Exam 1 EAQs

What musculoskeletal system change is associated in older adult clients? A. Decrease in height B. Decreased neck rigidity C. Increase in fine-motor dexterity D. Increased range of motion

A Loss of height and deformity and shortening of the trunk are common in older adults d/t vertebral compression and degeneration. Rigidity in the neck, shoulders, back, hips, and knees increases with age d/t loss of elasticity in ligaments, tendons, and cartilage. A decline in fine-motor dexterity occurs in the older adult d/t slow impulse conduction along motor units. Range of motion is limited in the older adult d/t cartilage erosion, increased friction between the bones, and overgrowth of bone around joint margins.

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)? A. Barrel chest B. Cyanosis C. Hyperventilation D. Lordosis

A Clients with COPD often develop a barrel chest over time because of air being trapped, thus resulting in enlarged lungs and thoracic cavity. This also causes the lungs to have less flexibility. Cyanosis is a bluish discoloration, especially of the skin and mucous membranes, caused by excessive concentration of deoxyhemoglobin in the blood caused by deoxygenation. COPD sufferers can exhibit this, but barrel chest is the most obvious sign, as other respiratory/cardiovascular disorders can cause cyanosis as well. Hyperventilation is the act of breathing faster or deeper than normal, which causes excessive expulsion of circulating carbon dioxide. This causes the arterial concentration of carbon dioxide (PaCO 2) to fall below normal, raising blood pH, and results in alkalosis. COPD sufferers can experience hyperventilation, but barrel chest is the classic sign of COPD. Lordosis is an unusual inward curving of the spine in the lower part of the back. It can be considered medically significant; however, it is not associated with classic signs of COPD.

Which intrinsic factors may contribute to falls in older adults? Select all that apply. A. Deconditioning B. Impaired vision C. Inappropriate foot wear D. Improper use of assistive devices E. Unfamiliar environment of hospital room

A, B Falls in older clients may be due to intrinsic factors and extrinsic factors. Deconditioning and impaired vision are intrinsic factors that can lead to falls. Inappropriate foot wear, improper use of assistive devices like walkers, and a lack of familiarity with the hospital room are extrinsic factors.

A nurse is caring for an older adult with a hearing loss secondary to aging. What can the nurse expect to identify when assessing this client? Select all that apply. A. Dry cerumen B. Tears in the tympanic membrane C. Difficulty hearing high-pitched voices D. Decrease of hair in the auditory canal E. Overgrowth of the epithelial auditory lining

A, C Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.

Which factor does the nurse consider most likely contributes to the increased incidence of hip fractures in older adults? A. Carelessness B. Fragility of bone C. Sedentary existence D. Rheumatoid diseases

B Bones become more fragile because of loss of bone density associated with the aging process; this often is associated with lower circulating levels of estrogens or testosterone. Carelessness is a characteristic applicable to certain individuals rather than to people within a developmental level. Although prolonged lack of weight-bearing activity is associated with bone demineralization, hip fractures also occur in active older adults. Rheumatoid diseases can affect the skeletal system but do not increase the incidence of hip fractures.

A nurse is assessing the skin of an older adult. Which findings will the nurse determine are expected? Select all that apply. A. Scaly skin B. Tenting of the skin C. Transparent skin D. Increased wrinkles E. Pigmented lesions

B, C, D, E Decreased subcutaneous fat with degeneration of elastic fibers allows tenting of the skin and increased wrinkles. Decreased dermal thickness results in paper-thin, transparent skin. Pigmented lesions (liver spots, solar lentigines) increase in number, size, and distribution with aging. Scaling of the skin is more commonly associated with psoriasis than aging.

When teaching about aging, the nurse explains that older adults usually have what characteristic? A. Inflexible attitudes B. Periods of confusion C. Slower reaction times D. Some senile dementia

C A decrease in neuromuscular function slows reaction time. The ability to be flexible has less to do with age than with character. Confusion is not necessarily a process of aging, but it occurs for various reasons such as multiple stresses, perceptual changes, or medication side effects. Most older adults do not have organic mental disease.

