Chapter 27 My Nursing Test Banks

DAmico/Barbarito Health & Physical Assessment in Nursing, 2/e
Chapter 27

Question 1

Type: MCSA

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.

Correct Answer: 3

Rationale 1: The term senescence has become the preferred terminology to distinguish changes, such as graying hair, wrinkling of the skin and others, that have no impact on viability from those changes that create risks for disease, disability, and death.

Rationale 2: Error theories explain aging as the result of cellular damage in response to internal and external stressors.

Rationale 3: Programmed theories, not error theories, indicate that aging follows a timetable.

Rationale 4: The major categories of aging theories include programmed theories, error theories, and those that overlap.

Global Rationale: Programmed theories, not error theories, indicate that aging follows a timetable. The term senescence has become the preferred terminology to distinguish changes, such as graying hair, wrinkling of the skin and others, that have no impact on viability from those changes that create risks for disease, disability, and death. Error theories explain aging as the result of cellular damage in response to internal and external stressors. The major categories of aging theories include programmed theories, error theories, and those that overlap.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Evaluation

Learning Outcome: 27.1: Describe several theories of aging.

Question 2

Type: MCMA

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 clients skin may appear more damaged than another person this clients age?

Standard Text: Select all that apply.

1. I know I drink too much alcohol, but why stop now?

2. Ive smoked 12 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.

Correct Answer: 1,2,4,5

Rationale 1: I know I drink too much alcohol, but why stop now? Older clients who have exposed their bodies to the effects of alcohol will speed up the aging that occurs within their skin.

Rationale 2: Ive smoked 12 packs per day for the last 48 years. Clients who use nicotine will exhibit more effects of skin aging than their peers who do not smoke nicotine.

Rationale 3: My sister was a sun-worshipper, but I avoided the sun because it made my skin feel too dry. The clients sister may appear older due to the effects of the sun on her skin. The client avoided the sun and may not exhibit the skin effects of aging as much as her sister.

Rationale 4: I used to work as a radiology tech. Working around radiation can increase the skins aging.

Rationale 5: I was exposed to Agent Orange during the war. Older clients who have been exposed to chemicals used in warfare may look older than their stated age.

Global Rationale: Older clients who have exposed their bodies to the effects of alcohol will speed up the aging that occurs within their skin. Clients who use nicotine will exhibit more effects of skin aging than their peers who do not smoke nicotine. Working around radiation can increase the skins aging. The clients sister may appear older due to the effects of the sun on her skin. Older clients who have been exposed to chemicals used in warfare may look older than their stated age.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 3

Type: MCMA

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?

Standard Text: Select all that apply.

1. The client has been voluntarily restricting fluid intake due to issues with incontinence.

2. The clients 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.

Correct Answer: 1,2,3,4

Rationale 1: The client has been voluntarily restricting fluid intake due to issues with incontinence. The client who voluntarily restricts fluid intake may develop a urinary tract infection due to this practice.

Rationale 2: The clients skin has become thinner and drier, and the client exhibits signs of pruritis. The older clients skin is thinner, drier and the clients skin may feel itchy. When clients scratch their skin, they may break the skin and produce a portal of entry for pathogens.

Rationale 3: The client has decreased sebum production. Sebum is protective. It is produced by the sebaceous gland to oil the skin and protect the skin from pathogens.

Rationale 4: The gastric emptying time is delayed. Gastric emptying times are significantly slowed with aging, contributing to gastritis and peptic ulcers due to Helicobacter pylori infections.

Rationale 5: The client has diminished calcium absorption. The clients reduced calcium absorption contributes to osteoporosis, not necessarily an increased risk for infection. The client with osteoporosis has an increased risk of injuring the body after falling.

Global Rationale: The client who voluntarily restricts fluid intake may develop a urinary tract infection due to this practice. The older clients skin is thinner and drier, and the clients skin may feel itchy. Scratching increases the risk for skin breakdown providing a portal of entry for pathogens. Sebum is protective. It is produced by the sebaceous gland to oil the skin and protect the skin from pathogens. Gastric emptying times are significantly slowed with aging, causing feelings of premature fullness and contributing to gastritis and peptic ulcers due to Helicobacter pylori infections. The clients reduced calcium absorption contributes to osteoporosis, not necessarily an increased risk for infection. The client with osteoporosis has an increased risk of injuring the body after falling.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 4

Type: MCSA

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

Correct Answer: 1

Rationale 1: Xanthelasma are soft, yellow plaques on the lids at the inner canthus and are a part of normal aging, not related to vision or eye problems.

Rationale 2: Pingueculae are yellowish nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust. They may be on either side of the pupil.

Rationale 3: Pterygium is opacity of the bulbar conjunctiva that can grow over the cornea and block vision.

Rationale 4: Arcus senilis is a light gray or white ring surrounding the iris at the corneal margin due to the deposition of lipids. This is a common finding.

Global Rationale: Xanthelasma are soft, yellow plaques on the lids at the inner canthus and are a part of normal aging, not related to vision or eye problems. Pingueculae are yellowish nodules that are thickened areas of the bulbar conjunctiva caused by prolonged exposure to sun, wind, and dust. They may be on either side of the pupil. Pterygium is opacity of the bulbar conjunctiva that can grow over the cornea and block vision. Arcus senilis is a light gray or white ring surrounding the iris at the corneal margin due to the deposition of lipids. This is a common finding.

Cognitive Level: Understanding

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.2: Identify normal anatomical and Physiologic changes in older adults.

Question 5

Type: FIB

The nurse is assessing the older adult clients waist-to-hip ratio to determine the clients risk for developing hypertension. The clients hip circumference is 72 centimeters. The clients waist circumference is 81 centimeters. Calculate the clients waist-to-hip ratio. Round to the hundredths place.

Standard Text:

Correct Answer: 1.13

Rationale: The clients waist-to- hip ratio is 1.125 and when rounded to the hundredths place, it is 1.13. This clients waist-to-hip ratio is greater than 0.95. This client has an increased risk for developing hypertension.

