HESI Case Study Gerontology: Age-Related Risks

How many mL of fluid should the client drink per day? - At least 30 mL/kg - At least 1500 mL/day - Mr. Rogers weighs 226 lbs (102.7 kg)

3081 30x102.7

(With the following information,) the nurse sets the insulin drip to deliver how many mL/hr? - Mr. Rogers weighs 226 lbs (102.7 kg) - His blood glucose is 312 mg/dL - Insulin drip is pre-mixed 100 units per 100 mL NS - Insulin infusion protocol (for CBG 300-329) = 4

4

Which lab value needs to be reported immediately? Serum creatinine 1.2 mg/dL. Arterial pH 7.05. Negative ketones. Serum osmolality 285 mOsom/kg.

Arterial pH 7.05 An arterial pH below 7.35 indicates an abnormal blood gas and indicates a shift to an acidotic state. This is an emergency situation.

Which recommendation by the nurse may help improve mild symptoms of BPH during the "watchful waiting" period? Take a mild decongestant at night to reduce nocturia. Increase fluids before bedtime to dilute acidic urine. Introduce acidic foods into the diet. Avoid sources of caffeine.

Avoid sources of caffeine. Caffeine may stimulate an overactive bladder and irritate an already enlarged prostate.

Which results can affect drug distribution and influence drug-to-drug interactions? Which results can affect drug distribution and influence drug-to-drug interactions? Elevated BUN. Low serum albumin levels. Reduced glomerular filtration rate. Elevated creatinine levels.

Low serum albumin levels. Serum albumin levels can affect the binding of drugs. Low levels of albumin can result in toxic effects, especially in the elderly.

Which response by the client if of most concern to the nurse? "I usually have to get up during the night at least once to urinate." "It takes me longer to urinate than it did when I was younger." "My urine had a foul smell this morning." "My urine is yellow and pale in color."

"My urine had a foul smell this morning." New onset of a foul smell in the urine could be a sign of UTI and should be investigated further. Bladder (cystitis) and kidney (pyelonephritis) infections are common problems in clients with diabetes.

Which of the following statements made by Mr. Rogers indicates the need for further teaching (regarding the medication doxazosin)? "I should report any dizziness or fainting episodes." "I will take this medication to improve my urine flow." "This medication may cause a rise in my blood pressure." "I will need to take this medication for the rest of my life."

"This medication may cause a rise in my blood pressure." Doxazosin (Cardura) can result in a drop in blood pressure.

Which results of the dipstick urinalysis does the RN recognize as abnormal? +1 Ketones. pH 5.0. Absence of glucose. Scant sediment. Trace leucocytes.

+1 Ketones. Ketones are not normally found in the urine. Positive ketones can be associated with uncontrolled diabetes, malnutrition, or pregnancy. Scant sediment. Cloudiness or turbidity of the urine is an abnormal finding, which may be associated with an infection or with contamination of the specimen. Trace leucocytes. The presence of leucocytes in the urine is an abnormal finding, which may be associated with specimen contamination or with infection.

When using an 8-ounce drinking glass, the client should drink how many glasses per day to ingest 3081 mL in 1 day? 30 mL = 1 ounce

13 30 mL = 1 ounce 8 ounces x 30 mL = 240 mL/glass 3081 mL per day ÷ 240 mL/glass = 12.8 glasses Round to 13 glasses

The pharmacist delivers dose of ampicillin in a 100mL bag of NS. In order to deliver the medication over 30 minutes, the nurse sets the pump to deliver how many mL/hr?

200 100 mL to be delivered over thirty minutes is given at 200 mL/hr.

The nurse understands that which information is correct regarding the prescribed insulin? Glargine (Lantus) is rapid-acting insulin typically administered 15 minutes before meals. Lispro (Humalog) is intermediate-acting insulin that peaks in 4 to 10 hours. Glargine (Lantus) does not have a peak interval. Lispro (Humalog) is typically given at bedtime on an empty stomach.

>>>Glargine (Lantus) does not have a peak interval. Glargine (Lantus), long-acting insulin, has an onset of 1 to 2 hours, has no pronounced peak, and has a duration of 24+ hours. Lispro (Humalog), rapid-acting insulin, has an onset of 15 minutes and is typically given before meals, peaks in 60 to 90 minutes.

Which antimicrobial medications are safe alternatives for clients with penicillin allergies?

