Hesi Case study Gerontology: Age-Related Risks

The nurse reviews potential adverse and side effects of gabapentin (Neurontin) with Mr. Rogers, who denies experiencing them at the present time. The nurse asks Mr. Rogers a series of questions related to his urinary and bowel elimination patterns. Which response by the client is of most concern to the nurse? "I usually have to get up during the night at least once to urinate." "It takes me longer to urinate than it did when I was younger." "My urine had a foul smell this morning." "My urine is yellow and pale in color."

"My urine had a foul smell this morning." New onset of a foul smell in the urine could be a sign of UTI and should be investigated further. Bladder (cystitis) and kidney (pyelonephritis) infections are common problems in clients with diabetes.

Mr. Rogers is prescribed a new medication, doxazosin (Cardura) to treat his benign prostatic hyperplasia (BPH). Which of the following statements made by Mr. Rogers indicates the need for further teaching? "I should report any dizziness or fainting episodes." "I will take this medication to improve my urine flow." "This medication may cause a rise in my blood pressure." "I will need to take this medication for the rest of my life."

"This medication may cause a rise in my blood pressure." Doxazosin (Cardura) can result in a drop in blood pressure.

Which results of the dipstick urinalysis does the nurse recognize as abnormal? Select all that apply +1 Ketones. pH 5.0. Absence of glucose. Scant sediment. Trace leucocytes.

+1 Ketones. Ketones are not normally found in the urine. Positive ketones can be associated with uncontrolled diabetes, malnutrition, or pregnancy Scant sediment. Cloudiness or turbidity of the urine is an abnormal finding, which may be associated with an infection or with contamination of the specimen. Trace leucocytes. The presence of leucocytes in the urine is an abnormal finding, which may be associated with specimen contamination or with infection.

The nurse understands that the elderly client should drink at least 30 mL/kg of fluid each day with a minimum of 1500 mL/day. Mr. Rogers weighs 226 lbs (102.7 kg).

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The HCP prescribes arterial blood gases to be drawn as well as serum electrolytes. Which lab value needs to be reported immediately? Serum creatinine 1.2 mg/dL. Arterial pH 7.05. Negative ketones. Serum osmolality 285 mOsom/kg.

Arterial pH 7.05. An arterial pH below 7.35 indicates an abnormal blood gas and indicates a shift to an acidotic state. This is an emergency situation.

Which recommendation by the nurse may help improve mild symptoms of BPH during the "watchful waiting" period? Take a mild decongestant at night to reduce nocturia. Increase fluids before bedtime to dilute acidic urine. Introduce acidic foods into the diet. Avoid sources of caffeine.

Avoid sources of caffeine. Caffeine may stimulate an overactive bladder and irritate an already enlarged prostate.

The nurse reports the abnormal findings to the HCP, who orders a urinalysis and urine for culture and sensitivity. The nurse obtains a clean catch specimen and sends it to the lab for analysis. The lab report states that there is greater than 100,000 E. coli bacteria, and Mr. Rogers is diagnosed with a UTI. Nearly half of all men over the age of 75 suffer from benign prostatic hyperplasia (BPH), also called benign prostatic hypertrophy. The HCP prescribes an oral antibiotic to treat the UTI and recommends the conservative "watchful waiting" approach for managing the BPH. The nurse understands that which symptoms are commonly associated with BPH? Select all that apply Bladder distention. Frequent stopping and starting of urinary stream. Straining while urinating. Dribbling at the end of urination. Priapism.

Bladder distention. Enlargement of the prostate can cause obstruction, preventing emptying of the bladder and resulting in bladder distention. Frequent stopping and starting of urinary stream. Enlargement of the prostate causes obstructive symptoms such as difficulty maintaining a steady stream of urine. Straining while urinating. Enlargement of the prostate causes obstruction, making it difficult to urinate without straining. Dribbling at the end of urination. Enlargement of the prostate may cause an obstruction, making it difficult to end the urinary stream, resulting in dribbling.

The nurse considers which pharmacological age-related principles when administering medications or monitoring the effects of medications in the elderly client? Select all that apply Gastric pH is often decreased in the elderly. Decreased cardiac output increases the risk for adverse drug reactions. Mucosal edema can increase the absorption of drugs. Drugs administered intravenously have a faster absorption rate than oral drugs. Dehydration can decrease the half-life of drugs.

