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. (A), (C) and (D) are all common with pneumonia, but the most
important finding is confusion and evidence of dehydration, which require treatment for this
frail elderly 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?
A. Boredom may influence how the taste of food is perceived, and different seasonings can
stimulate taste.
B. With age, an increase in sodium intake is needed to compensate for a decrease in renal
function.
C. Short-term memory loss and confusion may be the reason they want to over-season their
food.
D. Taste buds often are dull due to atrophy so older clients should use other seasonings in-
stead of salt. - ANSWER D. Taste buds are often dull due to atrophy so older clients
should use other seasonings instead of salt.
1
,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. (A), (B), and
(C) are not normal aging processes related to taste.
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?
A. Barrel chest with increased chest diameter
B. Crackles and pulse oximetry level of 88%
C. Low hemoglobin and hematocrit levels
D. Arterial blood gases indicating respiratory acidosis - ANSWER B. Crackles and pulse oxi-
metry level of 88%
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact ade-
quate oxygenation, which should be reported to the HCP. (A) occurs due to chronic hyperin-
flation of the lungs and is common in clients with COPD. Anemia (C) is frequently identified
in clients with COPD, and respiratory acidosis (D) due to CO2 retention contributes to a
lower blood pH.
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?
A. Explain that she is in a new home called an assisted living community
B. Question the client about her perception of where she might be now.
C. Distract the client with a scenario that she is on an outing with her family.
D. Reassure the client not to worry because she will meet new friends. - ANSWER A. Ex-
plain 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. (B, C, and D) do not provide the client with feedback
that is reality based.
2
, 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?
A. Arts and crafts
B. Current events discussion group
C. Group sing-along
D. Daily exercise group - 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. (A), (C), and a current events discussion group (B) are thought-
provoking activities that require attention to detail and short-term memory to participate in
the group activity which may be stressful and frustrating to the resident who has difficulty
remembering sequence of the details.
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?
A. Use the FACE pain scale
B. Ask the client to rate pain on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating habits - ANSWER C. Observe for facial grimac-
ing
Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a cli-
ent who cannot communicate due to Alzheimer disease. (A) and (B) may not be understood
by a client with end-stage Alzheimer's disease. (D) is not a helpful tool for pain assessment.
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?
A. Query client to clarify the client's idea of an intimacy problem.
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. (A), (C) and (D) are all common with pneumonia, but the most
important finding is confusion and evidence of dehydration, which require treatment for this
frail elderly 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?
A. Boredom may influence how the taste of food is perceived, and different seasonings can
stimulate taste.
B. With age, an increase in sodium intake is needed to compensate for a decrease in renal
function.
C. Short-term memory loss and confusion may be the reason they want to over-season their
food.
D. Taste buds often are dull due to atrophy so older clients should use other seasonings in-
stead of salt. - ANSWER D. Taste buds are often dull due to atrophy so older clients
should use other seasonings instead of salt.
1
,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. (A), (B), and
(C) are not normal aging processes related to taste.
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?
A. Barrel chest with increased chest diameter
B. Crackles and pulse oximetry level of 88%
C. Low hemoglobin and hematocrit levels
D. Arterial blood gases indicating respiratory acidosis - ANSWER B. Crackles and pulse oxi-
metry level of 88%
Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact ade-
quate oxygenation, which should be reported to the HCP. (A) occurs due to chronic hyperin-
flation of the lungs and is common in clients with COPD. Anemia (C) is frequently identified
in clients with COPD, and respiratory acidosis (D) due to CO2 retention contributes to a
lower blood pH.
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?
A. Explain that she is in a new home called an assisted living community
B. Question the client about her perception of where she might be now.
C. Distract the client with a scenario that she is on an outing with her family.
D. Reassure the client not to worry because she will meet new friends. - ANSWER A. Ex-
plain 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. (B, C, and D) do not provide the client with feedback
that is reality based.
2
, 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?
A. Arts and crafts
B. Current events discussion group
C. Group sing-along
D. Daily exercise group - 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. (A), (C), and a current events discussion group (B) are thought-
provoking activities that require attention to detail and short-term memory to participate in
the group activity which may be stressful and frustrating to the resident who has difficulty
remembering sequence of the details.
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?
A. Use the FACE pain scale
B. Ask the client to rate pain on a scale of 1 to 10
C. Observe for facial grimacing
D. Review documentation of recent eating habits - ANSWER C. Observe for facial grimac-
ing
Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a cli-
ent who cannot communicate due to Alzheimer disease. (A) and (B) may not be understood
by a client with end-stage Alzheimer's disease. (D) is not a helpful tool for pain assessment.
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?
A. Query client to clarify the client's idea of an intimacy problem.
3
