Questions → Task Question

Rationale
Answer A: Correct - nurse should always assess before implementing; nurse should
identify all risk factors
Answer B: Incorrect - appropriate action; assess before implementing
Answer C: Incorrect - appropriate action; assess before implementing
Answer D: Incorrect - appropriate action; assess before implementing
Question
The nurse cares for the client at risk for falling. Which action should the nurse
take first?

RIGHT
A.
Conduct a comprehensive risk assessment.
B.
Instruct the client to remove all throw and area rugs in the
house.
C.
Encourage the client to turn the lights on at night.
D.
Teach the client to strengthen the body's core.
Questions → Task Question
Rationale
Answer A: Correct - functional status of the older adult is more important than age
because the effects of aging differ between clients
Answer B: Incorrect - past health history is as important in the older adult as the
younger; however, it will be longer and take more time to obtain
Answer C: Incorrect - older adults may have different concerns and needs due to
disability, chronic disease and changes normal to aging
Answer D: Incorrect - older adults may consider many pathological problems to just be
normal to aging
Question
The student nurse prepares to obtain a health history from an older adult. The student
nurse identifies which statement is true about older adults?

RIGHT
A.
It is better to define the older adult by functional status rather
than age.
B.
The value of the health history to predict future health
problems in older adults is questionable.
C.
Health needs and concerns in older adults are identical to
those of younger adults.
D.
Older clients easily distinguish symptoms related to aging
from pathological conditions.
Questions → Task Question
Rationale
Answer A: Incorrect - more common in women than men
Answer B: Incorrect - cerebral blood flow does decrease with aging, but depression is
not normal
Answer C: Correct - depression in the older adult may be overlooked as physiological
(decreased sense of taste causing loss of appetite) or psychological changes
associated with aging; older adults may also think that depression will go away with time
Answer D: Incorrect - age does not make treating depression more difficult
Question
The nurse identifies which statement is true about depression in older adults?
A.
Depression is more likely to occur in older adult males than
females.
B.
Depression is a normal finding in older adults due to
decreased cerebral blood flow.
RIGHT
C.
Depression is frequently overlooked since normal changes in
aging may mask symptoms.
D.
Depression is more difficult to treat in older adults simply due
to advanced age.
O.S. is an 87-year-old female who has been released from the hospital, back to the
assisted living facility, after treatment for pneumonia. From the chart, the nurse finds
that the client was admitted with pneumonia on the same date as her sister's funeral.
The client had lived with her sister her entire life. The client's past medical history
includes seizures (well-controlled) and the recent case of pneumonia. She has
cataracts, hearing loss (uses an assistive hearing aid), and uses a walker or wheelchair
to assist with mobility. O.S. reports watching her diet closely and limits her fluid intake to
prevent frequent urination.
Client Content V. 3

Chart Assessment Scoring Explanation:

Your Selecting Data score reflects the number of correct pertinent items you selected as
compared to the number of pertinent items identified by the case author. Pertinent data
items may also have equivalents for which you may also receive credit. You will receive
credit for only one equivalent per pertinent item, but all equivalents that you marked as
pertinent will be labeled as Selected. Your score is expressed both in raw numbers and
as a percentage.
Your Questions score reflects the number of questions that you got correct, compared
to the total number of questions in this section. It is expressed both in raw numbers and
as a percentage.
Your Module Total reflects your total score for Selecting Data and Questions. It is
expressed both in raw numbers and as a percentage.
Omitted Selections are criteria identified by the case author that you omitted. Non-
Criteria Selections are incorrect items that you selected, or they are duplicates to criteria
items.
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → General Weakness

 General Weakness
Equivalents:

SELECTED
Initial Assessment → Musculoskeletal → Symptoms: → Weakness

 Weakness — uses walker

RIGHT
Initial Assessment → Admission Data → Assistive Devices: → Wheelchair

 Wheelchair
Equivalents:

SELECTED
Initial Assessment → Musculoskeletal → Activity Devices: → Wheelchair

 Wheelchair

SELECTED
Initial Assessment → Admission Data → Arrival Mode: → Wheelchair

 Wheelchair

RIGHT
Initial Assessment → Psychosocial → Client is Feeling: → Sad

 Sad — Sister, Dorothy, died 17 days ago after being in adjoining long term care
facility. Patient and sister had lived together all of their lives. "I miss Dorothy a lot. It's
bad, but at least she is no longer suffering. It was really hard watching her this last
year."
Equivalents:

Initial Assessment → Psychosocial → Recent Stress:

Sister died 17 days ago, moved from home one year ago to place sister in long term
care. Hospitalized night of funeral with pneumonia

RIGHT
Initial Assessment → Musculoskeletal → Activity Devices: → Walker

 Walker — whenever up
Equivalents:

SELECTED
Initial Assessment → Admission Data → Assistive Devices: → Walker

 Walker
Initial Assessment → Psychosocial → General Appearance:
Well-groomed older adult woman, neat appearance, stooped, walks with a limp using
walker
Initial Assessment → Temperature/Skin → Factors that Might Lead to Skin Alterations: → Limited Activity/Mobility

RIGHT
Initial Assessment → Education/Discharge Planning → Other Comments:
Accepted for readmission to assisted living facility.
Equivalents:

Initial Assessment → Admission Data → Reason for Seeking Medical Attention:

Returning to Assisted Living after hospitalization for pneumonia.