Decreased cardiac output increases the risk for adverse drug reactions. Decreasing cardiac function is responsible for about 50% of blood flow to the kidneys, leading to reduced kidney efficiency. Drugs are not filtered as quickly from the bloodstream, which increases their half-life and leads to toxicity. Drugs administered intravenously have a faster absorption rate than oral drugs. Decreased gastric blood flow and motility in the elderly can slow oral drug absorption. Dehydration can decrease the half-life of drugs. Dehydration leads to a delay in the filtration process of drugs. The extended biological half-life of drugs in the older adult increases the risk of adverse reactions.

Mr. Rogers lost 4 lbs (1.81 kg) in 1 month prior to his hospital admission. The nurse assesses Mr. Rogers for signs of nutritional problems. Which data is most important to report to the HCP? Dyspnea. Constipation. Heartburn. Pallor.

Dyspnea. Dyspnea can result from nutritional problems and may be indicative of anemia; therefore, it is the most important symptom to report.

The nurse suspects that Mr. Rogers is dehydrated and encourages him to increase his oral intake of fluids, especially during his treatment for a UTI.

Elevated hemoglobin and hematocrit. No single laboratory test result confirms or rules out dehydration. Instead it is determined by laboratory findings with clinical manifestations. Common findings are elevated hemoglobin and hematocrit levels from hemo concentration (an increase in the number of red blood cells/plasma). In the case of dehydration, BUN would be elevated. of the kidney. Increased serum osmolarity. During dehydration, increased levels of sodium, BUN or glucose in the blood can increase the serum osmolarity. caused by dehydration. Increased serum glucose. Increased amounts of solutes, such as glucose or protein, can also increase specific gravity of the urine.

During Mr. Rogers' hospital stay, the HCP prescribes an insulin pen to replace Mr. Rogers' insulin syringes and insulin vials. Mr. Rogers is taught by the nurse to dial the pen to the prescribed amount and to use a magnifying glass to ensure that the amount of insulin is correct with each injection. The nurse ensures that the two insulin pens are clearly marked as glargine (Lantus) or lispro (Humalog) so Mr. Rogers can identify them easily. The nurse understands that which information is correct regarding the prescribed insulin? Glargine (Lantus) is rapid-acting insulin typically administered 15 minutes before meals. Lispro (Humalog) is intermediate-acting insulin that peaks in 4 to 10 hours. Glargine (Lantus) does not have a peak interval. Lispro (Humalog) is typically given at bedtime on an empty stomach.

Glargine (Lantus) does not have a peak interval. Glargine (Lantus), long-acting insulin, has an onset of 1 to 2 hours, has no pronounced peak, and has a duration of 24+ hours.

The nurse reports the findings to the HCP, who orders serum laboratory assessments. The nurse draws Mr. Rogers' blood and sends it to the laboratory. Which laboratory finding is of most concern to the nurse? Potassium 3.9 mEq/L. Sodium 140 mEq/L. Phosphate 4.1 mg/dL. Hemoglobin 11.2 g/dL.

Hemoglobin 11.2 g/dL. Normal hemoglobin for an adult male is 13.2 to 17.3 g/dL. Although lower levels are often found in older adults, 11.2 g/dL indicates anemia.

In the older adult, the mechanism for thirst is impaired. The nurse assesses the client for common signs of extracellular fluid loss. Which of the following objective signs indicate dehydration? Select all that apply Hematuria. Increased urine output. High creatinine levels. Postural hypotension. Heart rate greater than 100 bpm.

High creatinine levels. Creatinine levels may decrease after rehydration, which improves renal blood flow. This can be attributed to low renal blood flow due to dehydration and/or diabetic nephropathy. Postural hypotension. Hypovolemia, which can result from dehydration, can cause a drop in systolic BP of 10 to 15 mmHg when a client changes from a lying to a standing position. Heart rate greater than 100 bpm. Tachycardia, or an increase in heart rate, may occur with a drop in blood volume related to dehydration to help the body maintain adequate cardiac output.

Before Mr. Rogers' bath, the nurse examines Mr. Rogers' right heel and documents a stage II nonhealing ulcer. A dressing change is prescribed. Prior to changing the dressing on Mr. Rogers' right heel ulcer, the nurse should first take which actions? Inspect the feet carefully for temperature, sensation, and drainage. Elevate the affected foot. Avoid weight-bearing activities. Administer broad-spectrum antibiotics.

Inspect the feet carefully for temperature, sensation, and drainage. An inspection must be done by the nurse to assess for drainage in case a culture/sensitivity needs to be done to rule out the possibility of infection. Peripheral neuropathy may begin with nerve irritation and pain that progresses to the loss of sensation to fine touch. Diabetic clients may often ignore or be unaware of irritation or injury to their feet.

