Chapter 14 Older Adults

The nurse is performing an admission assessment on an 80-year-old patient who has frequent hospital admissions. The patient appears more disoriented and confused than usual. Which action by the nurse is correct? a. Asking about medication doses b. Asking for a neurologist consult c. Requesting orders for liver function tests d. Suspecting impaired renal function

ANS: A An initial sign of drug toxicity in elderly patients may be confusion or changes in behavior. The nurse should ask about drug doses and notify the provider of the behaviors. The provider may order further evaluation based on examination of the patient.

An older pt. who reports a 2-3 yr history of upper gi symptoms will begin taking ranitidine (Zantac) to treat this disorder. The pt has completed a health history form. The nurse notes that the pt answered no when asked if any meds were being taken. Which action will the nurse take next? a. Ask whether the pt uses (OTC) medications b. Obtain a careful dietary hist for the past 2 weeks. c. Recommend that the pt take antacid tablets. d. Suggest that the pt add high-k foods to the diet.

ANS: A Many patients do not think of OTC products as medications and often do not list them when asked about medication use. A patient who takes ranitidine along with an OTC antacid could be duplicating medications. A dietary history is important as well but would not be the most important action in this case. The nurse should not recommend antacid tablets or highpotassium foods

An 80-year-old patient is being treated for an infection. An order for which type of antibiotic would cause concern for the nurse caring for this patient? a. Aminoglycoside b. Cephalosporin c. Penicillin d. Sulfonamide

ANS: A Penicillins, cephalosporins, tetracyclines, and sulfonamides are normally considered safe for the older adult. Aminoglycosides are excreted in the urine and are not usually prescribed for patients older than 75 years.

4. Which of the following statements by a new graduate nurse should be corrected by an experienced nurse? • "Most older patients are ill and disabled. That's why we care for so many of them in the hospital." • "Older adults are many times still interested in sexual relations." • "Patients over age 65 are still lifelong learners." • "Many older adult patients remain independent enough to live alone."

ANS: A Although many experience chronic conditions or have at least one disability that limits their performance of activities of daily living, in 2004, 37.4% of noninstitutionalized older adults assessed their health as excellent or very good. Older adults do report continued enjoyment of sexual relationships. Although changes in vision or hearing and reduced energy and endurance sometimes affect the process of learning, older adults are lifelong learners. Most older adults live in noninstitutional settings with family members or alone

9. Several theories on aging have been put forth, and the nurse should use these theories to: • Guide nursing care. • Explain the stochastic view of genetically programmed physiological changes. • Select one theory to guide nursing care for all geriatric patients. • Understand the nonstochastic views of aging as the result of cellular damage.

ANS: A Although theories on aging are in various stages of development and have limitations, the nurse should use them to increase understanding of the phenomena affecting the health and well-being of older adults and to guide nursing care. Stochastic theories view aging as the result of random cellular damage occurring over time. No one single universally accepted theory predicts and explains the complexities of the aging process. Nonstochastic theories view aging as the result of genetically programmed physiological mechanisms within the body.

13. During assessment of an older adult's skin integrity, expected findings include which of the following? • Decreased elasticity • Oily skin • Increased facial hair in men • Faster nail growth

ANS: A Loss of skin elasticity is a common finding in the older adult. Other common findings include pigmentation changes, glandular atrophy (oil, moisture, sweat glands), thinning hair (facial hair: decreased in men, increased in women), slower nail growth, and atrophy of epidermal arterioles

21. One of the greatest challenges for the nurse caring for older adults is ensuring safe medication use. One way to reduce the risks associated with medication usage is to: • Periodically review the patient's list of medications. • Inform the patient that polypharmacy is to be avoided at all cost. • Be aware that medication is absorbed the same way regardless of patient age. • Focus only on prescribed medications.

ANS: A Periodic and thorough review of all medications is important to restrict the number of medications used to the fewest necessary to ensure the greatest therapeutic benefit with the least amount of harm. Although polypharmacy reflects inappropriate prescribing, the concurrent use of multiple medications is necessary in situations where an older adult has multiple acute and chronic conditions. Older adults are at risk for adverse drug effects because of age-related changes in the absorption, distribution, metabolism, and excretion of drugs. Work collaboratively with the older adult to ensure safe and appropriate use of all medications —both prescribed medications and over-the-counter medications.

