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Health Assessment for Nursing Practice 4th Edition Wilson Giddens Test Bank

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Health Assessment for Nursing Practice 4th Edition Wilson Giddens Test Bank

ISBN-13: 978-0323053228

ISBN-10: 032305322X

 

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Health Assessment for Nursing Practice 4th Edition Wilson Giddens Test Bank

ISBN-13: 978-0323053228

ISBN-10: 032305322X

 

 

 

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Free Nursing Test Questions:

 

Wilson & Giddens: Health Assessment for Nursing Practice,

4th Edition

 

Test Bank

 

Chapter 22: Assessment of the Older Adult

 

MULTIPLE CHOICE

 

  1. In assessing the mood of older adult clients, a nurse documents which finding as abnormal?
a. Sadness and grief after returning from the funeral of a long time friend
b. Depression that interferes with the ability to perform activities of daily living
c. Frustration about rearranging the day’s schedule to attend a grandson’s birthday party
d. Crying about the unexpected death of a pet which had been with the family 12 years

 

 

ANS:   B

Correct: Persistent depression that interferes significantly with ability to function is not an expected finding.

Incorrect A: Emotional experiences of sadness, grief, response to loss, and temporary “blue” moods are normal responses in older adults.

Incorrect C: This is a normal response for any adult.

Incorrect D: Emotional experiences of sadness, grief, response to loss, and temporary “blue” moods are normal responses in older adults.

 

DIF:    Cognitive Level: Application             REF:    563

OBJ:    NCLEX Client Need Category: Physiologic Integrity: Physiological Adaptation: Alteration in Body Systems

TOP:    Older Adult Health: Mental Health Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. A 75-year-old notes that he was told he has presbycusis and asks what this is. The nurse explains that presbycusis is:
a. A persistent ringing of the ears associated with low-frequency hearing loss.
b. Chronic ear infections associated with accumulation of ear wax.
c. Impaired coordination related to damage to the middle ear.
d. Gradual high-frequency hearing loss associated with aging.

 

 

ANS:   D

Correct: This is a description of presbycusis, a sensorineural hearing loss, and an expected change with aging.

Incorrect A: This does not describe presbycusis and is not an expected change with aging.

Incorrect B: This does not describe presbycusis and is not an expected change with aging.

Incorrect C: This does not describe presbycusis and is not an expected change with aging.

 

DIF:    Cognitive Level: Application             REF:    563

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Ear Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. A 75-year old client tells the nurse, “I just do not enjoy eating as much as I used to because the food does not have much taste or smell.” Which statement by the nurse is most appropriate?
a. “You should make an appointment with your health care provider.”
b. “Try eating small, frequent meals.”
c. “The senses of smell and taste decrease as we age.”
d. “Maybe you should use saline drops in your nose.”

 

 

ANS:   C

Correct: A decreased sense of smell is caused by a decrease in the number of sensory cells in the nasal lining. Taste perception may also diminish due to gradual atrophy of the tongue and a decrease in the number of papillae and taste buds.

Incorrect A: This action is not warranted in this case; these changes are expected with aging.

Incorrect B: This is practical advice, but will not alter the change in smell and taste.

Incorrect D: This is practical advice, but will not alter the change in small and taste.

 

DIF:    Cognitive Level: Application             REF:    563

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Nose and Mouth Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. During inspection of the mouth of an older adult, a nurse notices which finding as an expected change associated with aging?
a. Exposed root surfaces of teeth
b. Aphthous ulcers of the mucosa
c. Collection of debris at the gingival margins
d. Leukoplakia of the dorsal and ventral tongue

 

 

ANS:   A

Correct: Root surfaces of the teeth are exposed to caries formation because of gingival recession.

Incorrect B: Ulcers are not an expected finding.

Incorrect C: Collection of debris at the gingival margins is not an expected finding.

Incorrect D: This is not an expected finding; leukoplakia is a white patch or plaque that cannot be scraped off and often represents a premalignant lesion.

