1.A nurse is performing an assessment on an older adult client who has chronic pain. Which of the following effects of unrelieved pain should the nurse identify as a priority finding to report?
- Impaired mobility
- Decreased independence
- Decreased self-esteem
- Impaired socialization
Explanation:
Chronic pain in older adults often leads to impaired mobility as a primary concern because it directly affects their ability to move, perform daily activities, and maintain independence. This can increase the risk of falls, further injury, and a decline in overall health, making it a priority to report and address.
2.A nurse in an assisted living facility is assessing an older adult client who moved in 3 months ago following the death of his partner. The client reports awakening early in the morning and admits to feeling very sad. The nurse should identify that the client is experiencing which of the following types of grief?
- Anticipatory grief
- Delayed grief
- Acute grief
- Disenfranchised grief
Explanation:
Acute grief is the intense emotional response that occurs shortly after a loss, often within the first few months. The client’s symptoms of sadness and early morning awakening 3 months after the partner’s death align with acute grief, which is a normal response to a recent loss.
3.A nurse is reviewing the records of a group of older adult clients. Which of the following findings should the nurse identify as an unexpected manifestation of the aging process?
- Decreased absorption of nutrients
- Impaired excretion of medications
- High-pitched frequency hearing loss
- Obesity
Explanation:
While aging can lead to decreased absorption of nutrients, impaired excretion of medications, and high-pitched frequency hearing loss (presbycusis) as expected physiological changes, obesity is not a normal part of aging. It is often related to lifestyle factors, medical conditions, or medication side effects and should be addressed as an unexpected finding.
4.A nurse is teaching an older adult client about osteoporosis. Which of the following statements should the nurse include in the teaching?
- "Cottage cheese is a good source of calcium."
- "Increase your caffeine intake."
- "Brisk walking will help prevent bone loss."
- "Hormone replacement therapy with estrogen will increase your risk of osteoporosis."
Explanation:
Weight-bearing exercises like brisk walking are recommended for older adults to help maintain bone density and prevent bone loss associated with osteoporosis. Cottage cheese is a source of calcium, but the statement isn’t as directly impactful as exercise. Increasing caffeine can actually worsen bone loss, and hormone replacement therapy with estrogen typically reduces the risk of osteoporosis, not increases it.
5.A nurse is teaching a group of older adult clients about dietary needs. Which of the following dietary recommendations should the nurse include in the teaching?
- "You should consume 1,200 milligrams of calcium daily."
- "Consume 4 percent of your diet as fat."
- "You should drink 1,500 milliliters of fluid daily."
- "Consume 40 percent of your diet protein."
Explanation:
Older adults need about 1,200 mg of calcium daily to support bone health, especially to prevent osteoporosis. The other options are incorrect: 4% fat is too low (healthy fats should be around 20-35% of the diet), 1,500 mL of fluid is insufficient (older adults typically need 2,000-3,000 mL unless restricted), and 40% protein is excessive (protein should be about 10-20% of the diet).
6.A nurse is caring for an older adult client who has moderate hearing loss. Which of the following actions should the nurse take to enhance communication?
- Speak with exaggerated lip movement.
- Speak at a moderate rate.
- Speak in a louder voice.
- Speak using a higher pitch.
Explanation:
Speaking at a moderate rate helps ensure clarity and allows the client with hearing loss to process the information more effectively. Exaggerated lip movements can distort speech, a louder voice may not help if the issue is clarity rather than volume, and a higher pitch can be harder to hear for those with age-related hearing loss (presbycusis), which often affects higher frequencies.
7.A nurse working in a community health center is completing an assessment of an older adult female client. Which of the following findings should the nurse identify as a priority?
- Rales heard in the bases of the lungs
- Constipation
- Urinary frequency
- Painful intercourse
Explanation:
Rales (crackles) in the lungs can indicate a serious condition such as pneumonia, heart failure, or fluid overload, which are potentially life-threatening in older adults. This finding requires immediate attention. The other options, while important, are less urgent: constipation and urinary frequency are common in older adults, and painful intercourse, though concerning, is not immediately life-threatening.
