Chapter 32: Assessing Older Adults (A & J)

An older client demonstrates mental status changes after being diagnosed with a urinary tract infection. Which finding suggests that this client is experiencing delirium?

experiencing visual hallucinations Explanation: Visual hallucinations are associated with delirium. Refusing to eat could be caused by a variety of health problems. Becoming progressively worse and deteriorating performance of self-care activities are manifestations of dementia.

Which statement by an older adult alerts the nurse that health teaching was ineffective?

"Leaking urine is a normal part of aging." Explanation: Urinary incontinence is not a normal part of aging. Thinning of the hair and getting shorter as one ages are normal changes with aging. Thick yellow toenails are characteristic of a fungal infection, onychomycosis, which is not a normal change of aging.

The nurse is reviewing the results of laboratory blood tests with the older adult. The client asks, "Why is my creatinine elevated?" Which is the best response by the nurse?

"As a person gets older, the kidneys do not work as well in removing waste materials." Explanation: The best response by the nurse is, "As a person gets older, the kidneys do not work as well in removing waste materials." The size and function of the kidneys decrease with age. Consequently, the kidneys do not work as well in removing waste materials. The glomerular filtration rate is decreased and is reflected in a decrease in urinary creatinine clearance and increased serum creatinine. While the response, "Creatinine is an indicator of how well the kidneys are functioning in removing wastes." is correct, it does not explain to the client why the level may be elevated.

An older adult client, who is a retired construction worker, presents with an ulcerated lesion on his left auricle. What teaching should the nurse provide to this client?

"Notify your healthcare provider about the possibility of cancer." Explanation: Ulcerated lesions on the auricle in older men with a history of sun exposure (e.g., golfers, outdoor workers, farmers) may represent squamous cell carcinoma and should be evaluated. Cancer on the auricle is not usually related to hearing loss.

An older client who typically weights 160 lbs. appears withdrawn and disheveled and causes the nurse to be concerned since the last visit a month ago. For which body weight should the nurse conduct a complete nutritional assessment?

152 lbs. Explanation: The weight of 152 lbs. represents a 5% weight loss over the last month and is considered an abnormal finding. The nurse needs to investigate the reason for the weight loss by completing a nutritional assessment and analyzing the other symptoms which may indicate a loss of appetite. The other body weights would not be considered red-flags and do not need to be investigated.

How do many older adults define their health?

Ability to function independently Explanation: Many older adults define their health by their ability to perform self-care, which health care providers identify as functional abilities. Functional ability in an older adult can vary widely during his or her later years.

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 Explanation: 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.

An older client arrives at her primary care provider's office with complaints of irregularly shaped tan, scaly lesions that bleed and are inflamed. The nurse should recognize this condition as which of the following?

Actinic keratoses Explanation: Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed and that form on the outermost layer of the skin after years of exposure to ultraviolet (UV) light, such as sunlight. Senile purpura is a normal finding in skin of an elderly client. Pinpoint-sized, red-purple, nonblanchable petechiae are a common sign of platelet deficiency. Shingles are vesicles due to herpes zoster infection.

To reduce the risk for late recognition of cognitive impairment in the older adult client, which actions should the nurse take? Select all that apply.

Adopt more direct questions. Use geriatric screening tools. Consult family members or caregivers. Explanation: Older adult clients may be reluctant to report their symptoms or overlook them believing that they are a normal part of aging. To reduce the risk for late recognition and delayed intervention of any health problem in the older adult client, it is important to adopt direct questions, use geriatric screening tools, and consult family members or caregivers. Normalizing forgetfulness encourages under-reporting of symptoms and may prevent the older adult client from offering more detailed information about the memory loss. Teaching about sexual health would not be an appropriate action to take when reducing the risk for late recognition of cognitive impairment.

Claire's daughter brings her in today after she fell at her home. Which assessments are indicated at this time?

