ch 32: geriatric

Which question asked by the nurse is appropriate when assessing instrumental activities of daily living (IADLs)? "Do you need help getting to the bathroom?" "Do you need getting up from the chair?" "Do you need assistance to bathe yourself?" "Are you able to prepare meals for yourself?"

"Are you able to prepare meals for yourself?" Instrumental activities of daily living include use of the telephone, shopping, food preparation, housekeeping, laundry, financial management, and use of transportation. Activities of daily living include bathing, grooming and dressing, toileting, continence, transferring, and feeding.

The nurse is reviewing the results of laboratory blood tests with the older adult. The client asks, "Why is my creatinine elevated?" Which is the best response by the nurse? "As a person gets older, the kidneys do not work as well in removing waste materials." "The kidneys filter waste materials at an increased rate as a person get older." "Creatinine is an indicator of how well the kidneys are functioning in removing wastes." "An elevated creatinine suggests increased reabsorption of this substance by the kidneys."

"As a person gets older, the kidneys do not work as well in removing waste materials." The best response by the nurse is, "As a person gets older, the kidneys do not work as well in removing waste materials." The size and function of the kidneys decrease with age. Consequently, the kidneys do not work as well in removing waste materials. The glomerular filtration rate is decreased and is reflected in a decrease in urinary creatinine clearance and increased serum creatinine. While the response, "Creatinine is an indicator of how well the kidneys are functioning in removing wastes." is correct, it does not explain to the client why the level may be elevated.

The nurse is assessing the older adult for depression. The older adult scores 10 on the short-form of the Geriatric Depression Scale. Which is the best question for the nurse to ask first? "Do you feel sad, hopeless, and powerless every day?" "Do you have any thoughts of wanting to harm or kill yourself?" "Do you ever feel like life is mentally too much to handle?" "Do you struggle with completing activities of daily living?"

"Do you have any thoughts of wanting to harm or kill yourself?" A score of 10 on the short-form of the Geriatric Depression Scale indicates depression. The priority for the nurse would be to conduct a suicide assessment. The best question for the nurse to ask first is, "Do you have any thoughts of wanting to harm or kill yourself?" Risk factors for suicide include depression and other mental health disorders, physical illness, alcohol abuse, lack of a spouse or social support, and recent life events and losses. The GDS includes questions regarding feelings of depression include sadness, hopelessness, and powerlessness. So, it would be redundant of the nurse to ask about these symptoms again. Individuals experiencing depression may have difficult performing activities of daily living due to lack of interest or motivation and may feel mentally overwhelmed with simple or everyday issues.

An older adult client is being discharged home after being admitted with a large bowel obstruction. What education should the nurse provide to the client to prevent future gastrointestinal problems such as constipation? Select all that apply. "Eat a low-residue diet." "Avoid decaffeinated beverages." "Drink plenty of water throughout the day." "Try to eat foods high in fiber." "Make sure you stay active during the day."

"Drink plenty of water throughout the day." "Try to eat foods high in fiber." "Make sure you stay active during the day." Peristalsis decreases as we age due to decreased physical exercise, decreased fluid intake (or use of diuretics) and decreased intake of fiber (due to poor dentition making it difficult to eat fresh fruits and vegetables). In order to prevent gastrointestinal problems associated with decreased peristalsis, such as constipation and obstructions, the nurse should instruct the client to drink plenty of decaffeinated fluids (such as water so the stool does not become hard in the gastrointestinal tract) and eat a diet high in fiber. (Fiber will provide the bulk of the stool; if raw fruits and vegetables cannot be tolerated, then over-the-counter products should be suggested.) A low-residue diet will not help prevent constipation. The client should not avoid decaffeinated beverages such as water; they should increase their intake of them.

An older client is admitted with a change in mental status, but no other motor deficits are observed. The caregiver tells the nurse that the client seemed okay yesterday but confused today. How should the nurse respond? "It is a normal part of the aging process." "It is common for older clients to have mental status changes when they have an infection." "The client most likely suffered a stroke." "It is rare for people to have such a sudden change in mental status, no matter what the age."

"It is common for older clients to have mental status changes when they have an infection." Disease states often present differently in older adults, for example, an infection may cause changes in mental status. It is not rare, especially in older adults, to have a change in mental status due to infection, oxygenation, or medications. Because the client does not have any motor deficits, it is unlikely the client had a stroke. Sudden changes in mental status are not a normal part of the aging process.

An older client asks why the leg muscles have become flabby over the last few years. What should the nurse respond to this client? "It means that you have a vitamin deficiency." "It occurs with aging but is encouraged by sitting too much." "There is nothing that can be done to avoid it." "It happens because of not enough of protein in the diet."

"It occurs with aging but is encouraged by sitting too much." Sarcopenia is the loss of lean body mass and strength with aging. The causes of muscle loss are multifactorial, including inflammatory and endocrine changes as well as sedentary lifestyle. The loss of muscle mass is not because of a vitamin deficiency or an inadequate intake of protein. There is substantial evidence that strength training in older adults can slow or reverse this process.

Which statement by an older adult alerts the nurse that health teaching was ineffective? "It is not normal for my toenails to be yellow and thick." "My hair will get thinner as I get older." "Getting shorter as I get older is normal." "Leaking urine is a normal part of aging."

"Leaking urine is a normal part of aging." Urinary incontinence is not a normal part of aging. Thinning of the hair and getting shorter as one ages are normal changes with aging. Thick yellow toenails are characteristic of a fungal infection, onychomycosis, which is not a normal change of aging.

A client calls the clinic and asks to speak to the nurse. The client tells the nurse that she has just started taking morphine for advanced cancer, is constipated, and wonders what is causing this. What would be the nurse's best response? "People can become constipated when they eat a lot of fiber." "People can become constipated when they are more active than usual." "People can become constipated for no reason at all." "People can become constipated when taking certain medications."