What is the main reason a nurse raises three of the four side rails on the bed of an 83 y/o client who had surgery for a fractured hip? A. As a safety measure because of the client's age B. Because clients older than 60 y/o should use side rails C. To be used as handholds to facilitate the client's ability to move in bed D. Because all older adults are disoriented for several days after anesthesia

A The need to use side rails for safety is important with any older client because the client could fall or try to get out of bed without assistance. Side rails are not always used on all clients over 60 y/o. Each individual must be evaluated based on mental and physical status. The client may use the side rails to move around in bed, but safety is always first. Some older adults become disoriented for a few days after anesthesia, but not all older adults.

A nurse is educating an older adult for the purpose of promoting wellness. What instruction should the nurse give the client to reduce the risk of disability? A. "Engage in physical activities to stay fit." B. "Don't exhaust yourself by engaging in physical activities." C. Pay no heed to your financial problems if you want to stay healthy." D. "Stay away from people so as to prevent anxiety and stress disorders."

A The nurse should instruct the older adult to engage in physical activities as a means of extending the years of active independent life and reducing the risk of disability. To promote a healthy lifestyle, the nurse should encourage the older adult to engage in physical activities. The nurse should understand that the willingness of the other adult to participate in health promotion activities depends in part on socioeconomic factors; moreover, the nurse should not provide financial advice to the client. The nurse should ensure that the older adult has social support to promote health and provide access to resources.

The nurse is preparing an individualized teaching plan for a client with osteoarthritis. The nurse recognizes which abnormality specific to osteoarthritis? A. Ulnar drift B. Heberden nodes C. Swan-neck deformity D. Boutonniere deformity

B Heberden nodules are the bony or cartilaginous enlargements of the distal interphalangeal joints that are associated with osteoarthritis. Ulnar drift, swan-neck deformity, and boutonnière deformity occur with rheumatoid arthritis.

A client with a fractured hip is placed in traction until surgery can be performed. What should the nurse explain is the primary purpose of the traction? A. Relieving muscle spasm and pain B. Preventing contractures from developing C. Keeping the client from turning and moving in bed D. Maintaining the limb in a position of external rotation

A Traction may be used in the treatment of a fractured hip to align the bones (reduction of fracture). If such traction is not employed, the muscles may go into spasm, shifting the bone fragments and causing pain. Traction is a temporary measure before surgery; contractures result from a shortening of the muscles by prolonged immobility. Although the affected extremity must be properly aligned, turning and moving the client can and should be done. External rotation is contraindicated and prevented by the use of positioning aids.

A nurse is assessing an older adult during a regular checkup. Which findings during the assessment are normal? Select all that apply. A. Loss of turgor B. Urinary incontinence C. Decreased night vision D. Decreased mobility of ribs E. Increased sensitivity to odors

A, C, D In older adults, the skin loses its turgor or elasticity and there is fat loss in the extremities. Visual acuity declines with age; therefore, decreased night vision is a normal finding in older adults. Decreased mobility of the ribs is found in older adults d/t calcification of the costal cartilage. Urinary incontinence is an abnormal finding in older adults. In older adults, a diminished, not increased, sensitivity to odor, is often found.

The nurse is providing home to care to an older adult client with decreased bone density. Which nursing intervention will be most beneficial for the client? A. Teaching isometric exercises B. Encouraging the client to do weight-bearing exercises C. Instructing the client to sit in supportive chairs with arms D. Providing moist heat, such as shower or moist compresses

B Older adults are at risk of developing decreased bone density. Elderly clients with decreased bone density should be encouraged to do weight-bearing exercises. Teaching isometric exercises would be beneficial for a client with muscular atrophy. A client with kyphotic posture should be instructed to sit in supportive chairs with arms. Providing moist heat would be beneficial for a client with cartilage degeneration.

