ms3 exam 1

a nurse is caring for a client who is scheduled to undergo a liver biopsy for a suspected malignancy. which of the following lab findings should the nurse monitor prior to the procedure? a. Prothrombin time b. serum lipase c. biliruben d. calcium

A

which of the following menu choices by a client with a new ileostomy indicates a need for further teaching? SATA a. bananas b. strawberries and raspberries c. dried fruit d. brocolli e. brown rice

BCDE

a nurse is caring for a client with cirrhosis and ascites. which of the following interventions will the nurse implement to reduce dyspnea, skin breakdown, and general discomfort? SATA a. using an alternating pressure air mattress b. distracting the client with video games or music c. placing the client in a high fowlers position d. ensuring adequate sodium intake e. placing the client in the supine position

ABC

a nurse is admitting a client who has cirrhosis. which of the following prescriptions should the nurse anticipate? a. obtain a clients PR and INR measurements b. administer lactulose 30ml PO 4x a day c. obtain daily weight and abdominal girth measurements d. administer daily multivitamin e. place the client on a low protein diet

ABCD

a client with acute pancreatitis is admitted with NV and epigastric pain. assessment reveals HR of 110bpm, 100F, and elevated serum amylase and lipase levels. which interventions does the nurse anticipate?SATA a. trendelenburg position b. IV hydration with isotonic crystalloid solution c. high fat diet d. IV opioid analgesics

BD

a nurse is caring for a client who is at high risk for developing ascites because of cirrhosis. how should the nurse assess for ascites? a. observe the client for respiratory distress b. percuss the clients abdomen and listen for dull sounds c. palpate the lower extremities over the tibia and observe for edema d. listen for decreased or absent bowel sounds while auscultating the abdomen

B

a nurse is demonstrating colostomy care to a client who has a new colostomy. which of the following actions should the nurse teach the client to perform? a. use antimicrobial ointment on the peristomal skin b. empty the bag when it is one third to one half full c. cut the skin barrier opening a little larger than the ostomy d. wash the peristomal skin with mild soap and water e. apply the skin barrier while the skin is slightly moist

BCD

a nurse is assessing a client in the ED who complains of epigastric pain, NV. lab studies show increased serum amylase and lipase. which of the following signs is most likely to be found on an examination of this client? a. chvosteks sign b. murphys sign c. cullens sign d. koplik spots

C

a nurse is caring for a client who was admitted to ED with hematemesis. which is a priority Nursing intervention? a. give supplemental oxygen by nasal cannula b. insert a urinary catheter c. establish IV access with large bore IV

C

while caring for a client who has an NG feeding tube, the nurse prepares his next enteral feeding. before administering the feeding, the nurse checks the gastric residual and notes that the residual amount is 550mL. which of the following actions by the nurse are appropriate? SATA a. place client in trendelburg position b. return half of the gastric residual and discard the rest c. notify physician d. withhold next feeding e. wait one hour and administer the feeding

CD

a nurse is educating a client diagnosed with viral hepatitis. which of the following are true about viral hep? SATA a. HEP A has an incubation period of 6-24weeks b. hep A is transmitted via body fluids c. hep D can cause fulminant hepatitis d. hep C can be prevented by vaccine e. lab studies for hep B show HDV antibodies f. hep B increase risk of liver cancer

CF

a nurse is assessing a client with pancreatitis who is admitted with abdominal pain, NV for two days. vital signs are 100.8F, BP 88/42, HR 120bpm, and RR 30/min, and 02 is 87%. which of the following does the nurse know may be affecting the accuracy of the clients pulse oximetry reading? a. increased body temp b. tachypnea c. tachycardia d. hypotension

D

which of the following body substances can transmit hep C?SATA a. sweat b. urine c. stool d. blood e. semen

