Meiner Ch. 17 & 18

An older patient with presbycusis has been advised to purchase a hearing aid and asks about its function and use. Which information is most accurate to give the patient about the function of hearing aids? A. Hearing aids amplify sound but do not improve the ability to hear. B. Hearing aids improve hearing by intensifying the duration of sound waves. C. Hearing aids control the input of sound waves to eliminate extraneous noise. D. Hearing aids intensify sound waves and improve the ability to hear.

ANS: A Hearing aids amplify sound but do not improve the ability to hear. The other statements are not accurate regarding hearing aids.

In creating community education on various types of skin cancer, the nurse places the highest priority on early diagnosis of melanoma because A. it accounts for the largest number of mortalities. B. extensive surgery can be avoided if caught early. C. once it has spread there is no chance of curing it. D. it is the most commonly occurring skin cancer.

ANS: A Melanoma is a malignant neoplasm of pigment-forming cells that is capable of metastasizing to any organ of the body, even before the lesion is noted; therefore early detection is crucial. Therefore it is critical that the condition is diagnosed promptly. Basal cell carcinoma is the most common type of skin cancer.

An older diabetic patient reports a candidiasis infection. When asked, the patient states all blood sugars have been within the target range. What action by the nurse is best? A. Facilitate having a hemoglobin A1C drawn. B. Teach the patient preventive measures. C. Teach the patient about the side effects of medications. D. Review the patient's medication history.

ANS: A Often candidiasis infections in diabetics indicate hyperglycemia. The patient may or may not be truthful about the blood sugar reports, or the patient may be missing periods of hyperglycemia when testing. The nurse should consult with the provider about checking an A1C. The other options are appropriate as well but do not give information as to the background cause.

A 66-year-old patient has been diagnosed with type 2 diabetes mellitus and related vision loss. Which statement demonstrates the ability to manage her condition? A. "I schedule my yearly eye examination for the week of my birthday." B. "When I notice haloes around lights, I'll know I have a problem with retinopathy." C. "My sister had diabetic retinopathy, and the vessels in her eyes were scarred." D. "I understand that the eye problems need to be diagnosed with an ophthalmoscopic exam."

ANS: A Patients with diabetes should have a yearly examination by an ophthalmologist. Scheduling the exam for the week of her birthday will keep the patient from forgetting to do so. The other statements are not related to management.

A patient had a chemical splash into the eye at work. What action by the occupational health nurse takes priority? A. Begin flushing the patient's eye with cool water. B. Call emergency medical services. C. Ask about the patient's tetanus status. D. Tape the eye closed to prevent injury.

ANS: A The nurse should begin flushing the eye immediately. While the eye is being irrigated, the nurse can call 9-1-1 and inquire about the patient's last tetanus shot. The eye should not be taped shut.

An older adult patient reports pruritus. The nurse educates the patient on the importance of which action? A. Applying a lanolin-rich cream and avoiding scratching the areas B. Taking warm baths and gently rubbing of affected areas with a terrycloth towel C. Minimizing ingestion of fried foods and use of an antihistamine cream D. Avoiding bath oils and allowing the skin to air-dry after bathing

ANS: A The nurse suggests that the patient apply emollients (e.g., Lubriderm, Moisturel, or Eucerin lotion or cream), which have more lanolin or oily substances than many commercial lotions. Time should be planned to teach the patient and family about etiologic factors and the importance of not scratching. The other options are not helpful and will not decrease the itching.

A patient in a nursing home is confused, nonverbal, but pleasant. The nurse notes the patient has suddenly become agitated and is screaming and scratching at the eyes. While the nurse is examining the patient, the patient vomits. What action by the nurse is best? A. Consult the provider about an ophthalmologic exam. B. Sedate the patient so she won't injure herself. C. Place mitts on the patients hands to avoid scratches D. Give the patient a prn medication for pain.

