Jarvis HA Ch 32: Functional Assessment of the Older Adult
The nurse is caring for a geriatric patient who reports insomnia. What does the nurse suggest to promote sleep in the patient? "Avoid prolonged exposure to sunlight." "Ensure that drapes are closed throughout the day." "Talk to a friend over the phone until you feel sleepy." "Avoid working or watching television in the bedroom."
"Avoid working or watching television in the bedroom." Insomnia is difficulty in falling asleep. The bedroom must be used only for sleeping; this helps the brain associate the room with sleep and induces it. Therefore, activities such as reading and watching television should be avoided in the bedroom. Exposure to sunlight during the day is necessary, because it helps set the circadian rhythm that helps reduce the insomnia. If the patient closes drapes throughout the day, then the patient has less exposure to the sunlight and the environment; this does not promote proper sleep. Talking continuously on the phone or spending time in recreational activities near bedtime stimulates the brain, and the patient will not be able to sleep. Therefore, the nurse advises the patient to avoid talking for a long time over the phone before going to bed.
While assessing an older adult patient, the nurse finds that the patient is a spiritual person. What other question should the nurse ask the patient to obtain a better spiritual assessment? "How does spirituality help among your family members?" "How does spirituality relate to your concept of health?" "How does spirituality improve your financial situation?" "How does spirituality help in your family relationships?"
"How does spirituality relate to your concept of health?" While assessing a patient who places a high value on spirituality, the nurse asks how spirituality relates to the patient's perception of health and health care decisions in order to ensure proper assessment. The nurse may ask about the role of spirituality in the family, but only after assessing the health of the patient. The nurse does not require knowledge of the role of the patient's spirituality when asking about the patient's financial aspects. The nurse may ask about the role of spirituality in maintaining family relationships, but only after assessing the health of the patient.
The nurse teaches an older adult about dietary modifications to promote sleep. Which statement made by the patient indicates effective teaching? "I can have a heavy meal for dinner." "I can have milk and crackers at bedtime." "I can include two chocolate drinks at dinner." "I can have one alcoholic drink in the evening."
"I can have milk and crackers at bedtime." Older adults may have sleep disturbances caused by many factors. Having milk and crackers at bedtime helps prevent hypoglycemia during sleep, and may prevent some sleep disturbances. An older adult patient should refrain from eating a heavy meal at bedtime, because it can cause increased acidity and interfere with sleep. Chocolate is a stimulant and should not be consumed at night. Older adults can consume one alcoholic drink per day, but before lunch. Drinking alcohol after dinner may interfere with the quality of sleep.
During a home health nursing visit, an elderly patient reports having trouble seeing traffic signals and pavement markings clearly while driving. The nurse also finds many traffic tickets lying on the table. What is the best nursing intervention in this situation? "You should completely stop driving." "You should not drive for long distances." "You should have lights near the steering wheel." "You should open the car windows when driving."
"You should completely stop driving." The American Association of Retired Persons (AARP) put together a list of indicators about when an older person should stop driving. Older persons should stop driving when they have difficulty recognizing traffic signals and pavement markings, as well as when they receive multiple traffic tickets from traffic or law-enforcement officers. Therefore, the nurse instructs the elderly patient to stop driving. Excessive lighting near the steering wheel may reflect into the patient's eyes and further increase the risk of accidents. Because the patient is unable to recognize traffic signals and pavement markings, driving shorter distances may also lead to accidents. Opening of the windows will not help the patient recognize traffic signals and pavement markings; instead, it diverts the driver's concentration.
10. An 85-year-old man has been hospitalized after a fall at home, and his 86-year-old wife is at his bedside. She tells the nurse that she is his primary caregiver. The nurse should assess the caregiver for signs of possible caregiver burnout, such as: A. Depression. B. Weight gain. C. Hypertension. D. Social phobias
A. Depression. Caregiver burden is the perceived strain by the person who cares for an elderly, chronically ill, or disabled person. Caregiver burnout is linked to the caregiver's ability to cope and handle stress. Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss. Screening caregivers for depression may also be appropriate.
