1. The nurse is assessing a 72-year-old patient who was diagnosed with osteoporosis at age 65.
The nurse detects the patient has kyphosis on exam. The nurse suspects:
1. kyphosis is related to previous injury and should be monitored
2. kyphosis will require the patient to be in a wheelchair.
3. kyphosis is a normal finding for this age group because of osteoporosis.
4. kyphosis is not normal and must be evaluated further
2. The nurse is performing an assessment on an older patient. Which change that occurs with
aging explains why an older adult may be unaware of an infection or injury to the eye?
1.
2.
3.
4.
Decreased corneal sensitivity
Diminished tearing
Reduced visual acuity
Increased density of the lens
3. The nurse is assessing an 88-year-old woman who has a blood pressure reading of 160/90 mm
Hg. This blood pressure reading indicates:
1.
2.
3.
4.
High blood pressure
Prehypertension
Hypertension
A normal value for an older adult
4. The daughter of an elderly patient is concerned because her mother has been falling lately. The
nurse performs a head-to-toe assessment. Which finding indicates a need for further evaluation?
1.
2.
3.
4.
The patient is 60 years old
The patient appears agitated.
The patient is not taking medications.
The patient relies on her daughter for transportation.
5. The nurse is preparing to assess an older patient’s basic activities of daily living (BADLs).
What should be included in this assessment? Select all that apply
1.
2.
3.
4.
5.
6.
Shopping
Food preparation
Driving
Walking
Bathing
Dressing
6. The student nurse is studying the difference between middle-age adults and older adults. The
student nurse should be aware that the neurologic responses of older adults
1.
2.
3.
4.
should be the same as those of younger adults
may be slower than those of younger adults
are present but difficult to evaluate.
are enhanced as a result of irritability.
The nurse is assessing a 72-year-old patient in the clinic. Which statement made by a 72-year-old
patient describes a normal process of aging?
1.
2.
3.
4.
“My tongue feels swollen.”
“My tonsils are large and sore.”
“I have a black spot on my gums.”
“Food does not taste the same as it used to.”
The nurse is assessing an older patient’s ability to perform IADLs. What is included in this
assessment? Select all that apply
1.
2.
3.
4.
5.
6.
Proper use of medications
Cooking dinner
Using public transportation
Walking
Bathing
Writing checks
The nurse is reviewing risk factors for respiratory infection with an older adult patient. Which
physiologic change that occurs with aging predisposes the older adult to respiratory infections?
1.
2.
3.
4.
Mucous membranes become drier and more difficult to clear.
Calcification occurs at the rib articulation points.
The alveoli become less elastic and more fibrous.
There is a reduction of interalveolar folds.
The nurse is preparing to assess an older patient’s ability to perform IADLs. Which statement
about IADLs is true?
1.
2.
3.
4.
The nurse uses direct observation to implement this tool.
They are not useful in the acute hospital setting.
They are designed as a self-report measure of performance rather than ability.
They are best used for those residing in an institutional setting.
The nurse is documenting information about the client using Problem-Oriented Charting and the
acronym SOAP. Rank the following pieces of information in the order that they should be
documented.
A. The client states, "I am so tired all of the time. I feel like I'm not getting enough air into my
lungs."
B. The client's skin is cool and dusky. Poor capillary refill noted. Oxygen saturation level is 90%
on room air. The client was diagnosed with COPD in 1993.
C. The client is most likely experiencing an exacerbation of a chronic lung disease.
D. The nurse will apply oxygen at two liters per minute per healthcare provider's orders, when
the client's oxygen saturation level is below 92%.
A-B-C-D
Which action is appropriate for the nurse to include in the client's health history portion of the nursing
assessment?
A. Monitoring blood pressure.
B. Discussing cultural traditions.
C. Assessing lung sounds.
D. Monitoring temperature.
The nurse has palpated an abnormal mass within the client's scrotum. Which assessment activity is
appropriate for the nurse to perform next?
A. The nurse should gently squeeze the mass between the fingers.
B. The nurse should attempt to transilluminate behind the area in which the abnormal mass was
palpated.
C. The nurse should percuss the client's scrotum.
D. The nurse should inspect the inguinal area.
The nurse is performing a head-to-toe assessment on an older adult client who was admitted to the
hospital with dehydration. Which findings are consistent with this condition?
A. Tenting noted on dorsal aspect of client's hand when skin turgor was assessed.
B. Client has produced 175 milliliters of urine over the last 8 hours.
C. Dentures are loose, small sores noted on oral mucosa.
D. Healthcare provider notes client is exhibiting xerostomia.
E. Client's apical heart rate is 82 beats per minute.
The nurse is performing an assessment on an adolescent client. Which finding would be
unexpected?
A. Apical heart rate of 110 beats per minute.
B. Respiratory rate of 14 breaths per minute.
C. Blood pressure of 98/58 mmHg.
D. Temperature of 98.8°F.
Adolescent HR 60-120, BP
During the physical assessment, the hospitalized client states, "I've been under an incredible amount
of stress since my healthcare provider diagnosed me with colon cancer 2 days ago." Which
assessment data collected by the nurse are associated with increased stress?
A. Apical heart rate is 104 beats per minute.
B. Respiratory rate is 16 breaths per minute.
C. Pupils were equal, dilated, and round.
D. Client is hypoglycemic.
E. Blood pressure is 158/94.
The nurse is performing routine assessments on five hospitalized clients. Which clients does the
nurse expect to exhibit poor skin turgor."
A. The client had an open appendectomy 2 days ago.
B. The client was admitted with severe nausea and vomiting.
C. The client has lost 16 pounds during the last 30 days.
D. The client has had a high fever during the last four days and was admitted through the
Emergency Department last night.
E. The client was admitted this morning with a severe migraine.
The nurse is preparing to perform a rapid assessment as the more experienced nurse observes.
Which statement by the student nurse indicates that further education is required?
A. "The rapid assessment should last approximately 10 minutes."
B. "I should perform a rapid assessment for all of my assigned clients at the beginning of the
shift to help me prioritize care."
C. "The rapid assessment will help me establish baseline data about the client."
D. "After I perform the rapid assessments on the clients I've been assigned, I can go back and
get more information during my routine assessments."
Won’t able to establish baseline date about the client, not conduct a physical examination, more
like a general survey
Priority: expected finding, amongst unexpected, who already treated, who if I don’t treat now
will do
Fumer SPICES: Sleep disorder (insomnia), P- eating, nutrional status, I is incontinence,
neurocognitive issues
Know the physical findings for geriatric patients, it is expected for certain signs