HA: EAQ #6

After assessing a geriatric patient, the nurse infers that the patient is independent, maintains proper health care, performs activities of daily living, and enjoys good health. Which finding helped the nurse reach this conclusion?

" Staying Healthy at 50+" is a guide that helps maintain a proper lifestyle as a person ages. A patient who follows the guide maintains a healthy diet and a proper lifestyle. If the patient refrains from attending parties, it indicates that the patient does not like socializing and maintains a solitary life, which may lead to depression. A person who does not attend religious functions reduces socializing, which may lead to depression. Therefore, the patient who does not attend parties or religious activities might not maintain proper health. The patient should include exercises to stay healthy and fit. A relaxed, sedentary lifestyle may cause a decline in health by increasing the risk of obesity or cardiac problems.

While assessing an elderly patient with cardiovascular disease, the nurse finds that the patient has difficulty ambulating. What information should the nurse provide to promote health in the patient?

"You should try water activities." "You may need to walk with a cane." "You ought to try riding a stationary bike."

Which tool does the nurse use to evaluate a patient's ability to live independently and to manage finances?

*The DAFA is a 10-item observational instrument that assesses the ability of self-care, independence, and money management.* The Lawton instrumental activities of daily living scale comprises eight activities: use of the telephone, shopping, meal preparation, housekeeping, laundry, transportation, self-medication, and management of finances, to assess the living conditions of the patient. The DAFA is an additional instrument of the Lawton Instrumental Activities of Daily Living. The Barthel Index measures functional disability by quantifying the patient's performance in ten activities of daily life. The Barthel Index includes the definitions of each task, which facilitates the ease of scoring. The Katz Index of Independence in Activities of Daily Living helps assess functional status as a measurement of the patient's ability to perform activities of daily living independently. The Functional Independence Measure is more sensitive than other ADL instruments and is more time-consuming.

The nurse advises an elderly patient with insomnia to have a glass of milk at bedtime. What would be the reason for this advice?

A light bedtime snack of milk, or cheese and crackers reduces hypoglycemia in the patient. Therefore, to promote sleep, the nurse advises the patient to have a snack. The light snack of milk, or cheese and crackers will not induce sleep by reducing anxiety in the patient; instead, maintenance of a proper sleeping schedule reduces anxiety in the patient. This light snack does not reduce heartburn; instead, refraining from heavy, spicy foods may reduce heartburn. The light snack of milk, or cheese and crackers will not help reduce bladder fullness. Restricting fluids before bedtime will reduce bladder fullness in the patient.

A patient uses the Lawton Independent Activities of Daily Living (IADL) scale for self-assessment of the daily activities. Which parameters are included in the scale?

Ability to prepare meals Ability to perform laundry Ability to manage finances

While taking care of an elderly patient, the nurse closely monitors whether the patient is grooming and walking on a daily basis. What is the purpose of the observation?

Activities of daily living (ADL) are tasks that are necessary for self-care in adults. ADLs measure the domains of eating/feeding, bathing, grooming, dressing, toileting, walking, using stairs, and transferring in an elderly person. A loss of the ability to perform ADLs because of acute illness and hospitalization is common in older adults and can have significant negative consequences. The assessment procedure involves the identification of older adults who are at the greatest risk for loss of ADLs or mobility at this critical time. The assessment of cognitive status in older adults is an important part of the functional assessment. Altered cognition in older adults is commonly attributed to three disorders: dementia, delirium, and depression. The caregiver, rather than the patient, is screened to assess caregiver burden.

Which instrument does the nurse use to assess the risk of delirium in a patient?

Delirium is a sudden change in the state of mind that results in confusion and emotional breakdown. The Neecham Confusion Scale and the Confusion Assessment Method are assessment tools that help assess delirium in a patient. The nurse uses the Mini-Cog to assess the patient's visuospatial skills, as well as orientation and work memory. The Get Up and Go Test helps evaluate the risk of fall in the patient. The Tinetti Gait and Balance Evaluation is a 28-point scale that helps evaluate the risk of fall in the patient.

