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Nursing Health Assessment 3rd Edition Dillon Test Bank

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Nursing Health Assessment 3rd Edition Dillon Test Bank

ISBN-13: 978-0803644007

ISBN-10: 0803644000

 

 

Description

Nursing Health Assessment 3rd Edition Dillon Test Bank

ISBN-13: 978-0803644007

ISBN-10: 0803644000

 

 

 

 

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Free Nursing Test Questions:

Chapter 18: Assessing the Older Adult

 

Multiple Choice

Identify the choice that best completes the statement or answers the question.

 

____     1.   Which is the most likely cause of wrinkles in the skin of older adults?

1) Decreased collagen and subcutaneous fat
2) Atrophy of sweat glands
3) Decline in fibroblast proliferation
4) Decreased vascularity

 

 

____     2.   Which is the cause of arcus senilis?

1) Decreased aqueous humor fluid
2) Increased vitreous debris
3) Increased lipid deposits around cornea
4) Increased density of lens

 

 

____     3.   An older adult patient reports a decreased range in vision, particularly peripheral vision. Which is the most likely causes for this assessment finding?

1) An increase in vitreous debris
2) Atrophy of ciliary muscles
3) Decreased corneal sensitivity
4) Decreased pupil size

 

 

____     4.   Which is an unlikely cause for conductive hearing loss that may occur during the aging process?

1) Impacted cerumen
2) Degeneration of the middle ear bones
3) Tympanic membrane thickening
4) Organ of Corti atrophy

 

 

____     5.   Which is likely to cause orthostatic hypotension in older adult patients?

1) Decreased baroreceptor response
2) Decreased compliance/stiffer vessels
3) Increased peripheral vascular resistance
4) Rigid arteries

 

 

____     6.   The nurse is providing care to an older adult patient who states, “I have lived a good life and I know that I have done my best.” Which stage of Erikson’s theory does this statement represent?

1) Autonomy versus doubt
2) Integrity versus despair
3) Generativity versus stagnation
4) Intimacy versus isolation

 

 

____     7.   Which is the most commonly held belief about older adults that transcends most cultures?

1) Older people are to be respected and revered.
2) Old age is a state of mind.
3) Older people have an important role in teaching and keeping rituals.
4) Older people are respected and are believed to become wiser with age.

 

 

____     8.   During the health history, an older adult patient has difficulty answering the questions. Which is the priority action by the nurse?

1) Ask a family member for the answers.
2) Speak louder and face the patient.
3) Speak more slowly and wait for a response.
4) Use a written questionnaire.

 

 

____     9.   Which is true about older adults?

1) They have short medical histories.
2) They believe old wives’ tales more than traditional medicine.
3) They may not report all symptoms as significant.
4) All of the above.

 

 

____   10.   There are several challenges for gathering a health history on an older adult patient. Which is true regarding the majority of older adults?

1) They are ready to die.
2) They want attention for their symptoms.
3) They are not truthful about their symptoms.
4) They have multiple health problems.

 

 

____   11.   An older adult female patient presents in the emergency department (ED) with a fever and newly developed incontinence. The patient denies pain on urination but states, “I feel like I have to go more often and I don’t always make it to the toilet on time.” Based on this data, which nursing action is the priority for this patient?

1) Checking reflexes
2) Assessing for flank pain
3) Inspecting the perineum
4) Assessing the rectum

 

 

____   12.   Which is the most appropriate action by the nurse before beginning the health history when assessing an older adult patient?

1) Reviewing past 10 years of medical records
2) Doing a complete physical assessment
3) Doing a review of systems
4) Assessing orientation and mental status

 

 

____   13.   Which is the most common cause of limited range of motion (ROM) in the older adult population?

1) Rheumatoid arthritis (RA)
2) Osteoarthritis
3) Gout
4) Fractures

 

 

____   14.   The nurse is providing care to an older adult patient diagnosed with severe multiple sclerosis (MS). The patient has the urge to urinate but is often incontinent because of an inability to navigate to the toilet. Which type of incontinence is the patient experiencing?