An older adult fell at home and fractured the left hip. Which response should the emergency department nurse identify as a typical clinical indicator associated with a fractured hip? A. Affected hip is ecchymotic B. Left leg is noticeably shorter than the right C. Left extremity is internally rotated D. Affected hip is tender when touched

B There is overriding of bones in the fractured hip, and the leg on the affected side appears noticeably shorter than the unaffected leg. Ecchymosis is evidence of soft tissue and blood vessel damage; this may or may not be associated with a fractured hip. The affected leg is externally, not internally, rotated with a fractured hip. Pain associated with a fractured hip is not mild; it causes extreme pain.

What important points should the nurse keep in mind when caring for an older adult to promote health? Select all that apply. A. Focus on achieving the highest level of health and absence of disease B. Encourage regular physical activity and the use of stress-management strategies C. Encourage the client to accept help for carrying out activities of ADLs D. Consider the client's social environment and strengthen social support to promote health E. Assess the client for fear of falling and provide support by making environmental changes

B, D, E The nurse should encourage the client to include physical activity regularly and to use stress-management strategies to promote a healthy lifestyle. The nurse should consider the client's social environment and strengthen social support to promote health. Because a fear of falling is a significant risk r/t older adults, the nurse should assess the client for fear and provide support by making environmental changes. The nurse should not focus on the absence of a disease, but on achieving the highest level of health in the presence of disease. The nurse should encourage older adults to perform activities of daily living on their own to promote health.

A nurse is caring for an older adult who had an open reduction and internal fixation of a fractured hip. What clinical finding requires the nurse to notify the primary healthcare provider? A. Lack of productive cough 2 days post-operatively B. Rectal temperature 100.2ºF 3 days post-operatively C. Complaints of right-sided chest pain 6 days post-operatively D. Fatigue in the leg on the unaffected side 5 days post-operatively

C Chest pain, along with dyspnea, cough, hemoptysis, and apprehension, is a classic sign of a pulmonary embolism. Six days postoperatively is a prime time for symptoms of a pulmonary embolus to occur, because decreased mobility promotes the development of deep vein thrombosis. The lack of a productive cough does not require nursing intervention; a productive, not nonproductive, cough indicates a respiratory infection requiring intervention. An increase in temperature can result from the inflammatory process; the temperature-regulating mechanisms in older adults may be compromised slightly, and they may show a slight elevation in body temperature for a longer period of time after surgery than a younger client. Weight bearing is being done by the unaffected leg at this time, and fatigue is expected.

When nurses are conducting health assessment interviews with older clients, what step should be included? A. Leave a written questionnaire for clients to complete at their leisure B. Ask family members, rather than the client, to supply the necessary information C. Spend time in several short sessions to elicit more complete information from the clients D. Keep referring to previous questions to ascertain that the information given by clients is correct.

C Spending time in several short sessions reduces client fatigue and compensates for a shortened attention span, which is common in the older adult. The questionnaire may never be completed if it is left for the client to complete at their leisure. Asking family members rather than the client to supply the necessary information is degrading to the client; the client should be asked initially and, if necessary, family can be asked to fill in details later. Constantly referring to previous questions may be overwhelming and create feelings of anger and resentment.

Which intrinsic factor is associated with the fall of an older adult? A. Wet floors B. Poor lighting C. Deconditioning D. Inappropriate footwear

C Intrinsic risk factors associated with the fall of an older adult may include deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.

A nurse is completing the health history of a client admitted to the hospital with osteoarthritis. The nurse expects the client to report that which joints were involved initially? Select all that apply. A. Hips B. Knees C. Ankles D. Shoulders E. Metacarpals

A, B Osteoarthritis affects the weight-bearing joints (e.g., hips and knees) first, because they bear the most body weight. The resulting joint damage causes a series of physiologic responses (e.g., release of cytokines and proteolytic enzymes) that lead to more damage. Although the ankles are weight-bearing joints and eventually are affected, the motion in the ankles is not as great as in the hips and knees; thus there is less degeneration. Shoulder joints are not the most likely to be involved first, because these are not weight-bearing joints. Although the distal interphalangeal joints are commonly affected, the remaining interphalangeal joints and metacarpals are not.

