Deck 15: Nursing Care of Older Adult Patients

Question 1

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

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

Answer 1

Decreased height

Question 2

The nurse is reinforcing teaching provided to an older patient on how to safely rise from a seated to a standing position.Which age-related change does the nurse use to emphasize the need to change positions gradually for safety?

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

Answer 2

Decreased circulatory efficiency

Question 3

The nurse is caring for a patient with Alzheimer's disease.Which environment should the nurse provide to decrease the patient's symptoms?

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

Answer 3

A familiar, non-stimulating environment

Question 4

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) Increased muscular retention of heat
D) Decreased muscular retention of heat

Question 5

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 6

The nurse is collecting patient data.Which findings should the nurse expect because of a decrease in melanin?

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

Question 7

The nurse is making a home health visit to a frail but basically 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 8

The nurse is making recommendations to the plan of care for a patient who has limited mobility.On which skin condition should the nurse focus as the greatest risk for this patient?

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

Question 9

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

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

Question 10

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 11

The home health nurse is visiting an older patient who fears becoming incontinent and reports restricting personal fluid intake to prevent urinary leakage.Which action should the nurse take?

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

Question 12

Which measure should the nurse recommend for inclusion in the plan of care for an older adult who has a nursing diagnosis of ineffective sexual patterns?

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

Question 13

The nurse is reinforcing teaching with an older patient.When interacting with the patient the nurse should recognize which effect of aging on short- and long-term memory?

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

Question 14

The nurse has reinforced teaching about age-related mouth changes.Which client statement indicates a correct understanding of the cause of tooth loss in an older adult?

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

Question 15

The home health nurse is visiting an older adult who reports nocturia.Which night-light bulb color should the nurse suggest to increase safety and enable the patient to see better at night?

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

Question 16

The nurse has been providing interventions to address an older patient's nutritional status.Which observation should the nurse use to determine if nursing care has been effective?

A) Appetite
B) Skin turgor
C) Body weight
D) Urine output

Question 17

The nurse is making recommendations to an older patient's plan of care for safety measures.Which musculoskeletal change should the nurse consider as contributing to a reduction in the older adult's ability to safely perform routine tasks?

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

Question 18

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 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 action should the nurse take first?

A) File the nails.
B) Dry feet well.
C) Apply lotion to the feet.
D) Soak feet in warm water.

Question 20

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 21

The nurse is contributing to the plan of care for an older adult.What should the nurse recognize as being age-related changes in the cardiovascular system? (Select all that apply.)

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

Question 22

The nurse is contributing to the plan of care for an older adult.Which should the nurse recognize as being age-related changes of the integumentary system? (Select all that apply.)

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

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 preferred location.
E) Plan ahead and communicate plans to patient.

Question 24

The nurse is evaluating the skin of an older patient who has been lying in bed for most of the day.How long would it take a pressure ulcer to begin to form in this patient?

A) 5 minutes
B) 10 minutes
C) 15 minutes
D) 20 minutes

Question 25

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 26

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
F) Increasing bone density

Question 27

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
F) Wearing oxygen at 2 L per nasal cannula

Question 28

The nurse is assisting in the preparation of a teaching session for older patients on respiratory health.What information should the nurse suggest be included in this program? (Select all that apply.)

A) Instruct regarding the importance of frequent position changes to stimulate all lung lobes
B) Recommend deep breathing and coughing as part of a daily exercise program
C) Encourage receiving pneumonia vaccination and annual influenza vaccination
D) Suggest taking an over-the-counter expectorant every day to help remove lung secretions
E) Remind that life-long habits and exposure to respiratory irritants may influence breathing

Question 29

The nurse has finished drawing blood from an older patient.How long should the nurse apply pressure to the puncture site?

A) 2 minutes
B) 3 minutes
C) 4 minutes
D) 5 minutes

Question 30

The nurse is contributing to a staff education program on grooming techniques for older adults.Which methods should the nurse recommend to reduce the potential for nail infections? (Select all that apply.)

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

Question 31

The nurse is administering medications to a group of older residents and monitors them for adverse reactions.In which way should the nurse recognize that a reduction in liver enzyme production effects medication metabolism in the older patient?

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

Question 32

An older patient with diabetes mellitus reports difficulty sleeping.Which manifestations should the nurse recognize as being related to sleep deprivation? (Select all that apply.)

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

Question 33

The nurse is reviewing the ages of assigned patients in a skilled nursing facility.Which patient age represents the fastest-growing segment of individuals in the United States?

A) 64
B) 70
C) 81
D) 87

Question 34

The nurse is concerned that an older patient is demonstrating signs of depression.What did the nurse observe to come to this conclusion? (Select all that apply.)

A) Difficulty sleeping
B) Change in behavior
C) Reminiscing about past events
D) Increase in physical complaints
E) Inability to recall events from a week ago

Question 35

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

Question 36

The nurse is identifying recommendations to help an older patient with sleeping needs.What should the nurse recognize as a sleeping pattern in the older adult?

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

Question 37

During a home visit,the nurse suspects that an older patient recovering from an acute illness is not taking medications as prescribed.What should the nurse assess to determine the patient's adherence to prescribed medications? (Select all that apply.)

A) Use of over-the-counter or herbal remedies
B) Pharmacy that filled the patient's prescriptions
C) Location of the medications in the patient's home
D) Frequency with which medication doses are being skipped
E) Frequency with which medications are being taken as prescribed

Question 38

During a visit to the wellness clinic,an older patient with arthritis asks what can be done to improve joint motion.What should the nurse suggest to this patient? (Select all that apply.)

A) Walk with an assistive device as needed.
B) Wear non-skid sturdy shoes when walking.
C) Perform range-of-motion exercises in warm water.
D) Consume a balanced diet rich in vitamin D and calcium.
E) Take prescribed anti-inflammatory medications before exercising.