Ignatavicius: Medical-Surgical Nursing, 9th Edition

Chapter 03: Common Health Problems of Older Adults

Answer Key – NCLEXÒ Examination Challenges and Clinical Judgment Challenges

Answer Key – NCLEXÒ Examination Challenges

NCLEXÒ Examination Challenge 3-1, Health Promotion and Maintenance

1. Which statement by the older adult indicates a need for further teaching about meeting
nutrition and hydration needs?

a. “I will make sure I eat plenty of fruits and vegetables and avoid red meat.”
b. “I will stop drinking liquids after dinner to prevent getting up at night.”
c. “I’m going to check if I can get food stamps to help me afford better food.”
d. “I’ve got to increase more fiber in my diet to help my bowels work better.”

ANS: B

Decreasing fluids before bedtime can result in concentrated urine which may irritate the bladder.
Fiber, fruits, and vegetables are important to maintain health in older adults and resources such
as food stamps can help them obtain healthy foods.
Cognitive Level: Analyzing
Integrated Process: Teaching and Learning

NCLEXÒ Examination Challenge 3-2, Safe Effective Care Environment

1. The nurse performs an initial assessment for an older adult being admitted to an assisted living
facility. Which nursing findings indicate that the client is at risk for falls? (Select all that apply.)

a. Uses a roller walker

b. Has had arthritis for 20 years
c. Is oriented to person, place, and time
d. Wears eyeglasses
e. Has bilateral cataracts
f. Has severe osteoporosis

ANS: A, B, D, E, F

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Answer Key 3-2

The client has decreased mobility and visual acuity, which increases the risk for falls.
Cognitive Level: Applying
Integrated Process: Nursing Process

NCLEXÒ Examination Challenge 3-3, Physiological Integrity

1. A nurse conducts an assessment of an older adult's medications and herbal/nutritional

supplements. Which supplement is most likely to cause an interaction with prescribed

medications?

a. Probiotics

b. Echinacea

c. Vitamin D

d. Vitamin C

ANS: B

Echinacea is an herbal supplement that enhances the immune response. It should not be taken
with immunosuppressive agents which decrease the immune response. Probiotics are useful for
bowel function; Vitamin C promotes tissue healing, and Vitamin D promotes absorption of
calcium in the body, which older adults, especially women, need due to bone loss.
Cognitive Level: Understanding
Integrated Process: Nursing Process

NCLEXÒ Examination Challenge 3-4, Physiological Integrity

1. An older adult has been taking furosemide 20 mg daily for the past six months. The family

reports that the client suddenly became confused, weak, and very agitated. What is the nurse's

best action?

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Answer Key 3-3

a. Begin intravenous fluid therapy.

b. Draw blood to assess electrolyte levels.

c. Start oxygen via mask at 6 L/min.

d. Place the client on strict intake and output.

ANS: B

Furosemide is a diuretic that works to lose sodium and therefore water from the body. If sodium
loss is too much, the client can have confusion, mental changes, and weakness. Therefore,
checking serum electrolyte levels is the most appropriate action.
Cognitive Level: Analyzing
Integrated Process: Nursing Process

Answer Key – Clinical Judgment Challenges

None.

Copyright © 2018 Elsevier Inc. All rights reserved.