chapter 28 jensen
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?" "Have you been diagnosed with an abdominal aneurysm?" "Do you have problems with atrial fibrillation?" "Do you suffer from congestive heart failure?"
"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 means that you have a vitamin deficiency." "There is nothing that can be done to avoid it." "It happens because of not enough of protein in the diet." "It occurs with aging but is encouraged by sitting too much."
"It occurs with aging but is encouraged by sitting too much."
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? -10% -25% -50% -75%
50%
A nurse completes a Geriatric Depression Scale for an older adult client. The nurse determines that the client is not depressed by which score? -9 -14 -20 -25
9
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 Petechiae Shingles Senile purpura
Actinic keratoses
Claire's daughter brings her in today after she fell at her home. Which assessments are indicated at this time? Orthostatic vital signs Review of her medications Assessment of gait and balance All of the above
All of the above
An older adult client who enjoys good overall health has sought care because of a recent onset of weakness and fatigue. The client is unaware of any precipitating events. How should the nurse proceed with assessment? Perform a focused respiratory assessment. Obtain the client's vaccination history. Assess the client for signs and symptoms of anemia. Assess the client for evidence of chronic heart failure.
Assess the client for signs and symptoms of anemia.
Which of the following changes in vision is expected with normal aging? Cataract Glaucoma Macular degeneration Blurring of near vision
Blurring of near vision
A nurse has assessed an elderly client and is preparing to analyze the assessment data. Which of the following would the nurse need in order to accurately perform data comparison? Client's major complaints Client's usual daily patterns Client's adherence to treatment Client's underlying pathology
Client's usual daily patterns
During a visit to an assisted living facility, the nurse suspects that a resident is developing pneumonia. What finding caused the nurse to have this suspicion? Select all that apply. Confusion Dark foul-smelling urine Blood pressure 96/50 mm Hg Respiratory rate 28 per minute Productive cough with yellow sputum
Confusion Blood pressure 96/50 mm Hg Respiratory rate 28 per minute Productive cough with yellow sputum
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? Acute pain Delirium Infection Depression
Delirium
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? Dementia Depression Malnutrition Decreased mobility
Depression
Blood pressure abnormalities found more commonly in Western elderly include which of the following? Isolated elevation of the diastolic BP Narrow pulse pressure Elevation of the systolic BP Elevation of the BP with standing
Elevation of the systolic BP
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? Select all that apply. Exercise injuries Hair dryers and flammable clothing Ladders and stepstools Bathroom injuries Yard and garden equipment
Exercise injuries Hair dryers and flammable clothing Ladders and stepstools Bathroom injuries Yard and garden equipment
The nurse is assessing an older adult with a persistent cough. The client states that he has never smoked a cigarette in his life. The client's vital signs are normal, and the client states that he feels fine other than the cough. What does the nurse know about the lungs of the older adult? Fewer cilia line the airways, making lung clearance more difficult More cilia line the airways, making lung clearance more difficult Increased lung rigidity makes lung clearance more difficult Decreased lung rigidity makes lung clearance more difficult
Fewer cilia line the airways, making lung clearance more difficult
The Morse Fall Scale was developed for whom? Homebound elders Independent elders Hospitalized elders Confused elders
Hospitalized elders
A nurse recognizes that a slight barrel-shaped chest in an elderly client is due to what physiologic change in the thorax as a result of the aging process? Decreased vital capacity Increased residual volume Loss of skeletal muscle strength Use of accessory muscles
Loss of skeletal muscle strength
What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client? Speak loudly to compensate for a hearing deficit Ask the caregiver questions if the client is cognitively impaired Plan for additional time to allow as much independence as possible Address the client by the first name to reduce confusion
Plan for additional time to allow as much independence as possible
