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After performing an assessment and determining that there are no other causes, the nurse concludes that the older adult’s recent hearing loss in one ear may be from cerumen accumulation from age-related changes. The nurse’s conclusion was based on which age-related changes that contribute to the cerumen accumulation?
- A. Reduced sweat gland activity; thinning and drying of the skin lining the ear canal
- B. Ossicular bone calcification; longer and thicker hair growth in the ear canal
- C. Degenerative structural changes of the eardrum preventing cerumen passage
- D. Over activity of the sweat glands contributing to the development of presbycusis
Correct Answer: A
Rationale: Reduced sweat gland activity and thinning/drying of the ear canal skin cause cerumen buildup, affecting sound perception. Ossicular calcification, eardrum changes, and presbycusis are unrelated.
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The nurse is caring for the 94-year-old hospitalized client of the Muslim faith who is near death. Which nursing action is most inappropriate?
- A. Spraying perfume in the client’s room
- B. Placing the client supine facing Mecca
- C. Offering grief counseling to family members
- D. Checking records for wishes of organ donation
Correct Answer: C
Rationale: Grief counseling is discouraged in Muslim faith, making it inappropriate. Perfuming, facing Mecca, and checking organ donation are culturally appropriate.
The nurse is caring for the chronically ill middle-aged adult who has had numerous hospitalizations. Which behaviors may interfere with the client’s achievement of the developmental task associated with middle adulthood? Select all that apply.
- A. Writes thank-you notes to friends
- B. Stays at home and refuses visitors
- C. Self-absorbed in own psychological needs
- D. Attempts to perform own personal cares
- E. Continually relays feelings of inadequacy
Correct Answer: B;C;E
Rationale: Staying home, self-absorption, and feelings of inadequacy interfere with maintaining social relationships and generativity. Thank-you notes and self-care support generativity.
When the office nurse completes height measurement for the 72-year-old female, the client says that she lost half an inch. Which explanation by the nurse is most accurate?
- A. As we age, we lose muscle mass.'
- B. Bone loss is due to lack of exercise.'
- C. As we age, we lose knee and hip cartilage.'
- D. The vertebral column shortens with aging.'
Correct Answer: D
Rationale: Aging causes vertebral column shortening due to water and bone density loss, leading to height reduction. Muscle mass, exercise, and cartilage loss don’t primarily affect height.
The nurse has limited time to teach the middle-aged adult client. The nurse should initially plan to take which action?
- A. Provide brochures and handouts that the client can discuss with family members
- B. Make a referral to outpatient resources for the client to receive the needed teaching
- C. Establish the highest-priority learning needs and teach with each client or family contact
- D. Answer the client’s questions and leave the extensive teaching for the nurse on the next shift
Correct Answer: C
Rationale: Prioritizing learning needs ensures important teaching is completed efficiently during limited time. Brochures alone, referrals, or deferring teaching are less effective initially.
The nurse is reviewing a laboratory report for a 61-year-old client. Which finding is most important for the nurse to address with the HCP?
- A. Total cholesterol 180 mg/dL; was 140 at age 50
- B. Erythrocyte sedimentation rate (ESR) increased
- C. Alkaline phosphatase increased
- D. AST, ALT, and serum bilirubin increased
Correct Answer: D
Rationale: Elevated liver function tests (AST, ALT, bilirubin) are not age-related and suggest liver pathology, requiring immediate HCP notification. Cholesterol, ESR, and alkaline phosphatase increases are normal with aging.