10. The nurse correctly describes psychosocial theories on aging as theories that: • Describe role changes in behaviors in older adults. • Emphasize that all adults age in similar ways. • Stress the need for the aging to discontinue activities as they age. • Describe behavior patterns for all aging adults as unpredictable.

ANS: A Psychosocial theories of aging explain changes in behaviors, roles, and relationships that come with aging. Although some theories generalize about aging, biologically and psychosocially each individual ages uniquely. The activity theory considers the continuation of activities performed during middle age as necessary for successful aging. The continuity theory states that personality remains the same and behavior becomes more predictable as people age

22. An older adult patient has developed acute confusion. The patient has been on tranquilizers for the past week. The patient's vital signs are normal. What should the nurse do? • Take into account age-related changes in body systems that affect pharmacokinetic activity. • Increase the dose of tranquilizer if the cause of the confusion is an infection. • Note when the confusion occurs and medicate before that time. • Restrict telephone usage to prevent further confusion.

ANS: A Sedatives and tranquilizers sometimes prescribed for acutely confused older adults sometimes cause or exacerbate confusion. Carefully administer drugs used to manage confused behaviors, taking into account age-related changes in body systems that affect pharmacokinetic activity. When confusion has a physiological cause (such as an infection), specifically treat that cause, rather than the confused behavior. When confusion varies by time of day or is related to environmental factors, nonpharmacological measures such as making the environment more meaningful, providing adequate light, etc., should be used. Making telephone calls to friends or family members allows older adults to hear reassuring voices, which may be beneficial

26. A recently widowed 80-year-old male is dehydrated and is admitted to the hospital for intravenous fluid replacement. During the evening shift, the patient becomes acutely confused. The nurse's best action is to assess the patient for which of the following reversible causes? (Select all that apply.) • Electrolyte imbalance • Hypoglycemia • Drug effects • Dementia • Cerebral anoxia

ANS: A, B, C, E Delirium, or acute confusional state, is a potentially reversible cognitive impairment that is often due to a physiological event. Physiological causes of delirium can include electrolyte imbalances, cerebral anoxia, hypoglycemia, medications, drug effects, tumors, subdural hematomas, and cerebrovascular infection, infarction, or hemorrhage. Unlike delirium, dementia is a gradual, progressive, irreversible cerebral dysfunction

The nurse is preping an 80 yr old pt for disch. home from the hosp . The pt will receive new meds. The pt lives alone but has several fam members who stop by qid. Which suggestions will the nurse make for this family? (sata.) a. Ask the pharmacy for non-childproof med bottles. b. Ask the pt to record all meds and the times they are taken. c. Place the pills in an organizer container. d. Provide the pt with the drug manufacturer info sheets. e. Put h20 bottles near pills for convenience.

ANS: A, C, E To help older patients with compliance, medications should be convenient and easy to open. Asking the pharmacist for non-childproof containers will help make medications easier to get. Using an organizer container helps patients remember which drugs should be taken at what time. Placing water bottles nearby eliminates a step in the process and increases the likelihood that a medication will be taken on time.

The nurse is caring for a 78-year-old ptwho lives independently. The patient will begin a new drug regimen that requires taking multiple drugs at various times per day. Which intervention is appropriate for the nurse to implement with this pt? a. Ask the patients family members to monitor the patients drug regimen. b. Develop a log to record the times each drug will be taken. c. Reinforce the need to take the drugs as scheduled. d. Write the med administration times on each rx label

ANS: B The patient should be advised to keep a medication record of drugs and when they will be taken. The patient is independent, and this helps maintain independence. Family member support is essential when older patients are confused. Reinforcing information without providing a means to keep track of the medications does not necessarily improve compliance. Writing medication times on prescription labels does not help to organize the medication schedule.

The nurse is caring for an 82-year-old patient who takes digoxin to treat chronic atrial fibrillation. When caring for this patient, to monitor for drug side effects, what will the nurse will carefully assess? a. Blood pressure b. Heart rate c. Oxygen saturation d. Respiratory rate

ANS: B Most of digoxin is eliminated by the kidneys, so a decline in kidney function can cause digoxin accumulation, which can cause bradycardia. Digoxin should not be given to any patient with a pulse less than 60 beats per minute.

