A nurse is creating a plan of care for an 80-year-old client at high risk for falls. Which intervention is a priority to include in the plan?
[a] Keep all four side rails in the up position at all times.
[b] Ensure the bed is in the lowest position with the call bell within reach.
[c] Place the client in a room far from the nursing station to ensure a quiet environment.
[d] Advise the client to wear only socks when walking to the bathroom.
An 82-year-old client, admitted for a urinary tract infection, suddenly becomes acutely confused, inattentive, and is seeing things that are not there. The family states this is a new behavior. The nurse correctly identifies this condition as:
[a] Dementia.
[b] Depression.
[c] Delirium.
[d] Age-related memory loss.
Polypharmacy is a significant concern in the geriatric population. The nurse understands that the primary risk associated with a patient taking multiple medications is:
[a] Increased cost of healthcare.
[b] Non-adherence to the medication schedule.
[c] Increased risk of adverse drug interactions.
[d] Improved management of chronic conditions.
The physiological changes of aging include a decrease in the glomerular filtration rate (GFR). This change primarily puts the elderly patient at risk for:
[a] Dehydration.
[b] Drug toxicity.
[c] Hypertension.
[d] Anemia.
A nurse is using the Braden Scale to assess an immobile 88-year-old client's risk for developing pressure ulcers. Which of the following factors is assessed by this tool?
[a] Age and weight.
[b] Blood pressure and heart rate.
[c] Moisture, mobility, and nutrition.
[d] Cognitive status and pain level.
Which factor is a common cause of poor nutritional intake in the elderly population?
[a] Increased metabolic rate.
[b] An enhanced sense of smell.
[c] Ill-fitting dentures and decreased sense of taste.
[d] A heightened sensation of thirst.
An elderly client has difficulty hearing high-pitched sounds and understanding conversations in noisy environments. The nurse recognizes this common age-related hearing loss as:
[a] Presbyopia.
[b] Presbycusis.
[c] Otosclerosis.
[d] Tinnitus.
An elderly patient with a myocardial infarction may not present with classic chest pain. The nurse should be alert for which atypical symptom?
[a] High fever.
[b] Severe headache.
[c] Leg cramps.
[d] Acute confusion or fatigue.
A nurse is teaching a group of older adults about preventing osteoporosis. Which recommendation is most important?
[a] Avoid all sun exposure.
[b] Engage in swimming as the primary form of exercise.
[c] Perform regular weight-bearing exercises like walking.
[d] Follow a low-calcium, high-protein diet.
A home health nurse is visiting an elderly client and notices several unexplained bruises in various stages of healing. When asked, the client appears fearful and looks at their caregiver before answering. What should be the nurse's primary concern?
[a] The client has a bleeding disorder.
[b] The client is prone to falling.
[c] Potential elder abuse or neglect.
[d] Side effects of medication.
An elderly client is often awake for long periods during the night and naps frequently during the day. Which nursing intervention would be most effective to promote a normal sleep-wake cycle?
[a] Administer a sedative hypnotic every night at bedtime.
[b] Encourage a consistent daily routine of activity and rest.
[c] Suggest drinking a cup of warm tea before bedtime.
[d] Keep the television on in the room all night.
When communicating with an elderly client who has a hearing impairment, the nurse should:
[a] Shout loudly into the client's ear.
[b] Speak very quickly to keep the client's attention.
[c] Face the client and speak clearly in a low-pitched voice.
[d] Exaggerate lip movements to facilitate lip-reading.
An elderly client with Alzheimer's disease becomes agitated while the nurse is attempting to provide morning care. What is the most appropriate initial nursing action?
[a] Tell the client to calm down and be cooperative.
[b] Administer a prn sedative medication.
[c] Stop the care for a moment and redirect the client's attention.
[d] Continue with the care quickly to get it over with.
The nurse is assessing for dehydration in an 85-year-old client. Which finding is a more reliable indicator in this age group than skin turgor?
[a] Increased perspiration.
[b] A low hematocrit level.
[c] Dry oral mucous membranes.
[d] Bounding peripheral pulses.
What is the primary rationale for recommending annual influenza vaccinations for the elderly?
[a] The vaccine provides lifelong immunity to all flu viruses.
[b] The vaccine is required for admission to nursing homes.
[c] Older adults are at a higher risk for severe complications from influenza.
[d] The vaccine helps prevent the common cold.
A common gastrointestinal problem in older adults is constipation. A primary nursing intervention to manage this is to:
[a] Recommend daily use of stimulant laxatives.
[b] Advise a diet low in fiber and fluids.
[c] Encourage increased fluid intake and high-fiber foods.
[d] Suggest bed rest to conserve energy.
A nurse is caring for an elderly client with functional incontinence. Which intervention would be most helpful for this client?
[a] Inserting an indwelling urinary catheter.
[b] Teaching Kegel exercises to strengthen the pelvic floor.
[c] Providing clothing that is easy to remove, such as pants with an elastic waistband.
[d] Restricting fluid intake in the evening.
Which statement best describes the purpose of the Beers Criteria list in geriatric care?
[a] It lists the most effective antibiotics for treating infections in older adults.
[b] It identifies potentially inappropriate medications to be avoided or used with caution in older adults.
[c] It is a screening tool for assessing cognitive function and dementia.
[d] It outlines the recommended daily caloric intake for elderly individuals.
An older adult client expresses feelings of sadness and worthlessness following the recent death of their spouse and moving to a new home. This is an example of which common psychosocial challenge in the elderly?
[a] Fear of death.
[b] Grief and coping with loss.
[c] Ageism.
[d] Cognitive impairment.
The nurse recognizes that decreased subcutaneous fat and reduced sweat gland activity in older adults places them at a higher risk for:
[a] Skin infections.
[b] Overhydration.
[c] Allergic reactions.
[d] Impaired thermoregulation (hypothermia and hyperthermia).
A home care nurse is performing a safety assessment for an elderly client. Which finding represents the greatest risk for a fall?
[a] Bright lighting in the hallways.
[b] Grab bars installed in the bathroom.
[c] Small throw rugs on polished floors.
[d] A telephone by the bedside.
When assessing pain in an elderly client with severe dementia, the nurse should primarily rely on:
[a] The client's verbal report of pain on a 0-10 scale.
[b] The family's opinion of whether the client is in pain.
[c] Nonverbal cues such as facial grimacing, restlessness, and moaning.
[d] Changes in vital signs, such as an elevated temperature.
What is a primary goal of palliative care for an elderly client with a chronic, life-limiting illness?
[a] To cure the underlying disease.
[b] To provide care only in the last few days of life.
[c] To improve quality of life by managing symptoms and stress.
[d] To hasten the end of life.
A common age-related change in the eye is presbyopia. The nurse expects a client with this condition to report:
[a] A loss of peripheral vision.
[b] Seeing halos around lights.
[c] Difficulty reading small print or focusing on near objects.
[d] A cloudy or opaque lens.
A nurse is discussing advance directives with an alert and oriented 80-year-old client. The client asks what a "Living Will" is. The best response by the nurse is:
[a] "It is a document that distributes your property after you die."
[b] "It is a legal document that outlines your wishes for medical treatment if you become unable to make decisions for yourself."
[c] "It names a person to make financial decisions for you if you become incapacitated."
[d] "It is the form you sign to consent for surgery."
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