 

DIF:    Cognitive Level: Comprehension      REF:    563

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Mouth Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. While inspecting the tympanic membrane of an older adult, a nurse notices the membrane is more translucent and sclerotic, which contributes to which hearing impairment?
a. Gradual high-frequency hearing loss associated with aging
b. Conductive hearing loss
c. Difficulty hearing high-pitched sounds such as s and th
d. Sensorineural hearing loss

 

 

ANS:   B

Correct: Conductive hearing loss occurs when the tympanic membrane becomes more translucent and sclerotic.

Incorrect A: This change occurs with sensorineural hearing loss.

Incorrect C: This change occurs with sensorineural hearing loss.

Incorrect D: Sensorineural hearing loss develops as the hair cells in the organ of Corti begin to degenerate, usually after age 50. Hearing loss first occurs with high-frequency sounds and progresses to lower-frequency tones.

 

DIF:    Cognitive Level: Comprehension      REF:    563

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Ear Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. The nurse notes which finding as normal on assessment of an older adult client’s abdomen?
a. Hyperactive bowel sounds in all quadrants
b. Decreased fatty deposits over the abdomen
c. Marked concavity of the abdominal contour
d. Report of heartburn after most meals

 

 

ANS:   D

Correct: Older adults have decreased motility in the esophagus; there is a decrease in the lower esophageal pressure, resulting in increased likelihood of regurgitation.

Incorrect A: The opposite is true; decreased peristalsis causes hypoactive bowel sounds.

Incorrect B: The opposite is true; older adults may have increased fat deposits over the abdominal area.

Incorrect C: The opposite is true due to the increased fat deposits over the abdominal area.

 

DIF:    Cognitive Level: Comprehension      REF:    563, 568

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Gastrointestinal Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. In collecting a history from an older adult, which information does the nurse consider least essential for a client of this age?
a. Past health history
b. Genogram
c. Functional abilities
d. Mental health

 

 

ANS:   B

Correct: A genogram is not routinely used to document the family history for an older adult. The health status and cause of death of the client’s parents and siblings lose value as the client ages.

Incorrect A: It is important to document the client’s chronic illnesses.

Incorrect C: This provides data about how well the client performs activities of daily living.

Incorrect D: These data are essential to collect about all clients regardless of age.

 

DIF:    Cognitive Level: Comprehension      REF:    565

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Health History

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. During an office visit, a 78-year-old woman is upset because her height is “2 inches less than it was when I was 40!” The nurse explains that:
a. Reduced height may occur as one ages due to shortening of the vertebrae.
b. She is probably experiencing this height change due to arthritis.
c. She needs to improve her posture by performing stretching exercises.
d. This is a rare occurrence and warrants a bone density test.

 

 

ANS:   A

Correct: Decreased bone formation reduces height in most older adults, which may cause shortening of the vertebrae and thinning of the vertebral disks.

Incorrect B: Decreased bone formation reduces height in most older adults and is not due to arthritis.

Incorrect C: This is appropriate advice, but is not related to the client’s height.

Incorrect D: This is an expected occurrence and does not warrant concern.

 

DIF:    Cognitive Level: Application             REF:    564

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Musculoskeletal Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. When assessing the pain level of an older adult, a nurse considers which factor?
a. Neural transmission of pain is increased as a part of the aging process.
b. Older adult clients are not reliable in their descriptions of pain and how it affects them.
c. Physiologic indicators of pain that are unique to older adults are tachycardia and hypotension.
d. The older adult may believe that pain is a factor of aging and not worth mentioning.

 

 

ANS:   D

Correct: Some older adults may perceive pain as an expected aspect of aging that they must endure.

Incorrect A: This is an incorrect statement; the neural transmission is the same for older and younger adults.

Incorrect B: This is an incorrect statement; becoming older does not diminish one’s ability to describe pain.

Incorrect C: This is an incorrect statement; the physiologic indicators are the same for older and younger adults.

