Older Adults Ch 11 Hinkle
The nurse identifies which of the following as an age-related change in the respiratory system? A - Increased residual lung volume B - Increased diffusion capacity C - Increased cough efficiency D - Increased vital capacity
A - Increased residual lung volume (The older adult experiences an increase in residual lung volume, decreased vital capacity, decreased diffusing capacity, and decreased cough efficiency.)
A client reports to the nurse that her mother had macular degeneration and is concerned that she, too, may be at risk. What should the nurse tell the client? A - Vision loss is not hereditary. It is related to diet. B - Wear sunglasses with ultraviolet (UV) protection when outside. C - Reduce the amount of cigarettes smoked daily from 20 to 10. D - This condition is now curable.
B - Wear sunglasses with ultraviolet (UV) protection when outside. (A risk factor for macular degeneration is sunlight exposure. Wearing sunglasses provides some protection. Cigarette smoking is another risk factor, and the client must stop smoking to reduce risk. Still another risk factor is heredity, and the client's mother had macular degeneration. Macular degeneration may be treated, but there is no cure.)
A nurse is educating teenagers on ageism. Which statement by the nurse is appropriate? A - "Ageism is the fear of memory loss." B - "Ageism is the fear of growing old." C - "Ageism is the fear of being in the same room as older adults." D - "Ageism is the bias against older people based solely on chronological age."
D - "Ageism is the bias against older people based solely on chronological age." (Individuals demonstrating ageism base their beliefs and attitudes about older people on chronological age without consideration of functional capacity. Fear of aging and the inability of many to confront their own aging process may trigger ageist beliefs. Ageism is not the fear of being in the same room as older adults, fear of memory loss, or the fear of growing old.)
A nurse is preparing a presentation for a local senior center about the health status of older adults. What trends in health promotion and disease prevention activities would the nurse explain as contributing to declining death rates in the older adult population? Select all that apply. A - screening for hypertension B - improved nutrition C - decreased exercise D - decreased smoking E - early detection of elevated cholesterol levels F - decreased community-based services
A - screening for hypertension B - improved nutrition D - decreased smoking E - early detection of elevated cholesterol levels (Most deaths in the United States occur in people 65 years or older, with one-half of these caused by heart disease and cancer. Decreased smoking, improved nutrition, screening for hypertension, and early detection of elevated cholesterol levels are contributing factors to a decreased death rate in older adults. Older adults are encouraged to increase exercise and increase community-based services.)
The nurse is working in a long-term care facility. When assessing her patients, what body system dysfunction should the nurse look for as the leading cause of morbidity and mortality in the older adult population? A - Genitourinary B - Respiratory C - Gastrointestinal D - Cardiovascular
D - Cardiovascular (Most deaths in the United States occur in people 65 years of age and older; 48% of these are caused by heart disease and cancer)
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? A - Decreased norepinephrine level B - Increased norepinephrine level C - Increased acetylcholine level D - Decreased acetylcholine level
D - Decreased acetylcholine level (A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.)
The client asks the nurse why she seems to have bone changes since she has gotten older. What is the best response by the nurse? A - "Bone changes from aging result from a loss of vitamin absorption." B - "Bone changes from aging result from most medication therapies." C - "Bone changes from aging result from a loss of magnesium." D - "Bone changes from aging result from a loss of calcium."
D - "Bone changes from aging result from a loss of calcium." (Age-related changes that affect mobility include alterations in bone remodeling and loss of bone calcium, leading to decreased bone density, loss of muscle mass, deterioration of muscle fibers and cell membranes, and degeneration in the function and efficiency of joints. Bone changes do not occur from loss of magnesium, most medications, and loss of vitamin absorption.)
The nurse is preparing an elderly hospitalized client for discharge to home within the hour. What should be the priority for the nurse? A - Instruct the client to receive at least 1 hour of sun exposure each day. B - Administer intravenous morphine for report of postoperative pain. C - Encourage physical activity of 30 minutes following breakfast daily. D - Assess the need for pneumococcal and influenza vaccinations.
D - Assess the need for pneumococcal and influenza vaccinations. (Activities that help elderly people maintain respiratory function include pneumococcal and yearly influenza immunizations. The nurse is to ensure the safety of the client. It is unsafe to administer an intravenous pain medication and then immediately discharge the client. Elderly clients should limit sun exposure to 10 to 15 minutes daily, and avoid heavy activity after eating to prevent indigestion.)
