Prep U Ch 32
An older client demonstrates mental status changes after being diagnosed with a urinary tract infection. Which finding suggests that this client is experiencing delirium
experiencing visual hallucinations
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
During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process
Retraction of the nipples
A nurse who coordinates care in a public health unit is teaching staff how best to communicate with the older clients who dominate the demographic area. Which of the following directives should the nurse provide
"Allow your client's stamina and abilities to guide the pace and content of your interactions."
Which question asked by the nurse is appropriate when assessing instrumental activities of daily living (IADLs)
"Are you able to prepare meals for yourself?"
The nurse notes that the left arm of an older woman is larger than the right. Which question is best for the nurse to ask to determine the suspected cause of this finding
"Have you had a mastectomy of the left breast?"
An older client asks why the leg muscles have become flabby over the last few years. What should the nurse respond to this client
"It occurs with aging but is encouraged by sitting too much."
The nurse is assessing a new client, age 68 years, for orthostatic hypotension. The nurse would know that this means a drop in systolic blood pressure of 20 mm Hg or more or diastolic blood pressure of 10 mm Hg or more within how many minutes of standing
3 minutes
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
85
A nurse is working with an elderly client with symptoms of urinary tract infection who says she does not 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 older client arrives at her primary care provider's office with complaints of irregularly shaped tan, scaly lesions that bleed and are inflamed. The nurse should recognize this condition as which of the following
Actinic keratoses
The nurse is assessing an older adult with intact cognition. A younger family member is present. The client is slightly hearing impaired, so the nurse must speak up. What should the nurse never do in relation to the client in this situation
Address the family member if the client hesitates when answering a question
In the older adult, which changes in the peripheral vascular system can increase blood pressure
Arterial walls are less elastic and stiffen
What does the nurse use to formulate a nursing care plan
Assessment data
The nurse notes that it takes an older client 45 seconds to complete the "get up and go" test. Which activities of daily living should the nurse plan to assist the client with completing? Select all that apply
Bathing Climbing stairs Getting in and out of bed
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
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
Bright lighting
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
Delirium
A 70-year-old retired auto mechanic comes to the office because his neighbour is concerned about the client's memory. The client admits to misplacing his keys more often and forgetting what he is supposed to buy from the grocery store and where he has parked the car. He denies getting lost in familiar places. Upon further questioning, he states that his wife of 40 years died 8 months ago; his three children live in three different provinces; and he has limited his activities because the people he interacted with were "his wife's friends, not his." He drinks a six-pack of beer daily; he does not smoke or use illicit drugs. The nurse performs a mini-mental state examination and obtains a total score of 24 out of 28. Based on this information, what is the most likely diagnosis
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
Depression
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
Document findings and notify the healthcare provider
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
Document findings and refer the client for follow-up
The nurse is concerned about an older client's ability to live independently in the home. For which activities should the nurse assess this client? Select all that apply
Does own laundry Balances check book Dials telephone numbers Shops for groceries
Mrs. Geller is somewhat quiet today. She has several bruises of different colours 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
Elder abuse
Blood pressure abnormalities found more commonly in Western elderly include which of the following
Elevation of the systolic BP
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
Encourage the client to wear sunscreen daily.
The nurse providing an educational event for the families of elderly clients. What would the nurse tell them that ER visits and fatalities frequently involve
Exercise injuries Hair dryers and flammable clothing Ladders and stepstools Bathroom injuries Yard and garden equipment
A 76-year-old female client's blood pressure is 132/76 in a supine position, 128/71 when dangling at the side of her bed, and 105/58 when she is standing. These assessment findings constitute a risk for which of the following health problems
Falls
Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age
Fever.
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
Functional
When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls
postural orthostatic hypotension
While assessing an elderly client, the nurse finds the client to be confused, hypotensive, with an increased respiratory rate. Upon further review, the nurse identifies the nurse has not been eating in the last 48 hours. What does the nurse suspect
Pneumonia
A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum
Left side-lying
Identify the priorities of nursing care for clients diagnosed with a cognitive disorder. Select all that apply
Managing agitation Maintaining safety Communication Support the family
Which of the following indicates that an elderly client has been affected by polypharmacy
Medications are used to counteract side effects of other prescribed medications.
The nurse is doing a shift assessment on an older adult client with diabetes who has had a 2 pack/day smoking habit for 22 years. The nurse cannot palpate a dorsalis pedis pulse even with a Doppler. When reviewing previous assessment findings, they show that pulses were weakly palpable. What would be the first nursing action
Notify the primary provider
Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence
Obtain a voiding diary
While the nurse is interviewing a newly admitted older adult client, the client repeats the same story to the nurse several times. What is the nurse's next, best action
Perform mini mental status exam
On receiving results of some lab work for a patient, a nurse learns that the patient has a platelet deficiency. Which skin condition related to this finding should the nurse look for in this client
Petechiae
A hospitalized client develop thrombocytopenia. Which lab result does the nurse expect in this client
Platelet count less than 100,000
The nurse is assessing an elderly client that has been hospitalized with weakness. The nurse identifies that what disease is most likely to occur in an elderly hospitalized client
Pneumonia
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
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
Preparing food
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
Remind the client to ask for assistance Assist with exercise to strengthen lower extremities Remove rugs or other loose carpet
When looking at a review of systems for an elderly client, which gastrointestinal data should cause the nurse the most concern
Reports of constipation
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
A priority nursing diagnosis for the client experiencing altered perception, extreme agitation, and acute confusion is
Risk for Injury.
An older adult client presents with raised yellow lesions on the face. What does this finding most likely suggest to the nurse
Seborrheic keratoses
During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding
Senile purpura
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
Shingles
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
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
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
The epidermis thins Nails become thick and brittle with slow growth Wound healing slows as a result of decreased mitotic activity
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
Urge
An objective assessment that is frequently indicated when the subjective assessment reveals a history of falling is
a Get Up and Go test.
A neurologic change associated with normal aging is
a decrease in reaction time.
A risk factor for sinusitis in the frail elderly is
a nasogastric feeding tube.
The nurse wants to ensure that a thorough medication history has been completed with the older adult client. Which checks need to be included
a. medication name b. medication dose c. medication frequency d. client's understanding of the the need for the medication
The physical declines of aging often first become noticeable when
acute or chronic illness places excessive demands on the body.
The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has
aortic aneurysm
An older adult client with type 2 diabetes reports leg pain. Which characteristic will assist the nurse in determining if this is persistent pain
cramping legs for 3 months
A gastrointestinal problem that often requires emergency treatment in the frail elder is
diverticulitis.
A nurse completes an AUDIT-C with a male older adult client who is suspected of having issues with alcohol abuse. The score on the AUDIT-C is 4. Which clue indicates risky drinking
fasting blood glucose is 108 mg/dl (6 mmol/L)
Common conditions or problems that accompany aging are often called
geriatric syndromes
Which sign can the nurse include in the general survey of the older adult client during the physical exam
odor
The nurse is performing a skin examination on a 68-year-old. The nurse notes raised, yellowish lesions that appear like warts and feel greasy. The nurse understands this is most likely
seborrheic keratoses
Any new onset of incontinence in the frail elder should be investigated for
urinary tract infection.