The nurse is caring for an 80-year-old patient who is taking warfarin (Coumadin). Which action does the nurse understand is important when caring for this patient? a. Encouraging the patient to rise slowly from a sitting position b. Initiating a fall-risk protocol c. Maintaining strict intake and output measures d. Monitoring blood pressure frequently

ANS: B Patients who take anticoagulants have an increased risk of hemorrhage. Older patients have an increased risk of falls that can lead to bleeding complications. Initiating a fall-risk protocol is important. Warfarin does not affect blood pressure and would not cause orthostatic hypotension. Warfarin does not alter urine output.

To assist an older, confused patient to adhere to a multidrug regimen, the nurse will provide which recommendation? a. Avoid the use of over-the-counter medications. b. Bring all medications to each clinic visit. c. Review the manufacturers information insert about each medication. d. Save money by getting each drug at the pharmacy with the lowest price

ANS: B Patients who take multiple medications should be advised to bring medications to each clinic visit. Patients may take OTC medications as long as those are included in the list of medications reviewed by the provider. Manufacturers inserts provide an overwhe

A 75-year-old patient is readmitted to the hospital to treat recurrent pneumonia. The patient had been discharged home with a prescription for antibiotics 5 days prior. The nurse admitting this patient will take which initial action? a. Ask the patient about over-the-counter drug use. b. Ask the patient how many doses of the antibiotic have been taken. c. Discuss increasing the antibiotic dose with the provider. d. Obtain an order for a creatinine clearance test.

ANS: B There are many reasons for non-adherence to a drug regimen in an older patient, so if a patient is readmitted, the nurse should first ascertain whether or not the medications have been used. Asking the patient how many doses have been taken will help to assess this. If it i

1. As the aging population in the United States increases, the nurse knows that the: • Baby boomer generation accounts for a very small percentage of this group. • Extension of the average life span has also increased. • Population segment over age 85 is decreasing. • Diversity of this age group will certainly decrease.

ANS: B According to estimates, the number of older adults will increase to 72.1 million by 2030. Part of that increase is due to extension of the average life span. Two other factors that contribute to the projected increase in the number of older adults are the aging of the baby boom generation and the growth of the population segment over age 85. The baby boomers are the large group of adults born between 1946 and 1964.The diversity of the group over age 65 will also possibly increase

23. Which of these assessments of an older adult, who has a urinary tract infection, requires an immediate nursing intervention? • Presbycusis • Confusion • Death of a spouse 3 months ago • Temperature of 97.6° F

ANS: B Confusion is a common manifestation in older adults with urinary tract infection; however, the cause requires further assessment. There may be another reason for the confusion. Confusion is not a normal finding in the older adult, even though it is commonly seen with concurrent infections. Difficulty hearing, presbycusis, is an expected finding in an older adult. Coping with the death of a spouse is a psychosocial concern to be addressed after the acute physiological concern in this case. Older adults tent to have lower temperatures, so the nurse needs to assess for slight elevations. A temperature of 97.6° F is within normal limits

2. As a patient ages, the nursing plan of care: • Should be standardized because all geriatric patients have the same needs. • Needs to be individualized to the patient's unique needs. • Should be based on chronological age alone. • Focuses on the disabilities that all aging persons face.

ANS: B Every older adult is unique, and the nurse needs to approach each one as a unique individual. The nursing care of older adults poses special challenges because of great variation in their physiological, cognitive, and psychosocial health. Nurses need to take into account the cultural, ethnic, and racial diversity represented by these numbers (not just age) as they care for older adults from these groups. Aging does not inevitably lead to disability and dependence

12. An 80-year-old male is brought to the emergency department with an exacerbation of chronic obstructive pulmonary disease (COPD). He states that he quit smoking 30 years ago, so it can't be COPD. He argues, "It's just these colds I've been getting. They're just getting worse and worse." The nurse understands that: • These symptoms are more associated with normal aging than with disease. • Older adults do not have to alter physical activity because of physical changes. • The patien

ANS: B Older adults face the necessity of adjustment to the physical changes that accompany aging. As body systems age, changes in appearance and functioning occur. These changes are not associated with a disease but are normal changes. The presence of disease sometimes alters the timing of the changes or their impact on daily life. Acceptance of personal aging does not mean retreat into inactivity, but it does require a realistic review of strengths and limitations. Some older adults find it difficult to accept that they are aging.