A nurse is caring for a client with dementia. A family member of the client asks what the most common cause of dementia is. Which response by the nurse is most appropriate? A - "The most common cause of dementia in the elderly is Alzheimer's disease." B - "Drug interactions are the most common cause of dementia in the elderly." C - "Dementia is a terrible disease of the elderly." D - "Depression may manifest as dementia in elderly clients."
A - "The most common cause of dementia in the elderly is Alzheimer's disease." (The nurse should inform the family member that Alzheimer's disease is the most common cause of dementia in elderly clients. Dementia is a clinical manifestation, not a disease process. Although drug interactions and overmedication are causes of dementia, these causes aren't as common as Alzheimer's disease. Depression is common in elderly clients, but it doesn't cause dementia.)
Which is a true statement regarding pharmacologic aspects of aging? A - Absorption may be affected by changes in gastric pH. B - Elderly have a decreased percentage of body fat. C - Medication compliance is a single-faceted issue among the elderly. D - Potential for drug-drug reactions decreases with the number of drugs prescribed.
A - Absorption may be affected by changes in gastric pH. (During the aging process, absorption may be affected by changes in gastric pH. The elderly have an increased percentage of body fat. The potential for drug-drug interaction increases with the number of drugs prescribed. The aged population tends to be less compliant with their medication regimen because of several factors, such as cost, vision changes, mobility issues, and education.)
Why are IV solutions usually given at a slower rate to older adults? A - Older adults may have cardiac or renal disorders. B - Veins of older adults tend to be rigid. C - Older adults may have poor skin turgor. D - Older adults often find infusions painful.
A - Older adults may have cardiac or renal disorders. (IV solutions usually are given at a slower rate to older adults because these clients usually have cardiac or renal disorders. Veins of older adults tend to be rigid and they have poor skin turgor, making venipuncture difficult; however, this factor does not affect infusion. Older adults do not find infusion more painful than other clients.)
An elderly client who lives in a retirement community has been having a mild depressive episode over the past few weeks. What should the nurse recommend for the client? A - watching television during the day B - participating in a social activity C - asking the health care prescriber for antidepressant medication D - sleeping after lunch
B - participating in a social activity (For the elderly client experiencing mild depression, nonpharmacologic measures can be effective. These measures include increasing interpersonal interactions, such as by participating in a social activity. Other nonpharmacologic measures include bright lighting and exercise. Watching television limits interpersonal interactions. Exercising instead of sleeping should be recommended. Antidepressants are indicated for major depression.)
The nurse is describing hospice services to the family of a patient with end-stage heart failure. Which of the following would the nurse be least likely to include as a major focus of care? A - Emotional support B - Pain control C - Invasive therapy D - Symptom management
C - Invasive therapy (The goal of hospice is to improve the patient's quality of life by focusing on symptom management, pain control, and emotional support.)
A nurse notes that an older female client has lost 2 inches in height since her appointment last year. The client reports lumbar back pain as unchanged. Which of the following would the nurse instructs the client? Select all answers that apply. A - Allow for additional phosphorus intake in her daily diet. B - Decrease the frequency of any exercise. C - Take calcium and vitamin D supplements daily. D - Obtain the prescribed bone density screening. E - Increase intake of foods that are high in calcium.
C - Take calcium and vitamin D supplements daily. D - Obtain the prescribed bone density screening. E - Increase intake of foods that are high in calcium. (Older clients may experience decreased bone density and, thus, back pain as a result of aging. Strategies to assist them are to instruct clients to increase calcium in the diet and take calcium and vitamin D supplements. A bone density test made be done to determine the degree of bone loss. The client needs to limit phosphorus intake because a high-phosphorus blood level decreases calcium blood levels. The client needs to continue with a regular exercise program.)
An elderly client exhibits blood pressure of 110/76 while prone, 100/72 sitting, and 92/64 standing. The nurse instructs the client to A - Take daily hot showers. B - Use whirlpool baths for relaxation. C - Minimize the use of stool softeners. D - Ingest five or six small meals each day.
D - Ingest five or six small meals each day. (A client who experiences orthostatic hypotension should eat five or six small meals to minimize hypotension that can occur after large meals. The client should avoid straining when having a bowel movement. A stool softener would be useful. Hot showers and whirlpools should be avoided.)
A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? A - Place the client in a secluded room until calm. B - Continue taking the vital signs. C - Document the inability to assess vital signs due to client's agitation. D - Distract the client with a familiar object or music.