"People can become constipated when taking certain medications." Constipation is usually related to multiple medications, inactivity, and/or low fluid/bulk intake. Eating a lot of fiber does not cause constipation. There is generally a reason for constipation. Active people generally do not suffer from constipation.

An older female client who is hospitalized requires frequent linen changes due to incontinence when they cough or sneeze. How should the nurse document the client's incontinence? "The client requires frequent linen changes due to stress incontinence." "Due to incontinence, the client is unable to make it to the bathroom." "The client has overflow incontinence requiring frequent linen changes." "The client has functional incontinence requiring frequent linen changes."

"The client requires frequent linen changes due to stress incontinence." The client is exhibiting signs of stress incontinence, which is the involuntary loss of urine during activities, such as coughing, sneezing, or physical activity. Stress incontinence is caused by a weakening of the pelvic floor muscles, which frequently occurs after childbirth. Functional incontinence occurs when a client lacks the cognitive ability or impairment in mobility to get to the bathroom to void. Documenting that "due to incontinence, the client is unable to make it to the bathroom" is not accurate documentation of the situation. Overflow incontinence occurs either with narrowing of the urethra such as in prostate enlargement in men or decreased sensation or urgency to void seen in neuropathy of males and females.

A nurse is working with a client who is considered to be part of the "frail elderly." At which age can is a person typically first considered to be a part of this group? 65 95 85 75

85 The term frail elderly describes the vulnerability of the old-old (generally mid-eighties, nineties, and centenarians) to be in poorer health, to have more chronic disabilities, and to function less independently.

An older client arrives at her primary care provider's office with complaints of irregularly shaped tan, scaly lesions that bleed and are inflamed. The nurse should recognize this condition as which of the following? Petechiae Actinic keratoses Shingles Senile purpura

Actinic keratoses Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed and that form on the outermost layer of the skin after years of exposure to ultraviolet (UV) light, such as sunlight. Senile purpura is a normal finding in skin of an elderly client. Pinpoint-sized, red-purple, nonblanchable petechiae are a common sign of platelet deficiency. Shingles are vesicles due to herpes zoster infection.

An elderly client is complaining of weakness and fatigue. The nurse suspects the client may be experiencing what? Anemia Depression Signs of cancer Normal aging process

Anemia Anemia must be ruled out when an older client complains of weakness and fatigue. Weakness and fatigue is not part of the normal aging process. Cancer may include many symptoms. A symptom of depression may include fatigue, but not weakness.

An elderly client calls the health care clinic and asks the nurse if it is okay to use an over-the-counter nasal spray to help with sinus congestion. Which question should the nurse ask before assuring the client it is okay to use this medication? Have you ever been tested for diabetes mellitus? Do you get up at night to use the bathroom? Do you have a history of nasal polyps? Are you taking any drugs for high blood pressure?

Are you taking any drugs for high blood pressure? Decongestant medications may increase the blood pressure by vasoconstriction of the blood vessels. These medications should be avoided in people with hypertension or a history of cardiac dysrhythmias. Diabetes mellitus, getting up at night to use the bathroom, and a history of nasal polyps are not pertinent to the use of a decongestant medication.

What does the nurse use to formulate a nursing care plan? Subjective data Assessment data Objective data A preprinted care plan

Assessment data The nurse uses assessment data to formulate a nursing care plan with client outcomes and interventions. The nurse uses both objective and subjective data, but neither is sufficient by itself. The nurse may use a preprinted care plan, but again, this is not the best answer for this question since the plan is based on specialized assessment data.

A nurse assesses an elderly client and determines that the client is at risk for falls. Which interventions are appropriate to reduce the incidence of actual falls the client incurs? Select all that apply. Assist with exercise to strengthen lower extremities Discourage the use of dependence on walkers Remove rugs or other loose carpet Remind the client to ask for assistance Limit the amount of activity

Assist with exercise to strengthen lower extremities Remove rugs or other loose carpet Remind the client to ask for assistance The nurse should focus on removing hazards form the environment such as loose rugs and other obstacles. Remind the client to ask for assistance with ambulation. Exercise may help to strengthen the muscles to increase stability. The use of assistive devices such as canes and walkers may help to reduce the anxiety and fear associated with an unstable gait.

A nurse inspects an elderly client's abdomen and notices the presence of a mass. What is an appropriate action by the nurse in regards to this finding? Ask if the client needs to empty the bladder Measure the mass to determine the diameter Auscultate for the presence of a bruit Palpate the mass to determine if it is solid or fluid filled

Auscultate for the presence of a bruit If a nurse observes a mass in the abdomen, it should be auscultated for the presence of a bruit. A bruit suggests an abdominal aortic aneurysm. If present, the mass should not be palpated because of the risk of rupture. The nurse should rule out the presence of an aneurysm before palpating or measuring the mass. A bladder should not be able to be observed unless there is a great deal of muscle mass lost in the abdomen that would make all the underlying structures prominent.

An elderly male client presents to the health care clinic with reports of urinary frequency, nocturia, and difficulty starting his stream. A nurse knows that the most common cause of these symptoms is what condition? Urinary tract infection Renal insufficiency Sexually transmitted disease Benign prostatic hypertrophy

Benign prostatic hypertrophy Benign prostatic hypertrophy (BPH) is the benign growth of the prostate gland in older males and is very common. Urinary tract infections are often the result of the BPH. Sexually transmitted diseases are not common in the older population but when present are most often accompanied by odor, pain, and discharge. Renal insufficiency manifests as a change in the amount of urine production not necessarily as a change in the ability to urinate.