The nurse understands that which physiological age-related change is often responsible for dehydration in the elderly? Taste buds are more sensitive, leading to a decreased desire for liquids. Thirst decreases, contributing to less fluid intake. Increased glomerular filtration rate. Constriction of the esophagus prevents fluid metabolism.

Thirst decreases, contributing to less fluid intake. Older adults have a higher baseline osmolality and, thus, a higher osmotic operating point for thirst sensation. As the thirst mechanism decreases, the elderly individuals are more likely to take in fewer fluids. Urine output rises from osmotic diuresis

The nurse notifies the HCP of the laboratory findings and the client is diagnosed with pernicious anemia. The nurse anticipates that the client will receive which treatment for pernicious anemia? Iron supplements by mouth daily. Increase in vitamin C in the diet. Intramuscular injection of vitamin B-12. Prescription strength folic acid supplements.

Intramuscular injection of vitamin B-12. Pernicious anemia is a deficiency of vitamin B-12 that is often caused by a lack of intrinsic factor.

The nurse making rounds finds Mr. Rogers unresponsive. His vital signs are BP 92/60 mmHg, apical pulse 135 beats/min, T 100.4° F (38.0° C). His chemstick reading is high. What conditions, other than hyperglycemia, might Mr. Rogers have? Hypernatremia. Hypervolemia. Ketonuria. Osmotic diuresis. Glycosuria.

Ketonuria. The lack of glucose in cells results in fat breakdown by the liver, and ketonuria results from the excretion of ketones in the urine. Osmotic diuresis. Glucose is an osmotically active particle, and lack of glucose results in cellular dehydration. Glycosuria. When blood glucose levels exceed the renal threshold, the glucose spills into the urine, causing glycosuria.

The nurse is carefully monitoring Mr. Rogers' laboratory values. Which results can affect drug distribution and influence drug-to-drug interactions? Elevated BUN. Low serum albumin levels. Reduced glomerular filtration rate. Elevated creatinine levels.

Low serum albumin levels. Serum albumin levels can affect the binding of drugs. Low levels of albumin can result in toxic effects, especially in the elderly.

Mr. Rogers completes his round of antibiotics. He reports that his UTI symptoms have resolved, and follow-up urinalysis results are normal. The nurse creates Mr. Rogers' care plan and records a nursing diagnosis for knowledge deficit related to signs and symptoms of hypoglycemia. Which teaching points should be included in this plan of care? Select all that apply Report a blood glucose reading of 70 mg/dL. Notify the HCP if there is headache or irritability. Report excessive hunger and/or weakness. Report cold and clammy skin. Notify the HCP of hot, dry skin.

Notify the HCP if there is headache or irritability. Headache and irritability are symptoms of hypoglycemia, so these should be reported. Hypoglycemia can be dangerous when blood glucose levels are below 50 mg/dL in adults because it can cause irreversible damage to the cerebral cortex. The brain cannot burn anything other than glucose. A prn prescription for parenteral glucose or a carbohydrate meal is usually given. Report excessive hunger and/or weakness. Excessive hunger and weakness are a sign of hypoglycemia, which can be a result of not eating or an indication of a side effect of insulin or oral hypoglycemic agents. These symptoms should be reported. A prn prescription for parenteral glucose or a carbohydrate meal is usually given. Report cold and clammy skin. Hypoglycemia causes autonomic nervous system symptoms such as nervousness, sweating, irregular heart rhythm, tremor, and hunger, and these symptoms should be reported.

Based on the information gathered during the nurse's assessment, the HCP prescribes low doses of regular insulin by continuous IV infusion. In addition to the insulin, which of the following immediate measures would be indicated in the treatment of Mr. Rogers? Select all that apply In addition to the insulin, which of the following immediate measures would be indicated in the treatment of Mr. Rogers? Prednisone. Epinephrine. Potassium supplements. Sodium bicarbonate. 0.9% normal saline.

Potassium supplements Ketones accumulate, which produces a drop in blood pH and increases the number of hydrogen ions in the blood, resulting in acidosis. The body attempts to buffer the acidic hydrogen ions by exchanging them with intracellular potassium ions. Potassium supplements are given to restore normal potassium levels. Sodium bicarbonate. The sodium bicarbonate is administered to correct the metabolic acidosis. 0.9% normal saline. Fluids are used to correct profound dehydration and hyper osmolarity.