Global Rationale:

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 6

Type: MCMA

The nurse is assessing the older adult client for the presence of metabolic syndrome. Which of the following findings are consistent with the presence of this condition?

Standard Text: Select all that apply.

1. The clients waist-to-hip ratio is 0.88.

2. The clients apical heart rate is 58 beats per minute.

3. The clients blood pressure is 152/92.

4. The clients serum glucose level is 312 mg/dL.

5. The clients white blood cell count is 3,000 mm3.

Correct Answer: 3,4

Rationale 1: The clients waist-to-hip ratio is 0.88. The clients waist-to-hip ratio is below 0.95 and this finding is not consistent with metabolic syndrome.

Rationale 2: The clients apical heart rate is 58 beats per minute. The clients apical heart rate is decreased, which is not typically associated with metabolic syndrome.

Rationale 3: The clients blood pressure is 152/92. The clients blood pressure is elevated, which is a finding that is consistent with metabolic syndrome.

Rationale 4: The clients serum glucose level is 312 mg/dL. The clients serum glucose level is elevated, which is consistent with metabolic syndrome.

Rationale 5: The clients white blood cell count is 3,000 mm3. The clients white blood cell count is decreased. The client is experiencing leukopenia. White blood cell count is not necessarily elevated or decreased in the client with metabolic syndrome.

Global Rationale: The clients blood pressure is elevated, which is a finding that is consistent with metabolic syndrome. Metabolic syndrome is characterized by excess abdominal fat, hypertension, dyslipidemia, and insulin-resistant glucose metabolism, which reportedly exists in 50 percent of adults over 60 years of age. The clients serum glucose level is elevated, which is consistent with metabolic syndrome. The clients waist-to-hip ratio is below 0.95 and this finding is not consistent with metabolic syndrome. The clients apical heart rate is decreased, which is not typically associated with metabolic syndrome. The clients white blood cell count is decreased. The client is experiencing leukopenia. White blood cell count is not necessarily elevated or decreased in the client with metabolic syndrome.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 7

Type: MCMA

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?

Standard Text: Select all that apply.

1. The clients son states, Sometimes, she seems a little slow to respond during our conversations, like shes taking longer to process the information.

2. The clients bowel sounds are hyperactive in all four quadrants.

3. The client states, I just dont have the energy that I once did. Most of the time I just feel like sitting down.

4. The clients apical heart rate is 106 beats per minute.

5. The clients respiratory rate is 10 breaths per minute.

Correct Answer: 1,3,5

Rationale 1: The clients son states, Sometimes, she seems a little slow to respond during our conversations, like shes taking longer to process the information. Slowed mental processing can be associated with hypothyroidism.

Rationale 2: The clients bowel sounds are hyperactive in all four quadrants. Hyperactive bowel sounds are normally auscultated in clients with hyperthyroidism.

Rationale 3: The client states, I just dont have the energy that I once did. Most of the time I just feel like sitting down. The clients perception that her energy level has decreased is consistent with hypothyroidism.

Rationale 4: The clients apical heart rate is 106 beats per minute. The clients apical heart rate is elevated, which is normally associated with hyperthyroidism.

Rationale 5: The clients respiratory rate is 10 breaths per minute. The clients respiratory rate is decreased and this can be associated with hypothyroidism.

Global Rationale: Slowed mental processing can be associated with hypothyroidism. Hypothyroidism is a condition that develops when the client is unable to produce enough thyroid hormone. The clients perception that her energy level has decreased is consistent with hypothyroidism. The clients respiratory rate is decreased and this can be associated with hypothyroidism. Hyperactive bowel sounds are normally auscultated in clients with hyperthyroidism. The clients apical heart rate is elevated, which is normally associated with hyperthyroidism.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 8

Type: MCMA

The nurse has assessed the older adult client and has developed a nursing care plan based on the nurses findings. Which of the following age-related changes validates the nurses inclusion of the nursing diagnosis Risk for Injury?

Standard Text: Select all that apply.

1. The mucous membranes that line the respiratory passages become drier.

2. The client has developed bilateral cataracts.

3. The client has only three teeth in his mouth.

4. The clients body mass index (BMI) is 22.

5. The client has been diagnosed with hypothyroidism.

Correct Answer: 2,4,5

Rationale 1: The mucous membranes that line the respiratory passages become drier. The client with drier respiratory passages may have an increased risk of developing an infection.

Rationale 2: The client has developed bilateral cataracts. The client with bilateral cataracts will not be able to see as well. This client may have an increased risk of injury due to being unable to visualize obstacles or hazards.

Rationale 3: The client has only three teeth in his mouth. The client who has three teeth may not be able to receive adequate nourishment due to the inability to grind up the food with the teeth. Food must be chewed adequately for the body to be able to break down and gather nutrients from the food.

Rationale 4: The clients body mass index (BMI) is 22. The client who has a body mass index of 22 is underweight. This client has an increased risk of developing osteoporosis. This client may injure himself more during a fall than a client who has an ideal body weight.

Rationale 5: The client has been diagnosed with hypothyroidism. The client with hypothyroidism is more prone to injury because of delayed mental processing.

Global Rationale: The client with bilateral cataracts will not be able to see as well. This client may have an increased risk of injury due to being unable to visualize obstacles or hazards. The client who has a body mass index of 22 is underweight. This client has an increased risk of developing osteoporosis. This client may injure himself more during a fall than a client who has an ideal body weight. The client with hypothyroidism is more prone to injury because of delayed mental processing. The client with drier respiratory passages may have an increased risk of developing an infection. The client who has three teeth may not be able to receive adequate nourishment due to the inability to grind up the food with the teeth. Food must be chewed adequately for the body to be able to break down and gather nutrients from the food.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 9

Type: MCSA

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

Correct Answer: 4

Rationale 1: The loss of skin elasticity around the eyes is associated with bulging in the lower eyelids.