8.A nurse managing an adult day care is developing treatment plans for older adult clients. Which of the following therapeutic strategies should the nurse use to help the clients achieve Erikson’s developmental task for this age group?
- Music therapy
- Reminiscence therapy
- Meditation therapy
- Pet therapy
Explanation:
Erikson’s developmental task for older adults is "Ego Integrity vs. Despair," which involves reflecting on life to find meaning and acceptance. Reminiscence therapy, where clients recall and share past experiences, supports this task by helping them process their life story and achieve a sense of integrity. The other therapies, while beneficial, are less directly tied to this developmental goal.
9.A nurse is caring for an older adult client who is unresponsive following a stroke. Which of the following actions should the nurse take while providing oral care?
- Turn the client on his side before starting oral care.
- Use the thumb and index finger to keep the client’s mouth open.
- Cleanse the client’s oral mucosa with a toothbrush.
- Perform oral care using sterile gloves.
Explanation:
For an unresponsive client, turning them on their side during oral care helps prevent aspiration of fluids or debris, which is a significant risk following a stroke. Using fingers to keep the mouth open can be unsafe, a toothbrush may be too harsh for the mucosa (a soft sponge is better), and sterile gloves are not necessary for routine oral care unless there’s an infection concern.
10.A community health nurse is assessing an older adult client who lives alone. The nurse finds that, although the client is able to answer all questions appropriately, the client has a decreased attention span, expresses feelings of overwhelming sadness, and has a low energy level. The nurse should identify that the client is exhibiting manifestations of which of the following disorders?
- Delusions
- Dementia
- Delirium
- Depression
Explanation:
The client’s symptoms of decreased attention span, overwhelming sadness, and low energy are classic signs of depression in older adults. Delusions are false beliefs (not mentioned here), dementia involves memory loss and cognitive decline (the client answers questions appropriately), and delirium is an acute, often reversible change in mental status (not fitting the chronic nature of these symptoms).
11.A community health nurse is visiting the home of an older adult client and her caregiver. The client has excoriations to her wrists and ankles. Which of the following actions should the nurse take first?
- Refer the caregiver to a support group.
- Interview the client in private.
- Document the client’s wounds.
- Contact adult protective services.
Explanation:
Excoriations on the wrists and ankles may suggest potential abuse or neglect, such as from restraints. The nurse’s first action should be to interview the client in private to assess the situation safely and determine if abuse is occurring. This step ensures the client can speak freely without fear of the caregiver’s presence.
12.A nurse at a long-term care facility is planning care for an older adult client who has dementia. Which of the following interventions should the nurse include in the plan?
- Vary the staff members caring for the client.
- Use photographs as memory triggers.
- Provide a minimum of three activity choices to the client.
- Break client tasks down to three or four steps at a time.
Explanation:
Clients with dementia often struggle with complex tasks due to cognitive impairment. Breaking tasks into smaller, manageable steps (three or four at a time) helps reduce confusion and frustration, promoting independence and success.
13.A nurse is admitting an older adult client who has urinary incontinence and smells strongly of urine. The client states that he is sorry and embarrassed about the unpleasant smell. Which of the following responses should the nurse make?
- "A lot of clients who are cared for at home have the same problem."
- "Don’t worry about it. She will get a bath, and that will take care of the odor."
- "It must be difficult to care for someone who has incontinence."
- "When was the last time that she had a bath?"
Explanation:
This response directly addresses the client’s concern about the odor by gathering relevant information to assess the situation, such as hygiene practices, without dismissing the client’s feelings or making assumptions.
14.A nurse is teaching a client who has chronic obstructive pulmonary disease (COPD) and has been losing weight about ways to improve his nutritional intake. Which of the following statements by the client indicates an understanding of the teaching?
- "I will choose hot foods to decrease the sense of fullness when eating."
- "I should add grated cheese to sauces and vegetables."
- "I will eat my largest meal of the day in the evening."
- "I should consume a diet high in carbohydrates."