2. The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to: A. Observe the patient's ability to perform the tasks. B. Ask the patient's wife how he does when performing tasks. C. Review the medical record for information on the patient's abilities. D. Ask the patient's physician for information on the patient's abilities.
A. Observe the patient's ability to perform the tasks. There are two approaches for performing a functional assessment, asking individuals about their abilities to perform the tasks (using self-reports) or actually observing their ability to perform the tasks. For persons with memory problems, the use of surrogate reporters (proxy reports) such as family members or caregivers may be necessary, keeping in mind that they may either overestimate or underestimate their actual abilities.
5. The nurse is assessing an older adult's advanced activities of daily living, which would include: A. Recreational activities. B. Meal preparation. C. Balancing the checkbook. D. Self-grooming activities.
A. Recreational activities. Advanced activities of daily living (AADL) are activities that an older adult performs such as occupational and recreational activities. Self-grooming activities are basic activities of daily living (ADLs); meal preparation and balancing the checkbook are considered instrumental activities of daily living (IADLs)
8. A patient will be ready to be discharged from the hospital soon, and the patient's family membersare concerned about whether the patient is able to walk outside alone safely. The nurse will perform which test to assess this? A. The Get Up and Go Test B. The Performance Activities of Daily Living C. The Physical Performance Test D. Tinetti Gait and Balance Evaluation
A. The Get Up and Go Test The Get Up and Go Test is a reliable and valid test to quantify functional mobility. The test is quick, requires little training and no special equipment, and is appropriate to use in many settingsincluding hospitals and clinics. This instrument has been shown to predict a person's ability to gooutside alone safely. The Performance of Activities of Daily Living test has a trained observer actually observing as a patient performs various ADLs. The Physical Performance Test assesses upper body fine motor and coarse motor activities, as well as balance, mobility, coordination, andendurance. The Tinetti Gait and Balance Evaluation assesses gait and balance and provides information about fall risk
What disease process, as documented in the patient's records, may make it difficult to complete discharge teaching? Osteoarthritis Diabetes mellitus Alzheimer dementia Myocardial infarction
Alzheimer dementia The patient with Alzheimer dementia has altered cognition and memory loss. Therefore, the nurse needs to know the patient's ability to take medications independently so the nurse can perform appropriate discharge planning. The patient with osteoarthritis does not necessarily have memory loss; this disease does not interfere with planning the discharge of the patient. The patient with osteoarthritis might not have any cognitive impairment, so the patient could probably understand discharge instructions. The patient who sustained a myocardial infarction should not necessarily have any memory loss; therefore, the patient should be able to comprehend discharge teaching.
While taking care of an elderly patient, the nurse closely monitors whether the patient is grooming and walking on a daily basis. What is the purpose of the observation? Assessing cognition Assessing caregiver burden Assessing the activities of daily living (ADL) Assessing functional decline during hospitalization
Assessing the activities of daily living (ADL) Activities of daily living (ADL) are tasks that are necessary for self-care in adults. ADLs measure the domains of eating/feeding, bathing, grooming, dressing, toileting, walking, using stairs, and transferring in an elderly person. A loss of the ability to perform ADLs because of acute illness and hospitalization is common in older adults and can have significant negative consequences. The assessment procedure involves the identification of older adults who are at the greatest risk for loss of ADLs or mobility at this critical time. The assessment of cognitive status in older adults is an important part of the functional assessment. Altered cognition in older adults is commonly attributed to three disorders: dementia, delirium, and depression. The caregiver, rather than the patient, is screened to assess caregiver burden.
13. During a functional assessment of an older person's home environment, which statement or question by the nurse is most appropriate regarding common environmental hazards? A. "These low toilet seats are safe because they are nearer to the ground in case of falls." B. "Do you have a relative or friend who can help to install grab bars in your shower?" C. "These small rugs are ideal for preventing you from slipping on the hard floor." D. "It would be safer to keep the lighting low in this room to avoid glare in your eyes."