Which of the following changes in vision is expected with normal aging? Macular degeneration Blurring of near vision Glaucoma Cataract

Blurring of near vision The lens loses elasticity over time as part of normal aging, and the eye is less able to accommodate and focus on near objects. Therefore, older clients are expected to have blurring of near vision. Cataract, glaucoma, and macular degeneration are considered pathological processes.

An elderly client is admitted to the health care facility with an indirect inguinal hernia. Which abnormal data should the nurse expect to find in the client assessment? Masses or bulges in the scrotum Bowel sounds heard over scrotum Pain in the inguinal region Edema of the scrotal sac

Bowel sounds heard over scrotum The client with an indirect inguinal hernia will have bowel sounds heard over the scrotum. Scrotal edema will be present in obstruction of the portal vein and heart failure. Masses or bulges and pain will be present in testicular torsion and in cancer of the prostate gland.

The nurse notes that it takes an older client 45 seconds to complete the "get up and go" test. Which activities of daily living should the nurse plan to assist the client with completing? Select all that apply. Climbing stairs Getting in and out of bed Using the telephone Managing finances Bathing

Climbing stairs Getting in and out of bed Bathing The "get up and go" test is used to evaluate gait. A client who takes more than 30 seconds to complete the test tend to be dependent in some activities of daily living such as bathing, getting in and out of bed, or climbing stairs. The client with an elongated test result should be able to use the telephone or managing finances since these activities do not require mobility to complete.

A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as what abnormal finding? Uterine prolapse Rectocele Cystocele Atrophic vaginitis

Cystocele A bulge that originates from the anterior portion of the vagina is an indication of a cystocele. This occurs due to the relaxation of the pelvic musculature which allows the bladder to protrude into the vaginal wall. A rectocele is present if the bulge is seen in the posterior vaginal wall. Uterine prolapse causes the cervix to protrude through the vagina. Atrophic vaginitis is an inflammation of the vagina due to a thinned endometrium and increased vaginal pH level induced by estrogen deficiency. The earliest symptom is decreased vaginal lubrication.

A nurse recognizes that a sudden change in an elderly client's cognition accompanied by a change in the level of alertness may be an indication of what condition? Delirium Acute pain Infection Depression

Delirium A sudden change in cognition that develops over a short period of time and is characterized by changes in level of alertness, ranging from extreme lethargy to agitation, is called delirium. Acute pain does not often change the person's level of consciousness but does increase risk for falls. Infection may produce confusion but should not alter the level of consciousness. Depression in the elderly is often manifested by physical symptoms as well as cognitive changes.

It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause? Delirium Alzheimer's dementia Meningitis Stroke

Delirium These are not signs of normal aging and seem to be of acute onset. This makes Alzheimer's disease unlikely. Stroke and meningitis could cause these symptoms as well, but the combination of the heat and a recent infection make delirium much more likely. Though she was prescribed an antibiotic, her condition may not have improved because of bacterial resistance, non-compliance due to cost, depression, or even an underlying mild dementia. Dementia should not result in an acute mental status change, although illness may cause a worsening of dementia.

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what? Dementia Malnutrition Depression Decreased mobility

Depression Depression may occur in older adults for various reasons. It is more common in people with multiple chronic health problems and in those who have recently suffered the loss of a spouse, friend, family member, or pet. Decisions about moving out of a family home because of increasing care needs may also lead to depressive symptoms.

An older adult with a history of varicose veins presents with lower extremities that are reddish-brown and edematous. What is the nurse's best action? Place the legs in a dependent position Administer antibiotic therapy immediately Stage the affected area and apply an occlusive dressing Document findings and notify the healthcare provider

Document findings and notify the healthcare provider Instrumental activities of daily living include use of the telephone, shopping, food preparation, housekeeping, laundry, financial management, and use of transportation. Activities of daily living include bathing, grooming and dressing, toileting, continence, transferring, and feeding.

The nurse is assessing an elderly client and finds a suspicious lesion on the client's right forearm. The lesion is asymmetrical, has an irregular border, has color variation, and is approximately 8 mm in diameter. What is an appropriate nursing action for this client? Document findings as a normal age spot Call the physician immediately Document findings and refer the client for follow-up Take no action, because the findings correspond with a normal mole

Document findings and refer the client for follow-up Malignant melanoma is a pigmented macule, papule, nodule, patch, or tumor with the ABCD warning signs: symmetry, order irregularity, color variation, and diameter greater than 6 mm. This form of cancer is highly malignant. The nurse should document any suspicious lesions and refer the client for follow-up.

Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar aspects of her forearms and on her abdomen. She otherwise has no complaints, and her diabetes and hypertension are well managed. Her son from out of state accompanies her today and has recently moved in to help her. What should the nurse suspect? Depression Frequent falls Overuse of aspirin Elder abuse

Elder abuse The differing colors of the bruising indicate that they have occurred at different times and are unlikely to have resulted from a single fall. The location of the bruising on the ulnar aspects of the forearms potentially indicate that she was trying to defend herself and are not typical areas to bruise by a fall. Depression may be evident, but this is more likely to be a result than a cause of her situation today. While nothing is proven, it would be wise to interview her without her son in the room. If in doubt, a social work consult may be helpful to help determine if elder abuse is occurring.

Blood pressure abnormalities found more commonly in Western elderly include which of the following? Isolated elevation of the diastolic BP Elevation of the BP with standing Elevation of the systolic BP Narrow pulse pressure

Elevation of the systolic BP Isolated systolic hypertension is common in the elderly because of stiffening of the large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are often seen with postural changes and can account for falls as well.