ANS: A The patient could be having an episode of acute angle closure glaucoma, manifested by severe pain, nausea and vomiting, and visual disturbances. Because the patient is nonverbal, the nurse must assess for pain with behavioral changes. The nurse should contact the provider immediately about obtaining an ophthalmologic exam to determine if the patient has glaucoma. The other interventions will not help determine the cause of the problem. The nurse should attempt to discover the source of the behavior, not just try to control it.

An older adult patient has been taught measures to prevent the development of skin cancer. Which statement, if made by the patient, indicates the need for more teaching? A. "I will certainly miss my vegetable and flower gardening." B. "I should buy a sunscreen with an SPF of 15 or higher." C. "Now I have a good excuse to wear the straw hat my spouse hates." D. "My cool long-sleeved shirts will work just fine while I'm golfing."

ANS: A The patient is still able to garden as long as he or she takes appropriate sun precautions. The other statements show good understanding.

A patient with glaucoma is on timolol. The patient also takes metoprolol for hypertension. The patient reports to the clinic nurse that the eyedrops "Make me dizzy." What assessment by the nurse is most appropriate? A. Assess the patient's eyedrop instillation technique. B. Determine how long the patient has been on the drops. C. Assess the patient's gait and balance while walking. D. Ask the patient if breakfast is eaten prior to applying the eyedrops.

ANS: A The patient should be using punctal occlusion (closing the lacrimal duct by pressing lightly on the lower eye lid) when instilling these eyedrops to avoid a cumulative, systemic effect from the combination of both beta-blockers. The nurse can assess the other factors as well, but this is the most likely cause of the dizziness.

An older adult patient has an open, draining wound on the lower medial aspect of the right leg. The skin surrounding the wound is reddish brown with surrounding erythema and edema. Based on this information, the nurse edits the patient's care plan to include impaired skin integrity related to which factor? A. Altered venous circulation B. Arterial insufficiency C. Diabetic neuropathy D. Pressure ulcer

ANS: A Venous ulcers are usually on the medial aspect of the lower leg, with flat or shallow craters and irregular borders, accompanied by varicosities, liposclerosis (brown ruddy color and thickened skin), and itching. Venous ulcers generate a large amount of exudate and are usually surrounded by erythema and edema. Arterial insufficiency would produce shiny, taut, hairless skin. There is no indication the patient is a diabetic. There is no indication the patient has risks for pressure ulcers.

A 96-year-old patient reports symptoms of xerostomia. What action by the nurse will be most helpful in minimizing the effects of this condition? A. Providing appropriate fluids with the patient's meals B. Cutting the patient's meat into small bite-sized pieces C. Elevating the head of the patient's bed at mealtimes D. Assisting the patient with oral care before each meal

ANS: A Xerostomia, commonly referred to as dry mouth, is a subjective sensation of abnormal oral dryness. Reduced salivary flow is a common complaint of older adults. Dry mouth in the older adult can lead to an increased risk of serious respiratory infection, impaired nutritional status, and reduced ability to communicate. Offering appropriate fluids with meals will assist with proper nutrition. The other options will not provide relief for this condition.

A patient has been admitted to the post anesthesia care unit after a trabeculectomy. What assessment takes priority? A. Airway B. Pain C. Eye patch D. Blood pressure

ANS: A Airway always comes first when prioritizing care.

A nurse is assessing a patient who reports moderate tinnitus. The nurse should assess the patient for which of the following? (Select all that apply.) A. Alcohol and caffeine intake B. Unilateral or bilateral symptoms C. Cerumen impaction D. Frequent ear infections E. Exposure to radiation

ANS: A, B, C Important items for the nurse to assess in a patient with tinnitus include alcohol and caffeine intake, whether the symptoms are unilateral or bilateral, and cerumen impaction. Frequent ear infections and radiation exposure are not related.