B. "Do you have a relative or friend who can help to install grab bars in your shower?" Environmental hazards within the home can be a potential constraint on the older person's day-to-day functioning. Common environmental hazards including inadequate lighting, loose throw rugs, curled carpet edges, obstructed hallways, cords in walkways, lack of grab bars in tub and shower, and low and loose toilet seats are hazards that could lead to an increased risk of falls and fractures. Environmental modifications can promote mobility and reduce the likelihood of the older adult falling.
14. When beginning to assess a person's spirituality, which question by the nurse would be most appropriate? A. "Do you believe in God?" B. "How does your spirituality relate to your health care decisions?" C. "What religious faith do you follow?" D. "Do you believe in the power of prayer?"
B. "How does your spirituality relate to your health care decisions?" Open-ended questions provide a foundation for future dialog. The other responses are easily answered by one-word replies, and they are closed questions.
12. An elderly patient has been admitted to the intensive care unit (ICU) after falling at home. Within 8 hours, his condition has stabilized and he is transferred to a medical unit. The family is wondering whether he will be able to go back home. Which assessment instrument is most appropriate for the nurse to choose at this time? A. The Lawton IADL instrument B. Hospital Admission Risk Profile (HARP) C. The Mini-Cog D. The NEECHAM Confusion Scale
B. Hospital Admission Risk Profile (HARP) Hospital-acquired functional decline may occur within two days of a hospital admission. The HARP helps to identify older adults who are at greatest risk for loss of ADLs or mobility at this critical time. The Lawton IADL measures instrumental activities of daily living, which may be difficult to observe in the hospital setting. The Mini-Cog is an assessment of mental status. The NEECHAM Confusion Scale is used to assess for delirium.
4. The nurse is preparing to use the Lawton IADL instrument as part of an assessment. Which statement about the Lawton IADL instrument is true? A. The nurse uses direct observation to implement this tool. B. It is designed as a self-report measure of performance rather than ability. C. It is not useful in the acute hospital setting. D. It is best used for those residing in an institutional setting
B. It is designed as a self-report measure of performance rather than ability. The Lawton IADL instrument is designed as a self-report measure of performance rather than ability. Direct testing is often not feasible, such as demonstrating the ability to prepare food while a hospital inpatient. Attention to the final score is less important than identifying a person's strengths and areas where assistance is needed. The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings. It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident.
16. The nurse is assessing the abilities of an older adult. Which of these following activities are considered instrumental activities of daily living? Select all that apply. A. Feeding oneself B. Preparing a meal C. Balancing a checkbook D. Walking E. Toileting F. Grocery shopping
B. Preparing a meal C. Balancing a checkbook F. Grocery shopping Typically, instrumental activities of daily living tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation. The others listed are activities of daily living related to self-care.
6. When using the various instruments to assess an older person's activities of daily living (ADLs), the nurse needs to remember that a disadvantage of these instruments includes: A. The reliability of the tools. B. Self or proxy report of functional activities. C. Lack of confidentiality during the assessment. D. Insufficient detail about the deficiencies identified.
B. Self or proxy report of functional activities. A disadvantage of many of the ADL and IADL instruments is the self or proxy report of functional activities. The other responses are not correct.
15. The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain.Which statement about pain and the older adult is true? A. Pain is inevitable with aging. B. Older adults with cognitive impairments feel less pain. C. Alleviating pain should be a priority over other aspects of the assessment. D. The assessment should take priority so that care decisions can be made.
C. Alleviating pain should be a priority over other aspects of the assessment. If the older adult is experiencing pain or discomfort, then the depth of knowledge gathered through the assessments will suffer. Alleviating pain should be a priority over other aspects of the assessment. It is paramount to remember that older adults with cognitive impairment do not feel less pain.
