(N125/3) CH 31 (EAQ)

An elderly patient states, "I have difficulty breathing during the night to the point where it suddenly wakes me up. I also wake up drenched with sweat." What further question should the nurse ask the patient to obtain more information about this condition? 1. "Do you drink any alcohol before going to bed?" 2. "Do you eat any spicy meals prior to bedtime?" 3. "Do you restrict your coffee intake in the evening?" 4. "Do you restrict your fluid intake before bedtime?"

1 Rationale: Alcohol consumption before bedtime may result in obstructive sleep apnea and excessive sweating in the patient. Restriction of fluids before bedtime will not cause insomnia or breathing difficulties; instead, it interrupts sleep by causing bladder fullness in the patient. Restriction of coffee before going to bed will not cause insomnia and breathing difficulties; instead, it aids sleep by limiting caffeine intake. The consumption of spicy meals prior to bedtime will not cause insomnia and breathing difficulties. Instead, these foods cause insomnia due to heartburn in the patient.

The nurse finds the health care provider is gradually reducing the dose of a patient's psychotropic medications. Which risk does the nurse hope to minimize with this intervention? 1. Falls 2. Nausea 3. Insomnia 4. Dementia

1 Rationale: Psychotropic drugs may increase the possibility of falls, but withdrawal syndrome occurs upon the abrupt cessation of psychotropic drugs after prolonged use. Therefore, gradual reduction of the dose of the psychotropic drugs prevents withdrawal syndrome; at the same time, the lower dose reduces the likelihood of falls. Nausea may be minimized by the administration of antiemetic medications. Insomnia can be minimized by the administration of sedatives and hypnotics. Dementia may be minimized by the administration of medications that belong to the class of cholinesterase inhibitors.

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? 1. Respect the patient's wish by involving the family member in the assessment. 2. Notify the health care provider about the patient's resistance to the assessment. 3. 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.

1 Rationale: 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.

The parent of a child reports to the nurse that the child insists on having two soft drinks every night and is not sleeping well. What reason should the nurse suspect for this situation? 1. A blockage in the adenosine receptors 2. A decreased risk of hypoglycemic events 3. A decreased sensation of bladder fullness 4. A change in the body's core temperature

1 Rationale: Soft drinks contain caffeine, and caffeine blocks adenosine receptors in the body and impairs the child's ability to sleep at night. The consumption of two soft drinks does not decrease the risk of hypoglycemia or the sensation of bladder fullness, or decrease the core temperature of the body. The consumption of milk, cheese, or crackers during the night prevents hypoglycemia in the body and promotes sleep. Restricting the intake of fluids in the evenings decreases the amount of urine in the bladder at night. Taking a warm bath at night drops the core body temperature and promotes sound sleep. p. 842

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? 1. To prevent the risk of falls 2. To prevent the risk of delirium 3. To prevent the risk of hyperglycemia 4. To prevent the risk of hypothyroidism

1 Rationale: 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.

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? 1. "You should completely stop driving." 2. "You should not drive for long distances." 3. "You should have lights near the steering wheel." 4. "You should open the car windows when driving."

1 Rationale: 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.

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? 1. Get Up and Go Test 2. Cognition assessment 3. Activities of daily living (ADL) 4. Instrumental activities of daily living (IADL)

1 Rationale: 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 planning to assess the functional abilities of an elderly patient. What is the most suitable place for the assessment? 1. The patient's home 2. Acute hospital setting 3. Family member's home 4. Primary health care provider's office

1 Rationale: The most appropriate place to do a functional ability test of an elderly patient is the patient's home. The patient will feel comfortable and secure in a known setting, and the nurse will be able to assess how the patient functions in his or her daily environment. A family member's home would not provide the same level of comfort and familiarity. A comprehensive assessment of physical ability may require more than an hour. Therefore, it would not be feasible to occupy the primary health care provider's office or use the resources of an acute hospital setting.

The nurse is planning to evaluate the improvement in the mobility of a patient diagnosed with gout. Which is the best tool for the nurse to use for assessing the patient? 1. The Barthel Index 2. The Rapid Disability Rating Scale-2 3. The Functional Independence Measure 4. The Katz Index of Independence in Activities of Daily Living

1 Rationale; The Barthel Index measures functional disability by quantifying the patient's performance in ten activities of daily life. It is commonly used to assess the progress of limb movements in a patient with chronic musculoskeletal disorders such as gout. A family member or professional caregiver familiar with the abilities of the older adult completes the Rapid Disability Rating Scale-2. It may result in underestimation or overestimation of the patient's abilities. The Functional Independence Measure is a highly sensitive tool for the assessment of a patient's activities of daily living. The Katz Index of Independence in Activities of Daily Living helps assess the functional status as a measurement of the patient's ability to perform activities of daily living independently.

The nurse is assessing an older adult patient with altered cognition. Which action by the nurse ensures successful completion of the patient assessment? 1. Ask the patient yes or no questions during the assessment. 2. Repeat the same question over and over to help the patient. 3. Get the information from the caregiver in front of the patient. 4. Interview the patient in a relaxed setting for approximately 2 hours.

1 Rationale; While assessing the patient with altered cognition, the nurse uses single command questions to prevent frustration in the patient. Therefore, the nurse asks the questions that can be answered by a yes or a no. Interviewing the patient for many hours may irritate the patient; therefore, to perform complete assessment, the nurse splits the assessment into various sessions. It is more reliable to obtain the patient's information from the caregiver or family member without the patient present. Obtaining this information in front of the patient may cause anxiety. Therefore, the nurse obtains the patient's information when the patient is not present. Repeating the same question over and over may cause irritation and anxiety in the patient; therefore, the nurse refrains from repeating the same question to the patient.