DE

a nurse on med surg unit is assigned to a client who has a sengstaken-blakemore tube in place for treatment of bleeding varices. which of the following assessments should the nurse prioritize? a. a drop in BP of 10mmHg after administration of morphine b. rales on chest auscultation c. blood in the lumen of the tube d. temp of 100.1F

b. rales on chest auscultation sengstaken blakemore tube is a method of controlling esophageal bleeing by esophagogastric balloon tamponade. *most serious complications are aspiration and occlusion of airway. SS are coughing, dyspnea, and wheezing

a nurse is caring for a client with chronic hep B and cirrhosis. which of the following findings would indicate deficient Vit K absorption as a result of the clients disease? a, petechiae and purpura b. asterixis c. gynecomastia d. ascites

a vit k is a fat soluble vitamin necessary for production of clotting factors in liver. deficiency in vit k results in increased PT and INR. the expected signs are bruising, petechiae, purpura and bleeding gums

a nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. the nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent excessive alcohol use? a. gamma glutamyl transferase (GGT). b. alkaline phosphatase ALP c. serum biliruben d. alanine aminotransferase ALT

a. GGT

a nurse is caring for a 10 year old with UC. the client has undergone endoscopy of lower GI tract revealing ulcerations and strictures. which of the following is true about this disorder? a. anemia is common b. onset is sudden c. abdominal rigidity is characteristic d. upper GI is affected

a. anemia is common

a nurse is caring for a client with cirrhosis of the liver who has a prescription for IV albumin. the clients serum albumin level is 1.3. which of the following findings associated with hypoalbuminemia should the nurse anticipate when assessing this client? a. ascites b. altered mental status c. excess body hair d. easy bruising

a. ascites since albumin helps keep fluid in blood. with hypoalbuminemia, fluid goes ECF

a nurse is preparing a community education program about hepatitis B. which of the following statements should the nurse include in the teaching? a. hepatitis b immunization is recommended for those who travel, especially military personnel. b. a hep B immunization is given to infants and children c. hep B is acquired by earing foods contaminated during handling d. hep B can be prevented by using good personal hygiene habits and proper sanitation

b. a hep B immunization is given to infants and children

a nurse is providing teaching for a client who has a new prescription for ranitidine. which of the following statements indicates client understanding of the teaching? a. this med coats lining of my stomach b. this med will not stop my stomach pain immediately c. i may experience increased acid production with this med d. i should take this pill after i eat

b. this med will not stop my stomach pain immediately

a nurse is caring for a client with acute HEP A infection. which of the following nursing interventions should be implemented? a. provide low cal diet with fluid restriction b. limit alcohol to 1-2 drinks per day c. admin antipruritic meds only as needed d. keep client on strict bed rest

c. admin antipruritic meds only as needed

a nurse is caring for a client who has acute pancreatitis. which of the following serum lab values should return to the expected reference range within 72 hours of treatment beginning? a. aldolase b. lipase c. amylase d. lactic dehydrogenase

c. amylase

a nurse is caring for a client with chronic cirrhosis of the liver. the nurse knows that which of the following is a potentially life threatening complication of chronic liver cirrhosis? a. spider angiomas b. fetor hepaticus c. asterixis d. varices

d

a nurse is caring for a client with cirrhosis of the liver with ascites. the nurse knows hat ascites is caused by? a. reduction of coagulation factors b. increased albumin synthesis c. increased ammonia d. portal hypoertension

d

a nurse is providing teaching for a client diagnosed with cirrhosis of the liver. which of the following statements by the client indicates understanding of teaching? a. i should take acetaminophen instead of aspirin b. i should reduce my alcohol consumption to fewer than 4 drinks per week c i should eat a low carb low calorie diet d. i should avoid heavy lifting and binding clothes that increases abdominal pressure

d

A nurse is monitoring the lab results of a client who has end stage liver failure. which of the following results should the nurse expect? a. decreased lactate dehydrogenase b. increased serum albumin c. decreased serum ammonia d. increased prothrombin time

d. increased prothrombin time

a nurse is planning an in-service training sessions for a group of nurses regarding the role of enzymes in digestion. which of the following enzymes plays a role in the digestion of protein? a. amylase b. lipase c. steapsin d. pepsin

d. pepsin

a nurse is performing a GI assessment of a client who has liver cirrhosis with abdominal distention. which of the following actions should the nurse take to assess for changes in the clients abdominal distention? a. percuss the abdomen for tympanic sounds b. inspect the contour of the abdominal wall c. instruct the client to report increased abdominal discomfort d. take serial measurements of the abdomen with a tape measure

d. take serial measurements of the abdomen with a tape measure

the nurse is assessing a client with hepatitis. which of the following diagnostic tests will be recommended for this type of client? SATA a. LDH test b. serum potassium test c. serum sodium test d. HBV surface antigen e. serum chloride f. chest x ray g. ALP test h. AST test