Rationale 2: A reduction in the number of sweat glands is a normal occurrence in aging and results in a reduced production of perspiration.

Rationale 3: Reduced sebum production from the sebaceous glands is a normal finding in the aging client.

Rationale 4: The presence of large white spots may be vitiligo. The presence and underlying cause of integumentary changes will need to be evaluated.

Global Rationale: The presence of large white spots may be vitiligo. The presence and underlying cause of integumentary changes will need to be evaluated. The loss of skin elasticity around the eyes is associated with bulging in the lower eyelids. A reduction in the number of sweat glands is a normal occurrence in aging and results in a reduced production of perspiration. Reduced sebum production from the sebaceous glands is a normal finding in the aging client.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 10

Type: MCSA

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 bodys 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.

Correct Answer: 1

Rationale 1: The bodys bones have an increasing loss of density with aging. It is related in part to hormone levels. Fractures can result with little stress.

Rationale 2: The clients fracture may simply be a normal adverse effect associated with aging and not associated with any serious underlying disorder.

Rationale 3: Although the client should be encouraged to speak with healthcare provider, the nurse should attempt to meet the clients needs for immediate education.

Rationale 4: The nurse can explain to the client that as people age, their bones lose density and become more brittle.

Global Rationale: The bodys bones have an increasing loss of density with aging. It is related in part to hormone levels. Fractures can result with little stress. The clients fracture may simply be a normal adverse effect associated with aging and not associated with any serious underlying disorder. Although the client should be encouraged to speak with the healthcare provider, the nurse should attempt to meet the clients needs for immediate education. The nurse can explain to the client that as people age, their bones lose density and become more brittle.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 11

Type: MCSA

During a routine physical examination, a 66-year-old client reports feeling very tired throughout the day. Which of the following is the nurses best initial action?

1. Assess the clients 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.

Correct Answer: 1

Rationale 1: The clients sleep habits will need to be investigated. If they are inadequate, action will be warranted.

Rationale 2: Not all clients are candidates for napping. The nurses first action is to assess the clients sleep habits.

Rationale 3: Although changes in the evening routine may be helpful, there is inadequate information to make that recommendation. The nurses first action is to assess the clients sleep habits.

Rationale 4: It is inappropriate for the nurse to make recommendations to the healthcare provider concerning a prescription at this time. The nurses first action is to assess the clients sleep habits.

Global Rationale: The clients sleep habits will need to be investigated. If they are inadequate, action will be warranted. Not all clients are candidates for napping. Although changes in the evening routine may be helpful, there is inadequate information to make that recommendation. It is inappropriate for the nurse to make recommendations to the healthcare provider concerning a prescription.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.2: Identify normal anatomical and physiologic changes in older adults.

Question 12

Type: MCMA

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?

Standard Text: Select all that apply.

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 nurses 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.

Correct Answer: 1,2,3

Rationale 1: The nurse has requested that the client put on a cotton gown prior to the interview. Thin cotton examining gowns often make the older client feel uncomfortably chilly and less able to attend to the health history questions. The nurse could provide the client with a robe or wait to request that the client put on a robe until following the interview.

Rationale 2: The nurse seats the client so that the light from the window faces the client with the nurses back to the window. The client should have her back to the window or strong light source. Thus glare is reduced, and the light falls upon the face of the examiner.

Rationale 3: The nurse addresses the client by her first name. The nurse should address the client by her last name until the client states that it is appropriate to be more informal.

Rationale 4: The nurse maintains eye contact; both nurse and client are seated. The nurse should maintain good eye contact during the interview and assessment. The nurse and client should be able to communicate at eye level.

Rationale 5: During the interview, the nurse asks if the client is currently experiencing any pain or anxiety before proceeding further. The nurse should assess the clients level of pain and anxiety to ensure that the client does not require pain medication or an intervention prior to continuing with the interview and assessment.

Global Rationale: Thin cotton examining gowns often make the older client feel uncomfortably chilly and less able to attend to the health history questions. The nurse could provide the client with a robe or wait to request that the client put on a robe until following the interview. The client should have her back to the window or strong light source. Thus glare is reduced, and the light falls upon the face of the examiner. The nurse should address the client by her last name until the client states that it is appropriate to be more informal. The nurse should maintain good eye contact during the interview and assessment. The nurse and client should be able to communicate at eye level. The nurse should assess the clients level of pain and anxiety to ensure that the client does not require pain medication or an intervention prior to continuing with the interview and assessment.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27.3: Describe techniques required to assess older adults.

Question 13

Type: FIB

The nurse is using the Katz Index of Independence in Activities of Daily Living tool to assess the clients level of independence. Based on the table below, calculate the clients total number of points.

Screen Shot 2015-09-24 at 12.53.47 PM
___ points

Standard Text:

Correct Answer: 3 points

Rationale :

Global Rationale:

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.3: Describe techniques required to assess older adults.

Question 14

Type: MCSA

The nurse is preparing to perform an evaluation of the older adult clients 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 MiniMental State Examination seems like a quick way to determine how well the client is able to reason.

2. Its best to go ahead and give the MiniMental State Examination at the beginning of the focused interview because the clients 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 MiniMental State Examination is really easy to perform so its important to remember that the client may have just gone through these types of questions the day before with another healthcare provider.

Correct Answer: 2

Rationale 1: The MiniMental State Examination is one screening instrument of cognitive reasoning that has been used extensively for 30 years. It is familiar to most practitioners and rates well as a reliable and valid tool for detecting dementia and delirium relating to organic disease.The MiniMental State Examination is easy to use. It takes less than 10 minutes to administer and requires no special testing materials other than paper and pencil.

Rationale 2: The nurse should wait to develop rapport with the older adult client prior to performing a cognitive reasoning examination. The nurse should not perform this assessment at the beginning of the focused interview. The screening should be done toward the end of the verbal part of the interview, when the client has learned to feel comfortable with the interviewer and a rapport has developed.