A client is brought to the clinic by his daughter, who tells the nurse that she is concerned because her father appears to be losing weight and she doesn't know why. What would the nurse know is a cause of undernutrition? Poor time management Obsessive/compulsive disorder Acute organ failure Poverty
Poverty
An older adult client presents with raised yellow lesions on the face. What does this finding most likely suggest to the nurse? Solar lentigines Actinic keratoses Seborrheic keratoses Cherry angiomas
Seborrheic keratoses
When using the Romberg test of cerebellar function in an older client, which of the following findings is expected? -Moderate sway with eyes open -Inability to sustain balance with eyes open -Inability to sustain balance with eyes closed -Slight sway with eyes closed
Slight sway with eyes closed
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 Actinic keratoses Seborrheic keratoses Senile purpura
Solar lentigines
The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse? The client has decreased functional ability The client is being neglected The client is lazy and appearance no longer matters to him This client needs to live in a nursing home
The client has decreased functional ability
When assessing the eyes of an older adult, impairment of what gaze may be a result of age-related changes? Downward gaze Upward gaze Conjugate gaze Consensual gaze
Upward gaze
The nurse is reviewing an older adult's recent laboratory values prior to performing a physical assessment. What value would most clearly indicate the need for further nutritional assessment? Hemoglobin 12.2 g/dL Hematocrit 40% Serum albumin 39 g/dL Vitamin B12 91 μg/ml
Vitamin B12 91 μg/ml
A neurologic change associated with normal aging is -loss of long-term memory. -a decrease in reaction time. -swaying or shuffling gait. -a significant decline in judgment and cognition.
a decrease in reaction time
A neurologic change associated with normal aging is loss of long-term memory. a decrease in reaction time. swaying or shuffling gait. a significant decline in judgment and cognition.
a decrease in reaction time.
How do many older adults define their health? -Ability to work -Ability to function independently -Ability to perform activities related to their hobbies -Ability to maintain normal food intake
ability to function independently
An older adult client has come to the clinic with new complaints of fatigue, constipation, and cold intolerance. The nurse would refer the client for what type of testing? -Liver function testing -Cognitive testing -Lung function testing -Assessment of thyroid function
assessment of thyroid function
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? Loose electrical cords Slippery or irregular surfaces Chairs at awkward angles Bright lighting
bright lighting
The nurse is preparing to perform a pelvic examination on an elderly female client. What would the nurse expect to find? -Elongation of the vagina -Thick, pale epithelium -Decreased vaginal secretions -Palpable ovaries
decreased vaginal secretions
Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age? -Weakness. -Confusion. -Falls. -Fever.
fever
Common conditions or problems that accompany aging are often called conditions of aging geriatric symptoms symptoms of aging geriatric syndromes
geriatric syndromes
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? -Urge -Overflow -Functional -Stress
stress
A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is -nutritional deficiency. -dysphagia. -the degree to which dyspnea affects daily function. -a possible history of immunosuppression.
the degree to which dyspnea affects daily function
The student nurse examines a 62-year-old patient and reports to the preceptor that the patient appears to have an infection in an untreated laceration on the calf. The student is unsure of the assessment because the patient does not have a fever. The preceptor correctly explains that the older adult often does not have a fever with an infection. -True -False
true
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? -Stress -Urge -Overflow -Functional
urge
Any new onset of incontinence in the frail elder should be investigated for -prostatitis. -stroke. -fecal impaction. -urinary tract infection.
urinary tract infection
The nurse is interviewing an 82-year-old client who is accompanied by her daughter. The daughter states that her mother is "unable to hold her urine," and the client attests that this is true. What question should the nurse prioritize when assessing the client's urinary incontinence? Did you deliver your children vaginally or by cesarean section? Have you been prone to urinary tract infections in the past? Is this something that has begun to happen just recently? Have you noticed any change in your bowel function?
Is this something that has begun to happen just recently?
