Geriatric Nursing Exam #3

A nurse caring for a client who has begun menopause selects the nursing diagnosis of deficient knowledge when the client makes which statement? A) "I must be coming down with the flu because I am having hot flashes." B) "I need to begin weight-bearing exercises such as walking." C) "I need to obtain yearly mammograms." D) "I should increase my daily calcium intake to 1200 mg."

A) "I must be coming down with the flu because I am having hot flashes."

The charge nurse is concerned that nursing-assistive personnel (NAP) in a skilled facility are prone to ne-glecting the needs of the residents. What statement did the nurse hear one of the NAP make to come to this conclusion? A) "Maybe I'll bring you some water, if you behave." B) "I'll be back in a few minutes to take you to the din-ing room." C) "Your daughter will be here at 10 am. How about a shower now to get ready?" D) "Everyone's in the rec room watching the movie! Don't you want to see i

A) "Maybe I'll bring you some water, if you behave." Rationale: Threatening to withhold water un-less the person "behaves" can be a precursor to neglect. The NAP should be counseled because of this statement. Returning in a few minutes, helping a person get ready for family, and asking about watching a movie are not indica-tions that the residents are experiencing neglect.

The nurse reviews with an older adult the reasons they may experience dry skin during the winter months. Which statement indicates that this person understands ways to prevent this skin change from occurring? A) "Mild soap and warm water is better for me to use." B) "I should continue to take showers with hot water." C) " I will continue to drink about 4 10-ounce glasses of fluid each day." D) "A heavy towel that is dragged over my skin is the best way to dry it."

A) "Mild soap and warm water is better for me to use." Rationale: Xerosis or dry skin occurs more frequently as a person ages. Ways to prevent this skin change include overuse of harsh soaps and personal care products, frequent bathing with hot water, dehydration, and vigorous towel drying. Using mild soap indicates the person understands how to prevent this skin change from occurring.

What are the age-related risk factors for macular degeneration? A) >60 B) Vegan C) Cigarette smoker D) Normotensive E) HTN F) A diet high in antioxidants

A) >60 C) Cigarette smoker E) HTN

The nurse discusses factors that alter the sexual practice of older adults, which are __________. (Select all that apply.) A) Altered health status B) Inability to achieve orgasm C) Erectile dysfunction D) Loss of sexual partner E) Slowed sexual response time

A) Altered health status C) Erectile dysfunction D) Loss of sexual partner E) Slowed sexual response time

The nurse is concerned that an older person may fall when using the stairs at home. What should the nurse recommend to improve safety? A) Apply red tape on the edge of the steps B) Suggest carpeting with a geometric design C) Paint the entryway to the stairs a shade of blue D) Ensure lighting in the stairway has an appropriate shade

A) Apply red tape on the edge of the steps Rationale: The use red-colored tape or paint on the edges of stairs and in entryways provides warning and signals the need to step up or down. Carpeting with a complicated design should be avoided. Shades of blue are more difficult for aging eyes to discern. Lighting in the stairway should not be shaded. Lampshades are used to prevent glare.

The nurse is evaluating a patient who is in soft wrist restraints. Which of the following activities does the nurse perform? (Select all that apply.) A) Check the patient's peripheral pulse in the restrained extremity B) Evaluate the patient's need for toileting C) Offer the patient fluids if appropriate D) Release both limbs at the same time to perform range of motion (ROM) E) Inspect the skin under each restraint

A) Check the patient's peripheral pulse in the restrained extremity B) Evaluate the patient's need for toileting C) Offer the patient fluids if appropriate E) Inspect the skin under each restraint

The nurse is performing an assessment on an older adult client. Which assessment data would indicate a potential complication associated with the skin? A) Crusting B) Wrinkling C) Deepening of expression lines D) Thinning and loss of elasticity in the skin

A) Crusting

Normal changes of aging in the skin?

A) Dermis and epidermis are both thin, with loss of elasticity (cause of wrinkles) B) Dermis has decreased sensation C) Loss of subcutaneous fat (more at risk for bruising) D) Thinner hair E) Dull/thick nails F) Decreases sweat glands G) Difficulty regulating temperature

During a home visit the nurse notes that an older per-son, who lives alone, is being visited by an adult son who is asking their parent for money. After the son leaves, what should the nurse do to ensure for this per-son's safety? A) Devise a safety plan with the person B) Provide a list of caregiver-support groups C) Discuss identifying a guardian with an attorney D) Recommend that the person be admitted to a care facility immediately

A) Devise a safety plan with the person Rationale: For older adults who possess capacity to make their own decisions and remain in their home-living environment, an individualized safety plan should be devel-oped in which emergency phone numbers, location of a safe place to go (if needed), a list of essential items to be taken if a quick exit is required, and consideration of transportation needs are detailed. This person is an elder at risk and care-ful monitoring and follow up is required. Caregiver-support groups would be appropriate if the adult son is living with the person. Guardianship and hospital respite care would be appropriate if the adult person is being abused and needs to be removed from the home for safety.

The nurse identifies the person most likely to experience erectile dysfunction as the 65-year-old who has A) Diabetes B) Irritable bowel syndrome C) Chronic pancreatitis D) Osteoarthritis

A) Diabetes

The RN, at the change-of-shift report, learns that one of the clients in his care has bilateral soft wrist restraints. The client is confused, is trying to get out of bed, and had pulled out the IV line, which was subsequently reinserted. Which action(s) by the RN is appropriate? SATA. A) Document the behavior(s) that require continued use of the restraints B) Ensure that the restraints are tied to the side rails C) Provide range-of-motion exercises when the restraints are removed D) Orient the

A) Document the behavior(s) that require continued use of the restraints. C) Provide range-of-motion exercises when the restraints are removed. D) Orient the client. E) Assess the tightness of the restraints.

Signs of physical abuse?

