Deck 27: Assessing the Older Adult

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.

Answer 1

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?
1)Slight bulging along the lower eyelids
2)Reduced perspiration
3)Reduced sebum production
4)Large white spots on the upper arms and trunk

Answer 2

4

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?
1)Assess the client's sleep patterns.
2)Encourage the client to begin to take a nap each day.
3)Encourage the client to alter the evening routine to reduce potential evening stressors.
4)Ask the healthcare provider to prescribe a medication designed to help the client sleep better.

Answer 3

1

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?
1)The nurse has requested that the client put on a cotton gown prior to the interview.
2)The nurse seats the client so that the light from the window faces the client with the nurse's back to the window.
3)The nurse addresses the client by her first name.
4)The nurse maintains eye contact;both nurse and client are seated.
5)During the interview,the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further.

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?
1)Tenting noted on dorsal aspect of client's hand when skin turgor was assessed.
2)Client has produced 175 milliliters over the last 8 hours.
3)Dentures are loose,small sores noted in oral mucosa.
4)Healthcare provider notes client exhibiting xerostomia.
5)Client's apical heart rate is 82 beats per minute.

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?
1)Xanthelasma
2)Pingueculae
3)Pterygium
4)Arcus senilis

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.
1)"Do you have any concerns about your memory?" Choice
2)"It looks like you've lost some weight since your healthcare provider last saw you.How are your teeth?" Choice
3)"Can you tell me about how well you are sleeping?" Choice
4)"Have you had any problems holding your urine?" Choice
5)"I noticed that you have a large bruise on your knee.Did you fall recently?"

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?
1)Document the findings as normal.
2)Assess the pupils to determine if they equal,round,reactive to light,and accommodation.
3)Inquire about any past history of hypertension.
4)Inquire about a history of diabetes.

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?
1)The client's son states,"Sometimes,she seems a little slow to respond during our conversations,like she's taking longer to process the information."
2)The client's bowel sounds are hyperactive in all four quadrants.
3)The client states,"I just don't have the energy that I once did.Most of the time I just feel like sitting down."
4)The client's apical heart rate is 106 beats per minute.
5)The client's respiratory rate is 10 breaths per minute.

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

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?
1)Serum glucose level is 232 mg/dL.
2)White blood cells 32,000 mm³.
3)The client states,"I take Lasix every morning because I have some heart problems."
4)The client states,"I have diabetes but I don't check my blood sugar levels as often as I should."
5)Platelets 92,000 mm³.

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?
1)"The body's bones become increasingly brittle and lose density with aging."
2)"Unfortunately,this may signal a serious underlying health problem."
3)"You should discuss this with your healthcare provider."
4)"There is no good explanation for what has happened to you."

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?
1)The client has been voluntarily restricting fluid intake due to issues with incontinence.
2)The client's skin has become thinner and drier,and the client exhibits signs of pruritis.
3)The client has decreased sebum production.
4)The gastric emptying time is delayed.
5)The client has diminished calcium absorption.

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?
1)"I've been so lonely since my wife,Maggie,passed away 2 months ago."
2)"My mother had a history of depression."
3)"I was diagnosed with chronic bronchitis 4 years ago."
4)"My son visits at least once a week and takes care of my financial stuff."
5)"I visit my sister every Monday and she makes me dinner."

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?
1)"I take something to help my stomach not make so much acid."
2)"I've been taking something for depression ever since our son died 4 years ago."
3)"Sometimes,I have to take a medication to help me sleep at night."
4)"I've had trouble with my blood pressure for years and take a medication to keep it down."
5)"I take a baby aspirin every day."

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?
1)"The Mini-Mental State Examination seems like a quick way to determine how well the client is able to reason."
2)"It's best to go ahead and give the Mini-Mental State Examination at the beginning of the focused interview because the client's mind will be fresh."
3)"It sounds like some older people get really nervous about these cognitive reasoning examinations because they worry they may be developing problems."
4)"The Mini-Mental State Examination is really easy to perform so it's important to remember that the client may have just gone through these types of questions the day before with another healthcare provider."

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?
1)"Senescence refers to changes that organisms experience as they age."
2)"Error theories point to stressors as the cause for aging."
3)"Error theories indicate that aging follows a timetable."
4)"There are several major theories of aging: programmed,error,and those theories that overlap."

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?
1)"I know I drink too much alcohol,but why stop now?"
2)"I've smoked 1-2 packs per day for the last 48 years."
3)"My sister was a 'sun-worshipper,' but I avoided the sun because it made my skin feel too dry."
4)"I used to work as a radiology tech."
5)"I was exposed to Agent Orange during the war."

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?
1)Obtain an ophthalmology referral.
2)Inquire to determine if the client has any risk factors for glaucoma.
3)Inquire to determine if the client has a history of diabetes.
4)Document the findings as normal.

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?
1)Bursitis
2)Gouty arthritis
3)Osteoarthritis
4)Rheumatoid arthritis

Question 21

The nurse is conducting a focused interview with an elderly client.The client states that she is concerned about "All of these little bumps on my neck and chest." Moist,brownish,wart-like lesions are noted on the neck and chest.The nurse would suspect which of the following conditions?
1)Cherry angiomas
2)Acrochordons
3)Actinic keratoses
4)Seborrhea keratoses

Question 22

The nurse is examining the oral cavity of an elderly client with complaints of mouth soreness.Red,cracked skin is noted at each corner of the mouth.Which of the following findings is most consistent with this client's condition?
1)The client states,"I have an appointment next week to get some better fitting dentures."
2)Red blood cell count is 6.2 million/ mm³.
3)The healthcare provider has diagnosed the client with cheilitis.
4)The client suffered from a cerebrovascular accident last May.
5)The result of the culture of the drainage is that candida albicans is present.

