Pearson Custom For Older Adult Nursing Care By Nancy J.Brown And Linda- Test Bank

Pearson Custom For Older Adult Nursing Care By Nancy J.Brown And Linda- Test Bank

Brown Older Adult Nursing Care, 1/E
Chapter 9
Question 1
Type: MCSA
During a physical exam, an older adult female client asks the nurse to explain what causes the large number of varicose veins in her legs. Which one of the following responses by the nurse contains accurate information?
1. “During the aging process, the veins dilate, the vein valves don’t close properly, blood is returned to the heart inefficiently, and fluid stays down in the legs, causing varicose veins and swelling to occur.”
2. “The kidneys decrease in functioning due to aging, and excess fluid is pumped into the veins, causing them to dilate and distort.”
3. “Plaque deposits build up in the veins, preventing adequate blood flow and causing the veins to swell and deform.”
4. “A sedentary lifestyle, along with the aging process, causes the veins to become inflamed which then causes them to enlarge and become distorted.”
Correct Answer: 1
Rationale 1: Correct. Varicose veins and swelling in the feet and ankles are caused by venous stasis and inefficient return of blood to the heart due to defective vein valves.
Rationale 2: The kidneys do decrease in size, but fluid is not pumped into the veins. Blood becomes stagnant in the veins.
Rationale 3: Plaque builds up in the arteries due to a different problem known as atherosclerosis.
Rationale 4: Inflammation of the veins is a different condition known as thrombophlebitis.
Global Rationale:

Cognitive Level: Understanding
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome: Describe the normal changes of aging in the circulatory system.

Question 2
Type: MCSA
After taking the blood pressure of a frail older adult client, the nurse observes petechiae in the area where the cuff was located. The nurse suspects which of the following conditions at this point?
1. Atherosclerotic damage to the capillaries in the body
2. Capillary fragility due to aging and minor trauma
3. Increased blood pressure caused by the aging process
4. Decreased cardiac output due to aging, causing insufficient blood flow
Correct Answer: 2
Rationale 1: Atherosclerosis causes plaque formation within arteries, not petechiae.
Rationale 2: Correct. With the information the nurse has at this point, capillary fragility is all the nurse can surmise. The trauma may have been caused by the blood pressure cuff being inflated too much.
Rationale 3: Capillary fragility, not increased blood pressure, is the actual cause of petechiae formation.
Rationale 4: Decreased cardiac output has signs and symptoms such as fatigue, activity intolerance, and edema, not petechiae.
Global Rationale:

Cognitive Level: Applying
Client Need: Health Promotion and Maintenance
Client Need Sub:
Nursing/Integrated Concepts:
Learning Outcome: Describe the normal changes of aging in the circulatory system.