Question 1

The home health nurse is visiting an older patient who is incontinent and reports restricting personal fluid intake to prevent urinary leakage. Which of the following actions would be most appropriate for the nurse to take?

Accepted Answer

Restricting fluid intake can lead to dehydration and other health problems. Referring the patient to a continence program can provide education and resources to help manage their incontinence without resorting to harmful actions such as fluid restriction.

Question 2

The nurse is providing care for a person who has difficulty hearing high-pitched tones. Which of the following actions would be most appropriate for the nurse to take?

Accepted Answer

A

Question 3

Which of the following measures should the nurse recommend be included in the patient's plan of care for an older adult who has a nursing diagnosis of ineffective sexual patterns?

Accepted Answer

For an older adult with ineffective sexual patterns, scheduling private time may be beneficial to allow for exploration of preferences and desires. Playing favorite music, providing pain medication, and providing a soft mattress may not directly address the issue of ineffective sexual patterns.

Question 4

Which of the following actions should the nurse recommend be included in the patient's plan of care for a nursing diagnosis of imbalanced nutrition: less than body requirements related to inability to feed self?

Accepted Answer

The answer of Which of the following actions should the...

Question 5

The nurse is making a home health visit to a frail but basically healthy 86-year-old patient. The nurse documents a heart rate of 104 beats/minute. What would be an appropriate action by the nurse?

Accepted Answer

A heart rate of 104 beats/minute in an 86-year-old patient could be a cause for concern, but it is important to gather more information before alerting the physician. Asking about the patient's fluid intake and urinary patterns can reveal if there is a possible cause for the elevated heart rate, such as dehydration or a urinary tract infection. Teaching deep breathing exercises may also be helpful, but it is important to address any underlying issues first. Requesting a tranquilizer should not be the first course of action and should only be done under the guidance of a physician.

Question 6

The nurse is caring for a patient with Alzheimer's disease. Which of these environments would be most beneficial for the nurse to provide for the patient to decrease the patient's symptoms?

Accepted Answer

Patients with Alzheimer's disease often experience confusion and disorientation in new or unfamiliar environments. Providing a familiar, nonstimulating environment can help decrease their symptoms and increase their sense of security and comfort. Varying environments or physically challenging environments can further contribute to their confusion and discomfort. While a variety of sensory experiences can be enjoyable, it would be more important to prioritize providing a familiar environment for patients with Alzheimer's disease.

Question 7

The home health nurse is visiting an older adult who reports nocturia. Which of the following colors for a light bulb in a nightlight would be most appropriate for the nurse to suggest to increase safety and enable an older patient to see better at night?

Accepted Answer

Red light is less likely to interfere with melatonin production and sleep cycles, making it easier for the older adult to return to sleep after getting up at night. It also provides sufficient illumination for safety without being overly bright.

Question 8

The nurse is collecting data for an older patient. Which of these characteristics would the nurse likely identify in a patient with an age-related loss of water in the vertebral discs?

Accepted Answer

Age-related loss of water in the vertebral discs can lead to decreased height due to reduced cushioning between the vertebrae.

Question 9

The nurse makes recommendations to an older patient's plan of care for safety measures.Which of these musculoskeletal changes should the nurse consider can contribute to a reduction in an older adult's confidence level in being able to safely perform routine tasks?

Accepted Answer

As an older adult's muscle response time becomes slower, they may feel less confident in their ability to safely perform routine tasks due to an increased risk of falls or accidents. Increased reflexes, joint flexibility, and rapid nerve transmissions do not necessarily contribute to a reduction in confidence.

Question 10

A 70-year-old patient tells the nurse that it has been difficult to hear lately. What action should the nurse take?

Accepted Answer

Checking for increased cerumen (earwax) is a common and simple first step in assessing hearing difficulties, as it can block the ear canal and impair hearing.

Question 11

The nurse is reinforcing teaching for an older patient on how to safely rise from a seated to a standing position. Upon which of the following aging changes does the nurse base the need for the older patient to change positions gradually for safety?

Accepted Answer

Decreased circulatory efficiency in older adults can lead to dizziness or a drop in blood pressure when changing positions too quickly, making it important to rise gradually to ensure safety and prevent falls.

Question 12

Which of the following actions should the nurse recommend be included in the patient's plan of care to increase medication safety for a patient who is confused?

Accepted Answer

Having a family member set up and administer the medications can increase medication safety for a confused patient by ensuring that the medications are taken correctly and at the right time. Patients who are confused may have difficulty setting up and remembering to take their medications, which can result in missed or incorrect doses. Having a family member involved in the medication administration process can also allow for monitoring of the patient's response to the medication, side effects, and potential interactions with other medications or medical conditions. Options A, B, and D do not address the issue of confusion and may even increase the risk of medication errors.

Question 13

The nurse is monitoring a patient's skin status. Which of these does the nurse recognize as the first sign of prolonged pressure on the skin?

Accepted Answer

Redness is the first sign of prolonged pressure on the skin, which can progress to skin breakdown and the development of pressure ulcers. Coolness, cyanosis, and paleness are not typically associated with prolonged pressure on the skin.

Question 14

The nurse is caring for a patient who is prone to developing constipation. Which of the following actions would be most appropriate for the nurse to take?

Accepted Answer

Helping the patient develop an exercise routine can be a safe and effective way to prevent constipation. Instructing the patient to use suppositories once a week or take an oral laxative every night can be harmful and disrupt the natural bowel function. Giving the patient a Fleet enema should be a last resort and not used on a regular basis.

Question 15

The nurse has reinforced teaching with a patient about aging-related changes. Which of the following statements by the client would indicate a correct understanding of the cause of tooth loss in an older adult?

Accepted Answer

Tooth loss in older adults is primarily due to poor dental care, which can lead to gum disease and other dental issues, rather than the natural aging process itself.

Question 16

The nurse is collecting data for a patient. Which of these findings would the nurse expect with a decrease in melanin?

Accepted Answer

Decrease in melanin production results in graying of hair. Thinning or thickening of bone is not related to melanin production.

Question 17

The nurse is reinforcing teaching for an older patient. The nurse recognizes when interacting with the patient that aging has which of the following effects on short-term and long-term memory?

Accepted Answer

The answer of The nurse is reinforcing teaching for an...

Question 18

The nurse is contributing to a patient's plan of care for comfort needs. What age-related change would explain why an 84-year-old patient is chronically cold even with the thermostat set at 80°F (26.6°C)?

Accepted Answer

As people age, they lose subcutaneous fat which serves as an insulator, making them more susceptible to feeling cold.

Question 19

While assisting with the admission of a new resident to the long-term care facility, the nurse notes the patient's feet are moist with dry skin on the heels. The toenails are long and brittle. Which of the following actions should the nurse take first?

Accepted Answer

The answer of While assisting with the admission of a...

Question 20

The nurse is making recommendations to the plan of care for a patient who has limited mobility. The nurse understands that this patient is at highest risk for which of these skin conditions?

Accepted Answer

Patients with limited mobility are at highest risk for developing pressure ulcers due to prolonged pressure on certain areas of the body, such as the sacrum, heels, and elbows. Melanoma, rashes, and venous stasis ulcers are not directly related to limited mobility.

Quiz 15: Nursing Care of Older Adult Patients