Explanation:
Clients with COPD often experience weight loss due to increased energy expenditure from breathing difficulties. Adding calorie-dense foods like grated cheese to sauces and vegetables helps increase caloric intake without adding bulk, which can exacerbate feelings of fullness.
15.A nurse is teaching an older adult client who had a total hip arthroplasty about ambulating with a standard walker. Which of the following actions by the client indicates an understanding of the teaching?
- The client adjusts the height of the walker so the hand grips are at the level of his waist.
- The client moves the walker ahead about 15.24 cm (6 in) and then steps into the walker.
- The client uses the walker to pull himself up from a sitting to a standing position.
- The client uses the walker to climb the stairs.
Explanation:
Proper walker use involves moving the walker forward a short distance (about 6 inches) and then stepping into it, ensuring stability and safety.
16.A nurse is caring for a client who is using a continuous passive motion (CPM) device following a right total knee replacement. Which of the following actions should the nurse take when applying the CPM device?
- Apply the CPM device in the flexed position.
- Line up the frame joints of the CPM device with the client’s knee.
- Check the range-of-motion settings on the CPM device daily.
- Place the head of the client’s bed at 45° during CPM use.
Explanation:
The CPM device’s range-of-motion settings should be checked daily to ensure they align with the client’s prescribed therapy and to prevent overextension or discomfort. The device should be applied with the knee in a neutral position (not flexed), the frame joints should align with the client’s knee but this is part of setup, not a daily action, and the bed should be flat or slightly elevated (not at 45°) for comfort.
17.A nurse is teaching a group of healthy, older adult clients about expected age-related changes and sexual response. Which of the following changes should the nurse include as an age-related change?
- Decreased refractory time
- Decreased vaginal lubrication
- Loss of female clients’ orgasm ability
- Premature ejaculation
Explanation:
Decreased vaginal lubrication is a common age-related change in older women due to declining estrogen levels during menopause, affecting sexual response.
18.A nurse is caring for an older adult client who has a hip fracture and is rating his pain at 8 on a scale of 0 to 10. Which of the following medications should the nurse administer?
- Capsaicin topical gel
- Oxycodone/acetaminophen 7.5/325 tablet PO
- Celecoxib 200 mg capsule PO
- Aspirin 325 mg PO
Explanation:
A pain level of 8 out of 10 indicates severe pain, which requires a strong analgesic. Oxycodone/acetaminophen is an opioid/non-opioid combination suitable for managing severe pain in the acute setting of a hip fracture.
19.A nurse is teaching an older adult client who is healthy and has chronic constipation about establishing a bowel retraining program. Which of the following statements should the nurse include in the teaching?
- "Limit physical activity during the day."
- "Set a time limit of 10 minutes when attempting to defecate."
- "Increase the fiber content of your diet."
- "Increase your fluid intake to 5,000 milliliters per day."
Explanation:
Increasing dietary fiber helps promote regular bowel movements by adding bulk to the stool, which is essential for managing chronic constipation.
20.A nurse is assessing an older adult client who has right-sided heart failure. Which of the following findings is the nurse’s priority?
- Oxygen saturation is 92% on room air.
- The client consumes 20% of meals.
- Weight has increased 0.91 kg (2 lb) in 24 hr.
- The client has 1+ edema in the lower extremities.
Explanation:
In right-sided heart failure, a sudden weight gain of 0.91 kg (2 lb) in 24 hours is a priority finding as it indicates fluid retention, a sign of worsening heart failure that can lead to pulmonary edema or other complications.
21.A nurse is providing teaching to a client who is to start taking finasteride. Which of the following statements by the client indicates an understanding of the teaching?
- "I will improve in my symptoms within one week."
- "I can expect an increased libido with this medication."
- "I should see a decrease in my PSA levels."
- "I must take this medication within 60 min of sexual activity."
Explanation:
Finasteride is commonly used to treat benign prostatic hyperplasia (BPH) in older men by inhibiting the conversion of testosterone to dihydrotestosterone (DHT), which reduces prostate size. A decrease in PSA (prostate-specific antigen) levels is an expected outcome as the prostate shrinks. Improvement typically takes weeks to months, not one week, libido may decrease (not increase), and finasteride is not taken in relation to sexual activity like medications for erectile dysfunction.
