Prep-U Chapter 11

A client with moderate Alzheimer's disease has been eating poorly, losing weight, and playing with food at meals. The nurse best intervenes by

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.

When assessing an older adult, the nurse anticipates an increase in which component of respiratory status?

Residual lung volume.With an increase in residual lung volume the client experiences fatigue and breathlessness with sustained activity. The nurse anticipates decreased vital capacity. The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

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

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.

After teaching an older adult about measures to relieve constipation, which statement by the client indicates a need for additional teaching?

I should use a laxative every other day."Factors that may cause constipation include prolonged use of laxatives. the patient should avoid the regular use of laxatives.patient should ensure adequate fluid intake, engage in regular exercise, avoid foods high in fat.

The nurse is preparing an elderly hospitalized client for discharge to home within the hour. What should be the priority for the nurse?

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 assessing an older adult for depression using the Geriatric Depression Scale. Which question would the nurse ask first?

Are you basically satisfied with your life?"nurse would first question the patient about being satisfied with life. Then the nurse would continue the assessment, asking if the patient feels his or her life is empty, if the patient often gets bored, and if the patient is in good spirits most of the time.

An age-related change associated with the cardiovascular system is

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.

When assessing an older adult's gastrointestinal system, the nurse would identify an increase in which of the following as normal

Feeling of fullness In an older adult, gastric motility slows modestly, which results in delayed stomach emptying, which in turn leads to early satiety (feeling of fullness). Calcium absorption decreased

The nurse brings the older adult patient a dinner tray and observes the patient placing excess amounts of salt on the food. What suggestions for flavoring can the nurse provide to decrease the amount of salt the patient is placing on her food? (Select all that apply.)

Use low-sodium herbs and spices. Use pepper instead of salt. Use lemon instead of salt to flavor food.To add flavor to food without adding salt, the nurse should encourage the use of lemon, spices, and herbs. Drinking water or using an alcohol-based mouthwash prior to eating would not improve the taste of the food.

The reason that federal and state governments carefully regulate the treatment given in licensed health care facilities, particularly long-term care facilities, is expressed by which statement?

Vulnerability of older adult patients.Because of the vulnerability of older adults, federal and state 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.

A nurse is assessing an elderly client with senile dementia. Which neurotransmitter condition is most likely to contribute to this client's cognitive changes?

Decreased acetylcholine

Nursing students are reviewing different types of mental health problems in the older adult population. The students demonstrate an understanding of this information when they identify which condition as the most common affective disorder?

Depression.Depression is the most common affective or mood disorder of old age. Although anxiety may be common, anxiety disorders including phobias are not as common as depression. Schizophrenia is a thought disorder and is less common than depression.

Which action by the nurse demonstrates ageism?

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 client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate?

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

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?

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.

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?

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.

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

Post a sign stating "You are in the hospital" at the client's eye level.*Pt 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.

The nurse is attempting to take vital signs of an older adult hospitalized following knee surgery. The client continuously yells, "It's 1999 and you are going to hurt me!" What action should the nurse do first?

Reorient the patient.The client is likely experiencing delirium after surgery. The first action that should be taken by the nurse is to reorient the patient. Hospitalized older adults are at risk for disorientation and confusion. Although the nurse will still need to take the vital signs and assess for infection, reorienting the client remains the first action. If the client can be reoriented, then the nurse may be able to complete the other actions without difficulty or potentially harming the client. The nurse may need to notify the physician if the client is unable to be oriented or if the assessment is abnormal.

Which neurotransmitter is implicated in depression

serotonin. Serotonin is implicated in the development of depression. Atropine, acetylcholine, and epinephrine are not implicated in the development of depression

To encourage adequate nutritional intake for a client with Alzheimer's disease, a nurse should:

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 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:

"What precipitates the outbursts?" *Pt w 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.

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?

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.

An elderly client reports that he feels like he voids frequently during the day and at night but cannot empty his bladder. The nurse instructs the client to

Limit ingestion of caffeinated beverages.*Symptoms that the client describes may be indicative of benign prostatic hypertrophy. should limit caffeinated beverages. He does not want to decrease fluid intake; doing so may increase his susceptibility to urinary tract infections. needs to void frequently and not wait long periods between voiding. should limit his alcohol intake