The Aging Adult
A nurse is screening for Alzheimer's disease (AD) in patients in a long-term care facility. Which facts regarding AD are accurate? (Select all that apply.) a) Nearly half of 85-year-old adults have A b) AD accounts for about one-third of the cases of dementia in the United States. c) AD affects brain cells and is characterized by patchy areas of the brain that degenerate. d) AD primarily affects young to middle adults. e) AD is a progressively serious but not a life- threatening disease. f) Scientists estimate that more than 5 million people have AD.
Answer: A, C, F Rationale: The following facts about Alzheimer's disease (AD) are correct. Scientists estimate that more than 5 million people have AD. Nearly half of 85-year-old adults have AD. AD affects the brain cells and is characterized by patchy areas of the brain that degenerate. The first indications of AD usually occur after 60 years of age. AD is a progressively serious and ultimately fatal disorder.
Nurses who care for diverse populations must be aware of patterns of disease that are more likely to affect certain ethnic or racial groups. Which examples accurately reflect these profiles? (Select all that apply.) a) Tuberculosis is 11 times more common in Asian Americans than the white population. b) Black American men are 30% more likely to die from heart disease than non-Hispanic white men. c) Hispanics have higher rates of obesity than non-Hispanic Caucasians. d) Black Americans have the highest mortality rate of any minority for most major cancers. e) American Indian/Alaska Natives have an infant mortality rate 75% higher than that of Caucasians. f) Black adults are diagnosed with diabetes and die from diabetes almost three times as often as white adults.
Answer" A. B. C. D. Rationale: Several examples reflect correct information about particular ethnic or racial groups. Black American men are 30% more likely to die from heart disease than non-Hispanic white men. Hispanics have higher rates of obesity than non-Hispanic Caucasians. Black adults are diagnosed with diabetes and die from diabetes almost three times as often as white adults. Tuberculosis is 11 times more common is Asian American that the white population. Several examples were incorrect. American Indian/Alaska Natives have an infant mortality rate 60%, not 75%, higher than that of Caucasians. Black adults are diagnosed with diabetes and die from diabetes almost two times, not three times, as often as white adults.
A nurse is conducting an education session about appropriate measures to promote sleep with an older adult who is experiencing frequent awakenings at night and then awakening early in the morning. The nurse determines that the education was successful when the client states: a) "I need to try and go to bed and get up at the same time each night." b) "I should continue to take my sleep medication for as long as I need to." c) "I should avoid coffee, but tea is okay to drink before bed." d) "I should do some mild exercises about 2 hours before bedtime."
Answer: " I need to try to go to bed and get up at the same time each night." Rationale: Sleep measures include maintaining a routine, going to bed and getting up at the same time each night, avoiding exercise 3 to 4 hours before bed, using prescribed sleep medications only for the short-term (7 to 14 days), and avoiding alcohol, nicotine, and caffeine (which tea contains).
A nurse is teaching an elderly client's family about the causes of mental impairment. The nurse sees that the teaching has been effective when the family says which of the following? a) "Alzheimer's disease (AD) is a reversible neurologic illness." b) "Delirium progressively affects cognitive function and is a chronic process." c) "Sundowning is a common problem of dementia." d) "Dementia is an acute process and develops suddenly."
Answer: "Sundowning is a common problem dementia." Rationale: A common problem in patients with dementia is sundowning syndrome, in which an older adult habitually becomes confused, restless, and agitated after dark. Dementia is chronic and usually develops gradually. AD is the most common degenerative illness and is irreversible. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment.
The nurse is assigned to care for a client age 87 years admitted to the medical unit for congestive heart failure. It is the fourth hospital day, and the response to treatment has been good. The client is no longer short of breath and the lung sounds are clearing. There is still a diet restriction of decreased sodium and fluids are limited to no more than 1000 mL per day. The nurse is preparing the client and family for discharge. The nurse's discharge education, in order to promote the older client's health, will include which instructions? Select all that apply. a) Do not use the salt shaker at meals. b) Gradually increase activities as tolerated. c) Increased stress may interfere with recovery. d) Take several naps during the day.
