Sas 14 19 Coa

SHEENA PILAPIL CERELIJIA
3 BSN A6
Care of Older Adult
SAS 14
1. Answer: B. Verbally acknowledge the pain
Rationale: Acknowledging emotions or empathic listening needs to occur as
your client shares the direct experience of feeling emotion in the body.
2. Answer: A. Promote safe and sensible exercise programs
Rationale: Promoting safe and sensible exercise programs prevents injury to
the patient.
3. Answer: D. Encourage regular exercise.
Rationale: To help prevent osteoporosis, an increase dietary calcium intake
would be preferable. We must not promote sedentary lifestyle thus
encouraging regular exercise would be beneficial.
4. Answer: C. Weight-bearing exercise reduces the loss of bone mass
Rationale: Weight-bearing exercises helps to fight off degeneration of bone
5. Answer: A. Arthritis
Rationale: Arthritis is the swelling and tenderness of one or more of your
joints. The main symptoms of arthritis are joint pain and stiffness, which
typically worsen with age. The most common types of arthritis are
osteoarthritis and rheumatoid arthritis
6. Answer: B. Exercise
Rationale: Exercising an arthritic knee can be a great way to relieve your pain
and discomfort.
7. Answer: A. Stature, posture, and function
Rationale: As we age, bones become more brittle and may break more easily.
Overall height decreases, mainly because the trunk and spine shorten thus
affecting stature, posture and function.
8. Answer: B.
Rationale: Changes in the muscles, joints, and bones affect the posture and
walk, and lead to weakness and slowed movement. People lose bone mass or
density as they age, especially women after menopause. The bones lose
calcium and other minerals. The spine is made up of bones called vertebrae
9. Answer: B. Crepitation, the sound of osteoarthritis in the knee joint
Rationale: Crepitus, occasionally known as crepitation, describes any
crushing, screeching, cracking, grating, crunching or popping that can be
sensed while moving a joint
10.Answer: C. A mild exercise program including walking
Rationale: Exercising an arthritic knee can be a great way to relieve your pain
and discomfort.
SAS 15
1. Answer: C. Meats and dairy products
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Rationale: Good sources of vitamin B12 include meats and dairy
products.Option A: Whole grains are a good source of thiamine.Option B:
Green leafy vegetables are good sources of niacin, folate, and carotenoids
(precursors of vitamin A). Option D: Broccoli and Brussels sprouts are good
sources of ascorbic acid (vitamin C).
2. Answer: C. Drinks coffee or tea with meals
Rationale: Coffee and tea increase gastrointestinal motility and inhibit the
absorption of nonheme iron.Option A: Clients are instructed to add dried fruits
to dishes at every meal because dried fruits are a nonheme or nonanimal iron
source. Option B: Cooking in iron cookware, especially acid-based foods such
as tomatoes, adds iron to the diet.Option D: Clients are instructed to add a
rich supply of vitamin C to every meal because the absorption of iron is
increased when food with vitamin C or ascorbic acid is consumed
3. Answer: A. “What activities were you able to do 6 months ago compared with
the present?” It is difficult to determine activity intolerance without
objectively comparing activities from one time frame to another. Because iron
deficiency anemia can occur gradually and individual endurance varies, the
nurse can best assess the client’s activity tolerance by asking the client to
compare activities 6 months ago and at the present.Option B: Asking a client
how long a problem has existed is a very open-ended question that allows for
too much subjectivity for any definition of the client’s activity tolerance. Also,
the client may not even identify that a “problem” exists.Option C: Asking the
client whether he is staying abreast of usual activities addresses whether the
tasks were completed, not the tolerance of the client while the tasks were
being completed or the resulting condition of the client after the tasks were
completed. Asking the client if he is more tired now than usual does not
address his activity tolerance.Option D: Tiredness is a subjective evaluation
and again can be distorted by factors such as the gradual onset of the
anemia or the endurance of the individual.
4. Answer: B. Respiratory rate decreased by 5 breaths/minute The normal
physiologic response to activity is an increased metabolic rate over the
resting basal rate. The decrease in respiratory rate indicates that the client is
not strong enough to complete the mechanical cycle of respiration needed for
gas exchange. Option A: The post activity pulse is expected to increase
immediately after activity but by no more than 50 bpm if it is strenuous
activity. Option C: The diastolic blood pressure is expected to rise but by no
more than 15 mm Hg. Option D: The pulse returns to within 6 bpm of the
resting pulse after 3 minutes of rest.
5. Answer: B. Brown rice
Rationale: Brown rice is a source of iron from plant sources (nonheme iron).
