Questions

Hearing Chapter

Question 1

A 62-year-old client who has worked on an assembly line since age 24 began taking aspirin for arthritis 6 months ago. The client presents to the nurse with hearing problems and ringing in the ears. Which problem should the nurse suspect?

A. Tinnitus
B. Vertigo
C. Ototoxicity
D. Impacted cerumen

Answer: C. Ototoxicity

Rationale: Aspirin is an ototoxic medication and can cause hearing changes and tinnitus. Tinnitus describes the ringing itself, but the medication-related cause of the client’s symptoms is ototoxicity.

Question 2

A new nursing assistant asks the nurse how to best approach an older adult with hearing impairment. Which approach should the nurse recommend?

A. Raise the volume of your voice.
B. Leave the radio on to calm the older adult.
C. Lower the tone of your voice.
D. Use exaggerated lip movements.

Answer: C. Lower the tone of your voice.

Rationale: Older adults with hearing loss often hear lower-pitched sounds more easily than high-pitched sounds. The speaker should use a moderately loud, low-pitched voice, speak slowly and clearly, and reduce environmental noise.

Question 3

A nurse is teaching a group of hearing-impaired nursing home residents about hearing aids. Which point should the nurse emphasize?

A. It is not necessary to use the hearing aid during one-on-one conversations.
B. The hearing aid should be used only in the dining room or social area.
C. Insert the hearing aid while the volume is turned off.
D. If whistling is heard, increase the hearing aid’s volume.

Answer: C. Insert the hearing aid while the volume is turned off.

Rationale: The hearing aid should be inserted with the volume off and the canal portion directed into the ear. Hearing aids are useful during one-on-one conversations, but background noise in dining or social areas may make hearing more difficult; whistling usually requires decreasing the volume or adjusting the device.

Question 4

A nurse notes that a client with heart failure could hear well during the previous home visit but is having difficulty hearing today. Which laboratory finding is most likely associated with the client’s impaired hearing?

A. Albumin level of 4.1 g/dL
B. Creatinine level of 4.2 mg/dL
C. Potassium level of 4.3 mEq/L
D. Sodium level of 144 mEq/L

Answer: B. Creatinine level of 4.2 mg/dL

Rationale: A creatinine level of 4.2 mg/dL indicates significant renal dysfunction, which can decrease the clearance of ototoxic medications such as certain diuretics. Clients with heart failure may also have reduced renal and cardiac perfusion, increasing their risk for medication-related hearing loss.

Question 5

An 85-year-old woman who lives alone tells the nurse, “There is nothing I can do about my hearing. I am 85 years old, and I am not really interested in listening to television programs anymore.” Which response by the nurse is best?

A. “You are lucky you still live alone at 85, and I understand why you do not care about television programs.”
B. “Have you talked with your healthcare provider about a hearing evaluation? This would help determine the problem and possible solutions.”
C. “I know a hearing-aid dealer who offers free testing. Have you thought about trying a hearing aid?”
D. “Did you know that closed-caption television would allow you to enjoy some shows?”

Answer: B. “Have you talked with your healthcare provider about a hearing evaluation? This would help determine the problem and possible solutions.”

Rationale: The first step is a comprehensive hearing evaluation to identify the cause and determine appropriate treatment. Suggesting a hearing aid or adaptive equipment before assessing the problem skips the assessment phase of the nursing process.

Question 6

A 76-year-old adult expresses frustration about hearing loss despite a lifetime of avoiding known causes of hearing damage. Which age-related change may contribute to hearing loss?

A. Degeneration of inner-ear structures
B. Decreased viscosity and quantity of cerumen
C. Plaque formation and occlusion of the Eustachian tubes
D. Hypertrophy of the external-ear structures

Answer: A. Degeneration of inner-ear structures

Rationale: Age-related hearing loss, or presbycusis, results from degenerative changes such as loss of cochlear hair cells, reduced blood supply, decreased basilar-membrane flexibility, and neuronal loss. Cerumen generally becomes thicker and more viscous with aging rather than decreasing in viscosity.

Question 7 — Select All That Apply

A nurse who regularly visits an adult daycare center observes evidence of a hearing deficit in a man with no documented history of hearing loss. Which factors should the nurse consider when determining the possible cause of the hearing loss?

A. Genetic factors
B. Environmental conditions
C. Fluid and electrolyte imbalances
D. Ototoxic medications
E. Atherosclerosis or thrombotic events

Answers: A, B, and D

Rationale: Genetic predisposition, environmental noise exposure, and ototoxic medications can contribute to hearing loss in older adults. Fluid and electrolyte imbalances, atherosclerosis, and thrombotic events are not identified as common direct causes in this context.

Question 8

The incidence of hearing loss in a long-term care facility is high, especially among White men. Which communication strategy should caregivers use with older adults who have hearing loss?

A. Use less complex concepts when communicating with hearing-impaired older adults.
B. Use a high, consistent tone and pitch when speaking.
C. Speak loudly and directly into the less-affected ear.
D. Make eye contact before and during the conversation.

Answer: D. Make eye contact before and during the conversation.

Rationale: Eye contact allows the older adult to observe facial expressions and lip movements and helps maintain attention. Hearing impairment does not mean the person has impaired intelligence, so communication content should not automatically be simplified.

Question 9

As part of a comprehensive physical assessment, a nurse performs an otoscopic examination of an older adult. Which finding most clearly requires further assessment and possible intervention?

A. A small amount of cerumen is visible in the ear canal.
B. The epithelial lining of the ear canal is bright red.
C. The tympanic membrane is intact.
D. The tympanic membrane is pearl gray.

Answer: B. The epithelial lining of the ear canal is bright red.

Rationale: The epithelial lining should normally appear pinkish white. Bright redness may indicate inflammation or infection, whereas a small amount of cerumen and an intact, pearl-gray tympanic membrane are expected findings.

Question 10

A nurse has cared for an 83-year-old nursing-home resident for 2 years and has developed a high level of trust with the resident. Which recent behavioral change may signal possible hearing loss?

A. The resident occasionally appears disoriented to time.
B. The resident recently became visibly angry with a nursing assistant.
C. The resident has a short attention span and is easily distracted.
D. The resident has become increasingly disagreeable and terse.

Answer: C. The resident has a short attention span and is easily distracted.

Rationale: Difficulty hearing and understanding conversation may appear as distractibility or a shortened attention span. Anger, agitation, and disorientation may indicate other neurologic, cognitive, or psychosocial problems and require broader assessment.

Question 11

A gerontological nurse is presenting recent findings about age-related hearing loss. Which age-related change should the nurse include as a significant contributor to hearing loss and impaired speech perception?

A. Changes to the external auditory canal and pinna
B. Degenerative changes to the auditory brainstem
C. Growth of longer and thicker hair in the ear canal
D. Thickening of the tympanic membrane

Answer: B. Degenerative changes to the auditory brainstem

Rationale: Degeneration of central auditory structures, including the auditory brainstem and primary auditory cortex, contributes significantly to impaired hearing and speech perception. External-ear changes are not major direct causes of age-related hearing loss.

Question 12

The Functional Consequences Theory approach identifies health-promotion interventions for hearing wellness. Which intervention most directly supports the auditory health of an older adult?

A. Avoiding all medications
B. Receiving regular colonics
C. Smoking cessation
D. Wearing earmuffs during winter

Answer: C. Smoking cessation

Rationale: Smoking and secondhand-smoke exposure are recognized risk factors for hearing impairment. Older adults should not avoid all medications, but they should be assessed for potentially ototoxic medications.

Question 13

A nurse teaches an older adult about medications that may cause ototoxicity. Which medication category should the adult minimize or avoid unless prescribed and monitored?

A. Nonsteroidal anti-inflammatory drugs
B. Osmotic stool softeners
C. Over-the-counter sleep aids
D. Penicillin-type antibiotics

Answer: A. Nonsteroidal anti-inflammatory drugs

Rationale: Aspirin, salicylates, and other NSAIDs can cause ototoxic effects, particularly at high doses or with prolonged use. Other ototoxic medications include aminoglycosides, some macrolides, quinolones, antifungals, and certain diuretics.

Question 14 — Select All That Apply

After an older adult undergoes irrigation to remove impacted cerumen, which interventions can help prevent recurrence?

A. Use ceruminolytic drops as indicated.
B. Clean the ear canal daily with cotton-tipped swabs.
C. Use ear candling monthly.
D. Use a home oral-jet irrigator every 2 months.
E. Have the ears examined by a qualified healthcare provider every 6 to 12 months.

Answers: A and E

Rationale: Ceruminolytic agents can soften cerumen, and regular professional examinations are appropriate for clients at high risk for impaction. Cotton-tipped swabs, ear candles, and oral-jet irrigators can push cerumen deeper or injure the ear canal and tympanic membrane.

Question 15

A home-care nurse teaches a caregiver how to care for an older adult’s hearing aids. Which caregiver statement indicates that further teaching is required?

A. “I place a towel over the table while working on the hearing aids.”
B. “I turn off the hearing aid before changing the battery.”
C. “I wash the earmold with warm, soapy water each week.”
D. “I purchased enough batteries to last an entire year.”

Answer: D. “I purchased enough batteries to last an entire year.”

Rationale: Hearing-aid batteries should generally not be purchased more than about 1 month in advance because they may lose power during storage. The hearing aid should be handled over a soft surface, turned off before battery changes, and cleaned according to manufacturer instructions.

Vision Chapter

Question 1

A nurse develops a plan of care for an older adult recently diagnosed with Lewy body dementia. Which functional consequence is most important for the nurse to monitor?

A. Development of visual hallucinations
B. Visual acuity of 20/30
C. Improved visual acuity after receiving medications for dementia
D. Growth of cataracts

Answer: A. Development of visual hallucinations

Rationale: Visual hallucinations are a common and significant manifestation of Lewy body dementia. Dementia medications do not improve visual acuity, and cataracts are common in older adults but are not specifically caused by Lewy body dementia.

Question 2

A nurse is providing an educational program about age-related macular degeneration to a group of older adults. Which statement by an older adult indicates a need for further teaching?

A. “Smoking is a risk factor for macular degeneration.”
B. “Macular degeneration causes a loss of central vision.”
C. “People with macular degeneration should have any sudden vision changes evaluated.”
D. “The dry type of macular degeneration occurs rapidly.”

Answer: D. “The dry type of macular degeneration occurs rapidly.”

Rationale: Dry age-related macular degeneration usually progresses slowly. Wet macular degeneration can develop rapidly and cause sudden, significant central vision loss.

Question 3 — Select All That Apply

Which methods can the nurse use to informally assess an older adult’s visual abilities?

A. Ask the person to look out a window and describe specific details.
B. Perform a standard confrontation test to assess central vision.
C. Provide adequate illumination and ask the person to read printed material in different font sizes.
D. Perform a standard visual acuity test, testing each eye separately while allowing the person to cover the opposite eye with a hand.

Answers: A and C

Rationale: Informal vision assessment includes asking the older adult to describe distant objects and read materials with different print sizes under good lighting. The confrontation test evaluates peripheral vision, and the hand should not be used to cover the opposite eye during formal visual acuity testing because pressure may affect the result.

Question 4 — Select All That Apply

Which assessments are most important when evaluating visual function in an older adult?

A. Asking the older adult to read fine print on a medication bottle without a magnifying device
B. Asking whether the older adult has difficulty driving at night
C. Observing the older adult functioning in the usual home environment
D. Observing the older adult reading a newspaper without prescribed glasses

Answers: B and C

Rationale: Functional vision is best assessed by evaluating how the person performs usual activities in the normal environment. Difficulty driving at night may indicate cataracts or another visual impairment.

Question 5

A nurse is teaching an older adult about maintaining eye health. Which statement by the client indicates that the teaching was effective?