Answer: A, B, C Rationale: Promoting health for older adults includes ensuring adequate nutrition (e.g., low-fat diet, other diet modifications); balancing calories and activities; planning exercise as a daily activity; and educating the client that illness is a physical and emotional stress and increases the risk for complications. Taking naps will interfere with sleep at night
A nurse is reading a journal article about mood disorders in the older adult population. Which information about these conditions would the nurse expect to find? Select all that apply. a) Symptoms often mimic those of other chronic comorbidities of the older adult. b) Suicide is the most serious consequence of depression. c) The stigma associated with depression is less for older adults. d) Depression is often misdiagnosed. e) Depression is considered a normal part of aging.
Answer: A, B, D Rationale: Mood disorders (especially depression) are often unrecognized or misdiagnosed in older adults partly due to the false belief that depression is a natural reaction to illness, advanced age, or life changes that occur with age. Therefore, depression is not viewed as something that needs to be treated in the older adult. Furthermore, symptoms of depression may include poor cognitive performance, sleep problems, and lack of initiative ? symptoms commonly seen in people with multiple chronic comorbidities (such as diabetes or heart failure) or in clients with dementia or delirium, causing it to be unrecognized. Although depression is not a normal part of aging, older adults are at an increased risk of experiencing depression due to chronic illness and other age-related changes. The older adult population is also less likely to report symptoms due to the stigma attached. Suicide is the most serious consequence of depression.
The nurse is caring for an older adult with hypertension. Based on the nurse's understanding of inappropriate medications for use in the older adult, the nurse would question an order for which drug as initial treatment for hypertension? Select all that apply. a) Clonidine b) Furosemide c) Methyldopa d) Quinapril e) Prazosin
Answer: A, C, E Rationale: Medications such as prazosin, clonidine, and methyldopa are not recommended for treatment of hypertension in the older adult due to the high risk for orthostatic hypotension; their use should be avoided. Furosemide and quinapril are appropriate for use in the older adult
A nurse is preparing a presentation for a group of older adults about promoting safety while maintaining their mobility. Based on the nurse's understanding of factors placing the older adult at risk for falls, which area would the nurse most likely address? Select all that apply. a) environmental hazards b) hearing loss c) medication use d) changes in bowel function e) diminished strength
Answer: A, C, E Rationale: Multiple factors place the older adult at risk for falls, including the use of medications affecting balance, thinking, memory, and elimination; impaired vision; environmental hazards (e.g., slippery floors, throw rugs, poor lighting); decreased strength; loss of bone mass; and neurological and musculoskeletal problems. Hearing loss and changes in bowel function are not associated with an increased risk for falling.
The nurse is caring for an older adult client who is confused and agitated. When the client's family comes to visit the nurse asks how long the client has been confused. The family states that the client has been confused for a long time and the confusion is getting worse. The client is subsequently diagnosed with dementia. What is the most common cause of dementia in an older adult client? a) Depression b) Alzheimer's disease c) Delirium d) Excessive drug use
Answer: Alzheimer's disease Rationale: Alzheimer's disease is the most common cause of dementia in older adults. Approximately 10% of people over age 65 have Alzheimer's disease; about 50% of people over age 85 have the disease. Delirium, or acute confusion, is caused by an underlying disease and is not itself a cause of dementia. Depression is common in older adults but, in many cases, manifests itself in apathy, self-deprecation, or inertia — not dementia. Excessive drug use, commonly stemming from the client seeing multiple physicians who are unaware of drugs that other physicians have prescribed, can cause dementia. Although it is a problem among older adults, it is not as common as Alzheimer's disease.