All of the above Explanation: Falls are common in the elderly, and can often result in serious injuries. When assessing the cause of falls, gait and balance should be checked first. Medications, particularly use of more than three, are associated with falls. Vision problems, lower limb joint problems, and cardiovascular problems, such as arrhythmias, may be reasonable to search for. Orthostatic vital sign changes should be sought.

An elderly client is complaining of weakness and fatigue. The nurse suspects the client may be experiencing what?

Anemia Explanation: Anemia must be ruled out when an older client complains of weakness and fatigue. Weakness and fatigue is not part of the normal aging process. Cancer may include many symptoms. A symptom of depression may include fatigue, but not weakness.

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? Explanation: 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. Diabetes mellitus, getting up at night to use the bathroom, and a history of nasal polyps are not pertinent to the use of a decongestant medication.

What does the nurse use to formulate a nursing care plan?

Assessment data Explanation: The nurse uses assessment data to formulate a nursing care plan with client outcomes and interventions. The nurse uses both objective and subjective data, but neither is sufficient by itself. The nurse may use a preprinted care plan, but again, this is not the best answer for this question since the plan is based on specialized assessment data.

The nurse notes that it takes an older client 45 seconds to complete the "get up and go" test. Which activities of daily living should the nurse plan to assist the client with completing? Select all that apply.

Bathing Climbing stairs Getting in and out of bed Explanation: The "get up and go" test is used to evaluate gait. A client who takes 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, or climbing stairs. The client with an elongated test result should be able to use the telephone or managing finances since these activities do not require mobility to complete.

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 Explanation: Benign prostatic hypertrophy (BPH) is the benign growth of the prostate gland in older males and is very common. Urinary tract infections are often the result of the BPH. Sexually transmitted diseases are not common in the older population but when present are most often accompanied by odor, pain, and discharge. Renal insufficiency manifests as a change in the amount of urine production not necessarily as a change in the ability to urinate.

Which of the following changes in vision is expected with normal aging?

Blurring of near vision Explanation: The lens loses elasticity over time as part of normal aging, and the eye is less able to accommodate and focus on near objects. Therefore, older clients are expected to have blurring of near vision. Cataract, glaucoma, and macular degeneration are considered pathological processes.

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

Cystocele Explanation: 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 rectocele is present if the bulge is seen in the posterior vaginal wall. Uterine prolapse causes the cervix to protrude through the vagina. 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.

It is summer and an 82-year-old woman arrives at the emergency room from her home after seeing her primary care physician 2 days ago, when she had been started on an antibiotic. Today, she does not know where she is or what year it is. What could be a likely cause?

Delirium Explanation: These are not signs of normal aging and seem to be of acute onset. This makes Alzheimer's disease unlikely. Stroke and meningitis could cause these symptoms as well, but the combination of the heat and a recent infection make delirium much more likely. Though she was prescribed an antibiotic, her condition may not have improved because of bacterial resistance, non-compliance due to cost, depression, or even an underlying mild dementia. Dementia should not result in an acute mental status change, although illness may cause a worsening of dementia.

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 Explanation: 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. Acute pain does not often change the person's level of consciousness but does increase risk for falls. Infection may produce confusion but should not alter the level of consciousness. Depression in the elderly is often manifested by physical symptoms as well as cognitive changes.

A son brings his 80-year-old father into the clinic. The son is concerned because he feels as if his father is growing weak, losing interest in things he used to care about, and no longer coming to dinner on Sundays. The nurse would know that the father is at risk for what?

Depression Explanation: Depression may occur in older adults for various reasons. It is more common in people with multiple chronic health problems and in those who have recently suffered the loss of a spouse, friend, family member, or pet. Decisions about moving out of a family home because of increasing care needs may also lead to depressive symptoms.

An older adult with a history of varicose veins presents with lower extremities that are reddish-brown and edematous. What is the nurse's best action?