1) Stress
2) Overflow
3) Urge
4) Functional

 

 

____   15.   Which nursing action is appropriate when conducting a health history interview for an older adult patient?

1) Speaking slowly with a lower pitch
2) Allowing less time than would be required for a younger patient
3) Asking several questions before allowing the patient to respond
4) Standing while the patient sits in a chair on the opposite side of the room

 

 

____   16.   When assessing the sleep patterns of an older adult patient, which should the nurse take into consideration?

1) Short stage 1 and 2
2) Increased rapid eye movement (REM) sleep
3) Decreased stage 3 and 4
4) Absent REM

 

 

____   17.   The nurse is using the Katz Index of Activities of Daily Living during the assessment of an older adult patient. Which finding indicates the patient is independent?

1) The patient is able to get in and out of the tub without assistance.
2) The patient gets dressed but needs help with tying the shoes.
3) The patient does not get out of bed.
4) The patient feeds self but receives assistance with buttering bread.

 

 

____   18.   The nurse conducts a Barthel Index assessment for an older adult patient who receives a score of 52. What does this score indicate?

1) Patient has minimal dementia.
2) Patient’s respiratory effort is compromised.
3) Patient has decreased ROM.
4) Patient needs assistance with activities of daily living (ADLs).

 

 

____   19.   The nurse is conducting a health history interview, and the patient asks the nurse what an advance directive is. Which response by the nurse is appropriate?

1) “Advance directives ensure end-of-life care is comfort measures only.”
2) “Advance directives ensure healthcare wishes are carried out.”
3) “Advance directives ensure acute illness will be treated aggressively.”
4) “Advance directives ensure treatment will be withheld for life-threatening injury or illness.”

 

 

____   20.   Which is a common back problem in older adult patients that the nurse will need to assess for during the physical assessment process?

1) Scoliosis
2) Lordosis
3) Kyphosis
4) Spondyloarthrosis

 

 

____   21.   Which change that occurs with aging is responsible for graying of hair color?

1) Decrease in melanocytes
2) Decreased hair follicle density
3) Decreased blood supply to hair
4) Increased lipid deposits

 

 

____   22.   Which change caused by aging puts the older adult at greater risk than younger adults for pneumonia?

1) Thickening of alveoli
2) Atrophy of cilia
3) Decreased elastic recoil
4) All of the above

 

 

____   23.   An older patient with peripheral-vascular disease reports foot pain. Which color does the nurse expect when inspecting the patient’s feet?

1) Pink
2) Red
3) Yellow
4) Blue

 

 

____   24.   Which technique will the nurse suggest regarding dental hygiene for the older adult patient because of decreased dentine and gingival recession?

1) Brushing with a stiff toothbrush
2) Brushing five times a day with a hard toothbrush
3) Brushing with a soft toothbrush and flossing
4) Rinsing with mouthwash

 

 

____   25.   The nurse is conducting a health history assessment for an older adult patient. The patient states, “I have to get up and use the bathroom several times each night.” Which term will the nurse use when documenting this assessment finding?

1) Nocturia
2) Dysphagia
3) Aphasia
4) Pruritis

 

 

____   26.   The nurse is conducting a physical assessment for a patient who had a stroke and is having difficulty swallowing. Which term will the nurse use when documenting this finding?

1) Aphasia
2) Dysphagia
3) Atrophy
4) Ectropion

 

 

____   27.   The nurse finds a dowager’s hump when conducting a physical assessment for an older adult patient. Which term will the nurse use when documenting this assessment finding?

1) Scoliosis
2) Pruritis
3) Varicosities
4) Kyphosis

 

 

____   28.   The nurse is assessing an older adult patient who had a stroke. Which term will the nurse use to describe the patient’s impaired speech communication when documenting the assessment findings?

1) Atrophy
2) Gynecomastia
3) Aphasia
4) Ectropion

 

 

____   29.   The nurse is assessing an older adult male patient who has enlarged mammary glands. Which term will the nurse use when documenting this finding?

