Ch.32 PrepU Assessing Older Adults

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."

An older adult client comes to the clinic and reports difficulty with driving at night. What would be the most appropriate response from the nurse to provide when attempting to address the client's concern?

"With aging, the pupils do not respond to light as quickly, so many people have difficulty driving at night."

The nurse familiar with the National Center for Health Statistics identified which of the following as causes of adult mortality in people 65 years and older? (select all that apply)

-Diseases of the heart -Malignant neoplasms -chronic lower respiratory diseases -Alzheimer's disease

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 -Shops for groceries -Balances check book -Dials telephone numbers

A nurse assesses an elderly adult 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.

-Remove rugs or other loos carpet -Remind the client to ask for assistance -Assist with exercise to strengthen lower extremities

A neurologic change associated with normal aging is

A decrease in reaction time

When receiving the shift report, the nurse should identify which client as being at highest risk for falls?

73-year-old with confusion and incontinence

An objective assessment that is frequently indicated when the subjective assessment reveals a history of falling is

A Get Up and Go test

Which nursing action is most appropriate when providing care to the older adult with impaired vision?

Announce presence every time by identifying self by name

Which nursing action is most appropriate when providing care to the older adults with impaired vision?

Announce presence every time by identifying self by name

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

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 should the nurse ask before assuring the client it is okay to use this medication?

Are you taking any drugs for high blood pressure?

What does the nurse use to formulate a nursing care plan?

Assessment data

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

The nurse suspects that an older client has undiagnosed Parkinson's disease. What finding caused the nurse to make this clinical determination?

Bradykinesia

The nursing assistant informs the nurse of an older adults client's vital signs: Blood pressure 130/78; Pulse 60; Respirations 16; Temperature 98.7 degrees Fahrenheit. What is the nurse's best action?

Check the client's mental status

A sign of infection in the elder that is more common than fever is

Confusion

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 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

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as is 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

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

A gastrointestinal problem that often requires emergency treatment in the frail elder is

Diverticulitis

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 has assessed and informed the healthcare provider of a brown-colored lesion on an older adult 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

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

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

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

When orienting a new staff nurse to the hospital unit, the charge should include which information?

Geriatric medical clients have an increased risk of falls while hospitalized

Which strategy can the nurse use to effectively approach the older adult client during the health history?

Have the room well-lit with minimal background noise

With a client suspected of suffering from presbycusis, the nurse would expect difficulty hearing:

High-pitched sounds

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

The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?

Kyphosis

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

Left side-lying

Which of the following indicated that an elderly client has been affected by polypharmacy?

Medications are used to counteract side effects of other prescribed medication

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

Obtain 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

A hospitalized client develop thrombocytopenia. Which lab result does the nurse expect in this client?

Platelet count less than 100,000

Diminished vibratory sensations and slowed motor responses in advanced age result in

Postural instability

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

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

Reports of constipation

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

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

A 75-year-old female client tells the nurse that she is sexually active but that is causes her pain when she has intercourse. What would the nurse suggest to alleviate this pain?

Taking warm baths

A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is

The degree to which dyspnea affects daily function

Which finding noted during assessment of the oral cavity of an older adult alerts the nurse that the older adult may be neglecting oral care?

White patchy plaque on the tongue

When inspecting the toenails of an elderly client, an expected finding is:

Yellowed, thickened, lusterless nails

An older adult has experienced two falls in the past week. Which test would be most appropriate for the nurse to administer?

Timed Get Up and Go Test

Any new onset of incontinence in the frail elder should be investigated for

Urinary tract infection

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

Use lanolin-based products