The nurse has assessed and informed the healthcare provider of a brown-colored lesion on an older client's left cheek. The lesion is diagnosed as solar lentigines. What is the nurse's best action? Warn the client of the likelihood of metastasis. Prepare the client for a skin biopsy. Encourage the client to wear sunscreen daily. Teach the client how to apply topical chemotherapeutic agents.

Encourage the client to wear sunscreen daily. Sun exposure causes solar lentigines, a benign skin lesion also known as age or liver spots. Usually these lesions are diagnosed by appearance and biopsy is not necessary. Malignant melanomas, not solar lentigines, are known to metastasize. A chemotherapeutic agent is not prescribed for this type of benign lesion.

A 76-year-old female client's blood pressure is 132/76 in a supine position, 128/71 when dangling at the side of her bed, and 105/58 when she is standing. These assessment findings constitute a risk for which of the following health problems? Stroke Delirium Peripheral vascular disease Falls

Falls Orthostatic hypotension, as demonstrated by the woman's positional changes in blood pressure, constitutes an increased risk of falls. It is not linking as closely with risk of CVA, PVD, or delirium.

An older client admits that she has recently begun wetting her pants. On further questioning by the nurse regarding the cause of the incontinence, the client explains, "I move so slowly these days that I can't always make it to a bathroom in time." The nurse recognizes this as which type of incontinence? Stress Overflow Urge Functional

Functional Functional incontinence is the inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition. Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. Stress incontinence involves involuntary loss of urine when coughing, sneezing, or laughing. Overflow incontinence is the condition in which the client has involuntary loss of urine associated with overdistention of the bladder.

A nurse is inspecting an elderly client's head and neck. Which of the following findings should most prompt the nurse to suspect onset of a chronic condition? Reduced range of motion of head and neck Atrophy of face and neck muscles Development of "buffalo hump" at top of cervical vertebrae Involuntary facial or head movements

Involuntary facial or head movements Normal findings with old age include atrophy of the face and neck muscles, reduced range of motion of the head and neck, shortening of the neck due to vertebral degeneration, and development of a buffalo hump at the top of the cervical vertebrae. Involuntary facial or head movements may indicate an extrapyramidal disorder such as Parkinson's disease or side effects of some medications.

Which of the following statements regarding delirium in older adults is most accurate? It has a slow, insidious onset that family and clinicians often overlook. It is associated with a significantly increased risk of suicide. It often manifests in a daily cycle that includes sundowning. It typically develops over a short period measured in days, not weeks or months.

It typically develops over a short period measured in days, not weeks or months. Delirium has an identifiable cause and involves changes in cognition that evolve over a short period. It is not associated with a significantly increased suicide risk. Dementia, not delirium, involves sundowning.

A nurse would like to assess an elderly client's general functional status in performing daily chores. Which of the following should the nurse implement to make this assessment? Get Up and Go test Katz Activities of Daily Living tool Vision testing Activity tolerance testing

Katz Activities of Daily Living tool There are many tools available for measuring ability to perform activities of daily living (ADLs). One commonly used tool, which is thought to be the most appropriate for assessing functional status in older adults, is the Katz Activities of Daily Living, which includes those activities necessary for well-being as an individual in a society. Vision and activity tolerance testing, along with the Get Up and Go test, evaluate specific body regions and systems but not general functional status in performing daily chores.

A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old? Knowing the person's baseline functional status and recognizing deviations from it Knowing the statistical occurrence of the condition among people the same age Knowing the client's mental status Knowing the client's family history

Knowing the person's baseline functional status and recognizing deviations from it Knowing the older person's usual daily pattern and functional level is the best baseline against which to compare assessment data. For example, new onset incontinence for the 92-year-old resident of an assisted-living facility who still drives her own car should not be viewed as a normal consequence of aging. The incontinence could be the result of an infection or worsening heart failure. A more subtle presentation of these same problems could be signaled by complete incontinence in a 92-year-old man with severe cognitive impairment who until very recently had only occasional incontinence. Clearly, the key to recognizing pathology and illness in the very old is in knowing the person's baseline functional status and recognizing a deviation from it. Knowing the statistical occurrence of the condition among people of the same age, the client's family history, and the client's mental status would not be as helpful in identifying pathology in the client as knowing deviations from the client's baseline functional status.

A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum? Standing Prone Lithotomy Left side-lying

Left side-lying The anus and rectum should be assessed with the client in left side-lying position for better accessibility and comfort. The lithotomy position is used for assessment of female genitalia. The standing position is used for assessment of male genitalia. The prone position does not give access to anus and rectum.

An elderly client presents to the emergency department with reports of a productive cough of blood-tinged sputum, fatigue, weight loss, and shortness of breath. The nurse recognizes that these are symptoms associated with which respiratory disease process? Pneumonia Chronic obstructive pulmonary disease (COPD) Lung cancer Tuberculosis (TB)

Lung cancer A recurrent cough, fatigue, weight loss, and shortness of breath are hallmarks of lung cancer. COPD clients do not usually have a blood-tinged cough. Hallmark symptoms of TB include weight loss and night sweats. Pneumonia in the elderly often does not manifest with the normally associated symptoms but rather with increased respiratory rate or other subtle changes.

An elderly client states that the right eye has better eyesight than the left. A nurse recognizes that this may indicate the onset of what eye condition? Macular degeneration Presbyopia Arcus senilis Glaucoma

Macular degeneration Better vision in one eye is a warning sign of macular degeneration, a leading cause of blindness in elderly people. Presbyopia is impaired near vision, which is common as people age. Glaucoma usually occurs in both eyes, but it may involve each eye to a different extent. Most people with glaucoma have no early symptoms or pain. Arcus senilis is a normal condition in the elderly in which a white arc appears around the limbus and has no effect on vision.