A) Dry lips B) Visible poor hygiene C) Wearing dirty clothes D) Not attending appointments E) Weight loss F) Pressure injuries G) Dermatitis from being incontinent

An older person is concerned about bleeding from the ear when using a cotton swab to remove cerumen. What should the nurse explain to the person about this symptom? A) Dryness of the ear canal B) Loss of sensory hair cells C) Atrophy of the organ Corti D) Increased production of cerumen

A) Dryness of the ear canal Rationale: Dryness of the canal can also cause pruritus, and the epithelial lining of the ear canal may be easily irritated and injured if anything is inserted into the ear, increasing the risk of secondary infection. Loss of sensory hair cells and atrophy of the organ of Corti are inner ear changes that affect hearing. There is no change in the amount of cerumen produced with aging.

An older person seeks medical attention for irritation of the lower eyelid. Which age-related change in the eye should the nurse attribute to this person's symptom? A) Ectropion B) Arcus senilis C) Decrease eyelid muscles D) Thin skin around the eye

A) Ectropion Rationale: With an ectropion, the bottom lid sags outward and is no longer in contact with the eye. This can cause chronic eye irritation and bacterial conjunctivitis. Arcus senilis describes corneal calcium deposits that only cause cosmetic effects. Decreased eyelid musculature causes dropping eyelids. Thinning of the skin around the eye has cosmetic implications only.

An older adult seeks medical attention for irritation of the lower eyelid. Which age related change in the eye should the nurse attribute this client's symptom? A) Ectropion B) Arcus senilus C) Decrease eyelid muscles D) Thin skin around the eye

A) Ectropion With Ectropion, the bottom lid sags and is no longer in contact with the eye. This can cause chronic eye irritation.

What are the benefits of sexuality in older adults? Select all that apply A) Improves their mood B) Nothing C) Function status improves D) Increases quality of life

A) Improves their mood C) Function status improves D) Increases quality of life

Which nursing intervention can help a client maintain healthy skin? A) Keep the client well hydrated. B) Avoid bathing the client with mild soap. C) Remove adhesive tape quickly from the skin. D) Recommend wearing tight-fitting clothes in hot weather.

A) Keep the client well hydrated.

The nurse prepares teaching material for an older person experiencing stress incontinence. Which assessment finding did the nurse use to select this topic for education? A) Leaks urine when sneezing B) Experiences difficulty voiding C) Feels the urge to void every hour D) Wakes up several times during the night to void

A) Leaks urine when sneezing Rationale: A characteristic of stress incontinence is leaking a small amount of urine when intraabdominal pressure is increased, such as when sneezing. Difficulty voiding can be a symptom of renal failure or benign pros-tatic hypertrophy. Feeling the urge to void every hour may indicate frequency associated with a urinary-tract infec-tion. Waking up several times during the night to void may be an age-related change in renal functioning.

The daughter of an older patient is researching viable skilled facilities to have the patient admitted. Institutional abuse information on facilities is difficult to find. What are some of the reasons for this? Select all that apply. A) Managers fear adverse publicity B) Family members fear needing to find a new agency for the patient C) Billing department members fear not getting paid for services D) Staff members fear losing their jobs E) Residents fear retribution

A) Managers fear adverse publicity B) Family members fear needing to find a new agency for the patient D) Staff members fear losing their jobs E) Residents fear retribution

RN notes several older persons with family caregivers are waiting to see the HC provider for a scheduled appointment. For which person will the RN make completing the Elder Assessment Instrument a priority? A) Person sitting with head down, hair uncombed, shoes untied B) Person talking with family caregiver about a magazine article C) Person watching the television while the family caregiver makes a telephone call D) Person asking the family caregiver if they can go to the store after the appoin

A) Person sitting with head down, hair uncombed, shoes untied Rationale: An older adult appearing disheveled with poor hygiene should be evaluated for potential neglect if there is a responsible caregiver who may be having trouble meeting the caregiving needs of the older person. Talking, asking questions, & watching television are not indications that the older person might be experiencing neglect

An older adult has visibly darker and more weathered skin over the face, arms, and lower legs. What should the nurse suspect as the reason for this skin change pattern? A) Photoaging B) Dehydration C) Low-fat diet D) Vitamin deficiency

A) Photoaging Rationale: The older adult who has spent a lot of time outdoors, either for work or leisure, may have long-term UVR damage known as photoaging, the damage that is done to the skin from lifelong exposure to UV radiation. These changes occur on exposed areas such as the face, neck, arms, and hands and include freckling, loss of elasticity, damaged blood vessels, and a general coarse and weathered appearance. This skin change is not caused by dehydration, a low-fat diet, or a vitamin deficiency.

The nurse has been caring for a patient over the past several years in an outpatient clinic. The nurse notices the patient has been much more withdrawn at visits and reports her children refuse to take her to church any more, an activity the patient has done for years and enjoys. The patient's daughter is also very demeaning to the patient at the visit. The nurse knows these can be signs of: A) Psychological or emotional abuse B) Neglect C) Physical abuse D) Financial abuse

A) Psychological or emotional abuse

An older patient's plan of care includes frequent position changes, application of skin lotion, and assistance with ambulation three times a day. Which goal was used when selecting these interventions? A) Skin integrity will remain intact B) Demonstrate safety with ambulation C) Explain the importance of activity and exercise D) Pressure injury will demonstrate signs of healing

A) Skin integrity will remain intact Rationale: Nursing care of the older person should focus on the prevention of pressure injuries since research has shown that most pressure injuries can be prevented. Actions to prevent this injury includes frequent position changes, use of protective skin products, and increased activity. These interventions do not focus on safety or activity and exercise. Since these interventions do not address wound care, it is unlikely that this person has a pressure injury.

