Chapter 21: Assessment of the Older Adult Nursing School Test Banks

Chapter 21: Assessment of the Older Adult
Test Bank

MULTIPLE CHOICE

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

Feedback
A This action is not warranted in this case; these changes are expected with aging.
B This is practical advice, but will not alter the change in smell and taste.
C A decreased sense of smell is caused by a decrease in the number of sensory cells in the nasal lining. Taste perception may also diminish due to gradual atrophy of the tongue and a decrease in the number of papillae and taste buds.
D This is practical advice, but will not alter the change in smell and taste.
DIF: Cognitive Level: Apply REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

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

Feedback
A Root surfaces of the teeth are exposed to caries formation because of gingival recession.
B Ulcers are not an expected finding.
C Collection of debris at the gingival margins is not an expected finding.
D This is not an expected finding; leukoplakia is a white patch or plaque that cannot be scraped off and often represents a premalignant lesion.
DIF: Cognitive Level: Understand REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

3. Which assessment finding of older adult patients indicates expected respiratory function?
a. Increased elasticity of the alveoli
b. Flaccidity of the chest wall
c. Reduced inspiratory and expiratory effort
d. Decreased anteroposterior diameter
ANS: C

Feedback
A With aging, alveoli become less elastic and more fibrous.
B With aging, the chest wall may become stiffer, possibly because of calcification at rib articulation points, resulting in decreased chest wall compliance.
C Diminished strength of the respiratory muscles results in reduced maximal inspiratory and expiratory force.
D The anteroposterior diameter increases with aging due to kyphoscoliosis.
DIF: Cognitive Level: Understand REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

4. During an office visit, a 78-year-old woman is upset because her height is 2 inches less than it was when I was 40! How does the nurse explain this change to the patient?
a. Reduced height may occur as you age due to shortening of the vertebrae.
b. You may be experiencing this height change due to arthritis.
c. You need to improve your posture by performing stretching exercises.
d. This is a rare occurrence and warrants having a bone density test.
ANS: A

Feedback
A Decreased bone formation reduces height in most older adults, which may cause shortening of the vertebrae and thinning of the vertebral disks.
B Decreased bone formation reduces height in most older adults and is not due to arthritis.
C This is appropriate advice, but is not related the patients height.
D This is an expected occurrence and does not warrant concern.
DIF: Cognitive Level: Apply REF: 516
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

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

Feedback
A Past health history is important to document the patients chronic illnesses.
B A genogram is not routinely used to document the family history for an older adult. The health status and cause of death of the patients parents and siblings lose value as the patient ages.
C Assessing functional abilities provides data about how well the patient performs activities of daily living.
D Mental health data are essential to collect about all patients regardless of age.
DIF: Cognitive Level: Understand REF: 517
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

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

Feedback
A Emotional experiences of sadness, grief, response to loss, and temporary blue moods are normal responses in older adults.
B Persistent depression that interferes significantly with the ability to function is not an expected finding.
C This is a normal response for any adult.
D Emotional experiences of sadness, grief, response to loss, and temporary blue moods are normal responses in older adults.
DIF: Cognitive Level: Apply REF: 518
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

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

Feedback
A Neural transmission is the same for older and younger adults.
B Becoming older does not diminish ones ability to describe pain.
C The physiologic indicators are the same for older and younger adults.
D Some older adults may perceive pain as an expected aspect of aging that they must endure.
DIF: Cognitive Level: Apply REF: 519
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

8. A nurse is assessing the pain of an 86-year-old man who had hip surgery recently. The patient has been slightly confused since his surgery, but he responds to simple questions. What is the best way to assess this patients pain?
a. Ask him to rate his pain on a scale of 0 to 10.
b. Ask him to rate his pain using a list of descriptive adjectives.
c. Ask him to rate his pain using a vertical numeric scale.
d. Observe his behavior and measure his vital signs.
ANS: C

Feedback
A This scale is appropriate for adolescents and adults, but older adults are assessed more accurately with a scale that they can see.
B This method is not effective for assessing pain because adjectives have different meanings to different people. It is best to use a scale or pictures of faces.
C Pain assessment in older adults is significantly improved by using a vertical numeric scale or pain faces.
D Patient behavior and vital signs are not accurate ways to assess a patients perception of pain.
DIF: Cognitive Level: Apply REF: 519
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