The student nurse examines a 62-year-old patient and reports to the preceptor that the patient appears to have an infection in an untreated laceration on the calf. The student is unsure of the assessment because the patient does not have a fever. The preceptor correctly explains that the older adult often does not have a fever with an infection. True False
True
A group of students is reviewing information about the frail elderly and functional status. The students demonstrate understanding when they identify which as an instrumental activity of daily living? Bathing Cooking Toileting Eating
cooking
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 onset after a fall edema in the lower legs onset after cardiac catheterization 2 weeks ago
cramping legs for 3 months
Which of the following accompanies decreased ovarian function? -Increased sleep -Decrease in sexual interest -Enlargement of the clitoris -Decreased vaginal secretions
decreased vaginal secretions
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? -Acute pain -Delirium -Infection -Depression
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? Benign forgetfulness Dementia Meningitis Depression
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? -Dementia -Depression -Malnutrition -Decreased mobility
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? -Stage the affected area and apply an occlusive dressing -Place the legs in a dependent position -Administer antibiotic therapy immediately -Document findings and notify the healthcare provider
document findings and notify the healthcare provider
An older client demonstrates mental status changes after being diagnosed with a urinary tract infection. Which finding suggests that this client is experiencing delirium? -refusing to eat -becoming progressively worse -experiencing visual hallucinations -deteriorating performance of self-care activities
experiencing visual hallucinations
During the assessment of an older client the nurse focuses on household activities and home environment. On which geriatric syndrome is the nurse focusing during this assessment? fall risk nutrition independence skin breakdown
fall risk
What is the most common reason for admission of the older adult to the emergency department (ED)? -Falls -Chest pain -COPD -Congestive heart failure
falls
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) blood pressure 118/75 mm Hg with antihypertensive medication reports 7 hours consecutive sleep per night body mass index (BMI) is 24
fasting blood glucose is 108 mg/dl (6 mmol/L)
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? Stress Urge Overflow Functional
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? -Neurologic -Respiratory -Gastrointestinal -Genitourinary
gastrointestinal
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? -Neurological -Respiratory -Gastrointestinal -Genitourinary
gastrointestinal
Which strategy can the nurse use to effectively approach the older adult client during the health history? -Limit open-ended questions. -Have the room well-lit with minimal background noise. -Limit the use of brief screening tools -Keep the pace of the history moving forward to reduce time.
have the room well-lit minimal background noise
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 -Knowing the statistical occurrence of the condition among people the same age -Knowing the client's family history -Knowing the client's mental status
knowing the persons 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? -Heberden nodes -Hip contracture -Increased ROM -Kyphosis
kyphosis
An elderly client states that the right eye has better eyesight than the left. A nurse recognizes that this may indicate the onset of what eye condition? Presbyopia Macular degeneration Glaucoma Arcus senilis
macular degeneration
The nurse wants to ensure that a thorough medication history has been completed with the older adult client. Which checks need to be included? Select all that apply. -medication name -medication dose -medication frequency -client's understanding of the the need for the medication -sleep log
medication name medication dose medication frequency client's understanding of the the need for the medication
The nurse wants to ensure that a thorough medication history has been completed with the older adult client. Which checks need to be included? Select all that apply. medication name medication dose medication frequency client's understanding of the the need for the medication sleep log
medication name medication dose medication frequency client's understanding of the the need for the medication
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 older adult's condition does not improve after a medication is discontinued. -Medications that might promote health of the older adult are not prescribed. -Medications that are contraindicated are not prescribed for the older adult.
medications are used to counteract side effects of other prescribed medications
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 -cherry angioma -actinic keratonoses -actinic purpura -seborrheic keratoses
seborrheic karatoses
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 cherry angioma actinic keratonoses actinic purpura
seborrheic keratoses
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 result as per the score? -Mildly abnormal -Moderately abnormal -Normal -Severely abnormal
severely abnormal
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? -Actinic keratoses -Petechiae -Shingles -Senile purpura
shingles
The nurse is assessing an elderly client who is receiving tube feedings via a nasogastric tube. The nurse would assess the client for which complication? -Gingivitis -Sinusitis -Epiglottitis -Cellulitis
sinusitis
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 -Urge -Overflow -Functional
stress
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 -Managing finances -Using the telephone -Getting in and out of bed
-Bathing -Climbing stairs -Getting in and out of bed
An older client who typically weights 160 lbs. appears withdrawn and disheveled and causes the nurse to be concerned since the last visit a month ago. For which body weight should the nurse conduct a complete nutritional assessment? 152 lbs. 155 lbs. 158 lbs. 162 lbs.