1) Nocturia
2) Gynecomastia
3) Arcus senilis
4) Ectropion

 

 

____   30.   The nurse is assessing an older adult patient who is bedridden. The nurse notes some muscle wasting. Which term will the nurse use when documenting this finding?

1) Atrophy
2) Varicosity
3) Melanocyte
4) Ectropion

 

 

____   31.   The nurse is assessing an older adult patient who reports dry skin and itching. Which term will the nurse use when documenting the occurrence of itching?

1) Pruritus
2) Ectropion
3) Varicosity
4) Atrophy

 

 

____   32.   The nurse is reviewing the medical record for an older adult patient. The patient is noted to have an opaque white ring around the periphery of the cornea. Which is the medical term that was used for this finding in the medical record?

1) Kyphosis
2) Arcus senilis
3) Varicosities
4) Melanocytes

 

 

____   33.   When conducting a peripheral vascular assessment for an older adult patient, the nurse notes what looks like twisted veins. Which term will the nurse use when documenting this finding?

1) Gynecomastia
2) Varicosities
3) Melanocytes
4) Ectropion

 

 

____   34.   The nurse is conducting a physical assessment and notes senile entropion. Based on this data, which is the patient at risk for developing?

1) Dry eye
2) Conjunctivitis
3) Corneal abrasion
4) Blindness

 

 

____   35.   The nurse is assessing the skin of an older adult patient and notes skin tags. Which term will the nurse use when documenting this finding in the medical record?

1) Lentigines
2) Ichthyosis
3) Acrochordons
4) Varicosities

 

 

____   36.   The nurse conducts a cranial nerve (CN) assessment for an older adult patient. Which finding indicates decreased functioning of CN II?

1) Decreased sense of smell
2) Decreased visual acuity
3) Decreased reaction to light
4) Decreased taste

 

 

____   37.   The nurse is conducting a physical assessment for an older adult patient. The nurse notes that the patient has yellow, thickened nails. Which is the most likely cause for this finding?

1) This is an expected finding based on the patient’s age.
2) This finding indicates liver dysfunction.
3) The finding indicates a fungal infection.
4) The finding indicates poor renal function.

 

Chapter 18: Assessing the Older Adult

Answer Section

 

MULTIPLE CHOICE

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 475

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Synthesis [Creating]

Concept: Assessment, Skin Integrity

Difficulty:

  Feedback
1 Aging skin has decreased collagen and subcutaneous fat, which is the cause of wrinkling.
2 An atrophy of sweat glands does not cause wrinkles.
3 A decline in fibroblast proliferation does not cause wrinkles.
4 A decrease in vascularity does not cause wrinkles.

 

 

PTS:   1                    CON:  Assessment | Skin Integrity

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 492

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Sensory Perception, Assessment

Difficulty: Easy

  Feedback
1 Decreased aqueous humor fluid is not the cause of arcus senilis.
2 Increased vitreous debris is not the cause of arcus senilis.
3 Increased lipid deposits around the cornea are the cause of arcus senilis.
4 Increased density of the lens is not the cause of arcus senilis.

 

 

PTS:   1                    CON:  Sensory Perception | Assessment

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 477

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Synthesis [Creating]

Concept: Sensory Perception, Assessment

Difficulty: Difficult

  Feedback
1 An increase in vitreous debris is not responsible for this assessment finding.
2 Because of atrophy of the ciliary muscles of the eye, peripheral vision is decreased.
3 A decrease in corneal sensitivity is not responsible for this assessment finding.
4 A decrease in pupil size is not responsible for this assessment finding.

 

 

PTS:   1                    CON:  Sensory Perception | Assessment

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 477

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Sensory Perception

Difficulty: Moderate

  Feedback
1 Conductive hearing loss is often caused by impacted cerumen (ear wax).
2 Conductive hearing loss is often caused by the degeneration of the middle ear bones.
3 Conductive hearing loss is often cause by a thickening of the tympanic membrane.
4 Perceptive, not conductive, hearing loss is caused by atrophy of the organ of Corti.

