NCLEX-PN Test #11 3 Flashcards

An 82-year-old client is admitted with a new diagnosis of urinary tract infection (UTI). Which presentation is atypical and commonly seen in older adults?

Answer: Sudden onset of confusion (delirium)

Older adults with UTI often present with atypical symptoms: acute confusion (delirium), falls, incontinence, or general malaise without the classic dysuria and frequency. This atypical presentation is due to blunted immune response and altered pain perception. Delirium in the elderly should always prompt a search for an underlying cause.

The PN is assessing an 80-year-old client on multiple medications (polypharmacy). Which drug combination poses the greatest fall risk?

Answer: Lorazepam + terazosin + oxycodone

Polypharmacy with CNS depressants, alpha-blockers, and opioids significantly increases fall risk in the elderly through multiple mechanisms: sedation, orthostatic hypotension, and impaired balance. The Beers Criteria flags benzodiazepines, opioids, and alpha-blockers as high-risk medications in older adults for fall-related injuries.

When caring for an elderly client, the nurse recognizes which physiological change of aging directly increases the risk for drug toxicity?

Answer: Decreased renal creatinine clearance

Renal clearance of medications decreases by approximately 1% per year after age 40. The decline in GFR means renally-excreted drugs (digoxin, lithium, aminoglycosides, NSAIDs) accumulate to toxic levels at standard adult doses. Serum creatinine may be normal despite decreased GFR in the elderly due to reduced muscle mass.

A client with dementia is being repositioned and becomes agitated, calling out and striking at the nurse. What is the best response?

Answer: Use a calm voice, provide reassurance, and redirect using familiar objects or music

Non-pharmacological approaches are first-line for behavioral symptoms of dementia. A calm, reassuring tone, simple clear communication, and redirection with meaningful stimuli (familiar music, objects) are evidence-based strategies. Physical restraints increase agitation, confusion, and risk of injury and should be avoided.

An 85-year-old client is at high risk for skin breakdown. Which intervention is most important for pressure injury prevention?

Answer: Reposition the client every 2 hours using a turn schedule and use a pressure-redistributing mattress

Pressure injury prevention requires: repositioning every 2 hours (or more frequently based on risk), pressure-redistributing mattresses/overlays, keeping skin clean and dry, maintaining nutrition, and using transfer aids to reduce shear. Massaging reddened skin is contraindicated as it can worsen tissue damage by increasing capillary disruption.

The nurse is assessing an elderly client for depression. Which screening tool is most appropriate for older adults?

Answer: Geriatric Depression Scale (GDS)

The Geriatric Depression Scale (GDS) was specifically developed and validated for use in older adults. It uses simple yes/no questions and avoids questions about somatic symptoms (fatigue, appetite, sleep) that are common in the elderly regardless of depression, making it more specific for this population than tools developed for general adults.