In the assessment of older adults, which activities may be considered activities of daily living (ADLs)? 1. Walking 2. Dressing 3. Using the stairs 4. Preparing meals 5.Taking medications

1, 2, 3 Rationale: ADLs are tasks necessary for self-care. These include tasks such as dressing, walking, and using the stairs. Instrumental ADLs are the tasks required for independent living. These include tasks such as preparing meals and taking medications.

A patient uses the Lawton Independent Activities of Daily Living (IADL) scale for self-assessment of the daily activities. Which parameters are included in the scale? (select all that apply) 1. Ability to prepare meals 2. Ability to perform laundry 3. Ability to manage finances 4. Ability to go outside safely 5. Ability to read information

1, 2, 3 Rationale: The Lawton IADL scale is most useful for identifying how a person is functioning now and for determining the improvement or deterioration over time. There are eight domains of function measured with the Lawton IADL scale. These items are telephone use, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, and management of finances. The patient's ability to go outside safely is assessed by the Get Up and Go Test. The nurse assesses the patient's ability to read information using the Direct Assessment of Functional Abilities (DAFA) scale.

While assessing an elderly patient admitted to the hospital for injuries sustained from a fall, the patient says, "I've had several injuries from frequent falls in the past." What conditions might the nurse identify as being responsible for this situation? 1. Syncope 2. Dementia 3. Spondylosis 4. Chronic bronchitis 5. Diabetic neuropathy

1, 2, 3, 5 Rationale: The patient with syncope can have dizziness, which increases the risk of falls. People with dementia are at risk of frequent falls due to memory impairment. The patient with diabetic neuropathy is at a high risk for falls. Spondylosis can result in frequent falls, because it causes an unsteady gait. Chronic bronchitis does not impair sensory perception; it does not cause frequent falls in the patient.

The nurse suspects geriatric syndrome in an older patient without any medical conditions. What statements by the patient are consistent with this condition? (select all that apply) 1. "I've lost my appetite." 2. "I fell a couple of times last month." 3. "I feel excessively thirsty a lot of the time." 4. "I sometimes have urinary incontinence." 5, "I sleep soundly when I go to bed at night."

1, 2, 4 Rationale: An adult patient with geriatric syndrome is characterized by changes in eating, which can cause the patient to have a loss of appetite. Aging can cause bladder-related problems such as urinary incontinence. Changes that happen in the aging process can cause the geriatric patient to have mobility issues and falls. Excessive thirst can be caused by diabetes insipidus, not by the aging process. Geriatric patients have a decreased thirst sensation. Geriatric patients actually require less sleep and may not sleep soundly.

While assessing an elderly patient with cardiovascular disease, the nurse finds that the patient has difficulty ambulating. What information should the nurse provide to promote health in the patient? 1. "You should try water activities." 2. "You may need to walk with a cane." 3. "You could apply salve before walking." 4. "You ought to try riding a stationary bike." 5. "You need a more sedentary lifestyle now."

1, 2, 4 Rationale: Patients with cardiovascular disease should include regular exercise to maintain optimal health. If walking is too taxing for the patient, the nurse suggests alternative exercises such as participating in water activities and stationary cycling to reduce the risks of worsening disease. A sedentary lifestyle results in arterial stiffening, thereby increasing the risk of cardiovascular diseases. Patients who have ambulation problems and need extra assistance to prevent falls may use a cane for walking. Applying ointment before walking does not help in reducing the risk of cardiovascular disease.

What are the characteristics of a Barthel Index? 1. Defines each task 2. Assesses mobility comprehensively 3. Develops through a consensus panel 4. Follows progress in a rehabilitation setting 5. Includes a proxy version of the instrument

1, 2, 4 Rationale; The Barthel Index includes definitions of each task to facilitate the ease of scoring. It assesses mobility comprehensively and is often used to follow progress in rehabilitation settings. A consensus panel of medical and rehabilitation staff developed the Functional Independence Measure (FIM). It has been widely tested on older adults. The process includes telephone, in-person, and proxy versions of the instrument.

The nurse is caring for a patient with delirium and sleep disturbances. Which measures would the nurse take to promote proper sleep in the patient? 1. Keep a clock in the patient's room. 2. Darken the patient's room during night hours. 3. Provide a heavy meal to the patient before sleep. 4. Open the drapes of the windows in the morning. 5. Administer a sedative medication to the patient.

1, 2, 4, 5 Rationale: The patient with delirium would have impaired orientation. Keeping a clock in the patient's room would allow the patient to be aware of day and night hours. The patient has a disturbed sleep-wake cycle. Awareness of daytime and nighttime helps establish the circadian rhythm. Therefore, the nurse should darken the patient's room during the night hours and open the drapes of the windows in the morning to help the patient maintain a normal sleep-wake cycle. The nurse may administer a sedative drug to a patient with a prescription from the health care provider. Eating a heavy meal before sleep aggravates sleep disturbances and thus should be avoided. The nurse cannot administer a sedative drug to a patient without the prescription of the primary health care provider.

While assessing the mental status of an older patient, the nurse uses the Folstein Mini-Mental State Examination (MMSE). Which parameters does the nurse assess in the patient? 1. Orientation 2. Depression 3. Memory recall 4. Visuospatial ability 5. Personal information

1, 3, 4 Rationale: The Folstein MMSE is performed to assess the mental state of the patient. In this test, the nurse assesses the orientation of the patient to know whether the patient is conscious about the time and place. The nurse assesses the patient's ability to recall the surroundings. The nurse also assesses the visuospatial ability of the patient to determine the patient's ability to perceive objects, drawing, and so forth. Patient depression is assessed in the Geriatric Depression Scale. The personal information of the patient is collected in the Short Portable Mental Status Questionnaire, which assesses the reason for the mental illness of the patient.