Rationale 3: Older clients who take the test on a periodic basis begin to learn the scoring system and keep track of their scores. They may become fearful of this progression of numbers and resist giving an opportunity for comparison if they feel it will show decline.

Rationale 4: One problem with the MiniMental State Examination is that it is so widely used that clients may become irritated when they find themselves taking the test over and over. It also becomes easy for anyone, young or old, with dementia or not, to become confused between the answers on one test and the next when they are given too close together.

Global Rationale: The MiniMental State Examination is one screening instrument of cognitive reasoning that has been used extensively for 30 years. It is familiar to most practitioners and rates well as a reliable and valid tool for detecting dementia and delirium relating to organic disease. The nurse should wait to develop rapport with the older adult client prior to performing a cognitive reasoning examination. The nurse should not perform this assessment at the beginning of the focused interview. The screening should be done toward the end of the verbal part of the interview, when the client has learned to feel comfortable with the interviewer and a rapport has developed. The MiniMental State Examination is easy to use. It takes less than 10 minutes to administer and requires no special testing materials other than paper and pencil. Older clients who take the test on a periodic basis begin to learn the scoring system and keep track of their scores. They may become fearful of this progression of numbers and resist giving an opportunity for comparison if they feel it will show decline. One problem with the MiniMental State Examination is that it is so widely used that clients may become irritated when they find themselves taking the test over and over. It also becomes easy for anyone, young or old, with dementia or not, to become confused between the answers on one test and the next when they are given too close together.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.3: Describe techniques required to assess older adults.

Question 15

Type: MCMA

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?

Standard Text: Select all that apply.

1. Ive 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.

Correct Answer: 1,2,3

Rationale 1: Ive been so lonely since my wife, Maggie, passed away 2 months ago. Loneliness is a risk factor for the development of depression.

Rationale 2: My mother had a history of depression. A family history of depression increases the clients risk.

Rationale 3: I was diagnosed with chronic bronchitis 4 years ago. Chronic illnesses such as chronic bronchitis increases the clients risk for becoming depressed.

Rationale 4: My son visits at least once a week and takes care of my financial stuff. This clients son visits. The client has evidence of a social support system.

Rationale 5: I visit my sister every Monday and she makes me dinner. The client visits a sibling each week and shares a meal with the sibling. This is more evidence of the presence of a social support system.

Global Rationale: Loneliness is a risk factor for the development of depression. A family history of depression increases the clients risk. Chronic illnesses such as chronic bronchitis increases the clients risk for becoming depressed. This clients son visits. The client has evidence of a social support system. The client visits a sibling each week. This is more evidence of the presence of a social support system.

Cognitive Level: Applying

Client Need: Psychosocial Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.3: Describe techniques required to assess older adults.

Question 16

Type: SEQ

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.

Standard Text: Click and drag the options below to move them up or down.

Choice 1. Do you have any concerns about your memory?

Choice 2. It looks like youve 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?

Correct Answer: 3,2,4,5,1

Rationale 1: The first thing to assess is how well the client is sleeping. The nurse needs to determine if the client may be experiencing any sleep disorders.

Rationale 2: The second thing is for the nurse to determine if the client is having any difficulty eating or feeding him or herself.

Rationale 3: The third thing is for the nurse to determine if the client is experiencing any difficulties with incontinence.

Rationale 4: The nurse must then assess for any clinical manifestations of confusion. Following that, the nurse can assess for any evidence that the client has fallen.

Rationale 5: The last thing is for the nurse to assess for any evidence of skin breakdown.

Global Rationale: The correct order to perform the Fulmer SPICES assessment framework is as follows:
S Sleep Disorders
P Problems with eating and feeding
I Incontinence
C Confusion
E Evidence of falls
S Skin Breakdown

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.3: Describe techniques required to assess older adults.

Question 17

Type: MCMA

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 clients tongue and discovers that it is red and dry with the presence of furrows. Based on the clients most likely condition, the nurse expects to learn which of the following?

Standard Text: Select all that apply.

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 dont check my blood sugar levels as often as I should.

5. Platelets 92,000 mm3.

Correct Answer: 1,3,4

Rationale 1: Serum glucose level is 232 mg/dL. A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels. This clients serum glucose level is elevated.

Rationale 2: White blood cells 32,000 mm3. The clients white blood cell count is elevated. This is an unexpected finding. This indicates that the client has an infection. A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels.

Rationale 3: The client states, I take Lasix every morning because I have some heart problems. A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels. The client takes a diuretic each day.

Rationale 4: The client states, I have diabetes but I dont check my blood sugar levels as often as I should. The client has diabetes but admittedly does not monitor serum glucose levels as frequently as recommended.

Rationale 5: Platelets 92,000 mm3. The clients platelet level is decreased. This is an unexpected finding. A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly especially in people taking diuretics or having elevated blood sugar levels.

Global Rationale: A dry and red tongue with longitudinal furrows may indicate dehydration in the elderly, especially in people taking diuretics or having elevated blood sugar levels. This clients serum glucose level is elevated. The client takes a diuretic each day. The client has diabetes but admittedly does not monitor serum glucose levels as frequently as recommended. The clients white blood cell count is elevated. This is an unexpected finding. The clients platelet level is decreased. This is an unexpected finding.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 18

Type: MCSA

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.

Correct Answer: 3

Rationale 1: These are abnormal findings. Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension.

Rationale 2: The assessment of PERRLA is not necessary at this time. The nurse must obtain additional information about a previous diagnosis of hypertension.

Rationale 3: Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension.

Rationale 4: The vessels in diabetic retinopathy display small, red spots or creamy, round lesions that indicate punctate hemorrhages.

Global Rationale: Narrowing and tapering of the arterioles are abnormal findings and are seen in clients with a history of hypertension. The nurse must obtain additional information about a previous diagnosis of hypertension. These are abnormal findings. The assessment of PERRLA is not necessary at this time. The vessels in diabetic retinopathy display small, red spots or creamy, round lesions that indicate punctate hemorrhages.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 19

Type: MCMA

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?

