test 4 chapter 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

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

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 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

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

An older adult client, who is a retired construction worker, presents with an ulcerated lesion on his left auricle. What teaching should the nurse provide to this client?

"Notify your healthcare provider about the possibility of cancer."

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 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 nurse tells the client that she is going to listen to his abdomen for sounds of blood rushing through the blood vessels. The client wants to know why the nurse is specifically listening for this. How would the nurse answer?

"Bruits over the aorta or renal or femoral artery are found in atherosclerotic disease."

An elderly client reports pain in the calves. What question is appropriate for a nurse to ask to determine the cause of this pain?

"How far do you walk before you experience pain?"

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

The nursing student asks the instructor why older adults develop wrinkles. Which information should the nurse omit when responding?

A decrease in goblet cells causes the skin to dry

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

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

An elderly client is complaining of weakness and fatigue. The nurse suspects the client may be experiencing what?

Anemia

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.

The nurse is assessing the client's risk for falls. What data identifies the client as having a fall risk? Select all that apply.

Antihypertensive medications Stiffness Wide gait

The nurse observes several patchy white areas on the scalp of an older adult client. What is the nurse's best action?

Apply prescribed steroid cream.

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?

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

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

Which of the following changes in vision is expected with normal aging?

Blurring of near vision

A nurse obtains an order to check an elderly client for orthostatic hypotension. Which finding alerts the nurse to a positive result for this test?

Heart rate increases 20 beats over the baseline rate

Rales

Crackles; wet crackling noise in lungs

A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as what abnormal finding?

Cystocoele

Which of the following represents an age-related change in the lungs?

Decreased chest wall compliance

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?

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?

Depression

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.)

Do you shop for groceries?" "Do you do your own laundry?" "Do you manage your own money?" "Who prepares your meals?"

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

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.

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.

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

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 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

Which of the following statements regarding delirium in older adults is most accurate?

It typically develops over a short period measured in days, not weeks or months.

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

Left side-lying

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?

Macular degeneration

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

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?

Poverty

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

Cystocoele

Protrusion of bladder into the anterior vagina May cause UTIs

A 75-year-old client admitted in respiratory failure has been placed on mechanical ventilation. The client develops acute confusion, purulent sputum, low oxygen saturation readings, and dyspnea. What breath sound is the nurse most likely to auscultate on exam?

Rales

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 Easily distracted by unimportant things

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.

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

A priority nursing diagnosis for the client experiencing altered perception, extreme agitation, and acute confusion is:

Risk for Injury.

During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding?

Senile purpura

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

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

When using the Romberg test of cerebellar function in an older client, which of the following findings is expected?

Slight sway with eyes closed

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

Some symptoms of dehydration are common to younger and older adults. Which one of the following cannot be used to determine dehydration in older adults?

Tenting of the skin when pinched.

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

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

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 elderly client reports pain in the leg which is not associated with any particular activity but is lessened when the leg is elevated. The nurse recognizes that the client may have which vascular condition?

Venous insufficiency

A characteristic sign of delirium is

a rapid decline in level of alertness

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

Yellowed, thickened, lusterless nails

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

a Get Up and Go test.

A risk factor for sinusitis in the frail elderly is

a nasogastric feeding tube.

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

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

bradykinesia

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.

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

diverticulitis.

inflammation of a diverticulum in the digestive tract (especially the colon)

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

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

The nurse observes a dark brown, pigmented waxy lesion 2-mm in size on the right forearm of an older adult. The nurse recognizes this lesion as:

seborrheic keratosis

When evaluating the blood pressure of an older adult, the nurse should understand that with aging, the

systolic blood pressure increases

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

urinary tract infection.