152 lbs
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? 65 75 85 95
85
A nurse completes a Geriatric Depression Scale for an older adult client. The nurse determines that the client is not depressed by which score? 9 14 20 25
9
An elderly client with a history of sinusitis has been taking antibiotics. The nurse should assess for what potential adverse effect of treatment? Exacerbation of cardiac dysrhythmias Candidal infection Overdrying of nasal passages Exacerbation of hypertension
Candidal infection
A nurse is using the Katz Activities of Daily Living tool to assess an older adult's functional status. What question will the nurse include in this assessment? Who generally prepares your meals and snacks? Do you require any assistance when showering or bathing? Do you feel like you have enough support from your family? Are you able to shop for your own groceries?
Do you require any assistance when showering or bathing?
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 Document findings as a normal age spot Take no action, because the findings correspond with a normal mole Call the physician immediately
Document findings and refer the client for follow-up
After teaching a group of students about geriatric syndromes, the instructor determines that the teaching was successful when the students identify what as an example? -Confusion -Pneumonia -Heart failure -Renal failure
confusio
A sign of infection in the elder that is more common than fever is -pain. -confusion. -diarrhea. -cough.
confusion
The nurse is reviewing the results of laboratory blood tests with the older adult. The client asks, "Why is my creatinine elevated?" Which is the best response by the nurse? "As a person gets older, the kidneys do not work as well in removing waste materials." "The kidneys filter waste materials at an increased rate as a person get older." "An elevated creatinine suggests increased reabsorption of this substance by the kidneys." "Creatinine is an indicator of how well the kidneys are functioning in removing wastes."
"As a person gets older, the kidneys do not work as well in removing waste materials."
The nurse is assessing the cognitive assessment of an older adult. Which statement by the nurse would be inappropriate? "The questions on this test should be things you know." "You might find some of the questions a little difficult." "Your spouse cannot help you answer the questions." "Testing your thinking skills will help me care for you better."
"The questions on this test should be things you know."
Which statement by an older adult alerts the nurse that health teaching was ineffective? "Leaking urine is a normal part of aging." "My hair will get thinner as I get older." "Getting shorter as I get older is normal." "It is not normal for my toenails to be yellow and thick."
"Leaking urine is a normal part of aging."
After teaching a group of students about geriatric syndromes, the instructor determines that the teaching was successful when the students identify what as an example? Confusion Pneumonia Heart failure Renal failure
confusion
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 -Wait for an answer from the client even if the patient is slow to recall information -Direct all questions to the client, not the family member -Address the family member if the client cannot provide information
Address the family member if the client hesitates when answering a question
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 Wait for an answer from the client even if the patient is slow to recall information Direct all questions to the client, not the family member Address the family member if the client cannot provide information
Address the family member if the client hesitates when answering a question
To reduce the risk for late recognition of cognitive impairment in the older adult client, which actions should the nurse take? Select all that apply. Adopt more direct questions. Use geriatric screening tools. Consult family members or caregivers. Normalize occasional loss of memory. Provide teaching about sexual health.
Adopt more direct questions. Use geriatric screening tools. Consult family members or caregivers.
Which question asked by the nurse is appropriate when assessing instrumental activities of daily living (IADLs)? -"Do you need getting up from the chair?" -"Do you need help getting to the bathroom?" -"Do you need assistance to bathe yourself?" -"Are you able to prepare meals for yourself?"
