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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 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.
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 nurse is caring for the 94-year-old hospitalized client of the Muslim faith who is near death. Which nursing action is most inappropriate?
- A. Spraying perfume in the client’s room
- B. Placing the client supine facing Mecca
- C. Offering grief counseling to family members
- D. Checking records for wishes of organ donation
Correct Answer: C
Rationale: Grief counseling is discouraged in Muslim faith, making it inappropriate. Perfuming, facing Mecca, and checking organ donation are culturally appropriate.
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 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.