Chapter 11

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate?

Distract the client with a familiar object or music.

Which actions by the nurse will assist in promoting an older adult's adherence to medication therapy? Select all that apply.

Encourage the client to keep a list of medications and review it frequently for updates. Use easy-to-open lids. Provide a written medication schedule.

An elderly client with heart failure reports constipation that has progressively worsened over the last several months. The client's vital signs are pulse 86 beats per minute, blood pressure 94/56, and respirations 18 breaths per minute. It would be best for the nurse to instruct the client to

Avoid straining when having a bowel movement.

The client asks the nurse why she seems to have bone changes since she has gotten older. What is the best response by the nurse?

"Bone changes from aging result from a loss of calcium."

Which older adult is at highest risk for medication-related toxicity?

A 65-year-old with renal insufficiency

Which is a true statement regarding pharmacologic aspects of aging?

Absorption may be affected by changes in gastric pH.

What is a nurse's role in providing home care for a client with Alzheimer disease?

Provide emotional and physical support.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

Decreased acetylcholine level

Which condition is characterized by a decline in intellectual functioning?

Dementia

Which neurotransmitter is implicated in depression?

Serotonin

Which is a factor that contributes to urinary incontinence in older female adults?

Relaxed perineal muscle

Which is an accurate rationale for why older adults are more susceptible to serious infections?

They have less efficient defense mechanisms.

The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following?

Impaired memory

The nurse identifies which of the following as an age-related change in the respiratory system?

Increased residual lung volume

Which is an age-related change associated with the cardiovascular system?

Decreased cardiac output

Students are preparing a class presentation on elder abuse. Which of the following would they include as the most common type of elder abuse?

Neglect

The nurse is attempting to take vital signs of an older adult hospitalized following knee surgery. The client continuously yells, "It's 1999 and you are going to hurt me!" What action should the nurse do first?

Reorient the patient.

The nurse works on a unit with elderly clients. Which of the following clients would the nurse visit first? The client who reports

"It feels like I have food stuck in my throat."

A client reports to the nurse that over the past few months the elderly mother has become increasingly angry, responds inappropriately to conversations, and does not respond to calls if her back is turned away. What is the nurse's best response?

Ask if the mother could come in for a hearing evaluation.

An older adult female client tells the nurse, "I have lost an inch [2.5 cm] of height and have a hump on my back. What can I do about this?" What is the best response by the nurse?

"In order to prevent further bone loss, eat a diet high in calcium and low in phosphorus."

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should:

stay with the client and encourage him to eat.

When assessing an older adult, the nurse anticipates an increase in which component of respiratory status?

Residual lung volume

An older adult has a score of 12 on the Geriatric Depression Scale (GDS). What action should the nurse complete first?

Assess for the potential for self-harm.

Which is an age-related change associated with the nervous system?

Postural hypotension

An elderly client who lives in a retirement community has been having a mild depressive episode over the past few weeks. What should the nurse recommend for the client?

participating in a social activity

The nurse is preparing an elderly hospitalized client for discharge to home within the hour. What should be the priority for the nurse?

Assess the need for pneumococcal and influenza vaccinations.

An elderly client is contemplating a move to a continuing care retirement community (CCRC). The nurse assesses that the client requires assistance with food preparation and recommends placement in

Assisted-living apartment

A nurse is preparing to assess an older adult patient. Which approach would the nurse most likely use?

Functional assessment

Nursing students are reviewing statistics related to the older adult population and leading causes of death in this age group. The students demonstrate understanding of this information when they rank the following conditions in the order from highest to lowest.

Heart disease Malignant neoplasms Cerebrovascular disease Chronic obstructive pulmonary disease Alzheimer's disease Diabetes

A nurse is educating a group of middle-aged adults on aging. What information should the nurse include in the teaching?

How old you feel will be determined by your physical and cognitive abilities.

A nurse notes that an older female client has lost 2 inches in height since her appointment last year. The client reports lumbar back pain as unchanged. Which of the following would the nurse instructs the client? Select all answers that apply.

Increase intake of foods that are high in calcium. Take calcium and vitamin D supplements daily. Obtain the prescribed bone density screening.

An elderly client recovering from a hip repair becomes disoriented and tries to get out of bed frequently. The client states, "I forget I am in the hospital." The best nursing intervention is to

Post a sign stating "You are in the hospital" at the client's eye level.

Which refers to the decrease in lens flexibility that occurs with age, resulting in the near point of focus getting farther away?

Presbyopia

Which action is included in a nurse's role when providing home care for a client with Alzheimer disease?

Provide emotional and physical support

A nurse is providing care to a patient with delirium. Which interventions would be most appropriate to implement? Select all that apply.