 

 

PTS:   1                    CON:  Sensory Perception

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 478

Heading: Review of Systems

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Synthesis [Creating]

Concept: Perfusion, Assessment

Difficulty: Difficult

  Feedback
1 Often, the cause of orthostatic hypotension in older adults is a decreased baroreceptor response.
2 Decreased compliance/stiffer vessels is not the likely cause of orthostatic hypotension in older adult patients.
3 Increased peripheral vascular resistance is not the likely cause of orthostatic hypotension in older adult patients.
4 Rigid arteries are not the likely cause of orthostatic hypotension in older adult patients.

 

 

PTS:   1                    CON:  Perfusion | Assessment

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 472

Integrated Processes: Nursing Process: Assessment

Client Need: Psychosocial Integrity

Cognitive level: Analysis [Analyzing]

Concept: Development

Difficulty: Moderate

  Feedback
1 Erikson’s stage of autonomy versus doubt is not the stage represented by this patient’s statement.
2 Erikson’s psychosocial development theory identifies the final stage of development as ego integrity versus despair, in which adults older than 65 years will be able to do a life review with a sense of satisfaction and accomplishment and be able to accept their own mortality.
3 Erikson’s stage of generativity versus stagnation is not the stage represented by this patient’s statement.
4 Erikson’s stage of intimacy versus stagnation is not the stage represented by this patient’s statement.

 

 

PTS:   1                    CON:  Development

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 472-473

Integrated Processes: Nursing Process: Assessment

Client Need: Psychosocial Integrity

Cognitive level: Analysis [Analyzing]

Concept: Diversity

Difficulty: Moderate

  Feedback
1 Most cultures believe that elders are to be valued and treated with respect.
2 most commonly held belief about older adults that transcends most cultures.
3 most commonly held belief about older adults that transcends most cultures.
4 most commonly held belief about older adults that transcends most cultures.

 

 

PTS:   1                    CON:  Diversity

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 474

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Analysis [Analyzing]

Concept: Assessment

Difficulty: Moderate

  Feedback
1 Asking a family member for the answers is not the priority action by the nurse.
2 Speaking louder and facing the patient is not the priority action by the nurse.
3 When obtaining a history, remember to ask one question at a time and allow enough time for your patient to respond. You may also need to repeat questions and confirm answers.
4 Using a written questionnaire is not the priority action by the nurse.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 473-474

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment

Difficulty: Easy

  Feedback
1 Older adult patients typically do not have a shorter medical history. This statement is not true.
2 Older adult patients may or may not believe in old wives’ tales more than traditional medicine.
3 Many older adults are health optimists, downplaying symptoms and giving a more positive evaluation of their overall health status in the face of disease and disability.
4 Not all of the answer options are true statements.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 473-474

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment

Difficulty: Easy

  Feedback
1 The majority of older adult patients are not ready to die.
2 The majority of older adult patients do not want attention for their symptoms.
3 The majority of older adult patients are truthful regarding their symptoms.
4 A major challenge in doing a history and physical on an older adult is the likelihood of multiple pathologies being present.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 480

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analysis [Analyzing]

Concept: Urinary Elimination

Difficulty: Moderate

  Feedback
1 Although assessing reflexes may be necessary, priority assessment by the nurse.
2 When an older adult patient presents with fever and incontinence, the nurse should suspect a urinary tract infection. The nurse would assess for flank pain, a common finding for a patient with a urinary tract infection.
3 Although an inspection of the perineum may be necessary, priority assessment by the nurse.
4 Although assessing the rectum may be necessary, priority assessment by the nurse.