Other sources of non heme iron are wholegrain cereals and breads, dark
green vegetables, legumes, nuts, dried fruits (apricots, raisins, dates),
oatmeal, and sweet potatoes. Option A: Egg yolks have iron but it is not as
well absorbed as iron from other sources. Option C: Vegetables are a good
source of vitamins that may facilitate iron absorption. Option D: Tea contains
tannin, which combines with nonheme iron, preventing its absorption.
6. Answer: A. Erythrocytes
Rationale: Anemia is defined as a decreased number of erythrocytes (red
blood cells).Option B: Granulocytopenia is a decreased number of
granulocytes (a type of white blood cells).Option C: Leukopenia is a
decreased number of leukocytes (white blood cells).Option D:
Thrombocytopenia is a decreased number of platelets.
7. Answer: D. Red blood cells that are microcytic and hypochromic
Rationale: The results of a CBC with iron deficiency anemia will show
decreased hemoglobin levels and microcytic and hypochromic red blood cells.
The red blood cell count is decreased. The reticulocyte count is usually
normal or slightly elevated.
8. Answer: A. T cells becoming less responsive to antigens.
Rationale: There is an increasing focus on the role of T cells during ageing
because of their impact on the overall immune responses. A steady decline in
the production of fresh naïve T cells, more restricted T cell receptor (TCR)
repertoire and weak activation of T cells are some of the effects of ageing.
9. Answer: C. becomes less effective at combating disease.
Rationale: The immune system makes cells and antibodies that destroy these
harmful substances. As you grow older, your immune system does not work
as well. The following immune system changes may occur: The immune
system becomes slower to respond
10.Answer: D. immune surveillance declines with age.
Rationale: Cancers are being frequently diagnosed in the elderly.
Immunosenescence which refers to the gradual deterioration of the immune
system brought on by natural age advancement, has been the key cross
center in the increasing frequency and severity of cancer, aging and
immunity
SAS 16
1. Answer: D. Hyperparathyroidism Hyperparathyroidism is most common in
older women and is characterized by bone pain and weakness from excess
parathyroid hormone (PTH). Clients also exhibit hypercalciuria-causing
polyuria. While clients with diabetes mellitus and diabetes insipidus also have
polyuria, they don’t have bone pain and increased sleeping.
Hypoparathyroidism is characterized by urinary frequency rather than
polyuria.
2. Answer: D. Consuming a low-carbohydrate, high protein diet and avoiding
fasting. To control hypoglycemic episodes, the nurse should instruct the client
to consume a low-carbohydrate, high protein diet, avoid fasting, and avoid
simple sugars. Increasing saturated fat intake and increasing vitamin
supplementation wouldn’t help control hypoglycemia
3. Answer: D. All of the above.
Rationale: According to NIA, women who smokes may go through menopause
about 1-1/2 years earlier than women who don't smoke.
4. Answer: D. B and C.
Rationale: Bones thin when ovaries stop producing estrogen. Cholesterol
levels can rise, which threatens heart health
5. Answer: B. Estrogen and progesterone. Used for a short time, hormone
therapy can help relieve symptoms of menopause. Long-term use, though,
raises the risk for breast cancer, heart attack, and stroke.
6. Answer: A, C, and D
Rationale: These symptoms are often reported by clients with insomnia.
Clients report nonrestorative sleep. Arising once at night to urinate (nocturia)
is not in and of itself insomnia.
7. Answer: D. Encourage quiet activities prior to bed time.
Rationale: The amount of sleep needed during the school years is
individualized because of varying states of activities and levels of health. A 6-
year old averages 11-12 hours of sleep nightly, whereas an 11-year old
sleeps about 9-10 hours. The 6- or 7-year old can usually be persuaded to go
to bed by encouraging quiet activities.
8. Answer: C, E, and F
Rationale: Lying in bed when one is unable to sleep increases frustration and
anxiety which further impede sleep; other activities, such as reading or
watching television, should not be conducted in bed. Counting backwards
requires minimal concentration but it is enough to interfere with thoughts
that distract a person from falling asleep
9. Answer: B. Melatonin
Rationale: Melatonin is a natural hormone that induces sleep. All the others
are medications classified as stimulants.
10.Answer: D. None of the above
Rationale: A patient with hyperthyroidism will present with the opposites of
the listed symptoms. Too much thyroxine is produced, causing the body’s
metabolism to rise. This leads to an intolerance to heat, a decrease in weight
gain, increased bowel movements, a rapid heart rate, and warm, clammy
skin.