Standard Text: Select all that apply.

1. Tenting noted on dorsal aspect of clients 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. Clients apical heart rate is 82 beats per minute.

Correct Answer: 2,3,4

Rationale 1: Tenting noted on dorsal aspect of clients hand when skin turgor was assessed. Tenting is not an appropriate way to monitor for dehydration in the older adult client due to loss of skin elasticity.

Rationale 2: Client has produced 175 milliliters over the last 8 hours. The client is not producing an adequate amount of urine, which may indicate the client is dehydrated. The client should have produced at least 240 milliliters over the last 8 hours.

Rationale 3: Dentures are loose, small sores noted in oral mucosa. The client with loosely fitting dentures and sores on the oral mucosa may be experiencing dehydration.

Rationale 4: Healthcare provider notes client exhibiting xerostomia. The client with xerostomia is not producing saliva and this can be associated with dehydration.

Rationale 5: Clients apical heart rate is 82 beats per minute. The clients heart rate is within normal limits and does not indicate that the client is dehydrated.

Global Rationale: The client is not producing an adequate amount of urine, which may indicate the client is dehydrated. The client should have produced at least 240 milliliters over the last 8 hours. The client with loosely fitting dentures and sores on the oral mucosa may be experiencing dehydration. The client with xerostomia is not producing saliva and this can be associated with dehydration. Tenting is not an appropriate way to monitor for dehydration in the older adult client due to loss of skin elasticity. The clients heart rate is within normal limits and does not indicate that the client is dehydrated.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 20

Type: MCMA

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?

Standard Text: Select all that apply.

1. I take something to help my stomach not make so much acid.

2. Ive 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. Ive had trouble with my blood pressure for years and take a medication to keep it down.

5. I take a baby aspirin every day.

Correct Answer: 2,3,4

Rationale 1: I take something to help my stomach not make so much acid. Proton-pump inhibitiors and histamine-2 blockers have not been associated with erectile dysfunction.

Rationale 2: Ive been taking something for depression ever since our son died 4 years ago. Medications that may cause erectile dysfunction include antidepressants such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants.

Rationale 3: Sometimes, I have to take a medication to help me sleep at night. Clients who take tranquilizers have an increased risk of experiencing erectile dysfunction.

Rationale 4: Ive had trouble with my blood pressure for years and take a medication to keep it down. Clients who take antihypertensives have an increased risk of experiencing erectile dysfunction.

Rationale 5: I take a baby aspirin every day. Aspirin is not associated with erectile dysfunction.

Global Rationale: Medications that may cause erectile dysfunction include antidepressants such as serotonin reuptake inhibitors, monoamine oxidase inhibitors, and tricyclic antidepressants. Clients who take tranquilizers have an increased risk of experiencing erectile dysfunction. Clients who take antihypertensives have an increased risk of experiencing erectile dysfunction. Proton-pump inhibitiors and histamine-2 blockers have not been associated with erectile dysfunction. Aspirin is not associated with erectile dysfunction.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 21

Type: MCSA

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.

Correct Answer: 4

Rationale 1: Since this is a normal finding based on the clients age, the nurse does not need to attempt to obtain an ophthalmology referral.

Rationale 2: The client is not exhibiting signs of glaucoma. Cupping of the disc is a sign of glaucoma.

Rationale 3: Small red spots or creamy round lesions are punctate hemorrhages and exudate seen in diabetic retinopathy.

Rationale 4: Age-related changes in the eyes include the presence of narrower and straighter vessels, which should be documented as a normal finding.

Global Rationale: Age-related changes in the eyes include the presence of narrower and straighter vessels, which should be documented as a normal finding. Since this is a normal finding based on the clients age, the nurse does not need to attempt to obtain an ophthalmology referral. The client is not exhibiting signs of glaucoma. Cupping of the disc is a sign of glaucoma. The client is not exhibiting signs of diabetes. Small red spots or creamy round lesions are punctate hemorrhages and exudate seen in diabetic retinopathy.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 22

Type: MCSA

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

Correct Answer: 3

Rationale 1: Bursitis produces heat, redness, swelling, and pain with movement of the joints.

Rationale 2: Gouty arthritis produces heat, redness, swelling, and pain with movement of the joints.

Rationale 3: Osteoarthritis causes swelling and joint deformity with early morning stiffness and pain.

Rationale 4: Rheumatoid arthritis produces heat, redness, swelling, and pain with movement of the joints, but is more likely to be seen in younger adults.

Global Rationale: Osteoarthritis causes swelling and joint deformity with early morning stiffness and pain. Bursitis and gouty arthritis produce heat, redness, swelling, and pain with movement of the joints. Rheumatoid arthritis produces heat, redness, swelling, and pain with movement of the joints, but is more likely to be seen in younger adults.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 23

Type: MCSA

The nurse is assessing the elderly clients 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 clients 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

Correct Answer: 2

Rationale 1: Emphysema produces diminished breath sounds.

Rationale 2: Rales that extend upward and do not clear with cough suggest pulmonary edema. Dullness indicates fluid accumulation from pulmonary edema.

Rationale 3: The absence of breath sounds, harsh rhonchi, or bronchovesicular breath sounds in the periphery are indicative of advanced chronic lung disease.

Rationale 4: Coarse, loud rales may be signs of pulmonary fibrosis and are usually found in clients with longstanding lung disease.

Global Rationale: Rales that extend upward and do not clear with cough suggest pulmonary edema. Dullness indicates fluid accumulation from pulmonary edema. Emphysema produces diminished breath sounds. The absence of breath sounds, harsh rhonchi, or bronchovesicular breath sounds in the periphery are indicative of advanced chronic lung disease. Coarse, loud rales may be signs of pulmonary fibrosis and are usually found in clients with longstanding lung disease.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 24

Type: MCSA

The daughter of an elderly client reports that the client is experiencing a decrease in hearing ability in the clients 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.