The nurse formulates Mr. Rogers' plan of care and notes that teaching should be initiated related to Mr. Rogers' diabetic peripheral neuropathy. The nurse understands that which symptoms are associated with diabetic peripheral neuropathy? Select all that apply Reduced ability to feel pain or temperature in the extremities. Frequent UTIs or incontinence. Muscle weakness and difficulty walking. Problems with erectile dysfunction. Extreme sensitivity to touch.

Reduced ability to feel pain or temperature in the extremities. Peripheral neuropathy is the most common form of diabetic neuropathy affecting the ends of the nerves in the feet and legs first, followed by neuropathy affecting the hands and arms in a stocking- like pattern. Problems with erectile dysfunction. This is a type of diabetic autonomic neuropathy, a condition in which the nerves of nearly all body systems (autonomic system) are impaired. Extreme sensitivity to touch. Peripheral neuropathy is the most common form of diabetic neuropathy affecting the ends of the nerves in the feet and legs first, followed by neuropathy affecting the hands and arms.

The nurse performs a focused assessment, checks Mr. Rogers' blood glucose with a glucometer, then administers the prescribed dose of insulin during morning medication administration rounds. Which information about the client is of most concern to the nurse? c Blood glucose rises from 120 mg/dL to 125 mg/dL in 8 hours. Washes hands with soap and water and allows alcohol swab wipe to dry before performing chemstick. Reports a new onset of blurry vision. Depends on handwritten notes to recall his last blood glucose reading.

Reports a new onset of blurry vision. Blurry vision can indicate cataracts, glaucoma, optic nerve damage or diabetic retinopathy.

The nurse reports Mr. Rogers' blurry vision to his HCP, who then evaluates and treats Mr. Rogers for worsening diabetic retinopathy. Select all that apply Which other symptoms should the nurse expect to find in a client with a diagnosis of diabetic retinopathy? Reports of floaters. Loss of vision. Jaundice of the sclera. Difficulty with color perception. Pupil fixation.

Reports of floaters. Small micro aneurysms protrude from the vessel walls, causing the client to see red and black spots or lines described as floaters Loss of vision. Micro aneurysms and edema can lead to increased intraocular pressure, retinal detachment and glaucoma, which can all cause loss of vision. Difficulty with color perception. Macular edema associated with diabetic retinopathy can cause impaired hue discrimination resulting in impaired color perception.

Mr. Rogers is placed on an EKG monitor because of a concern about hypokalemia. Which pattern should the nurse report immediately to the HCP? ST depression and "U" waves. Sinus tachycardia. Sinus bradycardia. Sinus arrhythmia.

ST depression and "U" waves. After insulin therapy, hypokalemia is expected because the potassium shifts back into the cell. Hypokalemia is a serum potassium level less than 3.5 mEq/L and can be life threatening. Flat or inverted T waves or increased "U" waves can occur with hypokalemia.

The nurse understands that which concept is important when addressing the client's physiological and psychosocial needs? Socialization is important, but community dining should be avoided because the timing is restrictive and could lead to adverse reactions of medications. The client's need for a special diabetic meal plan overrides the benefits of community dining; therefore meals should be prepared in the apartment. The client's diabetes mellitus should not present a problem for community dining. The nurses in the community dining center should take any food containing sugar away from clients who have diabetes mellitus.

The client's diabetes mellitus should not present a problem for community dining. The client should be able to order or select dishes on his diabetic meal plan from the community dining center. A special dietary need will not typically prevent a client from enjoying the social benefits of a community dining experience.

Meet the Client: Carl RogersCarl Rogers is a 67-year-old African American male with a history of type 2 diabetes mellitus. Mr. Rogers schedules a visit with the healthcare provider (HPC) because he develops a nonhealing ulcer on his right heel. After several weeks of home remedies, he decides he needs to see the HCP. Upon arrival at the clinic, Mr. Rogers' vital signs are taken and a physical assessment completed.Vital Signs:The HCP discusses the diagnoses with Mr. Rogers and explains that it is necessary to admit him to the inpatient medical-surgical unit immediately to treat the heel ulcer.Diagnoses: Mr. Rogers was diagnosed last year with type 2 diabetes mellitus. He explains that he is experienced with self-administration of insulin injections three times per day. Mr. Rogers states that his eating habits are not great, but he never misses his insulin injections. He lives alone and doesn't like to eat by himself, so he rarely cooks. Mr. Rogers explains that other than an occasional walk, he does not exercise.