When assessing the patient's vision, the nurse should understand that older adults may report common aging changes, including which of the following? (Select all that apply.) A. "My eyelids droop so unattractively." B. "The whites on my eyes seem a bit yellow." C. "The vision in my right eye seems blurry." D. "I've started to use over-the-counter eye moisturizing drops." E. "I have noticed the night driving has become more difficult."

ANS: A, B, D, E The eyelids lose tone and become lax, which may result in ptosis of the eyelids, redundancy of the skin of the eyelids, and malposition of the eyelids. The conjunctiva thins and yellows in appearance. In addition, this membrane may become dry because of the diminished quantity and quality of tear production. Peripheral vision decreases, night vision diminishes, and sensitivity to glare increases.

An older adult diagnosed with Ménière disease is prescribed meclizine and hydrochlorothiazide. The nurse's educational instructions include which of the following? (Select all that apply.) A. The need to avoid alcoholic beverages B. Instructions to take the medication with food C. Symptoms of electrolyte imbalances D. That drowsiness is a common side effect E. Stopping the medication if chest pain occurs

ANS: A, C, D Meclizine may cause drowsiness; patients should be instructed to avoid alcoholic beverages while taking this drug. A patient on a diuretic such as hydrochlorothiazide needs to be monitored for evidence of fluid or electrolyte imbalances.

Which of the following are appropriate steps to take when removing cerumen from an older person's ear? (Select all that apply.) A. Instill a softening agent first. B. Use hot water and hydrogen peroxide. C. Use an ear syringe and warm water for irrigation D. Have the patient lean backward to drain the water. E. Have the patient lean forward toward the affected side to drain the water.

ANS: A, C, E The nurse instills a softening agent and uses warm (not hot) water mixed with hydrogen peroxide or saline to irrigate the ear. An ear syringe is used and is inserted just inside the meatus so the tip is still visible. Tip the patient's head toward the side being irrigated. When draining, the patient can lean forward and toward the affected side.

The presence of which skin assessment finding should cause the nurse to suspect a premalignancy? A. Numerous small red papules on the chest and back B. A rough, reddish macule on the ear C. An irregularly shaped mole on the shoulders D. Brown, greasy lesions on the neck

ANS: B Actinic keratosis begins in vascular areas as a reddish macule or papule that has a rough, yellowish brown scale that may itch or cause discomfort. Actinic keratosis may evolve into squamous cell carcinoma (SCC) if not treated, so it should receive prompt attention. Red papules, irregularly shaped moles, and brown greasy lesions are not likely to be precancerous.

The nurse assesses a patient using the Braden scale. The patient scores a 13. What action is most important to add to the patient's care plan? A. Encourage high-protein meals and snacks. B. Turn the patient every 1.5 to 2 hours. C. Assess the patient's skin daily. D. Monitor patient's prealbumin weekly.

ANS: B A Braden scale score of 13 indicates high risk for developing a pressure ulcer. The most important intervention is to turn the patient frequently. Good nutrition is important for wound healing and prevention, but a high-protein snack and monitoring prealbumin do not immediately impact the patient's skin condition. Assessing the skin will not prevent an ulcer.

An older patient has been treated for a small basal cell carcinoma on the face. What assessment finding indicates to the nurse that the goals for a priority diagnosis have been met? A. The patient verbalizes relief there is no metastasis. B. Wound edges are approximated without redness. C. The patient expresses satisfaction with the cosmetic outcome. D. The patient relates the need for proper sun protection.

ANS: B All findings indicate positive resolution of various nursing diagnoses. However, physical diagnoses take priority, so the best response is the one that indicates lack of infection.

An older adult patient newly diagnosed with peripheral vascular disease (PVD). What assessment finding indicates the patient may have an arterial ulcer resulting from this disease? A. Deep, necrotic, and painless sore B. Shiny, dry, cyanotic skin surrounding the ulcer C. Ulcer appears shallow, crusty with warm skin D. Sore that has dull pain and is oozing

ANS: B As the disease advances, the extremity develops a cyanotic hue and becomes cool. The skin becomes thin, shiny, and dry and has an associated loss of hair and thickened nails, all of which results from the diminished blood supply. This assessment finding indicates an arterial ulcer.

