Nokea
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.
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A 72-year-old woman reports she is sexually active. It is most important for the nurse to follow up by asking which question?
- A. Can you tell me more about your sexual partners?'
- B. Have you tried artificial water-based lubricants?'
- C. Are any medications having any drying effects?'
- D. Do you need to use different sexual positions?'
Correct Answer: A
Rationale: Assessing sexual partners is critical due to rising STI/HIV rates in older adults. Lubricants, medication effects, and positions are secondary to infection risk.
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 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.
The nurse is admitting the older adult client to a nursing home. Which is the nurse’s best approach when obtaining information during the admission interview?
- A. Direct questions to the family member accompanying the client
- B. Speak clearly and slowly to the client using high-pitched vocal tones
- C. Take the client and family members to a private room without distractions
- D. Speak to the client loudly about familiar topics before asking questions
Correct Answer: C
Rationale: A private, distraction-free room respects confidentiality and aids focus. Directing questions to family, high-pitched tones, or loud familiar topics are inappropriate.
After performing an assessment and determining that there are no other causes, the nurse concludes that the older adult’s recent hearing loss in one ear may be from cerumen accumulation from age-related changes. The nurse’s conclusion was based on which age-related changes that contribute to the cerumen accumulation?
- A. Reduced sweat gland activity; thinning and drying of the skin lining the ear canal
- B. Ossicular bone calcification; longer and thicker hair growth in the ear canal
- C. Degenerative structural changes of the eardrum preventing cerumen passage
- D. Over activity of the sweat glands contributing to the development of presbycusis
Correct Answer: A
Rationale: Reduced sweat gland activity and thinning/drying of the ear canal skin cause cerumen buildup, affecting sound perception. Ossicular calcification, eardrum changes, and presbycusis are unrelated.