What interventions should the nurse follow when giving health education to an elderly client? Select all that apply. A. Assess the client for pain before teaching B. Take down notes while talking to the client C. Ensure the client is not preoccupied or anxious D. Teach one concept at a time, according to the client's interest E. Teach a family caregiver if the client does not respond quickly

A, C, D The nurse must assess the client for pain and ensure that the client is physically well enough to learn. The nurse must begin teaching after determining that the client is not preoccupied or too anxious to comprehend the material. The nurse must postpone teaching if the client appears disinterested. The nurse should sit facing the client so that the client is able to view the nurse's expressions and lip movement. The nurse should refrain from taking down notes during the teaching because this action conveys a lack of interest. Because older adults process information more slowly than young people, the nurse should allow the client to take some time to respond to the nurse's queries.

An older client asks, "How do I know that all the medications that I take are safe?" What information should the nurse include in response to this client's question? Select all that apply. A. "Ask your HCP how and when you should be taking your medications" B. "Stop taking a prescribed medication if you are not feeling better in a few days" C. "Discard medications into the toilet that have exceeded the expiration date on the bottle" D. "Check the name, dose, and instructions about administration of drugs each time before leaving the pharmacy" E. "Inform your HCP of OTC drugs, recreational drugs, and any amount of alcohol you may ingest"

A, D, E If unsure about any information, the client should be encouraged to ask for further instructions and more information. A client needs to be proactive and should check all aspects of the prescription with the pharmacist before leaving the pharmacy. A pharmacist may have permission to substitute a generic form of the drug or may change the number of pills that deliver the prescribed dose, both of which can confuse the client (e.g., one tablet may deliver 50 milligrams of a drug and be equal to two 25-milligram tablets). Because of the risk of drug interactions associated with polypharmacy and altered age-related physiological functioning that can cause drug toxicity, the client should inform the health team about all drugs (e.g., prescription, over-the-counter, recreational), herbal preparations, and amount of alcohol ingested to ensure safety. A client should stop taking a prescribed medication only after consultation with the health care provider. Unused and expired medications should not be discarded into the toilet because they can contaminate groundwater.

When two nurses are getting an older adult out of bed, the client reports feeling light-headed. The nurse identifies that the client's pulse is stable and the client's color has not changed. What should the nurses assist the client to do? A. Slide slowly to the floor to prevent a fall and injury B. Sit on the edge of the bed while they hold the client upright C. Bend forward because this will increase the blood flow to the brain D. Lie down quickly so the legs can be raised above the heart level

B Sitting allows the nurses to support the client until orthostatic hypotension subsides. The client's stable pulse and color indicate that the situation does not warrant placing the client in the supine position. Sliding slowly to the floor to prevent a fall and injury, bending forward, or rapid movement will permit flexion of the vertebrae, which may traumatize the spinal cord. A light-headed feeling usually is transient until the body adapts to the upright position, so leg elevation is unnecessary.

A nurse is caring for a community-dwelling older adult with hypertension. What interventions should the nurse take to ensure the client's well-being? Select all that apply. A. Suggest that the client have annual Papanicolaou (pap) smears and mammograms B. Promote dietary modifications by using varied techniques C. Assess the client's current lifestyle and promote lifestyle changes D. Monitor the client's blood pressure and weight and establish blood pressure screening programs E. Teach the client about correct body mechanics and the availability of mechanical appliances

B, C, D When caring for a community-dwelling older adult with hypertension, the nurse should promote dietary modifications, assess a client's current lifestyle and promote lifestyle changes, and monitor the client's blood pressure and weight and establish blood pressure screening programs. When caring for community-dwelling older women with cancer, the nurse should perform annual Papanicolaou (Pap) smears and mammograms for older adults. When caring for a community-dwelling older adult with arthritis, the nurse should teach the client about correct body mechanics and the availability of mechanical appliances.