22.A nurse at a long-term care facility is teaching an older adult client about ambulating with a quad-cane. Which of the following statements should the nurse include in the teaching?
- "Adjust the height of the cane so that you can flex your elbow at 45 degrees."
- "Hold the cane in the hand on the stronger side of your body."
- "Place the flat side of the cane away from your foot."
- "Move the cane and your stronger leg at the same time."
Explanation:
A quad-cane provides a wider base for stability. The flat side (with four prongs) should be positioned away from the foot to maximize stability and prevent tripping. The cane should be held on the stronger side, but the elbow should flex at about 15-30 degrees (not 45), and the cane should move with the weaker leg, not the stronger one, to support the weaker side during ambulation.
23.A nurse is caring for an older adult client who is having a stroke. After assessing airway, breathing, and circulation, which of the following assessments is the nurse’s priority?
- Level of consciousness
- Muscle tone
- Sensory changes
- Gag reflex
Explanation:
After ensuring airway, breathing, and circulation (ABCs) are stable, the nurse’s priority in a stroke patient is to assess the level of consciousness, as it indicates the severity of the neurological event and guides further interventions. Changes in consciousness can signal worsening brain injury or increased intracranial pressure.
24.A nurse is assessing an 85-year-old client. Which of the following findings should the nurse report to the provider?
- A widened anterior-posterior chest diameter
Explanation:
A widened anterior-posterior chest diameter (often called a "barrel chest") in an 85-year-old client may indicate chronic obstructive pulmonary disease (COPD) or another respiratory condition, which is not a normal age-related change. This finding should be reported to the provider for further evaluation. (Note: The question appears incomplete with only one option provided, but based on gerontology knowledge, this is the correct answer as it’s an abnormal finding.)
25.A nurse is caring for a client who has aphasia following a stroke. Which of the following actions should the nurse take?
- Present one idea in a sentence.
- Avoid using nonverbal communication techniques.
- Speak loudly.
- Use simplified language.
Explanation:
Aphasia impairs the ability to process language, so presenting one idea per sentence helps the client understand without becoming overwhelmed. Nonverbal communication (e.g., gestures) can be helpful, speaking loudly doesn’t address the language processing issue (unless hearing loss is also present), and overly simplified language may be condescending and less effective than clear, concise communication.
26.A nurse is providing teaching to a client who is to start taking alendronate sodium. Which of the following recommendations should the nurse include in the teaching?
- "The medication may be crushed if you have difficulty swallowing it."
- "Drink a full glass of milk when you take the medication."
- "Take the medication at bedtime."
- "Discontinue the medication if you develop heartburn."
Answer: None of the options are fully correct, but the closest appropriate teaching point would be to clarify proper administration.
Explanation:
Alendronate, a bisphosphonate used for osteoporosis, should be taken on an empty stomach with a full glass of water (not milk, as calcium can interfere with absorption), and the client should remain upright for at least 30 minutes to prevent esophageal irritation. It should not be crushed (it’s an enteric-coated tablet), should be taken in the morning (not at bedtime), and heartburn should be reported but not a reason to discontinue without consulting a provider. Since none of the options are correct, the nurse should teach the proper administration method, which is not listed.
27.A nurse is reviewing the medical record of an older adult client. For which of the following medications should the nurse conduct a hearing assessment of the client?
- Omeprazole
- Ferrous sulfate
- Digoxin
- Furosemide
Explanation:
Furosemide, a loop diuretic, is known to have ototoxic effects, potentially causing hearing loss or tinnitus, especially in older adults or with high doses. A hearing assessment is warranted to monitor for this side effect.
28.A nurse is performing skin assessments for a group of older adult clients. Which of the following findings should the nurse identify as a benign, age-related skin change commonly seen in older adult clients?
