Chapter 5 - Chronic Illness and Older Adults

22. Which nursing actions will the nurse take to assess for possible malnutrition in an older adult patient? (Select all that apply.) a. Assess for depression. b. Review laboratory results. c. Determine food preferences. d. Inspect teeth and oral mucosa. e. Ask about transportation needs.

Answer: A, B, D, E Rationale: The laboratory results, especially albumin and cholesterol levels, may indicate chronic poor protein intake or high-fat or high-cholesterol intake. Transportation affects the patient's ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.

9. An older patient reports having "no energy" and feeling increasingly weak. The patient has lost 12 pounds over the past year. Which action should the nurse take initially? a. Ask the patient about daily dietary intake. b. Schedule regular range-of-motion exercise. c. Describe normal changes associated with aging. d. Discuss long-term care placement with the patient.

Answer: a. Ask the patient about daily dietary intake> Rationale: In a frail older patient, nutrition is frequently compromised, and the nurse's initial action should be to assess the patient's nutritional status. Active range of motion may be helpful in improving the patient's strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient's assessment data are not consistent with normal changes associated with aging.

21. A family caregiver tells the home health nurse, "I feel like I can never get away to do anything for myself." Which action by the nurse would directly address this concern? a. Assist the caregiver in finding respite services. b. Assure the caregiver that the work is appreciated. c. Encourage the caregiver to discuss feelings openly with the nurse. d. Tell the caregiver that family members provide excellent patient care.

Answer: a. Assist the caregiver in finding respite services. Rationale: Respite services allow family caregivers to have time away from their caregiving responsibilities. The other actions may also be helpful, but the caregiver's statement clearly indicates the need for some time away

3. An alert older patient who takes multiple medications for chronic cardiac and pulmonary diseases lives with a daughter who works during the day. During a clinic visit, the patient tells the nurse that she has a strained relationship with her daughter and does not enjoy being alone all day. In planning care for this patient, which problem should the nurse consider as the priority? a. Risk for injury b. Social isolation c. Caregiver strain d. Difficulty coping

Answer: a. Risk for injury Rationale: The patient's age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. Problems with social isolation, caregiver strain, or difficulty coping are not physiologic priorities. Drug-drug interactions could cause the most harm to the patient and are therefore the priority.

13. The home health nurse visits an older patient with mild forgetfulness. Which new information is of most concern to the nurse in planning care? a. The patient has lost 10 lb (4.5 kg) during the past month. b. The patient tells the nurse that a close friend recently died. c. The patient is cared for by a daughter during the day and stays with a son at night. d. The patient's son uses a marked pillbox to set up the patient's medications weekly.

Answer: a. The patient has lost 10 lb (4.5 kg) during the past month. Rationale: A 10-pound weight loss may be an indication of depression or elder neglect and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an older adult would have friends who have died.

17. An older adult being admitted is assessed at high risk for falls. Which action should the nurse take first? a. Use a bed alarm system on the patient's bed. b. Administer the prescribed PRN sedative medication. c. Ask the health care provider to order a vest restraint. d. Position the patient in a geriatric recliner with locking tray.

Answer: a. Use a bed alarm system on the patient's bed. Rationale: The use of the least restrictive restraint alternative is required. Physical or chemical restraints may be necessary, but the nurse's first action should be an alternative such as a bed alarm.

12. The home health nurse cares for an older adult patient who lives alone and takes several different prescribed medications for chronic health problems. Which intervention, if implemented by the nurse, would support both the patient's self-management and the goal of medication adherence? a. Use a marked pillbox to set up the patient's medications. b. Discuss the option of moving to an assisted living facility. c. Remind the patient about the importance of taking medications. d. Visit the patient daily to administer the prescribed medications.

Answer: a. Use a marked pillbox to set up the patient's medications. Rationale: Because forgetting to take medications is a common cause of medication errors in older adults, the use of medication reminder devices is helpful when older adults have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication compliance. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living or instrumental ADLs.

19. The family of an older patient with chronic health problems and increasing weakness is considering placement in a long-term care (LTC) facility. Which action by the nurse will be most helpful in assisting the patient to make this transition? a. Have the family select an LTC facility that is relatively new. b. Ask the patient's preference for the choice of an LTC facility. c. Explain the reasons for the need to live in LTC to the patient. d. Request that the patient be placed in a private room at the facility.

