Question 1

The nurse is performing a physical assessment on an elderly patient. Which finding would be considered normal aging?

Accepted Answer

A)  Increased perspiration and sweating 
B)  Increased accumulation of ear cerumen 
C)  Increased pupillary reflex 
D)  Auscultation of an S3 heart sound 
A)  Increased perspiration and sweating 
B)  Increased accumulation of ear cerumen 
C)  Increased pupillary reflex 
D)  Auscultation of an S3 heart sound B

Question 2

When obtaining a health history and assessing an elderly patient in her home, which of the following would concern the nurse? Select all that apply.

Accepted Answer

A)  The female patient begins talking about when her children were born. 
B)  The house is very cluttered with newspapers on the floor. 
C)  The patient's teeth are broken and missing. 
D)  The patient's legs have no edema. 
E)  The patient is speaking in a loud tone. 
A)  The female patient begins talking about when her children were born. 
B)  The house is very cluttered with newspapers on the floor. 
C)  The patient's teeth are broken and missing. 
D)  The patient's legs have no edema. 
E)  The patient is speaking in a loud tone. B,C,E

Question 3

The nurse is assessing gait and position sense in the elderly patient. Which of the following would be correct for the nurse to ask of the patient?

Accepted Answer

A)  Ask the patient to walk away and then back, walking on his or her toes. 
B)  Ask the patient to walk heel-to-toe away and then back. 
C)  Ask the patient to hop on both feet. 
D)  Ask the patient to do a deep knee bend and assist the patient back up to standing if necessary. 
A)  Ask the patient to walk away and then back, walking on his or her toes. 
B)  Ask the patient to walk heel-to-toe away and then back. 
C)  Ask the patient to hop on both feet. 
D)  Ask the patient to do a deep knee bend and assist the patient back up to standing if necessary. B

Question 4

The elderly patient reports to the nurse that he coughs a lot during and after meals. What would be most important for the nurse to ask this patient first?

Accepted Answer

A)  "How much do you drink during the day?' 
B)  "Does the cough keep you awake at night?" 
C)  "Do you have difficulty swallowing?" 
D)  "Does it hurt when you cough?" 
A)  "How much do you drink during the day?' 
B)  "Does the cough keep you awake at night?" 
C)  "Do you have difficulty swallowing?" 
D)  "Does it hurt when you cough?"

Question 5

Which of the following is considered a normal aging change in the elderly patient?

Accepted Answer

A)  Presence of overgrowth of the gum tissues 
B)  A yellow color in the hard palate 
C)  Decreased saliva and a dry mouth 
D)  A dry, red soft palate 
A)  Presence of overgrowth of the gum tissues 
B)  A yellow color in the hard palate 
C)  Decreased saliva and a dry mouth 
D)  A dry, red soft palate

Question 6

A 78-year-old patient is complaining of chronic achy joint pain. She states, "I am so tired of living with pain." What is important to remember about pain and the elderly?

Accepted Answer

A)  The older adult will report pain accurately. 
B)  The older adult may not be compliant in taking pain medication. 
C)  The older adult is willing to report pain. 
D)  Older adults are not able to give reliable self-reports of pain. 
A)  The older adult will report pain accurately. 
B)  The older adult may not be compliant in taking pain medication. 
C)  The older adult is willing to report pain. 
D)  Older adults are not able to give reliable self-reports of pain.

Question 7

Which of the following statements is correct regarding alcohol use/abuse in the elderly? Select all that apply.

Accepted Answer

A)  More women than men abuse alcohol. 
B)  People who abuse alcohol generally have poor personal hygiene. 
C)  Those who abuse alcohol usually live alone. 
D)  Those who abuse alcohol tend to be married 
E)  Alcohol use/abuse in the elderly may be difficult to assess and/or diagnose. 
A)  More women than men abuse alcohol. 
B)  People who abuse alcohol generally have poor personal hygiene. 
C)  Those who abuse alcohol usually live alone. 
D)  Those who abuse alcohol tend to be married 
E)  Alcohol use/abuse in the elderly may be difficult to assess and/or diagnose.

Question 8

You are performing a comprehensive health assessment on a 68-year-old female. What normal assessment findings would the nurse expect to find in this elderly patient? Select all apply.

Accepted Answer

A)  Skin tenting 
B)  Thin, fragile skin 
C)  Actinic keratosis 
D)  Solar lentigo 
E)  Nevi less than 0.6 cm 
A)  Skin tenting 
B)  Thin, fragile skin 
C)  Actinic keratosis 
D)  Solar lentigo 
E)  Nevi less than 0.6 cm

Question 9

The elderly patient who is alert and oriented tells the nurse that she is incontinent when coughing and sneezing. The nurse knows that this patient has which type of incontinence?

