vSim - Millie Larsen
Which nursing intervention should the nurse undertake initially to help the patient
achieve partial restoration of bladder control?
a) Provide a bedside commode when appropriate.
b) Offer the patient frequent toileting cues.
c) Ensure easy access to bathroom.
d) Assess voiding patterns. - ✔️✔️d) Assess voiding patterns.
The older adult with incontinence may be able to achieve partial restoration of bladder
control through nursing interventions. The initial step should be to conduct a
comprehensive assessment to identify the cause of the incontinence, the potential for
regained bladder control, and the patient's needs. Ensuring that the bathroom is easily
accessible and providing the availability of a bedside commode of bedpan are also
appropriate interventions to consider after completing an initial assessment. Offering the
patient cues to consider toileting, including assistance, may also be appropriate but not
implementable until the assessment is completed.
Which assessment finding is an age-related change in the urinary tact?
a) Increased urinary tract infections
b) Increased frequency of urination
c) Decreased protein in the urine
d) Decreased amounts of glucose in voided urine - ✔️✔️b) Increased frequency of
urination
Age-related changes in the urinary system include hypertrophy and thickening of the
bladder muscle, decreasing its ability to expand and reducing its storage capacity
resulting in an increase in the frequency of urination. Aging typically causes the renal
threshold for glucose to increase. Aging does not typically result in a decreased risk for
urinary infections. There should not be any protein in the urine.
Which of the following should be included in a teaching plan for a patient with an
increased risk for developing a urinary tract infection?
a) Hydrate with clear liquids only.
b) Reduce fluid intake during daylight hours to 10 to 20 oz.
c) Drink cranberry juice daily.
d) Establish a 6- to 8-hour voiding schedule during the daytime. - ✔️✔️c) Drink
cranberry juice daily
,Medical research supports that regularly drinking cranberry juice is a means to reduce
the risk of urinary tract infections. Restricting fluid intake is not advisable, and drinking
only clear liquids is not necessary. The risk for urinary infection increases when the
urine is allowed to stagnate in the bladder, so bladder emptying should occur more
frequently than every 6 to 8 hours.
Which value should the nurse consider abnormal when reviewing a patient's routine
urinalysis report?
a) Urine pH of 3.0
b) Absence of glucose
c) Urine specific gravity of 1.003
d) Absence of protein - ✔️✔️a) Urine pH of 3.0
The pH of urine should be between 4.6 and 8.0. Urine specific gravity compares the
density of urine to the density of water. Urine specific gravity in an adult should be 1.000
to 1.030, which means that the kidneys are functioning at a normal level. Absence of
both protein and glucose in urine is appropriate.
What is the nurse's initial assessment focus for an older patient being admitted for acute
confusion?
a) Serum blood alcohol to rule out intoxication
b) Blood pressure to rule out hypotension
c) Hemoglobin and hematocrit to rule out hemorrhage
d) Fluid and electrolyte status to rule out dehydration - ✔️✔️d) Fluid and electrolyte
status to rule out dehydration
Older adults are at risk for dehydration because aging can cause a decreased sense of
thirst and an increase in urinary frequency. Confusion is a common sign of dehydration
among older patients. Although hypotension, hemorrhage, and alcohol intoxication may
all result in various degrees of confusion, they are not considered primary causes.
An older patient newly diagnosed with hypertension has been prescribed an
antihypertensive medication therapy. The nurse will include which recommendation
when providing the patient with medication education to reduce the risk of falling?
a) Eat a diet high in protein.
b) Get up slowly from a supine position.
c) Keep fluid intake to at least 1,500 mL/day.
d) Avoid exercise that increases heart rate. - ✔️✔️b) Get up slowly from a supine
position.
Postural hypotension is common in the older adult who is taking antihypertensive
medication. When the individual stands up too quickly after lying down, postural
hypotension can cause dizziness, which is a risk factor for falls. Older adults should be
, encouraged to exercise with the anticipated rise in heart rate within the limits of their
disease processes; eating a diet high in protein is not relevant to postural hypotension
related to antihypertensive medications. Although the older adult should drink 1,500 mL
of fluids daily to prevent dehydration, this response is not relevant to the use of
antihypertensive medications and postural hypotension.
Which blood pressure component is considered hypertensive in the older adult? (Select
all that apply.)
a) 92 mmHg diastolic
b) 144 mmHg systolic
c) 140 mmHg systolic
d) 88 mmHg diastolic
e) 90 mmHg diastolic - ✔️✔️a) 92 mmHg diastolic
b) 144 mmHg systolic
When blood pressure enters a level of less than 140 mmHg systolic and/or less than 90
mmHg diastolic, it is considered hypertensive.
With which of the following atypical manifestations of a urinary tract infection might the
older adult present? (Select all that apply.)
a) Weakness
b) Severe nocturnal headache
c) Decreased appetite
d) Alteration in cognitive function
e) Incontinence - ✔️✔️a) Weakness
c) Decreased appetite
d) Alteration in cognitive function
e) Incontinence
Infections in the older adult may not manifest in the same way as in a younger adult.
Fever, a typical presenting sign, can be undetected in the older adult. The older adult
may present with weakness, anorexia, changes in mental status, and incontinence.
Severe nocturnal headache is not a manifestation of a urinary tract infection.
Millie Larsen states that lately she tries to avoid laughing because of urine leakage.
