Deck 4: Gerontologic Assessment

Question 1

The nurse has administered the Apgar screen tool to assess an older client's family function status.Upon determining that the family functions at a 4, the nurse:

A)prepares to administer a more detailed tool.
B)prepares to report reasonable suspicion of elder abuse.
C)asks the client to identify specific family members to include in care planning sessions.
D)notifies social services that the family is not likely to be of much support to the client.

Answer 1

notifies social services that the family is not likely to be of much support to the client.

Question 2

The geriatric nurse admitting a client to an assisted living facility recognizes the importance of tools such as the Katz and the Barthel indexes because of the impact they have on:

A)planning the amount of help the client will need with ADLs.
B)the client's ability to be realistic about achieving independence.
C)creating an appropriate, client-specific nursing care plan.
D)appropriate staffing to ensure the safety needs of the clients are met.

Answer 2

creating an appropriate, client-specific nursing care plan.

Question 3

A nurse aide working in the geriatric unit's dining room tells the nurse that a client who was oriented to time and place this morning is now confused about what day it is and why she's "here." The nurse appropriately directs the nurse aide to:

A)take the client back to her room and put her safely in bed.
B)place a falls risk identification bracelet on the client and add the status to the Kardex.
C)immediately take the client's vital signs and report them to her.
D)reorient the client to time and place frequently and document the client's response.

Answer 3

immediately take the client's vital signs and report them to her.

Question 4

An 80-year-old client is being admitted to a long- term care facility.The nurse recognizes that the primary purpose of the initial geriatric health assessment is to:

A)identify the client's physiologic baselines.
B)ultimately create a plan of care that prevents disability and dependence.
C)initiate the therapeutic nurse-client relationship.
D)document self-care deficiencies that the client exhibits.

Question 5

An 81-year-old patient is reluctant to report multiple vague signs and symptoms, including lethargy, incontinence, and weight loss that have persisted for 6 weeks.The nurse recognizes that such symptoms place the client at great risk for:

A)viral infection.
B)disorientation.
C)malnutrition.
D)physical frailty.

Question 6

A nurse who cares for older adults recognizes which of the following clinical features associated with dementia? Select all that apply.

A)Failing to remember their room number
B)Becoming increasingly disoriented at night
C)Working on jig-saw puzzles for hours at a time
D)Often referring to a cup as a canyon
E)Misunderstanding when told "it's raining cats and dogs"

Question 7

The geriatric nurse recognizes that the body's homeostatic mechanisms may be compromised in the:

A)79 year old with moderate Alzheimer's disease who requires assistance with all ADLs.
B)73 year old with a history of chronic bronchitis who lives with family.
C)86 year old who lost a spouse and is moving into an assisted living facility.
D)69 year old diagnosed with peripheral vascular disease who is visited by a home health care worker weekly.

Question 8

An 81-year-old client who is accompanied by family is being admitted after a fall that has caused a painful leg injury.In preparing to interview the client for a health history, the nurse is initially concerned that:

A)the family should be present to help solve the assessment questions.
B)a therapeutic nurse-client relationship should be established.
C)the client should be free of hearing and vision barriers.
D)the client's pain should be effectively managed.

Question 9

When unsure about how to address older clients with advanced stage Alzheimer's disease, the nurse recognizes that it is best to address them by:

A)a pet name, such as "grandma" or "grandpa" because the clients are not likely to respond to their given names.
B)their first name in order to foster a friendly, relaxed atmosphere.
C)their full name to show respect for the clients as individuals.
D)a childhood nickname because long-term memory will likely still be intact.

Question 10

A 76-year-old postsurgical diabetic client has reported feeling dizzy and clammy.The daily serum glucose level shows the client's levels to be within normal limits.The geriatric nurse shows an understanding of established health norms for the older adult when stating:

A)"This client's normal may not be within the typical lab norms."
B)"I'll ask the lab to re-run the test so we can double check the results."
C)"There must be another reason for the symptoms."
D)"I'll compare the client's baseline lab work with today's results."

Question 11

An 80-year-old client is admitted to rule out bacterial pneumonia.The only abnormal assessment values include heart rate of 102 beats per minute, slight cyanosis of the nail beds, and mild confusion.The client's daughter questions the possibility of pneumonia stating, "He isn't coughing or having any difficulty breathing." The nurse responds most appropriately by saying:

A)"We are very lucky to determine the problem in its early stage."
B)"Respiratory problems develop only after the infection is well established."
C)"People your dad's age often lack the muscular strength to cough."
D)"Older adults frequently lack the typical signs of a respiratory infection."

Question 12

The nurse showing the best understanding of how personal attitude affects the interview process during a health assessment of an older adult client is one who:

A)proceeds with the interview as if the client were not elderly.
B)has incorporated therapeutic communication techniques into the assessment process.
C)treats all clients with respect regardless of age.
D)has self-reflected on his or her own feelings regarding aging.

Question 13

The nurse most effectively implements guided reminiscence during a client interview by:

A)reminding the client to share important memories of the past.
B)scheduling several short interviews rather than one long one.
C)controlling the interview by selecting the memories to be discussed.
D)encouraging the client to relive their memories while maintaining focus.

Question 14

In order to best minimize client anxiety and help ensure a successful history assessment interview, the geriatric nurse first:

A)asks whether the client has any questions about the interview.
B)makes sure the interview area is comfortable and private.
C)explains the reason for asking the questions.
D)assures the client that all solve to the questions will be kept confidential.

Question 15

A 78-year-old client is hospitalized after a fall that resulted in a fractured left ankle.By day 4 of the hospitalization that includes reduction of the fracture and analgesic drug therapy, the client has become mildly disoriented and is incontinent of urine.The nurse explains to the family that these symptoms reflect the:

A)relationship between aging and both physical and psychosocial responses to trauma.
B)response exhibited by many older adults who are hospitalized.
C)effects of stress-induced perceptual deficits often seen in the hospitalized older adult.
D)results of the pharmacologic pain control therapy.

Question 16

In order to establish a mutually respectful relationship with an older adult client being admitted to a skilled nursing unit, the nurse first introduces himself and then asks:

A)how the client would like to be addressed.
B)if the client has any specific requests to make of the staff.
C)the client to share a little about his or her personal likes and dislikes.
D)the client to read the orientation materials that the facility provides.