Question 23

The nurse is performing a focused interview with an elderly client.The client reports the presence of painful sores.The client states,"They wrap around in lines from my back toward my belly." During the assessment of the client's skin,the nurse discovers the sores are reddened vesicles.The nurse would suspect which of the following conditions?
1)Ecchymoses
2)Herpes zoster
3)Petechiae
4)Purpura

Question 24

The nurse is educating a client who has been diagnosed with stress incontinence.The nurse should include which of the following in the teaching care plan?
1)The client should maintain an ideal body weight.
2)The client should limit fluid intake to 4 glasses a day.
3)The client should try to void on a regular schedule.
4)The client should perform pelvic muscle strengthening exercises.
5)The client should increase fiber intake.

Question 25

The nurse is assessing the vital signs of an elderly client and obtains a temperature of 97.1 degrees Fahrenheit.Which of the following actions is most appropriate?
1)Document the finding as normal.
2)Encourage the client to drink warm fluids.
3)Request to turn up the client's thermostat.
4)Apply warmed blankets to the client.

Question 26

A 76-year-old client presents to the outpatient clinic with complaints consistent with influenza.During the interaction,the nurse notes the client's clothing appears too large.Which of the following actions by the nurse should be performed first?
1)Document the findings.
2)Report the findings to the healthcare provider.
3)Contact social services.
4)Engage the client in a discussion regarding dietary practices.

Question 27

During a routine physical examination,a client reports a close relative recently died from complications related to heart disease.The client requests information about her own risk for the development of heart disease.The nurse reviews the client's risk factors for the development of the disease.Which of the following risk factors associated with heart disease is modifiable?
1)Father died from coronary artery disease.
2)Client is 5′4″ and weighs 282 pounds.
3)Client is 73 years old.
4)Client is a female.

Question 28

While performing an integumentary assessment on a 72-year-old male client,the nurse notes the presence of tenting.Which of the following actions is indicated by the nurse first?
1)The nurse will need to notify the healthcare provider.
2)The rate of the intravenous infusion will need to be increased to combat dehydration.
3)A lung assessment will need to be performed.
4)No action is indicated.

Question 29

During the assessment of a 66-year-old client's apical pulse,the nurse notes the presence of a faint murmur.The nurse documents that a grade 3 murmur can be auscultated without radiation.The client denies ever having been diagnosed with any heart problems.Based upon your knowledge,which of the following statements is most correct?
1)The client is demonstrating mitral calcifications.
2)The client has valvular stenosis.
3)The client is presenting with the normal changes of aging.
4)The client has clinical manifestations associated with aortic calcifications.

Question 30

The nurse hears a bruit when auscultating the right carotid artery of an elderly client.The nurse would choose which of the following actions next?
1)Auscultate the heart for murmurs.
2)Obtain a surgical consult.
3)Document the findings as normal.
4)Assess for jugular vein distention.

Question 31

The nurse is planning an educational program for new nurses regarding healthcare needs of the elderly.Which of the following should be included?
1)Depression is not a common problem for the elderly.
2)Influenza vaccines should be given to most elderly clients.
3)Burns are the most common type of injuries experienced by older adults.
4)Pneumonia is the most common cause of death in older adults.

Question 32

The client is visiting the outpatient clinic for a routine blood pressure assessment.While speaking with the nurse,the client states,"I'm getting old and everything hurts." Which statement or question by the nurse is most appropriate?
1)"Tell me more about your pain."
2)"Normal aging can be quite painful."
3)"You must have osteoarthritis."
4)"What medications do you take?"

Question 33

The nurse is counseling an elderly couple and encourages both of them to receive the pneumococcal vaccine.The nurse would understand that further teaching is necessary if which of the following statements was made by one of the clients?
1)"We will need to get vaccinated each year."
2)"The vaccine is recommended for us because we are both over the age of 6
3)"The vaccine does not protect us against all types of pneumonia."
4)"We should get the influenza vaccine and the pneumonia vaccine."

Question 34

The daughter of an elderly client reports that the client is experiencing a decrease in hearing ability in the client's right ear.The nurse suspects a conductive hearing loss due to the presence of dried wax in the right ear canal.In which of the following ways can the nurse best validate this suspicion?
1)Perform the Weber test.
2)Perform the Rinne test.
3)Examine the external ear.
4)Perform the whisper test.

Question 35

The older adult client had been experiencing nocturia and decided to voluntarily restrict fluid intake during the day to help avoid the problem.Which of the following statements by the client's daughter indicates that the client may be experiencing a complication associated with this practice?
1)"He fell and hit his head because he's been so unsteady."
2)"His stools have started to look loose and bloody."
3)"I think he's beginning to develop Alzheimer's disease because he can get so confused."
4)"I don't think he's had a bowel movement since 1 week ago."
5)"His urine looks cloudy and dark."

Question 36

The nurse is assessing the elderly client's respiratory system.Upon auscultation,rales are detected bilaterally in both lower lobes.Scattered rales are heard in the upper lung fields.These adventitious sounds do not clear with a cough.The nurse percusses the client's lung fields and determines the presence of dull sounds.The nurse would correctly suspect which of the following?
1)Emphysema
2)Pulmonary edema
3)End-stage chronic obstructive pulmonary disease
4)Pulmonary fibrosis