Health Assessment Chapter 32: Assessing Older Adults

A nurse is working with an 86-year-old man who has developed pneumonia. The nurse is aware that this client, due to his age, is living with how much less cellular function in his organ systems throughout his body than a younger person?

50%

An elderly client reports pain in the calves. What question is appropriate for a nurse to ask to determine the cause of this pain?

"How far do you walk before you experience pain?"

A nurse is interviewing a 79-year-old client regarding her present health concern. Under which of the following conditions should the nurse consult a family member of the client to compare client's current cognition and behavior with a prior level of function

1) Client is lethargic and agitated 2) Client appears agitated 3) Client appears excessively distracted 4)Client offers inconsistencies in her responses

A nurse assess an elderly client and determines that that client is at risk for falls. Which interventions are appropriate to reduce the incidence of actual falls the client incurs?

1) Remove rugs or other loose carpet 2) Remind the client to ask for assistance 3) Assist with exercise to strengthen lower extremities

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?

1)Loss of firmness in labia 2) Increased dryness in the vagina 3) Uterine contractions with orgasm are painful

A nurse performs a "Get Up and Go" test on an elderly client. On completion of the test , the nurse documents the test score as 5. What is the gait assessment results as per the score?

5- Severly abnormal gait 4- Moderately abnormal gait 3- Mildly abnormal gait 1- Normal gait Elderly clients without impairment in gait or balance can complete the test in 10 seconds. People who take more that 30 seconds to complete the test tend to be dependent in some activities of daily living such as bathing, getting in and out of bed, and climbing stairs.

A nurse is working with a client who is considered to be part of the "frail elderly." At which age is a person typically first considered to be a part of this group?

85

A nurse is working with an elderly client with symptoms of urinary tract infection who says she doesn't like to report health problems and visit the doctor because some of her friends have had negative experiences with clinicians and have even seemed to get worse after doctor's visits. Which of the following interview techniques should the nurse use to encourage the client and build rapport, which will increase the likelihood of her returning for care?

Acknowledge the client's exercise habits that have kept her trim and healthy for so long

An elderly client calls the health care clinic and asks the nurse if it is okay to use an over- the-counter nasal spray to help with sinus congestion. Which question assuring the client it is okay to use this medication?

Are you taking any drugs for high blood pressure? - Decongestant med may increase the bp by vasoconstriction of the blood vessels. These kids should be avoided in people with hypertension or a history of cardiac dysrhythmias.

A nurse inspects an elderly client's abdomen and notices the presence of a mass. What is an appropriate action by the nurse in regards to this finding?

Auscultate for the presence of a bruit - If a nurse observes a mass in the abdomen, it should be auscultated for the presence of a bruit. A bruit suggests an abdominal aortic aneurysm. If present, the mass should not be palpated because of the risk for rupture. The nurse should rule out the presence of an aneurysm before palpating or measuring the mass

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?

Benign prostatic hypertrophy - BPH is the benign growth of the prostate gland in older males and is very common

An elderly client is admitted to the health care facility with an indirect inguinal hernia. Which abnormal data should the nurse expect to find in the client assessment

Bowel sounds heard over scrotum - The client with an indirect inguinal hernia will have bowel sounds heard over the scrotum

A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as what abnormal finding?

Cystocele - A bulge that originates from the anterior portion of the vagina is an indication of a cystocele. This occurs due to the relaxation of the pelvic musculature which allows the bladder to protrude into the vaginal wall

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?

Delirium

A nurse examines a frail elderly client's mouth and finds several broken and missing teeth and irritated gums. The nurse should assess this client closely for problems associated with which body system?

Gastrointestinal - Oral health is a vital component of good nutrition. It affects the frail elderly client's ability to chew food properly and ultimately affects digestion. If the client does not eat enough or digest properly, many gastrointestinal problems may arise as well as tendency towards malnutrition, undernutrition, or dehydration.

A nurse obtains an order to check an elderly client for orthostatic hypotension. Which finding alerts the nurse to a positive result for this test?

Heart rate increases 20 beats over the baseline rate

A nurse is assessing an elderly client with rheumatoid arthritis. The nurse observes that the client has difficulty rising from a chair and walking at a normal gait, which the client attributes to painful joints. The client's pulse rises about 10 beats/min on rising and returns to baseline in less than 1 minute. The nurse also learns from the client that she often experiences loss of urine when she laughs, coughs, or sneezes. Which of the following nursing diagnoses can the nurse make based on this information?

Impaired physical mobility

A nurse is inspecting an elderly client's head and neck. Which of the following findings should most prompt the nurse to suspect onset of a chronic condition?

Involuntary facial or head movements

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?

Katz activities of daily living tool

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?

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

A nurse should assist an elderly client to assume which position to facilitate the examination fo the anus and rectum

Left side-lying

A nurse recognizes that a slight barrel-shaped in an elderly client is due to what physiologic change in the thorax as a result of the aging process?

Loss of skeletal muscle strength - The loss of skeletal muscle strength of the thorax and diaphragm combined with the loss of resilience that holds the thorax in a slightly contracted position contribute to that slight barrel chest seen in the elderly. This causes a decreased vital capacity and an increased residual volume. A decrease in elastin and collagen causes the lungs to recoil less during expiration, which increases the energy needed to breath and required the active use of accessory muscles

An elderly client presents to the ED with reports of a productive cough of blood-tinged sputum, fatigue, weight loss, and shortness of breath. The nurse recognizes that these are symptoms associated with which respiratory disease process?

Lung cancer - A recurrent cough, fatigue, weight loss and shortness of breath are hallmarks of lung cancer

An elderly client states that the right eye has better eyesight that the left. A nurse recognizes that this may indicate the onset of what eye condition?

Macular degeneration - Leading cause of blindness in elderly people

A nurse recognizes that a priority goal of assessment in the frail elderly is what outcome?

Minimize disability associated with illness

Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence

Obtain a voiding diary - The most appropriate method of assessing urinary incontinence in an elderly client is by obtaining a voiding diary

What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client?

Plan for additional time to allow as much independence as possible

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?

Prepare foods that are pudding consistency or semisolid

When looking at a review of system for an elderly client, which gastrointestinal data should cause the nurse the most concern?

Reports of constipation - Constipation is not a normal process of aging but many factors contribute to its presence.

Which assessment data would a nurse expect to find in an elderly client with a pulmonary infection and a productive cough?

Respiration more than 25 breaths/min

During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change with the aging process?

Retraction of the nipples - Nipples retract in the elderly client due to loss of musculature. Unlike nipple retraction due to a mass, nipples retracted due to aging can be everted with gentle pressure.

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?

Rise from a chair to a standing position

During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding?

Senile Purpura

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?

Solar lentigines - Hyperpigmentation in sun-exposed areas appears as brown, pigmented, round or rectangular patches. They are often called liver spots. These are normal skin variations in the aging population.

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?

Stress

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 test to assess this sudden change in health status?

Urinalysis for the onset of a urinary tract infection

Which intervention should the nurse suggest to a client to improve the condition of dry skin?

Use lanolin-based products

An elderly reports pain in the leg which is not associated with any particular activity but is lessened when the leg is elevated. The nurse recognizes that the client may have which vascular condition?

Venous insufficiency - Pain unrelated to activity indicates venous insufficiency in the client