A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)

More difficulty seeing due to a greater sensitivity to glare

Dehydration of intervertebral discs

Decreased systolic blood pressure

Decreased cough reflex

Decreased bladder capacity

Answer and Explanation

Correct Answer : A,B,D,E

A. More difficulty seeing due to a greater sensitivity to glare is a common age-related change in vision.

B. Dehydration of intervertebral discs can occur with aging, leading to decreased flexibility and potentially contributing to back pain.

C. While systolic blood pressure may increase with age, decreased systolic blood pressure is not a typical age-related change.

D. Decreased cough reflex is an expected change, which can lead to an increased risk of respiratory infections in older adults.

E. Decreased bladder capacity is an expected age-related change due to changes in the bladder muscles and elasticity of the tissues. This can contribute to increased frequency of urination in older adults.

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Correct Answer is B

Explanation

A. After palpating the abdomen is not the ideal time to auscultate bowel sounds.
Palpation may stimulate bowel sounds and potentially give a false impression of their presence or absence.
B. Prior to percussing the abdomen is the correct sequence. Auscultation of bowel sounds should be done before any other abdominal assessment techniques, including percussion or palpation. This allows the nurse to accurately hear any existing bowel sounds without interference.
C. Prior to inspecting the abdomen is not the ideal time for auscultation. Inspection focuses on visual examination and assessment, which does not involve listening for bowel sounds.
D. After assessing for kidney tenderness is not the correct timing for auscultating bowel sounds. Assessing for kidney tenderness involves a different aspect of the physical examination and does not influence bowel sound assessment.

A. Observe client's respiratory status. B. Monitor intake and output every 8 hr. C. Elevate the head of the client's bed 30° to 45°. D. Check residual volume every 4 to 6 hr.

Correct Answer is A

Explanation

A. Observing the client's respiratory status is the priority action because a decreased level of consciousness can potentially lead to compromised airway and respiratory function. It's crucial to monitor for signs of respiratory distress or compromise, such as changes in respiratory rate, depth, and effort.
B. Monitoring intake and output every 8 hr is an important nursing responsibility, but it is not the top priority when the client's respiratory status is in question.
C. Elevating the head of the client's bed 30° to 45° is a standard practice to prevent aspiration and promote optimal digestion during enteral feedings. While important, it is not the immediate priority in this situation.
D. Checking residual volume every 4 to 6 hr is a part of enteral feeding management, but it is not the priority when the client's respiratory status is a concern.

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A nurse is teaching a class of older adults about the expected physiologic changes of aging. Which of the following changes should the nurse include in the discussion? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's bowel sounds. At which of the following points in the assessment should the nurse auscultate the client's abdomen?

Correct Answer is B

Explanation

A nurse is planning care for a client who has a decreased level of consciousness. The client is receiving continuous enteral feedings via a gastrostomy tube due to an inability to swallow. Which of the following is the priority action by the nurse?

Correct Answer is A

Explanation

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