Document findings and notify the healthcare provider Explanation: Stasis dermatitis is another common finding in older adults with a history of varicosities, phlebitis, and trauma. Lower extremities have a reddish-brown ruddy appearance and are usually edematous but are not inflamed or infected. Nurses often mistake stasis dermatitis for cellulitis, but the stasis changes do not respond to antibiotics. Stasis dermatitis may lead to leg ulcers on the lower shin area; these ulcers can become infected. Your assessment notes should include location, color and size of the area, size and depth of the ulcer (if present), presence of inflammation or warmth, and presence and severity of edema. Pressure ulcers are staged, not stasis dermatitis. If varicose veins are a common cause leading to stasis dermatitis, then the legs should be raised rather than placed in a dependent position.

A gastrointestinal problem that often requires emergency treatment in the frail elder is

diverticulitis. Explanation: If diverticula become infected, emergency treatment may be required to prevent perforation and sepsis.

The nurse is assessing an elderly client and finds a suspicious lesion on the client's right forearm. The lesion is asymmetrical, has an irregular border, has color variation, and is approximately 8 mm in diameter. What is an appropriate nursing action for this client?

Document findings and refer the client for follow-up Explanation: Malignant melanoma is a pigmented macule, papule, nodule, patch, or tumor with the ABCD warning signs: symmetry, order irregularity, color variation, and diameter greater than 6 mm. This form of cancer is highly malignant. The nurse should document any suspicious lesions and refer the client for follow-up.

The nurse is concerned about an older client's ability to live independently in the home. For which activities should the nurse assess this client? Select all that apply.

Does own laundry Shops for groceries Balances check book Dials telephone numbers Explanation: Safely living alone requires more than being able to perform activities of daily living. The nurse needs to assess for the client's ability to maintain own clothing by doing laundry, shopping for groceries, managing finances, and using a telephone for socialization and being able to call for help. Watching television is not an instrumental activity of daily living.

Mrs. Geller is somewhat quiet today. She has several bruises of different colors on the ulnar aspects of her forearms and on her abdomen. She otherwise has no complaints, and her diabetes and hypertension are well managed. Her son from out of state accompanies her today and has recently moved in to help her. What should the nurse suspect?

Elder abuse Explanation: The differing colors of the bruising indicate that they have occurred at different times and are unlikely to have resulted from a single fall. The location of the bruising on the ulnar aspects of the forearms potentially indicate that she was trying to defend herself and are not typical areas to bruise by a fall. Depression may be evident, but this is more likely to be a result than a cause of her situation today. While nothing is proven, it would be wise to interview her without her son in the room. If in doubt, a social work consult may be helpful to help determine if elder abuse is occurring.

Blood pressure abnormalities found more commonly in Western elderly include which of the following?

Elevation of the systolic BP Explanation: Isolated systolic hypertension is common in the elderly because of stiffening of the large arteries. This is often accompanied by widening of the pulse pressure. Orthostatic BP changes are often seen with postural changes and can account for falls as well.

The nurse has assessed and informed the healthcare provider of a brown-colored lesion on an older client's left cheek. The lesion is diagnosed as solar lentigines. What is the nurse's best action?

Encourage the client to wear sunscreen daily. Explanation: Sun exposure causes solar lentigines, a benign skin lesion also known as age or liver spots. Usually these lesions are diagnosed by appearance and biopsy is not necessary. Malignant melanomas, not solar lentigines, are known to metastasize. A chemotherapeutic agent is not prescribed for this type of benign lesion.

A 76-year-old female client's blood pressure is 132/76 in a supine position, 128/71 when dangling at the side of her bed, and 105/58 when she is standing. These assessment findings constitute a risk for which of the following health problems?

Falls Explanation: Orthostatic hypotension, as demonstrated by the woman's positional changes in blood pressure, constitutes an increased risk of falls. It is not linking as closely with risk of CVA, PVD, or delirium.

Some symptoms are common in elderly clients. Which of the following is less likely to be a common problem in old age?

Fever. Explanation: The signs and symptoms of illness often present differently in the oldest-old. Adverse events (AE) or adverse drug effects (ADE) in this population often include falls, confusion, incontinence, generalized weakness, and lethargy. These complications are also referred to as geriatric syndromes, and are more common signs and symptoms of illness in the very old than are the more common manifestations of illness in younger adults such as fever, pain, and abnormal lab values.