ADGH

a nurse who is caring for a client with a history of alcohol abuse and cirrhosis expects to find which of the following abnormalities when reviewing the clients lab tests? SATA a. increased prothrombin time b. decreased biliruben c. decreased ammonia d. increased albumin e. decreased sodium

AE

a nurse is caring for a client who asks about risk factors for colon cancer. which of the following increases the risk of colon cancer? SATA a. history of IBD b. family history of colorectal polyps or cancer c. tobacco use d. consumption of alcohol

ABCD

the nurse is assessing a client with intestinal obstruction. which of the following lab tests will be recommended? SATA a. serum amylase test b. ABG test c. electrolyte test d. WBC e. intrinsic factor test f. serum osmolality test g. pepsin test

ABCDF

a nurse is assigned to care for a client who is receiving enteral feedings. which of the following diagnoses would most likely warrant a need for enteral feedings? SATA a. dysphagia b. coma c. renal disease d. trauma to upper GI tract e. vomiting

ABD

a nurse is caring for a client with recurrent vomiting for the past 12h who is at risk for electrolyte disturbances. which of the following disturbances are most likely in this client? SATA a. hypokalemia b. hypermagnesemia c. metabolic alkalosis d. hyperkalemia e. metabolic acidosis

AC

a client with UC is scheduled for treatment with sulfasalazine. which of the following are correct about this drug? SATA a. can cause folate deficiency b. can cause hyperchloremia c. can cause megaloblastic anemia d. . can cause anaphylactic reaction e. can cause blindness f. can cause thrombocytosis

ACD

a home health nurse is planning care for a client who has a SBO and is receiving parenteral nutrition through a PICC line in their right arm. which of the following interventions should the nurse include in plan of care? SATA a. use a 10ml syringe to flush picc line b. apply gentle force if resistance is met during injection c. cleanse ports according to agency policy prior to use d. maintain a transparent dressing over insertion site e. flush with 5ml heparin before and after each infusion

ACD

the nurse is caring for a client with portal hypertension. which of the following are likely to occur with this condition? SATA a. esophageal varices b. thrombophlebitis c. encephalopathy d. ascites e. bone disease

ACD

the nurse is charting findings from a client with cirrhosis. which of the following findings are specifically related to the clients diagnosis? SATA a. anemia b. hypoglycemia c. bruising. d. gynecomastia e. bradycardia

ACD

a nurse is providing in service training to a group of newly licensed nurses about caring for clients who are receiving enteral nutrition through continuous infusion. which of the following instructions should the nurse provide in the training session? SATA a. administer with an infusion pump b. measure gastric residual every 2 hours c. flush the feeding tube every four hours d. return the aspirated residual feeding into the stomach e. reassess tolerance if the residual volume is greater than the prescribed amount

ACDE a. administer with an infusion pump ensures the correct volume of the feeding is being infused c. flush the feeding tube every four hours to maintain patency d. return the aspirated residual feeding into the stomach ensures that needed fluids, electrolytes, nutrients, and digestive enzymes are replaced e. reassess tolerance if the residual volume is greater than the prescribed amount because this is an indication that the amount of formula being infused is not being digested

a nurse is assisting a provider with performing a paracentesis on a client. which of the following actions should the nurse take? a. ask the client to empty his bladder before the procedure b. place the client leaning forward over the bedside table for the procedure c. inform the client he will be sedated during the procedure d. instruct the client to fast for 6hours prior to the procedure

a. ask the client to empty his bladder before the procedure

a community health nurse is planning an education program about hepatitis A. when preparing the materials, the nurse should identify that which of the following groups is most at risk for developing hep A. a. children b. older adults c. women who are pregnant d. middle aged men

a. children a child or young adult acquires the infection at school, through poor hygiene, hand to mouth contact, or another form of close contact

a nurse is caring for a client with UC experiencing a flare of the disease. which of the following factors is most likely of greatest significance in causing exacerbation of UC? a. demanding stressful job b. changing to a vegetarian diet c. beginning a weight training program d. walking 2 miles every day