Answer: b. Ask the patient's preference for the choice of an LTC facility. Rationale: The stress of relocation is likely to be less when the patient has input into the choice of the facility. The age of the long-term care facility does not indicate a better fit for the patient or better quality of care. Although some patients may prefer a private room, others may adjust better when given a well-suited roommate. The patient should understand the reasons for the move but will make the best adjustment when involved with the choice to move and the choice of the facility.

10. The nurse is admitting an acutely ill, older patient to the hospital. Which action should the nurse take? a. Speak slowly and loudly while facing the patient. b. Perform a physical assessment before interviewing the patient. c. Ask a family member to go home and retrieve the patient's cane. d. Begin care by obtaining a detailed medical history from the patient.

Answer: b. Perform a physical assessment before interviewing the patient. Rationale: When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiologic changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records. After the initial physical assessment to determine the patient's current condition, then the nurse could ask someone to obtain any assistive devices for the patient if applicable.

11. The nurse cares for an alert, homeless older adult patient who was admitted to the hospital with a chronic foot infection. Which intervention is the priority for the nurse to include in the discharge plan for this patient? a. Teach the patient how to assess and care for the foot infection. b. Refer the patient to social services for assessment of resources. c. Schedule the patient to return to outpatient services for foot care. d. Give the patient written information about shelters and meal sites.

Answer: b. Refer the patient to social services for assessment of resources. Rationale: An interprofessional approach, including social services, is needed when caring for homeless older adults. Even with appropriate teaching, a homeless individual may not be able to maintain adequate foot care because of a lack of supplies or a suitable place to accomplish care. Older homeless individuals are less likely to use shelters or meal sites. A homeless person may fail to keep appointments for outpatient services because of factors such as fear of institutionalization or lack of transportation.

4. Which method should the nurse use to obtain a complete assessment of an older patient? a. Review the patient's health record for previous assessments. b. Use a geriatric assessment instrument to evaluate the patient. c. Ask the patient to write down medical problems and medications. d. Interview both the patient and the primary caregiver for the patient.

Answer: b. Use a geriatric assessment instrument to evaluate the patient. Rationale: The most complete information about the patient will be obtained by using an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the medical record, interviews with the patient and caregiver, and written information by the patient are all included in a comprehensive geriatric assessment.

14. Which statement, if made by an older adult patient, would be of most concern to the nurse in planning care? a. "I prefer to manage my life without much help from other people." b. "I take three different medications for my heart and joint problems." c. "I don't go on daily walks anymore since I had pneumonia 3 months ago." d. "I set up my medications in a marked pillbox so I don't forget to take them."

Answer: c. "I don't go on daily walks anymore since I had pneumonia 3 months ago." Rationale: Inactivity and immobility lead rapidly to loss of function in older adults. The nurse should develop a plan to prevent further deconditioning and restore function for the patient. Self-management is appropriate for independently living older adults. On average, an older adult takes seven different medications so the use of three medications is not unusual for this patient. The use of memory devices to assist with safe medication administration is recommended for older adults.

7. Which nursing action will be most helpful in decreasing the risk for drug-drug interactions in an older adult? a. Teach the patient to have all prescriptions filled at the same pharmacy. b. Make a schedule for the patient as a reminder of when to take each medication. c. Ask the patient to bring all medications, supplements, and herbs to each appointment. d. Instruct the patient to avoid taking over-the-counter (OTC) medications or supplements.

Answer: c. Ask the patient to bring all medications, supplements, and herbs to each appointment. Rationale: The most information about drug use and possible interactions is obtained when the patient brings all prescribed medications, OTC medications, and supplements to every health care appointment. The patient should discuss the use of any OTC medications with the health care provider and obtain all prescribed medications from the same pharmacy. Use of supplements and herbal medications need to be considered in order to prevent drug-drug interactions. Use of a medication schedule will help the patient take medications as scheduled but will not prevent drug-drug interactions.

5. Which intervention should the nurse implement to provide optimal care for an older patient who is hospitalized with pneumonia? a. Use a standardized geriatric care plan. b. Plan for transfer to a long-term care facility. c. Consider the preadmission functional abilities. d. Minimize physical activity during hospitalization.

Answer: c. Consider the preadmission functional abilities. Rationale: The plan of care for older adults should be individualized and based on the patient's current functional abilities. A standardized geriatric care plan will not address individual patient needs and strengths. A patient's need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.

