Ch 10 Prep U Questions

A nurse is assessing an older adult for depression using the Yesavage Geriatric Depression Scale. Which score would the nurse identify as indicating possible depression?

6

A nurse is assessing an older adult using the short form of the geriatric depression scale. The nurse determines that the client is depressed based on which score?

6

A nurse is reviewing the medical records of several older adults admitted to the long-term care facility. Each of the clients has been assessed for depression using the Yesavage Geriatric Depression Scale. Which clients would the nurse identify as requiring interventions related to possible depression? Select all that apply.

80-year-old female with a score of 7 71-year-old male with a score of 10

After obtaining the health history from an older adult client, the nurse develops a plan of care and identifies a nursing diagnosis of Risk for Impaired Physical Mobility. A history of which condition would support this nursing diagnosis? Select all that apply.

Arthritis Hip fracture Stroke

The nurse is providing care to an older adult client. Which assessment finding would necessitate the inclusion of interventions in the nursing plan of care to decrease the risk for disability?

Client's current body mass index (BMI) is 40.

A nurse is caring for an older adult client who fell and sustained a hip fracture. Which intervention needs to be included in the nursing care plan? Select all that apply.

Cough and deep breathe every 2 hours. Avoid massaging over bony prominences. Auscultate breath sounds every 1-2 hours.

The nurse is assigned to care for a client age 87 years admitted to the medical unit for congestive heart failure. It is the fourth hospital day, and the response to treatment has been good. The client is no longer short of breath and the lung sounds are clearing. There is still a diet restriction of decreased sodium and fluids are limited to no more than 1000 mL per day. The nurse is preparing the client and family for discharge. The nurse's discharge education, in order to promote the older client's health, will include which instructions? Select all that apply.

Gradually increase activities as tolerated. Do not use the salt shaker at meals. Increased stress may interfere with recovery.

A nurse is assessing a 55-year-old female client. What is a normal physical change in the middle adult? Select all that apply.

Hearing acuity diminishes. There is a loss of calcium from bones. Cardiac output begins to decrease.

A nurse is preparing a presentation for families who are caring for older adults at home. Which information would the nurse most likely include about an older adult's cognition?

Many older adults retain full cognitive function into advanced age.

Which statement is true for nursing care of older adults?

Most older adults are functional, benefiting from health-oriented interventions.

A male client reports chronic insomnia. Which medication would the nurse not want to administer to the client?

Nasal decongestant for an upper respiratory infection

A nurse is preparing an in-service presentation for a group of nurses who work with older adults. The nurse would include which finding associated with this population? Select all that apply

Older adults living with a spouse decreases with age. Most older adults are satisfied with their life There are three times as many widows as widowers.

An client 81 years of age is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the client wandering in the hall. He says he is looking for his wife. What should the nursing approach should be?

Remind him of where he is and assess why he is having difficulty sleeping.

A nurse is providing care to an older adult at home after major abdominal surgery. Which nursing diagnosis would most likely be appropriate?

Risk for Infection

A nurse is preparing a presentation for a group of older adults about health promotion. Which statistic would the nurse need to keep in mind about this group?

The group experiencing the largest growth is those 85 years of age and older.

A 90-year-old woman is admitted to a nurse's unit status post CVA. The client is alert and oriented to person, place, and time but has limited mobility and hemiparesis of the left side of her body. She is experiencing urinary incontinence. What is the most appropriate nursing action?

Use the Braden scale to assess for pressure ulcers.

The nurse is planning an educational event for a group of senior citizens on the topic of the normal signs of aging. What would the nurse include in the education plan?

a decrease in muscle mass

An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition?

delirium

What term is used to describe various disorders that progressively affect cognitive function?

dementia

A 78-year-old woman is status post right hip fracture after a fall. She has stopped going to her church over the past few months. She has also asked her neighbor to help her and do her gardening, an activity she previously loved. The client tells the nurse "I just don't enjoy gardening like I used to. I am always worried about falling." What would most concern the nurse regarding the client?

depression

Family members of older adults with limitations from chronic illnesses may experience multiple stressors. Which is not considered one of these stressors?

feeling valued, useful, and productive

An older adult client is prescribed a sleep medication. When explaining the medication to the client, the nurse would emphasize which aspect of therapy?

greatest effectiveness with short term use

While providing care to an older adult client, the client states, "There's a huge spider on the wall over there that is coming at me." The nurse does not see anything. The nurse documents this finding as:

hallucination

When providing care to a client with dementia, which interventions would be most appropriate? Select all that apply.

maintain levels of sensory stimulation that are tolerable ensuring the use of assistive sensory devices using validation therapy

The nurse is assessing an older adult client who has suffered injury to his nervous system. The client has a history of chronic pain and currently reports pain on a scale of 8 out of 10. The nurse identifies this type of pain as most likely:

neuropathic pain.

A nurse is working on a unit where the majority of the clients are older adults. When reviewing the plans of care for these clients, the nurse notes that chronic pain management is a priority. The nurse implements measures for pain management based on the understanding that which condition is most likely involved?

osteoarthritis

A nursing instructor is educating a class about older adults. Which measure would the instructor identify as one of the most valuable to maximize the quality of life for this population?

pain palliation

A nurse is providing care to an older adult who is experiencing delirium. Which risk factors would the nurse identify as being most common? Select all that apply.

pre-existing cognitive impairment advanced age sleep deprivation

A nurse is preparing for a discussion with a group of older adults about the need for adequate nutrition. Which factor would the nurse address as placing an older adult at risk for decreased food intake? Select all that apply.

reduced thirst sensation early satiety reduced level of physical activity decreased number of taste buds

An older adult client being cared for at home has developed a decubitus ulcer. The nurse would instruct the family caregiver to institute measures to:

relieve sustained pressure.