Correct Answer: 1

Rationale 1: Excessive cerumen may cause a conductive hearing loss in the elderly due to cerumen dryness and an inability to remove the cerumen properly. The Weber test can validate this finding by showing sound lateralizing to the left ear.

Rationale 2: The Rinne test is used to validate sensorineural hearing loss, which normally demonstrates that air conduction is greater than bone conduction. The Weber test can validate the nurses finding by showing sound lateralizing to the left ear.

Rationale 3: Performing the whisper test is not a relevant action at this time. The Weber test can validate the nurses finding by showing sound lateralizing to the left ear.

Rationale 4: Earwax cannot always be visualized by external ear examination. The Weber test can validate the nurses finding by showing sound lateralizing to the left ear.

Global Rationale: Excessive cerumen may cause a conductive hearing loss in the elderly due to cerumen dryness and an inability to remove the cerumen properly. The Weber test can validate this finding by showing sound lateralizing to the left ear. The Rinne test is used to validate sensorineural hearing loss, which normally demonstrates that air conduction is greater than bone conduction. Performing the whisper test is not a relevant action at this time, and earwax cannot always be visualized by external ear examination.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 25

Type: MCSA

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.

Correct Answer: 1

Rationale 1: Bruits are abnormal signs of carotid stenosis and may signal an impending stroke. If a bruit is heard, auscultation of the aortic and pulmonic valves of the heart should be done to assess for murmurs that may be radiating into the neck. This is essential additional assessment data.

Rationale 2: There is no reason to obtain a surgical consult at this stage. The nurse should auscultate the aortic and pulmonic valves of the heart for the presence of murmurs. Murmurs may radiate into the clients neck.

Rationale 3: The findings are abnormal.

Rationale 4: The nurse should assess for jugular venous distention during the head-to-toe assessment. However, after hearing a bruit over the clients right carotid artery, the nurse must auscultate the heart for the presence of murmurs.

Global Rationale: Bruits are abnormal signs of carotid stenosis and may signal an impending stroke. If a bruit is heard, auscultation of the aortic and pulmonic valves of the heart should be done to assess for murmurs that may be radiating into the neck. This is essential additional assessment data. There is no reason to obtain a surgical consult, at this stage. The nurse should auscultate the aortic and pulmonic valves of the heart for the presence of murmurs. Murmurs may radiate into the clients neck. The findings are abnormal. The nurse should assess for jugular venous distention during the head-to-toe assessment, but at this point the nurse must auscultate the heart for the presence of murmurs.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 26

Type: MCSA

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 clients thermostat.

4. Apply warmed blankets to the client.

Correct Answer: 1

Rationale 1: The body temperature in older adults is lower than that of younger clients. The mean temperature is 36.2 degrees Centigrade (97.2 degrees Fahrenheit). The temperature described is within normal limits for an elderly client.

Rationale 2: There is no need to encourage the client to drink warm fluids. The temperature described is within normal limits for an elderly client.

Rationale 3: There is no reason to request to turn up the clients thermostat. The temperature described is within normal limits for an elderly client.

Rationale 4: There is no reason to apply warmed blankets to the client. The temperature described is within normal limits for an elderly client.

Global Rationale: The body temperature in older adults is lower than that of younger clients. The mean temperature is 36.2 degrees Centigrade (97.2 degrees Fahrenheit). The temperature described is within normal limits for an elderly client. There is no need to encourage the client to drink warm fluids. There is no reason to turn up the clients thermostat. There is no reason to apply warmed blankets to the client.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 27

Type: MCSA

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 clients 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

Correct Answer: 2

Rationale 1: Ecchymoses are bruises. The nurses findings are most consistent with the development of herpes zoster.

Rationale 2: Herpes zoster is also commonly called shingles. Herpes zoster is more common in older adults. The nurse should look for painful, red vesicular or pustular lesions that may be in a line or in patches on the thorax or abdomen.

Rationale 3: Petechiae are small areas where bleeding has occurred under the skin. The nurses findings are most consistent with the development of herpes zoster.

Rationale 4: Purpura is a reddish or purplish area that does not blanch when pressure is applied. The nurses findings are most consistent with the development of herpes zoster.

Global Rationale: Herpes zoster is also commonly called shingles. Herpes zoster is more common in older adults. The nurse should look for painful, red vesicular or pustular lesions that typically follow a linear pattern. Common sites are the thorax or abdomen. Ecchymoses are bruises. Petechiae are small areas where bleeding has occurred under the skin. Purpura is a reddish or purplish area that does not blanch when pressure is applied.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 28

Type: MCSA

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

Correct Answer: 4

Rationale 1: Cherry angiomas are vascular lesions that produce tiny, red spots usually on the trunk.

Rationale 2: They are pedunculated, flesh-colored lesions that occur on the neck, back, axillary area, and eyelids.

Rationale 3: Actinic keratoses are normal aging growths that appear as callus-like red, yellow, or flesh-colored plaques appearing on exposed areas such as ears, cheeks, lips, nose, upper extremities, or balding scalp.

Rationale 4: Seborrhea keratoses are benign, greasy, wart-like lesions that are yellow-brown in color. They commonly appear of the neck, chest, and back.

Global Rationale: Seborrhea keratoses are benign, greasy, wart-like lesions that are yellow-brown in color. They commonly appear of the neck, chest, and back. Cherry angiomas are vascular lesions that produce tiny, red spots usually on the trunk. Acrochordons are also called skin tags. They are pedunculated, flesh-colored lesions that occur on the neck, back, axillary area, and eyelids. Actinic keratoses are normal aging growths that appear as callus-like red, yellow, or flesh-colored plaques appearing on exposed areas such as ears, cheeks, lips, nose, upper extremities, or balding scalp.

Cognitive Level: Understanding

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 29

Type: MCMA

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 clients condition?

Standard Text: Select all that apply.

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.