>>>Vancomycin (Vancocin). IV vancomycin (Vancocin) is indicated for serious infections with susceptible organisms in clients who are allergic to penicillins. Cephalexin (Keflex). Clients who are allergic to penicillins may also have a cross-sensitivity to cephalosporin antibiotics. >>>Clindamycin (Cleocin). Clindamycin (Cleocin) is indicated for serious infections with susceptible organisms in clients who are allergic to penicillins. Ticarcillin (Timentin). This choice is incorrect because ticarcillin (Timentin) is a fourth generation penicillin that is used for serious pseudomonal infections. >>>Erythromycin (Erythrocin). Erythromycin (Erythrocin) is one of the drugs that is indicated for serious infections with susceptible organisms in clients who are allergic to penicillin.

The nurse understand that which symptoms are commonly associated with BPH?

Bladder distention. Enlargement of the prostate can cause obstruction, preventing emptying of the bladder and resulting in bladder distention. Frequent stopping and starting of urinary stream. Enlargement of the prostate causes obstructive symptoms such as difficulty maintaining a steady stream of urine. Straining while urinating. Enlargement of the prostate causes obstruction, making it difficult to urinate without straining. Dribbling at the end of urination. Enlargement of the prostate may cause an obstruction, making it difficult to end the urinary stream, resulting in dribbling.

The HCP writes a prescription to follow hospital protocol for an insulin drip to begin for Mr. Rogers, who currently weighs 226 lbs (102.7 kg) and whose blood glucose level is 312 mg/dL. Per hospital protocol, the blood glucose is monitored hourly for titration of the insulin infusion. The pharmacy sends a pre-mixed insulin drip with 100 units of regular insulin in 100 mL of 0.9% normal saline. Insulin Infusion Protocol

Blood Glucose (BG) Units/hr 110 to 119 0.5 120 to 149 1 150 to 179 1.5 180 to 209 2 210 to 239 2 240 to 269 3 270 to 299 3 300 to 329 4 330 to 359 5

Mr. Rogers' pernicious anemia improves after treatment, and he is taught that he will most likely need this treatment for the rest of his life.

Case Outcome The nurse and other members of Mr. Rogers' healthcare team continue to care collaboratively for Mr. Rogers when he is discharged to the assisted living facility. He is given instructions to follow up on treatment of his benign prostatic hyperplasia (BPH) and to watch for signs and symptoms of a re-occurrence of his UTI. The nurse completes discharge education about diabetes and instructs Mr. Rogers on the importance of diabetic control with well-balanced meals, frequent blood glucose checks, and self-administration of insulin. Mr. Rogers is feeling better and appreciates all of the care that the nurses have provided in the management of his diabetic complications. Once discharged, Mr. Rogers is looking forward to an increased independence that the assisted living facility allows and to having better control of his diabetes.

The nurse considers which pharmacological age-related principles when administering medications or monitoring the effects of medications in the elderly client? Gastric pH is often decreased in the elderly. Decreased cardiac output increases the risk for adverse drug reactions. Mucosal edema can increase the absorption of drugs. Drugs administered intravenously have a faster absorption rate than oral drugs. Dehydration can decrease the half-life of drugs.

Decreased cardiac output increases the risk for adverse drug reactions. Decreasing cardiac function is responsible for about 50% of blood flow to the kidneys, leading to reduced kidney efficiency. Drugs are not filtered as quickly from the bloodstream, which increases their half-life and leads to toxicity. Drugs administered intravenously have a faster absorption rate than oral drugs. Decreased gastric blood flow and motility in the elderly can slow oral drug absorption. Dehydration can decrease the half-life of drugs. Dehydration leads to a delay in the filtration process of drugs. The extended biological half-life of drugs in the older adult increases the risk of adverse reactions.

Which data is most important to report to the HCP (when assessing for signs of nutritional problems)? Dyspnea. Constipation. Heartburn. Pallor.

