Older Adult ch.7

6. A nurse utilizes the SPICES tool (Sleep disorders, Problems with eating, Incontinence, Confusion, Evidence of falls, and Skin breakdown) to assess an older female patient in the hospital. The nurse notes that the patient has new onset urinary incontinence. The first action by the nurse is to: a. conduct a more in-depth focused assessment of the urinary incontinence. b. call the provider and obtain an order for an antibiotic for a suspected urinary tract infection. c. send a urine specimen for culture and sensitivity. d. develop a plan of care with the patient to control episodes of incontinence.

ANS: A SPICES is an assessment tool. Anything that indicates a problem in any of the categories warns the nurse that a more in-depth assessment is needed. The nurse needs to further assess the urinary incontinence prior to implementing any interventions.

1. The FANCAPES assessment tool focuses on the older adult's: a. ability to meet personal needs to identify the amount of assistance needed. b. ability to perform instrumental activities of daily living (IADLs). c. cognitive abilities. d. level of dementia present.

ANS: A The FANCAPES assessment tool focuses on physical functioning and evaluates the individual's ability to meet his/her needs and how much assistance is needed to meet the needs. FANCAPES evaluates physical functioning. IADLs involve more than just physical functioning. FANCAPES does not assess cognitive function, nor does it assess dementia.

9. A nurse completes a functional status assessment of an older person using the Lawton IADL instrument, a self-reported instrument. The nurse knows that limitations of self-reported measures include that: (Select all that apply.) a. individuals tend to overestimate their functional ability. b. self-reports often differ from that of proxy reports. c. self-reports are not indicative of small changes in function. d. self-reports do not provide a valid measurement of function. e. older adults are not able to complete self-reported measurements.

ANS: A, B Individuals tend to overestimate their functional ability and often self-reported measures differ from proxy reports. Self-reported measures are a valid measurement of function, and older adults are able to complete them. The choice of tool and the type of scoring of the tool is the factor that determines if the small changes in function can be detected.

7. A nurse identifies a need to assess a patient's cognitive status. The nurse chooses to use the MMSE. The nurse knows that the patient must have which of the following abilities? (Select all that apply.) a. Number fluency b. Familiarity with analog clocks c. Ability to hear and see d. Ability to sit up for 10 minutes e. Ability to speak English

ANS: A, B, C The MMSE requires number fluency, ability to see and hear and hold a pencil, and experience with analog clocks. The instrument is available in languages other than English. It is a cognitive status exam and does not require that the patient be able to sit up.

8. Factors that complicate assessment of older adults include: (Select all that apply.) a. presence of multiple comorbid conditions. b. atypical presentation of illness. c. difficulty in differentiating symptoms of disease from normal age-related changes. d. increase in iatrogenic illness. e. lack of assessment instruments specific for the older adult population.

ANS: A, B, C, D Factors that complicate assessment of older adults include difficulty differentiating disease symptoms from normal age-related changes, the presence of multiple comorbidities, atypical presentations of illness, and the presence of iatrogenic illness. There are many assessment tools that are designed specifically for use in the older adult population.

10. A nurse is assessing a patient's activities of daily living. The nurse will assess which of the following? (Select all that apply.) a. Eating b. Continence c. Toileting d. Self-medication administration e. Bathing

ANS: A, B, C, E The basic activities of daily living include eating, transfer, toileting, bathing, continence, and dressing. Self-medication administration is an independent activity of daily living (IADL).

3. A 78-year-old man is being evaluated in the geriatric clinic. His daughter reports that he has been very forgetful lately, and she is concerned that he might be "senile." The advanced practice nurse administers the clock-drawing test and the patient draws a distorted circular shape and places the numbers all on one side of the shape. Based on his performance, the nurse concludes that the patient: a. probably has Alzheimer's disease. b. needs further evaluation. c. probably has delirium. d. needs a functional status assessment.

ANS: B Cognitively intact persons rarely produce errors on the clock-drawing test, such as grossly distorted contour. A low score on the clock-drawing test requires further evaluation. Alzheimer's disease is not a diagnosis using a mental status assessment tool. It is definitively diagnosed with a brain biopsy. The clock-drawing test does not assess for delirium. A low score on the clock-drawing test does not necessarily warrant a functional status assessment.

2. A limitation of the Katz Index of activities of daily living (ADLs) is that: a. completion of the tool requires the joint efforts of the interdisciplinary team. b. all ADLs are weighted equally. c. it puts a heavier weight on the cognitive abilities necessary to perform ADLs. d. it provides a range of performance for each task.

ANS: B The Katz Index assigns an equal weight to all of the ADLs, and because of that, it cannot be used to identify the particular area of need or change in any one task. Any health care professional can complete the Katz Index, although input from the interdisciplinary team is valuable. The Katz Index does not address the cognitive abilities necessary to perform ADLs. The ADLs are considered in dichotomous terms only, the ability to compete the task independently or the complete inability to do so.

4. When comparing the Older American's Resources and Services (OARS) with the Katz Index of ADLs, what is true? a. The Katz Index and the OARS both measure only ADL performance b. The OARS is a comprehensive assessment tool that measures ability in five areas; the Katz Index measures only ADL performance c. The OARS is used only for older adults in the long-term care setting; the Katz Index is used in all settings d. The OARS is not valid for use in older adults who are cognitively impaired, whereas the Katz Index is

ANS: B The OARS evaluates ability, disability, and capacity at which the person is able to function. Five dimensions are assessed: social resources, economic resources, physical health, mental health, and ADLs. The Katz Index only evaluates ADL ability. Both instruments are used in a variety of care settings and are valid for use with cognitively impaired older adults.

5. A resident of a long-term care facility is assessed by a nurse upon admission to the facility. The assessment includes a comprehensive health, social, and functional profile. The tool that the nurse utilizes is: a. Outcomes and Assessment Information Set (OASIS). b. Resident Assessment Instrument (RAI). c. Older Americans Resources and Services (OARS). d. Comprehensive Geriatric Assessment (CGS). e. Mini Mental Status Examination (MMSE).

ANS: B The OASIS is used in the homecare setting. The RAI is used in the long-term care setting. OARS is a functional status instrument. Comprehensive geriatric assessment is not a specific tool but rather an approach to assessment. The MMSE is a mental status assessment tool.