3. The nurse needs to assess a patient's ability to perform activities of daily living and should choose which tool for this assessment? A. Direct Assessment of Functional Abilities (DAFA) B. Lawton IADL C. Barthel Index D. Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL (OARS-IADL)
C. Barthel Index The Barthel Index is used to assess activities of daily living. The other options are used to measure instrumental activities of daily living
11. During a morning assessment, the nurse notices that an older patient is less attentive and is unable to recall yesterday's events. Which test is appropriate for assessing the patient's mental status? A. Geriatric Depression Scale, Short Form B. The Physical Performance Test C. Mini-Cog D. The Get Up and Go Test
C. Mini-Cog For nurses in various settings, cognitive assessments provide continuing comparisons to the individual's baseline to detect any acute changes in mental status. The Mini-Cog is a mental status test that tests immediate and delayed recall and visuospatial ability. The Geriatric Depression Scale, Short Form assess for depression and changes in the level of depression, not mental status. The Physical Performance Test assesses activities such as eating, dressing, transferring, and stair climbing, but not mental status. The Get Up and Go Test assesses functional mobility, not mental status.
7. The nurse is administering a test that is timed over 15 minutes and assesses a patient's upper body fine motor and coarse motor activities, balance, mobility, coordination, and endurance. During this test, activities such as dressing and stair climbing are timed. Which test is described by these activities? A. The Get Up and Go Test B. The Performance Activities of Daily Living C. The Physical Performance Test D. Tinetti Gait and Balance Evaluation
C. The Physical Performance Test The Physical Performance Test is appropriate for use with community-dwelling older adults. The test requires approximately 15 minutes to complete and assesses upper body fine motor and coarse motor activities, balance, mobility, coordination, and endurance. Activities such as eating, dressing and transferring, and stair climbing are simulated and timed.
9. The nurse is assessing the forms of support an older patient has before she is discharged. Which of these examples is an informal source of support? A. The local senior center B. Her Medicare check C. Meals on Wheels meal delivery service D. Her neighbor, who visits with her daily
D. Her neighbor, who visits with her daily Informal support includes family and close long-time friends and is usually provided free of charge. Another example of informal support is a neighbor who has daily contact with the client and shares food and company. Formal supports include programs such as social welfare and other social service and health care delivery agencies such as home health care. Semi formal supports such as church societies, neighborhood groups, and senior centers also form an important role in social support.
1. The nurse is assessing an older adult's functional ability. Which definition correctly describes one's functional ability? Functional ability: A. Is the measure of the expected changes of aging that one is experiencing. B. Refers to the individual's motivation to live independently. C. Refers to the level of cognition present in an older person. D. Refers to one's ability to perform activities necessary to live in modern society.
D. Refers to one's ability to perform activities necessary to live in modern society. Functional ability refers to one's ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks such as bathing and toileting.
While caring for a hospitalized older patient, the nurse finds that the patient is awake at night and has a difficult time staying awake during the day. What reason for this might the nurse expect to find in the patient? Epilepsy Syncope Delirium Hypertension
Delirium Delirium in a patient may result in the disruption of the sleep-wake cycles. Therefore, the patient with delirium can remain awake throughout the night and has a hard time staying awake during the day. Epilepsy does not disturb the sleep-wake cycle in the patient. Therefore, epilepsy does not make the patient stay awake all night and sleep during the day. Syncope does not disrupt the sleep-wake cycle in the patient; instead, a patient with syncope may experience dizziness. Hypertension does not disturb the sleep-wake cycle. Therefore, the patient with hypertension does not stay awake all night and fall asleep during the day.
