Chapter 27 Verified Test Bank Older Adults - Health Assessment in Nursing 4e Test Bank by Cynthia Fenske. DOCX document preview.
Health & Physical Assessment in Nursing, 4e (Fenske/Watkins/Saunders/D'Amico/Barbarito)
Chapter 27 Older Adults
- Which should the nurse attribute to the older adult's decreased skin elasticity? Select all that apply.
1. Subcutaneous layer decreases.
2. Elastin fibers decreases.
3. Epidermis thins.
4. Collagen decreases.
5. Sebum production decreases.
Page Ref: 706
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- An older adult asks the nurse why they are more susceptible to skin cancer. Which response should the nurse provide?
1. "Your skin has become very thin."
2. "The cells in your body that protect you do not work as effectively."
3. "You have a decreased production of melanin which increases your risk."
4. "The age spots on your skin are more prone to turn cancerous."
Page Ref: 24-25
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- The nurse notes that the skin of some older light-skinned clients appears pale. Which changes should the nurse attribute the finding to?
1. Inability to absorb iron.
2. Decreased time in the sun.
3. Decreased vascularity of the dermis.
4. Decrease production in melanin.
Page Ref: 25-41
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- The nurse notes small bright red spots on an older client's skin. Which terminology will the nurse use to document the finding?
1. Cutaneous horns.
2. Cutaneous tags.
3. Cherry angiomas.
4. Senile lentigines.
Page Ref: 707
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.5: Generate the appropriate documentation to describe the assessment findings for older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse performing a community cancer screening observes a conical projection on the anterior ear lobe. Which action should the nurse take?
1. Document the finding as normal.
2. Ask the client how long they have had this.
3. Refer the client to the healthcare provider.
4. Ask the client if they are exposed to the sun frequently.
Page Ref: 707
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse assessing the skin on the face of an older adult observes yellow plaques on the inner canthus of the eyes. Which action should the nurse take?
1. Assess the liver function.
2. Assess the client's vision.
3. Assess the remainder of the skin.
4. Assess the client's ability to produce tears.
Page Ref: 708
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse notes that an older client has a light grey ring around the iris. Which should the nurse attribute the finding to?
1. Pterygium.
2. Cataract formation.
3. Deposition of lipids.
4. Loss of pigmentation in the iris.
Page Ref: 708
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Evaluation
Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- An older adult asks the nurse how macular degeneration occurs. Which answer should the nurse provide?
1. The optic nerve is damaged.
2. The lens of the eye thickens.
3. The blood vessels in the eyes narrow.
4. The eyes have had prolonged exposure to the sun.
Page Ref: 709
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse is reviewing the causes of presbyopia with a client. Which changes in the eye should the nurse include in the discussion? Select all that apply.
1. Narrowing blood vessels.
2. Weakened ciliary muscles.
3. Loss of eye elasticity.
4. Decrease response of the optic nerve.
5. Decreased ability of the lens to change shape.
Page Ref: 708
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- An older adult asks the nurse why they have trouble hearing some parts of a conversation. Which response should the nurse provide?
1. "The auditory nerve does not function as well."
2. "The tympanic membrane thickens as you age."
3. "There is a loss of hair cells that transmit sound."
4. "There is a decreased blood flow to the tympanic membrane."
Page Ref: 709
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity; Sensory/Perceptual Alterations
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- A family member of an older adult tells the nurse they are worried because their father does not eat much. Which contributing factors should the nurse plan to discuss with the family member? Select all that apply.
1. Decreased sense of taste.
2. Diminished olfactory fibers.
3. Decreased saliva production.
4. Diminished gum lines.
5. Decreased motor function of the tongue.
Page Ref: 709-708
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Nutrition and Oral Hydration
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse reviewing the chart of an older adult notes that the client has angular stomatitis. Which assessment finding should the nurse anticipate to include in the documentation?
