Nokea
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.
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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.
The nurse is caring for the 55-year-old client. Which statement by the client related to psychosocial changes should the nurse most definitely explore?
- A. I really don’t want to color my hair, even though it seems to be getting grayer every day.'
- B. I can’t see as sharp anymore. I get frustrated by the small lettering on the medicine bottles.'
- C. My husband and I have a more active sexual life now that the children are out of the house.'
- D. My house is empty; I thought I’d be happy when my children finally left, but I feel lonely.'
Correct Answer: D
Rationale: The client’s statement suggests empty nest syndrome, a psychosocial concern requiring further exploration. Graying hair is a normal physiological change, vision issues are physiological, and an active sexual life indicates a healthy relationship.
The nurse completes teaching for the 80-year-old female client. Which statement made by the client indicates further teaching is needed?
- A. Instead of using sodium seasonings, I plan to try one with herbs and lemon.'
- B. Although I find my lavender-scented hand cream relaxing, I should not use it.'
- C. I should place a towel on the floor outside my shower so I don’t slip when getting out.'
- D. Rather than relying on laxatives, I should increase my intake of fruits and vegetables.'
Correct Answer: C
Rationale: Placing a towel on the floor increases fall risk; a slip-resistant mat is needed. Nonsodium seasonings, avoiding scented lotions, and increasing roughage are correct.
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 overhears a person say, 'I’m having a senior moment because I forgot.' How should the nurse interpret this statement?
- A. This phrase is a comical statement without age bias and is acceptable to others
- B. This phrase is a stereotypical reference to older adults that can be termed ageism
- C. This phrase admits that the older adult’s ability to learn new information is limited
- D. This phrase recognizes that all older adults have short- and long-term memory issues
Correct Answer: B
Rationale: The phrase is a stereotypical reference to older adults, perpetuating ageism. It’s not comical, doesn’t imply learning limits, and not all older adults have memory issues.