The nurse is planning to conduct the Get Up and Go Test in a functionally disabled patient. Which factors does the nurse evaluate during the assessment? (select all that apply) 1. Ability of the patient to walk several paces 2. Ability of the patient to identify object shapes 3. Ability of the patient to maintain sitting balance 4. Ability of the patient to sit back down in the chair 5. Ability of the patient to transfer from sitting to standing

1, 3, 4, 5 Rationale: The Get Up and Go Test is a reliable test that helps in quantifying the functional mobility of a patient who has a risk of falling. The nurse evaluates the patient's ability to walk, sitting balance, ability to sit back in a chair, and ability to transfer from sitting to standing. This test helps determine the strength of the skeletal muscles. The nurse may determine the patient's ability to identify object shapes while assessing the visuospatial skills of the patient.

The nurse is preparing a team to perform a comprehensive assessment of older adults. Who should participate in the assessment? 1. Social workers 2. Hospice caregiver 3. Speech therapist 4. Patient family members 5. Primary health care provider

1, 3, 5 Rationale: A comprehensive geriatric assessment is multidimensional and incorporates the physical examination and assessments of mental status, functional status, social and economic status, pain, and examination of the physical environment for safety concerns. Multiple disciplines may participate in this assessment. The primary health care provider is required for this process. A speech therapist is also sometimes essential for an elderly patient who has difficulty speaking. The presence of a social worker is necessary if elderly patients do not have the support of their family members or are financially unstable. Family members of the patient are not generally involved during this assessment. A hospice caregiver is only required if the patient is terminally ill.

Which interventions made by the nurse ensure proper assessment in the elderly patient? (select all that apply) 1. Involve the patient in all decision making about the interview. 2. Use medical language with the patient throughout the assessment. 3. Do the assessment after providing privacy in the examination room. 4. Communicate with the patient in an easy-to-hear, high-pitched voice. 5. Include touch whenever necessary while doing a patient assessment.

1, 3, 5 Rationale: During the assessment, the elderly patient may have difficulty answering the nurse's questions in the presence of others. Therefore, to get accurate information and to maintain the confidentiality of the patient's health information, the nurse provides for privacy during the assessment. Involving the patient in decision making about the interview establishes rapport and promotes trust. Therefore, the nurse involves the patient in decision making about how the assessment takes place. Patient anxiety may interfere with the assessment; therefore, therapeutic touch helps in reducing the anxiety and establishes a good rapport. Communicating in a high-pitched voice may cause irritation and anxiety in the patient. Therefore, the nurse speaks in a low-pitched and relaxed way to alleviate anxiety. Communicating using medical terminology can interfere with communication, resulting in not gathering complete information.

Which parameters does the nurse assess using the Short Portable Mental Status Questionnaire? 1. Orientation 2. Memory recall 3. Working memory 4. Visuospatial ability 5. General information

1, 3, 5 Rationale: The nurse uses the Short Portable Mental Status Questionnaire to assess the mental status of a patient. The patient parameters that are assessed using this scale include orientation, working memory, and general information. Visuospatial ability and immediate or delayed memory recall are assessed by the Mini-Mental State Examination (MMSE) and the Mini-Cog.

The nurse observes that an older patient struggles to understand the spatial relationships between objects and is unable to recognize familiar faces. The nurse suspects that the patient may have Alzheimer disease. Which cognitive tests should be used for further assessment? 1. Mini-Cog test 2. Get Up and Go Test 3. Mini-Mental State Examination 4. Short Portable Mental Status Questionnaire 5. Blessed Orientation-Memory-Concentration Test (BOMC)

1, 3, 5 Rationale: The patient with Alzheimer disease may have decreased visuospatial skills and delayed recall of memory. Therefore, the patient may be unable to recognize familiar faces. The nurse uses the Mini-Cog test to assess the patient's visuospatial skills along with orientation and work memory. The Mini-Mental scale helps assess the mental status of the patient. The Blessed Orientation-Memory-Concentration Test (BOMC) is a cognitive instrument that helps assess orientation, recall memory, and working memory. TheGet Up and Go Test helps evaluate the risk of fall in the patient. The Short Portable Mental Status Questionnaire helps assess the mental status of a patient.

The nurse finds that an elderly patient is experiencing depression related to changes in mobility related to aging. Which interventions should the nurse expect the health care provider to prescribe? 1. Initiate psychotherapeutic treatment for the patient. 2. Follow a wait-and-see approach before doing treatment. 3. Disregard it as it dissipates on its own within a few days. 4. Instruct the patient to perform regular active exercises. 5. Suggest the family members to leave the patient alone.

1, 4 Rationale: Depression in the elderly patient can persist for longer times and can recur later in life. Untreated depression in an elderly patient increases the risk of functional decline and decreases the time that an older adult maintains independence. Therefore, to prevent these consequences, the healthcare provider starts psychotherapeutic treatment for a depressed elderly patient. Active exercises help in reducing depression by encouraging the state of well-being; therefore, the health care provider instructs the patient to perform regular active exercises. Following a wait-and-see approach for treatment and ignoring the condition can worsen the risk, as depression in the patient tends to be long-lasting. Living alone may further depress the patient and result in functional decline in the patient.

What environmental modifications should the nurse suggest to an older patient to promote sleep? (select all that apply) 1. "Do not watch television while lying on the bed." 2. "Stay lying in bed even if you are having difficulty falling asleep." 3. "Keep the lights on during the night to decrease the risk of falls." 4. "Control the noise level to prevent possible sleep interruptions." 5. "Obtain a minimum of a half an hour of sunlight exposure per day."