Correct Answer: 1,3,4,5

Rationale 1: The client states, I have an appointment next week to get some better fitting dentures. Cheilitis may also be called angular stomatitis. Cheilitis is seen in persons with poorly fitting dentures.

Rationale 2: Red blood cell count is 6.2 million/ mm3. The clients red blood cell count is elevated. This is not necessarily associated with the development of cheilitis.

Rationale 3: The healthcare provider has diagnosed the client with cheilitis. The nurse would not be surprised to learn that the healthcare provider diagnosed the condition as cheilitis.

Rationale 4: The client suffered from a cerebrovascular accident last May. Clients who have a history of a stroke have an increased risk of developing cheilitis because they may be unable to swallow well.

Rationale 5: The result of the culture of the drainage is that candida albicans is present. Cheilitis can be caused by candida infection.

Global Rationale: Cheilitis may also be called angular stomatitis. Cheilitis is seen in persons with poorly fitting dentures. The nurse would not be surprised to learn that the healthcare provider diagnosed the condition as cheilitis. Clients who have a history of a stroke have an increased risk of developing cheilitis because they may be unable to swallow well. Cheilitis can be caused by candida infection. The clients red blood cell count is elevated. This is not necessarily associated with the development of cheilitis.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 30

Type: MCSA

During the assessment of a 66-year-old clients 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.

Correct Answer: 3

Rationale 1: Clicks and snaps can be associated with mitral calcifications.

Rationale 2: Loud murmurs grade 4 or greater with thrills or radiation can be associated with valvular stenosis.

Rationale 3: Grade 3 murmurs without radiation are commonly present in older people because of decreased cardiac muscle tone.

Rationale 4: Clicks and snaps can be associated with aortic calcifications.

Global Rationale: Grade 3 murmurs without radiation are commonly present in older people because of decreased cardiac muscle tone. Clicks and snaps can be associated with mitral calcifications. Loud murmurs grade 4 or greater with thrills or radiation can be associated with valvular stenosis. Clicks and snaps can be associated with aortic calcifications.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 31

Type: MCSA

The client is visiting the outpatient clinic for a routine blood pressure assessment. While speaking with the nurse, the client states, Im 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?

Correct Answer: 1

Rationale 1: Reports of pain should never be dismissed as a normal part of aging. The pain reports made by a client need to be investigated. The nurse will need to ask more questions about the clients pain to obtain additional assessment data.

Rationale 2: Normal aging is not always necessarily painful.

Rationale 3: It is inappropriate and beyond the scope of practice of the nurse to make a medical diagnosis.

Rationale 4: Asking about pharmacological therapies is a part of the assessment. However, the best question for the nurse to ask the client at this time is regarding the clients pain.

Global Rationale: Reports of pain should never be dismissed as a normal part of aging. The pain reports made by a client need to be investigated. The nurse will need to ask more questions about the clients pain to obtain additional assessment data. Normal aging is not always necessarily painful. It is inappropriate and beyond the scope of practice of the nurse to make a medical diagnosis. Asking about pharmacological therapies is a part of the assessment. However, the best question for the nurse to ask the client at this time is regarding the clients pain.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 32

Type: MCSA

A 76-year-old client presents to the outpatient clinic with complaints consistent with influenza. During the interaction, the nurse notes the clients 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.

Correct Answer: 4

Rationale 1: The findings must be documented but should be done after the interaction is finished. The nurse needs to determine the reason for the clients weight loss by conversing with the client.

Rationale 2: At this point, there is no need to consult with the healthcare provider. The nurse needs to determine the reason for the clients weight loss by conversing with the client.

Rationale 3: At this point, there is no need to contact social services. The nurse needs to determine the reason for the clients weight loss by conversing with the client.

Rationale 4: Baggy clothing may be reflective of recent weight loss. Obtaining information needed to assess for nutritional problems and dietary practices can best be assessed by conversation between the client and nurse.

Global Rationale: Baggy clothing may be reflective of recent weight loss. Obtaining information needed to assess for nutritional problems and dietary practices can best be assessed by conversation between the client and nurse. The findings must be documented but should be done after the interaction is finished. At this point, there is no need to consult with the healthcare provider. At this point, there is no need to contact social services. The nurse needs to determine the reason for the clients weight loss by conversing with the client.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 33

Type: MCSA

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.

Correct Answer: 4

Rationale 1: There is no need to notify the healthcare provider. The lack of skin turgor in an older client is a normal finding.

Rationale 2: It is beyond the nursing scope of practice for the nurse to independently alter the rate of the intravenous infusion of fluids.

Rationale 3: A lung assessment is not needed in relation to this clients clinical presentation.

Rationale 4: The lack of skin turgor in an older client is a normal finding. This is due to the reduction in elasticity of the skin.

Global Rationale: The lack of skin turgor in an older client is a normal finding. This is due to the reduction in elasticity of the skin. There is no need to notify the healthcare provider. It is beyond the nursing scope of practice for the nurse to independently alter the rate of the intravenous infusion of fluids. A lung assessment is not needed in relation to this clients clinical presentation.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.4: Differentiate between the normal and abnormal findings in the comprehensive assessment of the older adult.

Question 34

Type: MCSA

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 65.

3. The vaccine does not protect us against all types of pneumonia.

4. We should get the influenza vaccine and the pneumonia vaccine.

Correct Answer: 1

Rationale 1: Although it was originally considered that the vaccine would give once-a-lifetime immunization, the Centers for Disease Control and Prevention now recommends that boosters be given to those people who received their initial immunization more than 5 years ago. It is not administered each year. People should receive the influenza vaccine each year.

Rationale 2: The pneumonia vaccine is recommended for clients over the age of 65.

Rationale 3: The vaccine protects against 23 types of infections that cause 85% to 90% of all cases of pneumonia in the United States.

Rationale 4: It is important for the older adult to obtain vaccinations against influenza and pneumonia. These two diseases together constitute the fourth leading cause of death in people older than 65 years.

