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The nurse is assessing the 84-year-old client during a routine health examination. Which finding should the nurse investigate first?
- A. Decreased force of cough
- B. Impaired swallowing
- C. Urine light yellow in color
- D. Height decreased by ½ inch
Correct Answer: B
Rationale: Impaired swallowing increases aspiration risk and may indicate a non-age-related condition, requiring priority investigation. Decreased cough, light urine, and height loss are age-related.
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The nurse is caring for the older adult client. The nurse should identify that the client is at risk for developing skin breakdown when making which observations? Select all that apply.
- A. A nursing assistant applies a perfumed lotion to the client’s skin
- B. Two nursing assistants are elevating the client’s heels off the bed
- C. A family member brings the client’s favorite custard from home
- D. The nurse applies an alcohol-based hand wash to the client’s hands
- E. The nurse is directing the client to push with the heels to move up in bed
Correct Answer: A;D;E
Rationale: Perfumed lotion, alcohol-based wash, and heel friction increase skin breakdown risk. Elevating heels and nutrition reduce risk.
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 teaching newly hired NAs in a long term care facility. What information about skin care for older adults should the nurse emphasize?
- A. Avoid skin products purchased for the resident by family that contain alcohol
- B. Apply perfumed skin lots after the resident’s bath when the skin is still moist
- C. When taking residents outdoors, apply sunscreen with a sun protection factor of 8
- D. Apply a strong detergent to clothing with food stains before sending to laundry
Correct Answer: A
Rationale: Avoiding alcohol-containing products prevents skin drying in older adults with fragile skin. Perfumed lotions, low SPF, and strong detergents increase irritation risk.
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 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.