20. An outcome for an older adult patient living alone is to be free from falls. Which of these statements by a patient indicates that teaching on safety concerns has been effective? • "I'll leave my throw rugs in place so that my feet won't touch the cold tile." • "I'll take my time getting up from the bed or chair." • "I should wear my favorite smooth bottom socks to protect my feet when walking around." • "I will have my son dim the lighting outside to decrease the glare in my ey

ANS: B Older adults taking medications with adverse effects such as postural hypotension, dizziness, or sedation need to be aware of these potential effects and to take precautions such as changing position slowly or ambulating with assistance if unsteady. Household items that are easy to trip over, such as throw rugs, are a risk factor for falls. Other risk factors include wearing shoes in poor repair or slippery soles. Impaired vision and poor lighting are other risk factors.

19. A patient asks the nurse what the term polypharmacy means. The nurse defines this term as: • Multiple side effects experienced when taking a medication. • The concurrent use of many medications. • The many adverse drug effects reported to the pharmacy. • The risks of medication effects due to aging.

ANS: B Polypharmacy refers to the concurrent use of many medications. It does not have anything to do with side effects, adverse drug effects, or risks of medication use due to aging

15. Which symptom is an expected cognitive change in the older adult patient? • Disorientation • Slower reaction time • Poor judgment • Loss of language skills

ANS: B Slower reaction time is a common change in the older adult owing to degeneration of nerve cells, decreased neurotransmitters, and decreased rate of conduction of impulses. Symptoms of cognitive impairment, such as disorientation, loss of language skills, loss of the ability to calculate, and poor judgment are not normal aging changes and require further investigation of underlying causes.

18. A male older adult patient expresses his concern and anxiety about decreased penile firmness during erection. What is the nurse's best response? • Explain that over time, his libido will decrease, as will the frequency of sexual activity. • Tell the patient to double his antidepressant medication to increase his libido. • Tell the patient that this change is expected in aging adults. • Tell the patient that touching should be avoided unless intercourse is planned.

ANS: C Decreased firmness during erection is an expected change in aging adults. Libido does not necessarily decrease as one ages. Many older adults use prescription medications that depress sexual activity such as antihypertensives, antidepressants, sedatives, or hypnotics. Touch complements traditional sexual methods or serves as an alternative sexual expression when physical intercourse is not desired or possible

16. A patient with gradual, progressive cognitive impairment (dementia) is admitted to the nursing unit after hip replacement surgery. Which of the following is a nursing care principle for care of cognitively impaired older adults? • Maintain physical health. • Evaluate the patient's manifestations of standard symptoms. • Assist patient with all ADLs. • Isolate patients to protect others.

Ans A: The nurse works to monitor and maintain physical health. The nurse should also assess the person's unique manifestations of the disease as it progresses while facilitating independent performance of activities of daily living (ADLs). Social interaction based on the patient's abilities is to be promoted

8. A 70-year-old patient who suffers from worsening dementia is no longer able to live alone. When discussing health care services and possible long-term living arrangements with the patient's only son, what should the nurse suggest? • An apartment setting with neighbors close by • Having the patient utilize weekly home health visits • A nursing center because home care is no longer safe • That placement is irrelevant because the patient is retreating to a place of inactivity

ANS: C Some family caregivers consider nursing center placement when in-home care becomes increasingly difficult, or when convalescence from hospitalization requires more assistance than the family is able to provide. An apartment setting and the use of home health visits are not appropriate because some older adults deny functional decline and refuse to ask for assistance with tasks that place their safety at great risk. Others avoid activities designed to benefit older adults such as senior health promotion activities (such as some health visits), and thus do not receive the benefits that these programs offer. Acceptance of personal aging does not mean a retreat into inactivity, but it does require a realistic review of strengths and limitations.

11. When comparing developmental tasks of middle-aged persons versus older adults, what should the nurse infer? • Learning to cope with loss is most common during the middle adult years. • After age 65, most older adults age both biologically and psychologically the same way. • All older adults will need nursing assistance to deal with loss. • Older adults fear and resent retirement as a disruption of their lifestyle.

