ATI Learning System 3.0
A nurse is assisting with the admission of an older client who has urinary incontinence and smells strongly of urine. The clients partner, who has been caring for her at home, apologizes and expresses embarrasment about the unpleasant smell. Which of the following responses should the nurse make?
" It must be difficult to care for someone who has incontinence . "
A nurse at a long - term care facility hears an assistive personnel ( AP ) talking with an older adult client who has dementia with periods of confusion . Which of the following statements indicates that the AP requires further instructions ?
" It's almost time for your appointment . Let me do your hair for you and brush your teeth . "
A nurse is reinforcing teaching with a client who is scheduled to start taking alendronate sodium . Which of the following recommendations should the nurse include in the teaching ?
"Discontinue the medication if you develop heartburn"
A nurse at a long - term care facility is reinforcing teaching with an older adult client about ambulating with a quad - cane . Which of the following statements should the nurse include in the teaching ?
"Hold the cane in the hand on the stronger side of your body"
A community health nurse is conducting an initial home visit for an older adult client . Which of the following client statements should the nurse identify as a health alteration ?
"I have not had a bowel movement in 5 days"
A nurse is reinforcing teaching about nutrition with an older adult client . The client asks , " Do I need the same amount of nutrients that I did when I was younger ? " Which of the following responses should the nurse provide ?
"Older adults need an increased amount of calcium"
A nurse is reinforcing discharge teaching about calcium supplements with an older adult female client who has osteoporosis and recently underwent a repair of a fracture in her right hip . Which of the following instructions should the nurse include ?
"You should take your calcium supplement with a large glass of water . "
A nurse is contributing to the plan of care for a client with a history of gastroesophageal reflux disease ( GERD ) who had a recent stroke . For which of the following disorders should the nurse plan to monitor this client ?
Aspiration pneumonia
A nurse at a long - term care facility is contributing to the plan of care for a client who has Alzheimer's disease and wanders at night . Which of the following interventions should the nurse include in the plan ?
Assign the client to a room closer to the nurse's station
A nurse is caring for an older adult client who has a terminal illness . The client tells the nurse , " I just want to live for another month so I can see my grandchild get married . " Which of the following Kübler - Ross stages of grief is the client is experiencing ?
Bargaining
A nurse is reinforcing teaching with a newly hired assistive personnel about her role in helping older adult clients with activities of daily living ( ADLs ) . Which of the following is the most common factor that affects a client's ability to perform ADLS ?
Chronic physical disability
A nurse is assisting with the admission of an older adult client who fell at home 3 days ago . The client has a fractured hip and shows signs of malnutrition and dehydration . Which of the following laboratory values noted on admission should indicate prolonged malnutrition ?
Decreased albumin
A nurse is reinforcing teaching with a group of healthy older adult clients about expected age - related changes and sexual responses . Which of the following changes should the nurse include as an age - related change ?
Decreased vaginal lubrication
A nurse is collecting data from an older adult client who states he is homeless . Which of the following findings should the nurse document as comorbidities for this client ?
Dementia and tuberculosis
A nurse in the clinic is assessing an older adult client for the second time this week . The client reports a decreased energy level , insomnia , and anorexia . Diagnostic tests are within the expected reference ranges . For which of the following conditions should the nurse screen the client ?
Depression
A nurse is collecting data from an 85 - year - old client . Which of the following findings should the nurse report to the provider ?
Differences in pulse strength between lower extremities
A nurse at an ophthalmology clinic is collecting data from a client who was referred by the provider for a potential cataract . Which of the following client reports is consistent with cataracts ?
Halos when looking at lights
An older adult client in a cardiac clinic asks the nurse how the cardiovascular system changes with aging . The nurse's explanation should include which of the following alterations ?
Hypotension when standing up
A nurse in a long - term care facility is promoting reminiscence among older adult clients . Which of the following actions should the nurse take ?
Institute a daily storytelling hour
A nurse is part of a committee that is developing age - appropriate care standards for older adult clients . Which of Erikson's developmental tasks should the nurse recommend as the focus ?
Integrity
A community health nurse is visiting the home of an older adult client who has excoriations to her wrists and ankles. Which of the following actions should the nurse take first?
Interview the client in private
A nurse is caring for an older adult client who has gout and refuses to eat . The client's provider has approved the family to bring food from home . Which of the following foods should the client avoid ?
Lentil soup
A nurse is caring for an older adult client who is having a stroke. After assessing airway, breathing, and circulation, which of the following assessments is the nurse's priority?