In which situations is institutional mistreatment of older adults most likely to occur? Select all that apply. A) Staff burnout B) Staffing shortage C) Adequate staff training D) Patient aggressiveness E) Family members frequently visit

A) Staff burnout B) Staffing shortage D) Patient aggressiveness

The nurse is caring for an older patient who is 1 day post op from a total hip replacement.Which actions by the nurse prevent the development of pressure ulcers? SATA A) Strict 2 hour turning protocol is followed B) The nurse checks the surgical site frequently to ensure it is clean, dry, and intact C) The nurse wets a gauze and places it over wound to promote healing D) Pt is placed directly onto coccyx to avoid pressure on the affected hip E) Nurse instills help of nursing aid to change sheets

A) Strict 2 hour turning protocol is followed B) The nurse checks the surgical site frequently to ensure it is clean, dry, and intact E) Nurse instills help of nursing aid to change sheets Correct answers: A, B, E. Q2hr turning is crucial to prevent skin breakdown. Surgical sites should be kept clean, dry, and intact and avoid excessive moisture on skin to avoid skin breakdown. Pt should be offloaded off coccyx when in bed to avoid breakdown. If pt gets OOBinto a chair, the nurse should follow a q1hr turning schedule.

The nurse is caring for an older patient who is 1 day post op from a total hip replacement. Which actions by the nurse prevent the development of pressure ulcers? SATA A) Strict 2 hour turning protocol is followed B) The nurse checks the surgical site frequently to ensure it is clean, dry, and intact C) The nurse wets a gauze and places it over wound to promote healing D) Pt is placed directly onto coccyx to avoid pressure on the affected hip E) Nurse instills help of nursing aid to change sheets that have become soiled underneath pt F) Nurse allows pt to get up out of bed into a chair and allows them to relax there for a few hours

A) Strict 2 hour turning protocol is followed B) The nurse checks the surgical site frequently to ensure it is clean, dry, and intact E) Nurse instills help of nursing aid to change sheets that have become soiled underneath pt Q2hr turning is crucial to prevent skin breakdown. Surgical sites should be kept clean, dry, and intact and avoid excessive moisture on skin to avoid skin breakdown. Pt should be offloaded off coccyx when in bed to avoid breakdown. If pt gets OOB into a chair, the nurse should follow a q1hr turning schedule

The nurse suspects that an older person is at risk for elder mistreatment. Which finding supports the nurse's conclusion? A) The person is female B) Retired schoolteacher C) Volunteers at the library D) Lives with adult children

A) The person is female Rationale: Risk factors that increase the possibility of elder mistreatment include being of the female gender. Employment, volunteer status, or living arrangements do not increase the risk of elder mistreatment.

The nurse notes that an older adult has a large area of skin atrophy on the left forearm. What should the nurse consider as the reason for this skin change A) Topical steroids B) Topical antibiotics C) Systemic antibiotics D) Silver nitrate dressings

A) Topical steroids Rationale: Often corticosteroids are prescribed as topical treatment for dermatological problems in older people. These creams should be applied sparingly in thin layers to maximize therapeutic outcome and minimize the risk of side effects. Hydrocortisone 1% or 2.5% is a low-potency topical corticosteroid that can be applied for short-term treatment of inflamed dry skin. Long-term use may cause cutaneous side effects like skin atrophy. This skin change is not associated with topical or systemic antibiotics, or silver nitrate dressings.

What physical presentations in a pt with a wound would suggest the wound is not adequately healing? SATA A) Wound size is increasing B) Wound is producing purulent exudate C) Blackened tissue is forming over wound D) Reddened, warm skin is developing around wound E) Granulation of wound bed is occurring

A) Wound size is increasing B) Wound is producing purulent exudate C) Blackened tissue is forming over wound D) Reddened, warm skin is developing around wound Correct answers: A, B, C, D. Eschar formation is dead tissue that suggests the wound is nothealing. Infectious sx around the wound may also suggest the wound is not improving, such as exudate that is purulent and red, warm skin. Granulation is suggestive of adequate wound healing and new tissue is forming so should not be a concern

Blue ring around the iris

Arkus sinus (ring of cholesterol) NORMAL

Older adults impaired visual acuity decreased mobility and decreased hearing acuity prepare them for discharge

Assess the degree of impairment Obtain orders for visual/auditory screenings Obtain a home visit prior to the D/C to evaluate home Contact the case manager or social worker

The client with urge incontinence asks you, "How can I get rid of this process?" Which is the best response to this client? A) "It's important to accept that this is a natural part of aging" B) "You should avoid artificial sweeteners, caffeine, and alcohol" C) "It could help to void after every time you think of it" D) "Make sure you take your diuretic at bedtime. This will help you pee better"

B) "You should avoid artificial sweeteners, caffeine, and alcohol"

Which patient can you restrain? Select all that apply A) An 83-year old nursing home resident who frequently wanders at night. B) A 65-year old patient in the ED for alcohol withdraw and has started to become physically aggressive to staff C) A 72-year old patient on a medical-surgical floor with delirium from a UTI who rips out her IV that is needed for IV antibiotics D) A 91-year old patient on a medical-surgical floor who fell yesterday and broke her hip and continues to try to get out of bed

B) A 65-year old patient in the ED for alcohol withdraw and has started to become physically aggressive to staff C) A 72-year old patient on a medical-surgical floor with delirium from a UTI who rips out her IV that is needed for IV antibiotics

An older person reports that food does not "taste the same" since starting a new medication. Which drug should the nurse suspect is causing this symptom? A) Digoxin B) Captopril C) Furosemide D) Amiodarone

B) Captopril Rationale: Captopril is identified as a medication that adversely affects taste. Digoxin and amiodarone affect vision. Furosemide affects hearing.

