Question 1

What data would the nurse expect to find when performing an assessment of a 90-year-old suspected of having an upper respiratory infection?

Accepted Answer

Confusion is a common symptom in older adults with upper respiratory infections and may indicate underlying issues such as dehydration or cognitive impairment. Fever and elevated white blood count may not be present in all cases, and increased fluid intake may be a preventative measure rather than a symptom.

Question 2

What is the best way to assess psychological status in an older adult?

Accepted Answer

Direct observation allows for an objective assessment of the older adult's psychological status, providing firsthand information on their behavior and mental state.

Question 3

What is the correct term for the difference between the apical pulse and the radial pulse?

Accepted Answer

The term for the difference between the apical pulse and the radial pulse is pulse deficit. This occurs when the heart is not effectively pumping blood to the peripheral arteries, resulting in a difference between the number of heartbeats heard at the apex of the heart versus the number of pulses felt at the radial artery. Pulse pressure refers to the difference between the systolic and diastolic blood pressures, pulse ratio is not a term used in this context, and pulse quality refers to the strength, rhythm, and regularity of the pulse.

Question 4

What statement would put the older woman most at ease during a health interview?

Accepted Answer

Offering the older woman the location of the bathroom and letting her know that there will be a break in about 30 minutes can reassure her that her comfort and needs are being considered during the interview process. Additionally, it can alleviate any potential anxiety or concern about not having access to a restroom during the interview. The other answer choices may increase her stress or discomfort.

Question 5

Which statement by the nurse would be the most appropriate at the beginning of the health interview?

Accepted Answer

Option A provides a professional greeting that includes the nurse's name and a brief explanation of what will happen during the interview, which helps establish rapport and sets a clear expectation for the patient. The other options either use informal language or skip over important introductory information.

Question 6

How should the nurse begin the health interview in order to most effectively build rapport with the patient?

Accepted Answer

Focusing on the problems that the patient sees as important helps in building rapport by showing empathy and understanding towards the patient's concerns, making them feel valued and heard.

Question 7

Which screening test should be performed annually in a 55-year-old woman?

Accepted Answer

Annual fecal occult blood testing is recommended for colorectal cancer screening in adults starting at age 50.

Question 8

The 94-year-old woman has come to the health assessment interview with her 70-year-old daughter, who answers all the interview questions for her mother. What response by the nurse would be the most effective?

Accepted Answer

It is important to encourage the patient to speak for themselves as they are the focus of the assessment. Directly addressing the patient will acknowledge their presence and allow them to participate in their own care. It is also a respectful approach that upholds the patient's dignity.

Question 9

When conducting a health assessment, which finding would be recorded as crackles?

Accepted Answer

Crackles are fine, short sounds typically heard in the lung bases on inspiration. Option B describes rhonchi, option C describes wheezes, and option D describes pleural friction rubs.

Question 10

What communication technique would be most helpful during the health interview?

Accepted Answer

Keeping questions simple is the most helpful communication technique during a health interview. Using medical terminology may confuse or intimidate the patient. Helping patients finish their sentences may skew their responses and not allow them to fully express their thoughts. Allowing patients to ramble may waste time and not yield relevant information.

Question 11

The nurse conducting a patient assessment records a seated blood pressure of 135/86. What standing blood pressure would be indicative of orthostatic hypotension?

Accepted Answer

Orthostatic hypotension is defined as a decrease in systolic blood pressure of at least 20 mm Hg or a decrease in diastolic blood pressure of at least 10 mm Hg within three minutes of standing when compared to blood pressure from the sitting or supine position. Choice D, 124/62, represents a decrease of more than 20 mm Hg systolic and more than 10 mm Hg diastolic from the seated blood pressure of 135/86, fitting the criteria for orthostatic hypotension.

Question 12

During the health interview, the older adult complains of vague physical gastrointestinal complaints, the inability to fall asleep, frequent periods of wakefulness during the night, and a decrease in appetite. What should the nurse inquire about?

Accepted Answer

The symptoms described by the older adult, such as vague physical gastrointestinal complaints, difficulty falling asleep, frequent wakefulness during the night, and decreased appetite, can be indicative of depression, especially in older adults who may present with more somatic complaints rather than typical symptoms of sadness or hopelessness.

Question 13

The nurse charts, "Patient stated pain is at a level of 8 on a scale of 1 to 10 and that he is still nauseated. Patient complains of feeling cold and has an oral temperature of 97.8 $\degree$." What information would be considered objective findings?

Accepted Answer

The oral temperature measurement is an objective finding because it is factual and observable. The other information, such as the patient's pain level, presence of nausea, and sense of cold, are subjective findings because they are based on the patient's own perception and cannot be directly observed by the nurse.

Question 14

What is the purpose of a health screening?

Accepted Answer

The purpose of a health screening is to identify persons with unmet health needs who may need a referral for further evaluation and treatment. While some health screenings may collect data for research, and may be used to assess local health needs for the Public Health Department, the primary goal of a health screening is to identify health concerns in individuals so that appropriate treatment can be provided.

Question 15

By what means can a health screening be conducted? (Select all that apply.)

Accepted Answer

Health screenings can be conducted by health professionals, through telephone interviews, using telecommunication devices, via pen and paper surveys, and by trained laypersons.

Question 16

What special precautions should the nurse take during the physical exam of an 86-year-old woman?