Accepted Answer

A)  Urge incontinence 
B)  Stress incontinence 
C)  Functional incontinence 
D)  Overflow incontinence 
A)  Urge incontinence 
B)  Stress incontinence 
C)  Functional incontinence 
D)  Overflow incontinence

Question 10

The nurse is working in a senior housing complex assessing an 85-year old-resident. Which finding would be of greatest concern to the nurse?

Accepted Answer

A)  A blood pressure of 160/70 mm/Hg 
B)  A heart rate of 60 beats per minute 
C)  An echocardiogram report documenting an enlarged left ventricle 
D)  An irregular heartbeat of 120 beats per minute 
A)  A blood pressure of 160/70 mm/Hg 
B)  A heart rate of 60 beats per minute 
C)  An echocardiogram report documenting an enlarged left ventricle 
D)  An irregular heartbeat of 120 beats per minute

Question 11

Which of the following statements made by the elderly patient would alert the nurse to warning signs that the patient should stop driving? Select all that apply.

Accepted Answer

A)  "I got lost driving to my daughter's new house 50 miles away." 
B)  "I have had several traffic tickets this past year." 
C)  "I have pain in my neck when I turn my head." 
D)  "I only drive during the day." 
E)  "I have trouble getting out of my chair in my living room." 
A)  "I got lost driving to my daughter's new house 50 miles away." 
B)  "I have had several traffic tickets this past year." 
C)  "I have pain in my neck when I turn my head." 
D)  "I only drive during the day." 
E)  "I have trouble getting out of my chair in my living room."

Question 12

When performing a cardiac assessment, which of the following findings indicates the possibility of hypertrophy of the left ventricle?

Accepted Answer

A)  An S4 heart sound 
B)  An S3 heart sound 
C)  An ejection click 
D)  Opening snap 
A)  An S4 heart sound 
B)  An S3 heart sound 
C)  An ejection click 
D)  Opening snap

Question 13

The elderly patient's daughter is talking with the nurse. Which of the following statements made by the daughter would concern the nurse that the patient is a frail elder?

Accepted Answer

A)  "My mother fell last week and I noticed some bruises on her left arm." 
B)  "My mother weighed the same last year at her physical examination." 
C)  "My mother goes to the Senior Center twice a week."
4 "My mother still cooks her own meals."
4 "My mother still cooks her own meals." 
A)  "My mother fell last week and I noticed some bruises on her left arm." 
B)  "My mother weighed the same last year at her physical examination." 
C)  "My mother goes to the Senior Center twice a week."
4 "My mother still cooks her own meals."
4 "My mother still cooks her own meals."

Question 14

Which of the following would be important to include in the teaching plan for the elderly patient to help reduce the risk of osteoporosis? Select all that apply.

Accepted Answer

A)  Limit the amount of walking each day to reduce the stress on your joints. 
B)  Make sure you get enough vitamin D in your diet. 
C)  Medications will not affect your bones. 
D)  Make sure you get enough calcium in your diet. 
E)  Stop smoking. 
A)  Limit the amount of walking each day to reduce the stress on your joints. 
B)  Make sure you get enough vitamin D in your diet. 
C)  Medications will not affect your bones. 
D)  Make sure you get enough calcium in your diet. 
E)  Stop smoking.

Question 15

How would the nurse appropriately conduct the Whispered Voice test in the elderly patient?

Accepted Answer

A)  Have the patient stand in front of the nurse. 
B)  Stand in front of the patient and whisper two or three words. 
C)  Have the patient cover the ear the nurse is not assessing. 
D)  Conduct the Whispered Voice test to both ears at the same time. 
A)  Have the patient stand in front of the nurse. 
B)  Stand in front of the patient and whisper two or three words. 
C)  Have the patient cover the ear the nurse is not assessing. 
D)  Conduct the Whispered Voice test to both ears at the same time.

Question 16

The daughter of the elderly patient is talking to the nurse. Which of the following statements made by the daughter would concern the nurse regarding an increase in the risk of falls in the elderly? Select all that apply.

Accepted Answer

A)  "My mother takes an anticonvulsant for seizure control." 
B)  "My mother is able to get up out of the chair in one single movement." 
C)  "My mother is sometimes incontinent." 
D)  "My mother takes a benzodiazepine for her anxiety." 
E)  "My mother sometimes gets confused." 
A)  "My mother takes an anticonvulsant for seizure control." 
B)  "My mother is able to get up out of the chair in one single movement." 
C)  "My mother is sometimes incontinent." 
D)  "My mother takes a benzodiazepine for her anxiety." 
E)  "My mother sometimes gets confused."

Question 17

A patient has fallen in the nursing home. You are going to use the PLATT mnemonic to document the fall assessment. The "L" in the PLATT mnemonic stands for ____________________ of the fall.

Accepted Answer

The answer of A patient has fallen in the nursing...

Question 18

What is the correct technique for assessing the carotid artery in the elderly?

