Tiêu đề Care of the Older Persons.pdf ✅

NURSES LICENSURE EXAMINATION (NLE) Controlled Copy 2023 Rev. 00 CLASSIFIED EXAMINATION FOR CRITICAL TEST ANALYSIS Care of the Older Persons Philippine Nurses Licensure Examination Warning: This material is protected by Copyright Laws. Unauthorized use shall be prosecuted in the full extent of the Philippine Laws. For exclusive use of CBRC reviewees only. SITUATION – Due to changes brought about by aging or underlying medical conditions, older patients require specific care to ensure their optimal comfort and safety. Awareness of these information is essential for a nurse when they encounter older persons in the area. 1. A 90-year-old patient comes to the clinic with a family member. During the health history, the patient is unable to respond to questions in a logical manner. The gerontological nurse's action is to: A. Ask the family member to answer the questions. B. Ask the same questions in a louder and lower voice. C. Determine if the patient knows the name of the current president. D. Rephrase the questions slightly, and slowly repeat them in a lower voice. 2. When interviewing the older adult with a suspected dementia, it is MOST important that: A. Mental status be evaluated first in order to determine if the patient is a reliable historian B. The examiner uses short simple questions and recognize non-verbal signs of discomfort C. Postpone the mental status evaluation for the following visit and establish a rapport first D. The clinician gets in contact with a family member to obtain the history 3. When interacting with older adults having visual problems which of the following has to be considered? A. Position self anywhere, since patient can still hear B. Position objects within their visual field C. Position patient to where you are directed D. Position objects within their reach 4. The nurse needs to be careful in the application of hot water bag in an older patient making them prone to burns due to: A. Increased skin wrinkling B. Elasticity of the skin C. Decreased density of cutaneous receptors for touch sensation D. Increased skin thickness 5. The following nursing intervention are appropriate in the prevention of pressure sores among bedridden elderly clients, EXCEPT: A. Massage bony prominences B. Apply alcohol on the skin C. Keep the skin clean and dry D. Turn the client every 2 hours SITUATION – In assessing older adults, nurses may utilize different scales and tools to appropriately plan out their care. With this, it is essential to take note that age-specific approaches must be observed during assessment. 6. Assessment of older adults using different scales is essential in determining their level of functioning and independence. In the Katz Index of independence in Activities of daily living, which of the following is FALSE: A. Activities are scored in two points only: 1 for independence and 0 for dependence B. You can put a score of 1 in feeding if preparation of food is done by another person C. Activities like bathing, shopping, and toileting are included D. The highest possible score is 6 (independent) and the lowest possible score is 0 (very dependent) 7. Using the Katz Index of Independence in Activities of Daily Living, Nurse Elsa scores a patient who can get clothes from closets and drawers, put clothes on and outer garments complete with fasteners, and requires help when tying shoes with: A. 3 points C. 1 point B. 2 points D. 0 point 8. You decided to use Lawton Instrumental Activities of Daily Living scale to assess a male older person. Which category is NOT included in your assessment? A. Responsibility for own medications B. Ability to use telephone C. Continence D. Mode of transportation 9. Upon assessment, you noticed that the client’s skin appears to be dry, wrinkled, and less elastic. You should note that this is due to: A. Hypothermia B. Diminished collagen in the body C. Diminished sweat glands that presents decreased thermoregulation D. Improved sweat glands 10. As a nurse, it is important to consider that older persons have decreased thermoregulation capacity. During assessment that requires longer skin or bodily exposure to cold air or surrounding, the PRIORITY nursing action is to: A. Provide adequate warmth B. Give cooling blankets C. Maintain adequate hydration D. Decrease frequency of baths SITUATION – You are assigned to multiple older adult clients in the ward. As a nurse, you are aware of certain age-related changes in older persons and should take note that their assessment and care vary from that of adults and children. 11. Upon assessing a 75-year-old male client in the ward, you noticed changes in the vision wherein the person cannot focus clearly when objects are up close. This is referred to as: A. Strabismus C. Retinopathy B. Presbyopia D. Diplopia