A. “If my sensitivity to glare decreases and my contrast sensitivity increases, I will be evaluated for cataracts.”
B. “I wear sunglasses and a wide-brimmed hat when I am outside to help prevent cataracts.”
C. “Having Alzheimer disease increases my risk for macular degeneration.”
D. “Taking ototoxic medications increases my risk for cataracts.”

Answer: B. “I wear sunglasses and a wide-brimmed hat when I am outside to help prevent cataracts.”

Rationale: Protecting the eyes from ultraviolet sunlight can reduce the risk of cataract development. Cataracts cause increased glare sensitivity and decreased contrast sensitivity, while ototoxic medications affect hearing rather than vision.

Question 6

A nurse notes that most residents in a long-term care facility require corrective lenses. Which age-related change contributes to decreased visual acuity?

A. Decreased size and density of the lens
B. Increased intraocular pressure
C. Presence of floaters in the vitreous humor
D. Decreased responsiveness of the ciliary body

Answer: D. Decreased responsiveness of the ciliary body

Rationale: With aging, the ciliary body becomes smaller, stiffer, and less functional, reducing the eye’s ability to accommodate and focus on nearby objects. Increased intraocular pressure is pathologic, and the lens increases rather than decreases in mass with age.

Question 7

After an eye examination, a 70-year-old adult is told that the pressure inside the eye is elevated and must be monitored and treated to prevent optic nerve damage. Which diagnosis should the nurse expect?

A. Cataracts
B. Glaucoma
C. Age-related macular degeneration
D. Presbyopia

Answer: B. Glaucoma

Rationale: Glaucoma involves damage to the optic nerve, often associated with abnormal accumulation of aqueous humor and increased intraocular pressure. Cataracts affect the lens, macular degeneration affects central vision, and presbyopia is an age-related loss of near focusing ability.

Question 8

A nurse assesses risk factors for vision loss in a 71-year-old client. Which question should the nurse include?

A. “Do you have hypertension or diabetes?”
B. “Did your parents wear glasses or develop cataracts?”
C. “How much red meat do you usually eat?”
D. “Do you have high cholesterol?”

Answer: A. “Do you have hypertension or diabetes?”

Rationale: Hypertension and diabetes can damage retinal blood vessels and are major risk factors for vision loss. These conditions require consistent monitoring and treatment to reduce ocular complications.

Question 9

A 78-year-old client states, “My eyes are often dry, irritated, and uncomfortable.” Which intervention should the nurse recommend?

A. Rinse the eyes daily with tap water.
B. Stop prescribed medications temporarily to determine whether they are causing the problem.
C. Use over-the-counter artificial tears.
D. Keep the eyes closed for 3 to 5 minutes every hour.

Answer: C. Use over-the-counter artificial tears.

Rationale: Artificial tears or ocular lubricants commonly relieve age-related dry-eye symptoms. The nurse should not independently recommend stopping medications, and rinsing the eyes with tap water is not an appropriate treatment.

Question 10

A nursing-home resident has experienced progressive vision loss over several months because of diabetes. How should the nurse modify the resident’s environment?

A. Provide brightly colored grooming utensils.
B. Replace the resident’s tube television with a flat-screen television.
C. Remove books from the room to prevent reminders of the resident’s vision loss.
D. Paint the walls a neutral color that matches the flooring.

Answer: A. Provide brightly colored grooming utensils.

Rationale: Brightly colored and high-contrast objects are easier for a person with reduced visual acuity to identify and use. Matching walls and floors reduces contrast and may increase difficulty navigating the environment.

Question 11

A nurse assesses an older adult’s color perception. Which colors should the nurse expect the client to have the greatest difficulty distinguishing?

A. Blue and violet
B. Yellow
C. White and off-white
D. Tan and brown

Answer: A. Blue and violet

Rationale: Age-related changes in the lens reduce transmission of shorter light wavelengths, especially blue and violet. Older adults may therefore have difficulty differentiating these colors.

Question 12

A nurse gives a presentation about eye health at an older-adult wellness clinic. Which intervention should the nurse include?

A. Avoid reading under halogen lighting.
B. Perform cardiovascular exercise three times per week.
C. Sleep 8 to 10 hours each night.
D. Wear sunglasses with ultraviolet-absorbing lenses.

Answer: D. Wear sunglasses with ultraviolet-absorbing lenses.

Rationale: Ultraviolet light exposure contributes to cataracts and other eye diseases. Sunglasses with UV protection and wide-brimmed hats reduce harmful sunlight exposure.

Question 13

During an eye assessment of a 79-year-old adult, the nurse observes a white or gray ring around both irises. What is the correct term for this finding?

A. Glaucoma
B. Arcus senilis
C. Arthritis
D. Presbyopia

Answer: B. Arcus senilis

Rationale: Arcus senilis, also called corneal arcus, is a yellow, gray, or white ring that develops around the iris and is common with aging. It is not caused by increased intraocular pressure or loss of accommodation.

Question 14 — Select All That Apply

A nurse performs an eye assessment on a 93-year-old client. Which findings are associated with normal aging?

A. Ectropion
B. Enophthalmos
C. Erythematosus
D. Eschar
E. Exophthalmos

Answers: A and B

Rationale: Ectropion occurs when the lower eyelid turns outward, which can reduce lubrication, while enophthalmos refers to a sunken appearance of the eyes. Exophthalmos is abnormal protrusion of the eyes and may indicate thyroid disease or another pathologic condition.

Digestion and Nutrition Chapter

Question 1

A nurse teaches an older adult about age-related changes in nutritional requirements. Which meal choice demonstrates that the older adult understands the teaching?

A. Baked chicken, carrots, and angel food cake
B. Green salad, mashed potatoes, and an oatmeal cookie
C. Vegetable beef soup, crackers, and gelatin
D. Baked pork chop, green beans, and sherbet

Answer: A. Baked chicken, carrots, and angel food cake

Rationale: Older adults need fewer calories but foods with greater nutritional value. Baked chicken and carrots provide protein, vitamins, and minerals without excessive empty calories.

Question 2

A nurse teaches older adults about nutrition. Which statement by an older adult indicates a need for further teaching?

A. “Alcohol can interfere with the absorption of B-complex vitamins and vitamin C.”
B. “Certain diuretics can decrease the potassium level in my blood.”
C. “Anticholinergic medications can cause my intestines to work more slowly.”
D. “My over-the-counter beta-carotene supplement is appropriate for long-term use.”

Answer: D. “My over-the-counter beta-carotene supplement is appropriate for long-term use.”

Rationale: Long-term beta-carotene use can contribute to vitamin E deficiency. Supplements and herbal products can affect nutrient balance and should not automatically be considered safe for prolonged use.

Question 3

A 70-year-old client with urosepsis is admitted to the nursing unit. Laboratory findings include elevated sodium, blood urea nitrogen, hematocrit, and albumin. Which nursing diagnosis is the priority?

A. Constipation
B. Fluid volume deficit
C. Imbalanced nutrition: less than body requirements
D. Impaired tissue perfusion

Answer: B. Fluid volume deficit

Rationale: Elevated sodium, blood urea nitrogen, hematocrit, and albumin are consistent with hemoconcentration caused by dehydration. Restoring fluid balance is the immediate priority.

Question 4

A nurse plans the diet of an older adult with congestive heart failure. Which intervention would best support optimal nutrition?

A. Encourage high-calorie nutritional supplements.
B. Provide approximately 55% of calories from complex carbohydrates.
C. Teach the client to remain upright for 2 hours after every meal.
D. Use moderate to large amounts of flavor enhancers.

Answer: B. Provide approximately 55% of calories from complex carbohydrates.

Rationale: Complex carbohydrates should make up the majority of caloric intake for older adults. Many flavor enhancers contain sodium and should be limited in clients with heart failure.

Question 5

A nurse teaches a health education class for older adults about constipation. Which point should the nurse emphasize?

A. Older adults who do not have a daily bowel movement should use a laxative.
B. Older adults should limit high-fiber foods because of the risk for lactose intolerance.
C. If medication is needed for bowel regularity, a laxative or enema should be used.
D. If medication is needed for bowel regularity, a daily bulk-forming agent is preferred.

Answer: D. If medication is needed for bowel regularity, a daily bulk-forming agent is preferred.

Rationale: Bulk-forming agents are less likely to cause harmful effects than stimulant laxatives or enemas, provided the client has adequate fluid intake. A daily bowel movement is not required for normal bowel function.

Question 6

A nurse assesses an older adult in an assisted-living facility who has presbyphagia. Which body system should the nurse auscultate?

A. Abdomen for bruits
B. Gastrointestinal system for bowel sounds
C. Cardiovascular system for heart tones
D. Respiratory system for lung sounds

Answer: D. Respiratory system for lung sounds

Rationale: Presbyphagia increases the risk for aspiration. The nurse should assess lung sounds for evidence of aspiration-related respiratory complications.

Question 7

A nurse counsels an older adult regarding age-related nutritional requirements. Which teaching point is the priority?

A. “Try to eliminate animal fats completely from your diet.”
B. “You should eat less protein than you did when you were younger.”
C. “Overall, you do not need as many calories as you did when you were younger.”
D. “You no longer need as many starches and complex carbohydrates.”

Answer: C. “Overall, you do not need as many calories as you did when you were younger.”

Rationale: Older adults generally require fewer calories because of reduced metabolic rate and activity. Protein needs remain important, and complex carbohydrates should continue to provide a large portion of total calories.

Question 8

A nurse manager of a long-term care facility develops a plan to reduce nutritional deficits among residents. Which intervention should be included?

A. Encourage residents to eat alone in their rooms to reduce distractions.
B. Offer four or five small meals every day instead of three larger meals.
C. Promote oral care several times each day.
D. Provide rewards to residents who eat everything on their trays.

Answer: C. Promote oral care several times each day.

Rationale: Good oral hygiene improves chewing, taste, swallowing, and comfort, which can increase food intake. Eating alone may decrease intake, and using rewards may be coercive or patronizing.

Question 9

A nurse evaluates the plan of care for a client who experienced an ischemic stroke. Which finding suggests that the client may have developed dysphagia?

A. The client reports excessive hunger.
B. The client drinks large amounts of water with meals.
C. The client pockets food in the affected cheek during meals.
D. The client prefers to sit in high-Fowler’s position after eating.

Answer: C. The client pockets food in the affected cheek during meals.

Rationale: Food pocketing is a classic sign of impaired chewing or swallowing after a stroke. It increases the risk for aspiration and requires further swallowing assessment.

Question 10

A nurse admits a 90-year-old client with failure to thrive. Which laboratory findings should the nurse expect?

A. Low albumin and low red blood cell count
B. Elevated white blood cell count and low potassium
C. Low platelet count and low prothrombin time
D. Elevated calcium and magnesium

Answer: A. Low albumin and low red blood cell count

Rationale: Malnutrition commonly causes hypoalbuminemia and anemia. These findings are consistent with inadequate protein and nutrient intake.

Question 11

A nurse assesses older adults at a senior center. One older adult, age 78, has a body mass index of 15. Which response by the nurse is most appropriate?

A. “You are too skinny.”
B. “Have you been losing weight?”
C. “Have you tried to lose this extra weight?”
D. “Congratulations, your body mass index is excellent.”

Answer: B. “Have you been losing weight?”

Rationale: A BMI of 15 is significantly underweight and requires assessment for unintentional weight loss. The question is therapeutic, neutral, and focused on identifying nutritional risk.

Question 12

A nurse working for human services visits a long-term care facility. Which resident finding may indicate poor-quality care?

A. Body mass index of 29
B. Presence of dentures
C. Serum albumin level of 3.5 g/dL
D. Unintentional weight loss

Answer: D. Unintentional weight loss

Rationale: Unintentional weight loss is an important indicator of inadequate nutrition and may reflect poor monitoring or insufficient care. Dentures and a BMI up to 30 may be common in older adults, and an albumin level of 3.5 g/dL is within the expected range.

