vSim - Millie Larsen 1/2/3
Which age-related change is the greatest primary risk to experiencing a fall? a) Increasing cloudiness of the corneal lens b) Increasing incidence of hypertension c) Decreasing sense of discriminating touch d) Decreasing flexibility due to osteoarthritis
b) Increasing incidence of hypertension The high use of antihypertensive medications among the older population increases the risk for postural hypertension (dizziness), which is a risk factor for falls. The greatest risk from osteoarthritis is pain and stiffness. Cataract development results in clouded eye lenses, resulting in bothersome glare and impaired night vision. Diminished touch confers less tactile stimulation and so increases the risk for injury. These options present secondary risks for falling.
What factor increases the risk of falls in the older adult? (Select all that apply.) a) Dependence on assistive mobility devices b) Recent retirement c) Vision impairments d) Medication side effects e) Poor lighting
c) Vision impairments d) Medication side effects e) Poor lighting Falls are a major safety concern in the older adult. Many factors put the older adult at risk for falls, such as medications, sensory impairments (visual disturbances), and poor lighting. Dependence on mobility devices is likely to decrease the risk of falling. Being recently retired may be a factor for depression but is not a risk for falls.
Which blood pressure component is considered hypertensive in the older adult? (Select all that apply.) a) 92 mmHg diastolic b) 144 mmHg systolic c) 140 mmHg systolic d) 88 mmHg diastolic e) 90 mmHg diastolic
a) 92 mmHg diastolic b) 144 mmHg systolic When blood pressure enters a level of less than 140 mmHg systolic and/or less than 90 mmHg diastolic, it is considered hypertensive.
When considering applicable interventions for Millie Larsen's discharge, the nurse considers that older adults are cared for most often by whom? a) A female relative b) Formal agencies, such as home health agencies c) The oldest male child's family d) Grandchildren who live nearby
a) A female relative More than one half of the caregivers of older adults are wives, with the next largest group of caregivers being daughters and daughters-in-law. Most home care is provided by the patient's family, not by agencies. Daughters, more than sons, provide in-home care for their parents. Grandchildren are not the most common caregivers.
What aspects of caregiving does the acronym "TLC" evaluate? (Select all that apply.) a) Ability to recognize changes in the patient's physical needs b) Ability to spend time away from the caregiving role c) Ability to attend to personal, physical, and emotional needs d) Ability to provide the necessary care effectively e) Ability to effectively help manage the patient's financial resources
a) Ability to recognize changes in the patient's physical needs b) Ability to spend time away from the caregiving role c) Ability to attend to personal, physical, and emotional needs d) Ability to provide the necessary care effectively Caregivers must be competent to provide care and not jeopardize themselves in the process. They must make provisions for what gerontological nurses call TLC: T - training in caregiver techniques, safe medication use, recognition of abnormalities and available resources; L - leaving the care situations periodically to obtain respite and relaxation; and C - caring for themselves with adequate sleep, exercise, nutrition, socialization, financial security, stress reduction, and health management. Although a caregiver may be involve in managing the patient's finances, the ability to do so effectively is not an appropriate response concerning caregiver strain.
The daughter of an 80-year-old female recently found her mother confused and disoriented. Because her uncle had Alzheimer disease, the daughter is concerned that her mother has the same disease. Which manifestation(s) suggests that the mother has delirium not dementia? (Select all that apply.) a) Altered level of consciousness b) Disturbed intellectual function c) Sleep disturbances d) Altered attention span e) Insidious onset that lasts years
a) Altered level of consciousness b) Disturbed intellectual function c) Sleep disturbances d) Altered attention span The manifestations of delirium include rapid onset and short duration, altered attention span and level of consciousness, sleep disturbances, and disturbance in intellectual function. Dementia has an insidious onset; is progressive and irreversible; and affects memory, judgment, language, and problem-solving ability.
Which individual is demonstrating the ability to performing an instrumental activity of daily living (IADL)? a) An older male who sweeps his kitchen floor each evening b) A cognitively impaired older male who feeds himself c) An older female who dresses herself each morning d) An older female diagnosed with osteoarthritis who combs her hair
a) An older male who sweeps his kitchen floor each evening Assessment of the instrumental activities of daily living (IADLs) examines skills that are beyond the basic, which allow the individual to function independently in the community. These activities include cleaning their home environment. Feeding, grooming, and dressing are considered basic activities of daily living.
Furosemide (Lasix) has been ordered for Millie Larsen. The nurse should instruct her to take this medication at this time? a) During the morning hours b) At nighttime right before going to bed c) Dinnertime with food d) Anytime, as long as it's on an empty stomach
a) During the morning hours Diuretics are used in the treatment of hypertension. However, they can cause frequent restroom visits as well as increase the risk of falls so the nurse should plan administration timing that interferes least with the patient's schedule. Morning administration is usually preferable. Taking a diuretic at night could interrupt the patient's sleep. This medication should be taken with food, not on an empty stomach, to prevent gastrointestinal upset.