After obtaining the health history from an older adult client, the nurse develops a plan of care and identifies a nursing diagnosis of Risk for Impaired Physical Mobility. A history of which condition would support this nursing diagnosis? Select all that apply a) Glaucoma b) Hip fracture c) Diverticulitis d) Arthritis e) Stroke
Answer: B, D, E Rationale: Some chronic conditions such as walking, driving, shopping, and exercise can negatively affect aspects of mobility. Arthritis, gait and balance disorders (caused by musculoskeletal or neurologic conditions), and cataracts are among the many health conditions that cause mobility problems.
An older adult client enjoys good overall health, but has just been diagnosed with pneumonia and has begun receiving an intravenous (IV) antibiotic. Shortly after being administered the first dose, the client pulled out his IV line and is now attempting to scale his bed rails. Which of the following phenomena most likely underlies this change in the client's cognition? a) Disorientation b) Dementia c) Delirium d) Depression
Answer: Delirium Rationale: Delirium is a temporary state of confusion that is often precipitated by drug interactions or the effects of new drugs. Dementia is rooted in organic brain changes and rarely has a sudden onset. The client is not showing signs or symptoms of depression. Disorientation is a manifestation of a problem rather than a cause.
A 78-year-old woman is status post right hip fracture after a fall. She has stopped going to her church over the past few months. She has also asked her neighbor to help her and do her gardening, an activity she previously loved. The client tells the nurse "I just don't enjoy gardening like I used to. I am always worried about falling." What would most concern the nurse regarding the client? a) Realistic caution b) Depression c) Generalized anxiety disorder d) Bipolar disorder
Answer: Depression Rationale: One sign of depression is a lack of interest in previously enjoyable activities. Further investigation is necessary to make a formal diagnosis
The nurse understands that when caring for the older adult it is important to assist in maintaining independence and self-esteem. Assisting the client to adjust to a walker or wheelchair is an example of supporting which of Erikson's developmental tasks of the older adult? a) Ego integrity and coping with reality of limitations b) Adaptation to age and preservation of self c) Functional adaptation and self-awareness d) Prevention of injury and safety in navigation
Answer: Ego integrity and coping with reality of limitations Rationale: Age does affect the older adult due to many different physiological changes, as evidenced by a decrease of cardiac output, peripheral circulation, oxygenation of blood, decreased ability to control temperature, and a slower heart rate. Ego integrity is the task of the older adult, according to Erikson, including "wholeness," emotional integration, and acceptance of physical decline. The others are not developmental tasks described by Erikson.
Erikson identified ego integrity versus despair and disgust as the last stage of human development, which begins at about 60 years of age. Which intervention would best foster older patients' ego integrity? a) Encouraging life review b) Promoting independent living c) Distracting the patient d) Praising the patient
Answer: Encourage life review Rationale: The intervention that would best foster older clients' ego integrity would be encouraging life review. Older adults search for emotional integration and acceptance of the past and present, as well as acceptance of physiologic decline without fear of death. Older adults often like to tell stories of past events. This phenomenon, called life review or reminiscence, has been identified world-wide. In a sense, this is a way for an older adult to relive and restructure life experiences and is part of achieving ego integrity. Integrity versus despair and disgust would not be fostered by distracting the client, praising the client, or promoting independent living.
Gould viewed the middle years as a time when adults increase their feelings of self-satisfaction, value their spouse as a companion, and become more concerned with health. Which nursing action best facilitates this process? a) Counseling a patient who complains of being depressed b) Providing entertainment for a patient on bedrest c) Arranging for social services to assist with meals for a homebound patient d) Encouraging a patient to have regular checkups
Answer: Encouraging a patient have regular checkups Rationale: Gould viewed the middle years as a time when adults look inward (ages 35 to 43); accept their lifespan as having definite boundaries, and have a special interest in spouse, friends, and community (ages 43 to 50); and increase their feelings of self-satisfaction, value spouse as a companion, and become more concerned with health (ages 50 to 60). The nursing action that best facilitates this process would be encouraging a client to have regular checkups.