Which test does the nurse use to assess the risk of fall in a patient who has chronic illness?

Get Up and Go Test Tinetti Gait and Balance Evaluation

After reviewing the prescription of a patient, the nurse warns the patient about the possibility of insomnia. Which medication would have this effect?

Insomnia is difficulty falling asleep. Diuretics help remove excess fluid from the body; this may result in frequent urination, thereby disturbing the sleep, which may result in insomnia. Corticosteroids are anti-inflammatory drugs that act as central nervous system stimulants. Therefore, the patient may experience insomnia when taking corticosteroids. Bronchodilators help treat asthma by opening the air passages. These drugs also act as central nervous system stimulants, which may cause insomnia. Benzodiazepines are hypnotic drugs, which cause sedation and help treat insomnia effectively. Barbiturates are sedative drugs, which may cause drowsiness and help treat insomnia.

hich interventions made by the nurse ensure proper assessment in the elderly patient?

Involve the patient in all decision making about the interview. Do the assessment after providing privacy in the examination room. Include touch whenever necessary while doing a patient assessment.

While assessing the mental status of an older patient, the nurse uses the Folstein Mini-Mental State Examination (MMSE). Which parameters does the nurse assess in the patient?

Orientation Memory recall Visuospatial ability

The nurse is caring for an older adult patient who has cardiovascular disease. Which instruction regarding exercise does the nurse include in the care plan of the patient, according to the World Health Organization (WHO)?

Perform muscle-strengthening activities at least twice a week.

The nurse is preparing a team to perform a comprehensive assessment of older adults. Who should participate in the assessment?

Social workers Speech therapist Primary health care provider

While examining the mental status of a patient, the nurse assessed the orientation, and immediate and delayed recall of the patient in 6 minutes. Which cognitive instrument did the nurse use?

The BOMC is a cognitive instrument that helps in the assessment of the mental status of a patient. The nurse assesses orientation, recall memory, and working memory through this assessment. It takes a maximum of 6 minutes for this assessment. The Mini-Cog helps determine the mental status of the patient by assessing visuospatial ability and recall ability within 10 minutes. The Geriatric Depression Scale helps assess depression in a patient who has delirium. The DAFA is an additional Lawton Instrumental Activity of Daily Living that helps assess the daily living and money management of the patient. However, it does not assess the working memory of the patient.

Which scale would be most effective in assessing a geriatric patient's ability to perform activities of daily living (ADLs) in a rehabilitation center?

The FIM scale is widely used in older adults for the assessment of daily activities in rehabilitation settings. It is most feasible in a rehabilitation setting, because it provides accurate information about the progress of the patient's abilities. The Katz Index of ADLs relies on the patient reporting his or her abilities and is subjective (instead of objective) in data collection. The Lawton IADL is a scale to evaluate the advanced activities of daily living, such as socialization and money management. It is not feasible to use in an institutional setting, because the residents may manage most of the tasks included in the scale. The Rapid Disability Rating Scale-2 (RDS-2) measures what a patient can do, not what he or she should be able to do.

The nurse is planning to use Hospital Admission Risk Profile (HARP) instrument to screen a group of elderly patients who are at risk of functional decline. Which variables does the nurse consider while using this tool?

The HARP is a simple screening tool that classifies patients as being at low, intermediate, or high risk for losing the ability to perform the activities of daily living. The nurse considers the patient's age, cognitive function based on MMSE score, and the ability to perform independent activities of daily living. These variables are the major factors that can indicate functional decline in older patients. The nurse does not consider the patient's cultural beliefs, because these do not cause functional decline in the patient. The nurse does not consider the patient's Mini-Cog score, because it does not give accurate information about the cognitive function of the patient.

The nurse is assessing the ability of a geriatric patient to bathe, dress, toilet, and transfer from bed to chair. Which instrument should the nurse use during the assessment?