The nurse notes that an older person uses the bath-room to void every hour. Which age-related change should the nurse suspect this person is experiencing? A) Increase in the number of nephrons in the kidney B) Change in the contractility of the detrusor muscle C) Adverse reaction to potassium-sparing medications D) Thinning of the external sphincter muscle of the urethra

B) Change in the contractility of the detrusor muscle Rationale: The detrusor muscles, three layers of muscle that cover the bladder, become less contractile and also somewhat unstable. This may mean the older adult is subject to an inability to completely empty the bladder. The number of nephrons do not increase with aging. The need to void hourly is not caused by an adverse medication reaction. Thinning of the external sphincter muscle of the urethra increases the risk for incontinence in women.

Which statement is true regarding falls in the elderly? A) Most falls occur in the garage B) Hip fractures resulting from falls are a leading cause of placement in long-term care facilities C) Fall risk decreases with addition of medications D) Sedatives reduce the risk of falls

B) Hip fractures resulting from falls are a leading cause of placement in long-term care facilities A is not true because most falls in the elderly occur in the bathroom

The nurse arrives for a home visit & suspects that the older person is experiencing financial exploitation. Which observation caused the nurse to make this clinical decision? A) Dry cracked lips B) No electricity in the home C) Rat droppings on the kitchen floor D) Streaks of stool down the person's legs

B) No electricity in the home

The spouse of an older person is upset because of a change in the frequency of sexual intercourse since the person had surgery for bladder cancer. What should the nurse consider as causing this couple's distress with sexuality? A) Adverse effect from the anesthesia B) Presence of a urinary-collection device C) Residual fatigue and depression after the surgery D) Current side effects from postoperative medication

B) Presence of a urinary-collection device Rationale: If the bladder is removed, a stoma on the abdomen is created and an external collection device is worn over the stoma to collect urine. This type of sur-gery presents a challenge to the older person's body image, which would adversely affect comfort with sexual inter-course. It is unlikely that the person is experiencing an adverse effect from the anesthesia. Depending upon when the surgery occurred, fatigue and depression might be oc-curring; however, this is not identified within the scenario. There is no information to support that the person is re-ceiving post-operative medication

The nurse makes it clear to older adults in a long-term care facility that condoms are available from the medicine cart on request to: A) Guarantee safe sex practices. B) Reduce the incidence of sexually transmitted diseases (STDs). C) Show acceptance of sexual expression. D) Prevent soiling bed linens or furniture

B) Reduce the incidence of sexually transmitted diseases (STDs). Keep condoms available in nursing homes (cannot get pregnant but can still get STDs)

The nurse is aware that sexuality: A) Becomes absent with age. B) Remains part of life until death. C) As expressed through intercourse is not possible after the age of 65 years. D) Must be expressed in sexual intercourse

B) Remains part of life until death.

What is the most important nursing intervention for the prevention and treatment of pressure ulcers? A) Using pressure-reduction devices B) Repositioning the patient frequently C) Massaging pressure areas with lotion D) Using lift sheets and trapeze bars to facilitate patient movement

B) Repositioning the patient frequently Should reposition patient every 2 hours

The nurse obtains a prescription from a health care provider to restrain a client and instructs an unlicensed assistive personnel (UAP) to apply the safety device to the client. Which observation of unsafe application of the safety device would indicate that further instruction is required by the UAP? A) Placing a safety knot in the safety device straps B) Safely securing the safety device straps to the side rails C) Applying safety device straps that do not tighten when force is applied against

B) Safely securing the safety device straps to the side rails

The nurse notes that an older adult takes vitamin D supplements, propranolol, and lovastatin. Which nursing diagnosis should the nurse consider adding to this person's plan of care? A) Anxiety B) Self-care deficit C) Ineffective coping D) Imbalanced fluid volume

B) Self-care deficit Rationale: The medications and supplements that the person takes routinely can adversely affect taste. The nursing diagnosis most appropriate for this person's potential issue is Self-Care Deficit. Anxiety, Ineffective Coping, and Imbalanced Fluid Volume would not be appropriate considering this person's medication history.

The family member of an older patient recovering from spinal fusion surgery is asking about care of the surgical wound. What statement by the nurse indicates proper teaching about skin wound healing in older adults? A) Skin healing occurs quicker in older adults d/t epidermal thinner B) Skin healing occurs slower in older adults d/t decrease in epidermal mitosis C) Leave the wound open to air immediately after surgery to avoid skin breakdown and prevent infection D) Heat packs should be placed d

B) Skin healing occurs slower in older adults d/t decrease in epidermal mitosis D/t loss of elasticity and decrease in epidermal mitosis by over 30%, skin healing occurs slower in older adults. Surgical wounds should be covered with clean, dry dressing to avoid debris and other contaminants from getting into the surgical site because the risk for infection in older adults is greater. Heat should never be placed directly on skin to avoid burns, especially in older adults who have epidermal loss

During a home visit, the RN learns that an older adult spends no time out of doors because of a fear of developing skin cancer. Which action should the nurse take to help maintain this person's health status? A) Change the time for the next home visit to occur in the evening B) Suggest the healthcare provider measure the person's vitamin D level C) Recommend attending events for senior citizens scheduled in the evenings D) Discuss the importance of performing weight-bearing exercises everyday

B) Suggest the healthcare provider measure the person's vitamin D level Rationale: Since the person spends no time out of doors, the nurse should recommend that the primary care provider check the vitamin D blood level to ensure adequate calcium absorption. This person needs teaching on ways to prevent the development of skin cancer. There is no reason for the person to avoid going out of doors because of this fear. Changing the time for the next home care visit is not necessary. Recommending the person attend events that are scheduled in the evenings is encouraging this person's fear of the sun. Weight-bearing exercises are suggested to reduce the risk of osteoporosis which would be known only after learning the person's vitamin D level.

