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The nurse is completing an assessment on the 19 year - old female who participates in strenuous physical activities many hours daily. Which nursing assessment is most important?
- A. Check for the presence of lordosis
- B. Look for signs of an eating disorder
- C. Examine muscles for increased mass
- D. Ask about excessive bleeding with menses
Correct Answer: B
Rationale: Females who participate in strenuous physical activities are at risk for eating disorders. Strenuous activity does not cause lordosis, increased muscle mass is expected, and delayed menses, not excessive bleeding, is a concern with strenuous activity.
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The nurse is assessing the 50-year-old female client who is hospitalized. The nurse should assess the client for which physical changes associated with aging? Select all that apply.
- A. Increased sweat gland activity
- B. Decreased ability to read smaller print
- C. Weight loss due to hypermetabolism
- D. Increased sebaceous gland activity
- E. Absence of a menstrual cycle
Correct Answer: B;E
Rationale: Visual acuity declines, affecting near vision, and menopause causes absence of menstruation in middle-aged women. Sweat and sebaceous gland activity decrease, and weight gain, not loss, occurs due to slower metabolism.
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.
The nurse is obtaining nutrition information from four 20-year-old female clients. All have a BM] of 20 to 23. Which client requires the most immediate follow-up?
- A. The client eats three nutritious meals a day with no snacks
- B. The client limits her intake to 2500 calories per day
- C. The client eats only fruits, vegetables, seeds, and nuts
- D. The client eats three 350-calorie meals per day
Correct Answer: D
Rationale: By limiting meals to 350 calories each, the client consumes only 1050 calories daily, insufficient for a sedentary female’s basic energy needs, requiring immediate follow-up. Three nutritious meals may suffice, 2500 calories is appropriate, and a vegetarian diet needs protein assessment but is less urgent.
The nurse teaches the 18-year-old diabetic client to perform self-administration of insulin. Each time the client makes even a small mistake, the client apologizes for getting it wrong- The client also profusely apologizes when making a minimal mistake in other activities. Based on Erikson’s developmental stages, the nurse concludes that the client may have an unresolved developmental task of which age period?
- A. Infancy
- B. Early childhood
- C. School-aged childhood
- D. Adolescence
Correct Answer: B
Rationale: The behavior indicates an unresolved conflict of 'autonomy versus shame and doubt' associated with the 18-month to 3-year-old age group. When parents are overly critical, the child may develop an overly critical superego, manifesting as constant apologizing for small mistakes.
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.