Question 1

A nurse is assessing the pain of an 86-year-old man who had hip surgery recently. The patient has been slightly confused since his surgery, but he responds to simple questions. What is the best way to assess this patient's pain?

A) Ask him to rate his pain on a scale of 0 to 10.
B) Ask him to rate his pain using a list of descriptive adjectives.
C) Ask him to rate his pain using a vertical numeric scale.
D) Observe his behavior and measure his vital signs.

Accepted Answer

Pain assessment in older adults is significantly improved by using a vertical numeric scale or pain faces. Option A is appropriate for adolescents and adults, but older adults are assessed more accurately with a scale that they can see. Option B is not effective for assessing pain because adjectives have different meanings to different people. It is best to use a scale or pictures of faces. Patient behavior and vital signs are not accurate ways to assess a patient's perception of pain.

Question 2

The nurse notes which finding as expected during a history and examination of an older adult patient's abdomen?&#10;A) Hyperactive bowel sounds in all quadrants&#10;B) Decreased fatty deposits over the abdomen&#10;C) Marked concavity of the abdominal contour&#10;D) Soft abdomen on palpation in all quadrants

Accepted Answer

The abdomen of older adults may feel soft due to decreased abdominal muscle tone. The opposite is true; decreased peristalsis causes hypoactive bowel sounds. The opposite is true; older adults may have increased fat deposits over the abdominal area. The opposite is true due to the increased fat deposits over the abdominal area.

Question 3

During inspection of the mouth of an older adult, a nurse notices which finding as an expected change associated with aging?&#10;A) Exposed root surfaces of teeth&#10;B) Aphthous ulcers of the mucosa&#10;C) Collection of debris at the gingival margins&#10;D) Leukoplakia of the dorsal and ventral tongue

Accepted Answer

Root surfaces of the teeth are exposed to caries formation because of gingival recession. Ulcers are not an expected finding. Collection of debris at the gingival margins is not an expected finding. Option D is not an expected finding; leukoplakia is a white patch or plaque that cannot be scraped off and often represents a premalignant lesion.

Question 4

A nurse asks an older adult patient to rise from an arm chair without using the arms, stand with eyes closed, and turn around in a circle. What is the nurse assessing in this patient?&#10;A) Ability to follow instructions&#10;B) Muscle strength&#10;C) Balance&#10;D) Hearing

Accepted Answer

These are three of the activities of the Tinetti Balance and Gait Assessment Tool. Although following instruction is required for this balance assessment, it is not the primary purpose of the assessment. Muscle strength is tested by having the patient push or pull against resistance. Although hearing is required for this balance assessment, it is not the primary purpose of the assessment.

Question 5

A 75-year-old patient tells the nurse, &#34;I just do not enjoy eating as much as I used to because the food does not have much taste or smell.&#34; Which statement by the nurse is most appropriate?&#10;A) &#34;You should make an appointment with your health care provider.&#34;&#10;B) &#34;Try eating small, frequent meals.&#34;&#10;C) &#34;The senses of smell and taste decrease as we age.&#34;&#10;D) &#34;Maybe you should use saline drops in your nose.&#34;

Accepted Answer

A decreased sense of smell is caused by a decrease in the number of sensory cells in the nasal lining. Option A is not warranted in this case; these changes are expected with aging. Option B is practical advice, but will not alter the change in smell and taste. Taste perception may also diminish due to gradual atrophy of the tongue and a decrease in the number of papillae and taste buds. Option D is practical advice, but will not alter the change in smell and taste.

Question 6

An older adult patient reports being able to see her granddaughter play basketball out of the sides of her eyes, but not in the center of her eyes. Based on this information, what vision disorder does the nurse suspect?

A) Presbyopia
B) Macular degeneration
C) Pseudoptosis
D) Entropion

Accepted Answer

Gradual loss of central vision may be caused by macular degeneration due to changes in the retina. Presbyopia is a decrease in near vision that usually occurs after age 40 and is treated with corrective lenses. Pseudoptosis is a relaxed upper eyelid. Entropion is a disorder of the eyelid, in which the lower lid turns inward.

Question 7

The nurse examining the breasts of an older adult woman recognizes which finding as normal?&#10;A) Firm and rounded breasts of equal size and shape&#10;B) Relatively large size and number of mammary ducts&#10;C) Loose elasticity and puckering of the suspensory ligaments&#10;D) Flattened breasts with a slightly granular texture on palpation

Accepted Answer

The breasts in postmenopausal women may appear flattened and elongated or pendulous secondary to a relaxation of the suspensory ligaments. The breasts in postmenopausal women may appear flattened. Option B is not a finding in older women. The suspensory ligaments in older woman are relaxed, but not puckering.

Question 8

What is the best color for nurses to select when designing educational materials for older adults?&#10;A) Blue&#10;B) Yellow&#10;C) Violet&#10;D) Green

Accepted Answer

Color perception of blue, violet, and green may be impaired for older adults.

Question 9

What finding does a nurse look for when assessing the skin of an older adult with solar lentigo?&#10;A) Yellowish, thin papules with a central depression&#10;B) Pigmented, raised, wartlike lesions on the face or trunk&#10;C) Small, soft, pigmented tags of skin on the face and neck&#10;D) Irregular, flat, deeply pigmented macules on sun-exposed areas

Accepted Answer

Irregular, flat, deeply pigmented macules on sun-exposed areas is a description of solar lentigo. Yellowish, thin papules with a central depression is a description of sebaceous hyperplasia. Pigmented, raised, wartlike lesions on the face or trunk is a description of seborrheic keratosis. Small, soft, pigmented tags of skin on the face and neck is a description of acrochordon (skin tags).