Question 13 — Select All That Apply

A nurse plans care for an older adult who states that food is no longer appealing. The nurse observes a dry mouth and poor dentition. Which interventions should be included in the plan of care?

A. Provide an 8-ounce bottle of water between meals.
B. Provide a hard-bristled toothbrush.
C. Keep ice-cold water at the bedside.
D. Encourage the client to eat meals in the common dining room.
E. Provide oral care before each meal.

Answers: A, D, and E

Rationale: Adequate hydration, oral care before meals, and social dining can improve appetite and food intake. A soft toothbrush is preferred, and very cold fluids may be uncomfortable for a client with poor oral health.

Question 14

A nurse in a rehabilitation unit assesses an 86-year-old woman with a BMI of 30 and a history of heart failure whose oral intake is declining. Which factor may be contributing to the decrease in appetite?

A. Diuretic therapy
B. Regular exercise
C. Female sex
D. Obesity

Answer: A. Diuretic therapy

Rationale: Diuretics may decrease saliva production and impair smell and taste, reducing appetite. Exercise generally increases appetite, and obesity itself does not directly explain the recent decline in intake.

Question 15

An older adult states, “I feel full so quickly that I cannot finish my meals.” Which response by the nurse is most appropriate?

A. “Everyone feels that way after eating.”
B. “You need to make an urgent appointment with your healthcare provider.”
C. “Slower emptying of your stomach may be causing the early fullness.”
D. “This usually happens when a person has gallstones.”

Answer: C. “Slower emptying of your stomach may be causing the early fullness.”

Rationale: Aging can cause slower gastric emptying, especially after larger meals, resulting in early satiety. Gallstones more commonly cause pain rather than simple fullness.

Question 16

An older adult develops diarrhea. Which intervention is the nurse’s priority?

A. Assess the client for pancreatitis.
B. Determine the date of the client’s last bowel movement.
C. Review the client’s food preparation practices.
D. Review the client’s medication list.

Answer: D. Review the client’s medication list.

Rationale: Many medications commonly used by older adults can cause diarrhea, including antibiotics, laxatives, cimetidine, cardiovascular medications, and cholinesterase inhibitors. Recent antibiotic use also raises concern for Clostridioides difficile infection.

cardiovascular function

Question 1

Which individual is at the highest risk for orthostatic hypotension?

A. A 75-year-old woman who uses a walker
B. An 80-year-old man who strains to void while using the bedside commode
C. A 60-year-old adult who has a long-leg cast on the right leg
D. An 80-year-old woman who takes Premarin

Answer: B. An 80-year-old man who strains to void while using the bedside commode

Rationale: The incidence of orthostatic hypotension increases significantly after age 75. Straining during urination causes a Valsalva maneuver, which can further decrease venous return and blood pressure.

Question 2

Which statement by an older adult indicates a need for further teaching about cholesterol reduction?

A. “I will decrease my intake of foods high in polyunsaturated fatty acids.”
B. “I will increase my intake of soybeans, walnuts, and canola oil.”
C. “I will eat fish four times each week.”
D. “I will limit my intake of trans fats and saturated fats.”

Answer: A. “I will decrease my intake of foods high in polyunsaturated fatty acids.”

Rationale: Polyunsaturated fats can support cholesterol reduction and should generally be increased rather than decreased. Saturated and trans fats should be limited.

Question 3

An older adult is admitted to the emergency department with dyspnea and a sudden change in level of consciousness. For which disorder should the nurse assess first?

A. Myocarditis
B. Aortic aneurysm
C. Cor pulmonale
D. Myocardial infarction

Answer: D. Myocardial infarction

Rationale: Older adults experiencing myocardial infarction may present with atypical symptoms such as dyspnea, confusion, syncope, or other neurologic changes rather than classic chest pain. These findings require immediate cardiac assessment.

Question 4

Which consideration should the nurse prioritize when assessing an older adult who has an arrhythmia?

A. Assess only for adverse medication reactions.
B. Check the client’s electrolytes immediately before obtaining other information.
C. Evaluate the arrhythmia in relation to the client’s medical history.
D. Perform auscultation before obtaining the client’s history.

Answer: C. Evaluate the arrhythmia in relation to the client’s medical history.

Rationale: Arrhythmias may result from cardiac disease, electrolyte disturbances, or medication effects. The nurse needs the client’s history to identify possible underlying causes and determine the significance of the rhythm change.

Question 5

Which is the most important modifiable risk factor for cardiovascular disease in older adults?

A. Smoking
B. Stress
C. Sedentary lifestyle
D. Aggressive personality

Answer: A. Smoking

Rationale: Smoking is a major modifiable cardiovascular risk factor, and the benefits of cessation begin almost immediately. Smoking cessation remains effective even in advanced age.

Question 6

Older adults experience several changes in cardiovascular structure and function. Which change is considered a normal age-related finding?

A. Veins become thinner and more elastic.
B. Regulation of blood pressure and heart rate becomes less efficient.
C. Heart valves become atrophied and regurgitation normally develops.
D. Heart rate slows and ejection fraction increases.

Answer: B. Regulation of blood pressure and heart rate becomes less efficient.

Rationale: Aging decreases the responsiveness of cardiovascular regulatory mechanisms, including baroreceptor responses. Veins become thicker and stiffer, and valvular regurgitation is pathologic rather than a normal aging change.

Question 7

Nurses in a long-term care facility recognize the high prevalence of cardiovascular disease among older adults. Which intervention is most likely to prevent heart disease?

A. Advocate for organic dietary choices.
B. Establish a regular exercise program.
C. Teach residents about the relationship between family history and heart disease.
D. Teach residents to reduce stress.

Answer: B. Establish a regular exercise program.

Rationale: Physical inactivity is a major modifiable cardiovascular risk factor. A consistent exercise program directly improves cardiovascular function and reduces disease risk.

Question 8

A 79-year-old client experienced a syncopal episode after standing quickly while gardening. Which question is the nurse’s priority?

A. “Did you experience fatigue or blurred vision?”
B. “What did your healthcare provider say about this?”
C. “What medications do you take?”
D. “When did you last eat a meal?”

Answer: C. “What medications do you take?”

Rationale: Multiple medications, including antihypertensives, diuretics, vasodilators, and some psychotropic drugs, can contribute to orthostatic hypotension. A medication review helps identify a common and potentially correctable cause.

Question 9

Many residents on a geriatric long-term care unit have orthostatic hypotension. Which intervention should the nurse prioritize to promote safety?

A. Mobilize residents within 2 hours after meals.
B. Have residents take several deep breaths before standing.
C. Have residents sit on the edge of the bed for 1 to 2 minutes before standing or walking.
D. Encourage residents to use bedpans or briefs to avoid walking to the bathroom.

Answer: C. Have residents sit on the edge of the bed for 1 to 2 minutes before standing or walking.

Rationale: Dangling at the bedside allows the cardiovascular system time to adjust to the position change and reduces dizziness, syncope, and falls. Using briefs or bedpans solely for fall prevention unnecessarily reduces independence.

Question 10

A 70-year-old client has smoked cigarettes since adolescence and has made several unsuccessful attempts to quit. When encouraged to try again, the client states, “At this point in my life, it is probably too late.” Which response by the nurse is best?

A. “You will avoid having a future heart attack if you quit smoking now.”
B. “Three months after quitting, you will have the same risk as someone who never smoked.”
C. “In a way that is true, but you would feel better about yourself if you quit.”
D. “Actually, you will begin experiencing health benefits almost as soon as you quit.”

Answer: D. “Actually, you will begin experiencing health benefits almost as soon as you quit.”

Rationale: Smoking cessation provides health benefits at every age, and cardiovascular benefits begin soon after quitting. Quitting does not completely eliminate the risk of myocardial infarction or immediately reduce the person’s risk to that of a lifelong nonsmoker.

Question 11

A nurse identifies clients who have modifiable risk factors for cardiovascular disease. Which client should receive priority?

A. A 54-year-old client admitted with hepatitis A
B. A 72-year-old client who has experienced a second myocardial infarction
C. An 86-year-old obese woman who has type 2 diabetes
D. A 94-year-old client with a strong family history of early myocardial infarction

Answer: C. An 86-year-old obese woman who has type 2 diabetes

Rationale: Obesity and poor blood glucose control are modifiable cardiovascular risk factors. Family history and a previous myocardial infarction increase risk but cannot themselves be changed.

Question 12 — Select All That Apply

A nurse teaches an older adult who was recently diagnosed with hypertension. Which instructions should the nurse include?

A. Avoid home blood pressure monitoring.
B. Increase daily grain intake to approximately 8 ounces per day.
C. Read food labels and limit sodium intake to 1.5 g per day.
D. Walk for approximately 30 minutes on 5 of 7 days each week.
E. Notify the healthcare provider any time one blood pressure reading is higher than 130/80 mm Hg.

Answers: B, C, and D

Rationale: Hypertension management includes regular physical activity, reduced sodium intake, and a diet rich in grains, fruits, and vegetables. Home blood pressure monitoring is recommended, and treatment decisions should not be based on one isolated reading.

Question 13

A community nurse develops wellness outcomes for populations at increased risk for poor cardiovascular disease management. Which population should the nurse target?

A. African American women
B. Hindu men
C. Immigrant Indian adults
D. Adults with mental illness

Answer: A. African American women

Rationale: The source identifies women, African Americans, and people experiencing poverty as populations affected by cardiovascular health disparities and poorer disease management. The nurse should target populations facing increased risks and barriers to care.

Question 14

A nurse assesses an older adult’s dietary habits. Which statement represents a positive dietary habit for cardiovascular health?

A. “I avoid meat and eat nuts instead.”
B. “I do not eat vegetables.”
C. “I drink four glasses of wine every day.”
D. “I limit my sodium intake to 3,500 grams per day.”

Answer: A. “I avoid meat and eat nuts instead.”

Rationale: Heart-healthy eating patterns include nuts, fish, fruits, vegetables, and fiber-rich whole grains. Excessive alcohol and sodium intake increase cardiovascular risk.

Question 15 — Select All That Apply

A nurse provides education to an 82-year-old woman with postprandial hypotension. Which interventions should be included?

A. Avoid sitting still for prolonged periods.
B. Drink eight glasses of noncaffeinated beverages each day.
C. Eat regularly scheduled meals, with breakfast as the largest meal.
D. Participate in regular but not excessive exercise.
E. Limit alcohol intake to one drink each evening.

Source-Listed Answers: A, B, D, and E

Rationale: The source identifies hydration, avoiding prolonged inactivity, and regular nonstrenuous exercise as beneficial. It also states that clients should eat small, low-carbohydrate meals, avoid strenuous activity for approximately 2 hours after meals, and avoid alcohol.

Source inconsistency: Choice E states that one alcoholic drink is permitted, but the accompanying rationale says to avoid alcohol consumption. This answer should be verified against the textbook before using it on an exam.

respiratory function

Question 1

A nurse assesses an older adult’s overall respiratory function. Which interview question is most appropriate?

A. “Would you be interested in learning more about environmental smoke?”
B. “Did either of your parents experience lung disease?”
C. “Have you ever worked in a job where you were exposed to dust, fumes, smoke, or other pollutants?”
D. “What do you do to actively maintain your respiratory health?”

Answer: C. “Have you ever worked in a job where you were exposed to dust, fumes, smoke, or other pollutants?”

Rationale: Occupational exposures have cumulative effects over many years and may significantly affect older adults. Many older adults worked before workplace safety regulations were widely enforced, so a detailed work history is essential.