1. Diminished gum lines.
2. Excessive salivation.
3. Edentulism.
4. Decreased salivation.
Page Ref: 710
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.5: Generate the appropriate documentation to describe the assessment findings for older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse is caring for an older client with pneumonia. Which factors should the nurse recognize compromise the client's airway clearance? Select all that apply.
1. Weakened skeletal muscles.
2. Decreased ciliary function.
3. Dry mucus membranes.
4. Inability to cough.
5. Decreased lung elasticity.
Page Ref: 710
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse is preparing to assess the lungs of an older adult. Which findings should the nurse anticipate? Select all that apply.
1. Percussed hyperresonance.
2. Slight substernal retractions.
3. Shallow respiratory cycle.
4. Less audible breath sounds.
5. Slightly decreased respiratory rate.
Page Ref: 710
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- The nurse is preparing to assess the cardiovascular system of an older adult. Which findings should the nurse anticipate?
1. Increase in systolic pressure.
2. Decreased resting heart rate.
3. Decrease in systolic pressure.
4. Increase in resting heart rate.
Page Ref: 710
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- The nurse is preparing to screen an older client for dementia. Which assessment tool should the nurse use?
1. The Denver II.
2. Mini Cog.
3. Life Experiences Survey.
4. Mini-Mental Status Examination.
Page Ref: 714
Cognitive Level: Psychosocial Integrity
Client Need & Sub: Health Promotion and Maintenance; Sensory/Perceptual Alterations
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.4: Outline key considerations for physical assessment of older adults.
MNL Learning Outcome: 27.3. Utilize the appropriate techniques and tools for physical assessment of older adults.
- Which assessment findings in an older adult client does the nurse associate with the normal aging process? Select all that apply.
1. Increased systolic blood pressure.
2. Increased muscle tone.
3. Decreased cardiac output.
4. Increased vital capacity.
5. Decreased renal function.
Page Ref: 710-712
Cognitive Level: Remembering
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- Which should the nurse attribute to an older client's increased susceptibility to medication toxicity?
1. Decreased ammonia production.
2. Inability to produce adequate amounts of bicarb.
3. Reduced ability to reabsorb glucose.
4. Decreased ability to clear acids.
Page Ref: 711
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- The nurse is obtaining a focused assessment from a postmenopausal client about genitourinary changes. Which questions should the nurse include in the assessment? Select all that apply.
1. "Have you experienced a decreased libido?"
2. "Are you experiencing any leakage of urine?"
3. "Have you experienced any vaginal dryness?"
4. "Have you experienced a loss of bladder control?"
5. "Have you experienced an increase in vaginal discharge?"
Page Ref: 711
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 27.3: Determine questions about older adults to use for the focused interview.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- An older client tells the nurse they do not understand why they do not have the endurance to exercise like they did when they were younger. Which statement should the nurse provide the client?
1. "The muscles and joints become worn and do not move as easily as they used to."
2. "As individuals get older, there are normal changes that occur in the body, specifically the heart and lungs, that may contribute to decreased endurance."
3. "It is possible that you have not been consistently exercising."
4. "The body undergoes physiologic changes that can affect your endurance, such as decreased cardiac output and increased residual air volume in the lungs."
Page Ref: 710, 721
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults.
MNL Learning Outcome: 27.1. Consider the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
- The nurse is reviewing geriatric syndrome with the family of an older client. Which should the nurse include in the discussion? Select all that apply.
1. Frailty.
2. Polypharmacy.
3. Depression.
4. Stool incontinence.
5. Malnutrition.
Page Ref: 713
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: III.A.5. Explain the role of evidence in determining best clinical practice. | AACN Essentials Competencies: I.1. Integrate theories and concepts from liberal education into nursing practice. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse is preparing to review the risk for cognitive impairment with the family of an older adult. Which information should the nurse include? Select all that apply.
1. Frailty.
2. Aging.
3. Genetics.
4. Depression.
5. Poor nutrition.
Page Ref: 714
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity; Sensory/Perceptual Alterations
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- Which considerations should the nurse be aware of when obtaining a health history from an older adult? Select all that apply.