9. What finding does a nurse look for when assessing the skin of an older adult with solar lentigo?
a. Yellowish, thin papules with a central depression
b. Pigmented, raised, wartlike lesions on the face or trunk
c. Small, soft, pigmented tags of skin on the face and neck
d. Irregular, flat, deeply pigmented macules on sun-exposed areas
ANS: D

Feedback
A Yellowish, thin papules with a central depression is a description of sebaceous hyperplasia.
B Pigmented, raised, wart-like lesions on the face or trunk is a description of seborrheic keratosis.
C Small, soft, pigmented tags of skin on the face and neck is a description of acrochordon (skin tags).
D Irregular, flat, deeply pigmented macules on sun-exposed areas is a description of solar lentigo.
DIF: Cognitive Level: Apply REF: 522
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

10. When assessing the skin of an older adult, a nurse notices pigmented, raised warty-appearing lesions on the trunk. How does a nurse document this finding?
a. Solar lentigo
b. Basal cell skin cancer
c. Seborrheic keratosis
d. Sebaceous hyperplasia
ANS: C

Feedback
A Solar lentigo appears as irregularly shaped, flat, deeply pigmented macules that may appear on body surface areas with repeated exposure to the sun.
B Basal cell carcinoma appears as a nodular pigmented lesion with a depressed center and rolled borders found on sun-exposed areas.
C Seborrheic keratosis is described as pigmented, raised warty-appearing lesions on the trunk.
D Sebaceous hyperplasia appears as yellowish, flattened papules that have central depressions.
DIF: Cognitive Level: Understand REF: 523
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

11. In assessing the nails of an older adult, which finding does a nurse expect to find?
a. Transverse ridges
b. Thick, brittle, and yellow nails
c. Thin, brittle nails
d. Lateral edges turned upward
ANS: B

Feedback
A These changes occur when the patient has had nail trauma.
B Thick, brittle, and yellow nails are expected changes in the nails of older adults.
C These changes occur when the patient has anemia.
D This change, called spoon nail, occurs when the patient has anemia.
DIF: Cognitive Level: Understand REF: 523
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

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

Feedback
A This is a description of arcus senilis.
B This is a description of a normal variation.
C This occurs because the lacrimal apparatus may function poorly, producing fewer tears.
D This is a description of ectropion, an abnormal finding.
DIF: Cognitive Level: Apply REF: 523-524
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

13. What is the best color for nurses to select when designing educational materials for older adults?
a. Blue
b. Yellow
c. Violet
d. Green
ANS: B

Feedback
A Color perception of blue, violet, and green may be impaired for older adults.
B Color perception of blue, violet, and green may be impaired for older adults.
C Color perception of blue, violet, and green may be impaired for older adults.
D Color perception of blue, violet, and green may be impaired for older adults.
DIF: Cognitive Level: Understand REF: 523
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

14. A 75-year-old man reports he stopped playing cards with his friends because their voices sounded mumbled. How does the nurse explain the cause of this change?
a. Sudden low-frequency hearing loss
b. Accumulation of earwax in the outer ear
c. Damage to the middle ear from ear infections
d. Gradual high-frequency hearing loss
ANS: D

Feedback
A This does not describe presbycusis and is not an expected change with aging.
B This does not describe presbycusis and is not an expected change with aging.
C This does not describe presbycusis and is not an expected change with aging.
D This is a description of presbycusis, a sensorineural hearing loss, and an expected change with aging.
DIF: Cognitive Level: Apply REF: 524
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

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

Feedback
A Occasional ectopic beats are common and may or may not be significant.
B Sclerosis of the mitral and aortic valves may cause murmurs.
C These systolic pressures are above normal and require further evaluation.
D The S4 heart sound is common in older adults and may be associated with decreased left ventricular compliance.
DIF: Cognitive Level: Apply REF: 521-522
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

16. The nurse notes which finding as expected during a history and examination of an older adult patients abdomen?
a. Hyperactive bowel sounds in all quadrants
b. Decreased fatty deposits over the abdomen
c. Marked concavity of the abdominal contour
d. Soft abdomen on palpation in all quadrants
ANS: D

Feedback
A The opposite is true; decreased peristalsis causes hypoactive bowel sounds.
B The opposite is true; older adults may have increased fat deposits over the abdominal area.
C The opposite is true due to the increased fat deposits over the abdominal area.
D The abdomen of older adults may feel soft due to decreased abdominal muscle tone.
DIF: Cognitive Level: Understand REF: 525
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