An older client admits that she has recently begun wetting her pants. On further questioning by the nurse regarding the cause of the incontinence, the client explains, "I move so slowly these days that I can't always make it to a bathroom in time." The nurse recognizes this as which type of incontinence?

Functional Explanation: 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. Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. Stress incontinence involves involuntary loss of urine when coughing, sneezing, or laughing. Overflow incontinence is the condition in which the client has involuntary loss of urine associated with overdistention of the bladder.

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 Explanation: 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.

Which strategy can the nurse use to effectively approach the older adult client during the health history?

Have the room well-lit with minimal background noise. Explanation: To effectively approach an older adult during the health history, the nurse should have the room well-lit with minimal background noise. Brighter lighting helps compensate for changes in the lens and to see facial expressions and gestures more clearly. Minimizing background noise will limit misunderstandings related to possible hearing deficits. Open-ended questions should be used. The nurse should use other forms of information such as ample screening tools, medical records, and family caregivers. The nurse should adjust the pace according to the stamina of the client and consider another visit if necessary to complete the history.

With a client suspected of suffering from presbycusis, the nurse would expect difficulty hearing:

High-pitched sounds Explanation: Presbycusis is associated with a loss of higher-tone hearing that makes it more difficult for older clients to discern speech.

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 Explanation: 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 Explanation: 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. Vision and activity tolerance testing, along with the Get Up and Go test, evaluate specific body regions and systems but not general functional status in performing daily chores.

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 Explanation: 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. 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 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 Explanation: 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. Knowing the statistical occurrence of the condition among people of the same age, the client's family history, and the client's mental status would not be as helpful in identifying pathology in the client as knowing deviations from the client's baseline functional status.

The nurse is assessing an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?

Kyphosis Explanation: Increased kyphosis and decreased ROM are expected findings associated with aging. Heberden nodes are large nodules in the distal interphalangeal joints, common with arthritis. Hip contractures are abnormal.

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

Left side-lying Explanation: The anus and rectum should be assessed with the client in left side-lying position for better accessibility and comfort. The lithotomy position is used for assessment of female genitalia. The standing position is used for assessment of male genitalia. The prone position does not give access to anus and rectum.

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 Explanation: A recurrent cough, fatigue, weight loss, and shortness of breath are hallmarks of lung cancer. COPD clients do not usually have a blood-tinged cough. Hallmark symptoms of TB include weight loss and night sweats. Pneumonia in the elderly often does not manifest with the normally associated symptoms but rather with increased respiratory rate or other subtle changes.

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 Explanation: Better vision in one eye is a warning sign of macular degeneration, a leading cause of blindness in elderly people. Presbyopia is impaired near vision, which is common as people age. Glaucoma usually occurs in both eyes, but it may involve each eye to a different extent. Most people with glaucoma have no early symptoms or pain. Arcus senilis is a normal condition in the elderly in which a white arc appears around the limbus and has no effect on vision.

Which of the following indicates that an elderly client has been affected by polypharmacy?

Medications are used to counteract side effects of other prescribed medications. Explanation: Older adults live with one or more chronic conditions, which often results in a complex medication regimen. Older adults are at risk for adverse medications due to the numerous medications they may be taking. Side effects of one medication may necessitate another medication to manage the side effects. Consequently, older adults experience polypharmacy.

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

Obtain a voiding diary Explanation: The most appropriate method of assessing urinary incontinence in an elderly client is by obtaining a voiding diary. Inspecting the urethral meatus and vaginal opening helps in assessment of external genitalia. Asking the client to bear down helps in assessment of uterine, vaginal, and rectal prolapse.

On receiving results of some lab work for a client, a nurse learns that the client has a platelet deficiency. Which skin condition related to this finding should the nurse look for in this client?

Petechiae Explanation: Pinpoint-sized, red-purple, nonblanchable petechiae are a common sign of platelet deficiency. Senile purpura is a normal finding in skin of an elderly client. Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed. Shingles are vesicles due to herpes zoster infection.