Level of consciousness
A nurse is caring for an older adult client who is expressing feelings of grief and longing for his earlier life . Which of the following actions should the nurse take ?
Listen attentively and allow the client to talk about the past
A nurse is reinforcing teaching about skin changes in older adult clients with a newly licensed nurse . Which of the following findings should the nurse identify as a benign , age - related skin change commonly seen in older adult clients ?
Liver spots
A nurse is collecting data from an older adult client regarding age - related changes . Which of the following should the nurse identify as an age - related physical change ?
Loss of ventricular compliance
A nurse is transferring an older adult client who has right - sided weakness from the bed to a wheelchair . Which of the following actions should the nurse take to provide a safe transfer ?
Maintain a straight back and bend at the knees ,
A nurse at an assisted living center is conducting an orientation session for a group of newly hired assistive personnel ( AP ) . Which of the following instructions should the nurse include regarding clients who are hearing impaired ?
Maintain eye contact with the clients
A nurse is reviewing the records of a group of older adult clients . Which of the following findings should the nurse identify as an unexpected manifestation of the aging process ?
Obesity
A nurse is assisting with planning care for an older adult client following abdominal surgery for a bowel obstruction . Which of the following pieces of information about pain management should the nurse incluse in plan of care?
Older adult clients are sensitive to the analgesic effect of opiates
A nurse is collecting data from several clients . The nurse should understand that adjusting to free time and finding happiness are important developmental tasks for which of the following age groups ?
Older adults
A nurse is caring for an older adult client who has a hip fracture and is rating his pain at 8 on a scale of 0 to 10. Which of the following medications should the nurse administer ?
Oxycodone / acetaminophen 7.5 / 325 tablet PO
A nurse at a long - term care facility notes that a client with dementia is having problems with orientation . Which of the following actions should the nurse take to improve the client's level of orientation ?
Post a large calendar on the bulletin board
A nurse is assisting with planning care for a group of older adult clients in an assisted - living facility . Which of the following health - promoting behaviors should the nurse suggest to help these clients increase endurance and maintain muscle strength ?
Regular exercise program
A nurse in an adult day care facility is contributing to the development of treatment plans for older adult clients . Which of the following therapeutic strategies should the nurse use to help the clients achieve Erikson's developmental task for this age group ?
Reminiscence therapy
During a team meeting , a staff nurse recommends that a client , who is confused and wanders during the night , be placed in restraints . Which of the following responses about the use of restraints should the nurse manager offer ?
Restraints are used to prevent harm to clients and others
A nurse is planning to administer diphenhydramine hydrochloride to an older adult client . Which of the following actions should the nurse take prior to administration ?
Review the client's medical record for a history of glaucoma
A nurse is caring for an older adult client who has moderate hearing loss . Which of the following actions should the nurse take to enhance communication ?
Speak at a moderate rate
A nurse is reinforcing teaching with an older adult client who had a total hip arthroplasty about ambulating with a standard walker . Which of the following actions by the client indicates an understanding of the teaching ?
The client moves the walker ahead about 15.24 cm ( 6 in ) and then steps into the walker .
A nurse is reinforcing teaching with a newly licensed nurse about the sleep cycle of an older adult client . Which of the following pieces of information should the nurse include ?
The client spends more time in lighter stages of sleep .
A nurse at a long - term care facility is contributing to the plan of care for an older adult client who has dementia . Which of the following interventions should the nurse include in the plan ?
Use photographs as memory triggers
A nurse is assisting with the planning of an immunization clinic for older adults . At which of the following times should an older adult client receive the influenza vaccine ?
Annually in the fall
A nurse is completing medication reconciliation for an older adult client who is receiving multiple medications . Which of the following actions should the nurse take first ?
Ask the client about over - the - counter medications she is taking
A nurse is reinforcing dietary teaching about methods to increase peristalsis with an older client who is on bedrest following the development of deep vein thrombosis (DVT). Which of the following high-fiber food choices should the nurse recommend?
Navy bean soup
A nurse is caring for an older adult client with dementia who gets up frequently to pace during meals and eats sparingly . Which of the following actions should the nurse take ?
Provide finger foods for the client
A nurse is contributing to the plan of care for a client who had a stroke . Which of the following goals should the nurse identify as the priority for this client ?
The client's airway will remain clear , as evidenced by clear breath sounds .
A nurse is collecting data from an older adult client about cardiovascular changes that develop with aging Which of the following findings should the nume expect ?
Thickening of blood vessel walls
A nurse is reviewing the basic needs of older adult clients with a group of assistive personnel . Which of the following statements about this population should the nurse include ?