D - Distract the client with a familiar object or music. (The nurse should try to calm the patient by using distraction with a familiar object or music. Continuing to take the vital signs will cause further agitation and possible harm to the client or nurse. Placing the client in a secluded room may increase agitation and should not be used in this situation. The nurse should document the inability to assess vital signs and the reason why this should be done after the client's basic needs have been met.)
An elderly client is reporting changes in bowel movements from every day to every 3 to 4 days. The client also states that the stools are hard. Nursing interventions include instructing the client to A - Ingest foods high in fat. B - Exercise after meals. C - Use laxatives frequently. D - Increase fluid intake.
D - Increase fluid intake. (Factors that may cause constipation include prolonged use of laxatives and excessive dietary fat. To promote gastrointestinal motility, the client should ensure adequate fluid intake and avoid exercise immediately after eating.)
An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of A - Degeneration in the efficiency of bone joints B - The client's failure to exercise C - Decreased muscle mass and joint cartilage D - Loss of bone density
D - Loss of bone density (Elderly clients experience decreased bone density; they also may experience a loss of bone density from insufficient exercise. For this client, however, additional information indicates that she is taking prednisone, which may induce osteoporosis (loss of bone density). No information indicates that the client is not exercising or has experienced degeneration of bone joints. Degeneration in the efficiency of the bone joints and decreased muscle mass and joint cartilage would have more of an effect on increased pain than on decreased height.)
A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by A - Converting liquid foods to a gelatin texture B - Cutting the client's food into small pieces C - Serving hot foods at a warm temperature D - Placing one food at a time in front of the client during meals
D - Placing one food at a time in front of the client during meals (Tasks should be simplified for the client with Alzheimer's disease. All options are steps the nurse can take to promote eating for the client with Alzheimer's disease. Offering one food at a time, however, helps to prevent the client from playing with food.)
An older adult is experiencing bowel changes. She used to have a bowel movement every day, but she is now having one every 3 to 4 days. She also states that the stools are hard. Which of the following assessments would the nurse make? Select all answers that apply. A - Quantity of daily fluid intake B - Activity level of the client C - Amount of dietary fiber D - Use of laxatives E - Caloric intake
A - Quantity of daily fluid intake B - Activity level of the client C - Amount of dietary fiber D - Use of laxatives (Certain factors can predispose clients to constipation: lack of dietary fiber, prolonged use of laxatives, inactivity, and insufficient fluid intake. Caloric intake is not indicated as a factor for constipation.)
Family members report to the nurse that their elderly grandmother has had a sudden onset of confusion and that they are having difficulty providing care for her. What is the nurse's best response? A - Inform the family that this is a result of aging B - Administer donepezil every day C - Assess the grandmother for adventitious lung sounds D - Recommends placement of the grandmother in a nursing home
C - Assess the grandmother for adventitious lung sounds (Sudden onset of confusion may be the first symptom of an infection, such as pneumonia or urinary tract infection. The nurse needs to fully assess the situation before acting (such as telling the family this is a result of aging). Donepezil is used for Alzheimer's disease, which does not have acute onset. A recommendation for placement in a nursing home is premature without a full assessment at this time.)
An elderly client recovering from a hip repair becomes disoriented and tries to get out of bed frequently. The client states, "I forget I am in the hospital." The best nursing intervention is to A - Post a sign stating "You are in the hospital" at the client's eye level. B - Administer an oral dose of prescribed alprazolam (Xanax). C - Place the client in a Posey chest restraint with ties attached to the bed frame. D - Raise the upper and lower side rails of the bed.
A - Post a sign stating "You are in the hospital" at the client's eye level. (Client confusion increases the risk of falls. Environmental cues include a sign stating, "You are in the hospital." Measures that are not restraining are used first. Raising the lower side rails is considered a restraint. This increases a confused client's risk for falling. Placing a client in a Posey chest restraint is a last resort. Administering an anti-anxiety medication can increase confusion in a client who is already confused.)
To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should: A - stay with the client and encourage him to eat. B - fill out the menu for the client. C - help the client fill out his menu. D - give the client privacy during meals.
A - stay with the client and encourage him to eat. (Staying with the client and encouraging him to feed himself will ensure adequate food intake. A client with Alzheimer's disease can forget how to eat. Allowing privacy during meals, filling out the menu, or helping the client to complete the menu doesn't ensure adequate nutritional intake.)
A nurse is assessing a client brought to the emergency room by his daughter. Which statement by the daughter would most likely lead the nurse to suspect that the client may have an infection? A - "My dad told me that he felt a little more tired today." B - "My dad said he felt dizzy when he stood up from his chair." C - "All of a sudden my dad seemed to become confused." D - "My dad's temperature was 97.6 degrees F this afternoon."