 

 

PTS:   1                    CON:  Urinary Elimination

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 474

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

  Feedback
1 Although reviewing the patient’s medical records is important, priority.
2 A health history should be completed before conducting a complete physical assessment.
3 A review of systems is included in the health history, but most appropriate action before beginning the process.
4 When doing a review of systems, it is essential to evaluate the patient’s cognitive status to determine her or his ability to provide reliable health information.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 481

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Mobility, Assessment

Difficulty: Easy

  Feedback
1 RA may cause joint pain, but most common reason for limited ROM.
2 Osteoarthritis is the most common joint disease in the older adult and affects over 80 percent of people age 65 years and older.
3 Gout may cause joint pain, but most common reason for limited ROM.
4 Fractures can cause limited ROM, but most common cause for the older adult population.

 

 

PTS:   1                    CON:  Mobility | Assessment

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 483

Integrated Process: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Urinary Elimination

Difficulty: Easy

  Feedback
1 Stress incontinence occurs with increased intra-abdominal pressure.
2 Overflow incontinence results from leakage of an overdistended bladder.
3 Urge incontinence is leakage of urine because of inability to delay voiding.
4 Functional incontinence is urine leakage because of inability to get to the toilet because of cognitive or physical impairment.

 

 

PTS:   1                    CON:  Urinary Elimination

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 474

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

  Feedback
1 When conducting a health history interview for an older adult patient, it is appropriate for the nurse to speak slowly and use a lower pitch.
2 The nurse should allow more time, not less time, when conducting a health history interview for an older adult patient.
3 The nurse should ask one question at a time and allow the patient to respond to each question when conducting a health history interview.
4 The nurse should conduct a health history interview at the same level as the patient while not invading their personal space.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 482

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Comprehension [Understanding]

Concept: Assessment, Promoting Health

Difficulty: Easy

  Feedback
1 Older adult patients have longer, not shorter, time in stages 1 and 2 of sleep.
2 Older adult patients have decreased, not increased, REM sleep.
3 Older adult patients often have decreased time in the deeper stages of sleep, stages 3 and 4.
4 Although older adult patients have decreased REM sleep, it is not absent.

 

 

PTS:   1                    CON:  Assessment | Promoting Health

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 485

Integrated Processes: Nursing Process: Evaluation

Client Need: Health Promotion and Maintenance

Cognitive level: Analysis [Analyzing]

Concept: Assessment

Difficulty: Moderate

  Feedback
1 A patient who is able to get in and out of the tub without assistance is independent with activities of daily living such as bathing.
2 A patent who can dress self but needs help tying the shoes requires assistance with activities of daily living such as dressing.
3 A patient who does not get out of bed is dependent with activities of daily living.
4 A patient who feeds self but requires assistance buttering bread requires assistance with activities of daily living such as eating.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 486

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Analysis [Analyzing]

Concept: Assessment

Difficulty: Moderate

  Feedback
1 This tool is not used to assess for dementia.
2 This tool is not used to assess oxygenation.
3 This tool is not used to assess ROM.
4 The Barthel Index gives weighted scores for each ADL and allows the nurse to recognize small changes over time. A score of less than 60 on this index indicates that the patient needs assistance with ADLs.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 474

Integrated Processes: Teaching and Learning

Client Need: Safe and Effective Care Environment: Management of Care

Cognitive level: Application [Applying]

Concept: Legal

Difficulty: Moderate

  Feedback
1 This is not an appropriate response by the nurse in regards to advance directives.
2 Discussions about care decisions, executing a living will, and designating a proxy decision maker and durable power of attorney for healthcare will help the older adult make sure that his or her wishes are carried out if he or she can no longer dictate his or her own care.
3 This is not an appropriate response by the nurse in regards to advance directives.
4 This is not an appropriate response by the nurse in regards to advance directives.

 

 

PTS:   1                    CON:  Legal

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 493

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Application [Applying]

Concept: Assessment

Difficulty: Moderate

  Feedback
1 Scoliosis is more common in school-age and adolescent patients.
2 Lordosis is not a common back problem for older adult patients.
3 A common problem is senile kyphosis (dowager’s or widow’s hump). It is an accentuated thoracic curve in which the head tilts back and the neck shortens, giving a rounded “e” profile.
4 Spondyloarthrosis is not a common back problem for older adult patients.