a. demanding stressful job

a nurse is teaching a client who has a colostomy about ways to reduce flatus and odor. which of the following strategies should the nurse include? a. eat crackers and yogurt regularly b. chew minty gum throughout the day c. drink orange juice everyday d. put an aspirin in the pouch

a. eat crackers and yogurt regularly

a nurse is assessing a client who has a bleeding duodenal ulcer. which of the following findings should the nurse expect? a. emesis with coffee ground appearance b. increased BP c. decreased HR d. Bright green stools

a. emesis with coffee ground appearance

a nurse is caring for a client who has an acute exacerbation of crohns disease. which of the following actions should the nurse take? a. ensure bowel rest b. offer sparkling water frequently c. administer stool softener d. offer plain warm tea frequently

a. ensure bowel rest clients who have an exacerbation of crohns disease usually require NPO status to ensure bowel rest and promote healing and recovery

a nurse is teaching dietary modification strategies to a client who has been newly diagnosed with cirrhosis. which of the following foods should the nurse recommend? a. grilled chicken b. potato soup c. fish sticks d. baked ham

a. grilled chicken patient should have high protein to compensate disease related weight loss. patients with cirrhosis should avoid high sodium and high fat.

a nurse is caring for a client who had a gastric resection to treat a adenocarcinoma of the stomach. the client tells the nurse in the PACU that he does not remember why the surgeon said he has to have a tube in his nose. The nurse should explain that the NG tube serves which of the following purposes? a. prevents excessive pressure on suture lines b. allows gastric lavage after surgery c. allows early postoperative feeding d. facilitates obtaining gastric specimens for testing

a. prevents excessive pressure on suture lines

a nurse is caring for a client who underwent bowel surgery and cannot be fed via GI tract for at least 1 week. the client is receiving TPN through a central line in the subclavian vein. The current bag of solution was hung 24 hours ago and 400mL remain to infuse. which of the following actions should the nurse take? a. remove the bag and hang a new bag b. infuse the remaining solution at the current rate and then hang a new bag c. increase the infusion rate to the remaining solution is administered within 1 hour and hang a new bag d. remove the current bag and hang a bag of dextrose 5% in water

a. remove the bag and hang a new bag TPN solutions should be discarded after 24h

a nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. which of the following pieces of information should the nurse include in the teaching? a. the client will be places on mechanical ventilation prior to this procedure b. the tube will be inserted into the clients trachea c. the client will receive a bowel preparation with cathartics prior to this procedure d. the tube allows the application of a ligation band to the bleeding varices

a. the client will be places on mechanical ventilation prior to this procedure the client will require intubation and mechanical ventilation prior to this procedure to protect the airway

a nurse is assessing a client who is in the early stages of hepatitis A. which of the following manifestations should the nurse expect? a. jaundice b. anorexia. c. dark urine d. pale feces

b. anorexia everything else are LATE manifestations of hep A

a nurse receives lab results for a client with acute pancreatitis. which of the lab values should the nurse report? a. lipase 200u/l b. calcium 7.5 c. amylase 250 d .albumin 3.3

b. calcium 7.5

The nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hep A. which of the following instructions should the nurse include in the teaching? a. she may take acetaminophen for fevers and discomfort b. encourage her to eat foods high in carbs c. the provider will prescribe a medication to help her liver heal faster d. have her perform moderate exercise to restore her strength more quickly

b. encourage her to eat foods high in carbs diet should be high in carbs and calories with only moderate amounts of protein and fat

a nurse is caring for a client diagnosed with a flare of chronic pancreatitis. which of the following prescriptions does the nurse anticipate for this client? a. diet high in potassium b. enzymatic therapy c. diet low in complex proteins d. corticosteroid therapy

b. enzymatic therapy

a nurse is caring for a client who has ulcerative colitis. the provider prescribes bed rest with bathroom privileges. when the client asks the nurse why he has to stay in bed, which of the following responses should the nurse provide? a. you need to conserve energy at this time b. lying quietly in bed helps slow down the activity in your intenstines c. staying in bed promotes rest and comfort you need d. staying in bed will help prevent injury and minimize your fall risk