Which principles are appropriate for promoting older adult learning? Select all that apply. A. Emphasize abstract material B. Use past experiences while teaching C. Teach by presenting multiple examples at a time D. Keep the environmental distractions to a minimum E. Use audio, visual, and tactile cues to enhance learning

B, D, E The nurse should use past experiences while teaching an older client, keep environmental distractions to a minimal and use audio, visual, and tactile cues to enhance learning. This helps the client to remember all the information. The nurse should emphasize concrete material. The nurse should teach clients by using one example at a time.

A nursing student is listing points to remember about wellness promotion in older adults. Which points mentioned by the nursing student need correction? Select all that apply. A. "It is essential to prevent injuries in older adults when promoting wellness." B. "It is essential to focus on curing diseases or other illnesses completely in older adults to promote wellness." C. "It is essential to assess the level of fear of falling and provide support accordingly when caring for older adults." D. "It is necessary to prevent older adults from taking part in physical activities to keep them from sustaining injuries." E. "It is necessary to consider the older adult's social environment and ensure that he or she lives in social isolation to prevent stress."

B, D, E When promoting health in older adults, the nurse must focus on achieving the highest level of health in the presence of a disease instead of curing the disease completely. When providing care, the nurse should take the social environment into consideration and strengthen support as a means of promoting health and ensuring access to healthcare resources. To promote health and extend the years of independent active life, the nurse should encourage older adults to engage in physical activities. When caring for older adults, the nurse should remember that preventing injuries is the key mechanism in promoting and improving health. A nurse should understand that older adults refrain from taking up physical activities because they fear falling. The nurse should therefore assess the fear and provide support to reduce the risk of falls.

What should the nurse assess to determine whether a 75 y/o individual is meeting the developmental tasks associated with aging? A. Achievement of a personal philosophy B. Adaptation to the children leaving home C. Attainment of a sense of worth as a person D. Adjustment to life in an assisted-living facility

C Developing and participating in meaningful activities and satisfaction with past accomplishments increase feelings of self-worth. Achievement of a personal philosophy is a task of early adulthood. Adaptation to the children leaving home is a task of middle adulthood. Adjustment to life in an assisted-living facility is not a developmental task of older adults; not all older adults live in assisted-living facilities.

An older adult client states, "I walk 2 miles a day for exercise, but now that the weather is hot, I am worried about becoming dehydrated." What should the clinic nurse teach the client? A. "Drink fruit juices if you start to feel dehydrated" B. "Thirst is a good guide to use to determine fluid intake." C. "Fluids should be increased if the urine is getting darker." D. "Water should be consumed when the skin becomes dry."

C In hot weather, dark-colored urine indicates dehydration. When urine is dark, the amount of fluid to be excreted in decreased, and the body is attempted to conserve fluid. Fruit juices should be avoided during rehydration because of their high sugar content. By the time people become thirsty, they are already dehydrated, especially older adults. Dry skin in older adults may be related to aging rather than to dehydration and is not a good indication of dehydration in older adults.

An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? A. Assess the client's mobility B. Monitor respirations and breathing effort C. Teach coughing and deep-breathing exercises D. Determine normal activity levels and note when the client tires

C Older adults are at an increased risk for complications from both anesthesia and surgery. One of the age-related risk factors after surgery is a decrease in vital capacity. Teaching coughing and deep-breathing exercises may help in preventing pulmonary complications. Assessing the client's mobility may help an older client with a risk of musculoskeletal problems. Monitoring respirations and breathing effort . is required for an older client with decreased blood oxygenation. An older adult with cardiovascular changes requires determination of normal activity levels and noting when the client tires.

Nursing actions for an older adult should include health education and promotion of self-care. Which is most important when working with an older adult client? A. Encouraging frequent naps B. Strengthening the concept of ageism C. Reinforcing the client's strengths and promoting reminiscing D. Teaching the client to increase calories and focusing on a high-carbohydrate diet

C Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adults. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.

