Aging Client Health Needs
What is the most important assessment for a nurse to perform when caring for a 75-year-old client with multiple chronic conditions?
A. Blood glucose levels
B. Skin integrity
C. Bowel sounds
D. Peripheral pulses
Answer: B. Skin integrity
What is the primary purpose of a skin assessment in an elderly client?
A. To monitor for skin cancers
B. To detect areas of breakdown and prevent pressure ulcers
C. To evaluate cosmetic appearance
D. To identify fungal infections
Answer: B. To detect areas of breakdown and prevent pressure ulcers
Which of the following is a common symptom of Parkinson’s disease?
A. Unilateral muscle weakness
B. Facial muscle rigidity
C. Increased gait speed
D. Difficulty swallowing
Answer: B. Facial muscle rigidity
Which of the following is a sign of hypoglycemia in a diabetic client?
A. Nausea
B. Increased thirst
C. Shaking and sweating
D. Increased urination
Answer: C. Shaking and sweating
In the Clinical Judgment Model, what is the first step in making a clinical decision?
A. Recognizing cues
B. Analyzing data
C. Making a clinical judgment
D. Reflecting on outcomes
Answer: A. Recognizing cues
Which of the following is a normal part of aging that does not require immediate intervention?
A. Decreased visual acuity
B. Weight loss
C. Increased thirst
D. Loss of muscle mass
Answer: D. Loss of muscle mass
Which of the following is a risk factor for pressure ulcer development in an older adult?
A. Increased fluid intake
B. Decreased mobility
C. Increased protein levels
D. High blood pressure
Answer: B. Decreased mobility
A 70-year-old client with osteoarthritis has joint pain and stiffness. Which of the following should be included in the care plan?
A. Promote weight-bearing exercises
B. Avoid joint movement to reduce discomfort
C. Encourage deep tissue massage of affected areas
D. Recommend acetaminophen for pain relief
Answer: D. Recommend acetaminophen for pain relief
A client with diabetes asks what they should do if they miss a dose of insulin. The nurse should respond:
A. “Skip the dose and wait until your next dose.”
B. “Take double the dose at your next scheduled time.”
C. “Take the missed dose as soon as you remember, then resume your normal schedule.”
D. “Increase your activity to counteract the missed dose.”
Answer: C. “Take the missed dose as soon as you remember, then resume your normal schedule.”
When recognizing cues in a patient, the nurse notices a sudden increase in confusion and restlessness. What should the nurse do first?
A. Assess the patient’s vital signs
B. Notify the physician immediately
C. Offer the patient reassurance
D. Change the patient’s position
Answer: A. Assess the patient’s vital signs
A client is taking multiple medications for chronic conditions. What is the best way to assess potential polypharmacy issues?
A. Check for side effects of each medication
B. Ask the client to list their medications
C. Review the client’s medication list with the pharmacist
D. Perform a physical assessment
Answer: C. Review the client’s medication list with the pharmacist
A client has a stage 2 pressure ulcer on their heel. Which type of dressing is most appropriate for this wound?
A. Hydrocolloid dressing
B. Dry sterile dressing
C. Gauze with saline
D. Negative pressure wound vacuum (Wound Vac)
Answer: A. Hydrocolloid dressing
A client is experiencing a sudden onset of one-sided weakness and difficulty speaking. Which of the following actions should the nurse take first?
A. Assess the client’s airway
B. Administer oxygen
C. Call the physician
D. Take the client’s blood pressure
Answer: A. Assess the client’s airway
Which of the following is a priority for managing pain in a client with diabetic neuropathy?
A. Use of high-dose acetaminophen
B. Administration of nonsteroidal anti-inflammatory drugs (NSAIDs)
C. Use of tricyclic antidepressants or anticonvulsants
D. Frequent use of cold compresses
Answer: C. Use of tricyclic antidepressants or anticonvulsants
Which action best reflects the CJM component of “Taking Action” in a patient with decreased urine output?
A. Increase fluid intake
B. Perform a bladder scan
C. Monitor for signs of fluid overload
D. Notify the provider about the change
Answer: B. Perform a bladder scan
A client with osteoarthritis (OA) complains of joint pain and stiffness in the morning. Which of the following interventions should the nurse suggest?
A. Apply a warm compress to the joints
B. Limit fluid intake
C. Use cold packs to reduce inflammation
D. Increase physical activity during flare-ups
Answer: A. Apply a warm compress to the joints
A client with a diabetic ulcer is being treated with a negative pressure wound vacuum (Wound Vac). Which of the following is a priority nursing action?
A. Assessing for proper suction
B. Checking blood glucose every shift
C. Administering pain medications before dressing change
D. Using a dry sterile dressing to cover the wound after treatment
Answer: A. Assessing for proper suction
Which of the following is an appropriate intervention for a client experiencing neuropathic pain?
A. Use of NSAIDs
B. Use of opioid analgesics
C. Use of anticonvulsants like gabapentin
D. Apply heat to the affected area
Answer: C. Use of anticonvulsants like gabapentin
A client with diabetes mellitus is experiencing a slow-healing wound. Which of the following interventions is most appropriate?
A. Encourage high-protein snacks
B. Apply moist wound dressings daily
C. Promote strict bed rest to minimize movement
D. Increase the client’s water intake to flush out toxins
Answer: A. Encourage high-protein snacks
Using the CJM, a nurse identifies that a client’s wounds are not healing properly despite treatment. What should the nurse do next?
A. Continue current wound care without any changes
B. Ask the physician for a different antibiotic
C. Review the client’s nutrition and medication regimen
D. Apply more frequent dressing changes
Answer: C. Review the client’s nutrition and medication regimen
Which statement from the client indicates a need for further education about aging and medication management?
A. "I take my medications as prescribed every day."
B. "I keep all my medication bottles on the kitchen counter for easy access."
C. "I check the expiration dates on my medication once a year."
D. "I only take my medications if I feel sick."
Answer: D. "I only take my medications if I feel sick."
What is the most important aspect of wound care to prevent infection in a surgical wound?
A. Using an antimicrobial agent
B. Applying a wet-to-dry dressing
C. Ensuring sterile technique during dressing changes
D. Changing the dressing daily
Answer: C. Ensuring sterile technique during dressing changes
In the case of a client with a hip fracture, which of the following should be avoided during the first 24 hours post-surgery?
A. Encouraging weight-bearing exercises
B. Assisting with passive range-of-motion exercises
C. Using a fracture brace for stability
D. Administering pain medications as prescribed
Answer: A. Encouraging weight-bearing exercises
What is the correct order of priority for managing a client with diabetic ketoacidosis (DKA)?
A. Administer insulin
B. Administer fluids and electrolytes
C. Monitor blood glucose
D. Assess respiratory rate and oxygen saturation
Answer: D. Assess respiratory rate and oxygen saturation
Which of the following best demonstrates the CJM component of “Evaluating Outcomes” in wound care management?
A. Increasing dressing changes to every 4 hours
B. Reassessing the wound after 48 hours of treatment
C. Applying the same type of dressing without reevaluating
D. Notifying the healthcare provider of minor changes in the wound
Answer: B. Reassessing the wound after 48 hours of treatment