A nurse is making a home visit to an older adult with multiple chronic health problems. The client is alert and oriented and his cognition is intact. While talking with the client, he reveals that he thinks his son is stealing his social security checks to buy his beer and eat out all the time. The nurse interprets this statement as possibly suggesting which type of elder abuse? a) Abandonment b) Exploitation c) Emotional d) Physical
Answer: Exploitation Rationale: Exploitation involves illegally taking or misusing the funds, property, or assets of a vulnerable older adult. Physical abuse involves the infliction of pain/injury on a vulnerable older adult, the threat of inflicting such pain or injury, or depriving them of basic needs. Emotional/psychological abuse involves verbal or nonverbal actions causing mental pain, anguish, or distress on the older adult. Abandonment involves desertion of a vulnerable adult by anyone who has assumed responsibility for his care.
When caring for older adults, nurses must be aware of common conditions found in this population. Which statements accurately describe these conditions? (Select all that apply.) a) Polypharmacy is a term that is used to describe the habit of older adults to use many pharmacies to obtain their prescription drugs. b) Delirium is a permanent state of confusion occurring in older adulthood. c) Depression is a prolonged or extreme state of sadness occurring in many older adults. d) A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. e) As many as 50% of adults 65 years and older experience an episode of delirium during a hospitalization. f) Sundowning syndrome is a condition in which an older adult habitually becomes confused, restless, and agitated after dark.
Answer: F, C, D Rationale: Several of the statements listed are true statements. Sundowning syndrome is a condition in which an older adult habitually becomes confused, restless, and agitated after dark. Depression is a prolonged or extreme state of sadness occurring in many older adults. A significant percentage of older adults limit their activities because of fear of falling that might result in serious health consequences. There were three statements that were not true. First, delirium is not a permanent state of confusion occurring in older adulthood. Delirium, a temporary state of confusion, is an acute illness that can last from hours to weeks and resolves with treatment. Polypharmacy does not look at the number of pharmacies used to obtain prescriptions but the amount of drugs prescribed by health care providers for a variety of medical conditions. Polypharmacy, the use of many medications at the same time, can pose many hazards for older adults. Complicated regimens need careful review to minimize risks and complications and maximize benefits.
Which of the following health promotion measures should occur most frequently in older adult women? a) Tetanus booster b) Fecal occult blood test c) Colonoscopy d) Pelvic and Papanicolaou (Pap) exam
Answer: Fecal occult blood test Rationale: Fecal occult blood tests are recommended annually for older adults. Pap exams and pelvic exams are recommended at least every 3 years. Colonoscopy or sigmoidoscopy should be performed every 3 to 5 years, and a tetanus booster is only necessary every 10 years.
The middle adult is sometimes called the "sandwich generation". According to Erikson, the developmental task of the middle adult is what? a) Initiative versus guilt b) Ego-integrity versus despair c) Generativity versus stagnation d) Goal attainment versus crisis
Answer: Generativity versus stagnation Rationale: The developmental task of the middle adult is "generativity versus stagnation." They are in a stage of guiding the next generation, accepting their own changes and adjusting to need of aging parents, as well as evaluating their own goals and accomplishments. "Initiative versus guilt" is the developmental task for toddlers. "Ego integrity versus despair" is the developmental task for older adults. "Goal attainment versus crisis" is not a developmental task.
An older adult client is prescribed a sleep medication. When explaining the medication to the client, the nurse would emphasize which aspect of therapy? a) rare occurrences of confusion b) need for follow-up laboratory tests c) greatest effectiveness with short term use d) minimal risk of adverse effects
Answer: Greatest effectiveness with short term use Rationale: Sleep medications may be used, but these drugs are most effective when limited to short-term use (7 to 14 days); otherwise, the medications may actually interfere with sleep and cause other adverse outcomes such as falls, confusion, and constipation. The risks for adverse effects depend on the drug prescribed. There is no need for follow up laboratory tests.