Half way through a shift, a nurse reassesses an elderly client who was admitted with uncontrolled hypertension the day before. On reassessment, the nurse has difficulty palpating the client's right pedal pulse, which had been palpable and equal to the left pedal pulse at the start of the shift. What is the priority action of the nurse? Notify the health care provider. Document the findings. Ask the client if their right foot is usually cooler than the left. Reassess the pulse in 4 hours.

Notify the health care provider. Any change in pulses, especially absence of a pulse, needs to be reported to the health care provider immediately. If a pulse is not palpable it means that there is inadequate or no perfusion to that limb, which could lead to tissue necrosis and amputation if perfusion is not restored promptly. The nurse may ask the client about different sensations and temperatures in their feet, but this is not the priority at this time. The nurse should not wait 4 hours to reassess the client's pulse; action needs to be taken promptly to restore perfusion. Even though the nurse would document the findings, this is not the priority action. The best action of the nurse is taking the steps to restore perfusion promptly, for example, by contacting the health care provider immediately.

Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence? Ask the client to bear down Obtain a voiding diary Inspect the vaginal opening Inspect urethral meatus

Obtain a voiding diary The most appropriate method of assessing urinary incontinence in an elderly client is by obtaining a voiding diary. Inspecting the urethral meatus and vaginal opening helps in assessment of external genitalia. Asking the client to bear down helps in assessment of uterine, vaginal, and rectal prolapse.

The nurse is assessing an elderly client that has been hospitalized with weakness. The nurse identifies that what disease is most likely to occur in an elderly hospitalized client? Bleeding Sepsis Pressure ulcers Pneumonia

Pneumonia Pneumonia is the most common cause of infection related deaths in older adults. Sepsis, bleeding and pressure ulcers do occur but are not as common.

On receiving results of some lab work for a client, a nurse learns that the client has a platelet deficiency. Which skin condition related to this finding should the nurse look for in this client? Petechiae Actinic keratoses Shingles Senile purpura

Petechiae Pinpoint-sized, red-purple, nonblanchable petechiae are a common sign of platelet deficiency. Senile purpura is a normal finding in skin of an elderly client. Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed. Shingles are vesicles due to herpes zoster infection.

On receiving results of some lab work for a client, a nurse learns that the client has a platelet deficiency. Which skin condition related to this finding should the nurse look for in this client? Shingles Petechiae Senile purpura Actinic keratoses

Petechiae Pinpoint-sized, red-purple, nonblanchable petechiae are a common sign of platelet deficiency. Senile purpura is a normal finding in skin of an elderly client. Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed. Shingles are vesicles due to herpes zoster infection.

A client is brought to the clinic by his daughter, who tells the nurse that she is concerned because her father appears to be losing weight and she doesn't know why. What would the nurse know is a cause of undernutrition? Acute organ failure Obsessive/compulsive disorder Poor time management Poverty

Poverty Low weight is a key indicator of poor nutrition. Undernutrition is seen with depression, alcoholism, cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pulmonary), medication use, social isolation, and poverty.

The caretaker of an elderly person tells the nurse that she is worried that the client will choke because of swallowing problems secondary to a recent cerebrovascular accident (CVA). What suggestion should the nurse give the caretaker to minimize the risk of aspiration in the client? Offer water with meals to clear the throat Check the mouth frequently for retained food Prepare foods that are pudding consistency or semisolid Keep the client upright for 30 minutes after eating

Prepare foods that are pudding consistency or semisolid The nurse should suggest that the caretaker prepare semisolid foods and fluids of pudding consistency, alternating solid food with thickened foods, and encouraging the client to lean slightly forward and tuck the chin under to prevent gagging. Water and other thin liquids increase the risks of aspiration. Checking the mouth does not help to avoid aspiration. Keeping the client upright will help to prevent acid reflex but not aspiration.

Mrs. Glynn is 90-years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living? Bathing Preparing food Transferring from bed to chair Dressing

Preparing food Instrumental activities of daily living involve higher thought processes such as preparing food. Bathing, dressing, and transferring are considered physical activities of daily living.

Mrs. Glynn is 90-years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living? Bathing Transferring from bed to chair Dressing Preparing food

Preparing food Instrumental activities of daily living involve higher thought processes such as preparing food. Bathing, dressing, and transferring are considered physical activities of daily living.

A 75-year-old client admitted in respiratory failure has been placed on mechanical ventilation. The client develops acute confusion, purulent sputum, low oxygen saturation readings, and dyspnea. What breath sound is the nurse most likely to auscultate on exam? Stridor Rales Pleural friction rub Wheezing

Rales The client is exhibiting signs of ventilator associated pneumonia and is likely to exhibit rales or bronchial breath sounds.

During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process? Bilateral tenderness Macerated skin under the breasts Retraction of the nipples Unilateral nipple discharge

Retraction of the nipples Nipples retract in the elderly client due to loss of musculature. Unlike nipple retraction due to a mass, nipples retracted due to aging can be everted with gentle pressure. Macerated ski under the breasts may be due to perspiration or a fungal infection. Bilateral tenderness may be seen in women on hormone replacement therapy and indicate that the dose needs to be lowered. Nipple discharge is only normal in breast feeding women.

A simple test that a nurse can perform to assess an elderly client's activity tolerance is to ask the client to perform what task while monitoring the heart rate? Swing the arms overhead several times Walk around the room and observe gait Rise from a chair to a standing position Perform 4 to 5 slow, deep knee bends

Rise from a chair to a standing position A nurse should assess a client's activity tolerance by observing the client's ability to move from a sitting to a standing position and assessing the heart rate. Walking and observing the gait monitors a client's balance. The nurse should not ask an elderly client to perform deep knee bends because of the risk for falls. Swinging the arms overhead may also cause dizziness and increase the risk for falls.