17. Which approach does a nurse use to assess neck range of motion of an older adult patient?
a. Have the patient perform each neck movement separately.
b. Defer range of motion examination if the patient has kyphosis.
c. Ask the patient to turn the head against the resistance of the nurses hand.
d. Ask the patient to rotate the head starting with forward flexion and moving clockwise.
ANS: A

Feedback
A The nurse should assess range of motion of the neck with one movement at a time, rather than a full rotation of the neck, to avoid causing dizziness on movement.
B Assessing range of motion is important data to gather to determine how limited the range is due to the kyphosis.
C This technique tests muscle strength rather than range of motion.
D This technique tests muscle strength rather than range of motion.
DIF: Cognitive Level: Apply REF: 525
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

18. A nurse asks an older adult patient to rise from an arm chair without using the arms, stand with eyes closed, and turn around in a circle. What is the nurse assessing in this patient?
a. Ability to follow instructions
b. Muscle strength
c. Balance
d. Hearing
ANS: C

Feedback
A Although following instruction is required for this balance assessment, it is not the primary purpose of the assessment.
B Muscle strength is tested by having the patient push or pull against resistance.
C These are three of the activities of the Tinetti Balance and Gait Assessment Tool.
D Although hearing is required for this balance assessment, it is not the primary purpose of the assessment.
DIF: Cognitive Level: Analyze REF: 525-526
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Techniques of Physical Assessment

19. An older adult patient reports being able to see her granddaughter play basketball out of the sides of her eyes, but not in the center of her eyes. Based on this information, what vision disorder does the nurse suspect?
a. Presbyopia
b. Macular degeneration
c. Pseudoptosis
d. Entropion
ANS: B

Feedback
A Presbyopia is a decrease in near vision that usually occurs after age 40 and is treated with corrective lenses.
B Gradual loss of central vision may be caused by macular degeneration due to changes in the retina.
C Pseudoptosis is a relaxed upper eyelid.
D Entropion is a disorder of the eyelid, in which the lower lid turns inward.
DIF: Cognitive Level: Understand REF: 524| 528
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Physiologic Adaptation: Alteration in Body Systems

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

Feedback
A The breasts in postmenopausal women may appear flattened.
B This is not a finding in older women.
C The suspensory ligaments in older woman are relaxed, but not puckering.
D The breasts in postmenopausal women may appear flattened and elongated or pendulous secondary to a relaxation of the suspensory ligaments.
DIF: Cognitive Level: Understand REF: 525
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

MULTIPLE RESPONSE

1. What expected physiologic changes of aging put older adults at risk for respiratory infections? Select all that apply.
a. Breath sounds are bronchovesicular in the peripheral lung.
b. Alveoli are less elastic.
c. Weak intercostal muscles reduce effective coughing.
d. Fewer cilia make mucociliary clearance less effective.
e. Curvature of the spine limits chest wall expansion.
f. Cough reflex is impaired due to deceased sensitivity of receptors.
ANS: B, C, D, E
Correct: These are all expected findings of healthy older adults that impair their ability to breathe deeply and cough to prevent or recover from a respiratory infection.
Incorrect: Breath sounds are the same as for younger adultsvesicular in the peripheral lungs. Cough reflex is not changed in the older adult.

DIF: Cognitive Level: Analyze REF: 516| 524
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Health Promotion and Maintenance: Aging Process

2. What risk factors for falls does a nurse teach a group of older adults? Select all that apply.
a. Being a woman
b. Taking more than six medications
c. Having hypertension
d. Having cataracts
e. Muscle strength 3/5 bilaterally
f. Incontinence
ANS: B, D, E, F
Correct: Adverse effects of medications can contribute to falls. Cataracts impair vision, which is a risk factor for falls. Poor muscle strength is a risk factor for falls. Incontinence of urine or stool increases risk for falls.
Incorrect: Men have a higher risk for falls than women. Hypertension itself does not contribute to falls. Dizziness does contribute to falls.

DIF: Cognitive Level: Analyze REF: 528
TOP: Nursing Process: Assessment
MSC: NCLEX Patient Needs: Physiologic Integrity: Reduction of Risk Potential: Potential for Alteration in Body Systems

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