Chapter 08: Health Assessment for Older
Adults
Williams: Basic Geriatric Nursing, 8th Edition
MULTIPLE CHOICE
1. During the health interview, the older adult reports sadness, poor temperament and a
decline in “being able to think straight.” The nurse will ask further questions regarding
which aspect?
a. Feelings of depression
b. Time of last bowel movement
c. Environmental stimuli that disturb sleep
d. Frequency and size of meals
ANS: A
Sadness, loss of hope, poor temperament, decline in cognitive function are signals of
possible depression.
PTS: 1 DIF: 7 REF: p. 162 | Table 8.1
OBJ: 4 TOP: Symptoms of Depression
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease NOT: Analyzing
2. Which type of thermometer would be the best choice when assessing the temperature of
an older adult?
a. Electronic thermometer, because it only takes a few seconds to assess temperature
, b. Oral thermometer, because the presence of dry mucous membranes gives a more
valid temperature
c. Axillary thermometer, because its position is nearer the heart
d. Rectal thermometer, because it is the best indicator of the body core temperature
ANS: A
The electronic thermometer is the best device because it is accurate and quick.
PTS: 1 DIF: 3 REF: p. 165 OBJ: 8
TOP: Temperature Assessment KEY: Nursing Process Step: Data
Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease NOT: Understanding
3. Which term is the correct term for the difference between the apical pulse and the radial
pulse?
a. Pulse pressure
b. Pulse deficit
c. Pulse ratio
d. Pulse quality
ANS: B
The difference between the apical and radial pulse is referred to as the pulse deficit.
This is a pertinent piece of information because it may indicate peripheral circulatory
impairment.
PTS: 1 DIF: 1 REF: p. 166 OBJ: 8
TOP: Pulse Deficit KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT:
Remembering
, 4. When assisting with data collection, which finding would be recorded as crackles?
a. Fine, short sounds in the lung bases on inspiration
b. Continuous low-pitched snoring sounds over major bronchi
c. Squeaky musical sounds on expiration
d. Coarse grating sounds on inspiration and expiration
ANS: A
Crackles are adventitious breath sounds heard on inspiration that sound like crackling
paper.
PTS: 1 DIF: 4 REF: Table 8-2 | pp. 163-164
OBJ: 7 TOP: Adventitious Breath Sounds
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT:
Understanding
5. Where would the nurse place the head of the stethoscope when assessing an apical pulse?
a. Third intercostal space at proximal edge of the clavicle
b. Fourth intercostal space at the edge of the sternum
c. Fifth intercostal space even with the middle of the clavicle
d. Sixth intercostal space above the diaphragm
ANS: C
The correct placement of the stethoscope for the assessment of the apical pulse is at
the fifth intercostal space at the midclavicular line. The pulse should be counted for a
full minute.
PTS: 1 DIF: 3 REF: p. 166 OBJ: 8
TOP: Apical Pulse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort NOT:
Understanding
Adults
Williams: Basic Geriatric Nursing, 8th Edition
MULTIPLE CHOICE
1. During the health interview, the older adult reports sadness, poor temperament and a
decline in “being able to think straight.” The nurse will ask further questions regarding
which aspect?
a. Feelings of depression
b. Time of last bowel movement
c. Environmental stimuli that disturb sleep
d. Frequency and size of meals
ANS: A
Sadness, loss of hope, poor temperament, decline in cognitive function are signals of
possible depression.
PTS: 1 DIF: 7 REF: p. 162 | Table 8.1
OBJ: 4 TOP: Symptoms of Depression
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease NOT: Analyzing
2. Which type of thermometer would be the best choice when assessing the temperature of
an older adult?
a. Electronic thermometer, because it only takes a few seconds to assess temperature
, b. Oral thermometer, because the presence of dry mucous membranes gives a more
valid temperature
c. Axillary thermometer, because its position is nearer the heart
d. Rectal thermometer, because it is the best indicator of the body core temperature
ANS: A
The electronic thermometer is the best device because it is accurate and quick.
PTS: 1 DIF: 3 REF: p. 165 OBJ: 8
TOP: Temperature Assessment KEY: Nursing Process Step: Data
Collection
MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early
Detection of Disease NOT: Understanding
3. Which term is the correct term for the difference between the apical pulse and the radial
pulse?
a. Pulse pressure
b. Pulse deficit
c. Pulse ratio
d. Pulse quality
ANS: B
The difference between the apical and radial pulse is referred to as the pulse deficit.
This is a pertinent piece of information because it may indicate peripheral circulatory
impairment.
PTS: 1 DIF: 1 REF: p. 166 OBJ: 8
TOP: Pulse Deficit KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT:
Remembering
, 4. When assisting with data collection, which finding would be recorded as crackles?
a. Fine, short sounds in the lung bases on inspiration
b. Continuous low-pitched snoring sounds over major bronchi
c. Squeaky musical sounds on expiration
d. Coarse grating sounds on inspiration and expiration
ANS: A
Crackles are adventitious breath sounds heard on inspiration that sound like crackling
paper.
PTS: 1 DIF: 4 REF: Table 8-2 | pp. 163-164
OBJ: 7 TOP: Adventitious Breath Sounds
KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation NOT:
Understanding
5. Where would the nurse place the head of the stethoscope when assessing an apical pulse?
a. Third intercostal space at proximal edge of the clavicle
b. Fourth intercostal space at the edge of the sternum
c. Fifth intercostal space even with the middle of the clavicle
d. Sixth intercostal space above the diaphragm
ANS: C
The correct placement of the stethoscope for the assessment of the apical pulse is at
the fifth intercostal space at the midclavicular line. The pulse should be counted for a
full minute.
PTS: 1 DIF: 3 REF: p. 166 OBJ: 8
TOP: Apical Pulse KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort NOT:
Understanding