Based on Havighurst's theory of human development, which nursing intervention would best facilitate the accomplishment of a developmental task of older adulthood? a) Helping a patient become established in the community b) Helping a patient accept a move to live with a daughter c) Helping a patient move independently using a walker d) Helping a patient cope with living alone after the death of a spouse
Answer: Helping a patient move independently using a walker Rationale: According to Havighurst, the major tasks of old age are primarily concerned with the maintenance of social contacts and relationships. Successful aging depends on a person's ability to be flexible and adapt to new age-related roles. The person must find new and meaningful roles in old age while being reasonably comfortable with the social customs of the times. The only nursing intervention that addresses this theory would be helping a client move independently using a walker.
A nurse encourages residents of a long-term care facility to continue a similar pattern of behavior and activity that existed in their middle adulthood years to ensure healthy aging. This intervention is based on which aging theory? a) Disengagement theory b) Identity-continuity theory c) Life review theory d) Activity theory
Answer: Identity-continuity theory Rationale: The identity-continuity theory assumes that healthy aging is related to the older adult's ability to continue similar patterns of behavior from young and middle adulthood. Older adults search for emotional integration and acceptance of the past and present, as well as acceptance of physiologic decline without fear of death. Older adults often like to tell stories of past events. This phenomenon, called life review or reminiscence, has been identified world- wide. Disengagement theory, maintained that older adults often withdraw from usual roles and become more introspective and self-focused. This withdrawal was theorized as intrinsic and inevitable, necessary for successful aging, and beneficial for both the person and for society.
The nurse practitioner is examining a 55-year-old female client. Which of the following findings would be uncommon for this age group? a) Presbyopia occurs b) Lower extremity pulses are weak c) Agility gradually decreases d) Menopause occurs
Answer: Lower extremity pulses are weak. Rationale: Normal physiologic changes of the middle-aged adult do not include peripheral pulses becoming weak and not always palpable. The other options can be seen in a middle-aged adult.
A nurse is preparing a presentation for families who are caring for older adults at home. Which information would the nurse most likely include about an older adult's cognition? a) Delirium is more common in middle-age adults. b) Dementia is considered a normal part of aging. c) Many older adults retain full cognitive function into advanced age. d) Aging normally leads to impairments in judgment and insight.
Answer: Many older adults retain full cognitive function into advance age. Rationale: Many older adults retain full cognitive (thinking) function into advanced age. Dementia is not a normal part of aging. Older adults experience higher rates of delirium as compared to younger adults. Although some older adults may experience impairments in judgment and insight, this is not a normal change.
A nurse is preparing a presentation for families who are caring for older adults at home. Which information would the nurse most likely include about an older adult's cognition? a) Delirium is more common in middle-age adults. b) Many older adults retain full cognitive function into advanced age. c) Aging normally leads to impairments in judgment and insight. d) Dementia is considered a normal part of aging.
Answer: Many older adults retain full cognitive function into advanced age. Rationale: Many older adults retain full cognitive (thinking) function into advanced age. Dementia is not a normal part of aging. Older adults experience higher rates of delirium as compared to younger adults. Although some older adults may experience impairments in judgment and insight, this is not a normal change.
A male client reports chronic insomnia. Which medication would the nurse not want to administer to the client? a) Nasal decongestant for an upper respiratory infection b) Beta blocker for blood pressure control c) Diuretic in the morning for hypertension d) Acetaminophen for postoperative pain
Answer: Nasal decongestant for an upper respiratory infection Rationale: Decongestants can worsen insomnia in the older adult.