1, 4, 5 Rationale: Environmental modifications may be necessary to promote sleep. The bed should be used only for sleeping, not for any other activities such as watching television. This helps the patient to perceive bed as a cue for sleeping. The noise levels should be controlled to prevent any interruptions in sleep. The patient should have exposure to sunlight for at least half an hour per day. It helps to set up the circadian rhythm and the sleep-wake cycle. The patient should get up from the bed if not feeling sleepy. The patient can engage in some relaxing activity and again try to sleep after some time. The bright lights should be turned off, because they can interfere with the circadian rhythm. Night lights can be turned on to prevent falls.

After reviewing the prescription of a patient, the nurse warns the patient about the possibility of insomnia. Which medication would have this effect? 1. Diuretics 2. Hypnotics 3. Barbiturates 4. Corticosteroids 5. Bronchodilators

1, 4, 5 Rationale: Insomnia is difficulty falling asleep. Diuretics help remove excess fluid from the body; this may result in frequent urination, thereby disturbing the sleep, which may result in insomnia. Corticosteroids are anti-inflammatory drugs that act as central nervous system stimulants. Therefore, the patient may experience insomnia when taking corticosteroids. Bronchodilators help treat asthma by opening the air passages. These drugs also act as central nervous system stimulants, which may cause insomnia. Benzodiazepines are hypnotic drugs, which cause sedation and help treat insomnia effectively. Barbiturates are sedative drugs, which may cause drowsiness and help treat insomnia.

The nurse is planning to use Hospital Admission Risk Profile (HARP) instrument to screen a group of elderly patients who are at risk of functional decline. Which variables does the nurse consider while using this tool? 1. Age 2. Mini-Cog 3. Cultural beliefs 4. Mini-Mental State Examination (MMSE) 5. Instrumental Activities of Daily Living (IADL) function prior to admission

1, 4, 5 Rationale: The HARP is a simple screening tool that classifies patients as being at low, intermediate, or high risk for losing the ability to perform the activities of daily living. The nurse considers the patient's age, cognitive function based on MMSE score, and the ability to perform independent activities of daily living. These variables are the major factors that can indicate functional decline in older patients. The nurse does not consider the patient's cultural beliefs, because these do not cause functional decline in the patient. The nurse does not consider the patient's Mini-Cog score, because it does not give accurate information about the cognitive function of the patient.

The nurse is caring for a patient who has depression and who is prescribed an antidepressant medication. What other treatments would be beneficial for the patient? 1. Psychotherapy 2. Diuretic therapy 3. Hypnotic therapy 4. Decongestant therapy 5. Electroconvulsive therapy

1, 5 Rationale: A patient with depression is treated with antidepressants, which inhibit the reuptake of serotonin in the brain and help reduce depression. Psychotherapy is an interactive treatment that helps reduce stress and depression in a patient. Electroconvulsive therapy is an electrically induced treatment for mental illness. Therefore, psychotherapy and electroconvulsive therapy will be beneficial for the patients who have depression. Diuretic therapy helps reduce edema by removing excess fluids from the body. Hypnotic drugs cause sedation and help treat insomnia. Decongestants activate epinephrine and norepinephrine receptors and help relieve nasal congestion in the upper respiratory tract.

While discussing physical activities with the nursing instructor, the student nurse says, "Active physical activities promote sleep by stimulating daytime wakefulness and napping. It also reduces depression and the risk of obesity." Which information provided by the student nurse needs correction? 1. Physical activities reduce obesity. 2. Physical activities promote napping. 3. Physical activities reduce depression. 4. Physical activities stimulate daytime arousal.

2 Rationale: Active physical activities prevent napping and, therefore, promote sleep in the patient. Therefore, the student nurse stating that physical activity promotes napping needs correction. Active physical exercises help in reducing depression by encouraging a state of well-being in the patient. Active regular physical exercises also help burn excess calories in the patient and reduce the risk of obesity-related insomnia in the patient. Active physical activities promote daytime arousal, thereby, promoting sleep during the night and preventing insomnia in the patient.

While caring for a geriatric patient who is on diuretic therapy the nurse instructs the patient, "Take less fluid before going to bed." What is the reason for this instruction? 1. The patient may have a risk of syncope. 2. The patient may have a risk of insomnia. 3. The patient may have a risk of hypoglycemia. 4. The patient may have a risk of hyperthermia.

2 Rationale: Diuretic drugs help reduce edema by removing excess fluid from the body. The patient who is on diuretic therapy needs to wake up at night frequently to urinate. Therefore, the nurse instructs the patient to administer less fluid before going to bed to limit urine formation. The sudden loss of consciousness due to weakness is called syncope. Diuretic drugs are not associated with syncope, hypoglycemia, or hyperthermia. Low blood glucose levels, or hypoglycemia, is a complication of insulin therapy. Diuretic drugs may cause an imbalance of fluid and electrolytes, but not of blood glucose. Administering diuretics causes loss of water; this decreases the body temperature and may result in hypothermia, not hyperthermia.

While interacting with a patient, the nurse learns that the patient consumes excessive coffee and cigarettes. Which risk does the nurse expect in the patient? 1. Delirium 2. Insomnia 3. Osteoarthritis 4. Muscular atrophy

2 Rationale: Excessive intake of caffeine and nicotine disturbs the sleep cycle and causes insomnia. Delirium, osteoarthritis, and muscular dystrophy are not associated with excessive intake of caffeine or nicotine. Factors that increase the risk of delirium are dehydration, urinary tract infection, pneumonia, and skin and abdominal infections. Factors that predispose to osteoarthritis include obesity, old age, and a genetic defect in a joint or cartilage. Factors that predispose to muscular atrophy include injury or malnutrition.