6. The nurse cares for an older adult patient who lives in a rural area. Which intervention should the nurse plan to implement to meet this patient's needs? a. Suggest that the patient move closer to health care providers. b. Obtain extra medications for the patient to last for 4 to 6 months. c. Ensure transportation to appointments with the health care provider. d. Assess the patient for chronic diseases that are unique to rural areas.

Answer: c. Ensure transportation to appointments with the health care provider. Rationale: Transportation can be a barrier to accessing health services in rural areas. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area. There are no chronic diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by buying large quantities of the medications.

18. An older adult patient presents with a broken arm and visible scattered bruises healing at different stages. Which action should the nurse take first? a. Notify an elder protective services agency about possible abuse. b. Make a referral for a home assessment visit by the home health nurse. c. Have the family member stay in the waiting area while the patient is assessed. d. Ask the patient how the injury occurred and observe the family member's reaction.

Answer: c. Have the family member stay in the waiting area while the patient is assessed. Rationale: The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document data before notifying the elder protective services agency.

1. When caring for an older patient with hypertension who has been hospitalized after a transient ischemic (TIA), which topic is the most important for the nurse to include in the discharge teaching? a. Mechanism of action of anticoagulant therapy b. Effect of atherosclerosis on cerebral blood vessels c. Symptoms indicating that the patient should contact the health care provider d. Impact of the patient's family history on likelihood of developing a serious stroke

Answer: c. Symptoms indicating that the patient should contact the health care provider. Rationale: One of the priority tasks for patients with chronic illnesses is to prevent and manage a crisis. The patient needs instruction on recognition of symptoms of hypertension and TIA and appropriate actions to take if these symptoms occur. The other information may also be included in patient teaching but is not as essential in the patient's self-management of the illness.

20. The nurse manages the care of older adults in an adult health day care center. Which action can the nurse delegate to unlicensed assistive personnel (UAP)? a. Plan daily activities based on the individual patient needs and desires. b. Obtain information about food and medication allergies from patients. c. Take blood pressures daily and document in individual patient records. d. Teach family members how to cope with patients who are cognitively impaired.

Answer: c. Take blood pressures daily and document in individual patient records. Rationale: Measurement and documentation of vital signs are included in UAP education and scope of practice. Obtaining patient health history, planning activities based on the patient assessment, and patient education are all actions that require critical thinking and will be done by the registered nurse.

2. The nurse performs a comprehensive assessment of an older patient who is considering admission to an assisted living facility. Which question is the most important for the nurse to ask? a. "Have you had any recent infections?" b. "How frequently do you see a doctor?" c. "Do you have a history of heart disease?" d. "Are you able to prepare your own meals?"

Answer: d. "Are you able to prepare your own meals?" Rationale: The patient's functional abilities, rather than the presence of an acute or chronic illness, are more useful in determining how well the patient might adapt to an assisted living situation. The other questions will also provide helpful information but are not as useful in providing a basis for determining patient needs or for developing interventions for the older patient.

16. Which patient is most likely to need long-term nursing care management? a. 72-yr-old who had a hip replacement after a fall at home b. 64-yr-old who developed sepsis after a ruptured peptic ulcer c. 76-yr-old who had a cholecystectomy and bile duct drainage d. 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg)

Answer: d. 63-yr-old with bilateral knee osteoarthritis who weighs 350 lb (159 kg) Rationale: Osteoarthritis and obesity are chronic problems that will require planning for long-term interventions such as physical therapy and nutrition counseling. The other patients have acute problems that are not likely to require long-term management.

8. A patient who has just relocated to a long-term care facility is exhibiting signs of stress related to the move. Which action should the nurse include in the plan of care? a. Remind the patient that making changes is usually stressful. b. Discuss the reason for the move to the facility with the patient. c. Restrict family visits until the patient is accustomed to the facility. d. Have staff members write notes welcoming the patient to the facility.

Answer: d. Have staff members write notes welcoming the patient to the facility. Rationale: Having staff members write notes will make the patient feel more welcome and comfortable at the long-term care facility. Discussing the reason for the move and reminding the patient that change is usually stressful will not decrease the patient's stress about the move. Family member visits will decrease the patient's sense of stress about the relocation.

15. The nurse will assess an older patient who takes diuretics and has a possible urinary tract infection (UTI). Which action should the nurse take first? a. Palpate over the suprapubic area. b. Inspect for abdominal distention. c. Question the patient about hematuria. d. Request the patient empty the bladder.

Answer: d. Request the patient empty the bladder. Rationale: Before beginning the assessment of an older patient with a UTI and on diuretics, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient's ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.