ANS: C Some older adults deny their own aging in ways that are potentially problematic. For example, some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The need to cope with loss is much greater in the older adult population. Most older adults cope with the death of a spouse. Some must cope with the death of adult children and grandchildren. All experience the death of friends. The ways that older adults adjust to the changes of aging are highly individualized. Many older adults welcome retirement as a time to pursue new interests and hobbies, participate in volunteer activities, continue their education, or start a new business career.

5. Which teaching strategy is best to utilize with older adult patients? • Provide several topics of discussion at once to promote independence and making choices. • Avoid uncomfortable silences after questions by helping patients complete their statements. • Ask patients to recall past experiences that correspond with their interests. • Speak in a high pitch to help patients hear better.

ANS: C Teaching strategies include the use of past experiences to connect new learning with previous knowledge, focusing on a single topic to help the patient concentrate, giving the patient enough time in which to respond because older adults' reaction times are longer than those of younger persons, and keeping the tone of voice low; older adults are able to hear low sounds better than high-frequency sounds.

An older patient takes ibuprofen for arthritis pain. The patient tells the nurse that the ibuprofen causes gastrointestinal (GI) upset. Which action will the nurse take with this patient? a. Ask the provider about having the patient take a different medication. b. Instruct the patient to cut the ibuprofen dose in half to avoid GI upset. c. Explain that all drugs have adverse effects. d. Explore options to help decrease the drug side effects.

ANS: D Older adults are more likely to experience drug side effects, and nurses should be aware of measures that may decrease these side effects and thus improve adherence.

A 75-year-old patient will be discharged home with a prescription for an opioid analgesic. To help the patient minimize adverse effects, what will the nurse recommend for this patient? a. Sucking on lozenges to moisten oral mucosa b. Taking an antacid with each dose c. Taking the medication on an empty stomach d. Using a stool softener

ANS: D Opioid analgesics can cause constipation. Stool softeners can help minimize this effect. Opioids do not cause dry mouth. Drug absorption may be decreased with an antacid. Opioid analgesics should be taken with food or milk to decrease gastrointestinal irritation.

7. What is the best suggestion a nurse could make to a family requesting help in selecting a local nursing center? • Suggest choosing a nursing center that is as sanitary as possible. The closer the center is to hospital standards, the better. • Have family members evaluate nursing home staff according to their ability to get tasks done efficiently. • Make sure that nursing home staff members get patients out of bed every day for the entire day. • Explain that it is probably best f

ANS: D An important step in the process of selecting a nursing home is to visit the nursing home. The nursing home should not feel like a hospital. It is a home, a place where people live. Members of the nursing home staff should focus on the person, not the task. Residents should be out of bed and dressed according to their preferences, not staff preferences

14. An older adult patient in no acute distress reports being less able to taste and smell. What is the nurse's best response to this information? • Notify the physician immediately to rule out cranial nerve damage. • Perform testing on the vestibulocochlear nerve and a hearing test. • Schedule the patient for an appointment at a smell and taste disorders clinic. • Explain to the patient that diminished senses are normal findings.

ANS: D Diminished taste and smell senses are common findings in older adults. Scheduling an appointment at a smell and taste disorders clinic, testing the vestibulocochlear nerve, or an attempt to rule out cranial nerve damage is unnecessary at this time per the information provided.

24. Which of these patient statements is the most reliable indicator that an older adult has the correct understanding of health promotion activities? • "I need to increase my fat intake and limit protein." • "I should discontinue my fitness club membership for safety reasons." • "I'm up to date on my immunizations, but at my age, I don't need the tetanus vaccine." • "I still keep my dentist appointments even though I have partials now."

ANS: D General preventive measures for the nurse to recommend to older adults include keeping periodic dental appointments to promote good oral hygiene, eating a low-fat, well-balanced diet, exercising regularly, and maintaining immunizations for influenza, pneumococcal pneumonia, and tetanus

6. An older patient has fallen and broken his hip. As a consequence, the patient's family is concerned about his ability to care for himself, especially during his convalescence. What should the nurse do? • Stress that older patients usually ask for help when needed. • Inform the family that placement in a nursing center is a permanent solution. • Tell the family to enroll the patient in a ceramics class to maintain his quality of life. • Provide information and answer questions as

ANS: D Nurses assist older adults and their families by providing information and answering questions as they make choices among care options. Some older adults deny functional declines and refuse to ask for assistance with tasks that place their safety at great risk. The decision to enter a nursing center is never final, and a nursing center resident sometimes is discharged to home or to another less-acute residence. What defines quality of life varies from person to person. Nurses must listen to what the older adult considers to be most important rather than making assumptions about the individual's priorities.