1. Sit at eye level facing the client.
2. Consider the stamina of the client.
3. Allow the client to reminisce during the interview.
4. Adjust the questioning according to the client's behavior.
5. Interrupt the client if they are explaining something not understood.
Page Ref: 716
Cognitive Level: Applying
Client Need & Sub: Psychosocial Integrity; Therapeutic Communication
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 27.4: Outline key considerations for physical assessment of older adults.
MNL Learning Outcome: 27.3. Utilize the appropriate techniques and tools for physical assessment of older adults.
- An older client tells the nurse they are having difficulty seeing at night when they are driving. Which condition should the nurse suspect?
1. Presbyopia.
2. Cataracts.
3. Glaucoma.
4. Macular degeneration.
Page Ref: 717
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Diagnosis
Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse is preparing to discuss the changes in the urinary elimination with an older client. Which topics should the nurse discuss? Select all that apply.
1. Urinary retention.
2. Increased urine output.
3. Decreased bladder capacity.
4. Involuntary bladder contractions.
5. Weakening of the urinary sphincters.
Page Ref: 720
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Aging Process
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 27.1: Describe unique aspects of the anatomy and physiology of body systems in older adults.
MNL Learning Outcome: 27.2. Plan questions related to older adults for the focused interview.
- The nurse is preparing to assess a client with nocturia. Which findings should the nurse recognize are specifically associated with nocturia? Select all that apply.
1. Obesity.
2. Stool impaction.
3. Hyperglycemia.
4. Decreased bladder capacity.
5. Weakened bladder and urethral muscles.
Page Ref: 720
Cognitive Level: Applying
Client Need & Sub: Physiological Integrity; Elimination
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.
- The nurse is preparing to assess a client with benign prostatic hypertrophy (BPH). Which focused question should the nurse ask the client?
1. "Do you have a urinary tract infection?"
2. "Do you experience urinary retention?"
3. "Do you experience urinary frequency?"
4. "Do you have urinary leakage when you cough or sneeze?"
Page Ref: 720
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 27.3: Determine questions about older adults to use for the focused interview.
MNL Learning Outcome: 27.2. Plan questions related to older adults for the focused interview.
- The nurse is preparing to obtain a functional assessment from an older client. Which basic activities of daily living (ADL) should the nurse assess? Select all that apply.
1. Cooking.
2. Exercise.
3. Bathing.
4. Dressing.
5. Shopping.
Page Ref: 723
Cognitive Level: Applying
Client Need & Sub: Health Promotion and Maintenance; Health Screening
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 27.2: Identify the anatomic, physiologic, developmental, psychosocial, and cultural variations that guide assessment of older adults.
MNL Learning Outcome: 27.2. Plan questions related to older adults for the focused interview.
- The nurse is reviewing the medical history of a client with onychomycosis. Which disease should the nurse recognize is associated with the infection?
1. Liver disease.
2. Hyperthyroidism.
3. Renal disease.
4. Peripheral vascular disease.
Page Ref: 727
Cognitive Level: Applying
Client Need & Sub: Physiological Adaptation; Alterations in Body Systems
Standards: QSEN Competencies: I.B.3. Provide patient-centered care with sensitivity and respect for the diversity of human experience. | AACN Essentials Competencies: IX.3. Implement holistic, patient-centered care that reflects an understanding of human growth and development, pathophysiology, pharmacology, medical management, and nursing management across the health-illness continuum, across lifespan, and in all healthcare settings. | NLN Competencies: Knowledge and Science: Relationships between knowledge/science and quality and safe patient care. | Nursing/Integrated Concepts: Nursing Process: Implementation
Learning Outcome: 27.6: Identify abnormal findings in the physical assessment of older adults.
MNL Learning Outcome: 27.4. Differentiate normal and abnormal variations of older adults observed during physical assessment.