C - "All of a sudden my dad seemed to become confused." (Due to age-related changes in the nervous system, a sudden onset of confusion may be the first symptom of an infection. Feeling dizzy on arising suggests orthostatic hypotension. A temperature of 97.6 degrees F may or may not suggest an infection. Typically older adults do not experience a traditional fever. Complaints of being tired could indicate numerous conditions.)
An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? A - "Alzheimer disease can be a great burden on the family. What community resources do you know about?" B - "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." C - "What concerns you most about Alzheimer disease?" D - "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever."
B - "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." (Delirium is associated with a sudden onset of confusion, not Alzheimer disease. The family needs to be told the correct information, which is that several underlying conditions could be causing the confusion. Once the underlying cause(s) is found and treated, the confusion should subside; however, some clients may not recover from the underlying cause, so telling the family the client will be better than ever is not appropriate. Asking the family about their concerns about Alzheimer disease and what they know about community support related to it is not appropriate because the client is exhibiting symptoms related to delirium.)
An elderly client reports fatigue without shortness of breath with walking 30 minutes five times each week. The nurse assesses the resting heart rate as 72 beats per minute; 10 minutes after walking, the client's heart rate is 92 beats per minute. What should the nurse instruct the client to do next? A - Refrain from any form of exercise. B - Continue to walk at his current level. C - Increase walking at a faster pace. D - Decrease walking frequency to three times each week.
B - Continue to walk at his current level. (Elderly clients may report fatigue with increased activity as a result of a slower heart rate recovery, which may be a physiological response to aging. An appropriate nursing intervention is to educate the client to exercise regularly but also to pace activities. The nurse does not want to tell the client not to exercise, to walk faster, or to decrease frequency.)
A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes? A - Increased acetylcholine level B - Decreased acetylcholine level C - Decreased norepinephrine level D - Increased norepinephrine level
B - Decreased acetylcholine level (A decreased acetylcholine level has been implicated as a cause of cognitive changes in healthy elderly clients and in the severity of dementia. Choline acetyltransferase, an enzyme necessary for acetylcholine synthesis, has been found to be deficient in clients with dementia. Norepinephrine is associated with aggression, sleep-wake patterns, and the regulation of physical responses to emotional stimuli, such as the increased heart and respiratory rates caused by panic.)
A nurse is teaching nursing assistants in an extended-care facility measures to protect the skin of elderly clients. Which of the following measures is the nurse likely to recommend? A - Assisting clients to soak in the bathtub several times each week B - Encouraging clients to avoid cigarette smoking C - Instructing clients to use perfumed skin creams D - Taking the clients outside for sun exposure daily
B - Encouraging clients to avoid cigarette smoking (Measures to promote healthy skin function in elderly clients include not smoking. Other measures include avoiding exposure to the sun, using emollient skin cream containing petrolatum or mineral oil, and avoiding hot soaks in the bathtub.)
A client has recently brought her elderly mother home to live with her family. The client states that her mother has moderate Alzheimer's disease and asks about appropriate activities for her mother. The nurse tells the client to A - Allow the mother to smoke cigarettes outside on the porch without supervision. B - Ensure that the mother does not have access to car keys or drive an automobile. C - Turn off lights at night so that the mother differentiates night and day. D - Encourage the mother to take responsibility for cooking and cleaning the house.
B - Ensure that the mother does not have access to car keys or drive an automobile. (A person with Alzheimer's disease needs to be provided with a safe environment. Driving is prohibited. Cooking and cleaning may be too much stimulation and place the client in danger. Daily activities must be simplified, short, and achievable. Smoking is allowed only with supervision. The person needs adequate lighting, and nightlights are helpful, particularly if the person has increased confusion at night.)
The plan of care for a patient with advanced Alzheimer's disease includes the nursing diagnosis of risk for injury. The nurse has identified this nursing diagnosis most likely as related to which of the following? A - Communication difficulties B - Impaired memory C - Personality changes D - Separation from others
B - Impaired memory (Patients with Alzheimer's disease are at high risk for injury because they have impaired memory and poor judgment. They also exhibit impulsivity, which increases their risk. Maintaining a safe environment takes top priority. Communication difficulties could be the basis for several nursing diagnoses such as impaired verbal communication, powerlessness, and impaired social interaction. Separation from others could lead to social isolation, impaired social interaction, and social isolation. Personality changes may lead to a risk for self- or other directed violence, chronic low self-esteem, and risk for suicide.)