Question 10

In assessing the nails of an older adult, which finding does a nurse expect to find?&#10;A) Transverse ridges&#10;B) Thick, brittle, and yellow nails&#10;C) Thin, brittle nails&#10;D) Lateral edges turned upward

Accepted Answer

Thick, brittle, and yellow nails are expected changes in the nails of older adults. Transverse ridges occur when the patient has had nail trauma. Thin, brittle nails occur when the patient has anemia. Lateral edges turned upward, called spoon nail, occurs when the patient has anemia.

Question 11

When assessing the skin of an older adult, a nurse notices pigmented, raised warty-appearing lesions on the trunk. How does a nurse document this finding?&#10;A) Solar lentigo&#10;B) Basal cell skin cancer&#10;C) Seborrheic keratosis&#10;D) Sebaceous hyperplasia

Accepted Answer

The answer of When assessing the skin of an older...

Question 12

Which finding on cardiovascular assessment of an older adult patient warrants further evaluation?&#10;A) Occasional ectopic beats heard on auscultation of the heart&#10;B) Murmur heard over the mitral valve&#10;C) Systolic pressure of 156 in the right arm and 188 in the left arm&#10;D) Persistent S4 sound in a patient with a history of decreased ventricular function

Accepted Answer

The answer of Which finding on cardiovascular assessment of an...

Question 13

Which approach does a nurse use to assess neck range of motion of an older adult patient?&#10;A) Have the patient perform each neck movement separately.&#10;B) Defer range of motion examination if the patient has kyphosis.&#10;C) Ask the patient to turn the head against the resistance of the nurse's hand.&#10;D) Ask the patient to rotate the head starting with forward flexion and moving clockwise.

Accepted Answer

The answer of Which approach does a nurse use to...

Question 14

In collecting a history from an older adult, which information does the nurse consider least essential for a patient of this age?&#10;A) Past health history&#10;B) Genogram&#10;C) Functional abilities&#10;D) Mental health

Accepted Answer

The answer of In collecting a history from an older...

Question 15

When assessing the pain level of an older adult, a nurse considers which factor?&#10;A) Neural transmission of pain is increased as a part of the aging process.&#10;B) Older adult patients are not reliable in their descriptions of pain and how it affects them.&#10;C) Physiologic indicators of pain that are unique to older adults are tachycardia and hypotension.&#10;D) The older adult may believe that pain is a factor of aging and not worth mentioning.

Accepted Answer

The answer of When assessing the pain level of an...

Question 16

In assessing the external eyes of an older adult, a nurse documents which finding as abnormal?&#10;A) Gray-white circle where the cornea and the sclera merge&#10;B) Brown spots near the limbus in both eyes&#10;C) Lack of luster of the eye and dry bulbar conjunctiva&#10;D) Lower lid drops away from the globe

Accepted Answer

The answer of In assessing the external eyes of an...

Question 17

In assessing the mood of older adult patients, a nurse documents which finding as abnormal?&#10;A) Sadness and grief after returning from the funeral of a long-time friend&#10;B) Depression that interferes with the ability to perform activities of daily living&#10;C) Frustration about rearranging the day's schedule to attend a grandson's birthday party&#10;D) Crying about the unexpected death of a pet that had been with the family 12 years

Accepted Answer

The answer of In assessing the mood of older adult...

Question 18

A 75-year-old man reports he stopped playing cards with his friends because their voices sounded mumbled. How does the nurse explain the cause of this change?&#10;A) Sudden low-frequency hearing loss&#10;B) Accumulation of earwax in the outer ear&#10;C) Damage to the middle ear from ear infections&#10;D) Gradual high-frequency hearing loss

Accepted Answer

The answer of A 75-year-old man reports he stopped playing...

Question 19

During an office visit, a 78-year-old woman is upset because her height is &#34;2 inches less than it was when I was 40!&#34; How does the nurse explain this change to the patient?&#10;A) &#34;Reduced height may occur as you age due to shortening of the vertebrae.&#34;&#10;B) &#34;You may be experiencing this height change due to arthritis.&#34;&#10;C) &#34;You need to improve your posture by performing stretching exercises.&#34;&#10;D) &#34;This is a rare occurrence and warrants having a bone density test.&#34;

Accepted Answer

The answer of During an office visit, a 78-year-old woman...

Question 20

Which assessment finding of older adult patients indicates expected respiratory function?&#10;A) Increased elasticity of the alveoli&#10;B) Flaccidity of the chest wall&#10;C) Reduced inspiratory and expiratory effort&#10;D) Decreased anteroposterior diameter

Accepted Answer

The answer of Which assessment finding of older adult patients...

Question 21

What risk factors for falls does a nurse teach a group of older adults? (Select all that apply.)&#10;A) Being a woman&#10;B) Taking more than six medications&#10;C) Having hypertension&#10;D) Having cataracts&#10;E) Muscle strength 3/5 bilaterally in lower extremities&#10;F) Incontinence

Accepted Answer

The answer of What risk factors for falls does a...

Question 22

What expected physiologic changes of aging put older adults at risk for respiratory infections? (Select all that apply.)&#10;A) Breath sounds are bronchovesicular in the peripheral lung.&#10;B) Alveoli are less elastic.&#10;C) Weak intercostal muscles reduce effective coughing.&#10;D) Mucous membranes drier&#10;E) Curvature of the spine limits chest wall expansion.&#10;F) Cough reflex is impaired due to deceased sensitivity of receptors.

Accepted Answer

The answer of What expected physiologic changes of aging put...

Deck 21: Assessment of the Older Adult