Question 1

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?

Accepted Answer

Seborrheic keratoses are brownish, wart-like lesions that commonly occur on the neck and chest of elderly individuals. Cherry angiomas are small, red papules that commonly occur on the trunk and extremities. Acrochordons, or skin tags, are small, soft, skin-colored growths that commonly occur in skin folds. Actinic keratoses are scaly, rough patches of skin that commonly occur on sun-exposed areas of the skin.

Question 2

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?

Accepted Answer

The answer of The nurse is examining the oral cavity...

Question 3

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?

Accepted Answer

The description of painful, reddened vesicles that wrap around in lines is consistent with the presentation of herpes zoster, commonly known as shingles. Ecchymoses, petechiae, and purpura would present differently and are not indicated by the client's description.

Question 4

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?

Accepted Answer

The answer of The nurse is educating a client who...

Question 5

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?

Accepted Answer

A temperature of 97.1 degrees Fahrenheit is within the normal range for an elderly client. Therefore, the most appropriate action is to document the finding as normal. Encouraging warm fluids or applying warmed blankets may be appropriate if the client is experiencing hypothermia, but this is not indicated based on the temperature reading alone. Requesting to turn up the client's thermostat may also not be necessary if the client is comfortable at their current temperature.

Question 6

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?

Accepted Answer

Engaging the client in a discussion regarding dietary practices is the first step the nurse should take. This approach allows for an assessment of potential issues such as unintentional weight loss, malnutrition, or eating disorders, which could be indicated by the client's clothing appearing too large. It's a direct way to gather more information about the client's health status and lifestyle, which is essential before considering further actions.

Question 7

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?

Accepted Answer

Obesity is a modifiable risk factor for the development of heart disease. The other risk factors listed (family history, age, and gender) are non-modifiable.

Question 8

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?

Accepted Answer

The answer of While performing an integumentary assessment on a...

Question 9

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?

Accepted Answer

A grade 3 murmur without radiation is often a normal finding in older adults and can be related to the normal changes of aging rather than a pathological condition such as mitral calcifications, valvular stenosis, or aortic calcifications. However, it is important to further assess the client and monitor for any changes in the murmur or development of other symptoms.

Question 10

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?

Accepted Answer

A bruit heard in the carotid artery may indicate narrowing or blockage of the artery, which can lead to a stroke. The nurse should assess the client for any signs or symptoms of a stroke and auscultate the heart for murmurs, which may also indicate cardiovascular problems. Obtaining a surgical consult or assessing for jugular vein distention may not be necessary at this time. Documenting the findings as normal is not appropriate as a bruit is an abnormal finding.

Question 11

The nurse is planning an educational program for new nurses regarding healthcare needs of the elderly.Which of the following should be included?

Accepted Answer

Influenza vaccines are recommended for most elderly clients to prevent influenza, which can be particularly severe in older adults. This is a key aspect of preventive healthcare for the elderly.

Question 12

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?

Accepted Answer

The most appropriate response to the client's statement would be to ask for more information about their pain in order to gather more information and potentially address any concerns or issues the client may have. Options B and C may be dismissive of the client's concerns and option D is not relevant to the client's statement about pain.

Question 13

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?

Accepted Answer

The pneumococcal vaccine is only required once every 5 years for people over the age of 65, so yearly vaccination is not necessary. The other statements are accurate and show understanding of the information the nurse provided.

Question 14

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?

Accepted Answer

The answer of The daughter of an elderly client reports...

Question 15

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?

Accepted Answer

Voluntary fluid restriction can lead to dehydration, which may cause symptoms such as unsteadiness and falls (A), confusion (C), constipation (D), and concentrated, dark urine (E). Loose and bloody stools (B) are not typically associated with dehydration and could indicate a different health issue.

Question 16

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?

Accepted Answer

Bilateral rales in both lower lobes and scattered rales in the upper lung fields, along with dull sounds upon percussion, suggest the presence of pulmonary edema. This is likely caused by fluid accumulation in the lungs, which can be a complication of heart failure or other conditions that affect the heart's ability to pump blood effectively. The other options - emphysema, end-stage COPD, and pulmonary fibrosis - may also cause respiratory symptoms, but typically do not produce the same auscultatory findings as those seen in pulmonary edema.

Quiz 27: Assessing the Older Adult