A client admitted to the hospital with an acute episode of rheumatoid arthritis (RA) asks why physical therapy has not been prescribed. What is the most appropriate nursing response? A. "Your primary HCP must have forgotten to prescribe it" B. "Your condition is not severe enough to have PT approved" C. "Your joints are still inflamed, and PT can be harmful" D. "PT is not helpful for persons who suffer from RA"

C Rest is required during active inflammation of the joints to prevent injury; once active inflammation has receded, an activity and exercise regimen can begin. Physical therapy is not prescribed during a period of exacerbation because it can traumatize already inflamed joints. The extent of the arthritis is not the determinant; whether the process is in exacerbation or remission is the deciding factor. Physical therapy is helpful, but it is not performed during an acute exacerbation of the arthritis.

A nurse is preparing a community health program for senior citizens. The nurse teaches the group that what physical findings are typical in older adults? A. increased skin elasticity and an increase in testosterone production B. Impaired fat digestion and an increase in pepsin production C. Increased blood pressure and decreased cardiac output D. An increase in body warmth and some swallowing difficulties

C With aging, narrowing of the arteries causes some increase in the systolic and diastolic BPs. Decreases occur in diastolic pressure, diastolic filling, and beta-adrenergic stimulation; increases occur in arterial pressure, systolic pressure, wave velocity, and left ventricular end diastolic pressure. Decreased cardiac output and cardiac reserve decrease the older adult's response to stress. Changes in libido may occur. Testosterone levels do not affect erections produced by erotic stimuli. There is a loss of skin elasticity. By the age of 60, gastric secretions decrease 70% - 80% of those of the average adult. A decrease in pepsin may hinder protein digestion. There may be a decrease in SUBQ fat and decreasing body warmth. Some swallowing difficulties occur because older people are susceptible to fluid loss and electrolyte imbalance. This results from decreased thirst sensation, difficulty swallowing, chronic disease, reduced kidney function, diminished cognition, or adverse drug reactions.

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? A. Thinning subcutaneous layer B. Degeneration of elastic fibers C. Decreased dermal blood flow D. Benign proliferation of capillaries

C With decreased dermal blood flow the client is susceptible to dry skin; the nurse should advise the client to apply moisturizer when the skin is moist. If a client is found to have a thinning subcutaneous layer, the nurse should teach the client to dress warmly in cold weather. If a client presents with degenerated elastic fibers, the nurse should check the skin turgor on the forehead or chest of the client. If a client has benign proliferation of the capillaries, this indicates cherry hemangiomas; the nurse should teach the client that these are benign.

Which age-related change should the nurse consider when formulating a plan of care for an older adult? Select all that apply. A. Difficulty in swallowing B. Increased sensitivity to heat C. Increased sensitivity to glare D. Diminished sensation of pain E. Heightened response to stimuli

C, D Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older adult unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older adults. Older adults tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in older adults.

Which client would the nurse consider to have the highest risk of pneumonia? Client 1: 16 y/o with a poor nutritional status that has received the pneumococcal vaccine within the last 3 months. Client 2: 28 y/o that uses tobacco that has received the pneumococcal vaccine 2 years ago. Client 3: 45 y/o that consumes alcohol regularly and has received the pneumococcal vaccine within the past year. Client 4: 67 y/o with chronic lung disease that received the pneumococcal vaccine more than 5 years ago. A. Client 1 B. Client 2 C. Client 3 D. Client 4

D An older adult with chronic lung disease and has received the pneumococcal vaccine more than 5 years ago has the highest risk of pneumonia. An infection may occur because older adults with chronic lung disease are at a higher risk of infection. Client 1 received the pneumococcal vaccination in the last 3 months and thus has a lower risk of pneumonia. Client 2 received a pneumococcal vaccination in the last 2 years and may not have an elevated risk of pneumonia. Client 3 may have a lower risk of pneumonia d/t receiving the pneumococcal vaccine a year ago.