An older adult female is admitted to the hospital with a urinary tract infection (UTI). The nurse anticipates that management will likely be focused on the treatment of which pathogen? a) Escherichia coli b) Chlamydia trachomatis c) Staphylococcus aureus d) Proteus species
a) Escherichia coli The organism primarily responsible for UTIs in women is the Escherichia coli organism. Proteus is primarily responsible for UTIs in males. Staphylococcus aureus and Chlamydia trachomatis are not the primary organisms found in the urinary tract.
An 84-year-old woman has been living alone before being hospitalized for a urinary tract infection and a fall. When preparing the patient for discharge, which nursing intervention provides the most relevant information about the patient's ability to provide self-care? a) Functional assessment b) Complete history and physical c) Comprehensive health assessment d) Comprehensive review of body systems
a) Functional assessment The functional assessment provides information about the individual's ability to perform activities of daily living (ADLs). Functional decline may cause the individual to become more debilitated and frail. The Katz Index of Independence in Activities of Daily Living provides information on the patient's ability to perform ADLs independently. A history and physical, a review of body systems, or a comprehensive health assessment will not provide information on the ability of the patient to care for herself.
What is the primary reason that antibiotic therapy for an older adult must be used very selectively and cautiously? a) Older adults are at a higher risk for experiencing severe adverse reactions to antibiotics. b) The older adult is highly susceptible to antibiotic-induced confusion. c) Antibiotic medications are most likely to cause diarrhea, nausea, and vomiting among the older population. d) Excessive use of antibiotics by the older adult has contributed to the emergence of antibiotic-resistant bacteria.
a) Older adults are at a higher risk for experiencing severe adverse reactions to antibiotics. Antibiotic therapy is older adults must be used selectively and with caution because older adults experience more adverse reactions than do any other age group. Confusion is more closely associate with the presence of an infection but not the antibiotic therapy itself. The emergence of antibiotic-resistant bacteria is not due to older adult use of antibiotics in particular. Other side effects such as nausea and vomiting may occur, but these side effects are not specific to the older adult.
Which intervention will help Millie Larsen reduce medication errors and increase medication compliance once she is discharged to her home? (Select all that apply.) a) Provide a detailed written description of the medication's name, dosage, and route of administration. b) Recommend that medications have large-print labels and bottle caps that can be easily removed. c) Instruct Millie to notify her provider immediately if any adverse reaction develops. d) Suggest ways to save money by substituting prescribed medications with over-the-counter medications. e) Encourage Millie to take her medications when it is most convenient for her daily routine.
a) Provide a detailed written description of the medication's name, dosage, and route of administration. b) Recommend that medications have large-print labels and bottle caps that can be easily removed. c) Instruct Millie to notify her provider immediately if any adverse reaction develops. Some of the common self-medication administration errors include incorrect dosage, noncompliance due to lack of knowledge, discontinuation of medications without the advice of the healthcare provider, and usage of medications prescribed for a prior illness. Providing detailed instructions regarding the name, dosage, route of administration, adverse reactions that can occur, and when to call the health care provider may help reduce self-medication errors. Providing labels with large print and bottle caps that are easily opened can help the older adult patient who may have difficult reading fine print and who may have arthritic joints. The patient should not take any new medications without consulting the healthcare provider, including over-the-counter medications. Medication should be taken as prescribed to assure both safety and medication effectiveness.
When considering safety, which issue causes concerns about Millie Larsen's home? (Select all that apply.) a) Scatter rugs are used in the bathroom and kitchen. b) Fragrance dispensers are located throughout the home. c) There is a small table and coat rack just inside the front door. d) The hallway is lit with a hanging light fixture. e) Wall and floor coverings contain bold patterns.
a) Scatter rugs are used in the bathroom and kitchen. c) There is a small table and coat rack just inside the front door. e) Wall and floor coverings contain bold patterns. Scatter and area rugs can be an ideal source for falls and should not be used in the older adult home, especially if the patient has a history of falls as Millie does. Wall and floor coverings in bold designs can cause dizziness and confusion during ambulation and should be avoided to reduce the risk of falls. Likewise, small pieces of furniture should not obstruct well-traveled areas. Aromatherapy can stimulate the brain and would not be considered a safety risk for Millie. Keeping the hallway illuminated without added clutter to the space is considered appropriate in this situation.
The Katz Index of Independence in Activities of Daily Living (ADL) assessment tool has helped the nurse prepare Millie Larsen for discharge by providing what information? (Select all that apply.) a) She has the ability to feed herself independently b) She is able to move in and out of bed without assistance c) Her glaucoma causes vision problems d) She has control over both bladder and bowel function e) Her gait is steady when walking without assistance
a) She has the ability to feed herself independently b) She is able to move in and out of bed without assistance d) She has control over both bladder and bowel function The Katz Index of Independence in Activities of Daily Living assesses a person's ability to perform specific tasks associated with activities of daily living such as bathing, dressing, toileting, feeding, transferring to and from the bed or chair, and having urinary and bowel continence. Although it assesses for the ability to move in and out of the bed and/or chair, it does not specifically assess for an unsteady gait or the ability to walk without assistance. The tool does not provide information regarding sensory concerns such as vision problems.