SAS 17
1. Answer: B. The client is free from esophagitis and achalasia.
Rationale:Dysphagia may be the reason why a client with esophagitis or
achalasia seeks treatment. Dysphagia isn’t associated with rectal tenesmus,
duodenal inflammation, or abnormal gastric structures.
2. Answer: B. Elevated serum lipase
Rationale: Elevation of serum lipase is the most reliable indicator of
pancreatitis because this enzyme is produced solely by the pancreas. A
client’s BUN is typically elevated in relation to renal dysfunction; the AST, in
relation to liver dysfunction; and LD, in relation to damaged cardiac muscle.
3. Answer: D. alcohol abuse and smoking.
Rationale: Risk factors for peptic (gastric and duodenal) ulcers include alcohol
abuse, smoking, and stress. A sedentary lifestyle and a history of
hemorrhoids aren’t risk factors for peptic ulcers. Chronic renal failure, not
acute renal failure, is associated with duodenal ulcers.
4. Answer: D. “Be sure to get regular exercise.”
Rationale: Exercise helps prevent constipation. Fluids and dietary fiber
promote normal bowel function. The client should drink eight to ten glasses of
fluid each day. Although adding bran to cereal helps prevent constipation by
increasing dietary fiber, the client should start with a small amount and
gradually increase the amount as tolerated to a maximum of 2 grams a day.
5. Answer: C. The client exhibits firm skin turgor
Rationale: A client with diarrhea has a nursing diagnosis of Deficient fluid
volume related to excessive fluid loss in the stool. Expected outcomes include
firm skin turgor, moist mucous membranes, and urine output of at least 30
ml/hr. The client also has a nursing diagnosis of diarrhea, with expected
outcomes of passage of formed stools at regular intervals and a decrease in
stool frequency and liquidity. The client is at risk for impaired skin integrity
related to irritation from diarrhea; expected outcomes for this diagnosis
include absence of erythema in perianal skin and mucous membranes and
absence of perianal tenderness or burning.
6. Answer: A. Increase fiber intake
Rationale: A person can relieve this discomfort of constipation by increasing
fiber intake, increasing their fluid intake, exercising, and making dietary
changes.
7. Answer: D. Suggesting to the patient's family members that someone join the
patient for meals.
Rationale: For many people, eating is associated with family, friends,
conversation, celebrating, caring, religious events and cultural tradition.
Families and patients see meals as a time to provide nutrition, love and
caring, as well as a time to socialize.
8. Answer: D. Observing conditions under which the patient experiences
difficulty swallowing
Rationale: Noting the factors that may contribute to difficulty swallowing is
best to know the cause of dysphagia.
9. Answer: A. Pain control
Rationale: Severe pain is often the major symptom in patients with chronic
pancreatitis. Management of pancreatitis is directed towards relieving
symptoms and preventing or treating complications thus pain management
should be prioritized.
SAS 18
1. Answer: B. “It burns when I pee.”
Rationale: A common symptom of a UTI is dysuria. A patient with a UTI often
reports frequent voiding of small amounts and the urgency to void. Option D:
Urine that smells sweet is often associated with diabetic ketoacidosis.
2. Answer: C. A 50 y.o. postmenopausal woman
Rationale: Women are more prone to UTI’s after menopause due to reduced
estrogen levels. Reduced estrogen levels lead to reduced levels of vaginal
Lactobacilli bacteria, which protect against infection
3. Answer: B. Urinary incontinence isn’t a disease.
Rationale: Urinary incontinence isn’t a normal part of aging nor is it a disease.
It may be caused by confusion, dehydration, fecal impaction, restricted
mobility, or other causes. Certain medications, including diuretics, hypnotics,
sedatives, anticholinergics, and antihypertensives, may trigger urinary
incontinence. Most clients with urinary incontinence can be treated; some can
be cured.
4. Answer: C. Activities that increase abdominal pressure
Rationale: Stress incontinence is the involuntary loss of urine during such
activities as coughing, sneezing, laughing, or physical exertion. These
activities increase abdominal and detrusor pressure.
 Option A: A strong urge to urinate is associated with urge incontinence.
 Option B: Overdistention of the bladder can lead to overflow incontinence.
 Option D: Obstruction of the urethra can lead to urinary retention.
5. Answer: B. Avoid caffeine and alcohol
Rationale: Client’s with stress incontinence are encouraged to avoid
substances such as caffeine and alcohol which are bladder irritants.
 Option A: Emotional stressors do not cause stress incontinence. It is caused
most commonly be relaxed pelvic musculature.
 Option C: Wearing Girdles is not contraindicated.
