Dan Melton Anthony A.

Hizon

BSN3B

Care of the Older Person

Critical thinking? What should you do?

The home care nurse is caring for an older female client who lives with her son and is physically and
financially dependent on her son. The nurse notes multiples bruises on the client’s arms and asks the
client how these bruises occurred. The client confides in the nurse that her son takes out his anger on
her sometimes. What should the nurse do?

1. The nurse is providing medication instructions to an older client who is taking digoxin (Lanoxin)
daily. The nurse notes that which age-related body change could place the client at risk for digoxin
toxicity.
a. Decreased muscle strength and loss of bone density
b. Decreased cough efficiency and decreased vital capacity
c. Decreased salivation and decreased gastrointestinal motility
d. Decreased lean body mass and decreased glomerular filtration rate
2. The nurse is caring for an older client in a long-term care facility. Which action contributes to
encouraging autonomy in the client?
a. Planning meals
b. Decorating the room
c. Scheduling hair cut appointments
d. Allowing the client to choose social activities
3. The home care nurse is visiting an older client whose spouse died 6 months ago. Which behavior by
the client indicates ineffective coping?
a. Neglecting physical grooming
b. Looking at old snapshots of family
c. Participating in a senior citizens’ program
d. Visiting their spouse’s grave once a month
4. The nurse is providing instructions to the unlicensed assistive personnel (UAP) regarding care of an
older client with hearing loss. Which should the nurse tell the UAP about older clients with hearing
loss?
a. They are often distracted
b. They have middle ear changes
c. They respond to low-pitched tones
d. They develop moist cerumen production
5. The nurse is providing an educational session to new employees, and the topic is abuse of the older
client. The nurse helps the employees identify which client as most typically a victim of abuse?
a. A 75-year-old man who has moderate hypertension
b. A 68-yr-old man who has moderate cataracts
c. A 90-yr-old woman who has advanced Parkinson’s disease
d. A 70-yr-old woman who has early diagnosed Lyme disease
6. The nurse is performing an assessment on an older client who is having difficulty sleeping at night.
Which statement by the client indicates the need for further teaching regarding measures to
improve sleep?
a. I swim 3 times a week
b. I have stopped smoking cigars
c. I drink hot chocolate before bedtime
d. I read for 40 minutes before bedtime
7. The visiting nurse observes that the older male client is confined by his daughter-in-law to his room.
When the nurse suggests that he walk to the den and join the family, he says, “I’m in everyone’s
way, my daughter-in-law needs me to stay here.” Which is the most important action for the nurse
to take?
a. Say to the daughter-in-law, confining your father-in-law to his room is inhumane
b. Suggest to the client and daughter-in-law that they consider a nursing home for the client
c. Say nothing, because it is best for the nurse to remain neutral and wait to be asked for help
d. Suggest appropriate resources to the client and daughter-in-law, such as respite care and a
senior citizens’ center
8. The nurse is performing an assessment on an older adult client. Which assessment data would
indicate a potential complication associated with the skin?
a. Crusting
b. Wrinkling
c. Deepening of expression lines
d. Thinning and loss of elasticity in the skin
9. Then home health nurse is visiting a client for the first time. While assessing the client’s medication
history, it is noted that there are 19 prescriptions and several over-the-counter medications that
the client has been taking. Which intervention should the nurse take first?
a. Check for medication interactions
b. Determine whether there are medication duplication
c. Call the prescribing health care provider HCP and report polypharmacy
d. Determine whether a family member supervises medication administration
10. The long-term care nurse is performing assessments on several of the residents. Which are normal
age-related physiological change/s the nurse expects to note? SATA
a. Increased HR
b. Decline in visual acuity
c. Decreased RR
d. Decline in long-term memory
e. Increased susceptibility to urinary tract infections
f. Increased incidence of awakening after sleep onset
11. A Spanish-speaking client arrives at the triage desk in the emergency department and states to the
nurse, “ no Speak English, need interpreter”. Which is the best action for the nurse to take?”
a. Have one of the client’s family members interpret.
b. Have the Spanish-speaking triage receptionist interpret
c. Page an interpreter from the hospital’s interpreter services
d. Obtain a Spanish-English dictionary and attempt to triage the client.
12. The nurse is performing a neurological assessment on a client and elicits a positive Romberg’s sign.
The nurse makes this determination based on which observation?
a. An involuntary rhythmic, rapid, twitching of the eyeballs
b. A dorsiflexion of the ankle and great toe with fanning of the other toes
c. A significant sway when the client stands erect with feet together, arms at the side, and the
eyes closed.
d. A lack of normal sense of position when the client is unable to return extended fingers to a
point of reference.
13. The nurse notes documentation that a client is exhibiting Cheyne-Stokes respirations. On
assessment of the client, the nurse should expect to note which finding?
a. Rhythmic respirations with periods of apnea
b. Regular rapid and deep, sustained respirations
c. Totally irregular respiration in rhythm and depth
d. Irregular respirations with pauses at the end of inspiration and expiration
14. The nurse notes documentation that a client has conductive hearing loss. The nurse understands
that this type of hearing loss is caused by which problem?
a. A defect in the cochlea
b. A defect in the 8th cranial nerve
c. A physical obstruction to the transmission of sound waves ‘
d. A defect in the sensory fibers that lead to the cerebral cortex.
15. While performing a cardiac assessment on a client with an incompetent heart valve, the nurse
auscultates a murmur. Which describes the sound of a heart murmur?
a. Lub-dub sounds
b. Scratchy, leathery heart noise
c. Gentle blowing or swooshing noise
d. Abrupt, high-pitch snapping noise
16. The nurse is testing the extraocular movements in a client to assess for muscle weakness in the
eyes. The nurse should implement which assessment technique to assess for muscle weakness in
the eye?
a. Tests the corneal reflexes
b. Tests the six cardinal positions of gaze
c. Tests visual acuity, using a Snellen eye chart
d. Tests sensory function by asking the client to close eyes and then lightly touching the forehead,
cheeks and chin
17. The nurse is instructing a client how to perform a testicular self-examination TSE. The nurse should
explain that which is the best time to perform this exam?
a. After a shower or bath
b. While standing to void
c. After having a bowel movement
d. While lying in bed before arising
18. The nurse is assessing a client for meningeal irritation and elicits a positive Brudzinski’s sign. Which
finding did the nurse observe?
a. The client rigidly extends the arms with pronated forearms and plantar flexion of the feet
 b. The client flexes a leg at the hip and knee and reports pain in the vertebral column when the leg
is extended
c. The client passively flexes the hip and knee in response to neck flexion and reports pain in the
vertebral column
d. The client’s upper arms are flexed and held tightly to the sides of the body and the legs are
extended and internally rotated.
19. A client with diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of
adventitious lung sounds should the nurse expect to hear when performing a respiratory
assessment on this client?
a. Stridor
b. Crackles
c. Wheezes
d. Diminished
20. The clinic nurse prepares to perform a focused assessment on a client who is complaining of
symptoms of a cold, a cough, and lung congestion. Which should the nurse include for this type of
assessment? Select all that apply SATA
a. Auscultating lung sounds
b. Obtaining the client’s temperature
c. Assessing the strength of peripheral pulses
d. Obtaining information about the client’s respirations
e. Performing a musculoskeletal and neurological examination
f. Asking the client about a family history of any illness or disease.