Are you able to prepare meals for yourself?
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? Have you ever been tested for diabetes mellitus? Do you get up at night to use the bathroom? Do you have a history of nasal polyps? Are you taking any drugs for high blood pressure?
Are you taking any drugs for high blood pressure?
In the older adult, which changes in the peripheral vascular system can increase blood pressure? Arterial walls are less elastic and stiffen Arterial walls are more elastic and compliant Venous walls are less elastic and stiffen Venous return slows and increases afterload on the left ventricle
Arterial walls are less elastic and stiffen
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? -Conclude the interview -Request medication for Alzheimer's -Perform mini mental status exam -Question the client about recent events
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? Actinic keratoses Petechiae Shingles Senile purpura
Petechiae
The nurse is concerned that an older client is developing delirium. What findings caused the nurse to make this clinical determination? Select all that apply. Rambling speech Sleep disturbances Combative behavior Inability to recall recent events Easily distracted by unimportant things
Rambling speech Sleep disturbances Combative behavior Easily distracted by unimportant things
The nurse has assessed the thorax and lungs of an elderly client, as well as reviewing the results of lung function testing. What finding should the nurse attribute to possible pathology rather than expected, age-related changes? Respiratory rate of 30 breaths per minute Decreased vital capacity Increased residual volume Presence of a slight barrel chest
Respiratory rate of 30 breaths per minute
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? Select all that apply. The epidermis thins Nails become thick and brittle with slow growth Wound healing slows as a result of decreased mitotic activity Nails become thin and brittle with increased growth The epidermis thickens The number of sweat and sebaceous glands increases
The epidermis thins Nails become thick and brittle with slow growth Wound healing slows as a result of decreased mitotic activity
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? -"Provide and repeat verbal instructions to your clients instead of writing them down, because many of our clients have deteriorating eyesight." -"Don't speak in too low of a tone, because that makes it particularly hard for many older adults to hear you." -"It's best to perform one long visit rather than two shorter ones to maintain older adults' stamina." -"Allow your client's stamina and abilities to guide the pace and content of your interactions."
allow your clients stamina and abilities to guide the pace and content of your interactions
The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has? -atrial fibrillation -congestive heart failure -holosystolic murmur -aortic aneurysm
aortic aneurysm
An older adult client who enjoys good overall health has sought care because of a recent onset of weakness and fatigue. The client is unaware of any precipitating events. How should the nurse proceed with assessment? -Perform a focused respiratory assessment. -Obtain the client's vaccination history. -Assess the client for signs and symptoms of anemia. -Assess the client for evidence of chronic heart failure.
assess the client for signs and symptoms of anemia
A nurse is preparing an educational session on exercise for older adults. Which points should be included to promote the benefits of exercise for this age group? Select all that apply. being able to walk faster improved blood glucose regulation decreased risk for fractures improved thyroid function reversing the risk of a cardiac event
being able to walk faster improved blood glucose regulation decreased risk for fractures
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? -Urinary tract infection -Sexually transmitted disease -Renal insufficiency -Benign prostatic hypertrophy
benign prostatic hypertrphy
The nurse suspects that an older client has undiagnosed Parkinson's disease. What finding caused the nurse to make this clinical determination? -muscle atrophy -wide-based gait -tremor of the head -bradykinesia
bradykinesia
When examining the eyes of an elderly client, the nurse observes a brownish discoloration of the lens. The nurse interprets this finding as being suggestive of what health problem? -Conjunctivitis -Presbyopia -Glaucoma -Cataracts
cataracts
When examining the eyes of an elderly client, the nurse observes a brownish discoloration of the lens. The nurse interprets this finding as being suggestive of what health problem? Conjunctivitis Presbyopia Glaucoma Cataracts
cataracts
What familial condition is it important to assess for in older adults? -Osteoporosis -Hypertension -Hypothyroidism -Frequent falls
hypertension
The nurse is interviewing an 82-year-old client who is accompanied by her daughter. The daughter states that her mother is "unable to hold her urine," and the client attests that this is true. What question should the nurse prioritize when assessing the client's urinary incontinence? -Did you deliver your children vaginally or by cesarean section? -Have you been prone to urinary tract infections in the past? -Is this something that has begun to happen just recently? -Have you noticed any change in your bowel function?
