Nokea
The nurse is assessing an old-old client. Which assessment finding should the nurse consider as highest priority?
- A. Slowing of peristalsis
- B. Decreased sense of smell
- C. Loss of skin elasticity
- D. Temperature of 94°F
Correct Answer: D
Rationale: A temperature of 94°F indicates hypothermia, a life-threatening condition requiring immediate intervention.
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Which comment by the caregiver of an older adult patient with Alzheimer's disease would concern you the most?
- A. I get tired, but my daughter comes to relieve me each day
- B. I can't sleep because I am afraid he will get out of the house
- C. This illness has affected the entire family, not just him
- D. The disease is progressing about the way we were told to expect that it would
Correct Answer: B
Rationale: Fear of the patient wandering due to lack of sleep indicates caregiver stress and a safety risk for the patient.
A nurse working in the hospital complains about his assignment, saying, 'I don't have a single patient younger than 70 years old. I'll be babbling and confused by the end of my shift!' These comments reflect:
- A. humor in the workplace
- B. the practice of ageism
- C. an honest assessment of the assignment
- D. caregiver burnout
Correct Answer: B
Rationale: The comment stereotypes elderly patients, reflecting ageism by assuming they are inherently confusing.
An elderly patient with diabetes is admitted with low blood sugar and a syncopal episode. He is confused and unable to give clear answers to most questions. He is noted to have multiple decubiti, poor hygiene, and several old and new lacerations with varying areas of ecchymosis. Which is of most concern to you, the nurse?
- A. The possibility that elder abuse is occurring
- B. Obtaining an accurate medical history
- C. The need for diabetic teaching
- D. The need for a tetanus shot because of his lacerations
Correct Answer: A
Rationale: Signs of decubiti, poor hygiene, and multiple injuries suggest possible elder abuse, requiring immediate investigation.
An 80-year-old patient is hospitalized with a UTI and peripheral vascular disease. In addition, he has glaucoma and diabetes. Which nursing actions would be appropriate for him?
- A. Assess finger stick blood sugar as ordered
- B. Assess peripheral pulses, capillary refill, warmth, and color of extremities
- C. Assess risk for suicide or self-harm
- D. Perform mouth care every 8 hours or more often as needed
- E. Protect from injury due to impaired vision
- F. Encourage weight-bearing exercise and increased calcium intake
- G. Scan the bladder to detect urinary retention
Correct Answer: A,B,D,E,G
Rationale: These actions address the patient's specific conditions: diabetes, PVD, glaucoma, and UTI.
A nurse is caring for an elderly patient. Which physiological change is of the highest concern?
- A. Urinary retention
- B. Slowing of metabolism
- C. Impaired visual acuity
- D. Development of age spots on the skin
Correct Answer: A
Rationale: Urinary retention can lead to infections and kidney damage, making it a high-priority concern in elderly patients.