Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
Which of the following findings should the nurse expect?
A. Increased sensitivity to touch.
Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.
B. Increase in cerumen in the ear canal.
An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.
C. Increased peripheral vision.
Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.
D. Increase in size of pupils.
An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.
This question is an excerpt from Nurse Dive's nursing test bank - ATI Custom NSG 240 Final Proctored Exam. Take the full exam now
Full Explanation
Choice A rationale:
Increased sensitivity to touch is not typically an age-related change in older adults. In fact, older adults often experience a decrease in sensitivity due to factors like reduced skin elasticity and changes in nerve function.
Choice C rationale:
Increased peripheral vision is not a common age-related change. Visual changes in older adults usually involve decreased visual acuity, difficulties with night vision, and increased sensitivity to glare.
Choice D rationale:
An increase in the size of pupils is not an expected age-related change. Pupils may become smaller and react more sluggishly to changes in light in older adults, but a consistent increase in pupil size is not a common finding.
Choice B rationale:
An increase in cerumen in the ear canal is a common age-related change. Cerumen, or earwax, can accumulate more in older adults due to changes in the composition of earwax and slower migration of earwax out of the ear canal. It can lead to hearing difficulties and may need management. Moving on to the last question.
Similar Questions
A nurse is teaching a class about Freud's psychosexual stages.
The nurse should instruct that fixation at the oral stage of development can lead to which of the following conditions?
A. Inability to form healthy relationships.
Inability to form healthy relationships: This is more commonly associated with fixation at the phallic stage.
B. Feelings of shame.
Feelings of shame are associated with Freud's psychosexual stages, particularly during the anal stage. Fixation at the oral stage is more likely to result in issues related to dependency and oral fixation, which may manifest as habits like nail-biting or smoking, rather than feelings of shame.
C. Overeating.
According to Freud's psychosexual theory, fixation at the oral stage can lead to oral personality traits. These traits are often associated with oral activities like eating, drinking, smoking, and talking. Overeating is a common behavior linked to oral fixation, as it represents a seeking of oral gratification.
D. Bedwetting.
Bedwetting is not typically associated with fixation at the oral stage of development. Bedwetting is more commonly linked to issues at the anal stage. In the oral stage, the fixation is primarily related to dependency and oral behaviors. .
Full Explanation
Choice A rationale;
Inability to form healthy relationships: This is more commonly associated with fixation at the phallic stage.
Choice B rationale:
Feelings of shame are associated with Freud's psychosexual stages, particularly during the anal stage. Fixation at the oral stage is more likely to result in issues related to dependency and oral fixation, which may manifest as habits like nail-biting or smoking, rather than feelings of shame.
Choice C rationale:
According to Freud's psychosexual theory, fixation at the oral stage can lead to oral personality traits. These traits are often associated with oral activities like eating, drinking, smoking, and talking. Overeating is a common behavior linked to oral fixation, as it represents a seeking of oral gratification.
Choice D rationale:
Bedwetting is not typically associated with fixation at the oral stage of development. Bedwetting is more commonly linked to issues at the anal stage. In the oral stage, the fixation is primarily related to dependency and oral behaviors. .
A nurse is planning care for an older adult client.
The nurse should plan to monitor the client for which of the following?
A. Widened peripheral vision.
Widened peripheral vision. This choice is not an expected change in an older adult's vision. As individuals age, peripheral vision may diminish, but it doesn't typically widen. Therefore, this choice is not appropriate.
B. Increase in accommodation to near vision.
Increase in accommodation to near vision. This is the correct answer because it is a common age-related change in vision known as presbyopia. As individuals age, their ability to accommodate or focus on near objects diminishes. This change typically begins in the early 40s and progresses over time. It's a result of the lens of the eye becoming less flexible. Older adults may need reading glasses or bifocals to improve their near vision. The nurse should plan to monitor for this change as part of routine care for an older adult.