Millie Larsen states that lately she tries to avoid laughing because of urine leakage. Which type of incontinence does this finding indicate? a) Stress incontinence b) Functional incontinence c) Urgency incontinence d) Overflow incontinence
a) Stress incontinence Stress incontinence is caused by weak supporting pelvic muscles. When pressure is placed on the pelvic floor from coughing, sneezing, or laughing, urine is involuntarily lost. Urgency incontinence is the sudden elimination of urine caused by irritation or spasm of the bladder wall (e.g., from urinary tract infection, diverticulitis, tumors, etc.). Overflow incontinence occurs when urine accumulates in the bladder due to the bladder muscles failing to contract or the periurethral muscles failing to relax, which can result from medication or bladder neck obstruction. Functional incontinence is caused by dementia or other conditions that prevent independent toileting.
Regarding the management of Millie Larsen's diagnosed hypertension, her discharge education will initially focus on what information? a) The name, dosage, and effect of the prescribed antihypertensive medication b) The need to take her antihypertensive medication on an empty stomach c) The importance of regular blood pressure monitoring d) The impact diet and exercise have on the long-term management of hypertension
a) The name, dosage, and effect of the prescribed antihypertensive medication Patient teaching for patients receiving medication treatment should initially focus on reinforcing their understanding of the medication therapy, including medication names and dosages and their effects. Although education regarding blood pressure monitoring, proper medication administration, and the effects of diet and exercise are important and need to be addressed, they do not have the initial importance of basic understanding associated with the medication itself.
The children and grandchildren of an older adult are discussing who will provide care for the patient upon discharge from the hospital. Which of the following statements made by the nurse regarding family caregiving is correct? a) Typically, the majority of caregivers to the older adult are middle-aged daughters and daughters-in-law. b) The grandchildren, particularly granddaughters, should provide the care because their schedules are more flexible. c) Care at home is decided by the oldest male child or the firstborn child of the family. d) The majority of home care is provided by formal institutions. I will help you set up a home health visit.
a) Typically, the majority of caregivers to the older adult are middle-aged daughters and daughters-in-law. Most home care in the older adult is provide by daughters or daughters-in-law, not formal institutions. Grandchildren commonly live far away and are not available to provide regular home care, or they are not old enough to assume such a role. Males are not typically the primary caregivers.
Which value should the nurse consider abnormal when reviewing a patient's routine urinalysis report? a) Urine pH of 3.0 b) Absence of glucose c) Urine specific gravity of 1.003 d) Absence of protein
a) Urine pH of 3.0 The pH of urine should be between 4.6 and 8.0. Urine specific gravity compares the density of urine to the density of water. Urine specific gravity in an adult should be 1.000 to 1.030, which means that the kidneys are functioning at a normal level. Absence of both protein and glucose in urine is appropriate.
Discharge instructions for Millie Larsen recommend that she be sent home with a walker. Why is a walker more appropriate for Millie than a cane would be? a) Walkers provide a broader base of support. b) Canes provide mobility for individuals who cannot ambulate. c) Canes can result in a dependence on an assistive device. d) Canes can be used to correct weight-bearing issues.
a) Walkers provide a broader base of support. Walkers provide a broader base of support than canes and can therefore be used for weight-bearing issues. Wheelchairs, not canes, provide mobility for persons who are not able to ambulate because of various disabilities. Any assistive device should be used only when necessary.
With which of the following atypical manifestations of a urinary tract infection might the older adult present? (Select all that apply.) a) Weakness b) Severe nocturnal headache c) Decreased appetite d) Alteration in cognitive function e) Incontinence
a) Weakness c) Decreased appetite d) Alteration in cognitive function e) Incontinence Infections in the older adult may not manifest in the same way as in a younger adult. Fever, a typical presenting sign, can be undetected in the older adult. The older adult may present with weakness, anorexia, changes in mental status, and incontinence. Severe nocturnal headache is not a manifestation of a urinary tract infection.
Functional assessments should be done to ensure safety to those who are confused or otherwise functionally impaired. What is the focus of this type of assessment? a) Nursing diagnosis b) Activities of daily living (ADLs) c) Effectiveness of nursing interventions d) Medical diagnoses
b) Activities of daily living (ADLs) High risks to safety exist when a person is functionally impaired, such as from delirium or confusion. If conditions exist that compromise safety for the older adult, an assessment should be made to determine how ADLs are affected. Functional assessment do not focus on medical or nursing diagnoses but on how the individual functions with ADLs. Nursing interventions should be appropriate after determining what ADLs are affected.