The nurse is assessing an elderly client that has been hospitalized with weakness. The nurse identifies that what disease is most likely to occur in an elderly hospitalized client?

Pneumonia Explanation: Pneumonia is the most common cause of infection related deaths in older adults. Sepsis, bleeding and pressure ulcers do occur but are not as common.

A client is brought to the clinic by his daughter, who tells the nurse that she is concerned because her father appears to be losing weight and she doesn't know why. What would the nurse know is a cause of undernutrition?

Poverty Explanation: Low weight is a key indicator of poor nutrition. Undernutrition is seen with depression, alcoholism, cognitive impairment, malignancy, chronic organ failure (cardiac, renal, pulmonary), medication use, social isolation, and poverty.

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 Explanation: 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.

Mrs. Glynn is 90-years old and lives alone. She is able to bathe, dress, prepare her food, and transfer from bed to chair independently. She has children in the area who help her with her medications and transportation needs. Which of the following is considered an instrumental activity of daily living?

Preparing food Explanation: Instrumental activities of daily living involve higher thought processes such as preparing food. Bathing, dressing, and transferring are considered physical activities of daily living.

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 Remind the client to ask for assistance Assist with exercise to strengthen lower extremities Explanation: 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.

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 Explanation: 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. Walking and observing the gait monitors a client's balance. The nurse should not ask an elderly client to perform deep knee bends because of the risk for falls. Swinging the arms overhead may also cause dizziness and increase the risk for falls.

An older adult client presents with raised yellow lesions on the face. What does this finding most likely suggest to the nurse?

Seborrheic keratoses Explanation: Seborrheic keratoses are raised yellowish lesions that feel greasy. This is a benign lesion of aging. Solar lentigines are liver spots. Actinic keratoses are superficial flattened papules covered by a dry scale. Cherry angiomas are reddened areas of the face caused by superficial blood vessels.

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

Senile purpura Explanation: Senile purpura is a normal finding in skin of an elderly client. Actinic keratoses are the proliferative form of skin lesions. Dermatomycosis is the ringworm infection of the skin. Shingles are vesicles due to herpes zoster infection.

An elderly client visits her community health clinic with an outbreak of vesicles on her skin. She tests positive for the herpes zoster virus. The nurse should recognize this condition as which of the following?

Shingles Explanation: Shingles are vesicles due to herpes zoster infection. Senile purpura is a normal finding in skin of an elderly client. Actinic keratoses are round or irregularly shaped tan, scaly lesions that may bleed or be inflamed. Pinpoint-sized, red-purple, nonblanchable petechiae are a common sign of platelet deficiency.

When using the Romberg test of cerebellar function in an older client, which of the following findings is expected?

Slight sway with eyes closed Explanation: Increased sway in the Romberg test from diminished vibratory and position sense in the lower extremities is an expected finding among older clients. Sway with the eyes open or any inability to sustain balance would be considered pathological.

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

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 Explanation: 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. Overflow incontinence is the condition in which the client has involuntary loss of urine associated with overdistention of the bladder. 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 75-year-old female client tells the nurse that she is sexually active but that it causes her pain when she has intercourse. What would the nurse suggest to alleviate this pain?

Taking warm baths Explanation: Suggestions to alleviate pain might be changes in positions, use of lubrication, heat application, and warm baths.

Some symptoms of dehydration are common to younger and older adults. Which one of the following cannot be used to determine dehydration in older adults?

Tenting of the skin when pinched. Explanation: Pinching skin is not an accurate test of turgor in older adults.

The nurse is assessing an older adult client who lives alone and was brought to the clinic by the client's grandson. The client's hair is messy, clothes are very dirty, and the client has very bad body odor. What do these signs most likely indicate to the nurse?

