Deck 15: Nursing Care of Older Adult Patients

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?

A)Praise the patient for this creative action.
B)Instruct the patient to drink more fluids.
C)Provide the patient with literature on oral fluids.
D)Refer the patient to a continence program.

Answer 1

Refer the patient to a continence program.

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?

A)Speak softly, using a near-whisper tone.
B)Speak rapidly, using multiple hand gestures.
C)Speak loudly from across the room.
D)Speak slowly, emphasizing lip movements.

Answer 2

Speak softly, using a near-whisper tone.

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?

A)Play favorite music.
B)Provide pain medication.
C)Provide a soft mattress.
D)Schedule private time.

Answer 3

Schedule private time.

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?

A)Assessing which foods the patient prefers
B)Checking for patient pocketing of foods
C)Asking the order the patient wishes to eat foods
D)Providing liquids after meals

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?

A)Ask about liquids the patient is drinking and urination frequency.
B)Inform the physician of the heart rate immediately.
C)Teach the patient deep breathing exercises to reduce heart rate.
D)Have the patient request a tranquilizer from the physician at the next visit.

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?

A)An environment that varies weekly
B)A variety of sensory experiences
C)A familiar, nonstimulating environment
D)A physically challenging environment

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?

A)Red
B)White
C)Yellow
D)Orange

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?

A)Spinal flexion
B)Decreased height
C)Protruding bony prominences
D)Increased spinal flexibility

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?

A)Increased reflexes
B)Increased joint flexibility
C)Rapid nerve transmissions
D)Slower muscle response time

Question 10

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

A)Ask how loudly the television volume is set.
B)Ask the patient the date of his or her last hearing test.
C)Teach the patient several easy sign language words.
D)Check the patient's ears for the presence of increased cerumen.

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?

A)Joint stiffness
B)Leg muscle weakness
C)Decreased circulatory efficiency
D)Decreased neurological reflex times

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?

A)Have the patient set up the medications for an entire week.
B)Have patient turn medication bottles upside down after taking medication.
C)Have a family member set up and administer the medications.
D)Instruct the patient to take all of the medications together.

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?

A)Coolness
B)Cyanosis
C)Paleness
D)Redness

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?

A)Instruct the patient to use suppositories once a week.
B)Instruct the patient to take an oral laxative every night.
C)Help the patient develop an exercise routine.
D)Give the patient a Fleet enema.

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?

A)"The aging process."
B)"Poor dental care."
C)"Jawbone loss."
D)"Receding gums."

Question 16

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

A)Thinning of hair
B)Graying of hair
C)Thickening of bone
D)Thinning of bone

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?

A)Short-term memory is retrieved more easily than long-term memory.
B)Short-term memory is slightly more difficult to retrieve with aging.
C)Both types of memory are retrieved more easily with aging.
D)Long-term memory is retrieved more easily than short-term memory.

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)?

A)Decreased subcutaneous fat layer
B)Increased layer of subcutaneous fat
C)Decreased muscular retention of heat
D)Increased muscular retention of heat

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?

A)Soak feet in warm water.
B)File the nails.
C)Apply lotion to the feet.
D)Dry feet well.Multiple Response
Identify one or more choices that best complete the statement or answer the question.

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?

A)Melanoma
B)Pressure ulcer
C)Rashes
D)Venous stasis ulcer

Question 21

The nurse is administering medications to a group of older residents and monitors them for adverse reactions. The nurse recognizes that an age-related reduction in liver enzyme production affects medication metabolism in which of the following ways? (Select all that apply.?

A)There is increased detoxification of substances.
B)There is a need for an increase in the medication dosage.
C)The metabolism of substances is decreased.
D)The elimination of substances is increased.

Question 22

The nurse is contributing to a staff education program on grooming techniques for older adults. Which of the following methods should the nurse recommend to use to groom the resident's nails to reduce the potential for nail infections? (Select all that apply.?

A)File nails with an emery board.
B)Cut nails with scissors.
C)Clip nails with nail clippers.
D)Use resident's own grooming equipment.

Question 23

The nurse is contributing to the plan of care for an older adult. Which of the following would the nurse recognize as being age-related changes in the integumentary system when planning interventions? (Select all that apply.?

A)Decreased sweat production
B)Increased growth of nose, ear, and facial hair
C)Increase in nail growth rate
D)Increased dryness of the skin
E)Increased subcutaneous fat layer of skin
F)Thinning of the scalp hair

Question 24

The nurse is collecting data for a patient who has a developing pressure ulcer. Which of the following would the nurse expect to identify as early manifestations of a pressure ulcer? (Select all that apply.?

A)Report of redness at the site
B)Report of burning at the site
C)Coolness of site to touch
D)Cyanosis of site observed
E)Tenderness at site when touched
F)Report of decreased sensation at site

Question 25

The nurse makes recommendations for sleep needs to an older patient's plan of care. Which of these does the nurse recognize as characteristic of sleep patterns in the older adult? (Select all that apply.?

A)Sleep needs decrease.
B)Sleep needs remain unchanged.
C)Rest patterns are unchanged.
D)Rest time is decreased.Completion
Complete each statement.

Question 26

The nurse is contributing to the plan of care for an older adult. Which of the following would the nurse recognize as being age-related changes in the cardiovascular system when planning interventions? (Select all that apply.?

A)An increase in heart rate
B)An increase in irregular heartbeats
C)Decreased blood pressure
D)Thinning of the heart valves and aorta
E)Decreased cardiac output
F)Less efficient leg veins

Question 27

Of people over 65 years old, the fastest-growing segment is the group older than ________________years old.

Question 28

Pressure ulcers in an older adult can result from continuous pressure on a site of the body within ________________minutes.

Question 29

The nurse is contributing to a staff education program about the Joint Commission's National Patient Safety Goals. Which of the following would the nurse recognize as a Joint Commission National Patient Safety Goal? (Select all that apply.?

A)Promote healthy lifestyle choices by encouraging participation in genetic testing.
B)Monitor individual risk for pressure sore development.
C)Decrease the incidence of influenza by establishing vaccination protocols.
D)Identify patient fall risk and institute measures to reduce risk of falls.
E)Use at least two patient identifiers before providing medications.

Question 30

The nurse is contributing to a staff education program about aging changes. Which of these would the nurse include as a common change in the skeletal system of an older adult? (Select all that apply.?

A)Shortening in height
B)Increased flexibility
C)Increasing bone density
D)Thickening of bone
E)Eroded cartilage
F)Osteoporosis

Question 31

The nurse is contributing to the plan of care for an immobile patient. Which of the following would the nurse recognize as increasing the patient's risk of developing a pressure ulcer on the heels? (Select all that apply.?

A)Elevating legs on pillows
B)Impaired circulation
C)Being obese
D)Turning every hour
E)Wearing oxygen at 2 L per nasal cannula
F)Lying on wet linens

Question 32

After drawing blood from an older adult and withdrawing the needle, the nurse should apply light pressure to the needle puncture site for at least ________________minutes.

Question 33

Which of these manifestations, if reported by the patient who is diabetic and sleep deprived, would the nurse recognize as likely being related to sleep deprivation? (Select all that apply.?

A)Persistent hunger
B)Fatigue
C)Hyperactivity
D)Irritability
E)Decreased pain sensitivity
F)Anxiety