An older adult is admitted to the health care facility with a diagnosis of depression. The nurse would be especially alert for:

suicidal thoughts

An older adult is admitted to the health care facility with a diagnosis of depression. The nurse would be especially alert for:

suicidal thoughts.

The nurse is developing a plan of care for an older adult with late stage Alzheimer's disease. Which intervention would be most appropriate for the nurse to include in the plan of care?

validation therapy

A nurse is conducting an education session about appropriate measures to promote sleep with an older adult who is experiencing frequent awakenings at night and then awakening early in the morning. The nurse determines that the education was successful when the client states:

"I need to try and go to bed and get up at the same time each night."

A 78-year-old client asks the nurse about the using ibuprofen for relief of his joint pain. Which response by the nurse would be most appropriate?

"It's okay for you to take it once in a while but if you need it often, we'll talk with your doctor about adding another medication."

The staff at a long-term care facility have made minimal effort to secure a shared room for a couple in their late 80s, who have been married for several decades. The manager states, "I'm sure that bedroom activity is the last thing on their mind these days." How should the nurse best respond to the manager's characterization of sexuality in older adults?

"They might not be as active as in years past, but sexuality is still important for older people."

The nurse is assigned to a 52-year-old male client. He is talkative and usually friendly when the nurse enters his room. Today, however, he is standing at the mirror and says: "I lost my job because the company downsized; there isn't anything I can do." As his caregiver, the nurse recognizes this expression of concern is related to which of the following?

His career goals and retirement plans are compromised.

The older population, persons 65 and older, numbered over 43 million in 2012. There are limited resources to care for this aging population. Factors that influence society's attitude to this age group include which of the following myths?

Loneliness and isolation are problems associated with this age group. Old age begins at 65. The majority of senior citizens are not in good health. Most older adults live in nursing homes.

An older adult client is prescribed antipsychotic therapy. The nurse understands that this therapy has been initiated based on which reason? Select all that apply.

Other strategies have failed. There is a risk of harm to self or others. The client is displaying psychotic behavior.

A nurse is working at a senior health center. When providing care to the clients at the center, which information about this population's demographics would the nurse need to keep in mind? Select all that apply.

The number of older adults being seen will likely increase due to their increased life expectancy. A relatively small number of adults 65 years and older live in institutional settings. The women are more likely to be widowed than the men.

A home care nurse visits an older adult client with dementia due to Alzheimer's disease. As a result of the client's confused thinking, the client is experiencing significant difficulty in communicating with family members. Which intervention would be most appropriate for this client?

Validate the client's current needs.

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as:

abandonment

A nurse is providing an in-service program for a group of nurses who work with the older adult population. After describing the older adult population's risk for abuse and neglect, the nurse determines that the education was successful when the group identifies a vulnerable adult as having which characteristic? Select all that apply.

adult 60 years or older lacking self-care ability adult with disability adult in a long-term care facility adult receiving provider services while living in his own home

The nurse is caring for a client diagnosed with dementia. Which behaviors would the nurse most likely assess? Select all that apply.

asking questions repeatedly socially inappropriate behavior wandering irritabilty

Which suggestion would be most appropriate for an older adult experiencing sleep problems. Select all that apply.

avoiding watching television before bed keeping the bedroom cool and quiet avoiding watching the clock when awake

An older adult client tells the nurse, "I just don't seem to have an appetite and food just doesn't taste as good as it used to." The nurse understands that which factor may be playing a role in this client's lack of appetite? Select all that apply.

decreased number of taste buds decreased saliva production

A nurse is preparing a presentation for a group of families who are providing care to their older adult parents. One of the family members asks the nurse, "How common is Alzheimer's disease?" The nurse responds by telling the group that after age 65, the prevalence of Alzheimer's disease:

doubles every 5 years.

A nurse is reviewing the medical records of clients at a long-term care facility who are experiencing weight loss. The clients' medical conditions have been ruled out as a cause. The nurse understands that which situation would most likely be a factor? Select all that apply.

evidence of depression use of appetite-suppressing drugs need for staff to assist with meals

A nurse is making a home visit to an older adult with multiple chronic health problems. The client is alert and oriented and his cognition is intact. While talking with the client, he reveals that he thinks his son is stealing his social security checks to buy his beer and eat out all the time. The nurse interprets this statement as possibly suggesting which type of elder abuse?

exploitation

A nurse is caring for a 46-year-old male client who is being treated for depression following the death of his spouse. Which action best facilitates the accomplishment of a developmental task of this middle adult?

helping him to see the value of guiding his children to become responsible adults

A 78-year-old woman is on a nurse's rehabilitation unit status post a cerebrovascular accident (CVA). As the nurse assess her gait, the nurse notices that the client's left foot is dragging and she is not bending her left knee nor swinging her left arm. How would the nurse best describe the client's gait?

hemiparesis

The nurse is caring for an older adult postoperative critical care client. The nurse finds that the client is acutely confused and trying to get out of bed. What should the nurse do first?

review with the client that he is in the hospital

A nurse documents "dry, thin skin with several areas of ecchymoses" on an older adult client's chart. Which nursing diagnosis would be appropriate for this client?

risk for injury

An older adult who is newly widowed is not adjusting to this change in her role. She is unable to form new relationships. What is the client at risk for developing?

social isolation

An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence?

stress

Based on an understanding of the cognitive changes that normally occur with aging, what might the nurse expect a newly hospitalized older adult to do?

take longer to respond and react