 

 

PTS:   1                    CON:  Assessment

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 476

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Synthesis [Creating]

Concept: Assessment, Skin Integrity

Difficulty: Difficult

  Feedback
1 Decrease in melanocytes causes hair to gray.
2 A decreased hair density is not responsible for graying of hair color.
3 A decreased blood supply to hair is not responsible for graying of hair color.
4 Increased lipid deposits is not responsible for graying of hair color.

 

 

PTS:   1                    CON:  Assessment | Skin Integrity

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 493

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Health Promotion and Maintenance

Cognitive level: Synthesis [Creating]

Concept: Oxygenation, Infection

Difficulty: Difficult

  Feedback
1 This is one of the reasons why older adult patients are at an increased risk for pneumonia.
2 This is one of the reasons why older adult patients are at an increased risk for pneumonia.
3 This is one of the reasons why older adult patients are at an increased risk for pneumonia.
4 Decreased elastic recoil of lungs, atrophied cilia, and thickening of alveoli reduce pulmonary clearance.

 

 

PTS:   1                    CON:  Oxygenation | Infection

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 479

Heading: Physical Assessment

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Synthesis [Creating]

Concept: Perfusion

Difficulty: Difficult

  Feedback
1 The nurse would expect the patient’s feet to appear as pink if the patient did not have peripheral-vascular disease.
2 The nurse would expect the patient’s skin color to be red if the patient has an increased number of red blood cells. The medical term that is used to describe this is ruddy.
3 The nurse would expect a yellow skin color for a patient diagnosed with jaundice.
4 Feet will be cool to touch and dusky blue because of decreased circulation.

 

 

PTS:   1                    CON:  Perfusion

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 493

Integrated Processes: Teaching and Learning

Client Need: Health Promotion and Maintenance

Cognitive level: Synthesis [Creating]

Concept: Promoting Health

Difficulty: Difficult

  Feedback
1 A stiff toothbrush is not recommended.
2 Brushing five times per day with a hard toothbrush is not recommended.
3 Decreased dentin and gingival recession require gentle toothbrushing and flossing daily.
4 Rinsing with mouthwash is not recommended.

 

 

PTS:   1                    CON:  Promoting Health

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 480

Heading: Physical Assessment

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Communication

Difficulty: Moderate

  Feedback
1 Nocturia is the term the nurse will use to document this finding in the medical record.
2 Dysphagia is the term used for difficulty swallowing.
3 Aphasia is the term used to describe difficulty speaking.
4 Pruritis is the term used to describe itching.

 

 

PTS:   1                    CON:  Communication

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 477

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Communication, Neurologic Regulation

Difficulty: Moderate

  Feedback
1 Aphasia is the term used to describe an impairment with speech communication.
2 Dysphagia is the term the nurse would use because it means difficulty swallowing.
3 Atrophy is the term used to describe muscle wasting.
4 Ectropion is the term used to describe eversion of the eyelid.

 

 

PTS:   1                    CON:  Communication | Neurologic Regulation

 

  1. ANS:  4

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 493

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Assessment, Communication

Difficulty: Moderate

  Feedback
1 Scoliosis is a curvature of the spine.
2 Pruritis is the term used to describe severe itching.
3 Varicosities is the term used to describe twisted veins.
4 Kyphosis is the medical term used to describe a dowager’s hump.

 

 

PTS:   1                    CON:  Assessment | Communication

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 493

Heading: Physical Assessment

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Communication, Neurologic Regulation

Difficulty: Moderate

  Feedback
1 Atrophy is the term used to describe muscle wasting.
2 Gynecomastia is the term used to describe mammary gland enlargement in men.
3 Aphasia is the term used to describe impaired speech communication.
4 Ectropion is the term used to describe eversion of the eyelid.

 

 

PTS:   1                    CON:  Communication | Neurologic Regulation

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 495

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Communication, Male Reproduction

Difficulty: Moderate

  Feedback
1 Nocturia is the term used to describe excessive urination at night.
2 Gynecomastia is the term used to describe the enlargement of mammary glands in men.
3 Arcus senilis is the term used to describe an opaque white ring around the periphery of the cornea.
4 Ectropion is the term used to describe eversion of the eyelid.

