NUR 216 EXAM 4 - COMPLETE QUESTIONS &
ANSWERS (100% VERIFIED SOLUTIONS)
2026 UPDATE 2 versions
Question 1
A nurse is assessing an older adult client's functional ability. Which of the
following assessment tools is most appropriate for evaluating activities of
daily living (ADLs)?
A. Mini-Mental State Examination (MMSE)
B. Katz Index of Independence in Activities of Daily Living
C. Geriatric Depression Scale
D. Mini Nutritional Assessment
*Correct Answer: B. Katz Index of Independence in Activities of Daily
Living. *
Rationale: The Katz Index measures functional independence in basic ADLs
including bathing, dressing, toileting, transferring, continence, and feeding.
The MMSE assesses cognitive function, the Geriatric Depression Scale screens
for depression, and the Mini Nutritional Assessment evaluates nutritional
status .
Question 2
Which of the following is considered an instrumental activity of daily living
(IADL)?
A. Bathing
B. Dressing
,C. Managing finances
D. Toileting
*Correct Answer: C. Managing finances. *
Rationale: IADLs are more complex activities needed for independent living,
including managing finances, shopping, meal preparation, housekeeping, and
using transportation. ADLs are basic self-care tasks like bathing, dressing,
and toileting .
Question 3
During a functional assessment of an older adult, the nurse asks, "Can you
prepare your own meals?" This question is assessing which type of activity?
A. Basic ADL
B. IADL
C. Social activity
D. Physical activity
*Correct Answer: B. IADL. *
Rationale: Meal preparation is considered an instrumental activity of daily
living (IADL). It requires higher-level cognitive and physical functioning than
basic ADLs. The ability to prepare meals independently is important for
community living .
Question 4
A client reports a recent fall. Which of the following is the most important
component of a fall risk assessment?
A. Blood pressure measurement
B. Medication review
,C. Vision screening
D. Gait and balance evaluation
*Correct Answer: D. Gait and balance evaluation. *
Rationale: While all components are important, gait and balance evaluation
is the most critical component of a fall risk assessment. Abnormalities in gait
and balance are strong predictors of falls. The Timed Up and Go (TUG) test is
commonly used .
Question 5
Which of the following medications is most likely to increase the risk of falls
in an older adult?
A. Acetaminophen
B. Benzodiazepines
C. Aspirin
D. Metformin
*Correct Answer: B. Benzodiazepines. *
Rationale: Benzodiazepines are considered potentially inappropriate
medications for older adults due to their sedative effects and increased fall
risk. They can cause drowsiness, confusion, and impaired balance .
Question 6
A client is taking a diuretic. Which electrolyte imbalance should the nurse
monitor for that could increase fall risk?
A. Hyperkalemia
B. Hyponatremia
, C. Hypokalemia
D. Hypercalcemia
*Correct Answer: C. Hypokalemia. *
Rationale: Diuretics can cause hypokalemia (low potassium), which can lead
to muscle weakness and fatigue, increasing the risk of falls. Potassium levels
should be monitored regularly in clients taking diuretics .
Question 7
The "Get Up and Go" test is used to assess which of the following?
A. Cognitive function
B. Gait and balance
C. Nutritional status
D. Depression
*Correct Answer: B. Gait and balance. *
Rationale: The Get Up and Go (or Timed Up and Go) test assesses gait and
balance. The client is asked to stand up from a chair, walk 10 feet, turn
around, walk back, and sit down. Difficulty or time >12 seconds indicates
increased fall risk .
Question 8
Which of the following is a normal age-related change in the older adult's
nervous system?
A. Increased short-term memory
B. Increased reaction time
C. Increased brain mass
D. Increased nerve conduction velocity
ANSWERS (100% VERIFIED SOLUTIONS)
2026 UPDATE 2 versions
Question 1
A nurse is assessing an older adult client's functional ability. Which of the
following assessment tools is most appropriate for evaluating activities of
daily living (ADLs)?
A. Mini-Mental State Examination (MMSE)
B. Katz Index of Independence in Activities of Daily Living
C. Geriatric Depression Scale
D. Mini Nutritional Assessment
*Correct Answer: B. Katz Index of Independence in Activities of Daily
Living. *
Rationale: The Katz Index measures functional independence in basic ADLs
including bathing, dressing, toileting, transferring, continence, and feeding.
The MMSE assesses cognitive function, the Geriatric Depression Scale screens
for depression, and the Mini Nutritional Assessment evaluates nutritional
status .
Question 2
Which of the following is considered an instrumental activity of daily living
(IADL)?
A. Bathing
B. Dressing
,C. Managing finances
D. Toileting
*Correct Answer: C. Managing finances. *
Rationale: IADLs are more complex activities needed for independent living,
including managing finances, shopping, meal preparation, housekeeping, and
using transportation. ADLs are basic self-care tasks like bathing, dressing,
and toileting .
Question 3
During a functional assessment of an older adult, the nurse asks, "Can you
prepare your own meals?" This question is assessing which type of activity?
A. Basic ADL
B. IADL
C. Social activity
D. Physical activity
*Correct Answer: B. IADL. *
Rationale: Meal preparation is considered an instrumental activity of daily
living (IADL). It requires higher-level cognitive and physical functioning than
basic ADLs. The ability to prepare meals independently is important for
community living .
Question 4
A client reports a recent fall. Which of the following is the most important
component of a fall risk assessment?
A. Blood pressure measurement
B. Medication review
,C. Vision screening
D. Gait and balance evaluation
*Correct Answer: D. Gait and balance evaluation. *
Rationale: While all components are important, gait and balance evaluation
is the most critical component of a fall risk assessment. Abnormalities in gait
and balance are strong predictors of falls. The Timed Up and Go (TUG) test is
commonly used .
Question 5
Which of the following medications is most likely to increase the risk of falls
in an older adult?
A. Acetaminophen
B. Benzodiazepines
C. Aspirin
D. Metformin
*Correct Answer: B. Benzodiazepines. *
Rationale: Benzodiazepines are considered potentially inappropriate
medications for older adults due to their sedative effects and increased fall
risk. They can cause drowsiness, confusion, and impaired balance .
Question 6
A client is taking a diuretic. Which electrolyte imbalance should the nurse
monitor for that could increase fall risk?
A. Hyperkalemia
B. Hyponatremia
, C. Hypokalemia
D. Hypercalcemia
*Correct Answer: C. Hypokalemia. *
Rationale: Diuretics can cause hypokalemia (low potassium), which can lead
to muscle weakness and fatigue, increasing the risk of falls. Potassium levels
should be monitored regularly in clients taking diuretics .
Question 7
The "Get Up and Go" test is used to assess which of the following?
A. Cognitive function
B. Gait and balance
C. Nutritional status
D. Depression
*Correct Answer: B. Gait and balance. *
Rationale: The Get Up and Go (or Timed Up and Go) test assesses gait and
balance. The client is asked to stand up from a chair, walk 10 feet, turn
around, walk back, and sit down. Difficulty or time >12 seconds indicates
increased fall risk .
Question 8
Which of the following is a normal age-related change in the older adult's
nervous system?
A. Increased short-term memory
B. Increased reaction time
C. Increased brain mass
D. Increased nerve conduction velocity