b. lying quietly in bed helps slow down the activity in your intenstines

a nurse caring for a client diagnosed with UC who has a new prescription for sulfasalazine. which of the following should the nurse include when developing teaching materials for the client? a. eat a low protein diet and reduce calories b. maintain fluid intake of 2ooomL a day minimum c. stop medication when symptoms resolve d. limit caffeine to 1 cup of coffee with breakfast daily

b. maintain fluid intake of 2ooomL a day minimum

a nurse is caring for a client with ulcerative colitis. the disorder is related to the function of which of the following in response to stress? a. sympathetic nervous system affecting the pancreas b. parasympathetic nervous system affecting the adrenal glands c. hypothalamus gland affecting metabolism d. thyroid gland affecting metabolism

b. parasympathetic nervous system affecting the adrenal glands exacerbation can be triggered by environmental factors that include stress. emotions affect the PNS, which is a branch of the ANS, by increasing motility of GI tract and secretions within GI tract

a nurse is caring for a client with cirrhosis with prescriptions for oral spironolectactone, IV furosemide and IV albumin. which of the following lab findings should the nurse prioritize when communicating with the healthcare provider? a. sodium 132 b. potassium 2.9 c. albumin 2.6 d. INR 1.5

b. potassium use of loop diuretics (rids fluids) like furosemide can result in hypokalemia

a nurse is caring for a client who has a history of crohns disease. the client has concentrated urine, decreased turgor, hypotension, and weak thready pulse. which of the following is the most appropriate initial intervention by the nurse? a. encourage the client to drink at least 1000ml day b. provide parenteral rehydration therapy prescribed by the physician c. turn and reposition every 2 hours d. monitor vital signs every shift

b. provide parenteral rehydration therapy

a nurse is providing dietary teaching to a client who has ulcerative colitis. which of the following food selections by the client indicates an understanding of the teaching? a. raw veggie salad with low fat dressing b. roast chicken and white rice c. fresh fruit salad and milk d. peanut butter on whole wheat bread

b. roast chicken and white rice clients with UC are restricted to a low fiber diet

a nurse is completing a history and physical assessment for a client who has chronic pancreatitis. which of the following findings should the nurse identify as a likely cause of the clients condition? a. high calorie diet b. prior GI illnesses c. tobacco use d. alcohol use

d. alcohol use

a nurse is caring for a client with chronic hepatitis C and cirrhosis who was admitted for hepatic encephalopathy. which of the following does the nurse expect when assessing the client? a. hyperactive reflexes b. agitation and restlessness c. asterixis d. enlarged liver

c. asterixis

a home health nurse is performing an initial assessment of a client who has crohns disease and is experiencing fecal incontinence. which of the following actions should take priority? a. instruct the client to avoid fried, acidic, and spicy foods b. use positive communication skills to provide support for the client c. check the skin around the clients rectum for indication of breakdown d. encourage the client to keep a bowel movement diary to identify triggers

c. check the skin around the clients rectum for indication of breakdown

a nurse is assessing a client with jaundice who has clay colored stool. what is the most likely cause of these findings? a. increased cholecystokinin production b. increased bile production c. decrease flow of bile into intestine d. increased breakdown of HGB

c. decrease flow of bile into intestine

a nurse is caring for a client with a feeding tube. which action would most likely prevent clogging of the tube? a. daily heparin injections into the tube b. infusing the enteral formula at an increased rate c. flushing the tube with warm water after each use d. gently stripping the tube before administering the feeding

c. flushing the tube with warm water after each use

a nurse is caring for a client who has abdominal pain and possible pancreatitis. which of the following lab results should the nurse identify as an indication of pancreatitis? a. decreased WBC count b. increased albumin c. increased lipase d. decreased blood glucose

c. increased lipase due to the release of lipase into the pancreas, the pancrease autodigests causing an increased serum lipase

a nurse is assessing a client in the ED who presented with epigastric pain and nausea. the client has a bluish discoloration around the umbilicus. which of the following is the most appropriate initial nursing action? a. complete head to toe assessment b. place an NG tube c. notify healthcare provider d. establish IV access

c. notify healthcare provider

a nurse is caring for a client who is scheduled for an ileostomy. which of the following interventions would be most helpful in preparing the client psychologically for the surgery? a. include family members in preop teaching session b. encourage the client to ask questions about managing the ileostomy c. provide a brief thorough explanation of all preop and post op procedures d. invite a member of the ostomy association to visit the client