An older adult client presents with raised yellow lesions on the face. What does this finding most likely suggest to the nurse? Seborrheic keratoses Cherry angiomas Actinic keratoses Solar lentigines

Seborrheic keratoses Seborrheic keratoses are raised yellowish lesions that feel greasy. This is a benign lesion of aging. Solar lentigines are liver spots. Actinic keratoses are superficial flattened papules covered by a dry scale. Cherry angiomas are reddened areas of the face caused by superficial blood vessels.

During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding? Dermatomycosis Senile purpura Actinic keratoses Shingles

Senile purpura Senile purpura is a normal finding in skin of an elderly client. Actinic keratoses are the proliferative form of skin lesions. Dermatomycosis is the ringworm infection of the skin. Shingles are vesicles due to herpes zoster infection.

A nurse performs a "Get Up and Go" test on an elderly client. On completion of the test, the nurse documents the test score as 5. What is the gait assessment result as per the score? Mildly abnormal Moderately abnormal Severely abnormal Normal

Severely abnormal The client's gait is severely abnormal as per a score of 5. A mildly abnormal gait is scored as 3. A moderately abnormal gait is scored as 4, and normal gait is scored as 1. Elderly clients without impairment in gait or balance can complete the test in 10 seconds. People who take more than 30 seconds to complete the test tend to be dependent in some activities of daily living such as bathing, getting in and out of bed, and climbing stairs.

An elderly client visits her community health clinic with an outbreak of vesicles on her skin. She tests positive for the herpes zoster virus. The nurse should recognize this condition as which of the following? Senile purpura Petechiae Actinic keratoses Shingles

Shingles Shingles are vesicles due to herpes zoster infection. Senile purpura is a normal finding in skin of an elderly client. Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed. Pinpoint-sized, red-purple, nonblanchable petechiae are a common sign of platelet deficiency.

When using the Romberg test of cerebellar function in an older client, which of the following findings is expected? Inability to sustain balance with eyes open Moderate sway with eyes open Slight sway with eyes closed Inability to sustain balance with eyes closed

Slight sway with eyes closed Increased sway in the Romberg test from diminished vibratory and position sense in the lower extremities is an expected finding among older clients. Sway with the eyes open or any inability to sustain balance would be considered pathological.

A nurse notes the presence of brown, pigmented patches on an elderly client's hands. What is the proper term for the nurse to use to document this finding? Actinic keratoses Solar lentigines Seborrheic keratoses Senile purpura

Solar lentigines Hyperpigmentation in sun-exposed areas appears as brown, pigmented, round or rectangular patches. They are often called liver spots. These are normal skin variations in the aging population. Actinic keratoses are dry, scaly, rough-textured patches or lesions that form on the outermost layer of the skin after years of exposure to ultraviolet (UV) light, such as sunlight. These lesions typically range in color from skin-toned to reddish brown and are often pedunculated. Seborrheic keratoses are normal skin changes of aging and involve the outer layer of the skin. They have a characteristic waxy appearance and vary in color from light tan to black. Senile purpura are vivid purple patches on the skin that do not blanch to the touch.

The nurse is assessing the client's risk for falls. What data identifies the client as having a fall risk? Select all that apply. Stiffness Abnormal heart sounds Antihypertensive medications Wide gait Urinary frequency

Stiffness Antihypertensive medications Wide gait Risk factors for falls include a wide, unsteady gait, medications that may decrease the blood pressure, confusion and stiffness. Urinary frequency and abnormal heart sounds would not increase the client's risk for falls.

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record? Functional Urge Stress Overflow

Stress The nurse should document the findings as stress incontinence. Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. Overflow incontinence is the condition in which the client has involuntary loss of urine associated with overdistention of the bladder. Functional incontinence is the inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition.

A 75-year-old female client tells the nurse that she is sexually active but that it causes her pain when she has intercourse. What would the nurse suggest to alleviate this pain? Having sex in the morning Cold application Taking warm baths Exclusive use of a side-lying position

Taking warm baths Suggestions to alleviate pain might be changes in positions, use of lubrication, heat application, and warm baths.

Some symptoms of dehydration are common to younger and older adults. Which one of the following cannot be used to determine dehydration in older adults? Tenting of the skin when pinched. A furrowed tongue. Dry warm skin. Sunken eyes.

Tenting of the skin when pinched. Pinching skin is not an accurate test of turgor in older adults.

The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse? The client has decreased functional ability The client is lazy and appearance no longer matters to him The client is being neglected This client needs to live in a nursing home

The client has decreased functional ability Poor hygiene and inappropriate dress in an older adult may indicate decreased functional ability or may result from medications, infection, dehydration, or nutritional status. Inappropriate affect, inattentiveness, impaired memory, and inability to perform ADLs may indicate dementia from Alzheimer's disease or another cause. The information in the scenario does not indicate that the client is lazy; more investigation would be needed before the nurse would suspect neglect or abuse, as would the client's need to reside in a nursing home.

The nurse assesses an older adult using the short from of the Geriatric Depression Scale. The total score obtained is 11. Which interpretation by the nurse is correct? The client is most likely depressed. Further evaluation is needed to make a diagnosis. The client is not depressed. The score suggests depression may be a problem.

The client is most likely depressed. Scores on the short from of the Geriatric Depression Scale can range from 0 to 15. A score 10 is almost always indicative of depression. A score 5 is suggestive of depression.