The client has decreased functional ability Explanation: Poor hygiene and inappropriate dress in an older adult may indicate decreased functional ability or may result from medications, infection, dehydration, or nutritional status. Inappropriate affect, inattentiveness, impaired memory, and inability to perform ADLs may indicate dementia from Alzheimer's disease or another cause. The information in the scenario does not indicate that the client is lazy; more investigation would be needed before the nurse would suspect neglect or abuse, as would the client's need to reside in a nursing home.

The nurse assesses an older adult using the short from of the Geriatric Depression Scale. The total score obtained is 11. Which interpretation by the nurse is correct?

The client is most likely depressed. Explanation: Scores on the short from of the Geriatric Depression Scale can range from 0 to 15. A score 10 is almost always indicative of depression. A score 5 is suggestive of depression.

When assessing the skin, hair, and nails of the older adult, the nurse needs to know the normal effects of aging on these structures. Which of the following are normal effects of aging on the integumentary system? Select all that apply.

The epidermis thins Nails become thick and brittle with slow growth Wound healing slows as a result of decreased mitotic activity Explanation: The epidermis thins with aging, and the epithelium renews itself every 30 days instead of every 20 days as in children and adults. This decreased mitotic activity of cells leads to a 50% reduction in rate of wound healing. In addition, there are degeneration of the elastic fibers providing dermal support, a loss of collagen, and a loss of subcutaneous fat. The number of sweat and sebaceous glands decreases as a result of atrophy, and vascularity and capillary fragility of the skin layer are diminished. Nail beds become more rigid, thick, and brittle, with slowed growth.

In an interview with an elderly female client, the nurse learns that the client often has involuntary loss of urine associated with an abrupt and strong desire to void. What type of incontinence should the nurse document in the client's record?

Urge Explanation: Urge incontinence is the involuntary loss of urine associated with an abrupt and strong desire to void. Stress incontinence involves involuntary loss of urine when coughing, sneezing, or laughing. Overflow incontinence is the condition in which the client has involuntary loss of urine associated with overdistention of the bladder. 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.

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 Explanation: 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. Anemia, hepatitis, and electrolyte imbalances would not produce nocturia.

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

Use lanolin-based products Explanation: 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.

An older client presents to the clinic with a painful tongue fissure. The nurse should encourage the client to increase the intake of which nutrient?

Water Explanation: A slightly dry oral mucosa is more common in older adults, but a fissured tongue is a sign of dehydration. A bright red tongue can indicate vitamin C or B1 deficiency.

When inspecting the toenails of an elderly client, an expected finding is:

Yellowed, thickened, lusterless nails Explanation: Older adults' toenails tend to yellow, thicken, and become longitudinally striated.

An objective assessment that is frequently indicated when the subjective assessment reveals a history of falling is

a Get Up and Go test. Explanation: Observe the client's gait by performing the timed "Get Up and Go" test. Older adult clients without impairments in gait or balance can complete the test within 10 seconds.

A risk factor for sinusitis in the frail elderly is

a nasogastric feeding tube. Explanation: Older adult clients with nasogastric feeding tubes are at increased risk for sinusitis related to the obstruction.

A characteristic sign of delirium is

a rapid decline in level of alertness. Explanation: When a change in cognition develops over a short time and is characterized by a change in level of alertness from extreme lethargy to agitation, it is called delirium.

The physical declines of aging often first become noticeable when

acute or chronic illness places excessive demands on the body. Explanation: Many older adults are healthy, active, and independent despite these normal physical changes in their bodies. It is, rather, that advancing age has a tendency to place a person at greater risk for chronic illness and disability.

The nurse detects a pulsation when assessing the abdomen of an older adult. Which condition does the nurse suspect the older adult has?

aortic aneurysm Explanation: An abdominal aortic pulsation is indicative of an aortic aneurysm. Atrial fibrillation is one type of dysrhythmia characterized by an irregular heartbeat. Congestive heart failure is characterized by fluid retention, especially in the lower extremities. A loud or harsh holosystolic murmur suggests valvular stenosis.

