Deck 18: Assessing the Older Adult

Question 1

There are several challenges for gathering a health history on an older adult patient. Which is true regarding the majority of older adults?

A) They are ready to die.
B) They want attention for their symptoms.
C) They are not truthful about their symptoms.
D) They have multiple health problems.

Answer 1

They have multiple health problems.

Question 2

Which is the most common cause of limited range of motion (ROM) in the older adult population?

A) Rheumatoid arthritis (RA)
B) Osteoarthritis
C) Gout
D) Fractures

Answer 2

Osteoarthritis

Question 3

Which nursing action is appropriate when conducting a health history interview for an older adult patient?

A) Speaking slowly with a lower pitch
B) Allowing less time than would be required for a younger patient
C) Asking several questions before allowing the patient to respond
D) Standing while the patient sits in a chair on the opposite side of the room

Answer 3

Speaking slowly with a lower pitch

Question 4

The nurse is providing care to an older adult patient diagnosed with severe multiple sclerosis (MS). The patient has the urge to urinate but is often incontinent because of an inability to navigate to the toilet. Which type of incontinence is the patient experiencing?

A) Stress
B) Overflow
C) Urge
D) Functional

Question 5

Which is an unlikely cause for conductive hearing loss that may occur during the aging process?

A) Impacted cerumen
B) Degeneration of the middle ear bones
C) Tympanic membrane thickening
D) Organ of Corti atrophy

Question 6

The nurse is using the Katz Index of Activities of Daily Living during the assessment of an older adult patient. Which finding indicates the patient is independent?

A) The patient is able to get in and out of the tub without assistance.
B) The patient gets dressed but needs help with tying the shoes.
C) The patient does not get out of bed.
D) The patient feeds self but receives assistance with buttering bread.

Question 7

Which is true about older adults?

A) They have short medical histories.
B) They believe old wives' tales more than traditional medicine.
C) They may not report all symptoms as significant.
D) All of the above.

Question 8

Which is the most likely cause of wrinkles in the skin of older adults?

A) Decreased collagen and subcutaneous fat
B) Atrophy of sweat glands
C) Decline in fibroblast proliferation
D) Decreased vascularity

Question 9

The nurse is conducting a health history interview, and the patient asks the nurse what an advance directive is. Which response by the nurse is appropriate?

A) "Advance directives ensure end-of-life care is comfort measures only."
B) "Advance directives ensure healthcare wishes are carried out."
C) "Advance directives ensure acute illness will be treated aggressively."
D) "Advance directives ensure treatment will be withheld for life-threatening injury or illness."

Question 10

The nurse conducts a Barthel Index assessment for an older adult patient who receives a score of 52. What does this score indicate?

A) Patient has minimal dementia.
B) Patient's respiratory effort is compromised.
C) Patient has decreased ROM.
D) Patient needs assistance with activities of daily living (ADLs).

Question 11

Which is a common back problem in older adult patients that the nurse will need to assess for during the physical assessment process?

A) Scoliosis
B) Lordosis
C) Kyphosis
D) Spondyloarthrosis

Question 12

Which is the most commonly held belief about older adults that transcends most cultures?

A) Older people are to be respected and revered.
B) Old age is a state of mind.
C) Older people have an important role in teaching and keeping rituals.
D) Older people are respected and are believed to become wiser with age.

Question 13

During the health history, an older adult patient has difficulty answering the questions. Which is the priority action by the nurse?

A) Ask a family member for the answers.
B) Speak louder and face the patient.
C) Speak more slowly and wait for a response.
D) Use a written questionnaire.

Question 14

An older adult female patient presents in the emergency department (ED) with a fever and newly developed incontinence. The patient denies pain on urination but states, "I feel like I have to go more often and I don't always make it to the toilet on time." Based on this data, which nursing action is the priority for this patient?

A) Checking reflexes
B) Assessing for flank pain
C) Inspecting the perineum
D) Assessing the rectum

Question 15

When assessing the sleep patterns of an older adult patient, which should the nurse take into consideration?

A) Short stage 1 and 2
B) Increased rapid eye movement (REM) sleep
C) Decreased stage 3 and 4
D) Absent REM

Question 16

Which is likely to cause orthostatic hypotension in older adult patients?

A) Decreased baroreceptor response
B) Decreased compliance/stiffer vessels
C) Increased peripheral vascular resistance
D) Rigid arteries

Question 17

Which is the most appropriate action by the nurse before beginning the health history when assessing an older adult patient?

A) Reviewing past 10 years of medical records
B) Doing a complete physical assessment
C) Doing a review of systems
D) Assessing orientation and mental status

Question 18

An older adult patient reports a decreased range in vision, particularly peripheral vision. Which is the most likely causes for this assessment finding?