The nurse teaches an older adult about dietary modifications to promote sleep. Which statement made by the patient indicates effective teaching? 1. "I can have a heavy meal for dinner." 2. "I can have milk and crackers at bedtime." 3. "I can include two chocolate drinks at dinner." 4. "I can have one alcoholic drink in the evening."

2 Rationale: 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.

Which scale would be most effective in assessing a geriatric patient's ability to perform activities of daily living (ADLs) in a rehabilitation center? 1. Rapid Disability Rating Scale-2 (RDS-2) 2. Functional Independence Measure (FIM) 3. Katz Index of Activities of Daily Living (ADLs) 4. Lawton Instrumental Activities of Daily Living (IADLs)

2 Rationale: The FIM scale is widely used in older adults for the assessment of daily activities in rehabilitation settings. It is most feasible in a rehabilitation setting, because it provides accurate information about the progress of the patient's abilities. The Katz Index of ADLs relies on the patient reporting his or her abilities and is subjective (instead of objective) in data collection. The Lawton IADL is a scale to evaluate the advanced activities of daily living, such as socialization and money management. It is not feasible to use in an institutional setting, because the residents may manage most of the tasks included in the scale. The Rapid Disability Rating Scale-2 (RDS-2) measures what a patient can do, not what he or she should be able to do. p. 832

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? 1. Tinetti Gait and Balance Evaluation 2. Katz Index of Activities of Daily Living 3. Pittsburgh Sleep Quality Index (PSQI) 4. Lawton Instrumental Activities of Daily Living

2 Rationale: 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.

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? 1. "How does spirituality help among your family members?" 2. "How does spirituality relate to your concept of health?" 3. "How does spirituality improve your financial situation?" 4. "How does spirituality help in your family relationships?"

2 Rationale: 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.

While reviewing the records of an older patient with a chronic musculoskeletal disorder, the nurse finds that the patient's family members filled out the questionnaire. Which tool is used for the assessment? 1. The Barthel Index tool 2. The Rapid Disability Rating Scale-2 3. The Functional Independence Measure 4. The Katz Index of Independence in Activities of Daily Living

2 Rationale; A family member who is familiar with the abilities of the older adult completes the Rapid Disability Rating Scale-2.Based on the response, points ranging from 1 to 3 are assigned, indicating no, slight moderate, and severe impairment of activities of the patient. Unlike the Rapid Disability Rating Scale-2 tool, family members do not fill out the Barthel Index tool, the Functional Independence Measure tool, or the Katz Index of Independence in Activities of Daily Living tool. The Barthel Index measures the functional disability by quantifying the patient's performance in ten activities of daily life. The Functional Independence Measure is more sensitive than other ADL instruments and is more time-consuming. The Katz Index of Independence in Activities of Daily Living is used to assess the functional status as a measurement of the patient's ability to perform activities of daily living independently.

The nurse is caring for an older adult patient who has cardiovascular disease. Which instruction regarding exercise does the nurse include in the care plan of the patient, according to the World Health Organization (WHO)? 1. Perform the activity by taking a break every 30 minutes. 2. Perform muscle-strengthening activities at least twice a week. 3. Perform intense vigorous exercise for 300 minutes every week. 4. Perform moderate aerobic activity for 150 minutes every day.

2 Rationale; WHO has provided certain guidelines for the physical activity of older adults to improve physical and mental health and to reduce the risk of noncommunicable disease. The older adult patient should perform muscle-strengthening activities at least 2 days a week for proper muscle functioning. Older adults do not have much stamina and tend to get tired easily. An older adult patient would get extremely tired if he or she worked out continuously for a period of 30 minutes. Therefore, they should take a break after every 10 minutes. An older adult patient should perform vigorous exercise for 150 minutes a week to maintain proper health. If the older adult patient performs vigorous exercise for 300 minutes a week, it may cause strain to the patient. An older adult patient should perform moderate exercise for 300 minutes every week. If the older adult patient performs moderate exercise for 150 minutes every day, then the patient may experience excessive strain.

What are the advantages of the Katz ADL scale? 1. The patient can provide a self-report. 2. The instrument can be used in many settings. 3. The instrument takes 5 minutes to administer. 4. The nursing staff can assist the patient while grooming. 5. The primary health care provider does not need to observe the patient.

2, 3 Rationale: The Katz ADL scale is a handy instrument that can be used in many settings. The tool takes only 5 minutes to administer. The tool has some disadvantages as well. In an outpatient setting, the primary health care provider cannot watch the patient directly and the patient provides a self-report that may not be accurate. In a hospital setting, the nursing staff may also be assisting in transferring or grooming activities and may underestimate the ability for self-care.

The nurse is caring for an elderly patient with chronic illness. Which parameters does the nurse assess while evaluating the Advanced Activities of Daily Living (AADL)? 1. The ability of the patient to manage finances 2. The social activities performed by the patient 3. The patient's responsibilities as a family member 4. The recreational activities performed by the patient 5. The ability of the patient to prepare a meal or to use the telephone

2, 3, 4 Rationale: The AADL includes the activities performed by an older adult in a community, such as social activities and recreational activities within the community. AADL also includes the activities performed by an older adult within a family. The ability of the patient to manage finances is assessed in the Instrumental activities of daily living. The ability of a patient to prepare a meal or to use the telephone is included in the activities of daily living.

The nurse and health care provide r are assessing the mental status of a patient. Which patient findings suggest early-onset Alzheimer-type dementia? (select all that apply) 1. The patient has difficulty with vision. 2. The patient has difficulty finding words. 3. The patient has difficulty with ambulation. 4. The patient has difficulty in naming objects. 5.The patient has difficulty in holding objects.

2, 4 Rationale: 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.