What age-related changes increase the risk of falls in the older adult? (Select all that apply.) a) Decreased renal blood flow b) Altered center of gravity c) Urinary frequency d) Reduced visual capacity e) Reduced peripheral vascular circulation
b) Altered center of gravity c) Urinary frequency d) Reduced visual capacity Age-related changes that place the older adult at risk for falls include: reduced visual capacity, specifically problems with differentiating shades of the same color (blues, greens, and violets); altered center of gravity that causes loss of balance; and urinary frequency, which may cause the older adult to get out of bed more frequently and night and to feel hurried in getting to the bathroom in time. Although peripheral circulation is reduced, this age-related change may not be related to falls in the older adult, and reduced renal blood flow is not relevant to increasing the risk of falls in the older adult.
Millie Larsen's daughter is concerned about her mother's ability to live alone at home safely after being discharged from the hospital. Which nursing intervention will best address the daughter's concerns initially? a) Providing the daughter with information concerning in-home caregiver assistance b) Arranging for Millie to be evaluated by an occupational therapist c) Educating Millie concerning the use of assistive devices for bathing and grooming d) Recommending that the daughter telephone Millie daily to determine her needs
b) Arranging for Millie to be evaluated by an occupational therapist A particular high risk to safety exists when the individual has conditions such as delirium, dementia, depression, and previous fall issues. Interventions can be planned to address existing concerns. Referring Millie to an occupational therapist will provide evaluation and treatment for particular conditions that could interfere with her ability to perform activities of daily living. Once the therapist completes an evaluation, it will be clear which interventions are necessary.
An older adult is expecting to transition home from the hospital after an admission for a urinary tract infection. Her family expresses concern that the patient may lack some of the abilities to live alone independently. What interventions should be implemented first to best assure the patient's safe transition? a) Being the family discussion by asking the relations to make a list of their concerns. b) Assess the patient's ability to perform activities of daily living (ADLs). c) Advocate for the patient to remain in his or her home with the assistance he or she needs. d) Ask the patient how he or she plans to meet the challenges of living alone.
b) Assess the patient's ability to perform activities of daily living (ADLs). The first nursing intervention must be to assess the individual's health history and ability to perform ADLs. Although the other interventions may become appropriate, they will not be determined until the nurse conducts an assessment.
Millie Larsen's daughter is concerned about not being able to assure her mother's safety during the day once she is discharged to her home. What suggestion(s) could the nurse make to help her daughter with this concern? (Select all that apply.) a) Pay neighbors to check in on Millie several times during the day. b) Enroll Millie in an adult day services program. c) Arrange for Millie's extended family members to schedule their visits with her during the day. d) Engage a telephone reassurance program.
b) Enroll Millie in an adult day services program. d) Engage a telephone reassurance program. Adult day care programs provide a safe, therapeutic environment for adults with moderate physical or mental needs. Older adults participating in the telephone reassurance program receive a daily phone call at a mutually agreed upon time to provide them with social contact and to ensure that they are safe and well. They other options address her daughter's concern, but they do not have the thoroughness or reliability provided by an adult day care service or telephone reassurance program.
An older patient newly diagnosed with hypertension has been prescribed an antihypertensive medication therapy. The nurse will include which recommendation when providing the patient with medication education to reduce the risk of falling? a) Eat a diet high in protein. b) Get up slowly from a supine position. c) Keep fluid intake to at least 1,500 mL/day. d) Avoid exercise that increases heart rate.
b) Get up slowly from a supine position. Postural hypotension is common in the older adult who is taking antihypertensive medication. When the individual stands up too quickly after lying down, postural hypotension can cause dizziness, which is a risk factor for falls. Older adults should be encouraged to exercise with the anticipated rise in heart rate within the limits of their disease processes; eating a diet high in protein is not relevant to postural hypotension related to antihypertensive medications. Although the older adult should drink 1,500 mL of fluids daily to prevent dehydration, this response is not relevant to the use of antihypertensive medications and postural hypotension.
An older adult with a history of delirium, dehydration, hypertension, and occasional incontinence is admitted to the hospital after suffering two falls at home. Which assessment question will the nurse ask to assess the patient's risk for falls? (Select all that apply.) a) Can you remember falling? b) How often do you get up to urinate at night? c) When were you diagnosed with hypertension? d) How often do you drink liquids during the day? e) Does you antihypertensive medication cause you any side effects?
b) How often do you get up to urinate at night? d) How often do you drink liquids during the day? e) Does you antihypertensive medication cause you any side effects? Aging often results in an increased need to urinate especially at night and a decreased ability to perceive thirst both of which contribute to the risk for falling. Antihypertensive medications can cause postural hypotension, which contributes to dizziness--a risk factor for falls. Remembering when one fell or when a diagnosis was made assesses cognitive function but has little relevance to assessing a risk of falling.
Which statement by an older adult with a history of dysphagia suggests that the patient needs further education about medication administration of an antibiotic capsule? a) I called the pharmacist to get suggestions about swallowing medications in capsules. b) I was having trouble swallowing this capsule so can I crack it open and put the medicine in my food? c) The capsule is hard to swallow, but I drink a large glass or water to help it go down. d) If I have trouble swallowing the capsule, I'll call and get the antibiotic in another form.
b) I was having trouble swallowing this capsule so can I crack it open and put the medicine in my food? Generally, capsules are not to be opened and mixed. Medications are put into capsule form to mask an unpleasant taste or the coating will dissolve when it comes into contact with specific gastrointestinal secretions. If the capsule is difficult to swallow, it would be appropriate to drink more water. Talking to the pharmacist or the doctor would also be appropriate in this situation.
