The Point: Chapter 32 Older clients

An elderly client reports pain in the calves. What question is appropriate for a nurse to ask to determine the cause of this pain?

"How far do you walk before you experience pain?" Pain in the calves is usually a sign of arterial insufficiency. This is called intermittent claudication and usually occurs within a set distance the client walks. The pain abates when the client rests. Dizziness is associated with a cardiovascular problem. Changes in muscle tone may be manifest by fatigue or atrophy of the muscle itself. Medications generally cause an overall side effect.

Normal gait is scored

1

A mildly abnormal gait is scored

3

A moderately abnormal gait is scored

4

A nurse is working with an 86-year-old man who has developed pneumonia. The nurse is aware that this client, due to his age, is living with how much less cellular function in his organ systems throughout his body than a younger person?

50% The average 85-year-old is living with almost 50% less cellular function in organ systems throughout his body. On a daily basis, he may have no ill effects from this loss of reserve. However, if this 85-year-old is living with a chronic problem such as diabetes and then becomes suddenly sick with what is usually a very treatable problem in a younger person (such as a bladder infection), this loss of reserve can have dramatic consequences.

A nurse is working with a client who is considered to be part of the "frail elderly." At which age can is a person typically first considered to be a part of this group?

85

A decrease in gastric emptying leads to

A decrease in gastric emptying leads to early satiety.

. A decrease in the elastin and collagen causes

A decrease in the elastin and collagen causes the lungs to recoil less during expiration, which increases the energy needed to breathe and requires the active use of accessory muscles.

A rectocele is present

A rectocele is present if the bulge is seen in the posterior vaginal wall.

A nurse is working with an elderly client with symptoms of urinary tract infection who says she does not like to report health problems and visit the doctor because some of her friends have had negative experiences with clinicians and have even seemed to get worse after doctor's visits. Which of the following interview techniques should the nurse use to encourage the client and build rapport, which will increase the likelihood of her returning for care?

Acknowledge the client's exercise habits that have kept her trim and healthy for so long Many older adult clients approach clinicians with hesitation because they have known friends and family members who have become sicker or died as a result of intervention. They may also be reluctant to admit health problems because they fear being admitted to a hospital or nursing home. It is essential that the nurse adapt routine interviewing techniques to always convey that there is something positive the older person is doing. For example, it is important to look for good nutritional habits as well as to identify which foods are to be avoided, or to focus on everyday activities that keep an older person ambulatory in addition to identifying risk factors for falls. The nurse needs to acknowledge the older client's accomplishments that have made life meaningful.

Actinic keratoses

Actinic keratoses are dry, scaly, rough-textured patches or lesions that form on the outermost layer of the skin after years of exposure to ultraviolet (UV) light, such as sunlight. These lesions typically range in color from skin-toned to reddish brown and are often pedunculated.

Actinic keratoses are

Actinic keratoses are the proliferative form of skin lesions.

Arcus senilis

Arcus senilis is a normal condition in the elderly in which a white arc appears around the limbus and has no effect on vision.

An elderly client calls the health care clinic and asks the nurse if it is okay to use an over-the-counter nasal spray to help with sinus congestion. Which question should the nurse ask before assuring the client it is okay to use this medication?

Are you taking any drugs for high blood pressure? Decongestant medications may increase the blood pressure by vasoconstriction of the blood vessels. These medications should be avoided in people with hypertension or a history of cardiac dysrhythmias.

Arterial insufficiency may cause

Arterial insufficiency may cause insufficient or absent peripheral pulses and pain known as claudication with activity.

Asking the client to bear down helps in assessment of

Asking the client to bear down helps in assessment of uterine, vaginal, and rectal prolapse

Atrophic vaginitis

Atrophic vaginitis is an inflammation of the vagina due to a thinned endometrium and increased vaginal pH level induced by estrogen deficiency. The earliest symptom is decreased vaginal lubrication.