A nurse is providing care to a patient with delirium. Which interventions would be most appropriate to implement? Select all that apply. A - Keeping the patient awake as much as possible B - Using familiar cues about the environment C - Supervising nutritional intake D - Providing a calm, quiet environment E - Administering psychoactive drugs
B - Using familiar cues about the environment C - Supervising nutritional intake D - Providing a calm, quiet environment (Appropriate interventions when caring for a patient with delirium include maintaining a calm, quiet environment, supervising and monitoring nutritional and fluid intake, and using familiar environmental cues. Psychoactive drugs should be minimized to reduce the possibility of delirium. Keeping the patient awake as much as possible would lead to sleep deprivation, which would increase the patient's risk for delirium.)
An age-related change associated with the cardiovascular system is A - increased compliance of heart muscle. B - decreased cardiac output. C - decreased blood pressure. D - thinner heart valves.
B - decreased cardiac output. (Age-related changes associated with the cardiovascular system include decreased cardiac output, increased blood pressure, decreased compliance of the heart muscle, and thickening of the heart valves.)
A family of a patient with Alzheimer's disease asks the nurse what causes this condition? Which response by the nurse would be most appropriate? A - "A specific gene is involved in the development of this disorder." B - "This condition is most likely due to a stroke that the patient didn't realize he had." C - "Evidence shows that there are changes in nerve cells and brain chemicals." D - "The numerous drugs that he was taking contributed to his current confusion."
C - "Evidence shows that there are changes in nerve cells and brain chemicals." (Specific neuropathologic and biochemical changes are found in patients with Alzheimer's disease. These include neurofibrillary tangles and neuritic plaques as well as altered neurotransmitter function, specifically acetylcholine. Vascular dementia is associated with a subclinical stroke. Although genetics is being studied as an underlying mechanism for Alzheimer's disease, no specific gene or genetic marker has been identified. Delirium is often the result of the interaction or use of multiple drugs.)
An older adult female client tells the nurse, "I have lost an inch [2.5 cm] of height and have a hump on my back. What can I do about this?" What is the best response by the nurse? A - "In order to prevent further bone loss, eat a diet high in magnesium and high in phosphorus." B - "You can reverse the shape of your spine with surgical intervention." C - "In order to prevent further bone loss, eat a diet high in calcium and low in phosphorus." D - "Supplement your diet with a multivitamin."
C - "In order to prevent further bone loss, eat a diet high in calcium and low in phosphorus." (To promote musculoskeletal health, the nurse should tell the client to do the following: exercise regularly; eat a high-calcium diet; limit phosphorus intake; and take calcium and vitamin D supplements as prescribed.)
An older adult develops sudden onset of confusion and is hospitalized. The family expresses concern that their loved one is developing Alzheimer disease. What response by the nurse is most appropriate? A - "Once the underlying cause of the confusion is found and treated, your loved one will be better than ever." B - "Alzheimer disease can be a great burden on the family. What community resources do you know about?" C - "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." D - "What concerns you most about Alzheimer disease?"
C - "Several possible underlying factors could be causing the confusion. Alzheimer's usually does not present with sudden confusion." (Delirium is associated with a sudden onset of confusion, not Alzheimer disease. The family needs to be told the correct information, which is that several underlying conditions could be causing the confusion. Once the underlying cause(s) is found and treated, the confusion should subside; however, some clients may not recover from the underlying cause, so telling the family the client will be better than ever is not appropriate. Asking the family about their concerns about Alzheimer disease and what they know about community support related to it is not appropriate because the client is exhibiting symptoms related to delirium.)
A client with Alzheimer's disease is prescribed donepezil hydrochloride. When teaching the client and family about this drug, which of the following would the nurse include? A - "The client need to take this drug for the rest of his or her life." B - "Once it becomes effective, you can stop the drug." C - "The drug helps to control the symptoms of the disease." D - "This drug will help to stop the disease from getting worse."
C - "The drug helps to control the symptoms of the disease." (Donepezil hydrochloride is a cholinesterase inhibitor used to control symptoms of Alzheimer's disease. It does not cure or slow progression. Typically cognitive ability improves within 6 to 12 months of therapy, but if stopped, cognitive progression occurs. It is recommended that treatment continue at least through the moderate stage of the illness. However, it usually is not prescribed as life-long therapy.)