 

DIF:    Cognitive Level: Application             REF:    570

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Pain Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. A nurse is assessing the pain of an 86-year-old man who had hip surgery recently. The client has been slightly confused since his surgery, but he responds to simple questions. What is the best way to assess this client’s pain?
a. Asking him to rate his pain on a scale of 0 to 10
b. Asking him to rate his pain using descriptive adjectives
c. Asking him to rate his pain using a visual analog scale
d. Observing his behavior and measure his vital signs

 

 

ANS:   C

Correct: Pain assessment in older adults is significantly improved by using a visual analog scale or pain faces.

Incorrect A: This scale is appropriate for adolescents and adults, but older adults are assessed more accurately with a scale that they can see.

Incorrect B: This method is not effective for assessing pain because adjectives have different meanings to different people. It is best to use a scale or pictures of faces.

Incorrect D: Client behavior and vital signs are not accurate ways to assess a client’s perception of pain.

 

DIF:    Cognitive Level: Analysis                  REF:    670

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Pain Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. In assessing the skin of an older adult, a nurse recognizes a normal variation in the skin called solar lentigo, which is described as:
a. Yellowish, thin papules with a central depression.
b. Pigmented, raised, wart-like lesions on the face or trunk.
c. SmallRemember,ft, pigmented tags of skin on the face and neck.
d. Irregular, flat, deeply-pigmented macules on sun-exposed areas.

 

 

ANS:   D

Correct: This is a description of solar lentigo.

Incorrect A: This is a description of sebaceous hyperplasia.

Incorrect B: This is a description of seborrheic keratosis.

Incorrect C: This is a description of acrochordon (skin tags).

 

DIF:    Cognitive Level: Application             REF:    570

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Skin Assessment

MSC:   Integrated Process: Nursing Process

 

  1. When assessing the skin of an older adult, a nurse notices pigmented, raised warty-appearing lesions on the trunk and documents this finding as:
a. Solar lentigo.
b. Basal cell skin cancer.
c. Seborrheic keratosis.
d. Sebaceous hyperplasia.

 

 

ANS:   C

Correct: This is a description of seborrheic keratosis.

Incorrect A: Solar lentigo appears as irregularly-shaped, flat, deeply-pigmented macules that may appear on body surface areas with repeated exposure to the sun.

Incorrect B: Basal cell carcinoma appears as a nodular pigmented lesion with a depressed center and rolled borders found on sun-exposed areas.

Incorrect D: Sebaceous hyperplasia appears as yellowish, flattened papules that have central depressions.

 

DIF:    Cognitive Level: Comprehension      REF:    571

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Skin Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. In assessing the external eyes of an older adult, a nurse documents which finding as abnormal?
a. Gray-white circle where the cornea and the sclera merge
b. Brown spots near the limbus in both eyes
c. Lack of luster of the eye and dry bulbar conjunctiva
d. Lower lid drops away from the globe

 

 

ANS:   D

Correct: This is a description of ectropion, an abnormal finding.

Incorrect A: This is a description of arcus senilis.

Incorrect B: This is a description of a normal variation.

Incorrect C: This occurs because the lacrimal apparatus may function poorly, producing fewer tears.

 

DIF:    Cognitive Level: Application             REF:    572

OBJ:    NCLEX Client Need Category: Physiologic Integrity: Physiological Adaptation: Alteration in Body Systems                                   TOP:               Older Adult Health: Eye Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. The nurse teaches older clients that they are at risk of corneal irritation related to:
a. Impaired eye closure.
b. Ptosis.
c. Diminished tearing.
d. Frequent blinking.

 

 

ANS:   C

Correct: Diminished tearing occurs because lacrimal apparatus may function poorly, producing fewer tears.

Incorrect A: Impaired eye closure is not an expected finding of an older adult.

Incorrect B: Ptosis is drooping of the eyelids, which is not an expected finding of an older adult.

Incorrect D: Frequent blinking is not an expected finding of an older adult.