c. provide a brief thorough explanation of all preop and post op procedures

a nurse is caring for a client with chronic hepatitis C who has returned to the unit after a liver biopsy. which of the following is the priority nursing intervention? a. educate the client about cirrhosis and its progression b. review pre procedure coagulation studies c. turn the client on the right side to provide pressure at the site d. perform a detailed assessment

c. turn the client on the right side to provide pressure at the site

a nurse in the ED is caring for a client who has bleeding esophageal varices. the nurse should anticipate a prescription for which of the following meds? a. famotidine b. esomeprazole c. vasopressin d. omeprazole

c. vasopressin constricts the splanchnic bed and decreases portal pressure. it also constricts the distal esophageal and proximal gastric veins which reduces inflow into the portal system and is used to treat bleeding varices

a nurse in the ED is caring for a client with alcohol dependence who was admitted for abd pain. the client begins to vomit dark coffee appearing emises. which of the following is the priority nursing intervention? a. assess vial signs b. call healthcare provider c. place IV d. assist client into an upright seated position or turn to one side

d. assist client into an upright seated position or turn to one side RISK FOR ASPIRATION*

a nurse is caring for a client who has GI bleeding. the provider suspects a bleeding lesion in the colon. the initial approach to treatment likely will involve which of the following procedures? a. exploratory laparotomy b. double contrast barium enema c. magnetic resonance imaging d. colonoscopy

d. colonoscopy

a nurse is teaching a client who has cirrhosis of the liver and a history of alcohol consumption. the nurse should explain that alcohol can cause liver cirrhosis through which of the following actions? a. increasing the workload of the liver by releasing stored glycogen b. causing ulceration of liver tissue that can lead to bleeding c. dilating veins in the portal circulation d. destroying liver cells that are later replaced with scar tissue

d. destroying liver cells that are later replaced with scar tissue

a nurse is caring for a client who is receiving TPN therapy and has just returned to the room following physical therapy. the nurse notes that the infusion pump is for the clients TPN is turned off. after restarting the infusion pump, the nurse should monitor the client for which of the following findings? a. hypertension b. excessive thirst c. fever d. diaphoresis

d. diaphoresis the client has a potential to develop hypoglycemia due to sudden withdrawal of the TPN solution. Other manifestations include weakness, anxiety, confusion, and hunger

a nurse is providing postoperative teaching about the management of dumping syndrome to a client who had a partial gastrectomy. which of the following instructions should the nurse include in the teaching? a. consume atleast 4oz of fluid with meals. b. take a short walk after each meal. c. use honey to flavor foods like cereal d. eat protein with each meal

d. eat protein with each meal nurses should instruct client to eat meals that are high in protein and fat with low to moderate carb content. protein delays digestion which helps reduce the manifestations of dumping syndrome

a nurse is assigned to a client admitted to the ED with a suspected diagnosis of acute pancreatitis. which region will most likely be painful for this client? a. periumbilical pain migrating to the right lower quadrant b RUQ pain that radiates to the right shoulder c. right flank pain that radiates to the groin d. epigastric pain that radiated to the back

d. epigastric pain that radiated to the back

a nurse is assessing a client who has a complete intestinal obstruction. which of the following findings should the nurse expect? a. absence of bowel sounds in all 4 abd quadrants. b. passage of blood tinged liquid stool c. presence of flatus d. hyperactive bowel sounds above the obstruction

d. hyperactive bowel sounds above the obstruction

a nurse is providing teaching to a client who is scheduled for a sigmoid colon resection with colostomy. which of the following statement by the client indicated a need for further teaching? a. because most of my colon is still intact and functioning my stool will be formed b. my stoma will appear large at first but it will shrink over the next several weeks c. my colostomy will begin to function in 2 to 6 days after surgery d. ill have to consume a soft diet after surgery

d. ill have to consume a soft diet after surgery they can eat regular diet

a nurse is teaching about secondary prevention actions for colorectal cancer for a health fair for adults in the community. which of the following topics should the nurse include? a. smoking cessation b. benefits of a high diet in cruciferous veggies c. new types of ostomy appliances d. importance of colonoscopy screening starting at age 50 years old

d. importance of colonoscopy screening starting at age 50 years old