C. Eyes with large pupils.
Eyes with large pupils. Older adults often experience changes in the size of their pupils due to the aging process. Pupils may become smaller and less responsive to light, not larger. Thus, this choice is not accurate.
D. Infections of the eye.
Infections of the eye. While eye infections can occur in any age group, there's no specific reason to monitor an older adult for eye infections unless there are signs or symptoms suggesting an issue. It's not a routine aspect of care for older adults. Now, let's discuss the rationale for the correct answer, choice B:
Full Explanation
Choice A rationale:
Widened peripheral vision. This choice is not an expected change in an older adult's vision. As individuals age, peripheral vision may diminish, but it doesn't typically widen. Therefore, this choice is not appropriate.
Choice C rationale:
Eyes with large pupils. Older adults often experience changes in the size of their pupils due to the aging process. Pupils may become smaller and less responsive to light, not larger. Thus, this choice is not accurate.
Choice D rationale:
Infections of the eye. While eye infections can occur in any age group, there's no specific reason to monitor an older adult for eye infections unless there are signs or symptoms suggesting an issue. It's not a routine aspect of care for older adults. Now, let's discuss the rationale for the correct answer, choice B:
Choice B rationale:
Increase in accommodation to near vision. This is the correct answer because it is a common age-related change in vision known as presbyopia. As individuals age, their ability to accommodate or focus on near objects diminishes. This change typically begins in the early 40s and progresses over time. It's a result of the lens of the eye becoming less flexible. Older adults may need reading glasses or bifocals to improve their near vision. The nurse should plan to monitor for this change as part of routine care for an older adult.
A nurse is preparing to obtain a 24-hr urine collection from a client.
Which of the following actions should the nurse plan to take?
A. Discard the client's last void at the end of the collection time period.
Discard the client's last void at the end of the collection time period. This choice is not appropriate. When conducting a 24-hour urine collection, it's essential to include all urine produced during the specified time frame. Discarding the last void would result in an incomplete and inaccurate collection.
B. Include toilet paper with the collected urine.
Include toilet paper with the collected urine. This choice is also incorrect. Toilet paper is not typically included in a 24-hour urine collection. The purpose of this collection is to accurately measure substances excreted by the kidneys over a specific time period. Toilet paper is not part of this measurement and should not be included.
C. Save the first void at the start of the collection time period.
The first void at the beginning of the collection period is typically discarded, as it represents the urine that was in the bladder before the timed collection started. This helps ensure that the collection is accurate and only includes urine produced during the specified 24-hour period. It's important to follow this protocol to obtain reliable test results.
D. Refrigerate the urine during the collection time period.
Refrigerate the urine during the collection time period. This choice is accurate. When collecting a 24-hour urine sample, it is crucial to refrigerate the urine during the collection period. This helps prevent the breakdown of certain substances and ensures the sample's accuracy. Failure to refrigerate the urine can lead to inaccurate test results. Now, let's discuss the rationale for the correct answer, choice C:
Full Explanation
Choice A rationale:
Discard the client's last void at the end of the collection time period. This choice is not appropriate. When conducting a 24-hour urine collection, it's essential to include all urine produced during the specified time frame. Discarding the last void would result in an incomplete and inaccurate collection.
Choice B rationale:
Include toilet paper with the collected urine. This choice is also incorrect. Toilet paper is not typically included in a 24-hour urine collection. The purpose of this collection is to accurately measure substances excreted by the kidneys over a specific time period. Toilet paper is not part of this measurement and should not be included.
Choice D rationale:
This helps prevent the breakdown of certain substances and ensures the sample's accuracy. Failure to refrigerate the urine can lead to inaccurate test results. Now, let's discuss the rationale for the correct answer, choice C:
Choice C rationale:
The first void at the beginning of the collection period is typically discarded, as it represents the urine that was in the bladder before the timed collection started. This helps ensure that the collection is accurate and only includes urine produced during the specified 24-hour period. It's important to follow this protocol to obtain reliable test results.