A frail, elderly client is admitted to the unit with a diagnosis of pneumonia. Which finding

is most important for the registered nurse (RN) to report to the healthcare provider?

A. Fever and chills

B. Confusion and dehydration

C. Crackles in the lung fields

D. Nausea and vomiting - B. Confusion and dehydration

Rationale: Confusion and dehydration (B) are findings of inadequate oxygenation and

perfusion in this frail elderly client. (A), (C) and (D) are all common with pneumonia, but

the most important finding is confusion and evidence of dehydration, which require

treatment for this frail elderly client.

A frail elderly couple asks the registered nurse (RN) if they have to watch their salt

intake because food does not taste as good as it used to so they have to season most

foods. What information should the RN offer the couple?

A. Boredom may influence how the taste of food is perceived, and different seasonings

can stimulate taste.

B. With age, an increase in sodium intake is needed to compensate for a decrease in

renal function.

C. Short-term memory loss and confusion may be the reason they want to over-season

their food.

D. Taste buds often are dull due to atrophy so older clients should use other seasonings

instead of salt. - D. Taste buds are often dull due to atrophy so older clients should use

other seasonings instead of salt.

Rationale: Taste buds atrophy with normal aging, which influences an older client's

sensitivity to taste and is often compensated for the use of stronger tasting seasonings.

(A), (B), and (C) are not normal aging processes related to taste.

After taking a 10-day course of an antibiotic that was ineffective, a frail, elderly client

with chronic obstructive pulmonary disease (COPD) is admitted for pneumonia. The

client has a long history of smoking and still smokes a pack of cigarettes a day. Which

finding should the registered nurse (RN) report to the healthcare provider?

A. Barrel chest with increased chest diameter

B. Crackles and pulse oximetry level of 88%

C. Low hemoglobin and hematocrit levels

D. Arterial blood gases indicating respiratory acidosis - B. Crackles and pulse oximetry

level of 88%

Rationale: With pneumonia, crackles in the lungs and low O2 saturation (B) can impact

adequate oxygenation, which should be reported to the HCP. (A) occurs due to chronic

hyperinflation of the lungs and is common in clients with COPD. Anemia (C) is

frequently identified in clients with COPD, and respiratory acidosis (D) due to CO2

retention contributes to a lower blood pH.

An older female client recently moved to an assisted living facility. The family explains to

the registered nurse (RN) that the client is unmanageable and always confused,

disoriented and depressed. The client asks the RN repeatedly, "Where am I?". How

should the RN respond?

A. Explain that she is in a new home called an assisted living community

B. Question the client about her perception of where she might be now.

C. Distract the client with a scenario that she is on an outing with her family.

D. Reassure the client not to worry because she will meet new friends. - A. Explain that

she is in a new home called an assisted living community.

Rationale: Reality re-orientation (A) is the best response for a client who is confused

because the response is consistent and true. (B, C, and D) do not provide the client with

feedback that is reality based.

A new resident in an assisted living facility is an older client who is experiencing shortterm memory loss and confusion. Which activity should the registered nurse (RN)

schedule the client to do during the day?

A. Arts and crafts

B. Current events discussion group

C. Group sing-along

D. Daily exercise group - D. Daily exercise group

Rationale: A daily exercise group (D) allows the client to mirror the leader and minimizes

the client's stress to remember. (A), (C), and a current events discussion group (B) are

thought-provoking activities that require attention to detail and short-term memory to

participate in the group activity which may be stressful and frustrating to the resident

who has difficulty remembering sequence of the details.

The hospice nurse is completing a focused assessment of an older female client with

end stage Alzheimer's disease, who recently fractured her hip. What technique should

the registered nurse (RN) use to determine the client's pain?

A. Use the FACE pain scale

B. Ask the client to rate pain on a scale of 1 to 10

C. Observe for facial grimacing

D. Review documentation of recent eating habits - C. Observe for facial grimacing

Rationale: Observing for facial grimacing (C) is the best method for evaluating pain for a

client who cannot communicate due to Alzheimer disease. (A) and (B) may not be

understood by a client with end-stage Alzheimer's disease. (D) is not a helpful tool for

pain assessment.