The nurse is assessing the eyes of an older adult. Which assessment finding would the nurse recognize as a finding associated with aging?

arcus senilis Explanation: Arcus senilis is a grayish yellow ring surrounding the iris and is thought to be associated with elevated lipid deposits. Senile ptosis or sagging of the upper lid down across the eye, small pupil size, and sluggish papillary accommodation are considered normal changes associated with aging.

The nurse suspects that an older client has undiagnosed Parkinson's disease. What finding caused the nurse to make this clinical determination?

bradykinesia Explanation: Bradykinesia is the most characteristic clinical sign of Parkinson's disease. Muscle atrophy can be caused by a variety of disease processes. A wide-based gait is a sign of a cerebellar disorder. Tremor of the head is considered intentional and is not typically associated with Parkinson's disease.

A sign of infection in the elder that is more common than fever is

confusion. Explanation: Confusion is often a sign of infection in the frail older adult.

During the assessment of an older client the nurse focuses on household activities and home environment. On which geriatric syndrome is the nurse focusing during this assessment?

fall risk Explanation: A geriatric syndrome represents serious issues for older adults and is often related to functional decline. Geriatric syndromes impact quality of life. Household activities and home environment would assess the geriatric syndrome of fall risk. Assessing eating or feeding would determine nutritional status. Assessing continence and mentation would help determine independence. Mobility and nutritional intake would help determine skin status.

Common conditions or problems that accompany aging are often called

geriatric syndromes Explanation: Older adults often have conditions or difficulties referred to as geriatric syndromes because of the interaction of multiple chronic diseases. Because these syndromes are common, the nurse can play a key role in early detection or assessment of the problem so that interventions can be implemented.

When assessing an older adult client, the nurse notes which age-related changes of the cardiovascular system that increase the risk for falls?

postural orthostatic hypotension Explanation: A sudden drop in blood pressure upon rising to a standing position can cause light-headedness and increases the risk for falls. A decline in pacemaker cells in the sino-atrial node can affect the response to exercise and physiological stress. A rise in the systolic blood pressure can lead to risk for hypertension. Stiffening of the large arteries leads to atherosclerosis.

The nurse observes a dark brown, pigmented waxy lesion 2-mm in size on the right forearm of an older adult. The nurse recognizes this lesion as:

seborrheic keratosis Explanation: Seborrheic keratosis is a dark brown, pigmented waxy lesion. Basal cell carcinoma starts as a small smooth, hemispherical translucent papule covered by a thinned epidermis, usually on the face. The papule gradually enlarges into a pearly nodule with a ulcerated center. Squamous cell carcinoma starts as a hard, red, wart-like lesion with a raised or rolled gray yellow edged found on highly sun-exposed areas. Malignant carcinoma is a variegated pigmented macule, papule, nodule, patches, or tumor, usually asymmetric with an irregular border and greater than 6 mm in diameter.

When evaluating the blood pressure of an older adult, the nurse should understand that with aging, the

systolic blood pressure increases

A key area to assess in older adults with chronic respiratory or cardiac problems and some constant degree of dyspnea is

the degree to which dyspnea affects daily function. Explanation: Older adults with chronic respiratory or cardiac problems who experience some constant degree of dyspnea are unlikely to seek care or note dyspnea unless there is a change in functional capabilities.

For which reason should the nurse use the 10-minute screener when assessing the older adult client?

to evaluate age-related changes that support optimal functioning Explanation: The 10-minute geriatric screener evaluates for age-related changes that help older adults maintain optimal functioning. It covers the three important domains of geriatric assessment: physical, cognitive, and psycho-social function. The SPICES mnemonic focuses on frequent geriatric syndromes of the older adult. This assessment includes a focus on sleep disorders, problems with eating, incontinence, confusion, evidence of falls, and skin breakdown. The ETHICS mnemonic helps clinicians escape the pitfalls of group labeling by expanding the individual history taking to include the explanation, treatment, healers, negotiate, intervention, collaborate, and spirituality. The 10-minute screener is not structured to assess for activities of daily living.

Any new onset of incontinence in the frail elder should be investigated for

urinary tract infection. Explanation: Incontinence and confusion are often signs of infection in the frail older adult.