What instructions does the nurse give to prevent disturbances in the circadian rhythm in a patient with insomnia? (select all that apply) 1. "Take a cold shower before going to bed." 2. "Set an alarm to eat meals at regular intervals." 3. "Limit your alcohol intake to three drinks per day." 4. "Try eating a heavier dinner, which makes you sleepy." 5. "Keep the drapes of the room open throughout the day."

2, 5 Rationale: Circadian rhythm, also known as the biological clock, is a biological process that helps maintain the proper sleep-wake balance. Using an alarm for meals helps maintain the temporal pattern of an activity, which helps ensure synchronization of circadian rhythms. Circadian rhythm is influenced by brightness and darkness of the external environment. Therefore, the nurse should ask the patient to keep open the drapes throughout the day. A cold shower will not soothe, but stimulate the cells and awaken the patient. Therefore, the nurse advises the patient to take a warm shower. Consuming spicy and heavy foods during dinner may upset the stomach and cause heartburn; this may disturb the sleep of the patient. Therefore, the nurse advises the patient to avoid heavy and spicy food for dinner. Alcohol intake should be limited to one drink per day because it decreases alertness and disturbs sleep. Therefore, the nurse instructs the patient to take no more than one drink per day.

Which test does the nurse use to assess the risk of fall in a patient who has chronic illness? (select all that apply) 1. Mini-Cog 2. Get Up and Go Test 3. Neecham Confusion Scale 4. Advanced activities of daily living 5. Tinetti Gait and Balance Evaluation

2, 5 Rationale: The Get Up and Go Test helps evaluate the functional ability of the patient. In this test, the nurse asks the patient to rise from the chair, walk 10 feet, turn, walk back to the chair, and sit down. This test measures the balance of the patient in different postures to assess risk of fall. The Tinetti Gait and Balance Evaluation is a 28-point balance tool that helps assess the gait and balance of the patient. Therefore, these tests are useful to assess the risk of falls in older adult patients. The Mini-Cog, Advanced Activities of Daily Living, and the Neecham Confusion Scale help in the assessment of mental status. The Mini-Cog is performed to assess whether the patient has visuospatial disability or a delay in recalling memory. The Advanced Activities of Daily Living includes occupational and recreational activities. The nurse assesses the social life and recreational activities of the patient through the Advanced Activities of Daily Living. The Neecham Confusion Scale helps determine whether the patient has delirium.

The nurse advises an elderly patient with insomnia to have a glass of milk at bedtime. What would be the reason for this advice? 1. To promote sleep by reducing anxiety 2. To promote sleep by reducing heartburn 3. To promote sleep by reducing hypoglycemia 4. To promote sleep by reducing bladder fullness

3 Rationale: A light bedtime snack of milk, or cheese and crackers reduces hypoglycemia in the patient. Therefore, to promote sleep, the nurse advises the patient to have a snack. The light snack of milk, or cheese and crackers will not induce sleep by reducing anxiety in the patient; instead, maintenance of a proper sleeping schedule reduces anxiety in the patient. This light snack does not reduce heartburn; instead, refraining from heavy, spicy foods may reduce heartburn. The light snack of milk, or cheese and crackers will not help reduce bladder fullness. Restricting fluids before bedtime will reduce bladder fullness in the patient.

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? 1. Assessing cognition 2. Assessing caregiver burden 3. Assessing the activities of daily living (ADL) 4. Assessing functional decline during hospitalization

3 Rationale: 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.

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? 1. Epilepsy 2. Syncope 3. Delirium 4. Hypertension

3 Rationale: 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.

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? 1. Schedule another day for the assessment. 2. Report to the primary healthcare provider. 3. Use interpreters for better communication. 4. Request that family members translate.

3 Rationale: 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.

The nurse is assessing a patient with decreased ability to perform routine tasks. The nurse uses ten orientation questions, three registration items, and five attention items. Then the nurse asks the patient to recall the three previous registration items. Which assessment tool has the nurse used with this patient? 1. Neecham Confusion Scale 2. Confusion Assessment Method 3. Folstein Mini-Mental State Examination (MMSE) 4. Short Portable Mental Status Questionnaire

3 Rationale: The Folstein Mini-Mental State Examination (MMSE)is a brief 21-point tool that helps assess for the ability of an elderly patient to perform instrumental activities of daily living. The Neecham Confusion Scale and Confusion Assessment Method assess the patient who has delirium. The Short Portable Mental Status Questionnaire is a short questionnaire that helps screen for dementia signs and the degree of cognitive impairment in older patients.

The nurse is teaching a group of nurses about various instruments used to assess a patient's activities of daily living. Which instrument requires more training to implement? 1. Barthel Index 2. Rapid Disability Rating Scale-2 3. Functional Independence Measure 4. Katz Index of Independence in Activities of Daily Living

3 Rationale: The Functional Independence Measure scale uses a variety of methods or assessments. It is more sensitive than other ADL instruments, takes more time to administer, and requires formal training to implement. The Barthel Index measures functional disability by quantifying the patient's performance in ten activities of daily life. It includes definitions of each task that facilitate ease of scoring. A family member or professional caregiver familiar with the abilities of the older adult completes the Rapid Disability Rating Scale-2. It may result in underestimation or overestimation of the patient's abilities. The Katz Index of Independence in Activities of Daily Living is used to assess the functional status as a measurement of the patient's ability to perform the activities of daily living independently. The Barthel Index, The Rapid Disability Rating Scale-2, and The Katz Index of Independence in Activities of Daily Living are not sensitive and are less time-consuming. Therefore, the nurse did not refer to these instruments while teaching.

An elderly patient reports sleep disturbances and does not want to take medications. What advice does the nurse give to the patient in this situation? 1. "Avoid massages just before bedtime." 2. "Avoid reading directly before bedtime." 3. "Take a warm bath before going to bed." 4. "Trying drinking warm liquids going to bed."