A nurse inspects an elderly client's abdomen and notices the presence of a mass. What is an appropriate action by the nurse in regards to this finding?

Auscultate for the presence of a bruit If a nurse observes a mass in the abdomen, it should be auscultated for the presence of a bruit. A bruit suggests an abdominal aortic aneurysm. If present, the mass should not be palpated because of the risk of rupture. The nurse should rule out the presence of an aneurysm before palpating or measuring the mass. A bladder should not be able to be observed unless there is a great deal of muscle mass lost in the abdomen that would make all the underlying structures prominent.

An elderly male client presents to the health care clinic with reports of urinary frequency, nocturia, and difficulty starting his stream. A nurse knows that the most common cause of these symptoms is what condition?

Benign prostatic hypertrophy Benign prostatic hypertrophy (BPH) is the benign growth of the prostate gland in older males and is very common.

Bilateral tenderness may be seen in

Bilateral tenderness may be seen in women on hormone replacement therapy and indicate that the dose needs to be lowered.

An elderly client is admitted to the health care facility with an indirect inguinal hernia. Which abnormal data should the nurse expect to find in the client assessment?

Bowel sounds heard over scrotum The client with an indirect inguinal hernia will have bowel sounds heard over the scrotum.

A nurse is interviewing a 79-year-old client regarding her present health concern. Under which of the following conditions should the nurse consult a family member of the client to compare the client's current cognition and behavior with a prior level of function? Select all that apply.

Client is lethargic and agitated Client offers inconsistencies in her responses Client appears agitated Client appears excessively distracted If the older adult is too lethargic, agitated, or medically unstable to respond, appears excessively distracted, offers inconsistencies, or cannot answer specific questions or describe daily activities, then family or professional caregivers should be queried with regard to how current cognition and behavior compares with the client's prior level of function.

Complete obstructed blood flow manifests itself i

Complete obstructed blood flow manifests itself initially as acute pain, numbness, and coolness, also known as gangrene, which leads to amputation.

Crackles and rhonchi sounds are heard in

Crackles and rhonchi sounds are heard in pulmonary edema and pneumonia

A nurse palpates a bulge in the anterior wall of the vagina. The nurse recognizes this finding as what abnormal finding?

Cystocoele A bulge that originates from the anterior portion of the vagina is an indication of a cystocele. This occurs due to the relaxation of the pelvic musculature which allows the bladder to protrude into the vaginal wall

A nurse recognizes that a sudden change in an elderly client's cognition accompanied by a change in the level of alertness may be an indication of what condition?

Delirium A sudden change in cognition that develops over a short period of time and is characterized by changes in level of alertness, ranging from extreme lethargy to agitation, is called delirium.

"Get up and Go" types of results

Elderly clients without impairment in gait or balance can complete the test in 10 seconds. People who take more than 30 seconds to complete the test tend to be dependent in some activities of daily living such as bathing, getting in and out of bed, and climbing stairs.

Functional incontinence is

Functional incontinence is the inability to get to the bathroom in time or to understand the cues to void due to problems with mobility or cognition.

A nurse examines a frail elderly client's mouth and finds several broken and missing teeth and irritated gums. The nurse should assess this client closely for problems associated with which body system?

Gastrointestinal Oral health is a vital component of good nutrition. It affects the frail elderly client's ability to chew food properly and ultimately affects digestion. If the client does not eat enough or digest properly, many gastrointestinal problems may arise as well as the tendency towards malnutrition, undernutrition, or dehydration.

Hallmark symptoms of TB include

Hallmark symptoms of TB include weight loss and night sweats.

A nurse obtains an order to check an elderly client for orthostatic hypotension. Which finding alerts the nurse to a positive result for this test?

Heart rate increases 20 beats over the baseline rate Orthostatic hypotension is assessed by taking the client's blood pressure lying, sitting, and standing and watching for a drop in the systolic or diastolic pressure of more than 10mmHg or an increase in the heart rate of more than 20 beats or more per minute. A positive test places the client at risk for falls.

