Deck 15: Physiological Assessment

Question 1

An older male patient complains of urinary frequency and an interrupted stream. What would be an appropriate response?
1) Tell him to accept it and do nothing.
2) Tell him it is a completely normal part of aging.
3) Discuss with him that he may have prostate cancer.
4) Suggest that he sees a physician for a prostate-specific antigen (PSA) test.

Answer 1

4

Question 2

The nurse is planning to assess an older patient's ability to complete activities of daily living (ADLs). What should be included in this assessment? Select all that apply.
1) Feeding
2) Cooking
3) Continence
4) Telephoning
5) Transferring

Answer 2

1, 3, 5

Question 3

The nurse is assessing an older patient with osteoporosis. Which finding would indicate that the patient is experiencing a compression fracture of the spine?
1) Pain in legs
2) Acute lower back pain
3) Abdominal discomfort
4) Loss of control of urine

Answer 3

2

Question 4

The nurse is determining an older person's ability to bathe. Which home observation should facilitate this person's independence?
1) Bathtub
2) Walk-in shower
3) Garden hose outside
4) Stationary tub in the basement

Question 5

When assessing a patient's sense of smell, the nurse gives a whiff of freshly ground coffee beans to an older patient. The patient identifies coffee with the left nostril but cinnamon with the right nostril. How should the nurse interpret this finding?
1) Abnormal; odors should be perceived the same in both nostrils.
2) Normal; all people differentiate odors differently with each nostril.
3) Abnormal; the patient needs surgery immediately to cure a blockage.
4) Normal; it is necessary to use both nostrils together to determine odors accurately.

Question 6

An older person's self-care ability is being questioned. What should cause the nurse the most concern about this patient?
1) Wears nightgown and robe all day
2) Ambulates with a cane during the day and a walker at night
3) Eats one meal a day during the week that is delivered by the local community center
4) Walks to the bathroom to void but frequently has incontinent episodes; the bedroom and bathroom smell of urine

Question 7

The nurse notes that an older patient's radial pulse area is difficult to compress. What should this indicate to the nurse?
1) Dehydration
2) Poor nutrition
3) Fluid overload
4) Normal finding

Question 8

The nurse notes that an older patient's pupils sluggishly respond to light. What should the nurse do with this information?
1) Document it as a normal finding.
2) Report the finding to the charge nurse.
3) Discuss how long the patient had cataracts.
4) Explain that an ophthalmologist appointment is needed.

Question 9

The nurse documents that an older person's neurological status is within normal limits. What did the nurse use to make this clinical determination?
1) Hand grasps equal
2) Rigid lower extremities
3) Pedal pulses present in both feet
4) Full range of motion of both shoulders

Question 10

The nurse is completing a physical assessment with an older patient. What should be included when assessing the peripheral vascular system? Select all that apply.
1) Palpating peripheral pulses
2) Assessing for edema using a tape measure
3) Measuring the blood pressure on each arm
4) Observing the color and temperature of the skin
5) Noticing the hairiness or lack of hair on the extremities

Question 11

The nurse is completing a health history with an older patient. Which information should be collected to understand the older person's overall health status? Select all that apply.
1) Diet
2) Exercise
3) Water intake
4) Years retired
5) Sleep pattern

Question 12

An older patient is concerned about ongoing constipation. What should the nurse focus on when assessing this patient?
1) Fluid intake
2) Protein intake
3) Sleeping pattern
4) Leisure activities

Question 13

An older patient has a bright purple lesion on the left arm with clear borders. What should the nurse do?
1) Ask about recent falls.
2) Question about new medications or foods.
3) Set up an appointment with the dermatologist.
4) Explain the normal skin changes that include senile purpura.

Question 14

The nurse spent a great deal of time locating an older patient's right pedal pulse. What should the nurse do to ensure that future assessments of this pulse can be completed in a timely manner?
1) Mark the location with a felt-tipped pen.
2) Apply a gauze dressing over the location.
3) Tell the patient where the pulse is located.
4) Document the location in the medical record.

Question 15

The nurse suspects that an older patient has a stasis ulcer on the left inner ankle. For which health problem should the nurse assess this patient?
1) Varicose veins
2) Venous insufficiency
3) Arterial insufficiency
4) Deep vein thrombosis