A client reports to the nurse that her grandmother with Alzheimer's disease recently moved in with her and her two school-aged children. The client states the grandmother becomes agitated and starts yelling and crying frequently. The woman asks, "What can I do?" The nurse first responds: A - "Play quiet music that your grandmother may like." B - "Start rubbing her shoulders and her back." C - "What precipitates the outbursts?" D - "You need to remain calm during the outbursts."
C - "What precipitates the outbursts?" (A client with Alzheimer's disease may respond to exciting or confusing events with a catastrophic reaction, such as screaming, crying, or becoming abusive. The nurse needs to assess the situation and what precipitates the catastrophic reactions to best address how to prevent these events. Other nursing interventions include telling the client's granddaughter to remain calm and to distract the grandmother with quiet music, stroking, or both.)
Several staff members are taking a break in the unit's conference room when one of them states, "I dread getting old and having to retire. I don't want to just sit on the porch in my rocking chair." The statement reflects which of the following? A- Chronological aging B - Geriatrics C - Ageism D - Gerontology
C - Ageism (The staff member's statement reflects ageism, attitudes based on stereotypes that reinforce negative images of older people. Gerontology is the scientific study of the aging process. Geriatrics is the practice that focuses on the physiology, pathology, diagnosis, and management of disorders and diseases of older adults. Chronological aging refers to the passage of time as one gets older.)
Which action by the nurse demonstrates ageism? A - Allowing adequate time for the older adult to complete tasks B - Providing the same high quality of care to all clients C - Directing all health decisions to the older adult's child D - Encouraging the older adult to develop routines not associated with work
C - Directing all health decisions to the older adult's child (When the nurse directs all health care-related decisions to the older adult's child, the nurse is not respecting the individual choice of the older adult. The nurse is also assuming that the older adult cannot understand the decisions to be made, which is a myth about the elderly. The nurse should provide high-quality care to all clients, no matter what the age of the client. Allowing the client adequate time to complete tasks is appropriate and individualized. The older adult should be encouraged to develop routines not associated with work to decrease the potential for feeling nonproductive.)
A nurse is preparing to assess an older adult patient. Which approach would the nurse most likely use? A - Body region assessment B - Body system assessment C - Functional assessment D - Head-to-toe assessment
C - Functional assessment (Although various approaches may be used, a functional assessment is the most common framework or approach used to assess elderly patients because it addresses age-related changes as well as additional risk factors such as disease and effects of medications, which can have a negative impact on function.)
The reason that governments carefully regulate treatment given in licensed health care facilities, particularly long-term care facilities, is expressed by which statement? A - Clients lack different perspectives. B - Clients lack capacity because of cognitive impairment. C - Older adult clients are vulnerable. D - Clients are unable to make any health care decision.
C - Older adult clients are vulnerable. (Because of the vulnerability of older adults, governments have carefully regulated the treatment given in licensed health care facilities. Cognitive impairment does not automatically constitute incapacity. Older people with fluctuating cognitive status may retain sufficient ability to make some, if not all, their health care decisions. Individuals with different perspectives are required in ethics committees to resolve ethical dilemmas.)
Which assessment finding by the nurse and statement by an older adult would require the nurse to report suspected elder abuse? A - Diabetic with fasting blood sugar 92; "It is difficult to afford food with all of these medication costs." B - BMI 24; "My family never gives me my favorite foods." C - Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore." D - Obvious deformity to right arm; "I tripped on the rug and fell on my arm."
C - Stage II decubitus ulcer on coccyx; "No one is able to turn or lift me anymore." (Neglect is the most common form of elder abuse. The inability of an older adult to obtain basic care is considered neglect. If a client is not being turned or repositioned to prevent skin breakdown, then neglect is happening. A BMI of 24 is within the normal range, and the inability of the client to have his or her favorite foods would not be abuse. The client with diabetes has blood sugar within normal ranges, and the client is only expressing concern over the cost of medications; social services may need to be notified to provide help through community resources. The story provided by the older adult with the deformed arm is consistent with the injury.)
What is a nurse's role in providing home care for a client with Alzheimer disease? A - Contact the Motor Vehicle Department to have driver's license revoked. B - Provide assistance with administering IV fluids. C - Support client with household errands. D - Provide emotional and physical support.
D - Provide emotional and physical support. (Home health care nurses provide emotional support and intervene if family caregivers become overburdened. The nurse also instructs the family about physical care, the disease process, and treatment. Administering IV fluids or supporting clients with household errands is not a relevant role for a home nurse. The nurse should provide education about safety, saying that the client with Alzheimer disease should not drive, but contacting the licensing department is not the nurse's responsibility.)
