Chapter 16: caring for the older adult

A nurse is assessing an older adult for depression using the Yesavage Geriatric Depression Scale. Which score would the nurse identify as indicating possible depression?

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A 78-year-old woman is on a nurse's rehabilitation unit status post a cerebrovascular accident (CVA). As the nurse assess her gait, the nurse notices that the client's left foot is dragging and she is not bending her left knee nor swinging her left arm. How would the nurse best describe the client's gait?

Hemiparesis Hemiparesis is weakness on one side of the body.

A nurse documents "dry, thin skin with several areas of ecchymoses" on an older adult client's chart. Which nursing diagnosis would be appropriate for this client?

Risk for injury The dry, thin skin of older adult clients is prone to injury because it is less flexible and resilient than the skin of younger adults. The blood vessels in the skin are more fragile, and bruising results.

A nurse at a long-term care facility is working to develop a program to promote regular medical check-ups for the residents in order to minimize the risk of infection. When proposing this program to the facility's governing board, which statement would the nurse emphasize as the underlying rationale for this type of program?

The antibody response in older adults is lower, placing them at increased risk. Older adult clients are prone to infections due to a lower antibody response toward microorganisms.

After obtaining the health history from an older adult client, the nurse develops a plan of care and identifies the client has impaired physical mobility. What information would support this impairment? Select all that apply.

The client states the hip and knee joints hurt and are stiff when ambulating. The client states that he or she must use a walker for stability. The client reports weakness on one side of the body following a stroke Mild abdominal pain and improvement in vision following cataract surgery would not impair mobility.

A home care nurse visits an older adult client with dementia due to Alzheimer's disease. As a result of the client's confused thinking, the client is experiencing significant difficulty in communicating with family members. Which intervention would be most appropriate for this client?

Validate the client's current needs. The nurse should use validation therapy by validating the client's current needs in order to facilitate communication and to minimize the adverse consequences of confused thinking. Reality orientation is recommended for orienting people with reversible states of confusion. Providing appropriate sensory appliances like glasses and hearing aids, and maintaining levels of sensory stimulation, are not helpful in dementia or irreversible confusion.

A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as:

abandonment. Exploitation involves illegally taking or misusing funds, property, or assets of a vulnerable older adult. Neglect involves refusal or failure by those responsible to provide food, shelter, protection, or health care for a vulnerable older adult. Emotional abuse involves verbally or nonverbally causing mental pain, anguish or distress on the older adult.

A nurse is performing a home assessment for a 90-year-old widower who lives in a third story apartment. The assessment reveals there are smoke alarm and carbon monoxide alarm systems; slip-proof surfaces in the bathtub and shower; no throw-rugs present; handrails on the steps; unlocked cabinets with potential poisons; adequate lighting; large flat screen TV on wall; and the water set at a safe temperature. As the nurse considers the client's home environment, what modification can be made to enhance safety for the client?

handrails in bathroom As mobility impairment increases in persons over the age of 65, the risk of falls increases. Hip fractures are a particular risk factor for disability and death.

An older adult client being cared for at home has developed a decubitus injury. The nurse would instruct the family caregiver to institute measures to:

relieve sustained pressure. the priority would be to relieve sustained pressure, which is the underlying cause of a pressure injury, also known as a decubitus ulcer

A nurse is developing a plan of care for a client who recently lost his spouse. Which of the following would be most appropriate for the nurse to suggest to help the client cope with his loss?

seeking support from his faith

An older adult is admitted to the health care facility with a diagnosis of depression. The nurse would be especially alert for:

suicidal thoughts Suicide is the most serious consequence of depression.

An adult child accompanies an older adult client to the clinic and states, "I am not sure what is going on with my parent but I think it is depression." What questions should the nurse ask the client to determine if he or she is depressed? Select all that apply.

"Have you had any changes in weight recently such as a gain or loss?" "Can you tell me what your sleep patterns are?" "Have you lost interest in things you previously found pleasurable?" symptoms of depression, such as sleep disturbances, weight loss (sometimes gain), difficulty with concentration, irritability or anger, loss of interest in once pleasurable activities, vague pains, crying, fatigue, and suicidal thoughts or preoccupation with death

A home care nurse is caring for a client who lost the spouse to cancer 3 years ago. What question would the nurse ask to facilitate a life review?

"Would you tell me about your life when you first met your spouse?" Older adults search for emotional integration and acceptance of the past and present. They often like to tell stories of past events in life to reminisce, and to restructure life experiences to facilitate achieving ego integrity. This phenomenon, called life review or reminiscence, has been identified worldwide.

An older adult who is newly widowed is not adjusting to this change in her role. She is unable to form new relationships. What is the client at risk for developing?

Social isolation

A client aged 88 years who lives alone experiences dizziness caused by blood pressure medication. What intervention would the nurse prioritize in teaching this client?

Change positions slowly.

A older adult client reports that he was taking an over-the-counter antihistamine. He shows the nurse the package which lists chlorpheniramine as an ingredient. The nurse would assess the client for which adverse effect? Select all that apply. Confusion Decreased appetite Constipation Dry mouth Incontinence

Confusion Dry mouth Constipation Chlorpheniramine is a first generation antihistamine that is highly anticholinergic. As a result, the client is at risk for confusion, dry mouth and constipation.

An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition?

Delirium Delirium is a temporary state of confusion that is often precipitated by drug interactions or the effects of new drugs. The client is not showing signs or symptoms of depression. Disorientation is a manifestation of a problem rather than a cause.

What term is used to describe various disorders that progressively affect cognitive function?

Dementia

A nurse is preparing to medicate an older adult client with an opioid analgesic. Which information will the nurse obtain first to decide about administering the medication?

Determining if the client is able to communicate pain verbally or nonverbally The nurse should ascertain the level and intensity of the client's pain. The family is not able to give adequate information about the client's pain.

An 84-year-old client has returned from the postanesthesia care unit. The client is oriented to name only. The client's family is very upset because before having surgery the client knew the family. The client is diagnosed with delirium. Which action should the nurse take to help the family with their emotions?

Explain that delirium is a state of confused thinking and usually lasts only a short time. By explaining what delirium is and that it usually is short-term provides the family with information that can decrease the family's worry

A nursing instructor is educating a class about older adults. Which measure would the instructor identify as one of the most valuable to maximize the quality of life for this population?

Pain palliation

An client 81 years of age is in a long-term-care facility. His family could no longer cope with his progressing senile dementia, including wandering away and unpredictable behavior. Late one night the nurse finds the client wandering in the hall. He says he is looking for his wife. What should the nursing approach should be?

Remind him of where he is and assess why he is having difficulty sleeping. Reminding the client where he is will help orient him to his surroundings. Assessment is needed to determine any need that may be disturbing the client, such as the need to use the bathroom, feeling cold/warm, etc.

The nurse is assessing an older adult client that states, "I feel lonely." What factors might the nurse identify as contributing factors to the client's loneliness? Select all that apply. loss of an important relationship cognitive changes financial limitations depression

loss of an important relationship depression cognitive changes Loss of important relationships places an older person at risk for loneliness. Loneliness refers to a subjective emotional state of being alone, and there is a relationship between loneliness and health outcomes. Sensory losses may make it difficult for an older adult to communicate with others and can contribute to loneliness and depression. Depression may cause the person to become more socially isolated or physically separated from other people (Ivbijaro, 2013). Cognitive disorders (such as dementia) diminish the capacity to interact meaningfully or appropriately in social situations.