Which assessment finding is an age-related change in the urinary tact? a) Increased urinary tract infections b) Increased frequency of urination c) Decreased protein in the urine d) Decreased amounts of glucose in voided urine
b) Increased frequency of urination Age-related changes in the urinary system include hypertrophy and thickening of the bladder muscle, decreasing its ability to expand and reducing its storage capacity resulting in an increase in the frequency of urination. Aging typically causes the renal threshold for glucose to increase. Aging does not typically result in a decreased risk for urinary infections. There should not be any protein in the urine.
A nurse suspects that an older cognitively impaired adult patient and her daughter are demonstrating signs of an interrupted family process and caregiver strain. What nursing intervention should the nurse implement to help address these issues? (Select all that apply.) a) Encourage family members to keep the patient oriented. b) Instruct the family in techniques that foster effective communication. c) Assist with locating respite or adult day care centers. d) Assess the family's reactions to the patient's condition. e) Discuss the reality of disease processes with the family.
b) Instruct the family in techniques that foster effective communication. c) Assist with locating respite or adult day care centers. d) Assess the family's reactions to the patient's condition. e) Discuss the reality of disease processes with the family. The goal for this circumstance will be to demonstrate support and assistance to family members in their fulfillment of physical, emotional, and socioeconomic needs; the family will seek and accept assistance from external sources as appropriate. Nursing interventions include discussing the reality and prognosis of the patient's disease process with the family, assessing the family's reaction to the patient's condition, assisting with finding adult day care or other respite services, and facilitation open and honest communication among the family members. Orienting the patient does not impact the interrupted family.
Which intervention reduces the risk of falling while in the hospital? (Select all that apply.) a) Keeping all side rails up while the mobility-impaired patient is in bed b) Reinforcing the need for the patient to call for help when getting out of bed c) Making nonskid footwear available to the ambulating patient d) Leaving the bed in its lowest position except when providing care e) Assuring the call bell is within easy reach of the patient
b) Reinforcing the need for the patient to call for help when getting out of bed c) Making nonskid footwear available to the ambulating patient d) Leaving the bed in its lowest position except when providing care e) Assuring the call bell is within easy reach of the patient Nonskid footwear reduces the risk of slipping and falling. Leaving the bed in the position closest to the floor except when performing in-bed care decreases the risk of injury from falls. The risk of falls can be reduced by placing the call bell cord within the patient's reach and instructing him or her to call for assistance when transferring and ambulating. Side rails should be raised appropriately, but not all side rails should be up at all times.
Why might learning that she must begin in-home caregiving for her older adult parent cause frustration for the middle-aged woman? (Select all that apply.) a) Some feel needed by their parents and believe they can best provide care for them. b) Some might feel they need to be a "superwoman," trying to fulfill numerous roles. c) Some may be dealing with mixed feelings about their marriages and their own undesirable physical changes. d) Some are beginning to taste some freedom as their children leave home and gain independence.
b) Some might feel they need to be a "superwoman," trying to fulfill numerous roles. c) Some may be dealing with mixed feelings about their marriages and their own undesirable physical changes. d) Some are beginning to taste some freedom as their children leave home and gain independence. Women of the family are often the primary caregivers for their older adult relatives. After years of struggling with raising children, they are beginning o have a taste of freedom as their offspring become more independent and leave home. They may be dealing with a spouse who is going through a midlife crisis, having mixed feelings about marriage, or struggling with their own undesirable physical changes. Further, they may be living the "superwoman" myth by being the supportive parent, the understanding wife, the exciting lover, interesting friend, and aspiring employee.
The nurse will include what information when educating Millie Larsen and her daughter regarding the prescribed captopril therapy? a) This medication should be taken at mealtimes. b) The medication may cause a dry, persistent, nonproductive cough. c) White blood cell counts should be monitored every week. d) This medication increases the formation of angiotensin II.
b) The medication may cause a dry, persistent, nonproductive cough. Patients should taught that this medication causes the most frequent occurrence of dry, persistent, nonproductive cough. This medication should be taken 1 hour before meals because food in the gastrointestinal tract may reduce absorption of the medication. Captopril is an angiotensin-converting enzyme inhibitor, which dilates the arterioles by preventing the formation of angiotensin II. This medication does not appear to affect white blood cell formation, so regular monitoring is not required.