3 Rationale: The nurse can suggest nonpharmocologic measures to promote sleep for a patient with sleeping disorders if the patient refuses to take any medication. Therefore, the nurse advises the patient to take warm baths before going to sleep, because they soothe the body by reducing the body temperature and induce sleep in the patient. Reading before going to bed actually promotes sleep, so it should be encouraged instead of discouraged. Refraining from having a massage can further worsen any sleep disturbances because massage reduces stress, thus relaxing the brain and inducing sleep. Fluid intake just before bed can lead to frequent sleep interruptions from a full bladder. Therefore, drinking warm liquids should not be recommended for this patient.

What disease process, as documented in the patient's records, may make it difficult to complete discharge teaching? 1. Osteoarthritis 2. Diabetes mellitus 3. Alzheimer dementia 4. Myocardial infarction

3 Rationale: 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.

The nurse suspects that a patient with a chronic illness is mistreated. Which screening tool would the nurse use to assess this patient? 1. Neecham Confusion Scale 2. Confusion Assessment Method 3. Modified Caregiver Strain Index 4. Tinetti Gait and Balance Evaluation

3 Rationale: 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 instrument does the nurse use to assess the risk of delirium in a patient? 1. Mini-Cog 2. Get Up and Go Test 3. Neecham Confusion Scale 4. Confusion Assessment Method 5. Tinetti Gait and Balance Evaluation

3, 4 Rationale: Delirium is a sudden change in the state of mind that results in confusion and emotional breakdown. The Neecham Confusion Scale and the Confusion Assessment Method are assessment tools that help assess delirium in a patient. The nurse uses the Mini-Cog to assess the patient's visuospatial skills, as well as orientation and work memory. The Get Up and Go Test helps evaluate the risk of fall in the patient. The Tinetti Gait and Balance Evaluation is a 28-point scale that helps evaluate the risk of fall in the patient.

While assessing the personal functions of an older patient, the nurse uses the Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL (OARS-IADL). Which parameters does the nurse assess in the patient? 1. Memory 2. Orientation 3. Physical health 4. Mental health 5. Visuospatial ability

3, 4 Rationale: The OARS-IADL is an additional IADL instrument that assesses the personal function of a patient by assessing his or her social, economic, mental, and physical health and self-care capacity. Therefore, the nurse assesses the physical and mental health of the patient using this tool. The Folstein Mini-Mental State Examination (MMSE) is performed to assess the mental state of the patient. In this test, the nurse assesses the orientation of the patient to determine whether the patient is conscious about time and place. The nurse also assesses the patient's ability to recall the surroundings. The nurse assesses the visuospatial ability to determine whether the patient is able to perceive the objects, drawing, and so forth.

The nurse is monitoring instrumental activities of daily living (IADL) in an aged patient. What are the activities that the nurse should monitor in the patient? 1. Feeding 2. Walking 3. Shopping 4. Cooking 5. Counting

3, 4, 5 Rationale; Typically IADL tasks include shopping, meal preparation or cooking, laundry, managing finances or counting, basic housekeeping, taking medications, and using transportation. Tasks such as yard work and leisure activities such as reading and other hobbies are included in some, but not all IADL instruments. Feeding and walking are activities of daily living and are tasks necessary for self-care.

The nurse is assessing a group of geriatric patients in a community setting. What should the nurse remember to ensure that the patients receive effective care? (select all that apply) 1. Geriatric patients will be less vulnerable. 2. Geriatric patients have high self-esteem. 3. Geriatric patients have varied disabilities. 4. Geriatric patients' functional status is stagnant. 5. Geriatric patients will have varied independence.

3, 5 Rationale; Geriatric patients are predisposed to disability and have varying independence. Therefore, the nurse should consider these factors while assessing the patients. These factors will ensure effective care for these patients. Geriatric patients are highly vulnerable as they experience high emotional conflict. Therefore, the nurse should provide emotional support and keep in mind their vulnerable status while providing the care. All geriatric patients do not have high self-esteem; some of them exhibit decreased self-esteem, because abilities change with the aging process. As a result, the nurse should promote ways to boost the geriatric patient's self-esteem. The geriatric patient's functional status changes as the person ages, due to illnesses.

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? 1. The patient refrains from attending parties. 2. The patient does not go to religious functions. 3. The patient follows a relaxed, sedentary life style. 4. The patient follows the guide " Staying Healthy at 50+."

4 Rationale: " 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.

Which screening tool does the nurse use to assess circadian rhythm disturbance in a patient? 1. Mini-Cog 2. Confusion Assessment Method 3. Tinetti Gait and Balance Evaluation 4. Pittsburgh Sleep Quality Index (PSQI)

4 Rationale: 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.

The nurse is caring for a geriatric patient who reports insomnia. What does the nurse suggest to promote sleep in the patient? 1. "Avoid prolonged exposure to sunlight." 2. "Ensure that drapes are closed throughout the day." 3. "Talk to a friend over the phone until you feel sleepy." 4. "Avoid working or watching television in the bedroom."

4 Rationale: 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, the patient tells the nurse, "Even though I get regular exercise, I'm still overweight." What other statements made by the patient help the nurse to understand the reason for this situation? 1. "I restrict my intake of fluids before going to bed." 2. "I drink a glass of milk every night before I go to bed." 3. "I limit my salt intake to prevent water retention at night." 4. "I do not eat spicy meals and I limit alcohol to three drinks per day."

