Question 1

The client reports to the Emergency Department with complaints of severe pain.The client was diagnosed with a fractured hip.The client reported sitting down on the toilet seat and feeling his right hip break.The client asks how this could have happened.What information can be provided by the nurse?

Accepted Answer

A)  "The body's bones become increasingly brittle and lose density with aging."
B)  "Unfortunately,this may signal a serious underlying health problem."
C)  "You should discuss this with your healthcare provider."
D)  "There is no good explanation for what has happened to you." A

Question 2

The nurse is performing a focused interview with an elderly client.The client reports the presence of painful sores.The client states,"They wrap around in lines from my back toward my belly." During the assessment of the client's skin,the nurse discovers the sores are reddened vesicles.The nurse would suspect which of the following conditions?

Accepted Answer

A)  Ecchymoses
B)  Herpes zoster
C)  Petechiae
D)  Purpura B

Question 3

The older adult male client is visiting the outpatient clinic.During the focused interview,the client admits that he is experiencing clinical manifestations associated with erectile dysfunction.Which of the following statements by the client indicate that the client may be taking a medication that could produce this problem?

Accepted Answer

A)  "I take something to help my stomach not make so much acid."
B)  "I've been taking something for depression ever since our son died 4 years ago."
C)  "Sometimes,I have to take a medication to help me sleep at night."
D)  "I've had trouble with my blood pressure for years and take a medication to keep it down."
E)  "I take a baby aspirin every day." B,C,D

Question 4

The nurse is performing an assessment on a 70-year-old client.Which of the following findings will warrant further investigation?

Accepted Answer

A)  Slight bulging along the lower eyelids
B)  Reduced perspiration
C)  Reduced sebum production
D)  Large white spots on the upper arms and trunk

Question 5

The nurse is using the Katz Index of Independence in Activities of Daily Living tool to assess the client's level of independence.Based on the table below,calculate the client's total number of points.
___ points

Accepted Answer

The answer of The nurse is using the Katz Index...

Question 6

The daughter of an elderly client reports that the client is experiencing a decrease in hearing ability in the client's right ear.The nurse suspects a conductive hearing loss due to the presence of dried wax in the right ear canal.In which of the following ways can the nurse best validate this suspicion?

Accepted Answer

A)  Perform the Weber test.
B)  Perform the Rinne test.
C)  Examine the external ear.
D)  Perform the whisper test.

Question 7

The nurse is preparing to perform an evaluation of the older adult client's level of cognitive reasoning.The student nurse is observing.Which of the following statements by the student nurse indicates the need for further education?

Accepted Answer

A)  "The Mini-Mental State Examination seems like a quick way to determine how well the client is able to reason."
B)  "It's best to go ahead and give the Mini-Mental State Examination at the beginning of the focused interview because the client's mind will be fresh."
C)  "It sounds like some older people get really nervous about these cognitive reasoning examinations because they worry they may be developing problems."
D)  "The Mini-Mental State Examination is really easy to perform so it's important to remember that the client may have just gone through these types of questions the day before with another healthcare provider."

Question 8

The nurse is performing a head-to-toe assessment on an older adult client who was admitted to the hospital with dehydration.Which of the following findings are consistent with this condition?

Accepted Answer

A)  Tenting noted on dorsal aspect of client's hand when skin turgor was assessed.
B)  Client has produced 175 milliliters over the last 8 hours.
C)  Dentures are loose,small sores noted in oral mucosa.
D)  Healthcare provider notes client exhibiting xerostomia.
E)  Client's apical heart rate is 82 beats per minute.

Question 9

The nurse is assessing an 84-year-old client.The nurse notes the presence of edema in both knees and ankles.The client complains of joint stiffness and pain upon awakening.The nurse would suspect which of the following disorders?

Accepted Answer

A)  Bursitis
B)  Gouty arthritis
C)  Osteoarthritis
D)  Rheumatoid arthritis

Question 10

The nurse has provided an educational program for his peers regarding several theories of aging.Which of the following statements by a participant in the program indicates the need for further education?