Millie Larsen's daughter, Dina, wants to know how to minimize her mother's risk of becoming confused. What is the nurse's best response? a) Be sure your mother's blood pressure is being well managed because uncontrolled hypertension will increase her risk of becoming confused. b) You need to be able to recognize the signs and symptoms of a urinary tract infection that your mother usually experiences. c) Take care to keep your mom well hydrated so she won't keep getting bad urinary tract infections. d) Her history of confusion will require that you evaluate her mental status frequently, at least daily.
b) You need to be able to recognize the signs and symptoms of a urinary tract infection that your mother usually experiences. Urinary tract infections (UTIs) and infections in general may cause confusion in the older adult. With Millie Larsen's history, it is important for Dina to recognize the symptomology early so the infection can be treated effectively. Proper hydration is key to minimizing the risk of developing confusion. Hypertension is not typically viewed as a risk factor for developing acute confusion.
While in the hospital, the nurse assessed Millie Larsen with the Confusion Assessment Method (CAM) tool. Which assessment question asked of her daughter supports the goal of the assessment tool? a) How old is your mother? b) Has your mother been hospitalized before? c) Did your mother's confusion come on suddenly? d) Is your mother still capable of feeding and dressing herself?
c) Did your mother's confusion come on suddenly? The CAM tool asks if evidence exists of an acute change in mental status from the patient's baseline. Neither advanced age nor a decline in ability to perform activities of daily living is a component of the CAM tool. Prior hospitalizations are not assessed by the CAM tool.
Which of the following should be included in a teaching plan for a patient with an increased risk for developing a urinary tract infection? a) Hydrate with clear liquids only. b) Reduce fluid intake during daylight hours to 10 to 20 oz. c) Drink cranberry juice daily. d) Establish a 6- to 8-hour voiding schedule during the daytime.
c) Drink cranberry juice daily Medical research supports that regularly drinking cranberry juice is a means to reduce the risk of urinary tract infections. Restricting fluid intake is not advisable, and drinking only clear liquids is not necessary. The risk for urinary infection increases when the urine is allowed to stagnate in the bladder, so bladder emptying should occur more frequently than every 6 to 8 hours.
The nurse suspects that Millie Larsen's confusion has contributed most to the current poor management of her hypertension by causing which resulting behavior? a) Interfering with her ability to be physically active b) Increasing her usual level of anxiety c) Failing to take her medication as prescribed d) Decreasing her ability to eat a low-fat diet
c) Failing to take her medication as prescribed Confusion can result in all the negative behaviors listed, but the greatest impact on the patient's hypertension management is most likely to come from the lack of medication compliance. Anxiety, poor diet, and lack of exercise would take more time to cause noticeable negatives changes.
When addressing the family dynamics between Millie Larsen and her daughter, Dina, which family issue will the nurse place emphasis upon initially? a) How Dina feels about the loss of her father b) How Millie feels about needing Dina's care c) How Millie and Dina feel about one another d) What stressors Dina is feeling related to being a caregiver
c) How Millie and Dina feel about one another Assessing how family members feel about one another is important when assessing how the family unit functions. The questions of whether they love one another and whether they admire, respect, or enjoy each other's company are important. Feelings about the loss of a father as well as stressors relate to being her mother's caregiver need exploration but will be affected by the relationship Dina has with her mother. The changes in roles from caregiver to care-receiver require assessment but will also be influenced by the existing mother-daughter relationship.
When an older adult exhibits the signs and symptoms associated with delirium, which strategy promotes a safe and consistent environment? (Select all that apply.) a) Keeping the room brightly lit to minimize visual problems b) Playing the television all day to keep the patient distracted c) Managing traffic flow through the patient's environmental space d) Keeping the patient near the nursing station in order to provide cognitive stimulation e) Discussing planned activities and procedures with the patient
c) Managing traffic flow through the patient's environmental space e) Discussing planned activities and procedures with the patient It is important to speak to the patient regarding activities and procedures even though the level of intellect and/or consciousness may be reduced. Controlling environmental noise and traffic flow is important; the patient should be placed in a quiet area away from the mainstream traffic in order to minimize stimulation and the agitation that may result. The nursing station is an area of high activity and noise and so assigning a room near it is not a good choice.
Which statement represents ageist attitudes when speaking to an older adult? (Select all that apply.) a) Good afternoon, how are you feeling today? b) Good morning, remember that today you have your wound treatment. c) My, my, just look at the mess on your beautiful new blouse. d) You're such a sweetheart; it's time for a bath. e) Great heavens, what are you doing with your food?
c) My, my, just look at the mess on your beautiful new blouse. d) You're such a sweetheart; it's time for a bath. e) Great heavens, what are you doing with your food? It is important that the nurse fosters and maintains older adults' inner strengths. Nurses can facilitate empowerment through avoiding ageist attitudes when speaking with the older adult. Older adults must be spoken to with respect and dignity that includes using their surnames when addressing them. Providing them with information concerning their treatment plans is considered a patient right. Using terms like "sweetie" can be viewed as demeaning and should be avoided. Phrases such as "my, my" and "great heavens" in this context are patronizing and therefore disrespectful. Older adults should not be treated like children.
