A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding is
most important for the registered nurse (RN) to report to the healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting - ANSWER B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and perfu-
sion in this frail elderly client. (are all common with pneumonia, but the most important
finding is confusion and evidence of dehydration, which require treatment for this frail el-
derly client.
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake be-
cause food does not taste as good as it used to so they have to season most foods. What in-
formation should the RN offer the couple? - ANSWER D. Taste buds are often dull due to
atrophy so older clients should use other seasonings instead of salt.
Rationale: Taste buds atrophy with normal aging, which influences an older client's sensitiv-
ity to taste and is often compensated for the use of stronger tasting seasonings. (
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with
chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a
long history of smoking and still smokes a pack of cigarettes a day. Which finding should the
registered nurse (RN) report to the healthcare provider? - ANSWER B. Crackles and pulse
oximetry level of 88%
1
,Rationale: With pneumonia, crackles in the lungs and low O2 saturation, can impact ade-
quate oxygenation, which should be reported to the Health Care Provider.
An older female client recently moved to an assisted living facility. The family explains to the
registered nurse (RN) that the client is unmanageable and always confused, disoriented and
depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond? -
ANSWER A. Explain that she is in a new home called an assisted living community.
Rationale: Reality re-orientation (A) is the best response for a client who is confused because
the response is consistent and true.
A new resident in an assisted living facility is an older client who is experiencing short-term
memory loss and confusion. Which activity should the registered nurse (RN) schedule the
client to do during the day? - ANSWER D. Daily exercise group
Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the
client's stress to remember.
The hospice nurse is completing a focused assessment of an older female client with end
stage Alzheimer's disease, who recently fractured her hip. What technique should the regis-
tered nurse (RN) use to determine the client's pain? - ANSWER C. Observe for facial gri-
macing
Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a cli-
ent who cannot communicate due to Alzheimer disease.
An older male client arrives at the clinic for an annual physical examination. While the nurse
assesses the client, the client states that he is having intimacy problems with his wife. Which
information should the nurse provide to elicit more information from the client? - AN-
SWER A. Query client to clarify the client's idea of an intimacy problem.
2
, Rationale: Clarification of the client's concern is needed to appropriately address the specific
concern about intimacy issues (A).
The registered nurse (RN) is caring for an older female client with a 20 year history of rheu-
matoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated
with RA should the RN document? - ANSWER B. Small joint involvement in fingers.
Rationale: Small joint involvement (B) is common in rheumatoid arthritis.
The registered nurse (RN) is re-enforcing discharge instructions with the family of an older
client who was recently admitted for an intestinal obstruction. Which statement indicates
that the family understands the instructions? - ANSWER C. Report abdominal distention,
constipation, or any nausea and vomiting to the healthcare provider.
Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed
immediately.
An older client is transferred to a telemetry unit after placement of a pacemaker. What ac-
tion should the registered nurse (RN) take first?
A. View incision site
B. Obtain a blood pressure
C. Establish telemetry monitoring
D. Evaluate client for pain - ANSWER C. Establish telemetry monitoring.
Rationale: The first action is to establish continuous telemetry monitoring (C) to ensure the
pacemaker is functioning properly.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that
apply.)
A. Needs are greater than the caretaker's abilities
B. Client's declining strength
3
most important for the registered nurse (RN) to report to the healthcare provider?
A. Fever and chills
B. Confusion and dehydration
C. Crackles in the lung fields
D. Nausea and vomiting - ANSWER B. Confusion and dehydration
Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and perfu-
sion in this frail elderly client. (are all common with pneumonia, but the most important
finding is confusion and evidence of dehydration, which require treatment for this frail el-
derly client.
A frail elderly couple asks the registered nurse (RN) if they have to watch their salt intake be-
cause food does not taste as good as it used to so they have to season most foods. What in-
formation should the RN offer the couple? - ANSWER D. Taste buds are often dull due to
atrophy so older clients should use other seasonings instead of salt.
Rationale: Taste buds atrophy with normal aging, which influences an older client's sensitiv-
ity to taste and is often compensated for the use of stronger tasting seasonings. (
After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client with
chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The client has a
long history of smoking and still smokes a pack of cigarettes a day. Which finding should the
registered nurse (RN) report to the healthcare provider? - ANSWER B. Crackles and pulse
oximetry level of 88%
1
,Rationale: With pneumonia, crackles in the lungs and low O2 saturation, can impact ade-
quate oxygenation, which should be reported to the Health Care Provider.
An older female client recently moved to an assisted living facility. The family explains to the
registered nurse (RN) that the client is unmanageable and always confused, disoriented and
depressed. The client asks the RN repeatedly, "Where am I?". How should the RN respond? -
ANSWER A. Explain that she is in a new home called an assisted living community.
Rationale: Reality re-orientation (A) is the best response for a client who is confused because
the response is consistent and true.
A new resident in an assisted living facility is an older client who is experiencing short-term
memory loss and confusion. Which activity should the registered nurse (RN) schedule the
client to do during the day? - ANSWER D. Daily exercise group
Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes the
client's stress to remember.
The hospice nurse is completing a focused assessment of an older female client with end
stage Alzheimer's disease, who recently fractured her hip. What technique should the regis-
tered nurse (RN) use to determine the client's pain? - ANSWER C. Observe for facial gri-
macing
Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a cli-
ent who cannot communicate due to Alzheimer disease.
An older male client arrives at the clinic for an annual physical examination. While the nurse
assesses the client, the client states that he is having intimacy problems with his wife. Which
information should the nurse provide to elicit more information from the client? - AN-
SWER A. Query client to clarify the client's idea of an intimacy problem.
2
, Rationale: Clarification of the client's concern is needed to appropriately address the specific
concern about intimacy issues (A).
The registered nurse (RN) is caring for an older female client with a 20 year history of rheu-
matoid arthritis (RA), who is admitted for carpel tunnel release. Which finding associated
with RA should the RN document? - ANSWER B. Small joint involvement in fingers.
Rationale: Small joint involvement (B) is common in rheumatoid arthritis.
The registered nurse (RN) is re-enforcing discharge instructions with the family of an older
client who was recently admitted for an intestinal obstruction. Which statement indicates
that the family understands the instructions? - ANSWER C. Report abdominal distention,
constipation, or any nausea and vomiting to the healthcare provider.
Rationale: (C) are symptoms that occur with intestinal obstruction and should be addressed
immediately.
An older client is transferred to a telemetry unit after placement of a pacemaker. What ac-
tion should the registered nurse (RN) take first?
A. View incision site
B. Obtain a blood pressure
C. Establish telemetry monitoring
D. Evaluate client for pain - ANSWER C. Establish telemetry monitoring.
Rationale: The first action is to establish continuous telemetry monitoring (C) to ensure the
pacemaker is functioning properly.
Older clients are at highest risk for abuse and neglect due to which factors? (Select all that
apply.)
A. Needs are greater than the caretaker's abilities
B. Client's declining strength
3
