A
It is stated in a client’s living that no extraordinary measures should be attempted in the event the client stops breathing. When discussing this with the client, the client asks if that part of the will can be deleted. What should the nurse do?
A) contact legal counsel for the facility
B) strike out the section of the living will
C) document that the client wants support if breathing stops
D) notify the healthcare provider that the client has changed the living will
A. Contact legal counsel for the facility
An older adult client does not like to drink water and drinks only a few cups of tea each day. What should the nurse suggest the client ingest to increase this client’s intake of fluids?
A) ice
B) soup
C) celery
D) cucumbers
B) soup
An older adult client reports increasing difficulty swallowing food. What should the nurse suggest to this client?
A) Eat slower.
B) Increase fluid intake.
C) Eat foods with softer texture.
D)See the health care provider.
D. See the health care provider.
An older client questions if a lung infection is present even without a change in body temperature. What should the nurse explain to this client?
A) “An infection does not always cause a fever.”
B) “You might have had a fever but didn’t notice it.” C) “Normal body temperature levels change with aging.”
D) “A fever could have occurred during the night when you were sleeping.”
C) “Normal body temperature levels change with aging.”
A nurse is developing a plan of care for an older adult experiencing dysphagia. Which intervention would the nurse perform first?
A) Thicken liquids
B) Weigh the client
C) Observe the client's food intake
D) Offer the client verbal cues when eating
C) Observe the client's food intake
The nurse suspects that an older adult client who performs routine tasks and ambulation slowly is experiencing pain. What should the nurse do to encourage the client to discuss personal comfort?
A) ask if the client has sore joints
B) mention that pain medication is available if needed
C) offer a backrub or other comfort measure to relieve the client’s pain
D) recommend talking with the health care provider about pain symptoms
A) ask if the client has sore joints
The nurse notes that an older adult client experiences urinary incontinence only when taking a sedative. For which type of incontinence should the nurse plan care for this client?
A) mixed
B) transient
C) functional
D) established
C) functional
An older adult has been prescribed a potassium-sparing diuretic and a beta blocker for hypertension. Which action should be a priority for the nurse?
A) Monitoring the client for tachycardia
B) Closely monitoring the client's electrolyte levels C) Ensuring the client does not change position quickly
D) Assessing the client for changes in level of consciousness
C) Ensuring the client does not change position quickly
An older client says that sometimes an adult daughter is frustrated with needing to always be at the client’s home to provide care and will withhold providing prescribed medications. What action should the nurse take first?
A) Talk with the daughter
B) Report the client’s statement
C) Notify the health care provider
D) Document the information in the medical record
B) Report the client’s statement
The nurse notes that an older adult client has several broken teeth and one with an abscess. Which action will the nurse take next?
A) Ask the client to rinse the mouth with warm salt water.
B) Assess the client for signs of sepsis.
C) Take the vital signs.
D) Recommend the client eat a soft diet.
B) Assess the client for signs of sepsis.
The nurse is providing education about urinary incontinence to an older adult client. Which statement by the client requires further follow up by the nurse?
A) "Urinary incontinence is a condition for which there is no treatment."
B) "Several changes happen in the body with age that increase the risk for urinary incontinence."
C) "Control of urination depends on other body systems working as they should."
D) "Urination is both a voluntary and involuntary process, overall."
A. "Urinary incontinence is a condition for which there is no treatment."
The nurse assesses an older adult client for malnutrition. Which assessment finding indicates an increased risk for malnutrition in this client?
A) Client reports no bowel movement in 3 days
B) Concentrated and malodorous urine
C) Client reports a mild headache
D) Decreased skin turgor
A) Client reports no bowel movement in 3 days
The nurse is teaching a class to older adults about risk for small bowel obstruction. Which early symptom will the nurse include for this client population?
A) "Vomiting that provides some symptom relief occurs with small bowel obstruction."
B) "Vomiting and decreased level of consciousness occur with small bowel obstruction."
C) "Dehydration is the most common cause of small bowel obstruction."
D) "In older adults, small bowel obstructions usually resolve spontaneously."
A) "Vomiting that provides some symptom relief occurs with small bowel obstruction."