Accepted Answer

A)  Palpate both carotid arteries at the same time to compare carotid upstroke. 
B)  Auscultate for a bruit while the patient takes a deep breath. 
C)  Palpate each carotid artery one at a time. 
D)  Gently massage the carotid artery using a lateral motion. 
A)  Palpate both carotid arteries at the same time to compare carotid upstroke. 
B)  Auscultate for a bruit while the patient takes a deep breath. 
C)  Palpate each carotid artery one at a time. 
D)  Gently massage the carotid artery using a lateral motion.

Question 19

When administering the Mini Nutritional Assessment (MNA) to the elderly patient, which of the following would concern the nurse the most?

Accepted Answer

A)  The patient has a weight loss between 1 and 3 kg in the last 3 months. 
B)  The patient is ambulatory, but does not go out. 
C)  The patient has a body mass index (BMI) of less than 19. 
D)  The patient has mild dementia. 
A)  The patient has a weight loss between 1 and 3 kg in the last 3 months. 
B)  The patient is ambulatory, but does not go out. 
C)  The patient has a body mass index (BMI) of less than 19. 
D)  The patient has mild dementia.

Question 20

The nurse is making a home visit to an elderly client. Which statement made by the client's adult daughter would cause the nurse to assess the client for skin breakdown?

Accepted Answer

A)  "My mother takes a walk in the neighborhood every afternoon." 
B)  "My mother is able to go to the bathroom without assistance." 
C)  "My mother takes medication for her high blood pressure, diabetes, and a multivitamin." 
D)  "My mother eats three well-balanced meals a day." 
A)  "My mother takes a walk in the neighborhood every afternoon." 
B)  "My mother is able to go to the bathroom without assistance." 
C)  "My mother takes medication for her high blood pressure, diabetes, and a multivitamin." 
D)  "My mother eats three well-balanced meals a day."

Exam 22: Assessing the Older Adult

The nurse is performing a physical assessment on an elderly patient. Which finding would be considered normal aging?

When obtaining a health history and assessing an elderly patient in her home, which of the following would concern the nurse? Select all that apply.

The nurse is assessing gait and position sense in the elderly patient. Which of the following would be correct for the nurse to ask of the patient?

The elderly patient reports to the nurse that he coughs a lot during and after meals. What would be most important for the nurse to ask this patient first?

Which of the following is considered a normal aging change in the elderly patient?

A 78-year-old patient is complaining of chronic achy joint pain. She states, "I am so tired of living with pain." What is important to remember about pain and the elderly?

Which of the following statements is correct regarding alcohol use/abuse in the elderly? Select all that apply.

You are performing a comprehensive health assessment on a 68-year-old female. What normal assessment findings would the nurse expect to find in this elderly patient? Select all apply.

The elderly patient who is alert and oriented tells the nurse that she is incontinent when coughing and sneezing. The nurse knows that this patient has which type of incontinence?

The nurse is working in a senior housing complex assessing an 85-year old-resident. Which finding would be of greatest concern to the nurse?

Which of the following statements made by the elderly patient would alert the nurse to warning signs that the patient should stop driving? Select all that apply.

When performing a cardiac assessment, which of the following findings indicates the possibility of hypertrophy of the left ventricle?

The elderly patient's daughter is talking with the nurse. Which of the following statements made by the daughter would concern the nurse that the patient is a frail elder?

Which of the following would be important to include in the teaching plan for the elderly patient to help reduce the risk of osteoporosis? Select all that apply.

How would the nurse appropriately conduct the Whispered Voice test in the elderly patient?

The daughter of the elderly patient is talking to the nurse. Which of the following statements made by the daughter would concern the nurse regarding an increase in the risk of falls in the elderly? Select all that apply.

A patient has fallen in the nursing home. You are going to use the PLATT mnemonic to document the fall assessment. The "L" in the PLATT mnemonic stands for ____________________ of the fall.

What is the correct technique for assessing the carotid artery in the elderly?

When administering the Mini Nutritional Assessment (MNA) to the elderly patient, which of the following would concern the nurse the most?

The nurse is making a home visit to an elderly client. Which statement made by the client's adult daughter would cause the nurse to assess the client for skin breakdown?

Understanding Health Assessment

Interviewing the Patient for the Health History

Taking the Health History

Assessing Nutrition and Anthropometric Measurements

Assessment Techniques

General Survey and Assessing Vital Signs

Assessing Pain

Assessing the Skin, Hair, and Nails

Assessing the Head, Face, Mouth, and Neck

Assessing the Ears

Assessing the Eyes

Assessing the Respiratory System

Assessing the Cardiovascular System

Assessing the Abdomen

Assessing the Musculoskeletal System

Assessing the Female Breasts, Axillae, and Reproductive System

Assessing the Male Breasts and Reproductive System

Assessing the Anus and Rectum

Assessing the Newborn

Assessing the Child and Adolescent

Assessing the Pregnant Woman

Filters