While being transferred from her bed to a wheelchair, an older adult female becomes rigid and anxiously states, "Help me, please don't let me fall." How can the nurse best address the patient's fear of falling? a) Asking the patient why she thinks she is going to fall b) Assessing the patient for additional signs of anxiety c) Reassuring the patient that you will be very careful d) Postponing the transfer until the patient is less anxious
c) Reassuring the patient that you will be very careful The patient's fear should be acknowledged and respected while giving assurance that care will be taken to prevent a fall. Postponing the transfer will not address the fear. Although assessing for additional signs and the triggers for such anxiety is appropriate, doing so will not address the patient's current fear of falling.
What is the initial goal for treating incontinence? a) To teach the patient Kegel exercises b) To provide a bedside commode c) To assess for the cause of the incontinence d) To create a toileting schedule for the patent to adhere to
c) To assess for the cause of the incontinence The initial goal in treating an individual with incontinence is to assess and identify the cause of the incontinence. Treatment goals are then based on the underlying cause. A reasonable next step for stress incontinence, for example, would be to teach the patient Kegel exercises to strengthen the pelvic floor muscles. Adhering to a toileting schedule can help patients diagnosed with overflow incontinence, and bedside commodes can benefit patients with functional incontinence.
Which condition(s) is an early indicator of a urinary tract infection (UTI) in the older adult? (Select all that apply.) a) Hematuria b) Pyuria c) Urgency d) Fever e) Burning
c) Urgency d) Fever e) Burning Along with atypical signs and symptoms in older adults with infection, burning, urinary urgency, and fever may be early indicators of a UTI. Hematuria and pyuria may occur if infection progresses without intervention and treatment.
Which nursing intervention should the nurse undertake initially to help the patient achieve partial restoration of bladder control? a) Provide a bedside commode when appropriate. b) Offer the patient frequent toileting cues. c) Ensure easy access to bathroom. d) Assess voiding patterns.
d) Assess voiding patterns. The older adult with incontinence may be able to achieve partial restoration of bladder control through nursing interventions. The initial step should be to conduct a comprehensive assessment to identify the cause of the incontinence, the potential for regained bladder control, and the patient's needs. Ensuring that the bathroom is easily accessible and providing the availability of a bedside commode of bedpan are also appropriate interventions to consider after completing an initial assessment. Offering the patient cues to consider toileting, including assistance, may also be appropriate but not implementable until the assessment is completed.
Which of the following nursing interventions would be the priority when preparing Millie Larsen's daughter, Dina, for her mother's discharge? a) Providing Dina with contact information for various community resources b) Educating Dina about her mother's chronic diseases c) Consulting a case manager to assist Dina prior to her mother's discharge d) Assessing Dina's knowledge and ability to carry out the caregiver role
d) Assessing Dina's knowledge and ability to carry out the caregiver role Assessing Dina's knowledge and ability to carry out the role of caregiver is a priority. Consulting a case manager and referring to community resources may be included, but assessing the caregiver for ability and knowledge must come first. Educating Dina about her mother's chronic diseases would follow the assessment of knowledge.
The older adult should be monitored for which of the following when taking ciprofloxacin? a) Hearing loss b) Liver function c) Blood dyscrasia d) Blood glucose level
d) Blood glucose level Fluoroquinolones such as ciprofloxacin increase the risk of hypoglycemia or hyperglycemia; therefore blood glucose level should be monitored closely. Liver function and blood dyscrasia are not known adverse effects of ciprofloxacin, and hearing loss is a possible complications of parenteral aminoglycosides.
Millie Larsen will be discharged on captopril and metoprolol for her hypertension. In addition to dosage and timing, what should the nurse teach Millie about these medications? a) Metoprolol should be taken on an empty stomach. b) Both medications should be taken at the same time each day. c) Both medications should be taken at mealtime. d) Captopril is most effective when taken 1 hour before meals.
d) Captopril is most effective when taken 1 hour before meals. Captopril should be taken 1 hour before meals, whereas metoprolol should be taken with meals, not on an empty stomach. These medications are affected more by the presence of food in the stomach rather than specific times of ingestion.
Millie Larsen states that when she has trouble sleeping, she takes diphenhydramine (Benadryl). When considering the patient's safety, what response should the nurse make? a) We need to get you a different sleep aid because Benadryl puts older adults at risk for developing congestive heart failure. b) Benadryl can cause a drop in blood pressure, and you shouldn't use it since you are already taking an antihypertensive medication. c) Your glaucoma medication combined with Benadryl puts you at risk for developing diarrhea. d) Don't take Benadryl because it can cause you to experience memory problems and even make you confused.
d) Don't take Benadryl because it can cause you to experience memory problems and even make you confused. Diphenhydramine carries a high risk of anticholinergic side effects in older adults and should be avoided. These effects include dry mouth, blurred vision, constipation, drowsiness, memory impairment, difficulty urinating, and confusion. Diphenhydramine does not affect blood pressure, and it is not known to interact with pilocarpine eye drops to cause diarrhea. There is not known relationship between diphenhydramine and an increased risk for the development of congestive heart failure.