Dyspnea. Dyspnea can result from nutritional problems and may be indicative of anemia; therefore, it is the most important symptom to report. (can be indicative of anemia)

Along with clinical manifestations, which common laboratory findings indicate dehydration? Elevated hemoglobin and hematocrit. Decreased BUN. Increased serum osmolarity. Increased urine specific gravity. Increased serum glucose. Case Study Details

Elevated hemoglobin and hematocrit. No single laboratory test result confirms or rules out dehydration. Instead it is determined by laboratory findings with clinical manifestations. Common findings are elevated hemoglobin and hematocrit levels from hemo concentration (an increase in the number of red blood cells/plasma). In the case of dehydration, BUN would be elevated. Increased serum osmolarity. During dehydration, increased levels of sodium, BUN or glucose in the blood can increase the serum osmolarity. Increased urine specific gravity. Urine specific gravity is a measure of the concentration of dissolved substances or solutes (urea and sodium). The specific gravity of water is 1.000. An increase in urine specific gravity is caused by dehydration. Increased serum glucose. Increased amounts of solutes, such as glucose or protein, can also increase specific gravity of the urine.

Which lab finding is of most concern to the nurse? Potassium 3.9 mEq/L. Sodium 140 mEq/L. Phosphate 4.1 mg/dL. Hemoglobin 11.2 g/dL.

Hemoglobin 11.2 g/dL Normal hemoglobin for an adult male is 13.2 to 17.3 g/dL. Although lower levels are often found in older adults, 11.2 g/dL indicates anemia.

Which of the following objective signs indicate dehydration? Hematuria. Increased urine output. High creatinine levels. Postural hypotension. Heart rate greater than 100 bpm.

High creatinine levels. Creatinine levels may decrease after rehydration, which improves renal blood flow. This can be attributed to low renal blood flow due to dehydration and/or diabetic nephropathy. Postural hypotension. Hypovolemia, which can result from dehydration, can cause a drop in systolic BP of 10 to 15 mmHg when a client changes from a lying to a standing position. Heart rate greater than 100 bpm. Tachycardia, or an increase in heart rate, may occur with a drop in blood volume related to dehydration to help the body maintain adequate cardiac output.

Prior to changing the dressing on Mr. Rogers' right heel ulcer, the nurse should first take which actions? inspect the feet carefully for temperature, sensation, and drainage. Elevate the affected foot. Avoid weight-bearing activities. Administer broad-spectrum antibiotics.

Inspect the feet carefully for temp, sensation, and drainage. An inspection must be done by the nurse to assess for drainage in case a culture/sensitivity needs to be done to rule out the possibility of infection. Peripheral neuropathy may begin with nerve irritation and pain that progresses to the loss of sensation to fine touch. Diabetic clients may often ignore or be unaware of irritation or injury to their feet.

The nurse anticipates that the client will receive which treatment for pernicious anemia? Iron supplements by mouth daily. Increase in vitamin C in the diet. Intramuscular injection of vitamin B-12. Prescription strength folic acid supplements.

Intramuscular injection of vitamin B-12. Pernicious anemia is a deficiency of vitamin B-12 that is often caused by a lack of intrinsic factor

What conditions, other than hyperglycemia, might Mr. Rogers have? Hypernatremia. Hypervolemia. Ketonuria. Osmotic diuresis. Glycosuria.

Ketonuria. The lack of glucose in cells results in fat breakdown by the liver, and ketonuria results from the excretion of ketones in the urine. Osmotic diuresis. Glucose is an osmotically active particle, and lack of glucose results in cellular dehydration. Glycosuria. When blood glucose levels exceed the renal threshold, the glucose spills into the urine, causing glycosuria.

Carl Rogers is a 67-year-old African American male with a 20-year history of type 2 diabetes mellitus. After a scheduled visit and an assessment at the healthcare provider's office (HCP's), Mr. Rogers is directly admitted to the medical unit with a stage II non-healing ulcer on his right heel. The nursing admissions paperwork is completed, and pain medication is administered. During his admissions assessment, Mr. Rogers is diagnosed with a urinary tract infection (UTI) and dehydration.

Mr. Rogers was diagnosed last year with type 2 diabetes mellitus. He explains that he is experienced with self-administration of insulin injections three times per day. Mr. Rogers states that his eating habits are not great, but he never misses his insulin injections. He lives alone and doesn't like to eat by himself, so he rarely cooks. Mr. Rogers explains that other than an occasional walk, he does not exercise.

Which teaching points should be included (for a nursing diagnosis of knowledge deficit related to signs and symptoms of hypoglycemia)? Report a blood glucose reading of 70 mg/dL. Notify the HCP if there is headache or irritability. Report excessive hunger and/or weakness. Report cold and clammy skin. Notify the HCP of hot, dry skin.

