NCLEX Questions on Older Adults

Extract:

Question 1 of 5

The nurse’s assessment findings of the hospitalized older adult include: BP 96/64 mm Hg, P 118 bpm, RR 20/minute, weight 110 lb with an 8-lb weight loss in the last 3 months due to severe loss of appetite from chemotherapy, and BMI of 19. The client reports fatigue so does not go out, but is able to get around the house. Though tired, the client responds appropriately and clearly to questions and denies psychological issues. What score should the nurse assign to the client when completing the Geriatric Mini Nutrition Assessment?

Correct Answer: 4

Rationale: Score: Severe appetite loss = 0; >3 kg weight loss = 0; mobility (bed/chair but not out) = 1; acute disease (cancer) = 0; no psychological issues = 2; BMI 19 = 1.
Total = 4.

Question 2 of 5

The nurse is obtaining nutrition information from four 20-year-old female clients. All have a BM] of 20 to 23. Which client requires the most immediate follow-up?

A. The client eats three nutritious meals a day with no snacks B. The client limits her intake to 2500 calories per day C. The client eats only fruits, vegetables, seeds, and nuts D. The client eats three 350-calorie meals per day

Correct Answer: D

Rationale: By limiting meals to 350 calories each, the client consumes only 1050 calories daily, insufficient for a sedentary female’s basic energy needs, requiring immediate follow-up. Three nutritious meals may suffice, 2500 calories is appropriate, and a vegetarian diet needs protein assessment but is less urgent.

Question 3 of 5

The nurse is collecting information from the young adult client. Which psychosocial questions should the nurse ask during the admission assessment? Select all that apply.

A. Do you have any pets?' B. How many hours of sleep do you get?' C. When was your last bowel movement?' D. How much alcohol do you drink?' E. Can you describe your sexual activity?'

Correct Answer: A;B;D;E

Rationale: The nurse should ask about pets (enhances mental well-being), sleep (affects coping and immunity), alcohol use (impacts health risks), and sexual activity (STI/HIV risks). Bowel movement is physiological, not psychosocial.

Question 4 of 5

The nurse is caring for the 55-year-old client. Which statement by the client related to psychosocial changes should the nurse most definitely explore?

A. I really don’t want to color my hair, even though it seems to be getting grayer every day.' B. I can’t see as sharp anymore. I get frustrated by the small lettering on the medicine bottles.' C. My husband and I have a more active sexual life now that the children are out of the house.' D. My house is empty; I thought I’d be happy when my children finally left, but I feel lonely.'

Correct Answer: D

Rationale: The client’s statement suggests empty nest syndrome, a psychosocial concern requiring further exploration. Graying hair is a normal physiological change, vision issues are physiological, and an active sexual life indicates a healthy relationship.

Question 5 of 5

The nurse teaches the 18-year-old diabetic client to perform self-administration of insulin. Each time the client makes even a small mistake, the client apologizes for getting it wrong- The client also profusely apologizes when making a minimal mistake in other activities. Based on Erikson’s developmental stages, the nurse concludes that the client may have an unresolved developmental task of which age period?

A. Infancy B. Early childhood C. School-aged childhood D. Adolescence

Correct Answer: B

Rationale: The behavior indicates an unresolved conflict of 'autonomy versus shame and doubt' associated with the 18-month to 3-year-old age group. When parents are overly critical, the child may develop an overly critical superego, manifesting as constant apologizing for small mistakes.