PNR 108/PNR108 Exam 4 V2 | Gerontological
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing an older adult client who has a sudden onset of confusion and is
wandering the halls. Which condition should the nurse suspect first?
A. Dementia
B. Age-related memory loss
C. Depression
D. Delirium
Correct Answer: D
Explanation: Delirium is characterized by an acute and sudden onset of confusion, which
is often reversible if the underlying cause is addressed. In contrast, dementia is a slow,
progressive decline in cognitive function that is generally irreversible. The nurse must
prioritize identifying delirium because it may indicate an underlying infection, such as a
UTI, or a medication reaction.
2. Which age-related change in the respiratory system increases the risk for pneumonia in
older adults?
A. Increased elastic recoil of the lungs
B. Increased diameter of the bronchioles
C. Decreased cough reflex and ciliary action
,D. Decreased residual volume
Correct Answer: C
Explanation: As people age, the effectiveness of the cough reflex and the action of cilia in
the respiratory tract decrease. This reduction makes it more difficult for older adults to
clear secretions and foreign particles from their airways. Consequently, this change
significantly increases the risk of developing respiratory infections like pneumonia.
3. An older client complains of seeing ‘halos’ around lights and experiencing blurred vision.
Which eye condition is most likely responsible?
A. Cataracts
B. Glaucoma
C. Macular Degeneration
D. Presbyopia
Correct Answer: B
Explanation: Glaucoma, particularly narrow-angle or acute glaucoma, is often associated
with the perception of halos around lights due to increased intraocular pressure. This
condition can lead to optic nerve damage and permanent vision loss if not treated
promptly. It is essential for the nurse to facilitate an immediate ophthalmology referral for
diagnostic testing.
, 4. When educating an older adult about skin integrity, which factor should the nurse
emphasize as the primary cause of pressure ulcers?
A. Prolonged pressure on bony prominences
B. Inadequate intake of Vitamin C
C. Decreased subcutaneous fat
D. Thinning of the epidermal layer
Correct Answer: A
Explanation: The primary cause of pressure ulcers is prolonged, unrelieved pressure on
tissues overlying bony prominences, which leads to ischemia. While thinning skin and
nutritional deficits are contributing factors, the mechanical force of pressure is the most
direct cause. Nursing interventions should focus on frequent repositioning and the use of
pressure-relieving surfaces.
5. A nurse is caring for an older adult with urinary incontinence. Which intervention should
the nurse implement first?
A. Implement a bladder-training schedule
B. Limit fluid intake to 1000 mL per day
C. Insert an indwelling urinary catheter
D. Administer anticholinergic medications
Correct Answer: A
Nursing Q&A with Rationale | Fortis College
1. A nurse is assessing an older adult client who has a sudden onset of confusion and is
wandering the halls. Which condition should the nurse suspect first?
A. Dementia
B. Age-related memory loss
C. Depression
D. Delirium
Correct Answer: D
Explanation: Delirium is characterized by an acute and sudden onset of confusion, which
is often reversible if the underlying cause is addressed. In contrast, dementia is a slow,
progressive decline in cognitive function that is generally irreversible. The nurse must
prioritize identifying delirium because it may indicate an underlying infection, such as a
UTI, or a medication reaction.
2. Which age-related change in the respiratory system increases the risk for pneumonia in
older adults?
A. Increased elastic recoil of the lungs
B. Increased diameter of the bronchioles
C. Decreased cough reflex and ciliary action
,D. Decreased residual volume
Correct Answer: C
Explanation: As people age, the effectiveness of the cough reflex and the action of cilia in
the respiratory tract decrease. This reduction makes it more difficult for older adults to
clear secretions and foreign particles from their airways. Consequently, this change
significantly increases the risk of developing respiratory infections like pneumonia.
3. An older client complains of seeing ‘halos’ around lights and experiencing blurred vision.
Which eye condition is most likely responsible?
A. Cataracts
B. Glaucoma
C. Macular Degeneration
D. Presbyopia
Correct Answer: B
Explanation: Glaucoma, particularly narrow-angle or acute glaucoma, is often associated
with the perception of halos around lights due to increased intraocular pressure. This
condition can lead to optic nerve damage and permanent vision loss if not treated
promptly. It is essential for the nurse to facilitate an immediate ophthalmology referral for
diagnostic testing.
, 4. When educating an older adult about skin integrity, which factor should the nurse
emphasize as the primary cause of pressure ulcers?
A. Prolonged pressure on bony prominences
B. Inadequate intake of Vitamin C
C. Decreased subcutaneous fat
D. Thinning of the epidermal layer
Correct Answer: A
Explanation: The primary cause of pressure ulcers is prolonged, unrelieved pressure on
tissues overlying bony prominences, which leads to ischemia. While thinning skin and
nutritional deficits are contributing factors, the mechanical force of pressure is the most
direct cause. Nursing interventions should focus on frequent repositioning and the use of
pressure-relieving surfaces.
5. A nurse is caring for an older adult with urinary incontinence. Which intervention should
the nurse implement first?
A. Implement a bladder-training schedule
B. Limit fluid intake to 1000 mL per day
C. Insert an indwelling urinary catheter
D. Administer anticholinergic medications
Correct Answer: A