An older female person seeks medical attention for a new onset of pain with sexual intercourse. Which recommendation should the nurse make to help this person? A) Use the spoon position B) Use a water-soluble lubricant C) Consider changing the form of sexual expression D) Take a bath before engaging in sexual intercourse

B) Use a water-soluble lubricant Rationale: Dyspareunia, painful intercourse for the older woman, may be related to decreased vaginal lubrication, which can be experienced by over one-third of older women. The older couple might be advised to use a water-soluble vaginal lubricant as part of their sexual activity. The spoon position is helpful for couples with hip or joint discomfort. There is no need for the couple to change the form of sexual expression. Taking a bath before intercourse will not help reduce the vaginal discomfort.

An older patient has a Baden Scale score of 15. What should the nurse add to this patient's plan of care? A) Restrict oral protein intake B) Wash skin with tepid water C) Massage reddened skin areas D) Restrict vitamin c & zinc intake

B) Wash skin with tepid water Rationale: Skin care considerations to prevent pressure injuries in older adults at risk include washing the skin with tepid water, with a pH balanced skin cleanser. Protein is required for wound healing. Reddened areas should not be massaged. Nutritional supplements such as vitamin C and zinc promote skin healing.

During a home visit, the nurse notes that an older person experiences urinary incontinence. Which envi-ronmental issue should the nurse consider as contrib-uting to this person's urinary problem? A) Bathroom located within the bedroom B) Wearing pants with a zipper and button C) Kitchen on the other side of the dining room D) Three steps between the living room and the bedroom

B) Wearing pants with a zipper and button Rationale: The clothing that an older adult wears is a part of the environment and should be evaluated to see if it is impairing continence. The location of the bathroom might be an issue; however, the most obvious environ-mental cause for the incontinence is wearing clothing that might make it difficult to void. The location of the kitchen and the number of steps are not environmental issues con-tributing to this person's urinary incontinence.

What are some medications that increase the risk of falls

BP meds Sedative Antidepressants Anticonvulsants Diuretics → other antihypertensives Antihistamines Antipsychotics Pain meds (narcotics)

Braden Scale

Braden scale any score lower than 18 requires intervention 22 is reassess in 3-6 months

What is not a normal change of aging in regards to vision? A) "It's really hard to adjust my eyes at night." B) "There's this blue-ish ring around my iris." C) "My doctor said I have cataracts." D) "I really need my cheaters these days."

C) "My doctor said I have cataracts." More common, but not considered a normal change

The nurse plans to teach an older adult on the hazards of sun exposure to the skin. Which finding caused the nurse to implement this teaching? A) Generally red, rough, itchy skin B) Rough, dry skin over the arms and legs C) A sore, rough, scaly, reddened patch on the face D) Edematous lower extremities with areas of ecchymosis

C) A sore, rough, scaly, reddened patch on the face Rationale: The most common precancerous lesion is actinic keratosis, also known as solar keratosis and senile keratosis. Erythematous actinic keratosis is the most common type and appears as a sore, rough, scaly, reddened papule or plaque. The most common sites for all types of actinic keratoses are sun-exposed areas such as the back of the hands, forearm, face, V of the neck, nose, tips of the ears, and bald scalp. Red rough itchy skin and rough dry skin over the arms and legs may be caused by too frequent bathing, dehydration, or vigorous towel drying. Edematous lower extremities with areas of ecchymosis might be the result of a skin tear or another health problem.

During a home visit the nurse notes that an older person does not comment on the enticing smell of homebaked bread coming from the oven that the older son has prepared. Which diagnosis should the nurse use to guide this identified person's problem? A) Readiness for enhanced comfort B) Readiness for enhanced nutrition C) Altered nutrition: less than body requirements D) Impaired environmental-interpretation syndrome

C) Altered nutrition: less than body requirements Rationale: The inability to smell home baked bread indicates a change in this person's sense of smell. The nursing diagnosis most appropriate for this finding is Altered nutrition: less than body requirements since losing the sense of smell can contribute to anorexia and low nutritional intake. There is no evidence to support that the person is ready for enhance comfort or enhanced nutrition. Impaired environmental interpretation syndrome is used for a person with confusion.

An older adult has a stage 3 pressure injury over the sacral region. Which diagnosis should the nurse use to guide care? A) Risk for infection B) Altered skin integrity C) Altered tissue integrity D) Risk for altered skin integrity

C) Altered tissue integrity Rationale: Because a stage 3 pressure injury is full-thickness skin loss involving damage or necrosis of subcutaneous tissue that may extend down to, but not through, underlying fascia, Tissue integrity, impaired, is the most appropriate diagnosis for the person. There is insufficient information to determine the person's risk for infection. Skin integrity, impaired, and Skin integrity, high risk for impaired, describes situations in which the individual is at risk for or experiences damage to the epidermal and dermal tissue only.

Which patient is at the greatest risk for developing pressure ulcers? A) A 42 -year old obese woman with type 2 diabetes B) A 78-year old man who is confused and malnourished C) An 80-year old man who is comatose following a head injury D) A 65-year old woman who has urge and stress incontinence

C) An 80-year old man who is comatose following a head injury Patients who are not mobile are at higher risk

The nurse notes that an older person is prescribed a total-protein level. Which physical assessment finding would support this laboratory test being used as an indication of elder mistreatment? A) Weak hand grasps B) Inability to remember recent events C) Body wounds and bruises at various stages of healing D) Shortness of breath with ambulation and mild exertion

C) Body wounds and bruises at various stages of healing Rationale: Wounds and bruises at various stages of healing could indicate repeated episodes of elder physi-cal mistreatment. Weak hand grasps could be an expected change based upon the person's age. Loss of short-term memory is a sign of cognitive impairment and does not indicate elder mistreatment. Shortness of breath with am-bulation could indicate chronic lung disease, bleeding, chronic renal failure, or anemia caused by poor nutritional status.