An older adult patient reports burning and itching eyes. On assessment, the nurse notes swelling of the eyelid margins bilaterally. What additional data would the nurse assess for? A. Reports of visual disturbances such as halos. B. The eyelids are reddened from seborrhea. C. The patient is being treated with anticoagulants. D. Small corneal hemorrhages are present.

ANS: B Blepharitis is a chronic inflammation of the eyelid margins that is commonly found in older adults. It can be caused by seborrheic dermatitis or infection. The symptoms include red, swollen eyelids, matting and crusting along the base of the eyelash at the margins, small ulcerations along the lid margins, and complaints of irritation, itching, burning, tearing, and photophobia.

The nurse plans to assess for candidiasis as a priority intervention for which patient? A. 60-year-old with a history of bacterial pneumonia B. 72-year-old incontinence of urine and feces C. 58-year-old with a casted left foot D. 90-year-old receiving antihypertensives

ANS: B Candidiasis is most commonly seen in diaper-clad infants, incontinent patients, and bed-bound individuals and in moisture-prone areas of the body (e.g., skin folds and axillae). The other patients are not as likely to have this disorder as the incontinent patient.

The nurse of a bedridden 74-year-old woman is evaluating whether the family members understand how to position the patient correctly. The nurse is confident the family is capable of effective positioning when it is observed that the family members perform which action? A. Support the arms and legs on two pillows. B. Turn the patient at least every 2 hours. C. Hyperflex the neck using pillows D. Rest elbows on the bed with lower arms elevated.

ANS: B In the 1950s, Kosiak (1958) found that pressure applied to rabbits' ears over 2 hours would result in ulceration. Thus the universal recommendation of turning every 2 hours was established. The family should turn the patient at least every 2 hours, more often if the patient's skin shows signs of pressure injury during that timeframe. The other actions are not proper positioning techniques.

An older adult's chart documents that she has been diagnosed with macular disequilibrium. Based on an understanding of this condition the nurse suggests that the patient A. turn her head very slowly when looking from right to left B. dangle her legs at the bedside before getting out of bed. C. use the wall for stabilization when ambulating in the hallway. D. be careful to be seated when flexing or hyperextending her neck.

ANS: B Macular disequilibrium is vertigo precipitated by a change of head position in relation to the direction of gravitational force (e.g., severe dizziness when rising from bed). Dangling at the bedside and changing positions slowly will decrease the chance of injury. The other interventions do not relate to this disorder.

A patient has a wound that is a shallow lesion with a red, moist wound bed. What stage pressure ulcer does the nurse chart? A. Stage I B. Stage II C. Stage III D. Stage IV

ANS: B Stage II is a partial thickness ulcer that looks like an abrasion, blister, or shallow crater. The wound bed is pink or red and moist. A stage I pressure ulcer is redness or mottled skin that does not blanch. Stage III ulcers are full thickness deep craters. Stage IV ulcers may extend into the fascia and may be necrotic

An older adult patient reports "ringing" in the ears. What additional data should the nurse gather to help determine the cause of the patient's problem? A. History of ear surgery B. Use of prescription medications C. Exercise and sleep patterns D. Nutritional status, especially protein intake

ANS: B Tinnitus can be a result of damage to inner structures caused by the toxic effect of certain drugs. The other assessment findings are not as important for this problem.

The nurse knows that several age-related changes in the integumentary system increase older adults' risk for pressure ulcers. Which factors does this include? (Select all that apply.) A. Poor nutrition B. Living in a nursing home C. Thinning epidermis D. Decreased skin elasticity E. Vessel degeneration

ANS: C, D, E Thinning epidermis, decreased elasticity of the skin, and deterioration of the vasculature are all age-related changes increasing risk of pressure ulcer development. Poor nutrition and living in a nursing home are not expected age-related changes.

