During an assessment of an older adult, the nurse should expect to which finding as a normal physiologic change associated with the aging process?
Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities
Progressive atrophy of the intramuscular calf veins, causing venous insufficiency
Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure
Hormonal changes causing vasodilation and a resulting drop in blood pressure
The Correct Answer is C
A. Narrowing of the inferior vena cava, causing low blood flow and increases in venous pressure resulting in varicosities. The inferior vena cava does not significantly narrow with aging. Varicosities are more commonly due to valve insufficiency in the veins rather than vena cava narrowing.
B. Progressive atrophy of the intramuscular calf veins, causing venous insufficiency. Venous insufficiency is common in older adults, but it is primarily due to valve dysfunction and prolonged venous pressure rather than atrophy of calf veins.
C. Peripheral blood vessels growing more rigid with age, producing a rise in systolic blood pressure. Aging leads to arteriosclerosis, where blood vessels become stiffer, reducing their ability to expand and contract, which contributes to increased systolic blood pressure. This is a well-documented normal physiologic change in older adults.
D. Hormonal changes causing vasodilation and a resulting drop in blood pressure. While some hormonal changes occur with aging, they do not typically lead to significant vasodilation. In fact, the loss of vascular elasticity and autonomic dysfunction can contribute to postural hypotension, but not a generalized drop in blood pressure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Regular use of narcotic analgesics leads to drug addiction. While opioids can cause dependence with prolonged use, addiction is characterized by compulsive drug-seeking behavior. When used appropriately for pain management, addiction risk is low.
B. Amount of pain is reflective of actual tissue damage. Pain perception varies widely among individuals. Some may experience severe pain with minimal tissue damage, while others may have little pain despite significant injury.
C. Patients are the best judges of their pain. Pain is subjective, and only the patient can accurately describe its intensity and quality. Nurses should trust the patient's self-report rather than rely solely on appearance or behavior.
D. Chronic pain is psychological in nature. Chronic pain often has a physiological basis, such as nerve damage or inflammation, though psychological factors can influence pain perception. It is not purely psychological.
Correct Answer is B
Explanation
A. Take the temperature for 6-8 minutes. Modern digital thermometers provide accurate readings within seconds to a minute, making such a long duration unnecessary.
B. Wear gloves throughout the procedure. Gloves must be worn to maintain infection control and hygiene, as rectal temperature measurement involves contact with mucous membranes and potential exposure to bodily fluids.
C. Place the patient in the prone position. The left lateral (Sims') position is the preferred position for rectal temperature measurement, as it provides better access and comfort.
D. Insert the thermometer 2.5 inches into the patient's anus. For adults, the correct insertion depth is 1.5 inches (3-4 cm), while for infants, it is only 0.5 inches (1.3 cm) to prevent injury.
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