Question 2

A 65-year-old client with a long history of chronic obstructive pulmonary disease was recently prescribed warfarin after developing atrial fibrillation. Which statement by the client indicates a need for further teaching?

A. “I will continue to use smokeless tobacco because it is much safer than smoking.”
B. “I will avoid over-the-counter antihistamines because they can dry my respiratory secretions.”
C. “I will monitor my intake of dark green leafy vegetables because they can affect warfarin.”
D. “I will not take herbal preparations without first discussing them with my healthcare provider.”

Answer: A. “I will continue to use smokeless tobacco because it is much safer than smoking.”

Rationale: Smokeless tobacco is not a safe alternative to smoking. It is associated with oral cancer, gingivitis, tooth loss, and possibly pancreatic cancer.

Question 3

A 70-year-old client smoked for 30 years and has a history of COPD. The client’s spouse normally assists with cooking, cleaning, and transportation but has recently become ill. A home health nurse begins visiting the couple. Which intervention is the priority?

A. Perform the couple’s instrumental activities of daily living.
B. Develop a plan to ensure that the couple receives meals.
C. Set up all medications for both clients.
D. Begin a smoking-cessation plan.

Answer: B. Develop a plan to ensure that the couple receives meals.

Rationale: Adequate nutrition is a basic physiologic need and takes priority. The nurse should coordinate resources for instrumental activities of daily living rather than routinely performing all of them.

Question 4

A nurse completes a respiratory assessment of an older adult. Which finding is within expected age-related limits?

A. Kyphosis and an increased anteroposterior diameter of the chest
B. Increased intensity of lung sounds
C. Decreased resonance during percussion
D. Decreased adventitious sounds in the lower lungs

Answer: A. Kyphosis and an increased anteroposterior diameter of the chest

Rationale: Expected age-related findings include a shortened thorax, chest-wall stiffness, kyphosis, and an increased anteroposterior chest diameter. These changes reduce chest expansion but are not automatically signs of acute disease.

Question 5 — Select All That Apply

A nurse plans interventions in a skilled nursing facility to prevent lower respiratory infections. Which interventions should be included?

A. Encourage annual pneumococcal vaccination.
B. Encourage annual influenza vaccination.
C. Encourage annual chest radiographs to detect tuberculosis.
D. Encourage influenza vaccination every 5 years.
E. Encourage consistent hand hygiene among residents and staff.

Answers: B and E

Rationale: Influenza vaccination is recommended yearly, and hand hygiene is a primary method of preventing respiratory infection transmission. Chest radiographs do not prevent infection, and influenza vaccination is not given every 5 years.

Source note: The source describes pneumococcal vaccination as a one-time booster in certain adults age 65 or older, not as an annual vaccine. Therefore, choice A is incorrect as written.

Question 6

A nurse in a long-term care facility considers the effects of normal aging on the respiratory system. Which functional consequence is most likely associated with age-related changes?

A. Snoring and mouth breathing
B. Persistent dry cough
C. Increased sensitivity to environmental allergens
D. Hemoptysis with exertion

Answer: A. Snoring and mouth breathing

Rationale: Snoring and mouth breathing become more common with age. Hemoptysis and a persistent cough are pathologic findings and require further assessment.

Question 7

A nurse admits an 81-year-old man with aspiration pneumonia. Which risk factor should the nurse expect to find in the client’s history?

A. Cigarette smoking
B. Lung cancer
C. Dysphagia
D. Sleep apnea

Answer: C. Dysphagia

Rationale: Dysphagia increases the risk that food, fluids, or secretions will enter the airway and cause aspiration pneumonia. This is especially important after stroke or with neurologic impairment.

Question 8

A 78-year-old client is brought to the emergency department with a sudden change in mental status and significant weakness. For which condition should the healthcare team assess?

A. Alzheimer disease
B. Lung cancer
C. Pneumonia
D. Tuberculosis

Answer: C. Pneumonia

Rationale: Older adults with pneumonia may present with atypical symptoms such as confusion, weakness, fatigue, or functional decline rather than fever and productive cough. A sudden mental-status change should not be dismissed as normal aging.

Question 9

A community health nurse develops programs to promote respiratory health among older adults. Which program has the greatest potential benefit?

A. Lung cancer screening program
B. Smoking-cessation program
C. Tuberculosis screening program
D. Bronchitis immunization program

Answer: B. Smoking-cessation program

Rationale: Smoking cessation improves both respiratory and cardiovascular health and benefits adults at any age. It has a broader preventive effect than screening programs alone.

Question 10 — Select All That Apply

A 72-year-old man has been diagnosed with COPD. Which findings are unexpected and require follow-up?

A. Hemoptysis and orthostatic hypotension
B. Chest pain and shortness of breath
C. Cough and dyspnea
D. Apneic episodes and fatigue
E. Wheezing and digital clubbing

Source-Listed Answers: C and D

Rationale: The source states that common COPD manifestations include cough, dyspnea, wheezing, and increased sputum production. It also states that hemoptysis, orthostatic hypotension, apneic episodes, fatigue, and chest pain require follow-up.

Important source inconsistency: The listed answers do not match the provided rationale. Based on the rationale, choice C contains expected COPD findings and should not be selected. Choice A clearly contains unexpected findings, while choice B requires immediate evaluation for possible cardiac dysfunction. This question should be verified against the original textbook before studying the answer key.

Question 11

An older adult asks, “Why do all my friends seem to get pneumonia now? We never did when we were younger.” Which preventive intervention should the nurse include in the teaching?

A. Routine examinations by a healthcare provider
B. Consistent hand hygiene
C. Jogging or running regularly
D. Receiving the pneumococcal vaccine every year

Answer: B. Consistent hand hygiene

Rationale: Age-related immune changes increase susceptibility to respiratory infections. Hand hygiene helps prevent transmission, while pneumococcal vaccination is not administered annually.

Question 12

A nurse assesses older adults at a pulmonary clinic. Which question is most useful for identifying clients at risk for pulmonary disease?

A. “Do any of your children smoke?”
B. “In which state did you grow up?”
C. “What type of work did you do?”
D. “Where do you usually exercise?”

Answer: C. “What type of work did you do?”

Rationale: Certain occupations involve long-term exposure to dust, chemicals, asbestos, smoke, and other respiratory hazards. An occupational history can reveal major cumulative risk factors.

Question 13

A nurse interviews an older adult with pulmonary disease. The client says, “I worked hard in the shipyard all my life and provided for my family. I never smoked, so why did I get this disease?” Which response by the nurse is best?

A. “It is good that you never smoked.”
B. “Pulmonary disease can happen to anyone.”
C. “Your work in the shipyard placed you at increased risk.”
D. “You feel as though you are being punished.”

Answer: C. “Your work in the shipyard placed you at increased risk.”

Rationale: Shipyard work may involve exposure to asbestos and other respiratory hazards. This response directly addresses the client’s concern and provides relevant information.

Question 14

A nurse plans care for a frail older adult in a long-term care facility. Which intervention should be included to reduce the risk of respiratory infection?

A. Provide regular oral care.
B. Administer oxygen routinely.
C. Perform pulmonary function testing.
D. Perform routine tracheal suctioning.

Answer: A. Provide regular oral care.

Rationale: Poor oral hygiene increases bacterial colonization and contributes to pneumonia risk, especially when aspiration occurs. Oxygen, testing, and suctioning do not prevent infection in an otherwise stable resident.

Question 15

A nurse admits an older adult from a long-term care facility with a respiratory infection. Which diagnostic test should the nurse anticipate?

A. Electrocardiogram
B. Lung cancer screening
C. Mantoux tuberculin skin testing
D. Pulmonary function testing

Answer: C. Mantoux tuberculin skin testing

Rationale: Residents of long-term care facilities are at increased risk for tuberculosis exposure and transmission. Tuberculosis testing may be necessary to identify a contagious disease and protect other residents and staff.

mobility chapter

Question 1

A nurse is teaching health interventions to an older adult with osteoarthritis. Which statement indicates that the client needs additional teaching?

A. “I will avoid high-impact exercise.”
B. “I will get adequate calcium and vitamin D.”
C. “I will try to limit my use of walkers and other assistive devices.”
D. “I will lose weight if it is recommended.”

Answer: C. “I will try to limit my use of walkers and other assistive devices.”

Rationale: Walkers and other assistive devices reduce stress on weight-bearing joints and improve balance. Clients with osteoarthritis should use assistive devices as needed rather than avoiding them.

Question 2

A nurse teaches older adults at a senior center how to reduce their risk of falls. Which statement indicates that the teaching was effective?

A. “Diphenhydramine is a safe medication to take for sleep.”
B. “It is safe to keep rugs in my kitchen and bathroom.”
C. “It is safe to take a low dose of lorazepam when I feel anxious.”
D. “I understand that over-the-counter medications can contribute to falls.”

Answer: D. “I understand that over-the-counter medications can contribute to falls.”

Rationale: Prescription and over-the-counter medications can increase fall risk through sedation, dizziness, confusion, or impaired coordination. Diphenhydramine and benzodiazepines are especially concerning in older adults.

Question 3

A 99-year-old resident has fallen. Which functional consequence most strongly affects the plan of care?

A. The resident has a much higher risk of sustaining a fracture than a younger person.
B. The resident is more likely to have limited range of motion that affects activities of daily living.
C. The resident is unlikely to develop a fear of falling.
D. The resident will have reduced muscle strength because of decreased muscle mass.

Answer: A. The resident has a much higher risk of sustaining a fracture than a younger person.

Rationale: Increasing age and reduced bone density significantly raise the risk of fractures after a fall. Preventing additional falls and fractures becomes the major priority.

Question 4

Which nursing intervention should be the priority for a nurse working in a retirement community?

A. Use restraints to keep residents from getting out of chairs without assistance.
B. Establish a fall-prevention program for residents at risk.
C. Provide cordless phones or emergency call systems to all residents.
D. Provide monitoring devices to all residents who live alone.

Answer: B. Establish a fall-prevention program for residents at risk.

Rationale: A formal fall-prevention program addresses multiple risk factors and applies consistent preventive measures to high-risk residents. Restraints may increase injury risk and should not be used routinely.

Question 5

Which older adult is at greatest risk for developing osteoporosis?

A. A 65-year-old White woman with COPD who takes corticosteroids
B. A 65-year-old White man with rheumatoid arthritis
C. A 70-year-old African American man with a seizure disorder
D. A 68-year-old Hispanic woman who recently had a partial hysterectomy

Answer: A. A 65-year-old White woman with COPD who takes corticosteroids

Rationale: Older White women have an increased baseline risk for osteoporosis, and long-term corticosteroid therapy causes secondary bone loss. This combination creates the greatest risk.

Question 6

A 79-year-old woman is scheduled for hip replacement after sustaining a fracture from a fall. Which age-related change may have contributed to her susceptibility to fracture?

A. Increased protein synthesis
B. Infections within the synovial capsules
C. Loss of neural control of balance
D. Increased bone resorption

Answer: D. Increased bone resorption

Rationale: Bone resorption increases with age, causing reduced bone density and greater fracture risk. Protein synthesis decreases with aging, and infection is never considered a normal age-related change.

Question 7

During a safe and controlled transfer from a bathtub, an 84-year-old resident suddenly becomes rigid, grips the nurse forcefully, and cries, “Help me quickly!” What is the most likely explanation?

A. The resident is developing a cognitive deficit.
B. The resident is experiencing a normal age-related response.
C. The resident has a fear of falling.
D. The resident is appropriately ensuring personal safety.

Answer: C. The resident has a fear of falling.

Rationale: Fear of falling is common among older adults and may cause anxiety, stiffness, avoidance of movement, and loss of confidence. It is not considered an inevitable or normal consequence of aging.

Question 8

An 82-year-old client walked 2 miles last week and has avoided activity since then because of pain. Which nursing action is most appropriate?