A patient has a purulent, foul-smelling tunneling leg wound. What wound care practice is most appropriate? A. Leave the wound open to the air. B. Administer systemic antibiotics. C. Pack the wound with iodine-impregnated gauze. D. Prepare the patient for operative debridement.

ANS: C Antiseptics are not used on healthy granulating tissue. Iodine-impregnated gauze can be packed into the tunnels of this infected wound. A moist environment is needed for healing; leaving the wound open to air will cause too much drying. The patient may eventually need operative debridement. Systemic antibiotics may or may not be needed.

An 88-year-old patient is hospitalized for a retinal detachment. He is on bed rest, and both eyes are covered with patches. Which nursing diagnosis takes priority at this time? A. Self-esteem disturbance related to decreased independence B. High risk for altered thought processes related to visual impairment C. High risk for injury related to altered sensory perception D. Impaired social interaction related to visual deficit

ANS: C If the eyes are patched, safety precautions, such as keeping call lights, side rails, and necessary items within reach, must be instituted. Finally, assistance must be provided with activities of daily living (ADLs) and walking as needed to promote comfort and safety. The other diagnoses may be appropriate for selected patients

A patient has Meniere disease. What statement by the patient indicates a good ability to manage the condition? A. "Because it's from dehydration, I can increase salt in my food." B. "There are no medications, so I just have to learn to live with it." C. "If I get dizzy I should lie down immediately and hold my head still." D. "Because I have asthma, I cannot take any medications for Meniere disease."

ANS: C If the patient gets dizzy, he or she should lie down and hold the head still. A low-salt diet may help with fluid retention in the ear. There are several medications for Meniere disease, but because of the anticholinergic properties of some of them, people with asthma, glaucoma, or BPH should be monitored closely.

When assessing the older adult patient's skin, what finding would indicate the need to notify the provider as the priority? A. Thick, adherent scale with a soft center B. Small, inflamed lesion that bleeds easily C. Irregularly shaped multicolored mole D. Small, purple, hard nodule beneath the skin surface

ANS: C Melanoma's clinical hallmark is an irregularly shaped nevus (mole), papule, or plaque that has undergone a change, particularly in color. The other options do not display the characteristic signs of melanoma. This patient has the highest need for the nurse to communicate with the provider.

When assessing for squamous cell cancer (SCC), a home health nurse is particularly concerned about which suspicious lesion? A. Leg of a 60-year-old Asian female B. Neck of a 73-year-old Hispanic female C. Lower lip of a 70-year-old African American male D. Back of a 90-year-old Caucasian male

ANS: C SCC is skin cancer arising from the epidermis and is found most often on the scalp, outer ears, lower lip, and dorsum of the hands. Approximately 90% of lip lesions can be attributed to squamous cell carcinoma. SCC is more common in men and older adults. SCC is the most common skin cancer in African Americans.

An 87-year-old patient developed herpes zoster after surgical repair of a hip fracture. The priority nursing diagnosis is A. impaired skin integrity related to immunologic deficit. B. self-care deficit related to severe pain and fatigue. C. risk for infection related to impaired skin integrity. D. pain related to inadequate pain relief from analgesia.

ANS: C These vesicles are extremely vulnerable to secondary bacterial infections. The other diagnoses might be appropriate for some patients.

