 4 Nurses should respect a client's right not to be moved
Which administration guidelines would the nurse follow when administering midazolam to an older client?
*The increments should be smaller, and the rate of injection should be slower. 2 The medication should be given as a rapid intravenous push. 3 It is important to monitor for spikes in blood pressure elevation during administration. 4 During the procedure, the medication should be given as needed for pain management.
Which approach would the nurse take for an older adult client who is confused, does not recognize family members, and often soils clothing with feces and urine?
*Toileting the client every 2 hours 2 Placing the client in orientation therapy 3 Supervising the client's bathroom activities closely 4 Explaining to the client how offensive the behavior is to others
Which intervention would the nurse provide while caring for an older adult client who is reported to have decreased estrogen production?
*Use minimal tape on client's skin 2 Cover the client with warm clothing 3 Perform blood glucose test for the client 4 Monitor for bradycardia
An older client who has been undergoing months of treatment for osteomyelitis reports perianal itching and diarrhea. Which assessment finding would the nurse expect to identify?
*Whitish-yellow lesions in the oral cavity 2 Presence of glucose and ketones in urine 3 Flexion contracture of the lower extremities 4 Overgrowth of genital wart-like lesions
Which nursing action(s) may help in the effective assessment of older clients? Select all that apply. One, some, or all responses may be correct.
*he nurse makes eye contact with the client. 2 The nurse leans backward during the interaction. 3 *The nurse smiles at the client during the interaction. 4 The nurse shrugs her shoulders in response to a client's question. 5 The nurse asks the client to express details as quickly as possible
Which action is appropriate when caring for an elderly client admitted to a health care facility?
Ensure that the room is brightly lit. 2 Speak to the client in a loud voice. 3 Stand close to the client's ear while speaking. 4 *Invite a family member to join the conversation
When nurses are conducting health assessment interviews with older clients, which step would be included?
Leave a written questionnaire for clients to complete at their leisure. 2 Ask family members rather than the client to supply the necessary information. 3 *Spend time in several short sessions to elicit more complete information from the clients. 4 Keep referring to previous questions to ascertain that the information given by clients is correct
Which approach would the nurse use for an older adult client with Alzheimer disease who frequently switches from being pleasant and happy to being hostile and unhappy without apparent external cause?
Pointing out reality to the client 2 *Providing nursing care when the client is receptive 3 Encouraging the client to talk about personal feelings 4 Restraining the client when hostility is being exhibited
Which nursing interventions would the nurse provide to an older client with hypertension? Select all that apply. One, some, or all responses may be correct.
Provide skin care. Correct2 *Advise the client to limit salt intake. Correct3 *Teach stress management. Correct4 *Instruct the client to quit smoking. 5 Advise the client to eat finger foods.
Which clinical manifestation indicates a need for the nurse to contact the health care provider to increase the intravenous fluid infusion for an older client with an infection?
Pruritus 2 Erythema Correct3 *Acute confusion 4 General malaise