- Liver spots
- Nevi
- Atopic dermatitis
- Psoriasis
Explanation:
Liver spots (also called age spots or solar lentigines) are benign, flat, pigmented spots that are a common age-related skin change in older adults due to sun exposure over time. Nevi (moles) can be benign but should be monitored for changes, while atopic dermatitis and psoriasis are pathological conditions, not normal age-related changes.
29.A home-health nurse is caring for a client who has cancer and is using a fentanyl transdermal patch for pain control. Which of the following actions should the nurse take when caring for this client?
- Avoid using a heating pad on the area with the patch.
- To decrease the dose, cut the patch in half.
- Dispose of the used patch by placing it in the trash can.
- Assess the client for urinary retention every 8 hr.
Explanation:
Applying heat to a fentanyl patch can increase absorption, leading to a potentially fatal overdose, so this should be avoided. Cutting the patch can cause uncontrolled release of the drug, used patches should be disposed of properly (e.g., folded and flushed or placed in a sharps container, not in the trash), and while urinary retention can be a side effect of opioids, assessing every 8 hours is not specific to fentanyl patch use.
30.A nurse is completing medication reconciliation for an older adult client who is receiving multiple medications. Which of the following actions should the nurse take first?
- Clarify the client’s list of medications with the pharmacist.
- Compare the current list against the new medication prescriptions.
- Investigate any discrepancies on the list.
- Ask the client about over-the-counter medications she is taking.
Explanation:
The first step in medication reconciliation is to obtain a complete and accurate list of all medications the client is taking, including over-the-counter (OTC) drugs, as these can interact with prescribed medications. This ensures a comprehensive baseline before comparing lists, investigating discrepancies, or consulting the pharmacist.
31.A nurse is teaching an older adult client about methods to improve sleep. Which of the following statements should the nurse include in the teaching?
- "Go to bed at the same time every night."
- "Watch television in bed until you are sleepy."
- "Drink a glass of wine before going to bed."
- "Engage in physical activity in the evenings."
Explanation:
Establishing a consistent sleep schedule, such as going to bed at the same time every night, helps regulate the body’s internal clock and improve sleep quality, especially for older adults. Watching television in bed can stimulate the brain and disrupt sleep, alcohol (like wine) can interfere with REM sleep, and engaging in physical activity too close to bedtime may increase alertness, making it harder to fall asleep.
32.A nurse is transferring an older adult client who has right-sided weakness from the bed to a wheelchair. Which of the following actions should the nurse take to provide a safe transfer?
- Keep the client at arm’s length while performing the transfer.
- Bend at the waist to get down to the client’s level.
- Maintain a straight back and bend at the knees.
- Place the wheelchair at the head of the bed on the client’s right side.
Explanation:
To ensure a safe transfer and protect both the client and the nurse, the nurse should use proper body mechanics by maintaining a straight back and bending at the knees. This reduces the risk of injury. Keeping the client at arm’s length can lead to loss of control, bending at the waist can strain the nurse’s back, and placing the wheelchair at the head of the bed on the client’s right side is not ideal—typically, the wheelchair should be placed on the client’s stronger side (left side in this case) for better support.
33.A nurse at a long-term care facility is planning care for a client who has Alzheimer’s disease and wanders at night. Which of the following interventions should the nurse include in the plan?
- Place the client in wrist restraints at night.
- Request a prescription for a psychotropic medication.
- Assign the client to a room closer to the nurse’s station.
- Keep the television on at night.
Explanation:
For a client with Alzheimer’s disease who wanders at night, placing them in a room closer to the nurse’s station allows for better monitoring and quicker response to prevent falls or other risks. Restraints can increase agitation and are generally avoided unless absolutely necessary. Psychotropic medications should not be the first line of intervention for wandering, as they can have significant side effects. Keeping the television on at night can disrupt sleep and increase confusion in a client with Alzheimer’s.
34.A nurse is caring for an older adult client who is on bed rest. Which of the following foods should the nurse plan to include on the client’s breakfast tray to prevent constipation?