When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply. The epidermis thins Wound healing slows as a result of decreased mitotic activity Nails become thin and brittle with increased growth The epidermis thickens The number of sweat and sebaceous glands increases Nails become thick and brittle with slow growth

The epidermis thins Wound healing slows as a result of decreased mitotic activity Nails become thick and brittle with slow growth The epidermis thins with aging, and the epithelium renews itself every 30 days instead of every 20 days as in children and adults. This decreased mitotic activity of cells leads to a 50% reduction in rate of wound healing. In addition, there are degeneration of the elastic fibers providing dermal support, a loss of collagen, and a loss of subcutaneous fat. The number of sweat and sebaceous glands decreases as a result of atrophy, and vascularity and capillary fragility of the skin layer are diminished. Nail beds become more rigid, thick, and brittle, with slowed growth.

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine associated with an abrupt and strong desire to void. What type of incontinence should the nurse document in the client's record? Urge Overflow Functional Stress

Urge Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. Stress incontinence involves involuntary loss of urine when coughing, sneezing, or laughing. Overflow incontinence is the condition in which the client has involuntary loss of urine associated with overdistention of the bladder. Functional incontinence is the inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition.

An otherwise healthy elderly client develops the sudden onset of confusion, lethargy, anorexia, and nocturia. The nurse should obtain an order for which lab test to assess this sudden change in health status? Live enzymes for acute hepatitis Urinalysis for the onset of a urinary tract infection Electrolytes to determine the onset of dehydration Complete blood count for anemia

Urinalysis for the onset of a urinary tract infection Elderly clients often do not manifest the normal symptoms when an infection is present. The onset of confusion, lethargy, anorexia, and nocturia in an otherwise healthy elderly client often signify the onset of a urinary tract infection. A urinalysis is the appropriate test for this client. Anemia, hepatitis, and electrolyte imbalances would not produce nocturia.

To reduce the risk for late recognition of cognitive impairment in the older adult client, which actions should the nurse take? Select all that apply. Use geriatric screening tools. Provide teaching about sexual health. Normalize occasional loss of memory. Adopt more direct questions. Consult family members or caregivers.

Use geriatric screening tools. Consult family members or caregivers. Adopt more direct questions. Older adult clients may be reluctant to report their symptoms or overlook them believing that they are a normal part of aging. To reduce the risk for late recognition and delayed intervention of any health problem in the older adult client, it is important to adopt direct questions, use geriatric screening tools, and consult family members or caregivers. Normalizing forgetfulness encourages under-reporting of symptoms and may prevent the older adult client from offering more detailed information about the memory loss. Teaching about sexual health would not be an appropriate action to take when reducing the risk for late recognition of cognitive impairment.

An objective assessment that is frequently indicated when the subjective assessment reveals a history of falling is a 24-hour food diary. a tonometry exam. a Get Up and Go test. palpation of the joints for crepitus.

a Get Up and Go test. Observe the client's gait by performing the timed "Get Up and Go" test. Older adult clients without impairments in gait or balance can complete the test within 10 seconds.

A risk factor for sinusitis in the frail elderly is an accumulation of ear wax. a nasogastric feeding tube. decreased ability to detect odors. conductive hearing loss.

a nasogastric feeding tube. Older adult clients with nasogastric feeding tubes are at increased risk for sinusitis related to the obstruction.

The physical declines of aging often first become noticeable when acute or chronic illness places excessive demands on the body. cognitive declines become significant. approximately 50% of function is lost. the person is at least 75 years old.

acute or chronic illness places excessive demands on the body. Many older adults are healthy, active, and independent despite these normal physical changes in their bodies. It is, rather, that advancing age has a tendency to place a person at greater risk for chronic illness and disability.

The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has? congestive heart failure holosystolic murmur aortic aneurysm atrial fibrillation

aortic aneurysm An abdominal aortic pulsation is indicative of an aortic aneurysm. Atrial fibrillation is one type of dysrhythmia characterized by an irregular heartbeat. Congestive heart failure is characterized by fluid retention, especially in the lower extremities. A loud or harsh holosystolic murmur suggests valvular stenosis.

The nurse notes that an older client has a systolic murmur. What should this finding suggest to the nurse? onset of heart failure malfunction of the right atrium calcification of the aortic cusps hypertrophy of the left ventricle

calcification of the aortic cusps Middle-aged and older adults commonly have a systolic aortic murmur. With aging, fibrotic changes thicken the bases of the aortic cusps. Calcification follows, resulting in audible vibrations. Turbulence produced by blood flow into a dilated aorta may further augment this murmur. An S3 heart sound may indicate the onset of heart failure. Displacement of the point of maximum impulse would be associated with hypertrophy of the left ventricle. An atrial arrhythmia would indicate malfunctioning of the right atrium.

A sign of infection in the elder that is more common than fever is diarrhea. pain. cough. confusion.

confusion. Confusion is often a sign of infection in the frail older adult.

A gastrointestinal problem that often requires emergency treatment in the frail elder is lactose intolerance. hiatal hernia. Crohn disease. diverticulitis.

diverticulitis If diverticula become infected, emergency treatment may be required to prevent perforation and sepsis.

During the assessment of an older client the nurse focuses on household activities and home environment. On which geriatric syndrome is the nurse focusing during this assessment? fall risk skin breakdown independence nutrition

fall risk A geriatric syndrome represents serious issues for older adults and is often related to functional decline. Geriatric syndromes impact quality of life. Household activities and home environment would assess the geriatric syndrome of fall risk. Assessing eating or feeding would determine nutritional status. Assessing continence and mentation would help determine independence. Mobility and nutritional intake would help determine skin status.

The nurse is performing a general survey on an older adult client. Which assessment can the nurse include? gait blood pressure visual acuity pressure ulcers

gait The client's gait can be assessed by observing the client entering the exam room. This assessment can be included in the general survey and provide information regarding the client's physical activities of daily living. In order to assess blood pressure, vital signs must be taken. This is not part of the general survey. In order to assess pressure ulcers, the nurse must thoroughly inspect the skin, particularly bony prominences such as elbows and heels. These body areas will likely be covered by clothing and shoes. This is part of the physical examination, not the general survey. In order to assess visual acuity, the nurse would need to use the Snellen Chart and indicate the correction in each eye. This is part of the physical examination, not the general survey.