A 65-year-old man is seen in the outpatient clinic for treatment of psoriasis. The nurse educates the patient to the possibility of developing which other manifestation? A. Alopecia B. Orange-tinged urine C. Yellow-brown nails D. Cherry angiomas

ANS: C Changes in the nails occur in approximately 30% of patients and consist of yellow-brown discoloration with pitting, dimpling, separation of the nail plate from the underlying bed (onycholysis), thickening, and crumbling

For which patient does the nurse add compression therapy to the nursing care plan? A. Taut, white, shiny skin B. Faint pedal pulses C. Brownish skin and edema D. Large ulcer with skin graft

ANS: C Compression is the mainstay of venous ulcer treatment, and it should be applied when there is brownish skin and edema. The taut white shiny skin and faint pulses indicate arterial insufficiency, and compression will compromise circulation in those extremities even further. A skin graft needs to be protected, as it is vulnerable until healed.

A patient had cataract surgery without a lens implant. What teaching point is most important? A. Keep your follow-up appointment with the surgeon. B. Instill your eyedrops just like we have practiced. C. Do not drive and be careful going up or down stairs. D. Take acetaminophen if needed for pain.

ANS: C If cataract surgery was performed without a lens implant, the patient will wear glasses or contact lenses but will have a decrease in depth perception. The patient should not drive and should use extra caution navigating stairs. The other instructions are appropriate for any patient having cataract surgery.

A 77-year-old patient has impacted cerumen. During the nursing assessment, the nurse confirms supporting evidence of the condition when noting A. frothy drainage from the patients ears B. patient reports of dizziness. C. patient reports of a feeling of fullness in the ears. D. gray, metallic-appearing tympanic membrane.

ANS: C Patients with cerumen buildup may complain of ear fullness, itching, and difficulty hearing. The patient will not have frothy drainage, dizziness, or metallic-appearing tympanic membrane from cerumen.

An older diabetic patient has impaired mobility and decreased vision. The nurse examines the patient's feet at each clinical visit. The patient asks why this is necessary. What response by the nurse is best? A. "It's part of our diabetic clinic visit protocol." B. "You may not be able to see a sore on your feet." C. "Limited mobility may keep you from checking your feet. D. "You may get an ulcer and not be able to feel it."

ANS: D A diabetic with peripheral neuropathy may not be able to feel injuries on the feet. The injury may progress to a nonhealing ulcer requiring amputation. If the patient had good sensation to the feet, not being able to see or limited mobility would not be as big of a barrier because the patient could report the symptoms. Foot assessment is part of a diabetic clinic protocol but that answer does not educate the patient.

The nurse explains that the plan of care for an older adult patient with seborrheic dermatitis of the scalp should include which actions? A. Cleaning lesions with a weak hydrogen peroxide solution daily B. Cleaning the scalp with a low-dose steroidal shampoo C. Applying hydrocortisone 10% to scalp lesions D. Applying selenium shampoo to the scalp

ANS: D A successful strategy is to wet the hair, apply selenium shampoo, and then proceed with the rest of the bath or shower. The other measures will not be successful.

The preferred way for the nurse to communicate with a 72-year-old hearing-impaired patient is to A. speak loudly into the patient's unaffected ear. B. exaggerate the form of each word. C. provide all communication in written form. D. speak clearly and directly, facing the person.

ANS: D Interventions for the patient with a hearing impairment focus on aural rehabilitation and facilitation of communication. Patients should be spoken to using a clear voice and face to face, which gives the patient an unobstructed view of the speaker's face and lips. Speaking more loudly will not improve communication nor will exaggerating each work. While some written information will be helpful, it is not necessary to use writing for all communication, unless the patient directs the nurse to do so.

The morning of her scheduled cataract extraction and intraocular lens placement of the right eye, an older adult patient expresses concern that she will not remember her instructions for home care. Which statement is the best response to the patient's concern? A. "Is your family going to be here while you're in surgery?" B. "Are you anxious about the surgery?" C. "I'll reinforce the important points." D. "We will provide you with written instructions."

ANS: D Postoperative care requires teaching the patient and family home care procedures for the period after cataract surgery and should be given orally as well in written form. The patient may or may not have family present. Asking about anxiety could be important, but yes/no questions are not therapeutic. The nurse's idea of what are the important points may differ from the patient's.