The Katz Index of Activities of Daily Living is the scale that assesses the daily activities of living such as the ability to bathe, dress, and toilet in geriatric patients. The Tinetti Gait and Balance Evaluation is a test that helps evaluate the balance and the risk of fall in a patient. The Pittsburgh Sleep Quality Index (PSQI) is useful to measure the quality of the patient's sleep as well as sleep patterns. The Lawton Instrumental Activities of Daily Living helps evaluate the higher-order components of daily living such as socializing and money management.

What are the advantages of the Katz ADL scale?

The instrument can be used in many settings. The instrument takes 5 minutes to administer.

The nurse is planning to assess the functional abilities of an elderly patient. What is the most suitable place for the assessment?

The most appropriate place to do a functional ability test of an elderly patient is the patient's home. The patient will feel comfortable and secure in a known setting, and the nurse will be able to assess how the patient functions in his or her daily environment. A family member's home would not provide the same level of comfort and familiarity. A comprehensive assessment of physical ability may require more than an hour. Therefore, it would not be feasible to occupy the primary health care provider's office or use the resources of an acute hospital setting.

The nurse observes that an older patient struggles to understand the spatial relationships between objects and is unable to recognize familiar faces. The nurse suspects that the patient may have Alzheimer disease. Which cognitive tests should be used for further assessment?

The patient with Alzheimer disease may have decreased visuospatial skills and delayed recall of memory. Therefore, the patient may be unable to recognize familiar faces. The nurse uses the Mini-Cog test to assess the patient's visuospatial skills along with orientation and work memory. The Mini-Mental scale helps assess the mental status of the patient. The Blessed Orientation-Memory-Concentration Test (BOMC) is a cognitive instrument that helps assess orientation, recall memory, and working memory. TheGet Up and Go Test helps evaluate the risk of fall in the patient. The Short Portable Mental Status Questionnaire helps assess the mental status of a patient.

A 60-year-old patient complains to the nurse, "I think my age is catching up with me; I am unable to sleep properly at night." What does the nurse suggest to the patient to ensure proper sleep?

The patient with insomnia has difficulty staying asleep at night. Snacks such as toast or crackers contain carbohydrates, which reduce hypoglycemia and promote sleep. A heavy and spicy diet might cause heartburn that may disturb sleep. Therefore, the nurse does not advise the patient to eat a heavy and spicy diet. The bedroom should be used only to sleep; this helps the brain associate the room with sleep, and induces it. Therefore, activities such as reading and watching television should be avoided in the bedroom. Tea is a central nervous system stimulant that interferes with sleep patterns and hinders sleep.

The nurse is caring for an elderly patient with chronic illness. Which parameters does the nurse assess while evaluating the Advanced Activities of Daily Living (AADL)?

The social activities performed by the patient The patient's responsibilities as a family member The recreational activities performed by the patient

The nurse is monitoring instrumental activities of daily living (IADL) in an aged patient. What are the activities that the nurse should monitor in the patient?

Typically IADL tasks include shopping, meal preparation or cooking, laundry, managing finances or counting, basic housekeeping, taking medications, and using transportation. Tasks such as yard work and leisure activities such as reading and other hobbies are included in some, but not all IADL instruments. Feeding and walking are activities of daily living and are tasks necessary for self-care.

The nurse is assessing an older adult patient with altered cognition. Which action by the nurse ensures successful completion of the patient assessment?

While assessing the patient with altered cognition, the nurse uses single command questions to prevent frustration in the patient. Therefore, the nurse asks the questions that can be answered by a yes or a no. Interviewing the patient for many hours may irritate the patient; therefore, to perform complete assessment, the nurse splits the assessment into various sessions. It is more reliable to obtain the patient's information from the caregiver or family member without the patient present. Obtaining this information in front of the patient may cause anxiety. Therefore, the nurse obtains the patient's information when the patient is not present. Repeating the same question over and over may cause irritation and anxiety in the patient; therefore, the nurse refrains from repeating the same question to the patient.