17. To promote physical well-being and socialization in an older adult, what should the nurse realize? • Social isolationism is always a chosen behavior. • Body image plays no role in decision making by the older adult. • No community resources are focused on the older adult. • Older adults may have a functional purpose in social arenas.

ANS: D Social service agencies in most communities welcome older adults as volunteers and provide the opportunity for older adults to serve while meeting their socialization or other needs. Although some older adults choose isolation or a lifelong pattern of reduced interaction with others, other older adults do not choose isolation but are vulnerable to its consequences. Some older adults withdraw from social interaction because of feelings of rejection. These older adults see themselves as unattractive and rejected because of changes in their personal appearance due to normal aging changes or because of body image changes. Many communities have outreach programs designed to make contact with isolated older adults

25. A 72-year-old woman was recently widowed. She worked as a teller at a bank for 40 years and has been retired for the past 5 years. She never learned how to drive. She lives in a rural area that does not have public transportation. Which of the following psychosocial changes does the nurse focus on as a priority? • Sexuality • Housing and environment • Retirement • Social isolation

ANS: D The highest priority at this time is the potential for social isolation. This woman does not know how to drive and lives in a rural community that does not have public transportation. All of these factors contribute to her social isolation. Other possible changes she may be going through right now include sexuality related to her advanced age and recent death of her spouse; however, this is not the priority at this time. She has been retired for 5 years, so this is also not an immediate need. She may eventually experience needs related to housing and environment, but the data do not support this as an issue at this time.

3. Which of these findings, if identified in a patient on a gerontological unit, would be most surprising to a culturally sensitive nurse? • The older person not being functionally independent • Preferences in food, music, and religion • Use of conventions of the handshake, silence, and eye contact • Personal health practices and spiritual resources

Ans: A Most older people remain functionally independent despite the increasing prevalence of chronic disease. Examples of culturally competent nursing approaches to older adults include respect for preferences in food, music, and religion; appropriate use of conventions of the handshake, silence, and eye contact; use of interpreters; use of physical assessment norms appropriate for the ethnic group; and asking about personal health practices, family customs, lifestyle preferences, and spiritual resources

The nurse is caring for an older adult patient who is receiving multiple medications. When monitoring this patient for potential drug toxicity, the nurse should review which lab values closely? a. Complete blood count and serum glucose levels b. Pancreatic enzymes and urinalysis c. Serum creatinine and liver function tests (LFTs) d. Serum lipids and electrolytes

Answer: c Rationale: With liver and kidney dysfunction, the efficacy of drugs is generally increased and may cause toxicity. The nurse should review serum creatinine levels to monitor renal function and LFTs to monitor hepatic function. The other lab tests may be ordered for specific drugs if they affect those body systems

Which drug properties are problematic for older patients? (Select all that apply.) a. Drugs with anticholinergic effects b. Drugs that are highly protein-bound c. Drugs with a short half-life d. Drugs that undergo hepatic conjugation e. Drugs with a narrow therapeutic range

Older patients are more susceptible to drug side effects, especially those that cause anticholinergic effects. Older patients have a loss of protein-binder sites for drugs, so those that are highly proteinbound will have higher than usual serum levels and can cause toxicity. Drugs with a narrow therapeutic range require closer monitoring in all patients, but especially in older patients. Drugs with a short half-life are preferred because older patients have a decreased ability to metabolize and excrete drugs. Hepatic conjugation is usually not influenced by older age, liver diseases, or drug interaction.

The nurse is caring for an older patient who is taking 25 mg per day of hydrochlorothiazide. The nurse will closely monitor which lab value in this patient? a. Coagulation studies b. White blood count c. Liver function tests d. Serum potassium

Older patients who take doses of hydrochlorothiazide between 25 to 50 mg/day have increased risk of electrolyte imbalances, so potassium should be monitored closely.