A nurse is assessing an elderly client with rheumatoid arthritis. The nurse observes that the client has difficulty rising from a chair and walking at a normal gait, which the client attributes to painful joints. The client's pulse rises about 10 beats/min on rising and returns to baseline in less than 1 minute. The nurse also learns from the client that she often experiences loss of urine when she laughs, coughs, or sneezes. Which of the following nursing diagnoses can the nurse make based on this information?

Impaired Physical Mobility Based on the findings presented, the nurse can diagnose this client with impaired physical mobility related to painful joints due to rheumatoid arthritis. The client has symptoms of stress urinary incontinence, but not of functional urinary incontinence. Based on the results of the activity tolerance test, the client does not have activity intolerance. There is no indication that the client has a bathing or hygiene self-care deficit.

A nurse is inspecting an elderly client's head and neck. Which of the following findings should most prompt the nurse to suspect onset of a chronic condition?

Involuntary facial or head movements Normal findings with old age include atrophy of the face and neck muscles, reduced range of motion of the head and neck, shortening of the neck due to vertebral degeneration, and development of a buffalo hump at the top of the cervical vertebrae. Involuntary facial or head movements may indicate an extrapyramidal disorder such as Parkinson's disease or side effects of some medications.

A nurse would like to assess an elderly client's general functional status in performing daily chores. Which of the following should the nurse implement to make this assessment?

Katz Activities of Daily Living tool There are many tools available for measuring ability to perform activities of daily living (ADLs). One commonly used tool, which is thought to be the most appropriate for assessing functional status in older adults, is the Katz Activities of Daily Living, which includes those activities necessary for well-being as an individual in a society.

A nurse is working with an 88-year-old client who has developed stress incontinence. In this case, as in all cases, the nurse should understand that which of the following is the key to recognizing pathology and illness in the very old?

Knowing the person's baseline functional status and recognizing deviations from it Knowing the older person's usual daily pattern and functional level is the best baseline against which to compare assessment data. For example, new onset incontinence for the 92-year-old resident of an assisted-living facility who still drives her own car should not be viewed as a normal consequence of aging. The incontinence could be the result of an infection or worsening heart failure. A more subtle presentation of these same problems could be signaled by complete incontinence in a 92-year-old man with severe cognitive impairment who until very recently had only occasional incontinence. Clearly, the key to recognizing pathology and illness in the very old is in knowing the person's baseline functional status and recognizing a deviation from it.

A nurse should assist an elderly client to assume which position to facilitate the examination of the anus and rectum?

Left side-lying The anus and rectum should be assessed with the client in left side-lying position for better accessibility and comfort.

A nurse recognizes that a slight barrel-shaped chest in an elderly client is due to what physiologic change in the thorax as a result of the aging process?

Loss of skeletal muscle strength The loss of skeletal muscle strength of the thorax and diaphragm combined with the loss of resilience that holds the thorax in a slightly contracted position contribute to the slight barrel chest seen in the elderly. This causes a decreased vital capacity and an increased residual volume.

An elderly client presents to the emergency department with reports of a productive cough of blood-tinged sputum, fatigue, weight loss, and shortness of breath. The nurse recognizes that these are symptoms associated with which respiratory disease process?

Lung cancer A recurrent cough, fatigue, weight loss, and shortness of breath are hallmarks of lung cancer.

Macerated ski under the breasts may be due

Macerated ski under the breasts may be due to perspiration or a fungal infection.

An elderly client states that the right eye has better eyesight than the left. A nurse recognizes that this may indicate the onset of what eye condition?

Macular degeneration Better vision in one eye is a warning sign of macular degeneration, a leading cause of blindness in elderly people

Masses or bulges and pain will be present in

Masses or bulges and pain will be present in testicular torsion and in cancer of the prostate gland.

A nurse recognizes that a priority goal of assessment in the frail elderly is what outcome?