The bed alarm is ringing because an older adult client is attempting to get out of bed. A nurse enters the room and finds the client agitated and confused. The family member is upset and states, "He has never been like this. I don't know what to do." After getting the client back into bed, which nursing action is most appropriate? A. Asking the family member to step out of the room so the client can rest B. Placing a vest restraint on the client to prevent the client from falling out of bed C. Explaining to the family that it is common for older clients to get confused while in the hospital D. Requesting the nursing assistant to stay with the client while the nurse calls the PCP

D Because this is new for the client, the nurse should notify the primary healthcare provider. The client should be monitored continually for a while to prevent falling or injuring himself. This is an appropriate task to delegate to a nursing assistant. Since this is new for the client, reassuring the family that older adult clients often get confused in the hospital is not helpful. Evidence-based practice has shown that having a family member with the client is helpful. Therefore, the family member should be encouraged to stay with the client. Placing a restraint on the client should be done as a last resort and not instituted without a primary healthcare provider's prescription.

An older female client is seen in the primary HCP's office. Upon initial nursing assessment, the nurse notes the client's heigh has decreased by 1 inch since the last visit 1 year ago. The nurse knows that what is the most likely reason for this finding? A. The nurse was in error. B. Older adults are not active enough so they lose bone mass. C. Older adults have poor posture so that they are shorter. D. Older adults may have osteoporosis-related height changes.

D Due to the decreasing amounts of estrogen in older women, there is a loss of calcium as well, which can lead to bone loss and a loss in height. Most likely the nurse was not in error because of the age of the client and the likelihood of osteoporosis. Sweeping statements about older adults not being active enough or having poor posture are not accurate.

A nurse is teaching an older adult client about managing chronic pain with acetaminophen. Which client statement indicates that the teaching is effective? A. "I can drink beer with this, but not wine" B. "I need to limit my intake of acetaminophen to 650mg a day" C. "I should take an emetic if I accidentally overdose on acetaminophen" D. "I have to be careful about which OTC cold preparations I take when I have a cold"

D Many OTCs contain acetaminophen; the amount of acetaminophen in cold preparations must be taken into consideration when the total amount of acetaminophen taken daily is calculated. A typical single dose is 650mg a day for adults. Acetaminophen should not exceed 3-4 g per day, with a lower dose preferred in older adults. An emetic is contraindicated because it may reduce the client's ability to tolerate oral acetylcysteine, the antidote for acetaminophen toxicity. Alcohol of any type, when taken with acetaminophen, increases the risk of liver injury.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute bronchopneumonia. The client is in moderate respiratory distress. The nurse should place the client in what position to enhance comfort? A. Side-lying with the head elevated 45º B. Sims with the head elevated 90º C. Semi-fowler's with the legs elevated D. High-fowler using the bedside table to rest the arms

D The high-Fowler position elevates the clavicles and helps the lungs to expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.

An older client with depression is prescribed a tricyclic antidepressant. What is the priority nursing intervention in this situation? A. Providing psychotherapy to the client B. Teaching strategies to overcome depression C. Encouraging the client to walk for 30 minutes D. Requesting that the physician change the drug

D Tricyclic antidepressants have anticholinergic properties that can cause acute confusion, severe constipation, and urinary incontinence in older adults. Therefore the priority nursing care for an older client who is prescribed a tricyclic antidepressant is to request that the physician change the drug. Providing psychotherapy is an alternate treatment, which is of medium priority. Teaching strategies to overcome depression is of low priority. Encouraging the client to walk for 30 minutes overcomes the feelings of depression, but it is not the priority.

The nurse is caring for an elderly client who has a right hip fracture. Which priority intervention should be included in the plan of care? A. O2 therapy B. Cardiac monitoring C. Nutrition supplements D. VTE prevention

D VTE is common after hip surgery and must be prevented; this is a component of core measures. Nutritional supplements, cardiac monitoring, and oxygen therapy may be necessary in some clients with hip fractures, but not in all.