Nokea
The nurse is assessing the older adult. Which tool should the nurse select to identify the client’s needs and care deficits?
- A. Katz Index of Activities of Daily Living
- B. Maslow’s Hierarchy of Needs
- C. Mini Mental State Exam (MMSE)
- D. Erikson’s Developmental Tasks
Correct Answer: A
Rationale: The Katz Index assesses functional ability in daily activities, identifying care deficits. Maslow’s is a general needs theory, MMSE assesses cognition, and Erikson’s is developmental.
You may also like to solve these questions
The nurse is assessing the 88-year-old client. Which finding should the nurse associate with the normal aging process?
- A. Arm muscle strength 4 on a 0 to 5 scale
- B. Multiple fractures to the thoracic spine
- C. Ulnar deviation of the left hand fingers
- D. Slight pain in the right and left heel
Correct Answer: A
Rationale: Muscle strength of 4/5 is normal with aging. Fractures, ulnar deviation (rheumatoid arthritis), and heel pain (bone spurs) are not normal aging changes.
The nurse observes the NA providing a stuffed animal to the hospitalized older adult client who is experiencing delirium. Which action by the nurse is most appropriate?
- A. Reprimand the NA for treating the client like a child
- B. Remove the stuffed animal before anyone else sees it
- C. Report the NA’s action to the unit’s nurse manager
- D. Thank the NA for providing it for the client’s fidgeting
Correct Answer: D
Rationale: A stuffed animal can occupy a delirious client’s hands, preventing line removal, and may be comforting. Thanking the NA is appropriate; other actions are unnecessary or punitive.
The nurse is assessing the older adult client experiencing problems sleeping. Which statements, if made by the client, indicate that the client may benefit from teaching? Select all that apply.
- A. I am so tired that I need to take a nap in the middle of the day.'
- B. My routine includes a glass of warm chocolate milk at bedtime.'
- C. I installed room-darkening shades after my doctor advised these.'
- D. I’m in my bed a lot; it is the most comfortable place in my home.'
- E. I often take my pain pill for my leg pain just before going to bed.'
Correct Answer: A;B;D
Rationale: Daytime napping, chocolate milk (caffeine), and excessive bed time disrupt sleep, indicating teaching needs. Darkening shades and pain management are appropriate.
While attending a health fair, the 62-year-old female is found to have many risk factors for osteoporosis. The nurse at the booth recommends that she contact her HCP about scheduling a DEXA (dual-energy x-ray absorptiometry) scan. Which risk factors influenced the nurse’s recommendation? Select all that apply.
- A. Hyperthyroidism
- B. Postmenopausal
- C. Overweight
- D. African American
- E. 62-year-old female
Correct Answer: A;B;E
Rationale: Hyperthyroidism, postmenopausal status, and being a 62-year-old female are risk factors for osteoporosis, warranting a DEXA scan. Being overweight and African American are not major risk factors.
The nurse is caring for the 87-year-old hospitalized client. The nurse should assess for which age-related changes to best protect the client from friction injury?
- A. Increased tissue vascularity
- B. Increase in subcutaneous tissue
- C. Increased rate of cellular replacement
- D. Loss of skin thickness and elasticity
Correct Answer: D
Rationale: Loss of skin thickness and elasticity increases friction injury risk due to a thinner epidermis and reduced strength. Vascularity, subcutaneous tissue, and cellular replacement decrease with aging.