Minimize disability associated with illness The goal of assessment in the frail elderly is not so much focused on disease prevention as it is on minimizing the disability associated with chronic disease and prevention of complications and exacerbations of chronic maladies. Empowering the frail elderly to stay active, maintain relationships, and participate in events that they find meaningful are important at this stage of life. Reduction of medication side effects and identifying the need for assistance in activities of daily living are a part of minimizing the disability associated with illnesses.

Nipple discharge is only normal in

Nipple discharge is only normal in breast feeding women.

Which intervention by the nurse demonstrates the correct technique to assess urinary incontinence?

Obtain a voiding diary The most appropriate method of assessing urinary incontinence in an elderly client is by obtaining a voiding diary.

Overflow incontinence is

Overflow incontinence is the condition in which the patient has involuntary loss of urine associated with overdistention of the bladder.

What is an appropriate modification in technique that a nurse should take for the examination of the frail elderly client?

Plan for additional time to allow as much independence as possible The nurse should plan for additional time to complete the exam to allow the client as much independence as possible. Speaking clearly and at a moderate pace is more beneficial for a client who is hearing impaired. Do not assume that a client who is cognitively impaired is unable to answer questions. They may be able to understand one word directions or nonverbal cues to guide the examinations. Caregivers should be consulted only if there is discrepancy between subjective and objective data. This consultation should take place away from the presence of the client. It may be more acceptable to be formal rather than informal with the elderly client.

The caretaker of an elderly person tells the nurse that she is worried that the client will choke because of swallowing problems secondary to a recent cerebrovascular accident (CVA). What suggestion should the nurse give the caretaker to minimize the risk of aspiration in the client?

Prepare foods that are pudding consistency or semisolid The nurse should suggest that the caretaker prepare semisolid foods and fluids of pudding consistency, alternating solid food with thickened foods, and encouraging the client to lean slightly forward and tuck the chin under to prevent gagging. Water and other thin liquids increase the risks of aspiration. Checking the mouth does not help to avoid aspiration. Keeping the client upright will help to prevent acid reflex but not aspiration.

A nurse assesses an elderly client and determines that the client is at risk for falls. Which interventions are appropriate to reduce the incidence of actual falls the client incurs? Select all that apply.

Remove rugs or other loose carpet Assist with exercise to strengthen lower extremities Remind the client to ask for assistance The nurse should focus on removing hazards form the environment such as loose rugs and other obstacles. Remind the client to ask for assistance with ambulation. Exercise may help to strengthen the muscles to increase stability. The use of assistive devices such as canes and walkers may help to reduce the anxiety and fear associated with an unstable gait.

Renal insufficiency manifests as a

Renal insufficiency manifests as a change in the amount of urine production not necessarily as a change in the ability to urinate.

When looking at a review of systems for an elderly client, which gastrointestinal data should cause the nurse the most concern?

Reports of constipation The nurse should be most concerned about the report of constipation. Constipation is not a normal process of aging but many factors contribute to its presence. Production of saliva decreases, gastric emptying slows, and stool has a longer transit time. All these factors can lead to the development of constipation.

Which assessment data would a nurse expect to find in an elderly client with a pulmonary infection and a productive cough?

Respiration more than 25 breaths/min Respirations more than 25 breaths/min is the finding expected with pulmonary infection with productive sputum

Respirations less than 16 breaths/min indicate

Respirations less than 16 breaths/min indicate neurologic impairment.

During the breast exam of an elderly female client, which finding should a nurse recognize as a normal change associated with the aging process?

Retraction of the nipples Nipples retract in the elderly client due to loss of musculature. Unlike nipple retraction due to a mass, nipples retracted due to aging can be everted with gentle pressure.

A simple test that a nurse can perform to assess an elderly client's activity tolerance is to ask the client to perform what task while monitoring the heart rate?

Rise from a chair to a standing position A nurse should assess a client's activity tolerance by observing the client's ability to move from a sitting to a standing position and assessing the heart rate.

Scrotal edema will be present in

Scrotal edema will be present in obstruction of the portal vein and heart failure.

