Deck 15: Nursing Care of Older Adult Patients

Question 1

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

A)Being obese
B)Turning every hour
C)Lying on wet linens
D)Impaired circulation
E)Elevating legs on pillows 6.Wearing oxygen at 2 L per nasal cannula

Answer 1

Lying on wet linens
Impaired circulation

Question 2

The nurse is teaching a group of older adults about medication safety. Which statements made by these individuals would be of most concern to the nurse? (Select all that apply.)

A)"I will not crush my pill that has a coating on it."
B)"It is safe for me to take herbal medications with my prescription pills."
C)"I need to cut my medication in half until my next Social Security check comes."
D)"I will take my medicine just like my doctor explained to me."
E)"I can't see the label too well on my medication." 6."I put all my medicine in a dose divider."

Answer 2

"It is safe for me to take herbal medications with my prescription pills."
"I need to cut my medication in half until my next Social Security check comes."
"I can't see the label too well on my medication." 6."I put all my medicine in a dose divider."

Question 3

Which does the nurse identify as an extrinsic factor of aging?

A)Environmental influences
B)Biological clock theory
C)Perception of aging
D)Wear-and-tear theory

Answer 3

Environmental influences

Question 4

The nurse is reviewing a medication history for an older adult. Which medication would be of most concern to the nurse for a patient taking furosemide (Lasix)?

A)Atenolol (Tenormin)
B)Spironolactone (Aldactone)
C)Levothyroxine (Synthroid)
D)Azithromycin (Zithromax)

Question 5

The nurse is caring for a group of older adult patients. Which patient is at highest risk for suicide?

A)A patient who lives at a retirement center with his spouse and plays bingo daily
B)A patient with terminal lung cancer whose spouse recently suffered a debilitating stroke
C)A patient who is single and occasionally goes on cruises with a friend
D)A patient with diabetes who lives with her daughter and grandchildren

Question 6

The nurse is collecting data for a patient who has a developing pressure ulcer. What should the nurse expect to assess as early manifestations of a pressure ulcer? (Select all that apply.)

A)Coolness of site to touch
B)Cyanosis of site observed
C)Report of redness at the site
D)Report of burning at the site
E)Tenderness at site when touched 6.Report of decreased sensation at site

Question 7

The nurse is caring for a patient who is prone to developing constipation. Which action should the nurse take to help this patient?

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

Question 8

A patient tells the nurse he hit a large sign at a store with his vehicle. The nurse suspects which as a contributing factor to the accident?

A)Longer reaction time
B)Inability to maintain balance
C)Decreased hypothalamus function
D)Increased motor coordination

Question 9

The nurse is caring for an older adult who is experiencing early signs of inadequate oxygenation. Which clinical manifestation can the nurse expect to find?

A)Increased energy
B)New-onset confusion
C)Elevated blood glucose
D)Respiratory rate of 18

Question 10

The nurse is concerned about medication safety for a patient with confusion. Which action should the nurse recommend be included in the patient's plan of care to address this issue?

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

Question 11

A 70-year-old patient asks what can be done to protect his hearing. What should the nurse recommend to the patient?

A)Clean the ears of ear wax every day.
B)Cover the ears if loud noises are expected.
C)Have a hearing test performed twice a year.
D)Raise the volume on televisions and radios in the home.

Question 12

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

A)Osteoporosis
B)Eroded cartilage
C)Thickening of bone
D)Increased flexibility
E)Shortening in height 6.Increasing bone density

Question 13

The nurse is making a home health visit to a frail, but healthy 86-year-old patient. The nurse assesses a heart rate of 104 beats/minute. What action should the nurse take?

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

Question 14

The nurse is teaching a class about muscular age-related changes. Which should the nurse include in her education? (Select all that apply.)

A)Increased elasticity of tendons
B)Decreased muscle tone
C)Increased muscle mass
D)Slower muscle response
E)Decreased elasticity of ligaments

Question 15

The nurse is caring for a group of older adult patients. Which patient should the nurse see first?

A)A patient awaiting education for foot care
B)A patient with a reduced gag reflex
C)A patient who just received a pneumonia vaccination
D)A patient reporting constipation

Question 16

The nurse is caring for a group of older adult patients. Which patient is at highest risk for developing delirium?

A)A patient with autism attending outpatient support groups
B)A patient with a family history of dementia
C)A patient who is in the intensive care unit following hip surgery
D)A patient attending self-care seminars at the senior center

Question 17

The nurse is providing care to a person who has difficulty hearing high-pitched tones. Which action should the nurse take when caring for this patient?

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

Question 18

The nurse is teaching an older adult about methods to avoid constipation. Which statement made by the patient indicates a need for further teaching?

A)"I try to drink eight glasses of water each day."
B)"I go walking for 30 minutes every day."
C)"I take a suppository and enema daily."
D)"My spouse bought me some high-fiber foods."

Question 19

The nurse is caring for an older adult who has normal fine tremors of the hand. The nurse knows that which can cause these tremors to increase?

A)Overeating
B)Depression
C)Heat
D)Activity

Question 20

The nurse is teaching a patient with neuropathy about foot care. Which statement made by the patient indicates a need for further teaching?

A)"I should examine my feet once per week for any sores."
B)"I will wear tennis shoes when working outside."
C)"I should avoid putting lotion between my toes."
D)"I need to ask my podiatrist to treat the corn on my foot."

Question 21

The nurse is contributing to a staff education program to prevent falls in the older population. What should the nurse include as areas to assess for fall prevention? (Select all that apply.)

A)Use of alcohol
B)History of falls
C)Medication side effects
D)Pressure sore development
E)Gait and balance screening

Question 22

The nurse is caring for an older adult who received 2 liters of IV fluid and now has edema of the lower extremities. Which interventions should the nurse implement? (Select all that apply.)

A)Administer another liter of IV fluid.
B)Apply compression stockings.
C)Notify the HCP.
D)Elevate the lower extremities.
E)Encourage ambulation.

Question 23

The nurse is identifying ways to ensure environmental safety for an older patient. Which actions should the nurse recommend for this patient's plan of care? (Select all that apply.)

A)Place call light within reach.
B)Demonstrate confidence during care.
C)Ask for permission before moving items.
D)Return items to patient's preferred location.
E)Plan ahead and communicate plans to patient.

Question 24

The nurse is caring for a patient who reports an alteration in taste. When reviewing the health history, the nurse notes which contributing factors to altered taste? (Select all that apply.)

A)Periodontal disease
B)Loratadine (Claritin)
C)Smokes pack per day
D)Well-fitting dentures
E)Meticulous oral care

Question 25

The nurse is teaching a patient at risk for osteoporosis about foods high in calcium. Which food choices made by the patient indicate an understanding of the teaching? (Select all that apply.)

A)1/2 cup of spinach
B)One small chicken breast
C)2 ounces of cheese
D)1 cup of low-fat milk
E)1/2 cup of black beans
F)3/4 cup of yogurt