A nurse is providing care at an ambulatory care center to a wide range of older adults from diverse racial and ethnic groups. Based on recent statistics, which group would the nurse most likely identify as projected to be the largest? a) Asians b) Hispanics c) African Americans d) Non-Hispanic whites
Answer: Non-Hispanic Whites Rationale: In 2012, 21% of people 65 and over were members of racial or ethnic minority populations. Racial and ethnic minority groups have increased from 6.1 million in 2002 (17% of the older population) to 8.9 million in 2012 (21% of the older population) and are projected to increase to 20.2 million in 2030 (28%% of the older population). Between 2012 and 2030, the white non-Hispanic population 65 years or older is projected to increase by 54%, compared with 123.5% for older racial and ethnic minorities, including Hispanics (155%); African Americans (104%); American Indian and Native Alaskans (116%); and Asians (119%).
An 80-year-old client tells the nurse that he has been dizzy since starting to take an herbal remedy for arthritis in addition to prescribed medications. The nurse recognizes that the client may be experiencing the effects of which of the following? a) Fluid volume overload b) Polypharmacy c) Cascade iatrogenesis d) Sleep disorder
Answer: Polypharmacy Rationale: Polypharmacy, the use of many medications at the same time, can pose many hazards for older adults. Alternative therapies, such as herbal remedies, have the potential to interact with prescribed drugs. Fluid volume overload and sleep disorders are not the cause of dizziness. Cascade iatrogenesis is a sequence of adverse events in a frail, older adult.
An 85-year-old client's daughter calls the nurse and states her father is recently having periods of confusion, is unable to dress himself, and is having periods of incontinence. Which of the following should the nurse do first? a) Make arrangements for the client to move to an extended-care facility b) Perform a SPICES assessment c) Teach the daughter how to use reminiscence as a therapy d) Schedule an appointment for a physical examination
Answer: Schedule an appointment for a physical examination Rationale: Drug interactions, circulatory or metabolic problems, nutritional deficiencies, or a worsening illness are likely causes for confusion and changes in function, thus a physical examination is indicated. Moving to an extended-care facility is premature until physical causes have been examined. Reminiscence therapy, a way for older adults to facilitate adaptation by reliving past experiences, is used for psychosocial development. A SPICES (sleep problems, problems with eating and feeding, incontinence, confusion, evidence of falls, and skin breakdown) assessment is used to identify problems that can lead to negative outcomes in the elderly client. Although it may be useful in this client, the priority is finding the cause for the physical changes
In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client? a) Sleep deprivation b) Grieving c) Social isolation d) Noncompliance
Answer: Sleep deprivation Rationale: A common problem in clients with dementia is sundowning syndrome in which an older adult habitually becomes confused, restless, and agitated after dark and does not sleep. Implementing the nursing diagnosis of sleep deprivation will help the client obtain adequate sleep at night and awaken refreshed. Social isolation, grieving, and noncompliance are diagnoses that could be related to dementia but not sundowning.
In a report, the night nurse tells the incoming nurse that one client with dementia has sundowning syndrome. Which of the following nursing diagnoses would be most appropriate for this client? a) Sleep deprivation b) Noncompliance c) Grieving d) Social isolation
Answer: Sleep deprivation Rationale: A common problem in clients with dementia is sundowning syndrome in which an older adult habitually becomes confused, restless, and agitated after dark and does not sleep. Implementing the nursing diagnosis of sleep deprivation will help the client obtain adequate sleep at night and awaken refreshed. Social isolation, grieving, and noncompliance are diagnoses that could be related to dementia but not sundowning.
There is an 86-year-old female on the medical inpatient unit. She explains that the hospital is quite noisy and that she is having difficulty sleeping. Which is not true regarding sleep in the older adult? a) Deep sleep declines in the older adult. b) Chronic cardiovascular or respiratory illness can interfere with sleep. c) Stage 1 sleep increases in the older adult. d) Sleep medications are usually the first choice in treating sleep disturbance.
Answer: Sleep medications are usually the first choice in treating sleep disturbance. Rationale: Medications are typically the last choice for treating sleep disturbance because they can interact with other medications or have paradoxical effects on the older adult.