" Deep sleep is decreased "
A nurse is reinforcing teaching with the caregiver of an older adult client who is homebound . Which of the following signs of possible acute illness should the nurse instruct the caregiver to report to the provider ?
Abrupt decrease in ability to perform ADLS
A nurse is reinforcing teaching with a group of older adults . Which of the following behaviors should the nurse identify as relating to Erikson's expected developmental task for this age group ?
Accepting the possibility of the need for long - term care
A nurse in an assisted living facility is supporting the care of of an older adult client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief?
Acute grief
A nurse is reinforcing teaching about dietary requirements with a group of older adult female clients who are postmenopausal . Which of the following statements about the role of folic acid should the nurse provide ?
Adequate folic acid intake is associated with a reduced risk of heart disease
A nurse is collecting data from an older adult client . Which of the following actions should the nurse perform to collect subjective data ?
Allow sufficient time for the client to respond to the questions
A nurse is caring for a client who has Alzheimer's disease and refuses to take her morning antihypertensive medication . The client is oriented to name and place and is able to perform ADLs with minimal supervision . Which of the following actions should the nurse take ?
Ask the client to share her reasons for refusing the medication and document the event
A nurse is monitoring a client who has Alzheimer's disease during the administration of intermittent IV antibiotic therapy . The client repeatedly attempts to remove the IV access line during the administration of the medication . Which of the following actions should the nurse take ?
Assign an assistive personnel to remain with the client during the medication administration
A nurse is caring for a client who has cancer and is using a fentanyl transdermal patch for pain control . Which of the following actions should the nurse take when caring for this client ?
Avoid using a heating pad on the area with the patch
A nurse is collecting data from an older adult client to monitor for signs of dehydration . Which of the following findings should the nurse consider an expected part of the aging process ?
Decreased creatinine clearance
A nurse is monitoring the blood pressure of an older adult client . Which of the following age - related changes can contribute to an increase in systolic blood pressure among older adults ?
Decreased elasticity of the blood vessels
A nurse is caring for an older adult client . Which of the following physiological changes associated with aging can affect medication dosage in this client ?
Decreased gastric motility
A nurse is collecting data from an older adult client who lives alone . Although the client is able to answer all questions appropriately , the nurse notes that the client has a decreased attention span , expresses feelings of overwhelming sadness , and has a low energy level . This client is exhibiting manifestations of which of the following disorders ?
Depression
A nurse is collecting data from an older adult client who reports feeling anxious about financial concerns and has had difficulty sleeping for several months . Which of the following actions should the nurse take ?
Determine the client's usual sleep habits
A nurse is caring for an older adult client who has aspiration pneumonia . Which of the following changes that might develop with aging contributes to the development of aspiration pneumonia ?
Diminished cough reflex
A nurse is caring for an older adult client who reports that she has just retired and expresses feelings of loneliness due to the loss of daily interactions with coworkers . Which of the following responses should the nurse make ?
Do you know about the local senior citizen group ? "
A nurse is reinforcing teaching with an older adult client who has anemia . Which of the following foods should the nurse recommend to increase the client's iron intake ?
Dried fruit
A nurse is reviewing exercise safety with a group of older adult clients . Which of the following pieces of information should the nurse include ?
Drink water prior to , during , and after each exercise session . "
A nurse is reviewing the medical record of a client who is postmenopausal and has osteoporosis . The client has a new prescription for alendronate sodium . Which of the following findings in the client's history is a contraindication to this medication ?
Esophageal stricture
A nurse is talking with a group of clients at a senior center about risk factors for osteoporosis . Which of the following statements should the nurse include ?
Extended periods of immobility increase your risk of osteoporosis
A nurse is collecting data from an older adult client during an annual physical . Which of the following findings should the nurse report to the provider ?
Fasting blood glucose level 160 mg / dL
A nurse is reviewing the medical record of an older adult client . For which of the following medications should the nurse request a hearing assessment for the client ?
Furosemide
A nurse is collecting data from an older adult client who has chronic pain . Which of the following effects of unrelieved pain should the nurse identify as a priority finding to report ?
Impaired mobility
A nurse is collecting data from an older adult client who had a right - sided stroke 2 days ago . For which of the following findings should the nurse notify the provider immediately ?
Increased restlessness
A home health nurse is caring for an older adult client who states he does not like to leave his home . Which of the following is the priority factor the nurse should identify ?
Potential for falling
A nurse is caring for a client who has aphasia following a stroke . Which of the following actions should the nurse take ?