 Option D: Although clients may be inclined to limit physical exertion to avoid
incontinence episodes; they should be encouraged to seek treatment instead
of limiting their activities.
6. Answer: C. Involuntary urination with minimal warning
Rationale: A characteristic of urge incontinence is involuntary urination with
little or no warning. Option A: The inability to empty the bladder is urinary
retention. Option B: Loss of urine when coughing occurs with stress
incontinence. Option D: Frequent dribbling of urine is common in male clients
after some types of prostate surgery or may occur in women after the
development of
 Option A: The inability to empty the bladder is urinary retention.
 Option B: Loss of urine when coughing occurs with stress incontinence.
 Option D: Frequent dribbling of urine is common in male clients after some
types of prostate surgery or may occur in women after the development of a
vesicovaginal or ureterovaginal fistula
7. Answer: B. Pain with urination.
Rationale: Pain with urination is a common symptom of a lower UTI. Urine
output does not decrease, but frequency may be experienced. Flank pain and
nausea are associated with an upper UTI.
8. Answer: A. Teach the patient how to perform Kegel exercises.
Rationale: Exercises to strengthen the pelvic floor muscles will help reduce
stress incontinence. The Credé maneuver is used to help empty the bladder
for patients with overflow incontinence. Placing the commode close to the
bedside and assisting the patient to the bathroom are helpful for functional
incontinence.
9. Answer: C. Assist the patient to the bathroom q2hr
Rationale: In older or confused patients, incontinence may be avoided by
using scheduled toileting times. Indwelling catheters increase the risk for UTI.
Incontinent pads increase the risk for skin breakdown. Restricting fluids is not
appropriate in a patient with dehydration.
10.Answer: A. Place a bedside commode near the patient's bed.
Rationale: Environmental changes can make it easier for the patient to avoid
incontinence for patients with urinary incontinence. Checking for residual
urine and performing the Credé maneuver are interventions for overflow
incontinence. Kegel exercises are useful for stress incontinence.
SAS 19
1. Answer: B. "It will be important to keep that area clean and dry."
Rationale: After menopause, the vagina becomes dry, thinner, and
smoother. This atrophy places the vagina at risk for infection. The
combination of this fact with the presence of urine places the woman at
higher risk for infection. The nurse should teach the client good hygienic
practices to reduce the likelihood of infection. Education about
briefs/undergarments may be needed, and a referral to an incontinence
clinic would be very helpful, but neither takes priority over preventing
infection. Stating that incontinence is common is not a helpful strategy
2. Answer: B. "His testosterone levels will decrease only slightly until he is
quite old." Rationale: Men experience a gradual but slight decrease in
testosterone until they are in their 80s. Low testosterone levels do affect
sexual performance. Stating that the woman is lucky does not give
accurate information about sexual functioning.
3. Answer: D. Returning periods
Rationale: All client reports require some action by the nurse, but the
priority would be to further investigate and report the "returning periods."
In a postmenopausal woman, this can signal cancer.
4. Answer: B. "Estrogen deficiency causes the vaginal tissues to become
drier and thinner."
Rationale: Estrogen deprivation, which occurs as a result of menopause,
decreases the moisture-secreting capacity of vaginal cells, thereby
making the area drier. The vaginal tissues also become thinner and the
rugae become smoother. Reduced frequency of intercourse will not dry out
the vaginal tissues. Drinking excess water will not make the tissues less
dry. A water-soluble lubricant may make intercourse less difficult.
However, the client is asking what causes the problem.
5. Answer: B. "Make sure you take a calcium supplement every day."
Rationale: Calcium is important throughout life, but for the
postmenopausal woman, it is vital to help prevent osteoporosis. Folic acid
and B and C vitamins are very important for the woman taking oral
contraceptives. Iron might be important for this client for other reasons
but is especially important for women with heavy menstrual bleeding.
6. Answer: C. Document the observation and continue the assessment.
Rationale: As the male client ages, the scrotum loses rugae and becomes
increasingly pendulous. This is a normal assessment finding. No further
action is needed.
7. Answer: D. Pap smear annually
Rationale: Persons on HRT should have an annual Pap smear and
mammogram.
8. Answer: A. "Vaseline was good enough for my mother. It's good enough for
me." Rationale: Vaseline and petroleum products should be avoided
because they do nothing for long-term dryness.
9. Answer: A. diabetes and was very
Rationale: Diabetic men are at risk for erectile dysfunction even at young
ages.
10.Answer: A, B, C, D
Rationale: The response time is not decreased. All of the other options are
age-related changes in the female that affect satisfactory intercourse.
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