 

DIF:    Cognitive Level: Comprehension      REF:    572

OBJ:    NCLEX Client Need Category: Physiologic Integrity: Physiological Adaptation: Alteration in Body Systems                                   TOP:               Older Adult Health: Eye Assessment

MSC:   Integrated Process: Assessment

 

  1. In completing a physical assessment, the nurse recognizes that respiratory function of older adult clients normally declines because of:
a. Increased elasticity of the alveoli.
b. Flaccidity of the chest wall.
c. Reduced inspiratory and expiratory effort.
d. Decreased anteroposterior diameter.

 

 

ANS:   C

Correct: Diminished strength of the respiratory muscles results in reduced maximal inspiratory and expiratory force.

Incorrect A: With aging, alveoli become less elastic and more fibrous.

Incorrect B: With aging, the chest wall may become stiffer, possibly because of calcification at rib articulation points, resulting in decreased chest wall compliance.

Incorrect D: The anteroposterior diameter increases with aging due to kyphoscoliosis.

 

DIF:    Cognitive Level: Comprehension      REF:    22-2, Box 22-1, and 22-12

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Respiratory Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. Which finding on cardiovascular assessment of an older adult client would warrant further evaluation?
a. Occasional ectopic beats heard on auscultation of the heart
b. Murmur heard over the mitral valve
c. Systolic pressure of 156 in the right arm and 188 in the left arm
d. Persistent S4 sound in a client with a history of decreased ventricular function

 

 

ANS:   C

Correct: These systolic pressures are above normal and require further evaluation.

Incorrect A: Occasional ectopic beats are common and may or may not be significant.

Incorrect B: Sclerosis of the mitral and aortic valves may cause murmurs.

Incorrect D: The S4 heart sound is common in older adults and may be associated with decreased left ventricular compliance.

 

DIF:    Cognitive Level: Application             REF:    564, 573

OBJ:    NCLEX Client Need Category: Physiologic Integrity: Physiological Adaptation: Alteration in Body Systems

TOP:    Older Adult Health: Cardiovascular Assessment

MSC:   Integrated Process: Nursing Process

 

  1. To assess neck range of motion of an older adult client, a nurse uses which approach?
a. Asking the client to perform each neck movement separately
b. Deferring range of motion examination if the client has arthritis
c. Requesting the client turn the head to push the chin against the resistance of the nurse’s hand
d. Asking the client to hyperextend the neck against resistance from the nurse’s hand placed the back of the client’s head

 

 

ANS:   A

Correct: The nurse should assess range of motion of the neck with one movement at a time, rather than a full rotation of the neck, to avoid causing dizziness on movement.

Incorrect B: Assessing range of motion is important data to gather to determine how limited the range is due to the arthritis.

Incorrect C: This technique tests muscle strength rather than range of motion.

Incorrect D: This technique tests muscle strength rather than range of motion.

 

DIF:    Cognitive Level: Application             REF:    573

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Techniques of Physical Assessment                                                     TOP:    Older Adult Health: Neck Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. A nurse asks an older adult client to rise from an armed chair without using the arms, stand with eyes closed, and turn around in a circle. The primary purpose of these activities is to assess:
a. Ability to follow instructions.
b. Muscle strength.
c. Balance.
d. Hearing.

 

 

ANS:   C

Correct: These are three of the activities of the Tinetti Balance and Gait Assessment Tool.

Incorrect A: Although following instruction is required for this balance assessment, it is not the primary purpose of the assessment.

Incorrect B: Muscle strength is tested by having the client push or pull against resistance.

Incorrect D: Although hearing is required for this balance assessment, it is not the primary purpose of the assessment.

 

DIF:    Cognitive Level: Analysis                  REF:    564, 574

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Techniques of Physical Assessment

TOP:    Older Adult Health: Musculoskeletal Assessment

MSC:   Integrated Process: Nursing Process

 

  1. During a review of systems, an older adult client reports being able to see her granddaughter play basketball out of the sides of her eyes, but not in the center of her eyes. Based on this information, the nurse suspects this client may have:
a. Presbyopia.
b. Macular degeneration.
c. Pseudoptosis.
d. Entropion.