A. Discuss activity moderation and encourage continued movement.
B. Obtain a cane to reduce the client’s fear of pain.
C. Encourage the client to walk 2 miles every day.
D. Instruct the client to take ibuprofen every morning.

Answer: A. Discuss activity moderation and encourage continued movement.

Rationale: Osteoarthritis management includes regular low-impact activity balanced with rest. The previous 2-mile walk exceeded the client’s tolerance, but complete inactivity will worsen stiffness and functional decline.

Question 9

A 70-year-old woman wants to reduce her risk of osteoporosis. Which dietary recommendation should the nurse make?

A. Increase intake of salmon and fortified cereals.
B. Follow a high-protein, low-carbohydrate diet.
C. Increase intake of organic fruits and vegetables.
D. Take vitamin C supplements and consume a high-potassium diet.

Answer: A. Increase intake of salmon and fortified cereals.

Rationale: Salmon and fortified foods can provide calcium and vitamin D, which are important for maintaining bone health. The other choices do not directly address osteoporosis prevention.

Question 10 — Select All That Apply

A nursing home has experienced numerous resident falls. Which environmental factors should the nurse manager change?

A. Hallways leading to common areas do not have handrails.
B. Residents have private toilets, but only two shared bathing rooms are available.
C. Bedrails are kept raised whenever residents are in bed.
D. Most care is provided by nursing assistants under the supervision of one registered nurse.
E. Medications are administered from a rolling cart.

Answers: A and C

Rationale: Lack of handrails reduces support during ambulation, and raised bedrails may cause residents to climb over them and fall from a greater height. Shared bathing facilities and medication carts do not directly explain the increased fall rate.

Question 11 — Select All That Apply

A nurse cares for a client with advanced Alzheimer disease who is not independently mobile and is at high risk for falls. Which interventions should be included in the fall-prevention program?

A. Place a bright identification sticker on the resident’s door.
B. Place a padded mattress on the floor next to the bed.
C. Use a chest restraint while the resident is in a wheelchair.
D. Assess the resident frequently for toileting needs.
E. Keep the room and bathroom lights on continuously.
F. Place a sensor-pad alarm on the bed.

Answers: A, B, D, and F

Rationale: High-risk identification, a padded surface, frequent toileting, and a bed alarm can reduce fall-related harm. Restraints increase injury risk, and keeping lights on continuously may disrupt sleep and increase confusion.

Question 12

A physically active 64-year-old client participates in rock climbing and snowboarding. Which age-related functional consequence most strongly increases the client’s risk for fractures?

A. A strong musculoskeletal system protects bones.
B. Reduced osteoblastic production of bone matrix
C. Decreased blood flow to the long bones
D. Weight-bearing activity increases calcium uptake into bones.

Answer: B. Reduced osteoblastic production of bone matrix

Rationale: Aging decreases osteoblast activity, reducing new bone formation and increasing fracture risk. Weight-bearing activity is protective rather than harmful to bone health.

Question 13

A home health nurse assesses a frail older adult using the Timed Up and Go test. Which result places the client at the highest risk for falls?

A. 6 seconds
B. 9 seconds
C. 12 seconds
D. 15 seconds

Answer: D. 15 seconds

Rationale: A longer completion time indicates impaired gait, balance, and mobility. Scores above approximately 12 to 14 seconds are associated with increased fall risk.

Question 14

A nurse presents information about aging and mobility. Which age-related change should the nurse include?

A. Bone resorption decreases because parathyroid hormone decreases.
B. Position-sense awareness in the lower extremities decreases.
C. Collagen and elastin cells increase in number.
D. The number of skeletal muscle fibers increases.

Answer: B. Position-sense awareness in the lower extremities decreases.

Rationale: Reduced proprioception makes it more difficult for older adults to detect limb position and maintain balance, increasing fall risk. Aging also causes increased bone resorption, degeneration of collagen and elastin, and loss of muscle fibers.

Question 15

Which hospitalized older adult is at greatest risk for sustaining a hip fracture from a fall?

A. A 79-year-old client
B. A client receiving several cardiac medications
C. A client with a previous hip fracture caused by a fall
D. A client with newly diagnosed dementia

Answer: C. A client with a previous hip fracture caused by a fall

Rationale: A previous fracture nearly doubles the risk of another fracture. Age, medications, and dementia also increase risk, but a history of fracture is the strongest predictor among these choices.

Cognitive Function

Question 1

A nurse leads a word-quiz game with a group of nursing-home residents because the activity can help the residents maintain which cognitive ability?

A. Fluid intelligence
B. Adaptive thinking
C. Crystallized intelligence
D. Psychomotor memory

Answer: C. Crystallized intelligence

Rationale: Crystallized intelligence includes vocabulary, accumulated knowledge, verbal comprehension, and information gained through experience. Word quizzes specifically exercise stored knowledge and language skills.

Question 2

A 69-year-old client was recently diagnosed with mild cognitive impairment and asks the nurse for help improving memory. Which nursing diagnosis is most appropriate?

A. Deficient knowledge
B. Disturbed thought processes
C. Health-seeking behaviors
D. Ineffective health maintenance

Answer: C. Health-seeking behaviors

Rationale: The client is actively seeking strategies to improve wellness and cognitive function. This reflects health-seeking behavior rather than a lack of knowledge or an inability to maintain health.

Question 3

A 70-year-old client reports difficulty remembering names and missing two healthcare appointments. The nurse initiates a memory-training program. Which question best evaluates the effectiveness of the program?

A. “Have you noticed an improvement in your memory?”
B. “Are you less worried about your memory now?”
C. “How have the memory-training techniques helped you?”
D. “Are you currently using the memory-training techniques?”

Answer: C. “How have the memory-training techniques helped you?”

Rationale: This open-ended question encourages the client to describe specific benefits and identify which strategies are effective. It also communicates a positive expectation without leading the response.

Question 4

A 61-year-old client tells the nurse, “I cannot process information as quickly as I did when I was younger, and I cannot multitask like everyone talks about.” Which response by the nurse is most appropriate?

A. “Have you experienced any other symptoms of cognitive impairment?”
B. “Slower information processing can occur with aging, and there are strategies that can help.”
C. “Declines in cognitive ability usually begin around age 60.”
D. “You should not expect a decline in cognitive functions you use regularly.”

Answer: B. “Slower information processing can occur with aging, and there are strategies that can help.”

Rationale: Decreased perceptual and processing speed can occur with normal aging, although healthy older adults should not develop cognitive deficits that significantly interfere with daily functioning. The nurse should acknowledge the concern and provide practical support.

Question 5

Which point should the nurse emphasize when educating older adults about memory and cognition?

A. Long-term memory loss is a normal part of aging.
B. Calendars, written notes, and mental imagery can improve memory.
C. Caffeinated beverages should be used to stimulate cognition.
D. A diminished ability to learn is inevitable with aging.

Answer: B. Calendars, written notes, and mental imagery can improve memory.

Rationale: External aids, such as calendars and notes, and internal strategies, such as imagery, can improve memory performance. Significant long-term memory loss and inability to learn are not inevitable consequences of aging.

Question 6

An older adult is brought to a community clinic by an adult child because of increasingly frequent memory lapses. Which assessment question is most likely to identify a risk factor for impaired cognitive function?

A. “What did your parents die from?”
B. “What type of work did you perform?”
C. “What medications are you currently taking?”
D. “Where are you currently living?”

Answer: C. “What medications are you currently taking?”

Rationale: Medication adverse effects and drug interactions are common, potentially reversible causes of cognitive changes in older adults. A complete medication review should include prescriptions, over-the-counter drugs, and supplements.

Question 7

A 74-year-old client is distressed after forgetting an important appointment and losing a wallet. The client has always valued being intelligent and alert. How should the nurse interpret these recent memory deficits?

A. The client is probably in the early stage of Alzheimer disease.
B. The client is experiencing temporary delirium that will resolve without treatment.
C. The client is experiencing a normal age-related personality change.
D. The client may be experiencing mild cognitive impairment.

Answer: D. The client may be experiencing mild cognitive impairment.

Rationale: Mild cognitive impairment involves measurable cognitive decline that is greater than expected for normal aging but does not necessarily eliminate independence. The findings require assessment rather than immediate labeling as dementia or delirium.

Question 8

A nurse plans monthly activities for residents of an assisted-living facility. Which activity is most cognitively stimulating?

A. Book discussions
B. Movie night
C. Exercise session
D. Reminiscence therapy

Answer: A. Book discussions

Rationale: Book discussions require reading, interpretation, recall, communication, and active participation. These mentally challenging activities support cognitive reserve and neuroplasticity.

Question 9

A nurse in a long-term care facility wants to enhance residents’ cognitive function and reduce cognitive decline. Which action has the greatest potential benefit?

A. Encourage residents to openly express emotions and opinions.
B. Provide several low-fat, high-protein meals each day.
C. Encourage participation in mentally challenging activities.
D. Provide frequent opportunities for residents to make independent decisions.

Answer: C. Encourage participation in mentally challenging activities.

Rationale: Creative and intellectually stimulating activities support cognitive reserve and may help preserve cognitive function. Autonomy, nutrition, and emotional expression are beneficial but do not directly stimulate cognition as strongly.

Question 10

An 82-year-old client with type 2 diabetes and heart failure states that life is more satisfying now than when the client was younger. Which phenomenon is the client demonstrating?

A. Metamemory
B. Paradox of well-being
C. Crystallized intelligence
D. Neuroplasticity

Answer: B. Paradox of well-being

Rationale: The paradox of well-being describes older adults who report high levels of satisfaction and positive emotion despite chronic illness, losses, or functional limitations.

Question 11 — Select All That Apply

A nurse in an assisted-living facility develops interventions to improve residents’ cognitive abilities. Which activities should the nurse include?

A. Book club
B. Calisthenics
C. Christmas caroling
D. Letter writing
E. Reminiscence therapy
F. Shopping trip

Answers: A and D

Rationale: Reading, group discussion, and writing are creative and intellectually challenging activities that stimulate cognitive function. The other activities may provide physical, social, or emotional benefits but are less cognitively demanding according to the source.

Question 12

A nurse assesses an 82-year-old client with a history of coronary artery bypass surgery and heart failure. The family reports that the client’s ability to “figure out what is happening” has declined, but the client remains wise and continues to provide sound life advice. Which explanation best accounts for this finding?

A. Crystallized intelligence normally declines with age.
B. Older adults perform better than younger adults under every cognitive condition.
C. Mild cognitive impairment begins with cognitive dissonance.
D. Cardiovascular disease may impair some cognitive abilities.

Answer: D. Cardiovascular disease may impair some cognitive abilities.

Rationale: Fluid intelligence, such as processing new information and solving unfamiliar problems, may be impaired by circulatory and neurologic disease. Crystallized intelligence, including wisdom and accumulated knowledge, is often preserved.

Question 13

A nurse determines that an older adult has difficulty remembering current events and using technology. With which task is the client most likely to have difficulty?

A. Participating in a reminiscence group
B. Digitally recording blood glucose results
C. Remembering to obtain a daily weight
D. Understanding when to notify the healthcare provider

Answer: B. Digitally recording blood glucose results

Rationale: New technology may require unfamiliar problem-solving skills and processing of new information. The client may perform better using a familiar method, such as recording glucose readings on paper.

Question 14

A 90-year-old client participates in a life review and explains that she raised five children, experienced many challenges, and feels satisfied with her life. According to Cohen’s empowering model, which statement is she most likely to make?

A. “I would summarize my life this way.”
B. “I would still like to visit the Grand Canyon.”
C. “I hope to learn how to video-call my grandchildren.”
D. “I know I have done the best I could, and I will continue helping my family.”

Answer: D. “I know I have done the best I could, and I will continue helping my family.”