A) An increase in vitreous debris
B) Atrophy of ciliary muscles
C) Decreased corneal sensitivity
D) Decreased pupil size

Question 19

Which is the cause of arcus senilis?

A) Decreased aqueous humor fluid
B) Increased vitreous debris
C) Increased lipid deposits around cornea
D) Increased density of lens

Question 20

The nurse is providing care to an older adult patient who states, "I have lived a good life and I know that I have done my best." Which stage of Erikson's theory does this statement represent?

A) Autonomy versus doubt
B) Integrity versus despair
C) Generativity versus stagnation
D) Intimacy versus isolation

Question 21

The nurse is conducting a physical assessment for a patient who had a stroke and is having difficulty swallowing. Which term will the nurse use when documenting this finding?

A) Aphasia
B) Dysphagia
C) Atrophy
D) Ectropion

Question 22

The nurse is conducting a physical assessment and notes senile entropion. Based on this data, which is the patient at risk for developing?

A) Dry eye
B) Conjunctivitis
C) Corneal abrasion
D) Blindness

Question 23

Which technique will the nurse suggest regarding dental hygiene for the older adult patient because of decreased dentine and gingival recession?

A) Brushing with a stiff toothbrush
B) Brushing five times a day with a hard toothbrush
C) Brushing with a soft toothbrush and flossing
D) Rinsing with mouthwash

Question 24

The nurse is assessing an older adult patient who is bedridden. The nurse notes some muscle wasting. Which term will the nurse use when documenting this finding?

A) Atrophy
B) Varicosity
C) Melanocyte
D) Ectropion

Question 25

The nurse finds a dowager's hump when conducting a physical assessment for an older adult patient. Which term will the nurse use when documenting this assessment finding?

A) Scoliosis
B) Pruritis
C) Varicosities
D) Kyphosis

Question 26

The nurse is assessing the skin of an older adult patient and notes skin tags. Which term will the nurse use when documenting this finding in the medical record?

A) Lentigines
B) Ichthyosis
C) Acrochordons
D) Varicosities

Question 27

The nurse is conducting a physical assessment for an older adult patient. The nurse notes that the patient has yellow, thickened nails. Which is the most likely cause for this finding?

A) This is an expected finding based on the patient's age.
B) This finding indicates liver dysfunction.
C) The finding indicates a fungal infection.
D) The finding indicates poor renal function.

Question 28

Which change that occurs with aging is responsible for graying of hair color?

A) Decrease in melanocytes
B) Decreased hair follicle density
C) Decreased blood supply to hair
D) Increased lipid deposits

Question 29

Which change caused by aging puts the older adult at greater risk than younger adults for pneumonia?

A) Thickening of alveoli
B) Atrophy of cilia
C) Decreased elastic recoil
D) All of the above

Question 30

When conducting a peripheral vascular assessment for an older adult patient, the nurse notes what looks like twisted veins. Which term will the nurse use when documenting this finding?

A) Gynecomastia
B) Varicosities
C) Melanocytes
D) Ectropion

Question 31

An older patient with peripheral-vascular disease reports foot pain. Which color does the nurse expect when inspecting the patient's feet?

A) Pink
B) Red
C) Yellow
D) Blue

Question 32

The nurse is conducting a health history assessment for an older adult patient. The patient states, "I have to get up and use the bathroom several times each night." Which term will the nurse use when documenting this assessment finding?

A) Nocturia
B) Dysphagia
C) Aphasia
D) Pruritis

Question 33

The nurse is reviewing the medical record for an older adult patient. The patient is noted to have an opaque white ring around the periphery of the cornea. Which is the medical term that was used for this finding in the medical record?

A) Kyphosis
B) Arcus senilis
C) Varicosities
D) Melanocytes

Question 34

The nurse conducts a cranial nerve (CN) assessment for an older adult patient. Which finding indicates decreased functioning of CN II?

A) Decreased sense of smell
B) Decreased visual acuity
C) Decreased reaction to light
D) Decreased taste

Question 35

The nurse is assessing an older adult patient who had a stroke. Which term will the nurse use to describe the patient's impaired speech communication when documenting the assessment findings?

A) Atrophy
B) Gynecomastia
C) Aphasia
D) Ectropion

Question 36

The nurse is assessing an older adult patient who reports dry skin and itching. Which term will the nurse use when documenting the occurrence of itching?

A) Pruritus
B) Ectropion
C) Varicosity
D) Atrophy

Question 37

The nurse is assessing an older adult male patient who has enlarged mammary glands. Which term will the nurse use when documenting this finding?

A) Nocturia
B) Gynecomastia
C) Arcus senilis
D) Ectropion