RIGHT
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → Age Over 80

 Age Over 80
Equivalents:

Initial Assessment → Admission Data → Age:

87

RIGHT
Initial Assessment → Cardiovascular → Cardiovascular Problems: → High Blood Pressure

 High Blood Pressure — "I've taken a pill for my pressure for about 20 years."
Equivalents:

SELECTED
Initial Assessment → Medical History → Major Medical Problems → Hyper/Hypotension

 Hyper/Hypotension — takes hydrochlorothiazide 25 mg qd

SELECTED
Initial Assessment → Medications → Current Medications → hydrochlorothiazide

 hydrochlorothiazide — 25 mg qd

RIGHT
Initial Assessment → Medical History → Major Medical Problems → Seizures

 Seizures — for last 7 years - controlled with depakote

Equivalents:

SELECTED
Initial Assessment → Neurological → Symptoms → Seizures

 Seizures — "I haven't had a seizure in 3 years. I take my pill every day."
Initial Assessment → Medical History → Previous Hospitalizations/Surgeries:
Work-up of seizures 8 years ago
RIGHT
Initial Assessment → Musculoskeletal → Balance/Gait: → Unsteady

 Unsteady — very unsteady without walker

Equivalents:

Initial Assessment → Psychosocial → General Appearance:

Well-groomed older adult woman, neat appearance, stooped, walks with a limp using
walker

RIGHT
Initial Assessment → Psychosocial → Client is Feeling: → Worried

 Worried — "I need to get my strength back so that I can go to church and other
outings with the other residents. I haven't been able to do anything for the last year
while Dorothy was sick."
Equivalents:

Initial Assessment → Psychosocial → Financial Concerns:

"I hope I don't outlive my money. I want to leave something for my nieces and nephews.
I need to go through all of Dorothy's things. I have to talk to the bank about the
annuities."

RIGHT
Initial Assessment → Nutritional → Eating Problems: → Indigestion

 Indigestion — with spicy foods

Equivalents:

SELECTED
Initial Assessment → Medical History → Major Medical Problems → Gastrointestinal Problem

 Gastrointestinal Problem — indigestion when eating spicy foods

RIGHT
Initial Assessment → Gastrointestinal → Symptoms: → Constipation

 Constipation — "I take a pill every day."

Equivalents:

SELECTED
Initial Assessment → Gastrointestinal → Use of: → Laxatives

 Laxatives — oral laxative tablet daily

SELECTED
Initial Assessment → Medications → Current Medications → Senna glycoside

 Senna glycoside — 1 tablet qd

RIGHT
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → Impaired Mobility

 Impaired Mobility

RIGHT
Initial Assessment → Temperature/Skin → Factors that Might Lead to Skin Alterations: → Incontinence

 Incontinence — Stress incontinence, wears incontinence briefs

Equivalents:

SELECTED
Initial Assessment → Renal/Urinary → Symptoms: → Incontinent

 Incontinent — "Sometimes when I cough or lift something heavy I have problems."

SELECTED
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → Urgent/Frequent Elimination

 Urgent/Frequent Elimination

RIGHT
Initial Assessment → Nutritional → Usual Food Intake:
"I watch my diet very closely. I have cereal for breakfast and one cup of coffee. For
lunch I normally have some soup. For dinner I eat with the other residents. I don't like
meat much, but I eat a lot of fruits and vegetables. My doctor told me to watch my
cholesterol."
Equivalents:

SELECTED
Initial Assessment → Nutritional → Eating Problems: → Poor Appetite

 Poor Appetite

RIGHT
Initial Assessment → Medical History → Major Medical Problems → Arthritis

 Arthritis — bilateral hands and hips

RIGHT
Initial Assessment → Neurological → Symptoms → Hearing

 Hearing — Very hard of hearing, wears bilateral hearing aids

Equivalents:

SELECTED
Initial Assessment → Admission Data → Assistive Devices: → Hearing Aid

 Hearing Aid
RIGHT
Initial Assessment → Neurological → Symptoms → Sight

 Sight — Wears glasses

Equivalents:

SELECTED
Initial Assessment → Admission Data → Assistive Devices: → Glasses

 Glasses

SELECTED
Initial Assessment → Musculoskeletal → Indicators of Risk for Falls: → Impaired Senses (i.e. Vision)

 Impaired Senses (i.e. Vision)

SELECTED
Initial Assessment → Medical History → Major Medical Problems → Eye Problems

 Eye Problems — near sighted, cataracts bilaterally

RIGHT
Initial Assessment → Cardiovascular → Cardiovascular Problems: → Edema

 Edema — 1+ edema noted in ankles "My feet swell when I sit for too long."

Initial Assessment → Nutritional → Weight Loss Last 6 Mo.:

10 pounds (4.5 kg)
Initial Assessment → Temperature/Skin → Other Comments:
Encourage client to use walker and walk to dining room for meals
Initial Assessment → Nutritional → Usual Fluid Intake:
"I don't drink much. It just makes me go to the bathroom more. I have my coffee with
breakfast and a glass of water with meals."