Providing a calm, quiet environment Supervising nutritional intake Using familiar cues about the environment

An older adult is experiencing bowel changes. She used to have a bowel movement every day, but she is now having one every 3 to 4 days. She also states that the stools are hard. Which of the following assessments would the nurse make? Select all answers that apply.

Amount of dietary fiber Use of laxatives Activity level of the client Quantity of daily fluid intake

The nurse is working in a long-term care facility. When assessing her patients, what body system dysfunction should the nurse look for as the leading cause of morbidity and mortality in the older adult population?

Cardiovascular

An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of

Loss of bone density

After teaching an older adult about measures to relieve constipation, which statement by the client indicates a need for additional teaching?

"I should use a laxative every other day."

A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate?

"The most common cause of dementia in the elderly is Alzheimer's disease."

A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds:

"What precipitates the outbursts?"

A nurse is teaching nursing assistants in an extended-care facility measures to protect the skin of elderly clients. Which of the following measures is the nurse likely to recommend?

Encouraging clients to avoid cigarette smoking

A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to

Ensure that the mother does not have access to car keys or drive an automobile.

The nurse is describing hospice services to the family of a patient with end-stage heart failure. Which of the following would the nurse be least likely to include as a major focus of care?

Invasive therapy

An elderly client exhibits blood pressure of 110/76 while prone, 100/72 sitting, and 92/64 standing. The nurse instructs the client to

Ingest five or six small meals each day.

An elderly client is hospitalized for treatment related to leukemia. Family members want to visit with a toddler who has a cold. It would be best for the nurse to

Instruct the family to remove the toddler from the room for the protection of the client.

An elderly client reports that he feels like he voids frequently during the day and at night but cannot empty his bladder. The nurse instructs the client to

Limit ingestion of caffeinated beverages.

Which action by the nurse demonstrates ageism?

Directing all health decisions to the older adult's child

A nurse is obtaining the health history of a 72-year-old woman who has come to the ambulatory care center for an evaluation. When obtaining information about the woman's sleep patterns, which of the following would the nurse expect to assess?

Complaints about frequently waking up during the night

An elderly client reports fatigue without shortness of breath with walking 30 minutes five times each week. The nurse assesses the resting heart rate as 72 beats per minute; 10 minutes after walking, the client's heart rate is 92 beats per minute. What should the nurse instruct the client to do next?

Continue to walk at his current level.

A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate?

"Evidence shows that there are changes in nerve cells and brain chemicals."

An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate?

"Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion."

A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include?

"The drug helps to control the symptoms of the disease."

A hospitalized older adult complains of increased coughing and shortness of breath. The nurse assesses the vital signs as temperature 100.2°F oral, respirations 18, pulse 88, and BP 128/80. What action should the nurse do next?

Assess lung sounds and sputum.

Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response?

Assess the grandmother for adventitious lung sounds

When administering medications to an older adult patient, which medication does the nurse understand may remain in the body longer due to increased body fat?

Barbiturates

When assessing an older adult's gastrointestinal system, the nurse would identify an increase in which of the following as normal?

Feeling of fullness

An elderly client is reporting changes in bowel movements from every day to every 3 to 4 days. The client also states that the stools are hard. Nursing interventions include instructing the client to

Increase fluid intake.

When performing a respiratory assessment on an older adult patient, what changes associated with aging does the nurse expect to find? (Select all that apply.)

Increased residual volume Loss of elastic tissue surrounding the alveoli Reduced vital capacity

Students are reviewing information about visual changes and conditions associated with aging. The group demonstrates understanding of the information when they identify which condition as the major cause of vision loss in the elderly?

Macular degeneration

The reason that governments carefully regulate treatment given in licensed health care facilities, particularly long-term care facilities, is expressed by which statement?

Older adult clients are vulnerable.

Why are IV solutions usually given at a slower rate to older adults?

Older adults may have cardiac or renal disorders.

A nurse is providing a fall prevention clinic for a group of older adults. What information should the nurse include? Select all that apply.

Place grab bars in the shower and tub Have routine vision and hearing screenings Wear nonslip shoes or socks when walking Review medications routinely for side effects

A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by

Placing one food at a time in front of the client during meals

Older adults, who are more subject to falls, may fracture one or more ribs and be more susceptible to which condition after a rib fracture?

Pneumonia

A client reports to the nurse that her mother had macular degeneration and is concerned that she, too, may be at risk. What should the nurse tell the client?

Wear sunglasses with ultraviolet (UV) protection when outside.

A client with Alzheimer's disease is being admitted to the hospital for malnutrition and dehydration. What is the rationale for the nurse to place the client closer to the nurses' station?

limit wandering

A nurse is preparing a presentation for a local senior center about the health status of older adults. What trends in health promotion and disease prevention activities would the nurse explain as contributing to declining death rates in the older adult population? Select all that apply.

decreased smoking improved nutrition screening for hypertension early detection of elevated cholesterol levels