 

 

PTS:   1                    CON:  Communication | Male Reproduction

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 498

Heading: Physical Assessment

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Mobility, Communication

Difficulty: Moderate

  Feedback
1 Atrophy is the term used to describe muscle wasting.
2 Varicosity is the term used to describe veins that are twisted.
3 Melanocyte is the term used to describe the cells that contain skin pigment.
4 Ectropion is the term used to describe eversion of the eyelid.

 

 

PTS:   1                    CON:  Mobility | Communication

 

  1. ANS:  1

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 475

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Communication, Skin Integrity

Difficulty: Moderate

  Feedback
1 Pruritus is the medical term for severe itching that is often caused by dry skin.
2 Ectropion is the term for an eversion of the eyelid.
3 A varicosity is a twisted vein.
4 Atrophy is the term used to describe muscle wasting.

 

 

PTS:   1                    CON:  Communication | Skin Integrity

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 492

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Sensory Perception

Difficulty: Easy

  Feedback
1 Kyphosis is the term used to describe dowager’s hump.
2 Arcus senilis is the term used to describe the opaque white ring around the periphery of the cornea.
3 Varicosities is the term used to describe twisted veins.
4 Melanocytes is the term used to describe the cells that contain skin pigmentation.

 

 

PTS:   1                    CON:  Sensory Perception

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 494

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Perfusion, Communication

Difficulty: Moderate

  Feedback
1 Gynecomastia is the term used to describe the enlargement of mammary glands in men.
2 Varicosities is the term used to describe twisted veins.
3 Melanocytes is the term used to describe the cells that contain skin pigmentation.
4 Ectropion is the term used to describe eversion of the eyelid.

 

 

PTS:   1                    CON:  Perfusion | Communication

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 492

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Comprehension [Understanding]

Concept: Sensory Perception

Difficulty: Easy

  Feedback
1 A patient who has senile ectropion is at an increased risk for dry eye.
2 A patient who has senile ectropion is at an increased risk for conjunctivitis.
3 A patient who has senile entropion is at an increased risk for corneal abrasion.
4 A patient who has senile entropion is not at an increased risk for blindness.

 

 

PTS:   1                    CON:  Sensory Perception

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 500

Integrated Processes: Communication and Documentation

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Skin Integrity, Communication

Difficulty: Moderate

  Feedback
1 The medical term for a skin tag is not lentigines.
2 The medical term for a skin tag is not ichthyosis.
3 The medical term for skin tags is acrochordons.
4 The medical term for skin tags is not varicosities.

 

 

PTS:   1                    CON:  Skin Integrity | Communication

 

  1. ANS:  2

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 499

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Analysis [Analyzing]

Concept: Neurologic Regulation, Assessment

Difficulty: Difficult

  Feedback
1 A decreased sense of smell would indicate decreased functioning of CN I, the olfactory nerve.
2 A decrease in visual acuity indicates a decrease in function for CN II, the optic nerve.
3 A decreased reaction to light indicates a decrease in function of CN III, the oculomotor nerve.
4 A decrease in taste indicates a decrease in function of CN VII, the facial nerve.

 

 

PTS:   1                    CON:  Neurologic Regulation | Assessment

 

  1. ANS:  3

Chapter number and title: 18, Assessing the Older Adult

Chapter learning objective: N/A

Chapter page reference: 491

Integrated Processes: Nursing Process: Assessment

Client Need: Physiological Integrity: Physiological Adaptation

Cognitive level: Application [Applying]

Concept: Skin Integrity

Difficulty: Moderate

  Feedback
1 This is not an expected finding for this patient based on age.
2 Although yellowing of the skin may indicate liver dysfunction, this finding does not support liver dysfunction.
3 This finding is indicative of vascular disease or fungal infection.
4 This finding does not indicate poor renal function.

 

 

PTS:   1                    CON:  Skin Integrity

 

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