There is an 86-year-old female on the medical inpatient unit. She explains that the hospital is quite noisy and that she is having difficulty sleeping. Which is not true regarding sleep in the older adult? a) Deep sleep declines in the older adult. b) Stage 1 sleep increases in the older adult. c) Chronic cardiovascular or respiratory illness can interfere with sleep. d) Sleep medications are usually the first choice in treating sleep disturbance.
Answer: Sleep medications are usually the first choice in treating sleep disturbance. Rationale: Medications are typically the last choice for treating sleep disturbance because they can interact with other medications or have paradoxical effects on the older adult.
An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? a) Functional b) Urge c) Overflow d) Stress
Answer: Stress Rationale: Stress incontinence is caused by pelvic floor muscle weakness or urethral hypermobility. Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contraction. Overflow incontinence occurs when the bladder muscle distends and urine is forced out. Functional incontinence occurs when a physical or psychological impairment impedes continence despite a competent urinary system.
An older adult female client tells the nurse, "Whenever I sneeze or cough, I urinate a little bit. It's very embarrassing." The nurse interprets the client's statement as indicating which type of incontinence? a) Urge b) Stress c) Functional d) Overflow
Answer: Stress Rationale: Stress incontinence is caused by pelvic floor muscle weakness or urethral hypermobility. Urge incontinence is caused by an overactive detrusor muscle causing involuntary bladder contraction. Overflow incontinence occurs when the bladder muscle distends and urine is forced out. Functional incontinence occurs when a physical or psychological impairment impedes continence despite a competent urinary system.
When providing nursing care to the elderly, it is most important to provide comfort due to which of the following changes? a) Dementia b) Isolation c) Thermoregulation d) Sexuality
Answer: Thermoregulation Rationale: The body can adapt to environmental temperatures within broad limits, but age and health status greatly affect this capacity. Thus, in the provision of nursing care that focuses on comfort, the nurse must be aware of changes in thermoregulation
A 90-year-old woman is admitted to a nurse's unit status post CVA. The client is alert and oriented to person, place, and time but has limited mobility and hemiparesis of the left side of her body. She is experiencing urinary incontinence. What is the most appropriate nursing action? a) Insert a Foley catheter to prevent incontinence. b) Assist the client once per shift to use the commode. c) Use disposable padding (Chux) to keep the bedding dry. d) Use the Braden scale to assess for pressure ulcers.
Answer: Use the Braden scale to assess for pressure ulcers. Rationale: The Braden scale is an evidence-based tool used to assess for pressure ulcers. Pressure ulcers can result from urinary incontinence, particularly if the skin is moist and skin integrity is impaired. The client would likely require assistance every time she uses the toilet. A Foley catheter is an extreme solution to this problem.
A nurse arrives at the home of an older adult client. The agency was called because a neighbor noticed that the client was home alone. The nurse finds the client alone in the living room. When asked about the client's daughter who lives there and has been caring for her, the client says, "She went on vacation for about a month. She'll be back soon." Further assessment reveals that there are no other family members or services currently involved. The nurse would identify this situation as: a) emotional abuse. b) neglect. c) abandonment. d) exploitation.
Answer: abandonment Rationale: The client is alone and without any support or caregivers. Therefore, abandonment, which is the desertion or a vulnerable older adult by anyone who has assumed responsibility for that adult's care, would apply. Exploitation involves illegally taking or misusing funds, property, or assets of a vulnerable older adult. Neglect involves refusal or failure by those responsible to provide food, shelter, protection, or health care for a vulnerable older adult. Emotional abuse involves verbally or nonverbally causing mental pain, anguish or distress on the older adult.
A 76-year-old man is recovering from a myocardial infarction. In regards to his recovery, it is important for the nurse to: a) have a male counterpart address sexuality. b) instruct him to eliminate sex for 1 month. c) address any questions about sexuality. d) refer the client to a therapist.
