Deck 8: Health Assessment for Older Adults

Question 1

What data would the nurse expect to find when performing an assessment of a 90-year-old suspected of having an upper respiratory infection?

A) Temperature elevation over 101° F
B) Elevated white blood count
C) History of recent periods of confusion
D) Record of increased fluid intake

Answer 1

History of recent periods of confusion

Question 2

How should the nurse begin the health interview in order to most effectively build rapport with the patient?

A) Focus on the problems that the patient sees as important.
B) Explain the importance of health maintenance.
C) Inform the patient of the number of questions that will be asked.
D) Reassure the patient that the interview is private.

Answer 2

Focus on the problems that the patient sees as important.

Question 3

The nurse conducting a patient assessment records a seated blood pressure of 135/86. What standing blood pressure would be indicative of orthostatic hypotension?

A) 145/85
B) 134/76
C) 130/72
D) 124/62

Answer 3

124/62

Question 4

An 85-year-old man accompanied by his son is unable to recall the medications that he is presently taking. What would be the most appropriate response by the nurse?

A) Ask the question again.
B) Rephrase the question.
C) Ask the son for the information.
D) Leave that part of the health history blank.

Question 5

Which of the following tests should be performed annually in a 55-year-old woman?

A) Fecal occult blood test
B) Sigmoidoscopy
C) Hearing screening
D) Mammogram

Question 6

What is the purpose of a health screening?

A) Identifies persons with unmet health needs who may need a referral.
B) Assesses local health needs for the Public Health Department.
C) Collects data that will be used for research.
D) Provides appropriate treatment for identified health needs.

Question 7

During the health interview, the older adult complains of vague physical gastrointestinal complaints, the inability to fall asleep, frequent periods of wakefulness during the night, and a decrease in appetite. What should the nurse inquire about?

A) Feelings of depression
B) Time of last bowel movement
C) Environmental stimuli that disturb sleep
D) Frequency and size of meals

Question 8

The nurse charts, "Patient stated pain is at a level of 8 on a scale of 1 to 10 and that he is still nauseated. Patient complains of feeling cold and has an oral temperature of 97.8°." What information would be considered objective findings?

A) Pain measurement
B) Presence of nausea
C) Sense of cold
D) Oral temperature

Question 9

What is the correct term for the difference between the apical pulse and the radial pulse?

A) Pulse pressure
B) Pulse deficit
C) Pulse ratio
D) Pulse quality

Question 10

What is the best way to assess psychological status in an older adult?

A) Direct observation
B) Input from family members
C) Subjective findings
D) Review of nursing notes

Question 11

The nurse explains that the Minimum Data Set (MDS) 3.0 used in extended-care facilities is designed to

A) identify ethnic populations in long-term care.
B) group residents into specified activity levels.
C) organize information relative to diagnostic categories.
D) make assessment processes more consistent.

Question 12

How should the nurse interview a 90-year-old Chinese woman who is accompanied by her daughter?

A) Use direct, short questions.
B) Address all the questions to the daughter.
C) Use pictures of body systems rather than anatomical terms.
D) Use social conversation and indirect questions.

Question 13

What communication technique would be most helpful during the health interview?

A) Use medical terminology.
B) Keep questions simple.
C) Help patients by finishing their sentences.
D) Allow patients to ramble as they respond.

Question 14

The 94-year-old woman has come to the health assessment interview with her 70-year-old daughter, who answers all the interview questions for her mother. What response by the nurse would be the most effective?

A) Say, "I'm speaking to your mother. Please let her answer for herself."
B) Continue to interact with the daughter to facilitate completion of the interview.
C) Look directly at the patient and say, "Mrs. Smith, now I'd like to hear from you about your health."
D) Document that all answers to the interview came from a third party.

Question 15

When conducting a health assessment, which finding would be recorded as crackles?

A) High-pitched sounds in the lung bases on inspiration
B) Continuous low-pitched snoring sounds over major bronchi
C) Squeaky musical sounds on expiration
D) Coarse grating sounds on inspiration and expiration

Question 16

What type of thermometer would be the best choice when assessing the temperature of an older adult?

A) Electronic thermometer, because it only takes a few seconds to assess temperature
B) Oral thermometer, because the presence of dry mucous membranes gives a more valid temperature
C) Axillary thermometer, because its position is nearer the heart
D) Rectal thermometer, because it is the best indicator of the body core temperature

Question 17

Which statement by the nurse would be the most appropriate at the beginning of the health interview?

A) "Hello, Mrs. Smith. My name is Alice. We'll start with a few questions before the physical exam."
B) "Welcome, Sara. I'm Alice. Let's get down to some questions about your health."
C) "I'm Alice Jones. I'm here to do an interview about your health."
D) "Hey, Mrs. Smith! Are you ready for some questions about your health?"

Question 18

What special precautions should the nurse take during the physical exam of an 86-year-old woman?

A) Weigh the patient carefully without clothing.
B) Prevent the patient from becoming chilled during the examination.
C) Give fluids before the examination.
D) Elevate the patient's head while she is lying in a supine position.

Question 19

Where would the nurse place the head of the stethoscope when assessing an apical pulse?

A) Third intercostal space at proximal edge of the clavicle
B) Fourth intercostal space at the edge of the sternum
C) Fifth intercostal space even with the middle of the clavicle
D) Sixth intercostal space above the diaphragm

Question 20

What statement would put the older woman most at ease during a health interview?

A) "The interview will take quite a while."
B) "Please have a seat over there across from the desk."
C) "There are lots of questions that we must finish."
D) "The bathroom is behind that green door. We'll be taking a break in about 30 minutes."

Question 21

The nurse palpates a very weak pedal pulse in the right foot. What other findings would the nurse expect to find in the right foot and leg? (Select all that apply.)

A) Bruising
B) Darkened color
C) Cool skin
D) Diminished hair on limb
E) Capillary refill of 3 seconds

Question 22

What would be included in a list of the five techniques of health assessment? (Select all that apply.)

A) Inspection
B) Palpation
C) Interview
D) Auscultation
E) Percussion

Question 23

What data would be collected during the identifying information portion of the health interview? (Select all that apply.)

A) Ethnicity
B) Previous or current occupation
C) Educational background
D) Perception of general health
E) Completion of advanced directives

Question 24

What is true of the health assessment in a long-term care facility? (Select all that apply.)

A) It is the basis for the assignment of nursing diagnoses.
B) It is done only at admission to the facility.
C) It is performed only by a registered nurse.
D) It is a platform for the nursing care plan.
E) It is ongoing for the duration of the stay.

Question 25

How is objective data collected? (Select all that apply.)

A) Observation
B) Patient complaints
C) Physical examination
D) Laboratory findings
E) Family input

Question 26

What should be considered when planning a health interview with an older adult? (Select all that apply.)

A) Comfort of the physical setting
B) Methods to develop trust and rapport
C) Timing for minimal distractions
D) The age and ethnicity of the patient
E) Income level

Question 27

By what means can a health screening be conducted? (Select all that apply.)

A) A health professional
B) Telephone interview
C) Telecomputer
D) Pen and paper surveys
E) Lay persons

Question 28

The nurse explains that the tool that allows the evaluation of core function in a resident in a long-term facility is the __________ __________ __________.