Notify the HCP if there is headache or irritability. Headache and irritability are symptoms of hypoglycemia, so these should be reported. Hypoglycemia can be dangerous when blood glucose levels are below 50 mg/dL in adults because it can cause irreversible damage to the cerebral cortex. The brain cannot burn anything other than glucose. A prn prescription for parenteral glucose or a carbohydrate meal is usually given. Report excessive hunger and/or weakness. Excessive hunger and weakness are a sign of hypoglycemia, which can be a result of not eating or an indication of a side effect of insulin or oral hypoglycemic agents. These symptoms should be reported. A prn prescription for parenteral glucose or a carbohydrate meal is usually given. Report cold and clammy skin. Hypoglycemia causes autonomic nervous system symptoms such as nervousness, sweating, irregular heart rhythm, tremor, and hunger, and these symptoms should be reported.

In addition to the insulin, which of the following immediate measures would be indicated in the treatment of Mr. Rogers?

Potassium supplements. Ketones accumulate, which produces a drop in blood pH and increases the number of hydrogen ions in the blood, resulting in acidosis. The body attempts to buffer the acidic hydrogen ions by exchanging them with intracellular potassium ions. Potassium supplements are given to restore normal potassium levels. Sodium bicarbonate. The sodium bicarbonate is administered to correct the metabolic acidosis. 0.9% normal saline. Fluids are used to correct profound dehydration and hyper osmolarity.

The nurse understands that which symptoms are associated with diabetic peripheral neuropathy? Reduced ability to feel pain or temperature in the Frequent UTIs or incontinence. Muscle weakness and difficulty walking. Problems with erectile dysfunction. Extreme sensitivity to touch.

Reduced ability to feel pain or temperature in the extremities. Peripheral neuropathy is the most common form of diabetic neuropathy affecting the ends of the nerves in the feet and legs first, followed by neuropathy affecting the hands and arms in a stocking- like pattern. Problems with erectile dysfunction. This is a type of diabetic autonomic neuropathy, a condition in which the nerves of nearly all body systems (autonomic system) are impaired. Extreme sensitivity to touch. Peripheral neuropathy is the most common form of diabetic neuropathy affecting the ends of the nerves in the feet and legs first, followed by neuropathy affecting the hands and arms.

Which information about the client is of most concern to the nurse? Blood glucose rises from 120 mg/dL to 125 mg/dL in 8 hours. Washes hands with soap and water and allows alcohol swab wipe to dry before performing chemstick. Reports a new onset of blurry vision. Depends on handwritten notes to recall his last blood glucose reading.

Reports a new onset of blurry vision. Blurry vision can indicate cataracts, glaucoma, optic nerve damage or diabetic retinopathy.

Which other symptoms should the nurse expect to find in a client with a diagnosis of diabetic retinopathy? Reports of floaters. Loss of vision. Jaundice of the sclera. Difficulty with color perception. Pupil fixation.

Reports of floaters. Small micro aneurysms protrude from the vessel walls, causing the client to see red and black spots or lines described as floaters. Loss of vision. Micro aneurysms and edema can lead to increased intraocular pressure, retinal detachment and glaucoma, which can all cause loss of vision. Difficulty with color perception. Macular edema associated with diabetic retinopathy can cause impaired hue discrimination resulting in impaired color perception.

Which (possible EKG) pattern should the nurse report immediately to the HCP? ST depression and "U" waves. Sinus tachycardia. Sinus bradycardia. Sinus arrhythmia.

ST depression and "U" waves (Indicates hypokalemia) After insulin therapy, hypokalemia is expected because the potassium shifts back into the cell. Hypokalemia is a serum potassium level less than 3.5 mEq/L and can be life threatening. Flat or inverted T waves or increased "U" waves can occur with hypokalemia.

It is important for the client to report which potential adverse or side effect associated with gabapentin (Neurontin)? Restlessness. Tarry stool. Dry mouth. Flatulence.

Tarry stool. A tarry or black stool may be an indication of a gastrointestinal bleed, a potentially life-threatening complication.

The nurse understands that which concept is important when addressing the client's physiological and psychosocial needs? Socialization is important, but community dining should be avoided because the timing is restrictive and could lead to adverse reactions of medications. The client's need for a special diabetic meal plan overrides the benefits of community dining; therefore meals should be prepared in the apartment. The client's diabetes mellitus should not present a problem for community dining. The nurses in the community dining center should take any food containing sugar away from clients who have diabetes mellitus.