 

 

ANS:   B

Correct: Gradual loss of central vision may be caused by macular degeneration due to changes in the retina.

Incorrect A: Presbyopia is a decrease in near vision that usually occurs after age 40 and is treated with corrective lenses.

Incorrect C: Pseudoptosis is a relaxed upper eyelid.

Incorrect D: Entropion is a disorder of the eyelid, in which the lower lid turns inward.

 

DIF:    Cognitive Level: Comprehension      REF:    572, 576

OBJ:    NCLEX Client Need Category: Physiologic Integrity: Physiological Adaptation: Alteration in Body Systems                                   TOP:               Older Adult Health: Eye Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. The nurse examining the breasts of an older adult woman recognizes which finding as normal?
a. Firm and rounded breasts of equal size and shape
b. Relatively large size and number of mammary ducts
c. Loose elasticity and puckering of the suspensory ligaments
d. Flattened breasts with a slightly granular texture on palpation

 

 

ANS:   D

Correct: The breasts in postmenopausal women may appear flattened and elongated or pendulous secondary to a relaxation of the suspensory ligaments.

Incorrect A: The breasts in postmenopausal women may appear flattened.

Incorrect B: This is not a finding in older women.

Incorrect C: The suspensory ligaments in older woman are relaxed, but not puckering.

 

DIF:    Cognitive Level: Comprehension      REF:    575

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Breast and Axillae Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

COMPLETION

 

  1. A nurse is discussing the importance that an older adult receives the pneumococcal immunization because the nurse understands that older adults are at risk for respiratory infections due to the normal changes listed below, those labeled with numbers ____________________. (Your answer should appear as numbers separated by commas and spaces [e.g., 1, 2, 3, 4].)
  2. Breath sounds are bronchovesicular in the peripheral lung.
  3. Alveoli are less elastic.
  4. Weak intercostal muscles reduce effective coughing.
  5. Fewer cilia make mucociliary clearance less effective.
  6. Curvature of the spine limits chest wall expansion.
  7. Cough reflex is impaired due to deceased sensitivity of receptors.

 

ANS:

2, 3, 4, 5

Correct: These are all expected findings of healthy older adults that impair their ability to breathe deeply and cough to prevent or recover from a respiratory infection.

Incorrect 1: Breath sounds are the same as for younger adults—vesicular in the peripheral lungs.

Incorrect 6: Cough reflex is not changed in the older adult.

 

DIF:    Cognitive Level: Analysis                  REF:    563-564, 568

OBJ:    NCLEX Client Need Category: Health Promotion and Maintenance: Aging Process

TOP:    Older Adult Health: Respiratory Assessment

MSC:   Integrated Process: Nursing Process: Assessment

 

  1. The characteristics listed below, those labeled with numbers ____________________, are associated with risk factors for falls in older adults. (Your answer should appear as numbers separated by commas and spaces [e.g., 1, 2, 3, 4].)
  2. Being a woman
  3. Taking more than six medications
  4. Having hypertension
  5. Having cataracts
  6. Muscle strength 3/5 bilaterally
  7. Incontinence

 

ANS:

2, 4, 5, 6

Correct: (2) Adverse effects of medications can contribute to falls; (4) Cataracts impair vision, which is a risk factor for falls; (5) Poor muscle strength is a risk factor for falls; and (6) Incontinence of urine or stool increases risk for falls.

Incorrect 1: The opposite is true; men have a higher risk for falls.

Incorrect 3: Hypertension itself does not contribute to falls. Dizziness does contribute to falls.

 

DIF:    Cognitive Level: Analysis                  REF:    563-565

OBJ:    NCLEX Client Need Category: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems

TOP:    Older Adult Health: Musculoskeletal Assessment

MSC:   Integrated Process: Nursing Process: Assessment

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