4 Rationale: Regular exercises can prevent obesity. Even though the patient may perform regular exercises, poor sleep patterns in the patient may result in obesity. Limiting spicy meals before going to bed can reduce the risk of obesity by promoting sleep in the patient. However, consuming three drinks of alcohol at bedtime results in insomnia, because alcohol can cause obstructive sleep apnea, restless leg syndrome, and sweating in the patient. Foods high in salt cause water retention, which can lead to frequent nighttime urination. Drinking more fluids in the evening can cause insomnia by creating bladder fullness, but does not result in obesity in the patient. Eating a light snack, including milk, before bedtime promotes sleep by reducing hypoglycemia and does not result in obesity in the patient.

While examining the mental status of a patient, the nurse assessed the orientation, and immediate and delayed recall of the patient in 6 minutes. Which cognitive instrument did the nurse use? 1. Mini-Cog 2. Geriatric Depression Scale 3. Direct Assessment of Functional Abilities (DAFA) 4. Blessed Orientation-Memory-Concentration Test (BOMC)

4 Rationale: The BOMC is a cognitive instrument that helps in the assessment of the mental status of a patient. The nurse assesses orientation, recall memory, and working memory through this assessment. It takes a maximum of 6 minutes for this assessment. The Mini-Cog helps determine the mental status of the patient by assessing visuospatial ability and recall ability within 10 minutes. The Geriatric Depression Scale helps assess depression in a patient who has delirium. The DAFA is an additional Lawton Instrumental Activity of Daily Living that helps assess the daily living and money management of the patient. However, it does not assess the working memory of the patient.

Who often performs the assessment of the advanced activities of daily living (AADLs)? 1. Pharmacists 2. Speech therapists 3. Physical therapists 4. Occupational therapists

4 Rationale: The activities that any adult performs as a member of a family, a society, and a community, including occupational and recreational activities, are termed as AADLs. Occupational therapists most often perform the assessment of the AADLs. Pharmacists, speech therapists, and physical therapists do not often perform AADLs. Pharmacists dispense medications prescribed by health care providers. Speech therapists work with patients with speech and swallowing disorders. Physical therapists help patients with exercises to increase mobility.

What intervention should the nurse include to prevent falls while assessing mobility in an older adult with diabetic neuropathy? 1. Ambulate on smooth, high-gloss surfaces. 2. Decrease illumination and glare in the surroundings. 3. Observe the walking pattern from faraway to better see gait problems. 4. Reassure the patient that not everyone can perform all the tasks on the assessment

4 Rationale: The patient with diabetic neuropathy may have decreased sensation in the feet. While assessing mobility in this patient, the nurse should be sensitive to the fact that elderly patients may fear the outcome of mobility testing because it can mean the loss of independence. The nurse should reassure the patient that not everyone can perform all the tasks on the test, but that may or may not determine a change in the patient's lifestyle. The patient should not ambulate on high-gloss and shiny surfaces because that can lead to falls. There should be plenty of lighting in the patient's surroundings to make the pathways easier to visualize. The nurse should not watch the patient walk from far away because in that case the nurse cannot prevent the patient from falling if the patient becomes unsteady.

A 60-year-old patient complains to the nurse, "I think my age is catching up with me; I am unable to sleep properly at night." What does the nurse suggest to the patient to ensure proper sleep? 1. "Drink a cup of warm tea before going to bed." 2. "Consume a heavy and spicy diet during dinner." 3. "Read a book in bed before switching off the light." 4. "Consume a light snack with milk before going to bed."

4 Rationale: The patient with insomnia has difficulty staying asleep at night. Snacks such as toast or crackers contain carbohydrates, which reduce hypoglycemia and promote sleep. A heavy and spicy diet might cause heartburn that may disturb sleep. Therefore, the nurse does not advise the patient to eat a heavy and spicy diet. The bedroom should be used only to sleep; 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. Tea is a central nervous system stimulant that interferes with sleep patterns and hinders sleep.

Which tool does the nurse use to evaluate a patient's ability to live independently and to manage finances? 1. Barthel Index 2. Katz Index of Activities of Daily Living 3. Functional Independence Measure (FIM) 4. Direct Assessment of Functional Abilities (DAFA)

4 Rationale; The DAFA is a 10-item observational instrument that assesses the ability of self-care, independence, and money management. The Lawton instrumental activities of daily living scale comprises eight activities: use of the telephone, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, and management of finances, to assess the living conditions of the patient. The DAFA is an additional instrument of the Lawton Instrumental Activities of Daily Living. The Barthel Index measures functional disability by quantifying the patient's performance in ten activities of daily life. The Barthel Index includes the definitions of each task, which facilitates the ease of scoring. The Katz Index of Independence in Activities of Daily Living helps assess functional status as a measurement of the patient's ability to perform activities of daily living independently. The Functional Independence Measure is more sensitive than other ADL instruments and is more time-consuming.

An elderly patient with insomnia has been prescribed hypnotics and sedatives. What does the nurse inform the patient about the side effects of these medications? 1. "You may experience nausea." 2. "You may develop hypoglycemia." 3. "You may have decreased appetite." 4. "You may increase the risk of delirium." 5. "You may have an increased risk of falls."

4, 5 Rationale: Side effects associated with the administration of sedative and hypnotic medications are an increased risk of falls and delirium. In general, the functioning of the skeletal and nervous systems reduces gradually with age. These medications act as nervous system depressants, increasing the risks of falls and delirium. Sedatives and hypnotics do not act on the chemoreceptor trigger zone of the brain; therefore, these medications do not cause nausea. Sedative and hypnotic medications do not block the receptors that induce appetite in the patient. Therefore, these medications do not cause anorexia. Sedative and hypnotic medications do not act on the pancreatic beta cells; therefore, these medications do not cause hypoglycemia.

A loss of the ability to perform ADLs because of acute illness and hospitalization is common in _______

older adults