Accepted Answer

An 86-year-old woman may be more susceptible to feeling chilled during a physical exam due to decreased metabolic rate and thinner skin. Therefore, the nurse should take special precautions to ensure the patient is adequately covered and comfortable during the exam to prevent her from becoming chilled. Weighing the patient without clothing and giving fluids before the exam may be important aspects of the exam, but they are not specific to an 86-year-old woman. Elevating the patient's head while lying in a supine position is not necessary unless indicated for medical reasons.

Question 17

The nurse explains that the Minimum Data Set (MDS) 3.0 used in extended-care facilities is designed to

Accepted Answer

The purpose of MDS 3.0 is to make assessment processes more consistent in extended-care facilities. It does not identify ethnic populations or group residents into activity levels, nor does it necessarily organize information relative to diagnostic categories.

Question 18

Where would the nurse place the head of the stethoscope when assessing an apical pulse?

Accepted Answer

The apical pulse is best assessed at the fifth intercostal space at the midclavicular line, which corresponds to the location of the apex of the heart. This is where the heart's beat can be most accurately auscultated.

Question 19

What type of thermometer would be the best choice when assessing the temperature of an older adult?

Accepted Answer

Electronic thermometers are quick and non-invasive, making them suitable for older adults who may have difficulty holding a thermometer in place for a long time or may have fragile mucous membranes.

Question 20

An 85-year-old man accompanied by his son is unable to recall the medications that he is presently taking. What would be the most appropriate response by the nurse?

Accepted Answer

It would be appropriate for the nurse to ask the son for the medication information since the elderly man is unable to recall his own medication. The son may have knowledge of the medications his father has been taking, which can assist the healthcare team in providing appropriate care. Asking the question again or rephrasing it may not necessarily yield different results, and leaving that part of the health history blank would hinder the provision of proper care.

Quiz 8: Health Assessment of Older Adults

What data would the nurse expect to find when performing an assessment of a 90-year-old suspected of having an upper respiratory infection?

What is the best way to assess psychological status in an older adult?

What is the correct term for the difference between the apical pulse and the radial pulse?

What statement would put the older woman most at ease during a health interview?

Which statement by the nurse would be the most appropriate at the beginning of the health interview?

How should the nurse begin the health interview in order to most effectively build rapport with the patient?

Which screening test should be performed annually in a 55-year-old woman?

The 94-year-old woman has come to the health assessment interview with her 70-year-old daughter, who answers all the interview questions for her mother. What response by the nurse would be the most effective?

When conducting a health assessment, which finding would be recorded as crackles?

What communication technique would be most helpful during the health interview?

The nurse conducting a patient assessment records a seated blood pressure of 135/86. What standing blood pressure would be indicative of orthostatic hypotension?

During the health interview, the older adult complains of vague physical gastrointestinal complaints, the inability to fall asleep, frequent periods of wakefulness during the night, and a decrease in appetite. What should the nurse inquire about?

The nurse charts, "Patient stated pain is at a level of 8 on a scale of 1 to 10 and that he is still nauseated. Patient complains of feeling cold and has an oral temperature of 97.8 $\degree$ ." What information would be considered objective findings?

What is the purpose of a health screening?

By what means can a health screening be conducted? (Select all that apply.)

What special precautions should the nurse take during the physical exam of an 86-year-old woman?

The nurse explains that the Minimum Data Set (MDS) 3.0 used in extended-care facilities is designed to

Where would the nurse place the head of the stethoscope when assessing an apical pulse?

What type of thermometer would be the best choice when assessing the temperature of an older adult?

An 85-year-old man accompanied by his son is unable to recall the medications that he is presently taking. What would be the most appropriate response by the nurse?

Quiz 8: Health Assessment of Older Adults

What data would the nurse expect to find when performing an assessment of a 90-year-old suspected of having an upper respiratory infection?

What is the best way to assess psychological status in an older adult?

What is the correct term for the difference between the apical pulse and the radial pulse?

What statement would put the older woman most at ease during a health interview?

Which statement by the nurse would be the most appropriate at the beginning of the health interview?

How should the nurse begin the health interview in order to most effectively build rapport with the patient?

Which screening test should be performed annually in a 55-year-old woman?

The 94-year-old woman has come to the health assessment interview with her 70-year-old daughter, who answers all the interview questions for her mother. What response by the nurse would be the most effective?

When conducting a health assessment, which finding would be recorded as crackles?

What communication technique would be most helpful during the health interview?

The nurse conducting a patient assessment records a seated blood pressure of 135/86. What standing blood pressure would be indicative of orthostatic hypotension?

During the health interview, the older adult complains of vague physical gastrointestinal complaints, the inability to fall asleep, frequent periods of wakefulness during the night, and a decrease in appetite. What should the nurse inquire about?

The nurse charts, "Patient stated pain is at a level of 8 on a scale of 1 to 10 and that he is still nauseated. Patient complains of feeling cold and has an oral temperature of 97.8 °\degree° ." What information would be considered objective findings?

What is the purpose of a health screening?

By what means can a health screening be conducted? (Select all that apply.)

What special precautions should the nurse take during the physical exam of an 86-year-old woman?

The nurse explains that the Minimum Data Set (MDS) 3.0 used in extended-care facilities is designed to

Where would the nurse place the head of the stethoscope when assessing an apical pulse?

What type of thermometer would be the best choice when assessing the temperature of an older adult?

An 85-year-old man accompanied by his son is unable to recall the medications that he is presently taking. What would be the most appropriate response by the nurse?

The nurse charts, "Patient stated pain is at a level of 8 on a scale of 1 to 10 and that he is still nauseated. Patient complains of feeling cold and has an oral temperature of 97.8 $\degree$ ." What information would be considered objective findings?