Seborrheic keratoses are

Seborrheic keratoses are normal skin changes of aging and involve the outer layer of the skin. They have a characteristic waxy appearance and vary in color from light tan to black.

During the skin assessment of an elderly client, a nurse recognizes that which skin condition is a normal finding?

Senile purpura

Senile purpura are

Senile purpura are vivid purple patches on the skin that do not blanch to the touch.

A nurse performs a "Get Up and Go" test on an elderly client. On completion of the test, the nurse documents the test score as 5. What is the gait assessment result as per the score?

Severely abnormal The client's gait is severely abnormal as per a score of 5.

Sexually transmitted diseases are not common in the older population but when present are most often accompanied by

Sexually transmitted diseases are not common in the older population but when present are most often accompanied by odor, pain, and discharge.

Shingles are

Shingles are vesicles due to herpes zoster infection.

A nurse notes the presence of brown, pigmented patches on an elderly client's hands. What is the proper term for the nurse to use to document this finding?

Solar lentigines Hyperpigmentation in sun-exposed areas appears as brown, pigmented, round or rectangular patches. They are often called liver spots. These are normal skin variations in the aging population.

Speaking slowly and softly and requiring assistance standing and walking do not necessarily indicate

Speaking slowly and softly and requiring assistance standing and walking do not necessarily indicate loss of cognitive function requiring communication with a family member or caregiver.

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine when coughing, sneezing, or laughing. What type of incontinence should the nurse document in the client's record?

Stress The nurse should document the findings as stress incontinence. Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void.

The nurse should not ask an elderly client to perform deep knee bends or swing the arms overheard because

The nurse should not ask an elderly client to perform deep knee bends because of the risk for falls and cause dizziness

The term frail elderly describes

The term frail elderly describes the vulnerability of the old-old (generally mid-eighties, nineties, and centenarians) to be in poorer health, to have more chronic disabilities, and to function less independently.

An otherwise healthy elderly client develops the sudden onset of confusion, lethargy, anorexia, and nocturia. The nurse should obtain an order for which lab test to assess this sudden change in health status?

Urinalysis for the onset of a urinary tract infection Elderly clients often do not manifest the normal symptoms when an infection is present. The onset of confusion, lethargy, anorexia, and nocturia in an otherwise healthy elderly client often signify the onset of a urinary tract infection. A urinalysis is the appropriate test for this client.

Which intervention should the nurse suggest to a client to improve the condition of dry skin?

Use lanolin-based products The nurse should suggest the use of lanolin-based products for the elderly client with dry skin to relieve effects of dry skin. The nurse need not ask the client to have frequent baths as it could deplete the natural oils of the skin. The nurse should suggest the use of mild shampoos and soaps rather than asking the client to avoid the use of shampoos and soaps.

A 75-year-old female client is discussing with a nurse changes in her body that have affected her sexual life. Which of the following should the nurse expect to hear? Select all that apply.

Uterine contractions with orgasm are painful Loss of firmness in the labia Increased dryness in the vagina Men's and women's aging bodies change in a number of ways. Bloom lists these changes for women as the following: labia and tissue covering the pubic bone lose firmness; vaginal walls become less elastic and the vagina drier; the clitoris may become overly sensitive; and uterine contractions with orgasm may be painful

Uterine prolapse causes

Uterine prolapse causes the cervix to protrude through the vagina.

An elderly client reports pain in the leg which is not associated with any particular activity but is lessened when the leg is elevated. The nurse recognizes that the client may have which vascular condition?

Venous insufficiency Pain unrelated to activity indicates venous insufficiency in the client. Partial obstructed blood flow causes ulcers and increases risk of infection.

Walking and observing the gait monitors

Walking and observing the gait monitors a client's balance.

. Breath sounds may be distant over areas affected by

by barrel chest of aging.

Dermatomycosis is

is the ringworm infection of the skin.

Urinary tract infections are

often the result of the BPH.