Answer: address any questions about sexuality Rationale: With regard to sexuality, the nurse should spend time with the older adult; use clear, easy-to-understand language; help the client feel more comfortable talking about sex; be open minded and talk openly; listen, and encourage discussion; give advice or suggestions as needed; and understand that sex is not just for the young.
A nurse is providing care to an older adult who is experiencing delirium. Which risk factors would the nurse identify as being most common? Select all that apply. a) poor nutrition b) trauma c) sleep deprivation d) advanced age e) pre-existing cognitive impairment
Answer: advanced age; pre-existing cognitive impairment Rationale: Although trauma, poor nutrition, and sleep deprivation are risk factors for delirium, advanced age and preexisting cognitive impairment are the most common.
A nurse is preparing a presentation for a group of families who are providing care to their older adult parents. One of the family members asks the nurse, "How common is Alzheimer's disease?" The nurse responds by telling the group that after age 65, the prevalence of Alzheimer's disease: a) decreases by 10 for every year. b) triples every year. c) doubles every 5 years. d) declines but the rate is unknown.
Answer: doubles every year Answer: According to the Alzheimer's Association, the prevalence of Alzheimer's disease doubles every 5 years beyond age 65.
An elderly patient has come in to the clinic for her yearly physical. The patient tells the nurse that she is having difficulty with bowel movements. What intervention could the nurse suggest? a) Increasing caloric intake b) Adequate privacy c) Stress reduction d) Increasing intake of water
Answer: increasing intake of water Rationale: Age-related changes, as well as additional risk factors such as disease and the effects of medications, can result in a negative impact on function. Constipation is a common problem in aged people. The nurse should assess the patient for frequent laxative and antacid use, which is associated with constipation. The patient should eat high-fiber foods, drink eight to 10 glasses of water daily, and establish regular bowel habits. Interventions the nurse would not suggest are stress reduction, eating more, or insuring adequate privacy.
The nurse is assessing an older adult client who has suffered injury to his nervous system. The client has a history of chronic pain and currently reports pain on a scale of 8 out of 10. The nurse identifies this type of pain as most likely: a) central pain. b) postherpetic neuralgia. c) phantom limb pain. d) neuropathic pain.
Answer: neuropathic pain Rationale: Chronic pain is most commonly caused by osteoarthritis. Other conditions causing chronic pain include neuropathic pain (chronic pain resulting from an injury to the nervous system), central or neuropathic pain after stroke, postherpetic neuralgia (result of damage to nerve fibers caused by the herpes zoster virus, commonly known as shingles), and phantom limb pain after amputation.
While assessing an older adult, the client reports pain resulting from shingles. The nurse identifies this as which type of pain? a) Phantom limb pain b) Chronic pain c) Neuropathic pain d) Postherpetic neuralgia
Answer: postherpetic neuralgia Rationale: Chronic pain is most commonly caused by osteoarthritis. Other conditions causing chronic pain include neuropathic pain (chronic pain resulting from an injury to the nervous system), central or neuropathic pain after stroke, postherpetic neuralgia (result of damage to nerve fibers caused by the herpes zoster virus, commonly known as shingles), and phantom limb pain after amputation.
The nurse is assessing an older adult client who is having difficulty with mobility. Assessment reveals that the client has stiff and awkward muscle movements. The nurse identifies this as: a) spasticity. b) ataxia. c) disequilibrium. d) hemiparesis.
Answer: spasticity Rationale: Spasticity refers to stiff or awkward muscle movements. Hemiparesis refers to weakness on one side of the body. Ataxia refers to impaired muscle coordination. Disequilibrium would lead to balance problems.
A client is in the postoperative phase of an abdominal resection and colostomy. When educating the client on ostomy care by providing educational materials to read, it is important to assess the client's: a) gait. b) vision. c) hearing. d) social support.
Answer: vision Rationale: The nurse must ensure that the client's vision allows for reading. Social support and gait do not relate to the provision of written education materials.