Global Rationale: Although it was originally considered that the vaccine would give once-a-lifetime immunization, the Centers for Disease Control and Prevention now recommends that boosters be given to those people who received their initial immunization more than 5 years ago. It is not administered each year. People should receive the influenza vaccine each year. The pneumococcal vaccine is recommended for clients over the age of 65. The vaccine protects against 23 types of infections that cause 85% to 90% of all cases of pneumonia in the United States. It is important for the older adult to obtain vaccinations against influenza and pneumonia. These two diseases together constitute the fourth leading cause of death in people older than 65 years.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.5: Discuss the objectives in Healthy People 2020 for older adults.

Question 35

Type: MCSA

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.

Correct Answer: 2

Rationale 1: Depression is a common issue for older adults. Depression is often related to the presence of serious health disorders, financial concerns, and isolation.

Rationale 2: Influenza vaccines are recommended for the majority of older adults.

Rationale 3: Falls, not burns, are the most common injuries for older adults. Seniors who suffer hip fractures are often never able to live independently after the incident.

Rationale 4: Pneumonia is not the most common cause of death, but it is in the top 10.

Global Rationale: Influenza vaccines are recommended for the majority of older adults. Depression is a common issue for older adults. Depression is often related to the presence of serious health disorders, financial concerns, and isolation. Falls, not burns, are the most common injuries for older adults. Seniors who suffer hip fractures are often never able to live independently after the incident. Pneumonia is not the most common cause of death, but it is in the top 10.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 27.5: Discuss the objectives in Healthy People 2020 for older adults.

Question 36

Type: MCSA

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 clients 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 54 and weighs 282 pounds.

3. Client is 73 years old.

4. Client is a female.

Correct Answer: 2

Rationale 1: Modifiable risk factors are those over which the client has some degree of control. Family history is a nonmodifiable risk factor.

Rationale 2: Modifiable risk factors are those over which the client has some degree of control. Obesity is a modifiable risk factor.

Rationale 3: Modifiable risk factors are those over which the client has some degree of control. Age is a nonmodifiable risk factor.

Rationale 4: Modifiable risk factors are those over which the client has some degree of control. Gender is a nonmodifiable risk factor.

Global Rationale: Modifiable risk factors are those over which the client has some degree of control. Family history is a nonmodifiable risk factor. Age is a nonmodifiable risk factor. Gender is a nonmodifiable risk factor.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.5: Discuss the objectives in Healthy People 2020 for older adults.

Question 37

Type: MCMA

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?

Standard Text: Select all that apply.

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.

Correct Answer: 1,3,4

Rationale 1: The client should maintain an ideal body weight. The client should maintain an ideal body weight. Obesity is associated with stretching of perineal muscles and further contributes to stress incontinence in females.

Rationale 2: The client should limit fluid intake to four glasses a day. Limiting fluid to 4 glasses each day is not recommended. Fluid intake should include 8 to 10 glasses of decaffeinated fluid each day.

Rationale 3: The client should try to void on a regular schedule. The client should void on a regular schedule. Sometimes, when older adults are tired they are more likely to experience periods of incontinence. Voiding on a regular schedule can help prevent accidents when the client is fatigued.

Rationale 4: The client should perform pelvic muscle strengthening exercises. Pelvic muscle strengthening exercises can strengthen the muscles that are used to prevent incontinence.

Rationale 5: The client should increase fiber intake. Increasing fiber intake is recommended for elderly clients because it may help with constipation but will not help the client with stress incontinence.

Global Rationale: The client should maintain an ideal body weight. Obesity is associated with stretching of perineal muscles and further contributes to stress incontinence in females. The client should void on a regular schedule. Sometimes, when older adults are tired they are more likely to experience periods of incontinence. Voiding on a regular schedule can help prevent accidents when the client is fatigued. Pelvic muscle-strengthening exercises can strengthen the muscles that are used to prevent incontinence. Limiting fluid to 4 glasses each day is not recommended. Fluid intake should include 8 to 10 glasses of decaffeinated fluid each day. The client should try limiting intake only during the evening hours. Increasing fiber intake may help with constipation but will not help the client with stress incontinence.

Cognitive Level: Applying

Client Need: Health Promotion and Maintenance

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 27.6: Apply critical thinking in a selected simulated situation related to the care of the older adult.

Question 38

Type: MCMA

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 clients daughter indicates that the client may be experiencing a complication associated with this practice?

Standard Text: Select all that apply.

1. He fell and hit his head because hes been so unsteady.

2. His stools have started to look loose and bloody.

3. I think hes beginning to develop Alzheimers disease because he can get so confused.

4. I dont think hes had a bowel movement since 1 week ago.

5. His urine looks cloudy and dark.

Correct Answer: 1,3,4,5

Rationale 1: He fell and hit his head because hes been so unsteady. This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration may lead to an increased fall risk because dehydration may alter the clients electrolyte status, leaving him weak and tired. This will increase the clients risk of falling.

Rationale 2: His stools have started to look loose and bloody. This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Loose and bloody stools are not typically associated with dehydration.

Rationale 3: I think hes beginning to develop Alzheimers disease because he can get so confused. This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration can result in confusion.

Rationale 4: I dont think hes had a bowel movement since 1 week ago. This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration can result in constipation.

Rationale 5: His urine looks cloudy and dark. This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. The client who is suffering from dehydration may experience urinary tract infections. His urine may look dark and cloudy.

Global Rationale: This client is likely experiencing the effects of dehydration due to voluntarily restricting his fluid intake. Dehydration may lead to an increased fall risk because dehydration may alter the clients electrolyte status, leaving him weak and tired. This will increase the clients risk of falling. Dehydration can result in confusion. Dehydration can result in constipation. The client who is suffering from dehydration may experience urinary tract infections. His urine may look dark and cloudy. Loose and bloody stools are not typically associated with dehydration.

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub:

Nursing/Integrated Concepts: Nursing Process: Diagnosis

Learning Outcome: 27.6: Apply critical thinking in a selected simulated situation related to the care of the older adult.

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