The nurse prepares an educational seminar on female reproductive changes that occur with aging for mem-bers of a women's group. Which information should the nurse include? A) Increased estrogen levels B) Decreased autonomic innervation C) Decreased glandular tissue in breasts D) Increased lubrication of vaginal tissues

C) Decreased glandular tissue in breasts Rationale: An age-related change in the female re-productive system is a decrease in glandular tissue in the breasts. Estrogen levels decrease with aging. Autonomic innervation does increase; however, this is a change in bladder and urethra functioning. Lubrication of vaginal tissues decreases with aging.

An older person seeks medical attention for a facial laceration that reportedly occurred by hitting the face on the door of an open kitchen cabinet. Which information in the person's medical record will hinder the nurse's ability to discern if the injury is caused by elder mistreatment? A) Lives with adult daughter and 3 grandchildren B) Cares for an aging spouse with chronic health problems C) Mild cognitive changes associated with Alzheimer's disease D) Pays for a home-health aide who performs

C) Mild cognitive changes associated with Alzheimer's disease Rationale: Older adults with cognitive impairment are a challenge. Their self-reporting may be questioned for accuracy or they may be unable to express the mistreatment situation due to amnesia, aphasia, agnosia, or apraxia, which commonly occur with dementia. It is often difficult to determine whether the older adult's worsening physical condition is a result of the natural progression of illness or mistreatment on the part of a caregiver. Because some frail older individuals are prone to underlying conditions that give rise to trauma, such as instability of gait and poor vision resulting in falls, it may be difficult for clinicians to differentiate accidental from willful injuries. Living with family, being a caregiver, and paying for help in the home does not impact the nurse's ability to discern if the injury is caused by elder mistreatment.

To determine the severity of the symptoms for a patient with benign prostatic hyperplasia (BPH), the nurse will ask the patient about A) The presence of blood in the urine. B) Any erectile dysfunction (ED). C) Occurrence of a weak urinary stream. D) Lower back and hip pain.

C) Occurrence of a weak urinary stream.

The administrator is preparing for a site visit of the skilled-nursing facility. Which action indicates that the organization is prepared to address any issues of elder mistreatment to the proper authorities? A) Documentation when the most recent staff inservice on fire safety occurred B) Contact name & telephone number for the local & state Center for Aging C) Policy & process to report elder mistreatment placed in a folder posted in the nurse's station D) Names & numbers of all organization ad

C) Policy & process to report elder mistreatment placed in a folder posted in the nurse's station Rationale: Evidence that the organization is pre-pared to address issues of elder mistreatment include having the organization's policy and procedure on elder mistreatment, along with the telephone number and re-porting process, in a location for all staff to have access. Elder mistreatment is not reported to the Center for Aging. Fire safety is not the same as elder mistreatment. Access to administrator telephone numbers is not helpful when needing to report elder abuse.

An 87-year-old man is admitted to the hospital for cellulitis of the left arm. He ambulates with a walker and takes a diuretic medication to control symptoms of fluid retention. Which intervention is most important to protect him from injury? A) Leave the bathroom light on. B) Withhold the client's diuretic medication. C) Provide a bedside commode. D) Keep the side rails up.

C) Provide a bedside commode.

The patient is admitted from home with a clean stage II pressure ulcer. What does the nurse expect to observe when she does her wound assessment? A) Adherent gray necrotic tissue B) Clean, moist granulating tissue C) Red-pink wound bed, without slough D) Creamy ivory to yellow-green exudate

C) Red-pink wound bed, without slough

The manager of a skilled facility is concerned that residents are not receiving required care and are experiencing neglect. Which information caused the manager to make this assumption? A) Pressure ulcer healing rate at 10% B) Family members visiting more frequently C) Resident sitting in urine-saturated clothing for hours D) All residents prescribed the annual influenza vaccination

C) Resident sitting in urine-saturated clothing for hours

The manager of a skilled facility is concerned that residents are not receiving required care and are experiencing neglect. Which information caused the manager to make this assumption? A) Pressure ulcer healing rate at 10% B) Family members visiting more frequently C) Resident sitting in urine-saturated clothing for hours D) All residents prescribed the annual influenza vaccination

C) Resident sitting in urine-saturated clothing for hours Rationale: A resident made to wear and sit in urine-saturated clothing for hours is a form of neglect. Pressure ulcer healing may be delayed in a skilled facility because of the age of the resident, health problems, and nutritional status. Frequency of family visits is not an indication of possible neglect. Long-term care facilities take action to prevent an outbreak of a seasonal infection and will pro-vide the annual influenza vaccination to all residents

An 82-year old man is being cared for at home by his family. A pressure ulcer on his right buttock measures 1 X 2 X 0.8 cm in depth, and pink subcutaneous tissue is completely visible on the wound bed. Which stage would the nurse document on the wound assessment form? A) Stage 1 B) Stage 2 C) Stage 3 D) Stage 4

C) Stage 3 Subcutaneous should trigger you to think stage 3

In your patient's health history you read that the patient has a cataract in the right eye. You know that this eye disorder can be best described by which statement below? A) This eye disorder is caused by increased intraocular pressure that results in damage to the optic nerve B) Cataracts occur in the eye when the macula of the retina become damaged and impair the central vision C) The development of a cataract occurs when the lens of the eye loses its transparency D) This eye disorder occurs

C) The development of a cataract occurs when the lens of the eye loses its transparency

The home healthcare nurse is preparing an educational program for other healthcare providers regarding elder abuse. What information should the nurse include? Select all that apply. A) The typical abuser is the spouse B) The majority of abuse occurs in the long-term care setting C) The majority of abuse occurs in the home setting D) The typical abuser is the adult child E) The typical elder who is abused is a woman

C) The majority of abuse occurs in the home setting D) The typical abuser is the adult child E) The typical elder who is abused is a woman

The nurse is caring for an older person with a history of peripheral neuropathy caused by type 2 diabetes mellitus. Which information should the nurse provide to ensure for this person's skin integrity? A) Set water temperature to 130 degrees Fahrenheit B) Wear thick socks around the house C) Use a mirror to examine the bottoms of feet D) Place a heating pad on the medium setting to warm legs

C) Use a mirror to examine the bottoms of feet Rationale: Older persons with diabetes mellitus should place a mirror on the wall close to the floor, remove their shoes, and examine the bottoms of their feet daily for blisters, redness, or ulcerations. Water temperature should be set no higher than 1250F. The person should wear more than thick socks when walking around the home. Heating pads should be set on "low" and should not be applied directly to the legs since this increases the risk for burns.