- A banana
- Hash brown potatoes
- An egg and cheese omelet
- Stewed prunes
Explanation:
Stewed prunes are high in fiber and have natural laxative properties, making them an effective choice to prevent constipation in a client on bed rest. Bananas can help but are less effective than prunes for this purpose. Hash brown potatoes and an egg and cheese omelet are low in fiber and not ideal for preventing constipation.
35.A public health nurse is planning an immunization clinic for older adults. At which of the following times should an older adult client receive the influenza vaccine?
- Once during the client’s lifetime
- Every 10 years
- Every 5 years
- Annually in the fall
Explanation:
The influenza vaccine is recommended annually for older adults because the flu virus changes each year, and immunity wanes over time. The fall is the ideal time to get vaccinated, as it aligns with the start of flu season. The other options (once in a lifetime, every 10 years, or every 5 years) do not provide adequate protection against the flu.
36.A nurse is caring for an older adult client who reports that he has just retired and expresses feelings of loneliness due to the loss of daily interactions with coworkers. Which of the following responses should the nurse make?
- "Do you know about the local senior citizen group?"
- "You need to take a vacation."
- "But now you can finally relax and enjoy your life."
- "Why don’t you go to work and visit with your old friends?"
Explanation:
Suggesting a local senior citizen group addresses the client’s feelings of loneliness by offering a way to build new social connections, which is a constructive and supportive response. Telling the client to take a vacation or to relax dismisses their feelings, and suggesting they return to work to visit friends may not be practical or address the root issue of needing new social interactions.
37.A nurse is caring for an older adult client who has a terminal illness. The client tells the nurse, “I just want to live one more month so I can see my grandchild get married.” Which of the following Kübler-Ross stages of grief should the nurse identify the client is experiencing?
- Depression
- Acceptance
- Denial
- Bargaining
Explanation:
The client’s statement reflects the bargaining stage of Kübler-Ross’s stages of grief, where the individual negotiates for more time or a specific goal (e.g., living long enough to see the grandchild’s wedding). Depression would involve sadness or withdrawal, acceptance would show peace with the situation, and denial would involve refusing to acknowledge the terminal illness.
38.A nurse is caring for an older adult client who is expressing feelings of grief and longing for his earlier life. Which of the following actions should the nurse take?
- Listen attentively and allow the client to talk about the past.
- Change the topic of conversation.
- Let the client know that this is a common issue for older adult clients.
- Tell the client about some younger clients who are in worse shape than he is.
Explanation:
Listening attentively and allowing the client to reminisce about the past is a therapeutic approach that validates the client’s feelings and helps them process their grief. Changing the topic dismisses their emotions, saying it’s a common issue minimizes their experience, and comparing them to younger clients is inappropriate and unhelpful.
39.A nurse is assessing an older adult client who reports feeling anxious about financial concerns and having difficulty sleeping for several months. Which of the following factors should the nurse identify as a factor in the client’s sleep pattern?
- Older adults require much less sleep than young adults.
- Older adults seldom awake at night once they have fallen asleep.
- Older adults have an increase in stages III and IV of sleep.
- Anxiety can cause disturbed sleep patterns.
Explanation:
Anxiety is a well-known factor that can disrupt sleep patterns, leading to difficulty falling asleep or staying asleep, which aligns with the client’s report of sleep issues for several months. The other options are incorrect: older adults do not require much less sleep (they still need 7-8 hours), they often wake at night due to lighter sleep, and they typically have a decrease (not an increase) in stages III and IV (deep sleep) as they age.
40.A nurse is conducting an in-service for a group of assistive personnel about the basic needs of older adult clients. Which of the following statements should the nurse include in the teaching?
- "Caloric needs are increased."
- "Renal function is increased."
- "Deep sleep is decreased."
- "Exercise needs are decreased."
Explanation:
As people age, the amount of deep sleep (stages III and IV) decreases, which is a normal physiological change in older adults and an important point for assistive personnel to understand. Caloric needs typically decrease with age due to a slower metabolism, renal function declines rather than increases, and exercise needs do not decrease—older adults still benefit from regular physical activity to maintain health.
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