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The older adult client is experiencing relocation stress after being admitted to a nursing home. Which intervention is best for the nurse to implement?
- A. Ask family members to explore placing the client in another nursing home
- B. Change the client’s room every week until a compatible roommate is found
- C. Place the client’s favorite items, such as a family picture, at the client’s bedside
- D. Ask that family members avoid talking to the client about being in the nursing home
Correct Answer: C
Rationale: Familiar items like a family picture reduce relocation stress. Moving facilities, changing rooms, or avoiding discussion may increase stress.
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The nurse is teaching a group of middle-aged female nurses about middle-aged moral development applicable only to women. Which point should the nurse most specifically address?
- A. Gilligan’s moral development theory includes responsibility and caring for self and others
- B. Kohlberg’s moral development theory includes living according to universally agreed-upon principles
- C. Westerhoff’s stages of faith include putting faith into personal and social action and standing up for beliefs
- D. Fowler’s stages of spiritual development include becoming aware of truth from a variety of viewpoints
Correct Answer: A
Rationale: Gilligan’s theory, specific to women, emphasizes morality as integrity in relationships and caring for others and self, unlike Kohlberg’s justice-based theory. Westerhoff and Fowler address spiritual, not moral, development.
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.
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.
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.