A 50-year-old client confides to the nurse that she is experiencing dyspareunia during sexual intercourse. The nurse recommends which of the following for the client? A) Consume alcohol to reduce inhibitions. B) Tell the partner that sex is no longer desired. C) Use a vaginal lubricant. D) Reduce sexual contact to once a month

C) Use a vaginal lubricant.

What is an example of self-neglect?

Come in soaked in urine/feces Nails and hair look dirty Unintentional weight loss Not taking meds they should be Clothes are filthy Living in unsanitary or hazardous conditions

Prior to surgery, the provider orders bloodwork to assess the health of pt for post-op concerns. What result should be addressed with the patient prior to surgery? A) Hemoglobin: 14.2g/dL B) WBC: 8.3mcL C) A1c: 4.2% D) Prealbumin: 2mg/dL

Correct answer: D. Factors that may affect wound healing should be assessed in older patients including nutrition and infection. Elevated blood glucose levels can affect healing so a BGL and Hgb A1c should be assessed in all pts. Low levels of prealbumin and albumin may mean the pt is malnourished which will affect wound healing.

Which female patients are at risk for developing osteoporosis? Select all that apply. A) 60 year old white aerobic instructor. B) 55 year old Asian American cigarette smoker. C) 62 year old African American on estrogen therapy. D) 68 year old white who is underweight and inactive E) 58 year old Native American who started menopause prematurely.

Correct answers: B, D, E B) 55 year old Asian American cigarette smoker. D) 68 year old white who is underweight and inactive E) 58 year old Native American who started menopause prematurely --------Risk factors: asian/white patients, smokers, underweight and premature menopause C is not true b/c estrogen helps keep bone strength up

An older person is concerned about having to void large amounts of urine two times every night. Which response should the nurse make that explains this change in renal functioning? A) "This is an adverse effect of some medications you are taking." B) "This means that you are drinking too much fluid at the end of the day." C) "This is an early indication of renal failure that needs to be investigated." D) "Due to normal changes in the kidney, more urine is produced at night."

D) "Due to normal changes in the kidney, more urine is produced at night." Rationale: Blood flow to the kidney decreases as a result of atrophy in the supplying blood vessels, particularly in the renal cortex. In addition, the proximal tubules decrease in number and length. Because of this, the kid-neys of older adults excrete more fluid and electrolytes at night than in the daytime. More urine is formed at night, frequently interrupting sleep patterns and causing re-peated episodes of nocturia

An older adult is concerned about the number of leg wound infections that have been occurring over the last year. What should the RN explain about this development of these infections? A) The reason skin infections occur more frequently with aging is unknown B) Bacteria on the skin isn't being adequately washed when bathing C) Aging adversely affects immune function, increasing risk for all types of infections D) Aging causes skin thickness to decrease, which increases the risk for skin breaks & infections

D) Aging causes skin thickness to decrease, which increases the risk for skin breaks & infections Aging causes skin thickness to decrease, which increases the risk for skin breaks and infectionsRationale: Many normal age-related changes increase risk for cellulitis. Decreased skin thickness makes the older adult more susceptible to breaks in the skin that are more likely to become infected since wound healing is often delayed. The reason for skin infections with aging is known however bacteria on the skin is not identified as a risk factor. Although aging does affect immune function, this is not identified as a risk factor for the development of skin infections with aging.

The nurse reviews an older person's current medications. For which medication should the nurse assess the person's vision for any changes? A) Abilify B) Verapamil C) Furosemide D) Amiodarone

D) Amiodarone Rationale: Amiodarone can cause blurred vision, corneal changes, optic neuropathy, and halos. Abilify can adverse effect taste. Verapamil does not cause or contribute to sensory changes. Furosemide can adversely affect hearing.

An older person feels like their bladder is not com-pletely empty despite voiding several times a day. For which health problem should the nurse plan care for this person? A) Chronic renal failure B) Urinary-tract infection C) Functional incontinence D) Benign prostatic hyperplasia

D) Benign prostatic hyperplasia Rationale: The symptoms of BPH are sometimes referred to as "nuisances," and include urinary frequency (up to 8 or more times/day) and a feeling of incomplete bladder emptying. These symptoms are not associated with chronic renal fail

The nurse is setting up an education session with an 85-year-old patient who will be going home on anticoagulant therapy. Which strategy would reflect consideration of aging changes that may exist with this patient? A) Show a colorful video about anticoagulation therapy B) Present all the information in one session just before discharge C) Give the patient pamphlets about the medications to read at home D) Develop large-print handouts that reflect the verbal information presented

D) Develop large-print handouts that reflect the verbal information presented Rationale: Option D addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Option A does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand

The nurse is setting up an education session with an 85-year-old patient who will be going home on anticoagulant therapy. Which strategy would reflect consideration of aging changes that may exist with this patient? A) Show a colorful video about anticoagulation therapy. B) Present all the information in one session just before discharge. C) Give the patient pamphlets about the medications to read at home. D) Develop large-print handouts that reflect the verbal information presented

D) Develop large-print handouts that reflect the verbal information presented Rationale: Option D addresses altered perception in two ways. First, by using visual aids to reinforce verbal instructions, one addresses the possibility of decreased ability to hear high-frequency sounds. By developing the handouts in large print, one addresses the possibility of decreased visual acuity. Option A does not allow discussion of the information; furthermore, the text and print may be small and difficult to read and understand.