The nurse is assessing an elderly patient. The nurse asks the patient to rise from a chair, walk 10 feet, turn, walk back to the chair, and sit down. What is the nurse observing in the patient? Get Up and Go Test Cognition assessment Activities of daily living (ADL) Instrumental activities of daily living (IADL)
Get Up and Go Test The Get Up and Go Test is a reliable and valid test to quantify functional mobility. The nurse assesses the person's ability to go outside alone safely. The nurse asks the patient to rise from a chair, walk 10 feet, turn, walk back to the chair, and sit down. This enables the nurse to assess sitting balance, transfer from sitting, pace and stability of walking, ability to turn without staggering, and ability to sit back down in the chair. Activities of daily living (ADL) are the tasks necessary for self-care in adults. ADLs measure the domains of eating/feeding, bathing, grooming, toileting, walking, using stairs, and transferring in an elderly person. The assessment of cognitive status in older adults is an important part of the functional assessment. Altered cognition in older adults is commonly attributed to three disorders, namely dementia, delirium, and depression. Typically, IADL tasks include shopping, meal preparation or cooking, laundry, managing finances or counting, basic housekeeping, taking medications, and using transportation.
The nurse is assessing the ability of a geriatric patient to bathe, dress, toilet, and transfer from bed to chair. Which instrument should the nurse use during the assessment? Tinetti Gait and Balance Evaluation Katz Index of Activities of Daily Living Pittsburgh Sleep Quality Index (PSQI) Lawton Instrumental Activities of Daily Living
Katz Index of Activities of Daily Living The Katz Index of Activities of Daily Living is the scale that assesses the daily activities of living such as the ability to bathe, dress, and toilet in geriatric patients. The Tinetti Gait and Balance Evaluation is a test that helps evaluate the balance and the risk of fall in a patient. The Pittsburgh Sleep Quality Index (PSQI) is useful to measure the quality of the patient's sleep as well as sleep patterns. The Lawton Instrumental Activities of Daily Living helps evaluate the higher-order components of daily living such as socializing and money management.
The nurse suspects that a patient with a chronic illness is mistreated. Which screening tool would the nurse use to assess this patient? Neecham Confusion Scale Confusion Assessment Method Modified Caregiver Strain Index Tinetti Gait and Balance Evaluation
Modified Caregiver Strain Index While caring for a patient with chronic illness, the caregiver may experience severe stress. Stress may cause the caregiver to mistreat the patient. The MCSI helps assess the strain experienced by the caregiver or the nurse, which helps assess the risk of maltreatment in the patient. The Neecham Confusion Scale and the Confusion Assessment Method are tools that help assess the delirium of the patient who has dementia. The Tinetti Gait and Balance Evaluation is a 28-point scale that helps evaluate the risk of fall in the patient. The Neecham Confusion Scale, Confusion Assessment Method, and Tinetti Gait and Balance Evaluation do not help assess the risk of maltreatment in the patient.
Which screening tool does the nurse use to assess circadian rhythm disturbance in a patient? Mini-Cog Confusion Assessment Method Tinetti Gait and Balance Evaluation Pittsburgh Sleep Quality Index (PSQI)
Pittsburgh Sleep Quality Index (PSQI) Circadian rhythm, also known as the biological clock, is a biological process that helps maintain the proper sleep-wake cycle balance. PSQI is the scale that helps assess the sleep patterns in a patient. Therefore, the nurse uses the PSQI while assessing the circadian rhythms. The nurse uses the Mini-Cog to assess the patient's visuospatial skills, as well as orientation and work memory. The Confusion Assessment Method is a cognitive assessment instrument that helps assess delirium in a patient. The Tinetti Gait and Balance Evaluation is a 28-point assessment scale that assesses the risk of fall in a patient.
An elderly patient insists that the nurse delay a routine assessment until a member of the patient's family arrives at the appointment. What is the best nursing intervention in this situation? Respect the patient's wish by involving the family member in the assessment. Notify the health care provider about the patient's resistance to the assessment. Ignore the patient's words and begin the assessment before the family member arrives. Explain to the patient that there is no need to include a family member in this simple assessment.
