NUR314 Ex 1 Ch 28 Older Adults
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?
Cataracts
A home care nurse is assessing an older adult's functional status. The nurse should identify what as an instrumental activity of daily living?
Cooking Examples of activities of daily living (ADLs) include bathing, eating, grooming, and toileting activities.
An elderly client's history reveals the use of antihistamines. When inspecting the client's mouth, what would the nurse expect to find?
Decreased saliva Antihistamines have a drying effect and can lead to an even further decrease in saliva than that which occurs due to normal aging. Resorption of the gum ridge would be a normal finding.
Blood pressure abnormalities found more commonly in Western elderly include which of the following?
Elevation of the systolic BP
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 If the client does not eat enough or digest properly many gastrointestinal problems may arise as well as the tendency towards malnutrition, under nutrition, or dehydration.
The Morse Fall Scale was developed for whom?
Hospitalized elders
The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?
Increased kyphosis and decreased ROM are expected findings associated with aging.
During a health history, which of the following can the nurse ask to determine an older adult client's abilities to conduct instrumental activities of daily living? (Select all that apply.)
Instrumental activities of daily living include shopping, preparing food, doing laundry, and money management. Ability to feed self is considered a physical activity of daily living. "Do you shop for groceries?" "Do you do your own laundry?" "Do you manage your own money?" "Who prepares your meals?"
A nurse is inspecting an elderly client's head and neck. Which of the following findings should most prompt the nurse to suspect onset of a chronic condition?
Involuntary facial or head movements
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?
Is this something that has begun to happen just recently? assessing changes in the functional or health status of an older client, it is imperative to know the client's recent baselines
When using the Romberg test of cerebellar function in an older client, which of the following findings is expected?
Slight sway with eyes closed Increased sway in the Romberg test from diminished vibratory and position sense in the lower extremities is an expected finding among older clients. Sway with the eyes open or any inability to sustain balance would be considered pathological.
stress incontinence
Stress incontinence involves involuntary loss of urine when coughing, sneezing, or laughing.
A nurse is interviewing an elderly client and begins the interview inquiring about the client's mental status. The nurse does this based on an understanding of which of the following?
The aging brain is more easily affected by pathology.
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 incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. S
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?
Usual daily pattern
The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has?
abdominal aortic pulsation is indicative of an aortic aneurysm.
Pale mucous membranes can indicate
anemia or malnutrition
The nurse notes that an older client has a systolic murmur. What should this finding suggest to the nurse?
calcification of the aortic cuspsMiddle-aged and older adults commonly have a systolic aortic murmur. With aging, fibrotic changes thicken the bases of the aortic cusps. Calcification follows, resulting in audible vibrations.
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
Pocketing of food along with coughing and drooling suggests
dysphagia.
Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?
fever
The client presents to the clinic with complaints of a painful rash under the left breast. The nurse observes a red papular rash and suspects the client is suffering from:
herpes zoster
Functional incontinence
is the inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition.
Urge incontinence
is the involuntary loss of urine associated with an abrupt and strong desire to void
Stasis dermatitis occurs on the
legs and is characterized by a reddish-brown ruddy appearance and edema.
seborrhea occurs on
the scalp and is characterized by white scaly patches.
loud or harsh holosystolic murmur suggests
valvular stenosis.
A swollen red tongue is associated with a
vitamin B or riboflavin deficiency.
A bright red tongue is indicative of
vitamin C or B1 deficiency