Nokea
The nurse assesses the 75-year-old client and concludes that some findings are not age-related changes and require further follow-up. Which report by the client represents a non-age-related finding that requires additional investigation?
- A. Reports a decreased ability to see at night
- B. Reports seeing halos around lights
- C. Reports difficulty distinguishing some colors
- D. Reports diminished visual acuity
Correct Answer: B
Rationale: Seeing halos is a symptom of glaucoma, not an age-related change, requiring investigation. Night vision, color distinction, and acuity changes are normal with aging.
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The nurse is caring for the 55-year-old client. Which statement by the client related to psychosocial changes should the nurse most definitely explore?
- A. I really don’t want to color my hair, even though it seems to be getting grayer every day.'
- B. I can’t see as sharp anymore. I get frustrated by the small lettering on the medicine bottles.'
- C. My husband and I have a more active sexual life now that the children are out of the house.'
- D. My house is empty; I thought I’d be happy when my children finally left, but I feel lonely.'
Correct Answer: D
Rationale: The client’s statement suggests empty nest syndrome, a psychosocial concern requiring further exploration. Graying hair is a normal physiological change, vision issues are physiological, and an active sexual life indicates a healthy relationship.
The nurse’s assessment findings of the hospitalized older adult include: BP 96/64 mm Hg, P 118 bpm, RR 20/minute, weight 110 lb with an 8-lb weight loss in the last 3 months due to severe loss of appetite from chemotherapy, and BMI of 19. The client reports fatigue so does not go out, but is able to get around the house. Though tired, the client responds appropriately and clearly to questions and denies psychological issues. What score should the nurse assign to the client when completing the Geriatric Mini Nutrition Assessment?
Correct Answer: 4
Rationale: Score: Severe appetite loss = 0; >3 kg weight loss = 0; mobility (bed/chair but not out) = 1; acute disease (cancer) = 0; no psychological issues = 2; BMI 19 = 1. Total = 4.
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.
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 home health nurse suspects elder mistreatment of the 93-year-old client by the live-in caregiver. Which findings support the nurse’s conclusion? Select all that apply.
- A. Client has urine burns
- B. Client has wrist bruises
- C. Client states there have been some unexplained financial expenditures
- D. Client is more talkative than during previous home visits
- E. Smell of alcohol noted on live-in caregiver’s breath
Correct Answer: A;B;C;E
Rationale: Urine burns (neglect), wrist bruises (physical abuse), unexplained expenditures (financial abuse), and caregiver alcohol use (abuser characteristic) support mistreatment. Increased talkativeness suggests comfort, not abuse.