Which nursing intervention should be included in a fall prevention program for an acute care facility that focuses on the care of older adults? a) Illuminating hallways and bathrooms with fluorescent lighting to minimize falls b) Performing a psychosocial assessment to address the fear of falling c) Using sedatives to prevent falls for those demonstrating signs of severe dementia d) Evaluating the older adult's history of falls during the assessment process
d) Evaluating the older adult's history of falls during the assessment process A fall risk assessment and a history of the patient's previous falls/risk of falls should be incorporated in the fall prevention program because a history of falls is a risk factor for future ones. Psychosocial assessment would not likely prevent falls but rather evaluates potential fears. Sedatives increase the risk of injury because of their effects on muscle control, cognitive function, and fatigue. While proper illumination is important, fluorescent lighting causes eyestrain and glare.
What is the nurse's initial assessment focus for an older patient being admitted for acute confusion? a) Serum blood alcohol to rule out intoxication b) Blood pressure to rule out hypotension c) Hemoglobin and hematocrit to rule out hemorrhage d) Fluid and electrolyte status to rule out dehydration
d) Fluid and electrolyte status to rule out dehydration Older adults are at risk for dehydration because aging can cause a decreased sense of thirst and an increase in urinary frequency. Confusion is a common sign of dehydration among older patients. Although hypotension, hemorrhage, and alcohol intoxication may all result in various degrees of confusion, they are not considered primary causes.
When Millie Larsen's choices regarding her discharge plans create significant concerns for her daughter, the nurse initially will base the resolution process on which statement? a) Conflict is a natural outcome during periods of stress. b) The nurse advocates for the patient during a conflict. c) All involved parties should be included in conflict resolution. d) Information collection is the initial step in conflict resolution.
d) Information collection is the initial step in conflict resolution. When the family process is disrupted, some family members may not have their physical, emotional, socioeconomic, and spiritual needs met. To intervene appropriately, the nurse should first conduct a comprehensive family history including: ages, residences, roles, and responsibilities of all family members; communication, problem-solving, and crisis management abilities among family members; and recent changes in the family structure. Although advocating for the patient is a fundamental nursing role, such advocating cannot be effective and appropriate until making an assessment of related information. Conflict is a natural outcome of stress, and it is true that all involved parties should be involved in its resolution, but neither of these statements is fundamental to the initiation of the resolution process.
When an older adult man's health begins to deteriorate, his adult sons accuse their sister, the man's primary caregiver, of providing poor care. What is the nurse's most supportive response when addressing the family's concerns? a) Since you all have concerns, it would be better if you all arrange to have a professional caregiver for your father instead of your sister. b) If you all agree, a home health nurse can come into your father's home to assess the quality of care your sister is providing. c) Your father requires a lot of care, and your sister is doing the best she can. The decline is your father's health isn't her fault. d) It is difficult to see a parent's health begin to fail, but in order for you all to have a realistic understanding of his physical condition he needs to have a thorough medical assessment one.
d) It is difficult to see a parent's health begin to fail, but in order for you all to have a realistic understanding of his physical condition he needs to have a thorough medical assessment one. The decline of a parent's health can be very unsettling and emotionally trying time for a family. Feelings of guilt, resentment, and fear can result in accusations of improper care as a way of explaining the parent's health issues. It is important that these claims be acknowledged and the parent's health status evaluated to allow realistic assessment both of the claims and of the parent's needs. The remaining options make recommendations with first determining the patient's needs or the validity of the claims.
What is the priority nursing intervention when preparing Millie Larsen for her discharge instructions? a) Assess Millie's reading abilities b) Prepare to provide all instructions both orally and in writing c) Arrange to include family members when providing instructions d) Evaluate Millie's ability to learn
d) Evaluate Millie's ability to learn Assessing the patient's readiness and ability to learn is paramount. In this case, Millie Larsen may still have some cognitive impairment and may not retain information. Including the family and providing the most effective individualized materials are also important; however, these are not the priority actions. Assessing her ability to read is appropriate, but its usefulness is affected by her ability to learn.
Millie Larsen's daughter suspects that her mother is confused. Which of the following statements would be the nurse's best response? a) I wouldn't worry about your mother; she will come out of this without any problem. b) You really should be concerned about her change in mental status because it could be a sign of Alzheimer disease. c) Your mother is just getting older, so it is not unusual that she is becoming confused. d) The older adult may exhibit confusion and a change in mental status as a manifestation of urinary tract infection.
d) The older adult may exhibit confusion and a change in mental status as a manifestation of urinary tract infection. Urinary tract infections (UTIs) are the most common infection in older adults, affecting as many as 1 in 10 each year. Because infection may present differently in older adults than in younger adults, the nurse must be aware of atypical presenting signs. Changes in mental status, incontinence, and increased incidence of falls may be related to infection in the older adult; in fact, changes in mental status may be the only sign of a UTI in an older adult. Confusion is not a normal consequence of aging. Follow-up assessment is warranted in a confused older adult. The nurse should not be suggesting possible diagnoses, such as Alzheimer disease.