The client's diabetes mellitus should not present a problem for community dining. The client should be able to order or select dishes on his diabetic meal plan from the community dining center. A special dietary need will not typically prevent a client from enjoying the social benefits of a community dining experience.

The nurse reviews potential adverse and side effects of gabapentin (Neurontin) with Mr. Rogers, who denies experiencing them at the present time.

The nurse asks Mr. Rogers a series of questions related to his urinary and bowel elimination patterns.

Mr. Rogers completes his round of antibiotics. He reports that his UTI symptoms have resolved, and follow-up urinalysis results are normal.

The nurse creates Mr. Rogers' care plan and records a nursing diagnosis for knowledge deficit related to signs and symptoms of hypoglycemia.

With the understanding that Mr. Rogers' eating habits lack consistency, which physiological facts about the client's nutrition are most concerning to the nurse? The stage II non-healing ulcer on the client's right heel could require amputation. The development of hypoglycemia could be life-threatening. Lack of exercise and activity require less nutritional nutrients. Dehydration exacerbated by lack of nutrition. Lack of appetite and not wanting to eat alone could lead to malnutrition.

The stage II non-healing ulcer on the client's right heel could require amputation. Extra protein is needed for healing wounds and restoring losses. Extensive tissue destruction, such as that which occurs with burns, pressure sores, and diabetic ulcers requires a large protein increase for the healing and grafting processes. Older adults with diabetes mellitus II (DM) also demonstrate poor wound healing. The development of hypoglycemia could be life-threatening. This is a concern to the nurse. Dehydration exacerbated by lack of nutrition. Approximately 19% of total water intake comes from food. Uncontrolled diabetes mellitus causes an excess loss of water through urine as a result of high blood glucose levels. In such cases, the replacement of lost water and electrolytes is vital to prevent dehydration. Lack of appetite and not wanting to eat alone could lead to malnutrition. Many of the health problems of older adults result from general aging and states of malnutrition caused by poor food habits, such as a lack of appetite, or loneliness and not wanting to eat alone.

The nurse understands that which physiological age-related change is often responsible for dehydration in the elderly? Taste buds are more sensitive, leading to a decreased desire for liquids. Thirst decreases, contributing to less fluid intake. Increased glomerular filtration rate. Constriction of the esophagus prevents fluid metabolism.

Thirst decreases, contributing to less fluid intake. Older adults have a higher baseline osmolality and, thus, a higher osmotic operating point for thirst sensation. As the thirst mechanism decreases, the elderly individuals are more likely to take in fewer fluids. Urine output rises from osmotic diuresis.

Which technique is correct (for first dose of intramuscular B-12)?

Use a 1 to 1 ½ inch needle. For a male client who weighs 130 to 260 lbs (59 to 118 kg), a 1 to 1½ inch needle is recommended.

Which instruction related to bath safety is best? Use toes or elbow to make sure that the water is not too hot. Let hot bathwater sit for 10 minutes before entering the bath. Use equal amounts of hot and cold water when preparing the bath. Use a bath thermometer to ensure that the temperature is below 102° F (38.8° C).

Use a bath thermometer to ensure that the temperature is below 102° F (38.8° C). Use of an unbreakable thermometer to ensure temperature is below 102° F (38.8° C) will help prevent burns for the client with peripheral neuropathy.

Which actions will help to maintain skin integrity? Use heel protectors. Use special mattress or foot cradles. Apply drying agents, such as alcohol, to the skin. Apply skin moisturizers to prevent cracking. Instruct the client to wear clean white socks.

Use heel protectors. Heel protectors can help take pressure off the heels. Check heels for erythema, blisters, or breaks in skin integrity. Use special mattress or foot cradles. Pressure on infected or open wounds on the feet can be eliminated by the addition of a soft care mattress or use of a foot cradle. Apply skin moisturizers to prevent cracking. Foot deformities are common in diabetic neuropathy and may lead to callus formation, ulceration, and increased areas of pressure. Instruct the client to wear clean white socks. Clean white socks should be worn with shoes that fit properly.

The nurse should instruct the client to take which action first when collecting a urine sample? Collect 1 or 2 ounces of urine. Wipe the genital area clean. Dry any excess urine from the outer specimen cup. Hold the cup a few inches from the urethra.

Wipe the genital area clean. This step helps prevent contamination of the sample from the skin