is this something that has begun to happen just recently
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? -Vision testing -Katz Activities of Daily Living tool -Activity tolerance testing -Get Up and Go test
katz activities of daily living tool
An older adult client has received a diagnosis of stress incontinence, and the nurse is planning the client's subsequent care. What health education is most relevant to this client's needs? -Pelvic floor strength training and activity management -Appropriate use of incontinence pads and dietary modifications -Management of fluid and electrolyte intake -Aseptic technique for intermittent catheterization and fluid restriction
pelvic floor strength training and activity management
What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client? -Speak loudly to compensate for a hearing deficit -Ask the caregiver questions if the client is cognitively impaired -Plan for additional time to allow as much independence as possible -Address the client by the first name to reduce confusion
plan for additional time to allow as much independence as possible
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 -decline of pacemaker cells in the sino-atrial node -rise in the systolic blood pressure -stiffening of the large arteries
postural orthostatic hypotension
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 decline of pacemaker cells in the sino-atrial node rise in the systolic blood pressure stiffening of the large arteries
postural orthostatic hypotension
A client is brought to the clinic by his daughter, who tells the nurse that she is concerned because her father appears to be losing weight and she doesn't know why. What would the nurse know is a cause of undernutrition? Poor time management Obsessive/compulsive disorder Acute organ failure Poverty
poverty
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? -Bathing -Dressing -Preparing food -Transferring from bed to chair
preparing food
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? Bathing Dressing Preparing food Transferring from bed to chair
preparing food
A nurse assesses a client's blood pressure and the findings suggest orthostatic hypotension. Which area should the nurse emphasize during client education? -Daily exercise routine -Prevention of falls -Diet high in iron -Vitamin supplementation
prevention of falls
When looking at a review of systems for an elderly client, which gastrointestinal data should cause the nurse the most concern? -Reports of constipation -Inability to digest dairy products -Early satiety -Decreased production of saliva
reports of constipation
When evaluating the blood pressure of an older adult, the nurse should understand that with aging, the systolic blood pressure increases diastolic blood pressure increases peripheral vascular resistance remains stable peripheral vascular resistance decreases
systolic blood pressure increases
A 75-year-old female client tells the nurse that she is sexually active but that it causes her pain when she has intercourse. What would the nurse suggest to alleviate this pain? -Taking warm baths -Exclusive use of a side-lying position -Cold application -Having sex in the morning
taking warm baths
In order to let an older adult client establish his or her cultural identity, which statement would be most appropriate for the nurse to make first? -"Tell me your beliefs about the illness you are experiencing." -"I will contact your spiritual adviser to help me understand your illness." -"I have read books about your culture to help me understand your illness." -"I will make sure you are the only person I speak to about your illness."
tell me your beliefs about the illness you are experiencing
The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse? -The client has decreased functional ability -The client is being neglected -The client is lazy and appearance no longer matters to him -This client needs to live in a nursing home
the client has decreased functional ability
A nurse has assessed an elderly client and is preparing to analyze the assessment data. What would the nurse need in order to accurately perform data comparison? -Client's major complaints -Usual daily pattern -Level of dysfunction -Underlying pathology
usual daily pattern
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 bright red tongue pale mucous membranes presence of dentures
white patchy plaque on the tongue
When inspecting the toenails of an elderly client, an expected finding is: -Painless separated nail plate -Yellowed, thickened, lusterless nails -Thinned, slightly curved free nail edge -Whitish nail plate with reddish band near free edge
yellowed, thickened, lusterless nails
