A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?

Difficulty hearing low pitch

Increased taste discrimination

Impaired night vision

Heightened sense of smell

Answer and Explanation

The Correct Answer is C

Choice A reason: Difficulty hearing low pitch is not a typical age-related change. Presbycusis, common in older adults, primarily affects high-frequency hearing, making it hard to discern high-pitched sounds like consonants. Low-pitch hearing is generally preserved. This choice does not reflect a normal sensory change, as it misaligns with the expected auditory decline in aging.

Choice B reason: Increased taste discrimination is incorrect, as aging typically reduces taste sensitivity due to fewer taste buds and altered salivary function. Older adults often report diminished flavor perception, impacting appetite. This choice is not a normal sensory change, as it contradicts the expected decline in gustatory function associated with aging.

Choice C reason: Impaired night vision is a normal age-related change due to presbyopia and reduced pupil dilation, decreasing retinal light sensitivity. Older adults struggle with low-light conditions, increasing fall risk. This change, linked to lens yellowing and slower dark adaptation, is expected and aligns with typical visual decline in aging populations.

Choice D reason: Heightened sense of smell is not typical in older adults. Aging reduces olfactory sensitivity due to fewer olfactory neurons and mucosal changes, impairing smell detection. This can affect safety, like detecting gas leaks. This choice is incorrect, as it opposes the normal decline in olfactory function seen in aging.

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Correct Answer is D

Explanation

Choice A reason: The ego defense model, rooted in psychoanalytic theory, describes psychological mechanisms (e.g., denial) to cope with stress, not a normal line of defense for health. It focuses on mental protection, not holistic wellness, making it unrelated to the nursing theory described with a line of defense.

Choice B reason: The immunity model is not a recognized nursing theory. While immunity relates to biological defense, it does not encompass a “normal line of defense” for person, family, or community health. This choice is incorrect, as it lacks the holistic framework described in the question.

Choice C reason: Pender’s Health Promotion Model focuses on behaviors to enhance health but does not use the concept of a normal line of defense. It emphasizes individual motivation and barriers, not systemic protection against stressors, making it an incorrect match for the described nursing theory.

Choice D reason: The Neuman Systems Model views individuals, families, or communities as systems with a normal line of defense, a protective barrier against stressors. This holistic theory emphasizes maintaining stability through primary, secondary, and tertiary prevention, aligning with the described concept, making it the correct theory.

A. Narcolepsy B. Sleep deprivation C. Insomnia D. Obstructive sleep apnea

Correct Answer is D

Explanation

Choice A reason: Narcolepsy causes sudden sleep attacks and cataplexy but does not typically disrupt breathing patterns during sleep. It affects sleep-wake regulation, not airway mechanics. This condition is unlikely to cause ineffective breathing, as it lacks the respiratory obstruction linked to the nursing diagnosis.

Choice B reason: Sleep deprivation results from insufficient sleep, leading to fatigue and cognitive issues, but it does not directly cause ineffective breathing patterns. It may exacerbate other conditions, but without airway obstruction, it is not the primary cause of the respiratory diagnosis, making this choice incorrect.

Choice C reason: Insomnia involves difficulty falling or staying asleep, causing fatigue and irritability, but it does not typically affect breathing mechanics. It lacks the airway obstruction or hypoventilation associated with ineffective breathing patterns, making it an unlikely cause for the nursing diagnosis.

Choice D reason: Obstructive sleep apnea causes repeated airway collapse during sleep, leading to hypopnea, apnea, and ineffective breathing patterns. This disrupts oxygenation and ventilation, aligning with the nursing diagnosis. The nurse likely identified symptoms like snoring or pauses in breathing, making this the correct condition to monitor.

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A nurse is caring for an older adult. Which sensory change will the nurse identify as normal during the assessment?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the staff about a nursing theory that views a person, family, or community developing a normal line of defense. Which theory is the nurse describing?

Correct Answer is D

Explanation

The nurse adds a nursing diagnosis of Ineffective Breathing Pattern to a patient’s care plan. Which sleep condition likely caused the nurse to assign this nursing diagnosis?

Correct Answer is D

Explanation

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