Question 1

The nurse is assessing the older adult client's waist-to-hip ratio to determine the client's risk for developing hypertension.The client's hip circumference is 72 centimeters.The client's waist circumference is 81 centimeters.Calculate the client's waist-to-hip ratio.Round to the hundredths place.

Accepted Answer

1.13

Question 2

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

Accepted Answer

Large white spots on the upper arms and trunk may indicate a skin condition such as tinea versicolor or vitiligo, which may require further investigation or treatment. The other findings are common age-related changes and do not necessarily indicate a health problem.

Question 3

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

The client's fatigue could be related to sleep patterns, so the nurse's initial action should be to assess the client's sleep patterns. This will provide more information about what might be causing the fatigue and guide further interventions or referrals. Encouraging the client to nap or alter their evening routine may not address the underlying cause of fatigue and could potentially worsen sleep patterns. Asking the healthcare provider to prescribe a sleep medication should be avoided until the cause of the fatigue has been identified.

Question 4

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

The answer of The nurse is preparing to interview the...

Question 5

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

The answer of The nurse is performing a head-to-toe assessment...

Question 6

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

Xanthelasma presents as soft, yellow plaques on the eyelids at the inner canthus and is commonly seen in elderly clients. Pingueculae are raised, yellowish growths on the conjunctiva and are not typically found on the eyelids. Pterygium is a triangular thickening of the bulbar conjunctiva that grows onto the cornea and is not related to the eyelids. Arcus senilis is a gray-white arc or ring around the cornea, caused by lipid deposition, and does not typically present as soft, yellow plaques on the eyelids.

Question 7

The nurse is assessing the older adult client who has been admitted to the hospital following a fall.The nurse is using the Fulmer SPICES framework to assess the client for predicting and preventing problems that the client may experience.Rank the following assessment questions by the nurse in order of occurrence based on this framework.
A)"Do you have any concerns about your memory?" 
B)"It looks like you've lost some weight since your healthcare provider last saw you.How are your teeth?" 
C)"Can you tell me about how well you are sleeping?" 
D)"Have you had any problems holding your urine?" 
E)"I noticed that you have a large bruise on your knee.Did you fall recently?"

Accepted Answer

The answer of The nurse is assessing the older adult...

Question 8

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

Narrow and tapered vessels in the eyes can be indicative of changes due to hypertension. It's important for the nurse to inquire about a history of hypertension to understand if these findings are related to a pre-existing condition.

Question 9

The nurse is assessing an older adult client who has come to the outpatient clinic with complaints of fatigue.The nurse believes that the client is exhibiting clinical manifestations associated with hypothyroidism.Which of the following findings are consistent with the presence of this condition?

Accepted Answer

Hypothyroidism is characterized by a slowing down of metabolic processes. A) Cognitive changes such as slowed processing can occur due to the decreased metabolism affecting brain function. C) Fatigue and decreased energy levels are common symptoms as the body's energy production is reduced. E) A decreased respiratory rate can also be a manifestation, reflecting the overall reduction in metabolic rate and demand for oxygen. B) and D) are more indicative of hyperthyroidism or other conditions, as hypothyroidism typically leads to decreased, not increased, heart rate and would not directly cause hyperactive bowel sounds.

Question 10

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 11

The nurse is performing a focused interview with an elderly client.The client says,"My mouth is always so dry.Sometimes,I feel like my tongue has grooves in it." The nurse inspects the client's tongue and discovers that it is red and dry with the presence of furrows.Based on the client's most likely condition,the nurse expects to learn which of the following?

Accepted Answer

The answer of The nurse is performing a focused interview...

Question 12

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

As people age, their bones can become more brittle and lose density, which can increase the risk of fractures. This is a common explanation for fractures in elderly individuals.

Question 13

The nurse is assessing the older adult client.As the nurse completes the nursing care plan for the client,which of the following places the client at risk for infection?

Accepted Answer

Voluntarily restricting fluid intake can lead to dehydration and urinary tract infections. Thinner, drier skin with pruritis can lead to skin breakdown and infection. Decreased sebum production can compromise the skin's barrier function. Delayed gastric emptying can increase the risk of gastrointestinal infections.

Question 14

The nurse is performing a focused interview with an older adult client.Which of the following statements indicate the client has an increased risk of developing depression?

Accepted Answer

A) The loss of a significant other can lead to feelings of loneliness and grief, increasing the risk of depression.B) A family history of depression can increase an individual's risk of developing the condition due to genetic and environmental factors.C) Chronic illnesses, such as chronic bronchitis, can contribute to the development of depression due to the stress and limitations they impose on an individual's life.

Question 15

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

The answer of The older adult male client is visiting...

Question 16

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

The Mini-Mental State Examination (MMSE) is a tool used to assess cognitive function, but it should not necessarily be administered at the very beginning of an interview. Starting with the MMSE could potentially increase anxiety or discomfort in some clients. It's important to establish rapport and understand the client's current state through conversation before proceeding with formal assessments. This approach helps in obtaining more accurate and genuine responses.

Question 17

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

Error theories suggest that aging results from internal processes and external factors leading to cellular damage, not from a predetermined timetable. Programmed theories are the ones that suggest aging follows a specific biological timetable.

Question 18

The nurse is interviewing an older adult client prior to performing a head-to-toe assessment.Which of the following statements by the client indicate that the client's skin may appear more damaged than another person this client's age?

Accepted Answer

Alcohol consumption (A) can lead to dehydration and poor nutrition, affecting skin health. Smoking (B) significantly accelerates skin aging and damage. Working as a radiology tech (D) could imply exposure to radiation, which can damage the skin. Exposure to Agent Orange (E) has been associated with numerous health issues, including skin conditions. Avoiding the sun (C) would generally protect the skin, making it less likely to appear damaged.

Question 19

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

Accepted Answer

Narrow and straight vessels in the eyes are a normal age-related change, so the nurse should document the finding as normal. Referral to an ophthalmologist or inquiring about risk factors for glaucoma or diabetes would not be necessary based on this finding alone.

Question 20

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

Edema in the knees and ankles and joint stiffness and pain upon awakening are all common symptoms of osteoarthritis, a degenerative joint disease that commonly affects older adults. Bursitis typically presents with localized swelling and tenderness in the affected joint, while gouty arthritis often presents with sudden onset of severe pain and swelling in the affected joint. Rheumatoid arthritis typically presents with symmetric joint pain and swelling, but edema may not be as prominent as in osteoarthritis.

Quiz 27: Assessing the Older Adult