A gerontological nurse is providing care to an older adult client. Which situation best indicates that intervention is required by the nurse?
A) The client lacks the requisites to meet his or her needs independently.
B) The client, based on the judgment of health professionals, is in a compromised health state.
C) The client expresses a desire for assistance with self-care.
D) The client engages in behaviors that are not compatible with good health.
A) The client lacks the requisites to meet his or her needs independently.
An older adult client with a diagnosis of osteoarthritis complains of stiffness in the joints, tenderness, and pain. The nurse interprets the client’s statements as indicating which type of pain?
A) Somatic pain
B) Visceral pain
C) Nociceptive pain
D) Neuropathic pain
A) Somatic pain
A gerontological nurse is aware that quality of life is an important consideration when assessing the functioning of older adults. What measure should the nurse use when appraising older adults’ quality of life?
A) life expectancy
B) gerotranscendence
C) healthy life expectancy
D) rectangularization of the curve
C) healthy life expectancy
A registered nurse assesses an older adult client 24 hours after a retropubic suspension surgical procedure. The client is confused, exhibits muscle twitching, and reports being nauseated. Which laboratory data should the nurse assess?
A) sodium
B) hemoglobin
C) blood urea nitrogen
D) white blood cell count
A) sodium
The nurse teaches an older adult client about interactions between prescribed medications. Which client statement indicates that additional teaching is required?
A) “My laxative will not interact with the prescribed antidiabetic agent.”
B) “Antacids will increase the effectiveness of my digitalis preparation.”
C) “The sedative that I take every day will increase the effectiveness of my blood thinner.”
D) “My digitalis medication has no effect on the salicylate medication that I take every day
B) “Antacids will increase the effectiveness of my digitalis preparation.”
The nurse notes that an older adult client obtains approximately 3 to 4 hours of sleep a night. For what should the nurse assess this client?
A) Gas exchange
B) Fluid retention
C) Risk for suicide
D) Intracranial pressure regulation
C) Risk for suicide
The nurse reviews medications prescribed for a client with severe osteoarthritis pain. Which medication should the nurse question before administering to the client?
A) aspirin
B) ibuprofen
C) indomethacin
D) acetaminophen
C) indomethacin
An 80-year-old client presents with a low-grade fever and minimal pain. The client has a positive urinalysis. How will the nurse explain that, although the fever is unexpectedly low, the client has an active infection?
A) "Your inflammatory defense is declining with age." B) "You have less body mass at your age."
C) "As you age, people normally present with low temperature."
D) "Your metabolism lowers with age."
A) "Your inflammatory defense is declining with age."
An older adult client reports taking the antihypertensive as prescribed; however, the most recent blood pressure measurement is 170/90 mm Hg. What should the nurse consider as interfering with the effects of the antihypertensive medication?
A) Insulin
B) Antacid
C) Digoxin
D) Thiazide diuretic
B) Antacid
The nurse notes that an older adult client has decreased breath sounds. What should the nurse suspect is occurring with this client?
A) Decreased tidal volume
B) Undiagnosed pneumonia
C) Reduced ciliary movement
D) Untreated chronic lung disease
A) Decreased tidal volume
A palliative care team has taken over primary responsibility for the care of an older adult. A friend visiting the client inquires about the care that this individual is prescribed. Which response by the nurse is best?
A) “Palliative care is the spiritual and psychosocial care that takes place near the end of life.”
B) “Palliative care is the provision of holistic care to clients experiencing incurable health states.”
C) “Palliative care incorporates nursing care and medical treatment that prioritizes the wishes of clients and families.”
D) “Palliative care focuses on the prioritization of complementary and alternative measures over biomedical interventions.”
B) “Palliative care is the provision of holistic care to clients experiencing incurable health states.”
A home care nurse notes in the assessment that an older adult expresses anxiety and fatigue. The client sleeps 3 hours at a time at maximum and has had a 10 lb (4.5 kg) weight loss. Which intervention is priority?
A) Weigh the client.
B) Interview the family.
C) Perform an assessment of vital signs.
D) Assess the client’s level and intensity of pain.
D) Assess the client’s level and intensity of pain.