Respect the patient's wish by involving the family member in the assessment. Many elderly patients rely on family members for strength and support during stressful life events and illness. Elderly patients may worry they will not remember to ask important questions or remember the instructions the nurse provides unless they have a family member present during the assessment. Therefore, the nurse should respect this patient's opinion and involve a family member during the assessment. There is no need to report this to the health care provider, because it is not an emergency. Ignoring the patient's words may result in decreased trust of the patient in the nursing care, which would decrease the effectiveness of the care plan. The nurse should not try to convince the patient that it is unnecessary to have a family member present, because this may make the patient feel disrespected.
After assessing a geriatric patient, the nurse infers that the patient is independent, maintains proper health care, performs activities of daily living, and enjoys good health. Which finding helped the nurse reach this conclusion? The patient refrains from attending parties. The patient does not go to religious functions. The patient follows a relaxed, sedentary life style. The patient follows the guide "Staying Healthy at 50+."
The patient follows the guide "Staying Healthy at 50+." "Staying Healthy at 50+" is a guide that helps maintain a proper lifestyle as a person ages. A patient who follows the guide maintains a healthy diet and a proper lifestyle. If the patient refrains from attending parties, it indicates that the patient does not like socializing and maintains a solitary life, which may lead to depression. A person who does not attend religious functions reduces socializing, which may lead to depression. Therefore, the patient who does not attend parties or religious activities might not maintain proper health. The patient should include exercises to stay healthy and fit. A relaxed, sedentary lifestyle may cause a decline in health by increasing the risk of obesity or cardiac problems.
The nurse and health care provider are assessing the mental status of a patient. Which patient findings suggest early-onset Alzheimer-type dementia? Select all that apply. The patient has difficulty with vision. The patient has difficulty finding words. The patient has difficulty with ambulation. The patient has difficulty in naming objects. The patient has difficulty in holding objects.
The patient has difficulty finding words. The patient has difficulty in naming objects. The patient with Alzheimer-type dementia has impaired cognition in which the he or she has difficulty finding words and naming objects used in day-to-day life. Therefore, these findings would indicate a risk for Alzheimer dementia. The patient with Alzheimer-type dementia does not necessarily have difficulty with vision, walking, and holding objects. Patients with ocular disorders may have difficulty with vision. Patients with muscular dystrophy may have difficulty in walking. Patients with epilepsy may have difficulty in holding objects.
While collecting data on a Chinese patient, the nurse finds that the patient practices tai chi. What reason does the nurse expect for such practice by the patient? To prevent the risk of falls To prevent the risk of delirium To prevent the risk of hyperglycemia To prevent the risk of hypothyroidism
To prevent the risk of falls Tai chi is a Chinese martial art that increases the strength and elasticity of the skeletal muscles and therefore prevents the risk of falls. Delirium may occur due to dehydration and infections. Practicing tai chi does not replace the loss of fluids; therefore, it may not help in preventing the risk of delirium. Tai chi does not reduce the blood glucose levels in the patient, so it would not prevent the risk of hyperglycemia Tai chi does not normalize the thyroid hormone levels in the patient; therefore, this practice may not prevent the risk of hypothyroidism.
While assessing an older adult, the nurse finds that the patient does not speak or understand English. What should be the most important nursing intervention in this situation? Schedule another day for the assessment. Report to the primary healthcare provider. Use interpreters for better communication. Request that family members translate.
Use interpreters for better communication. If the patient does not communicate in English, interpreters can convey the nurse's words correctly to the patient in his or her own language to get exact information. The interpreter also translates what the nurse says to the patient. Therefore, the nurse uses interpreters to ensure a proper assessment. Delaying the assessment may increase risks in the patient, because it results in delayed treatment. There is no need to report this to the healthcare provider, because it is not an emergency. The family members may not effectively convey the nurse's words to the patient, which may result in obtaining inaccurate information. Therefore, to ensure proper assessment, the nurse should allow interpreters, not family members, to convey the information to the patient.