The stage II non-healing ulcer on the client's right heel could require amputation. Extra protein is needed for healing wounds and restoring losses. Extensive tissue destruction, such as that which occurs with burns, pressure sores, and diabetic ulcers requires a large protein increase for the healing and grafting processes. Older adults with diabetes mellitus II (DM) also demonstrate poor wound healing. The development of hypoglycemia could be life-threatening. This is a concern to the nurse. Dehydration exacerbated by lack of nutrition. Approximately 19% of total water intake comes from food. Uncontrolled diabetes mellitus causes an excess loss of water through urine as a result of high blood glucose levels. In such cases, the replacement of lost water and electrolytes is vital to prevent dehydration. Lack of appetite and not wanting to eat alone could lead to malnutrition. Many of the health problems of older adults result from general aging and states of malnutrition caused by poor food habits, such as a lack of appetite, or loneliness and not wanting to eat alone.

The RN prepares to administer the first dose of vitamin B-12 via intramuscular injection. Which technique is correct? Inject into the dorsogluteal site, the preferred injection site. Aspirate after injecting medication into the muscle. Inject into the fatty tissue of the abdomen. Use a 1 to 1 ½ inch needle.

Use a 1 to 1 ½ inch needle. For a male client who weighs 130 to 260 lbs (59 to 118 kg), a 1 to 1½ inch needle is recommended.

Mr. Rogers tells the nurse that he likes to take warm baths because it helps his joints feel better. The nurse is concerned that peripheral neuropathy may cause him to unintentionally burn himself when he is discharged to the assisted living facility. Which instruction related to bath safety is best? Use toes or elbow to make sure that the water is not too hot. Let hot bathwater sit for 10 minutes before entering the bath. Use equal amounts of hot and cold water when preparing the bath. Use a bath thermometer to ensure that the temperature is below 102° F (38.8° C).

Use a bath thermometer to ensure that the temperature is below 102 degrees F Use of an unbreakable thermometer to ensure temperature is below 102° F (38.8° C) will help prevent burns for the client with peripheral neuropathy.

The nurse is developes a plan of care to prevent Mr. Rogers' feet from further skin breakdown. Which actions will help to maintain skin integrity? Select all that apply Use heel protectors. Use special mattress or foot cradles. Apply drying agents, such as alcohol, to the skin. Apply skin moisturizers to prevent cracking. Instruct the client to wear clean white socks.

Use heel protectors. Heel protectors can help take pressure off the heels. Check heels for erythema, blisters, or breaks in skin integrity. Use special mattress or foot cradles. Pressure on infected or open wounds on the feet can be eliminated by the addition of a soft care mattress or use of a foot cradle. Apply skin moisturizers to prevent cracking. Foot deformities are common in diabetic neuropathy and may lead to callus formation, ulceration, and increased areas of pressure. Instruct the client to wear clean white socks. Clean white socks should be worn with shoes that fit properly.

Mr. Rogers is prescribed ampicillin (Principen) one gram every six hours for his urinary tract infection. He develops a maculopapular rash on his torso. The nurse notifies the HCP and the ampicillin (Principen) is discontinued.

Vancomycin (Vancocin). IV vancomycin (Vancocin) is indicated for serious infections with susceptible organisms in clients who are allergic to penicillins. Clindamycin (Cleocin). Clindamycin (Cleocin) is indicated for serious infections with susceptible organisms in clients who are allergic to penicillins Erythromycin (Erythrocin). Erythromycin (Erythrocin) is one of the drugs that is indicated for serious infections with susceptible organisms in clients who are allergic to penicillin.

The nurse asks Mr. Rogers additional questions related to his urinary symptoms. Mr. Rogers reports mild pain with urination and his temperature is 98° F (36.6° C). The nurse reports the foul smelling urine to the HCP who prescribes a random dipstick urinalysis test. The nurse should instruct the client to take which action first when collecting a urine sample? Collect 1 or 2 ounces of urine. Wipe the genital area clean. Dry any excess urine from the outer specimen cup. Hold the cup a few inches from the urethra.

Wipe the genital area clean. This step helps prevent contamination of the sample from the skin.

The nurse notes that Mr. Rogers takes PO gabapentin (Neurontin) every day when he is at home to treat his peripheral neuropathy. It is most important for the client to report which potential adverse or side effect associated with gabapentin (Neurontin)? Restlessness. Tarry stool. Dry mouth. Flatulence.

tarry stool A tarry or black stool may be an indication of a gastrointestinal bleed, a potentially life-threatening complication.