Which type of incontinence does this finding indicate?
a) Stress incontinence
b) Functional incontinence
c) Urgency incontinence
d) Overflow incontinence - ✔️✔️a) Stress incontinence
Which nursing intervention should the nurse undertake initially to help the patient
achieve partial restoration of bladder control?
a) Provide a bedside commode when appropriate.
b) Offer the patient frequent toileting cues.
c) Ensure easy access to bathroom.
d) Assess voiding patterns. - ✔️✔️d) Assess voiding patterns.
The older adult with incontinence may be able to achieve partial restoration of bladder
control through nursing interventions. The initial step should be to conduct a
comprehensive assessment to identify the cause of the incontinence, the potential for
regained bladder control, and the patient's needs. Ensuring that the bathroom is easily
accessible and providing the availability of a bedside commode of bedpan are also
appropriate interventions to consider after completing an initial assessment. Offering the
patient cues to consider toileting, including assistance, may also be appropriate but not
implementable until the assessment is completed.
Which assessment finding is an age-related change in the urinary tact?
a) Increased urinary tract infections
b) Increased frequency of urination
c) Decreased protein in the urine
d) Decreased amounts of glucose in voided urine - ✔️✔️b) Increased frequency of
urination
Age-related changes in the urinary system include hypertrophy and thickening of the
bladder muscle, decreasing its ability to expand and reducing its storage capacity
resulting in an increase in the frequency of urination. Aging typically causes the renal
threshold for glucose to increase. Aging does not typically result in a decreased risk for
urinary infections. There should not be any protein in the urine.
Which of the following should be included in a teaching plan for a patient with an
increased risk for developing a urinary tract infection?
a) Hydrate with clear liquids only.
b) Reduce fluid intake during daylight hours to 10 to 20 oz.
c) Drink cranberry juice daily.
d) Establish a 6- to 8-hour voiding schedule during the daytime. - ✔️✔️c) Drink
cranberry juice daily
,Medical research supports that regularly drinking cranberry juice is a means to reduce
the risk of urinary tract infections. Restricting fluid intake is not advisable, and drinking
only clear liquids is not necessary. The risk for urinary infection increases when the
urine is allowed to stagnate in the bladder, so bladder emptying should occur more
frequently than every 6 to 8 hours.
Which value should the nurse consider abnormal when reviewing a patient's routine
urinalysis report?
a) Urine pH of 3.0
b) Absence of glucose
c) Urine specific gravity of 1.003
d) Absence of protein - ✔️✔️a) Urine pH of 3.0
The pH of urine should be between 4.6 and 8.0. Urine specific gravity compares the
density of urine to the density of water. Urine specific gravity in an adult should be 1.000
to 1.030, which means that the kidneys are functioning at a normal level. Absence of
both protein and glucose in urine is appropriate.
What is the nurse's initial assessment focus for an older patient being admitted for acute
confusion?
a) Serum blood alcohol to rule out intoxication
b) Blood pressure to rule out hypotension
c) Hemoglobin and hematocrit to rule out hemorrhage
d) Fluid and electrolyte status to rule out dehydration - ✔️✔️d) Fluid and electrolyte
status to rule out dehydration
Older adults are at risk for dehydration because aging can cause a decreased sense of
thirst and an increase in urinary frequency. Confusion is a common sign of dehydration
among older patients. Although hypotension, hemorrhage, and alcohol intoxication may
all result in various degrees of confusion, they are not considered primary causes.
An older patient newly diagnosed with hypertension has been prescribed an
antihypertensive medication therapy. The nurse will include which recommendation
when providing the patient with medication education to reduce the risk of falling?
a) Eat a diet high in protein.
b) Get up slowly from a supine position.
c) Keep fluid intake to at least 1,500 mL/day.
d) Avoid exercise that increases heart rate. - ✔️✔️b) Get up slowly from a supine
position.
Postural hypotension is common in the older adult who is taking antihypertensive
medication. When the individual stands up too quickly after lying down, postural
hypotension can cause dizziness, which is a risk factor for falls. Older adults should be
, encouraged to exercise with the anticipated rise in heart rate within the limits of their
disease processes; eating a diet high in protein is not relevant to postural hypotension
related to antihypertensive medications. Although the older adult should drink 1,500 mL
of fluids daily to prevent dehydration, this response is not relevant to the use of
antihypertensive medications and postural hypotension.
Which blood pressure component is considered hypertensive in the older adult? (Select
all that apply.)
a) 92 mmHg diastolic
b) 144 mmHg systolic
c) 140 mmHg systolic
d) 88 mmHg diastolic
e) 90 mmHg diastolic - ✔️✔️a) 92 mmHg diastolic
b) 144 mmHg systolic
When blood pressure enters a level of less than 140 mmHg systolic and/or less than 90
mmHg diastolic, it is considered hypertensive.
With which of the following atypical manifestations of a urinary tract infection might the
older adult present? (Select all that apply.)
a) Weakness
b) Severe nocturnal headache
c) Decreased appetite
d) Alteration in cognitive function
e) Incontinence - ✔️✔️a) Weakness
c) Decreased appetite
d) Alteration in cognitive function
e) Incontinence
Infections in the older adult may not manifest in the same way as in a younger adult.
Fever, a typical presenting sign, can be undetected in the older adult. The older adult
may present with weakness, anorexia, changes in mental status, and incontinence.
Severe nocturnal headache is not a manifestation of a urinary tract infection.
Millie Larsen states that lately she tries to avoid laughing because of urine leakage.
Which type of incontinence does this finding indicate?
a) Stress incontinence
b) Functional incontinence
c) Urgency incontinence
d) Overflow incontinence - ✔️✔️a) Stress incontinence