When educating an older patient on skin conditions that can occur with aging, which statement is incorrect? A) Skin tears B) Pressure ulcers C) Dry skin D) Eczema

D) Eczema Correct answer: D. Eczema is not a specific skin condition that worsens with aging and is most often found in younger populations. All the other conditions are those that can worsen with aging.

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? A) Notify the health care provider immediately to rule out cranial nerve damage B) Schedule the patient for an appointment at a smell and taste disorders clinic C) Perform testing on the vestibulocochlear nerve and a hearing test D) Explain to the patient that diminished senses are normal findings

D) Explain to the patient that diminished senses are normal findings Worry about nutrition

The nurse documents that the family caregiver of an older person should be assessed for stress during every home visit. What caused the nurse to make this notation in the older person's medical record? A) The sink is full of dirty dishes B) Person sitting quietly watching television C) Unread newspapers stacked on the kitchen table D) Family caregiver complaining about the volume of laundry

D) Family caregiver complaining about the volume of laundry

A resident in an assisted-living facility is upset because a group of friends went to see a movie and didn't invite the resident to join them. Which finding should the nurse consider as a possible reason for the person's social isolation? A) Hearing deficit B) Timing of medications C) Use of a cane to ambulate D) Odor from incontinence pad

D) Odor from incontinence pad Rationale: Many older adults who experience uri-nary incontinence use disposable incontinence pads or protective undergarments. Although these may be helpful in managing the social consequences of UI, they are nei-ther a cure nor without adverse effects. Used incontinence products can have an unpleasant odor. It is unlikely that the resident is being avoided because of a hearing defi-cit, medication schedule, or use of an assistive device to ambulate.

The 50-year-old son of an elderly widow brings his mother to the clinic for an examination. He states that she is becoming confused and is falling in the home. When left to be examined by the nurse, the female widow appears fearful, lucid, and says that she has never fallen down in her own home. What type of situation might this elderly widow be experiencing? A) Psychological abuse. B) Financial abuse. C) Social abuse. D) Physical abuse.

D) Physical abuse.

An older person reports progressive hearing loss of both ears. Which medication should the nurse suspect is causing this change in hearing? A) Digoxin B) Baclofen C) Tamoxifen D) Propanolol

D) Propanolol Rationale: Propranolol causes tinnitus and hearing loss. Digoxin and tamoxifen adversely affect vision. Baclofen causes tinnitus.

The nurse observes nursing-assistive personnel (NAP) care for an older person with a severe hearing deficit. For which action performed by NAP should the nurse intervene? A) Faces the person when talking B) Stands next to the person's bed C) Pauses at the end of every phrase D) Shouts directly into one of the person's ears

D) Shouts directly into one of the person's ears Rationale: When talking with a person with a hearing deficit, speak slowly and clearly in a normal tone of voice. Shouting does not help the person hear any better. Face and stand near the person when talking. Pause at the end of every phrase to permit the person time to respond.

The patient is transferring from another facility with the description of a sore on her sacrum that is deep enough to see the muscle. What stage of pressure ulcers does the nurse expect to see on admission? A) Stage I B) Stage II C) Stage III D) Stage IV

D) Stage IV Muscle or bone is automatically stage 4, cannot get deeper than that

While completing an assessment, the nurse notes that an older adult has a large area of ecchymosis around a 3-inch scratch on the anterior surface of the lower left leg, reported to be caused by walking into an open dresser drawer a few days ago. What should the nurse consider as the reason for the wound's appearance? A) Poor nutritional status B) Excessive dryness of the skin C) Use of over-the-counter antihistamines D) Subcutaneous tissue atrophy with aging

D) Subcutaneous tissue atrophy with aging Rationale: A skin tear is a wound caused by shear, friction, and/or blunt force resulting in separation of skin layers. Independent older adults frequently sustain skin tears on the lower legs by bumping into open dresser drawers in the home environment. Skin tears may be accompanied by dark purple ecchymosis (senile purpura) and edema because of subcutaneous tissue atrophy. The wound's appearance is not because of the person's poor nutritional status, excessive skin dryness, or the use of antihistamines.

The nurse notes that a resident in an assisted-living facility leaves the dining room several times during the evening meal to void. What should the nurse sus-pect is occurring with this resident? A) Acute renal failure B) Chronic renal failure C) Urinary incontinence D) Urinary-tract infection

D) Urinary-tract infection Rationale: If an older adult presents with new symptoms of urinary urgency, a shortened period of time between the urge to void and actual urination, urinary frequency, or more than seven voids per 24-hour period, an investigation for a urinary-tract infection is necessary. The increased need to void is not a symptom of acute or chronic renal failure. The resident would be incontinent of urine if urinary continence is occurring.

What is the biggest symptom of a UTI in an older adult?

Delirium (altered mental status)

Ecotropion

Drooping of the eyelid

What would you use to assess a patients fall risk?

Heinrich 2 A high risk is a score greater than 5

Risk factors for macular degeneration

Hypertension Age Diabetes Smokers Exposure to sunlight High cholesterol White females

The nurse is assessing an older adult when she states "I don't know why everyone is so mean to me" What steps?

Step 1: suspected abuse? Step 2: if yes, report Step 3: maintain older adult's safety Step 4: document per facility protocol

If you are giving a sedative because a patient is aggressive what do you need to remember?

That a sedative is still a form of a restraint (chemical)

When assessing the older adult at a routine appointment, should the nurse also make time for a separate assessment for the caregiver to assess if they fit the definition of the psychopathology of the abuser/determine if they are an abuser?

The person they are with might be answering for them Separate patients from whoever they are with to try to get honest answers

How would we prevent osteoporosis?

Weight bearing exercises Foods high in calcium Green leafy vegetables