Rationale: In later life, older adults often reaffirm major life themes and express a desire to continue having a positive effect on others. This statement reflects meaning, continuity, and generativity.

Question 15

An older adult expresses frustration about the limitations of aging. Which response by the nurse best promotes wellness?

A. “Do you have any words of wisdom to share from your experiences?”
B. “How does your current life compare with your youth?”
C. “Have you met your neighbors? They seem friendly.”
D. “You are frustrated because others are not listening to you.”

Answer: A. “Do you have any words of wisdom to share from your experiences?”

Rationale: This response acknowledges the older adult’s experience, wisdom, and value. It supports self-esteem and empowerment rather than redirecting the conversation or focusing only on loss.

psychosocial function

Question 1

A 75-year-old woman previously went out to dinner frequently with friends but has stopped because of urinary incontinence and fear of having an accident in public. When her child asks why she no longer socializes, she says, “I am getting too old for that foolishness.” She refuses to see a healthcare provider. What is occurring?

A. She is experiencing learned helplessness and low self-efficacy.
B. She views incontinence as an inevitable consequence of aging.
C. She views incontinence as a negative functional consequence of aging.
D. Her healthcare provider is sympathetic, but no solution can be found.

Answer: B. She views incontinence as an inevitable consequence of aging.

Rationale: The client is passively accepting a potentially treatable problem as a normal and unavoidable part of aging. When older adults believe functional decline is inevitable, they may avoid evaluation and withdraw from meaningful activities.

Question 2

An older woman returns to her hospital room after abdominal surgery. During the assessment, she asks the nurse to pin her prayer cloth to her pillow. Which intervention is the priority?

A. Say, “I will pin it to your pillow after you are more stable.”
B. Ask, “What is the purpose of the prayer cloth? Did you make it?”
C. Ask, “What religion do you practice? Did your minister give it to you?”
D. Pin the prayer cloth to her pillow because it is important to her spiritual health.

Answer: D. Pin the prayer cloth to her pillow because it is important to her spiritual health.

Rationale: The request is safe, simple, and important to the client’s spiritual well-being. Respecting the client’s wishes individualizes care and demonstrates nonjudgmental, culturally sensitive nursing practice.

Question 3

A nurse manager in an extended-care facility wants to promote psychosocial health. Which intervention should be included?

A. Adapt the environment to compensate for residents’ sensory impairments.
B. Dress residents solely according to ease of toileting.
C. Arrange dining-room seating according to room and hallway assignments.
D. Position wheelchair users only according to ease of leaving the dining area.

Answer: A. Adapt the environment to compensate for residents’ sensory impairments.

Rationale: Adapting the environment helps residents communicate, participate, and maintain social relationships. Clothing, seating, and positioning should support personal choice and interaction rather than staff convenience.

Question 4

A nurse teaches a nursing assistant about the effect of culture on older adults’ psychosocial well-being. Which statement by the nursing assistant indicates a need for further teaching?

A. “Cultural background has little influence on what a person considers normal or abnormal behavior.”
B. “Western cultures often make a rigid distinction between health and illness.”
C. “Culture can influence mental health and mental illness.”
D. “Culture may influence how a person expresses symptoms.”

Answer: A. “Cultural background has little influence on what a person considers normal or abnormal behavior.”

Rationale: Culture strongly affects beliefs about normal behavior, illness, coping, symptoms, and treatment. The nurse must assess the client’s beliefs rather than assuming all people interpret psychosocial symptoms in the same way.

Question 5

A nurse manager develops policies to promote a sense of control among residents of an assisted-living facility. Which policy should be included?

A. Hold resident council meetings twice each month and invite all residents.
B. Post the weekly menu and require residents to request changes in advance.
C. Design emergency pull cords to blend into the wallpaper.
D. Have nursing assistants enter every room twice nightly using a passkey.

Answer: A. Hold resident council meetings twice each month and invite all residents.

Rationale: Resident council meetings allow older adults to express preferences and participate in decisions affecting their lives. Meaningful choice and autonomy improve perceived control and psychosocial well-being.

Question 6 — Select All That Apply

A nurse assists adults in preparing for changes that commonly occur in late adulthood. Which psychosocial consequences may result from life events during this period?

A. Expansion of social networks
B. Adjustment to relocation from home
C. Adjustment to reduced income
D. Adaptation to chronic illness
E. Coming to terms with mortality

Answers: B, C, D, and E

Rationale: Late adulthood may involve relocation, reduced finances, chronic illness, bereavement, and awareness of mortality. Social networks often become smaller rather than broader.

Question 7

A 69-year-old woman is distressed after being diagnosed with type 2 diabetes. Which action demonstrates problem-focused coping?

A. Seeking emotional support from her sister and neighbor
B. Obtaining diabetic cookbooks and changing her cooking habits
C. Seeking a second opinion from another healthcare provider
D. Choosing not to make lifestyle changes

Answer: B. Obtaining diabetic cookbooks and changing her cooking habits

Rationale: Problem-focused coping involves taking concrete action to manage or change the stressor. Learning new cooking habits directly addresses diabetes management.

Question 8

An older adult has impaired psychosocial functioning. Which consequence should the nurse monitor?

A. Anxiety
B. Elevated blood glucose
C. Increased independence
D. Resilience

Answer: A. Anxiety

Rationale: Anxiety is a common consequence of impaired psychosocial function. Independence and resilience are positive indicators of psychosocial wellness rather than impairment.

Question 9

A nurse in a long-term care facility organizes a Healthy Aging class. Which activity should be prioritized?

A. Present tools residents can use to improve psychosocial health.
B. Role-play responses to future life events.
C. Assess each resident’s coping strategies.
D. Discuss coping strategies that help with the challenges of aging.

Answer: D. Discuss coping strategies that help with the challenges of aging.

Rationale: Healthy Aging classes allow older adults to share experiences and discuss effective ways of adjusting to age-related changes. Peer discussion is central to the class.

Question 10

A nurse leads a Healthy Aging class at a community health center. Which question is most appropriate for generating group discussion?

A. “How did you adjust when you moved from your home to assisted living?”
B. “Are you satisfied with the care provided by your family doctor?”
C. “Why is your grandson living with you?”
D. “Have you had any cardiac testing since our last meeting?”

Answer: A. “How did you adjust when you moved from your home to assisted living?”

Rationale: This open-ended question encourages discussion about a common late-life transition and allows participants to share coping experiences. The other questions are more private, medical, or potentially intrusive.

Question 11

An 81-year-old widowed client is admitted with heart failure. The healthcare team is discussing a possible move to assisted living. Which nursing intervention best creates an opportunity for psychosocial wellness?

A. Ask the client to explain how care was managed at home.
B. Help the client discuss feelings about a possible move to assisted living.
C. Describe all long-term housing options.
D. Encourage the client to think positively about the move.

Answer: B. Help the client discuss feelings about a possible move to assisted living.

Rationale: Encouraging the client to express the meaning and emotions associated with relocation promotes coping and psychosocial wellness. The nurse should not dismiss negative emotions by simply telling the client to think positively.

Question 12 — Select All That Apply

A community health nurse teaches a class about retirement. Which points should the nurse include?

A. Delaying retirement until a person can no longer work is beneficial.
B. Health, relationships, and financial and social resources affect the transition.
C. Adjustment may be more difficult for the partner who was not employed.
D. Retirement adjustment is best completed rapidly and permanently.
E. A strong work ethic always improves retirement adjustment.

Answers: B and C

Rationale: Retirement adjustment is influenced by health, relationships, finances, identity, and available resources. The transition may also affect the nonworking partner and is often easier when it occurs gradually.

Question 13

A 75-year-old woman has stopped dining with friends because of urinary incontinence and believes that the condition is simply part of aging. How should the nurse best assist her?

A. Help her view the limitation as potentially temporary and treatable.
B. Encourage her to accept the condition as part of growing older.
C. Reframe the situation as one she can control and then leave all decisions entirely to her.
D. Teach her that most older adults rate their health as good or excellent.

Answer: A. Help her view the limitation as potentially temporary and treatable.

Rationale: The nurse should correct the belief that incontinence is an inevitable and untreatable part of aging. Reframing the problem as treatable can increase self-efficacy and encourage the client to seek evaluation.

Question 14

An 81-year-old widowed client with heart failure recently moved into an assisted-living facility and is now hospitalized. Which factor most likely contributed to the admission?

A. The move changed the client’s daily habits.
B. Age-related changes and risk factors increased.
C. The combined stress of widowhood and relocation affected the client’s health.
D. The assisted-living facility served meals high in saturated fat.

Source-Listed Answer: B. Age-related changes and risk factors increased.

Rationale: The source’s explanation states that chronic stress increases the risk for major illness and can worsen chronic disease.

Source inconsistency: The rationale supports C, not B. Widowhood and relocation are major stressors that could exacerbate heart failure. Verify this item against the original textbook before memorizing the answer.

Question 15

A nurse assesses an 85-year-old Hispanic woman who states that her husband was “punished by God.” To which illness is the woman most likely referring?

A. Alcohol abuse
B. Fainting
C. Posttraumatic stress disorder
D. Voodoo

Answer: A. Alcohol abuse

Rationale: The source explains that some Hispanic older adults may view mental illness or substance misuse as punishment for wrongdoing. The nurse should assess individual beliefs without stereotyping or assuming that all members of a cultural group share the same views.

psychosocial assessment

Question 1

A nurse performs a psychosocial assessment of an older adult living in the community. Which statement best describes the nature of a psychosocial assessment?

A. It is a formal psychological test of the individual’s condition and needs.
B. It identifies and analyzes the individual’s personality traits.
C. It determines whether the individual requires psychiatric care.
D. It is a component of holistic nursing care for older adults.

Answer: D. It is a component of holistic nursing care for older adults.

Rationale: Psychosocial assessment is part of holistic mind-body-spirit nursing care. It is not a formal psychological examination and is not performed solely to diagnose personality traits or determine the need for psychiatric treatment.

Question 2

While providing morning care to a recently admitted client, the client says, “I am pretty sure I will never see my apartment again.” Which response by the nurse demonstrates effective communication?

A. “What makes you feel that way?”
B. “I am sure that will not happen.”
C. “Overall, you are doing quite well.”
D. “There is a lot we can do, dear, to make sure you return home.”

Answer: A. “What makes you feel that way?”

Rationale: This open-ended response communicates empathy and encourages the client to explain concerns and expectations about recovery. The other responses give false reassurance, minimize the concern, or use patronizing language.

Question 3

A nurse assesses an older adult’s ability to think abstractly. Which question is most appropriate?

A. “Do you know why you are currently in the hospital?”
B. “What do a dog and a cat have in common?”
C. “What goals do you have for your treatment and recovery?”
D. “What would you do if you found a stamped, addressed letter on the ground?”

Answer: B. “What do a dog and a cat have in common?”

Rationale: Asking the client to identify a shared category or characteristic between two different objects assesses abstract thinking. Asking why the client is hospitalized assesses insight, while the letter question assesses judgment.

Question 4

A nurse assesses the social supports available to an older adult. Which action should the nurse include in the plan?

A. Ask the client direct questions about barriers to using social-support services.
B. Decide which available support program provides the highest-quality care.
C. Determine whether family members or friends can provide all necessary assistance.
D. Provide information about available support services without assessing barriers.

Source-Listed Answer: A. Ask the client direct questions about barriers to using social-support services.

Rationale: The nurse needs to identify barriers preventing the client from using available support. However, the source also states that direct questions may feel threatening, so these concerns should be explored sensitively and respectfully.

Source wording concern: The listed answer says to use direct questions, but the rationale warns that direct questions may be inappropriate or threatening. The intended principle is to assess barriers without making the client feel judged or pressured.