Present a single idea in a sentence .
A nurse is collecting data from an older adult female client . Which of the following findings should the nurse identify as a priority ?
Rales heard in the bases of the lungs
A nurse at a ling-term care facility is assisting with planning care for a group of older adult clients. When planning care, the nurse should consider that older adult clients are most likely to exhibit a decrease in which of the following?
Short-term memory
A nurse is caring for an older adult client who is on bed rest . Which of the following foods should the nurse plan to include on the client's breakfast tray to prevent constipation ?
Stewed prunes
A nurse is assisting with developing an exercise program for an older adult client who lives alone and has become sedentary since his partner died . Which of the following outcomes is the priority goal of this program for the client ?
To maintain functional ability
A nurse is reinforcing teaching with an older adult client who has osteoarthritis of the right hip and lower lumbar vertebrae . Which of the following statements by the client indicates an understanding of the teaching ?
To relieve the pressure on my hip , I can use a cane while ambulating . "
A nurse is caring for an older adult client who is unresponsive following a stroke . Which of the following actions should the nurse take while providing oral care ?
Turn the client on his side before starting oral care
A nurse is reinforcing teaching with a group of healthy older adult clients about screenings after age 50 years . Which of the following health screenings should the nurse recommend the clients complete annually ?
Visual acuity
A nurse is collecting data from an older adult client who has right - sided heart failure . Which of the following findings is the nurse's priority to report ?
Weight increase of 0.91 kg ( 2 lb ) in 24 hours
A nurse is assessing an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. Which of the following factors should the nurse identify as a factor in the clients sleep pattern?
anxiety can cause disturbed sleep patterns
A nurse is caring for an older adult client who has pneumonia . Which of the following physiological changes associated with aging places the client at a greater risk of pneumonia ?
Decreased number of cilia
A nurse is reinforcing teaching with a group of unit nurses about cardiac function in older adult clients . Which of the following changes in cardiac function should the nurse include in the teaching as a result of the normal aging process ?
Decreased rate of blood filling the left ventricle
A nurse is reinforcing teaching with an older adult client about methods to improve sleep . Which of the following statements should the nurse include in the teaching ?
" Go to bed at the same time every night . "
A nurse is reinforcing teaching with an older adult client who is scheduled to start taking warfarin . Which of the following statements indicates the client understands the teaching ?
" I can continue to eat green salads . "
A nurse is reinforcing teaching about ways to improve nutritional intake with a client who has chronic obstructive pulmonary disease ( COPD ) and has been losing weight . Which of the following statements by the client indicates an understanding of the teaching ?
" I should add grated cheese to sauces and vegetables . "
A nurse is reinforcing teaching with a client who is scheduled to start taking finasteride . Which of the following statements by the client indicates an understanding of the teaching ?
" I should see a decrease in my PSA levels . "
An older adult client tells a nurse at a health fair , " I am always forgetting things . I can't even remember where I parked my car ! Do you think I have Alzheimer's disease ? Which of the following is a therapeutic response by the nurse ?
" That must be upsetting . Can you tell me about your forgetfulness ? "
A nurse is caring for an older adult client who asks the nurse why she has more difficulty sleeping as she gets older . Which of the following responses should the nurse make ?
" The body rhythms that control the sleep - wake cycle weaken a bit with aging . "
A nurse is reinforcing teaching with a group of older adult clients about dietary needs . Which of the following dietary recommendations should the nurse include in the teaching ?
" You should consume 1,200 milligrams of calcium daily . "
A nurse is reinforcing teaching with an older adult client who is healthy and has chronic constipation about establishing a bowel retraining program . Which of the following statements should the nurse include in the teaching ?
" increase the fiber content of your diet . "
A nurse is reinforcing teaching with an older adult client about osteoporosis . Which of the following statements should the nurse include in the teaching ?
"Brisk walking will help prevent bone loss"
A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus . Which of the following physiological changes contributes to the development of type 2 diabetes ?
Decreased sensitivity to insulin
A nurse is collecting data from an older adult client . Which of the following findings should the nurse report to the provider ?
Decreased spinal column movement
A nurse is caring for a client who is using a continuous passive motion ( CPM ) device following a right total knee replacement . Which of the following actions should the nurse take when applying the CPM device ?
Line up the frame joints of the CPM device with the client's knee
A nurse is assisting with the care of an older adult client who has dementia . The client becomes agitated and confused at night and wanders into the hallway . Which of the following actions should the nurse take ?
Place the client's mattress on the floor