Common conditions or problems that accompany aging are often called geriatric syndromes conditions of aging symptoms of aging geriatric symptoms

geriatric syndromes Older adults often have conditions or difficulties referred to as geriatric syndromes because of the interaction of multiple chronic diseases. Because these syndromes are common, the nurse can play a key role in early detection or assessment of the problem so that interventions can be implemented.

The client presents to the clinic with complaints of a painful rash under the left breast. The nurse observes a red papular rash and suspects the client is suffering from: stasis dermatitis seborrhea onychomycosis herpes zoster

herpes zoster Herpes zoster is a red painful papular rash that follows the distribution of a dermatome along the trunk or even into the legs. Stasis dermatitis occurs on the legs and is characterized by a reddish-brown ruddy appearance and edema. Seborrhea occurs on the scalp and is characterized by white scaly patches. Onychomycosis is a fungal infection of the nail beds with the nails appearing very thick and yellow.

A nurse observes a nursing student assessing an older adult client who is hospitalized. Which action by the student nurse would require the nurse to intervene? percussing the client's lung tones assessing vision by asking the client to read newspaper print pinching the client's skin to determine skin turgor assessing the client's ability to swallow food and water

pinching the client's skin to determine skin turgor As people age, they lose collagen (which makes the skin elastic and fuller). As a result of reduced collagen, the skin becomes less elastic and more fibrous. Therefore, pinching the skin is not an effective way to determine turgor in older clients. The nurse should assess the client's ability to swallow food and water. Having an older client read newspaper print assesses nearsighted vision. Percussing lung tones assesses underlying structural changes, such as kyphosis or barrel chest.

The nurse observes a dark brown, pigmented waxy lesion 2-mm in size on the right forearm of an older adult. The nurse recognizes this lesion as: malignant carcinoma squamous cell carcinoma seborrheic keratosis basal cell carcinoma

seborrheic keratosis Seborrheic keratosis is a dark brown, pigmented waxy lesion. Basal cell carcinoma starts as a small smooth, hemispherical translucent papule covered by a thinned epidermis, usually on the face. The papule gradually enlarges into a pearly nodule with a ulcerated center. Squamous cell carcinoma starts as a hard, red, wart-like lesion with a raised or rolled gray yellow edged found on highly sun-exposed areas. Malignant carcinoma is a variegated pigmented macule, papule, nodule, patches, or tumor, usually asymmetric with an irregular border and greater than 6 mm in diameter.

A 76-year-old female client visits the primary care doctor for an annual physical. The client's spouse recently died and the client lives by themselves with no adult children nearby. The client's appearance is clean but disheveled and the client has lost weight since the last visit 3 months ago. The nurse is concerned about the client being able to care for themselves at home. Based on the client's findings and history, the client is at risk for : self-neglect Alzheimer disease elder abuse and the nurse should complete the Katz Activities of Daily Living complete the Lawson Scale for Instrumental Activities of Daily Living (IADLs) consult a social worker

self-neglect complete the Lawson Scale for Instrumental Activities of Daily Living (IADLs) The client is exhibiting early signs of self-neglect, which will likely become worse over time. The nurse should complete the Lawson Scale for Instrumental Activities of Daily Living (IADLs) to determine if the client is able to live independently and to determine what social services the client may benefit from, such as meals delivered to their home. There is no indication that the client is at risk for Alzheimer disease. Although a disheveled appearance and weight loss could be signs of elder abuse in other scenarios, there is no indication that elder abuse is occurring in this situation and the findings more directly point to self-neglect. The Katz Activities of Daily Living index assesses a client's ability to perform activities of daily living (ADLs) such as bathing, eating, toileting, and dressing independently; while there may be a concern about eating enough due the client's weight loss, the client's appearance is clean, and the main concern is whether they can live independently. The nurse should not consult a social worker before assessing the client, using the Lawson Scale.

A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is nutritional deficiency. dysphagia. the degree to which dyspnea affects daily function. a possible history of immunosuppression.

the degree to which dyspnea affects daily function. Older adults with chronic respiratory or cardiac problems who experience some constant degree of dyspnea are unlikely to seek care or note dyspnea unless there is a change in functional capabilities.

For which reason should the nurse use the 10-minute screener when assessing the older adult client? to identify geriatric syndromes to evaluate age-related changes that support optimal functioning to promote avoidance of group labelling to assess activities of daily living

to evaluate age-related changes that support optimal functioning The 10-minute geriatric screener evaluates for age-related changes that help older adults maintain optimal functioning. It covers the three important domains of geriatric assessment: physical, cognitive, and psycho-social function. The SPICES mnemonic focuses on frequent geriatric syndromes of the older adult. This assessment includes a focus on sleep disorders, problems with eating, incontinence, confusion, evidence of falls, and skin breakdown. The ETHICS mnemonic helps clinicians escape the pitfalls of group labeling by expanding the individual history taking to include the explanation, treatment, healers, negotiate, intervention, collaborate, and spirituality. The 10-minute screener is not structured to assess for activities of daily living.

To compensate for a stooped posture and less flexible knee, hip, and shoulder joints, the elderly person often walks with one leg slightly dragging behind the other. with a waddling type of gait. with the feet farther apart and the knees slightly bent. with a slight swaying side-to-side motion.

with the feet farther apart and the knees slightly bent. Client stands reasonably straight with feet positioned fairly widely apart to form a firm base of support. This stance compensates for diminished sense of proprioception in lower extremities. Body usually bends forward as well.