Question 5

Even in a high-acuity setting, a nurse can assess a client’s spiritual needs. Which question is appropriate for an older adult admitted to the intensive care unit with sepsis?

A. “Do you attend church services?”
B. “Is there a spiritual leader we can contact for you?”
C. “What are your beliefs about death?”
D. “What religion do you practice?”

Answer: B. “Is there a spiritual leader we can contact for you?”

Rationale: In an acute situation, the nurse can quickly identify and arrange meaningful spiritual support. Asking about formal religion is less important than determining what support the client currently wants.

Question 6

A nurse conducts a comprehensive psychosocial assessment of an older adult who recently moved into a long-term care facility. How should the nurse assess motor function?

A. Observe the client walking into or out of the room.
B. Assess deep tendon reflexes with a reflex hammer.
C. Perform passive range-of-motion exercises.
D. Ask the client to perform separate leg lifts while lying supine.

Answer: A. Observe the client walking into or out of the room.

Rationale: During a psychosocial assessment, motor function includes posture, movement, activity level, and body language. Reflexes, muscle strength, and range of motion are components of a physical or neurologic examination.

Question 7 — Select All That Apply

An older adult is admitted to a geriatric hospital unit. The emergency department nurse reports that the client is oriented to only one sphere. Which actions should the admitting nurse perform?

A. Discuss the client’s subjective concerns about cognitive function.
B. Orient the client to the room, unit, and plan of care.
C. Post a calendar with completed dates crossed off.
D. Reassess the client’s orientation status.
E. Repeat orientation information as needed.

Answers: B, C, D, and E

Rationale: The client may need time, environmental cues, repeated orientation, and reassessment after entering an unfamiliar setting. Acute illness may also temporarily impair memory and orientation.

Question 8

A nurse performs a psychosocial assessment of an older adult in the hospital. Which statement may indicate low self-esteem?

A. “I do not know who will care for my spouse while I am hospitalized.”
B. “I know I need help from others sometimes.”
C. “When I was younger, I worked constantly, and now I cannot even get to the toilet.”
D. “I am worried about what will happen after I leave the hospital.”

Answer: C. “When I was younger, I worked constantly, and now I cannot even get to the toilet.”

Rationale: The client is linking loss of function and dependence with personal worth, which may indicate low self-esteem. Concern about a spouse or discharge may be realistic and does not necessarily indicate impaired self-worth.

Question 9

A nursing-home resident repeatedly accuses staff members of stealing jewelry, even though valuables are kept in a locked box. The nurse responds empathically and explains why the accusation cannot be true, but the resident remains convinced. Which condition is the client experiencing?

A. Delusion
B. Hallucination
C. Unresolved anger
D. Illusion

Answer: A. Delusion

Rationale: A delusion is a fixed false belief that is not corrected through logical explanation or evidence. A hallucination is a sensory experience without an external stimulus, while an illusion is a misinterpretation of an actual stimulus.

Question 10

A nurse assesses an older adult’s insight regarding the plan of care. Which question should the nurse ask?

A. “Where would you go if you were discharged today?”
B. “How would you spend $100 if it were given to you today?”
C. “How are a doctor and a nurse similar?”
D. “Why do you think your healthcare provider admitted you to the hospital?”

Answer: D. “Why do you think your healthcare provider admitted you to the hospital?”

Rationale: Insight refers to the client’s understanding of the illness, current situation, and need for treatment. Hypothetical questions more commonly assess judgment or executive function.

Question 11

During an admission interview, an older adult says, “I cannot stay in my own home. Now that I have fallen and broken my hip, I am not sure what the doctor will say. My children do not want me.” Which response by the nurse is most appropriate?

A. “You are worried that the doctor will say you need surgery?”
B. “You fell and broke your hip?”
C. “You feel that your children do not want you?”
D. “Where do you want to live?”

Answer: C. “You feel that your children do not want you?”

Rationale: Reflection focuses on the emotional meaning of the client’s statement and encourages further discussion. Asking about housing choices is not therapeutic when the client believes there may be no choice.

Question 12

During an interview, an older adult moves her chair farther away from the nurse. Which response by the nurse is most appropriate?

A. Stop the interview and allow the client time to recover.
B. Move the nurse’s chair closer.
C. Sit upright and lean back slightly.
D. Ask whether the client is feeling ill.

Answer: C. Sit upright and lean back slightly.

Rationale: The client’s movement may indicate a need for more personal space. The nurse should respond to the nonverbal cue by increasing distance rather than moving closer or unnecessarily stopping the interview.

Question 13 — Select All That Apply

A nurse administers a Mini-Mental State Examination to an older adult who responds very slowly. Which conditions may be present and require follow-up?

A. Limited formal education
B. Dementia
C. Depression
D. Confabulation
E. Concrete thinking

Answers: B and C

Rationale: The amount of time and effort required to answer questions can help differentiate depression from dementia. Limited education and concrete thinking may affect performance but do not specifically explain slowed responses in the manner described.

Question 14

A nurse differentiates between dementia and depression in an older adult. Which finding is most consistent with depression?

A. Socially inappropriate behavior
B. A sad and negativistic mood
C. A mood that fluctuates throughout the day
D. A mood that changes easily with distraction

Answer: B. A sad and negativistic mood

Rationale: Depression often produces a consistently sad, pessimistic, or negativistic affect that does not improve significantly with distraction. In dementia, mood and affect may fluctuate and change in response to the environment.

Question 15 — Select All That Apply

An older adult develops hallucinations. For which conditions should the nurse assess?

A. Digoxin toxicity
B. Hyperglycemia
C. Infection
D. Myocardial infarction
E. Stroke

Answers: A, C, and E

Rationale: Digoxin toxicity, infection, and stroke can produce hallucinations or other acute cognitive and perceptual changes. These findings require assessment for an underlying medical cause rather than being assumed to represent a primary psychiatric disorder.

impaired cognitive function delrium and dementia

Question 1

Which nursing intervention is the priority when managing a client with delirium?

A. Administer low-dose oxygen as indicated and maintain fluid and electrolyte balance.
B. Reduce noise and place familiar objects in the client’s environment.
C. Provide a clock, watch, and calendar for temporal orientation.
D. Provide psychological support through cognitive and social stimulation.

Answer: A. Administer low-dose oxygen as indicated and maintain fluid and electrolyte balance.

Rationale: Delirium is usually caused or worsened by an acute physiologic problem. The nurse must first address oxygenation, hydration, and electrolyte abnormalities before implementing orientation and environmental interventions.

Question 2

A nurse teaches a class about factors that may protect against dementia. Which statement by an older adult indicates a need for further teaching?

A. “No healthy lifestyle can help reduce the risk of dementia.”
B. “Eating foods high in omega-3 fatty acids may help preserve cognition.”
C. “Participating in social activities may help prevent cognitive decline.”
D. “Regular exercise may help prevent symptoms of cognitive decline.”

Answer: A. “No healthy lifestyle can help reduce the risk of dementia.”

Rationale: Regular exercise, healthy nutrition, and meaningful social and cognitive activities may reduce cognitive decline. A healthy lifestyle cannot guarantee prevention, but it may lower risk and support brain health.

Question 3

A nurse teaches a client and care partner about cholinesterase inhibitors. Which statement should the nurse include?

A. “Rivastigmine has a high risk of interacting with other medications.”
B. “Starting with a low dose and increasing it gradually can reduce nausea, vomiting, diarrhea, and loss of appetite.”
C. “Rivastigmine is used only during mild Alzheimer disease and is stopped as the disease progresses.”
D. “A monthly medication holiday improves how well the medication works.”

Answer: B. “Starting with a low dose and increasing it gradually can reduce nausea, vomiting, diarrhea, and loss of appetite.”

Rationale: Cholinesterase inhibitors commonly cause gastrointestinal adverse effects, so treatment generally begins with a low dose and is titrated slowly. Abruptly stopping and restarting the medication may reduce its effectiveness.

Question 4

Which communication technique is appropriate when caring for a person with dementia?

A. Ask broad, open-ended questions so the person can make more choices.
B. Speak to a person with advanced Alzheimer disease as though speaking to a child.
C. Maintain eye contact and use a calm, relaxed, smiling approach.
D. Remind the person not to forget information the next time.

Answer: C. Maintain eye contact and use a calm, relaxed, smiling approach.

Rationale: Calm body language, eye contact, and a relaxed tone reduce anxiety and support communication. The nurse should avoid infantilization, criticism, and questions that are too broad or cognitively demanding.

Question 5 — Select All That Apply

A nurse develops a plan to manage dementia-related behaviors. Which interventions should be included?

A. Maintain a clutter-free environment.
B. Schedule regular rest periods.
C. Place photographs of familiar people in visible areas.
D. Lay out clothing in the order in which it should be put on.
E. Test the client’s memory during every conversation.

Answers: A, B, C, and D

Rationale: A simple environment, regular rest, familiar visual cues, and step-by-step organization reduce confusion and support independence. Repeatedly testing memory emphasizes deficits and may increase frustration or anxiety.

Question 6

An 80-year-old client has been diagnosed with Alzheimer disease. Which statement by the nurse uses appropriate terminology?

A. “It is difficult when a loved one becomes senile.”
B. “Although your parent is demented, we will promote quality of life.”
C. “Organic brain syndrome is common in the ninth decade of life.”
D. “We will work to promote wellness in a person who has dementia.”

Answer: D. “We will work to promote wellness in a person who has dementia.”

Rationale: Person-first language respects the client’s dignity and avoids stigmatizing terms. “Senile,” “demented,” and “organic brain syndrome” are outdated or inappropriate labels.

Question 7

A client experienced worsening cognitive decline before death. An autopsy revealed multiple infarcted areas of the brain caused by blood-vessel occlusions. Which type of dementia did the client most likely have?

A. Alzheimer disease
B. Vascular dementia
C. Lewy body dementia
D. Frontotemporal degeneration

Answer: B. Vascular dementia

Rationale: Vascular dementia results from impaired cerebral blood flow, infarctions, or vessel occlusion. The decline may occur in steps as additional vascular injury develops.

Question 8

A resident with newly diagnosed Alzheimer disease is discussed by a nurse who says, “At least she will never know what is happening to her.” Which fact should guide the colleague’s response?

A. People with dementia rarely recognize their cognitive deficits.
B. Many people with dementia remain aware that their cognition is declining.
C. Awareness occurs only in a few uncommon types of dementia.
D. Awareness means the condition is resolving.

Answer: B. Many people with dementia remain aware that their cognition is declining.

Rationale: People with dementia may retain insight and awareness, particularly during earlier stages. Assuming they are unaware can lead to dismissive care and failure to address fear, grief, and anxiety.

Question 9

A nurse provides ongoing care for an older adult with dementia. Which assessment goal should the nurse prioritize?

A. Identify strategies that will cure the dementia.
B. Determine which genetic or lifestyle factors caused the dementia.
C. Determine the exact medical subtype of dementia.
D. Identify factors affecting the client’s functioning and quality of life.

Answer: D. Identify factors affecting the client’s functioning and quality of life.

Rationale: Dementia is generally not curable, so nursing care focuses on preserving function, comfort, safety, dignity, and quality of life. The nurse should identify modifiable factors that worsen the client’s daily functioning.

Question 10

A nursing home is designing a new unit for residents with dementia. Which environmental feature should be included?

A. Neutral walls and floors in one monochromatic color
B. Pictures, signs, and color codes to identify locations
C. Bright, glossy floors for added sensory stimulation
D. Bright lighting during the day and total darkness at night

Answer: B. Pictures, signs, and color codes to identify locations

Rationale: Clear visual cues improve orientation and support independent movement. Glossy floors may appear wet or unsafe, monochromatic spaces reduce contrast, and total darkness increases fall risk.