Accepted Answer

A)  "Senescence refers to changes that organisms experience as they age."
B)  "Error theories point to stressors as the cause for aging."
C)  "Error theories indicate that aging follows a timetable."
D)  "There are several major theories of aging: programmed,error,and those theories that overlap."

Question 11

The nurse is preparing to interview the older adult client and perform a head-to-toe assessment.Which of the following actions by the nurse indicate the nurse requires further education?

Accepted Answer

A)  The nurse has requested that the client put on a cotton gown prior to the interview.
B)  The nurse seats the client so that the light from the window faces the client with the nurse's back to the window.
C)  The nurse addresses the client by her first name.
D)  The nurse maintains eye contact;both nurse and client are seated.
E)  During the interview,the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further.

Question 12

During a routine physical examination,a 66-year-old client reports feeling very tired throughout the day.Which of the following is the nurse's best initial action?

Accepted Answer

A)  Assess the client's sleep patterns.
B)  Encourage the client to begin to take a nap each day.
C)  Encourage the client to alter the evening routine to reduce potential evening stressors.
D)  Ask the healthcare provider to prescribe a medication designed to help the client sleep better.

Question 13

The nurse is planning an educational program for new nurses regarding healthcare needs of the elderly.Which of the following should be included?

Accepted Answer

A)  Depression is not a common problem for the elderly.
B)  Influenza vaccines should be given to most elderly clients.
C)  Burns are the most common type of injuries experienced by older adults.
D)  Pneumonia is the most common cause of death in older adults.

Question 14

The nurse is examining the eyes of an elderly client using the ophthalmoscope.The vessels of the eyes are narrow and tapered in appearance.The nurse would correctly choose which of the following actions?

Accepted Answer

A)  Document the findings as normal.
B)  Assess the pupils to determine if they equal,round,reactive to light,and accommodation.
C)  Inquire about any past history of hypertension.
D)  Inquire about a history of diabetes.

Question 15

The nurse is assessing the vital signs of an elderly client and obtains a temperature of 97.1 degrees Fahrenheit.Which of the following actions is most appropriate?

Accepted Answer

A)  Document the finding as normal.
B)  Encourage the client to drink warm fluids.
C)  Request to turn up the client's thermostat.
D)  Apply warmed blankets to the client.

Question 16

The nurse hears a bruit when auscultating the right carotid artery of an elderly client.The nurse would choose which of the following actions next?

Accepted Answer

A)  Auscultate the heart for murmurs.
B)  Obtain a surgical consult.
C)  Document the findings as normal.
D)  Assess for jugular vein distention.

Question 17

The nurse is interviewing an elderly client and notes the presence of several soft,yellow plaques on the eyelids at the inner canthus.The nurse would suspect that the client has developed which of the following conditions?

Accepted Answer

A)  Xanthelasma
B)  Pingueculae
C)  Pterygium
D)  Arcus senilis

Question 18

The client is visiting the outpatient clinic for a routine blood pressure assessment.While speaking with the nurse,the client states,"I'm getting old and everything hurts." Which statement or question by the nurse is most appropriate?

Accepted Answer

A)  "Tell me more about your pain."
B)  "Normal aging can be quite painful."
C)  "You must have osteoarthritis."
D)  "What medications do you take?"

Question 19

The nurse is educating a client who has been diagnosed with stress incontinence.The nurse should include which of the following in the teaching care plan?

Accepted Answer

A)  The client should maintain an ideal body weight.
B)  The client should limit fluid intake to 4 glasses a day.
C)  The client should try to void on a regular schedule.
D)  The client should perform pelvic muscle strengthening exercises.
E)  The client should increase fiber intake.

Question 20

The nurse is counseling an elderly couple and encourages both of them to receive the pneumococcal vaccine.The nurse would understand that further teaching is necessary if which of the following statements was made by one of the clients?

Accepted Answer

A)  "We will need to get vaccinated each year."
B)  "The vaccine is recommended for us because we are both over the age of 6
C)  "The vaccine does not protect us against all types of pneumonia."
D)  "We should get the influenza vaccine and the pneumonia vaccine."

Exam 27: Assessing the Older Adult