Question 11

A nurse prepares to administer medications to a resident with mild non-Alzheimer-type dementia. Which medication can be administered without concern for worsening delirium?

A. An anticholinergic
B. An atypical antipsychotic
C. A benzodiazepine
D. A cholinesterase inhibitor

Source-Listed Answer: A. An anticholinergic

Rationale: The source’s explanation states that anticholinergics, benzodiazepines, and atypical antipsychotics may contribute to delirium, while cholinesterase inhibitors are used to treat cognitive symptoms.

Source inconsistency: The rationale supports D, cholinesterase inhibitor, not A. Anticholinergic medications are a major cause of confusion and delirium in older adults. Do not memorize A.

Question 12

A 74-year-old client with mild Alzheimer disease asks how quickly the disease will progress. Which response by the nurse is most appropriate?

A. “Because you have no other health conditions, progression is usually gradual.”
B. “The medications will stop the disease from progressing.”
C. “There is no way to know anything about how Alzheimer disease progresses.”
D. “Progression is usually rapid, so you should make plans immediately.”

Source-Listed Answer: D. “Progression is usually rapid, so you should make plans immediately.”

Rationale: The source explanation states that Alzheimer disease usually progresses gradually and may decline more rapidly when additional health conditions are present. Medications may slow symptoms but do not stop progression.

Source inconsistency: The rationale supports A, not D. Alzheimer disease usually has a gradual, progressive course, although the rate varies among individuals.

Question 13 — Select All That Apply

An intensive care nurse cares for an 83-year-old client with sepsis who demonstrates agitation and illogical thinking. Which interventions should the nurse implement?

A. Administer a benzodiazepine routinely.
B. Assess the client for pain.
C. Promote a quiet, dark sleep period at night.
D. Initiate a fall-prevention program.
E. Place familiar family photographs in the room.

Answers: B, C, D, and E

Rationale: Sepsis and the ICU environment place older adults at high risk for delirium. Pain control, sleep promotion, familiar objects, and fall prevention address common delirium triggers and complications; benzodiazepines can worsen delirium.

Question 14

A caregiver states, “He fights me every time I try to bathe him. He has not taken a shower in 2 months.” Which response by the nurse is most appropriate?

A. “I understand that you are frustrated.”
B. “He wants choices. How do you usually get him into the shower?”
C. “You should place him in the shower because he needs to be clean.”
D. “Whatever worked in the past should continue to work now.”
E. “What other methods have you tried to keep him clean?”

Answer: E. “What other methods have you tried to keep him clean?”

Rationale: Hygiene can be maintained using sponge baths, partial baths, no-rinse products, or bathing at another time. If showering triggers distress or aggression, the caregiver should avoid forcing it and use a safer alternative.

Question 15

A nurse observes an aide asking a client with dementia what the client wants for breakfast, lunch, and dinner while simultaneously helping the client toilet. Which action should the nurse take?

A. Instruct the aide to present only one idea or choice at a time.
B. Encourage the aide to continue the conversation.
C. Take no action because the aide is encouraging independence.
D. Tell the aide not to speak with the client during toileting.

Answer: A. Instruct the aide to present only one idea or choice at a time.

Rationale: Multiple questions and tasks can overwhelm a person with dementia. The aide should complete one task and present one simple choice at a time.

impaired affective function: depression

Question 1

A nurse monitors older adults in a long-term care facility. Which symptom requires follow-up for possible depression?

A. Anorexia
B. Weakness
C. Labile affect
D. Impaired perception

Answer: A. Anorexia

Rationale: Appetite disturbances, particularly anorexia, are common physical manifestations of depression in older adults. Depression may present through somatic or functional symptoms rather than an obvious report of sadness.

Question 2

A nurse reviews the adverse effects of antidepressants with a group of older adults. Which statement indicates that teaching was effective?

A. “I will begin with the same dose that I will take for the rest of my life.”
B. “I should take fluoxetine in the evening because it will help me sleep.”
C. “I need to maintain adequate fluid intake while taking an antidepressant.”
D. “Treatment for a first episode of depression usually lasts 3 months.”

Answer: C. “I need to maintain adequate fluid intake while taking an antidepressant.”

Rationale: Adequate hydration helps reduce the risk of orthostatic hypotension and related falls. Antidepressants are usually started at a low dose and titrated gradually, and treatment for a first depressive episode commonly continues for at least 6 months.

Question 3 — Select All That Apply

Which conditions can be both risk factors for and functional consequences of depression in older adults?

A. Chronic pain
B. Functional impairment
C. Hypernatremia
D. Nutritional deficiencies
E. Renal impairment

Answers: A, B, and D

Rationale: Chronic pain, functional impairment, and poor nutrition can contribute to depression and can also worsen because of depression. Hypernatremia and renal impairment are not specifically identified as both causes and consequences of depression.

Question 4

A nurse educator teaches students about theories of late-life depression. Which statement by a student demonstrates understanding?

A. “Adverse events directly impair a person’s ability to evaluate themselves.”
B. “Depression results from decreased activity in the hypothalamic-pituitary-adrenal axis.”
C. “Older adults with both depression and chronic illness often experience more serious functional consequences.”
D. “Research has established a direct cause-and-effect relationship between depression and dementia.”

Answer: C. “Older adults with both depression and chronic illness often experience more serious functional consequences.”

Rationale: Depression combined with chronic illness is associated with greater disability, poorer outcomes, and more serious functional decline. Depression is associated with increased—not decreased—hypothalamic-pituitary-adrenal activity, and a direct causal relationship with dementia has not been established.

Question 5

An older adult has several risk factors for suicide. Which question is appropriate for the nurse’s initial assessment of whether suicidal thoughts are present?

A. “Under what circumstances would you take your life, and have you acted on a plan?”
B. “Do you have a plan to take your life, and what method would you use?”
C. “Does your life feel worthless, or do you ever think about escaping from your problems?”
D. “Do you think about harming yourself or committing suicide?”

Answer: C. “Does your life feel worthless, or do you ever think about escaping from your problems?”

Rationale: Initial suicide assessment may begin with indirect questions about hopelessness, worthlessness, or wanting to escape. Positive responses should be followed by increasingly direct questions about suicidal thoughts, intent, plan, means, and timing.

Question 6

A gerontological nurse assesses an older adult with a history of depression who has been drinking up to two bottles of wine daily. What should the nurse teach?

A. “If you use alcohol for depression, limit yourself to four or five drinks daily.”
B. “Everyone older than age 70 should completely avoid alcohol.”
C. “Alcohol can worsen depression, and depression can also increase alcohol use.”
D. “Stopping alcohol will definitely eliminate your depression.”

Answer: C. “Alcohol can worsen depression, and depression can also increase alcohol use.”

Rationale: Alcohol and depression have a reciprocal relationship: alcohol may contribute to depression, while depression may increase alcohol misuse. The nurse should not promise that stopping alcohol alone will cure the depression.

Question 7

An older adult is brought to a primary care appointment by an adult child who reports increasing apathy, isolation, and sadness. The client acknowledges several depressive symptoms. Which assessment should the nurse prioritize?

A. Functional assessment
B. Medication assessment
C. Musculoskeletal assessment
D. Cardiovascular assessment

Answer: B. Medication assessment

Rationale: Medications and drug interactions can cause or worsen depressive symptoms in older adults. Identifying a potentially reversible medication-related cause takes priority over assessing the effects of depression alone.

Question 8

Which statement by a nursing-home resident should prompt the nurse to assess for depression?

A. “I wake up around 4:00 or 5:00 every morning and cannot fall back asleep.”
B. “I have been craving sweet and salty snacks.”
C. “I have headaches more often than I used to.”
D. “The sore on my ankle is healing slowly.”

Answer: A. “I wake up around 4:00 or 5:00 every morning and cannot fall back asleep.”

Rationale: Early-morning awakening is a classic sleep disturbance associated with depression. Headaches and poor healing may occur with depression, but early awakening is more strongly associated with it.

Question 9

A nurse on an acute care for elders unit monitors clients for functional consequences of depression. Which statement requires the highest-priority follow-up?

A. “I feel as though a cloud is hanging over me.”
B. “I have no appetite, and eating takes all my energy.”
C. “I used to have so much energy, but now I only sit in a chair.”
D. “I think everyone would be better off if I were not here.”

Answer: D. “I think everyone would be better off if I were not here.”

Rationale: This statement suggests suicidal thinking and requires immediate assessment for intent, plan, access to means, and safety. Suicide risk takes priority over other manifestations of depression.

Question 10

An older adult developed depression after moving into a nursing home 6 weeks ago. Which intervention should the nurse implement?

A. Teach the client about suicide rates in older adults.
B. Provide opportunities for the client to interact with other residents.
C. Ask the client to make a list of positive aspects of the move.
D. Assign another resident to remain with the client as a buddy.

Answer: B. Provide opportunities for the client to interact with other residents.

Rationale: Social engagement can reduce isolation and support treatment of depression. Forced positivity or assigning a buddy may feel intrusive, patronizing, or dismissive of the client’s emotions.

Question 11

Which client is at greatest risk for suicide?

A. An 18-year-old who scheduled an appointment with a healthcare provider
B. A 60-year-old client with kidney stones
C. A 75-year-old woman living with her child and grandchildren
D. An 85-year-old man whose spouse died 1 year ago

Answer: D. An 85-year-old man whose spouse died 1 year ago

Rationale: Very old men, particularly White men, have a high suicide rate. Recent bereavement, loneliness, chronic illness, pain, and social isolation further increase risk.

Question 12 — Select All That Apply

Which are functional consequences of late-life depression?

A. Decreased functioning
B. Dementia
C. Increased incidence of stroke
D. Increased pain
E. Increased risk for suicide

Answers: A, D, and E

Rationale: Depression can reduce functional ability, intensify the perception of pain, and increase suicide risk. Stroke may be a risk factor for depression, while dementia is associated with depression but is not classified as a direct functional consequence.

Question 13 — Select All That Apply

An older adult is admitted with weight loss and cognitive impairment. Which findings should the nurse assess for when evaluating for major depressive disorder?

A. Decreased deep tendon reflexes
B. Loss of interest or pleasure
C. Psychomotor agitation
D. Respiratory difficulty
E. Sleep disturbance

Answers: B, C, and E

Rationale: Major depressive disorder may include loss of interest, appetite or weight changes, sleep disturbance, psychomotor agitation or slowing, fatigue, guilt, impaired concentration, and suicidal thoughts. Decreased reflexes and respiratory difficulty are not diagnostic criteria.

Question 14

An older adult began taking an antidepressant 1 week ago and states, “I do not want to take it because it is not doing anything.” Which response by the nurse is most appropriate?

A. “That is fine because you have the right to refuse.”
B. “It is too early to expect the full effect; improvement may begin after about 2 to 4 weeks.”
C. “We should ask the provider to prescribe another medication immediately.”
D. “What side effects are you experiencing?”

Answer: B. “It is too early to expect the full effect; improvement may begin after about 2 to 4 weeks.”

Rationale: Antidepressants do not produce immediate improvement, and an adequate trial may require up to 12 weeks. The nurse must provide education before accepting medication refusal when the client’s decision is based on misunderstanding.

Question 15 — Select All That Apply

A nurse teaches an older adult about a newly prescribed antidepressant. Which information should the nurse include?

A. Antidepressants may interact with alcohol and over-the-counter medications.
B. Depression is uncommon in older adults.
C. Stop the medication immediately if any adverse effects occur.
D. Do not expect immediate improvement; an adequate trial may take up to 12 weeks.
E. Take the medication only when depressive symptoms occur.

Answers: A and D

Rationale: Antidepressants may interact with alcohol, nicotine, prescription drugs, and over-the-counter medications. They must be taken consistently, and clients should consult the healthcare provider before stopping because of adverse effects.