ATI- Gerontology
A nurse is reinforcing discharge teaching about calcium supplements with an older adult female client who has osteoporosis and a recent repair of a fracture in her right hip. Which of the following instructions should the nurse include?
"You should take your calcium supplement with a large glass of water." Rationale: The nurse should instruct the client to take calcium supplements with a large glass of water, with or after meals, to promote absorption of the supplement.
A nurse is contributing to the plan of care for a client who had a recent stroke and a history of gastroesophageal reflux disease (GERD). For which of the following disorders should the nurse plan to monitor this client?
Aspiration pneumonia Rationale: GERD results in reflux of gastric secretions from the stomach into the lower esophagus. When regurgitation occurs, the client is at high risk for pneumonia. Pneumonia occurs due to aspiration of gastric contents into the airway. This client is at increased risk for dysphagia fur to the stroke and history of GERD, so the nurse should monitor closely for aspiration pneumonia.
A nurse is reinforcing teaching with a newly hired assistive personnel about her role in helping older adult clients with activities of daily living (ADLs). The nurse should explain that which of the following is the most common factor that affects a client's ability to perform ADLs?
Chronic phycial diability Rationale: Physical diability is the most common reason older adult lcients have difficulty performing ADLs. Self-care deficit, the nursing diagnosis that describes the inability of the client to perform self-care activities necessary for optimum health and cuntcion, is associated with several physcial etiologic factors: acticvity interolerance, pain, neuromuscular impairment, sensory-perceptual impairment, musculoskeletal impairment, and cognitive impairment.
A nurse is reviewing the medical record of a client who is postmenopausal and has osteoporosis. The client has a new prescription for alendronate sodium. Which of the following findings in the client's history should the nurse recognize is a contraindication to this medciation?
Esophageal stricture Rationale: Clients who has a history of esophageal abnormalities, such as stricture or achalasia, have delayed esophageal emptying, which greatly increases the client's risk for esophageal erosion, bleeding, and perforation. Alendronate sodium is a bisphosphonate, which prevents or slows weakening of bone. It is used to prevent and treat postmenopausal osteoporosis. The nurse should instruct the client to wait at least 30 minutes after taking alendronate sodium before eating, drinking, or taking other medications, and caution her not to lie down for at least 30 minutes after taking the medication. Standing or sitting upright ensures that the client gets the full dose decreases heartburn or the risk of injury to the esophagus.
A nurse at an assisted living center is conducting an orientation session for a group of newly hired assistive personnel (AP). Which of the following instructions should the nurse include regarding clients who are hearing impaired?
Maintain eye contact with the clients Rationale: Many older adult clients who are hearing impaired use lip-reading and gestures to help understand what is said to them. Maintaining eye contact will help to promote lip-reading. `
A nurse is planning to administer diphenhydramine hydrochloride to an older adult client. Which of the following actions should the nurse plan to take prior to administration?
Review the medical record for a client history of glaucoma Rationale: The nurse should review the medical record for a history of glaucoma prior to administration of the medication. Diphenhydramine is contraindicated for client who have narrow-angle glaucoma.
A nurse at a long-term care facility is assisting with with planning care for a group of older adult clients. When planning care, the nurse should consider that older adult clients are most likely to exhibit a decrease in which of the following?
Short-term memory Rationale: The ability to process short-term memories decreases as part of the aging process. As a result, older adult clients might require reminders regarding their medications, ADLs, or daily schedule. The nurse should recognize that residents might have difficulty remembering their names from day to day, ask the same question repeatedly, or need assistance remembering recent events.
A nurse is participating on a committee that is developing age-appropriate care standards for older adult clients. Which of the following of Erikson's tasks should the nurse recommend as the focus?
Integrity Rationale: Integrity vs. despair is the conflict that older adult clients must resolve when they reflect on their lives and their roles. If the client has achieved a sense of unity and fulfillment about life, she will accept death with a sense of integrity, not fear.
A nurse is caring for an older adult client. Which of the following physiologic changes associated with aging can affect medication dosage in this client?
Decreased gastric motility Rationale: Decreased gastric motility results in medications remaining in the digestive tract for longer periods of time, leading to slow absorption of the medication. The provider might have to allow for a longer time for medication onset and peak by extending the length of time between doses.
A nurse is caring for an older adult client who has pneumonia. Which of the following physiologic changes associated with aging placing the client at a greater risk for pneumonia?
Decreased number of cilia Rationale: A physiologic change associated with aging is a decreased number of cilia. This, along with a less effective cough, leads to diminished efficiency of the normal defense mechanisms for clearing the airway, putting the client at increased risk for infection, such as pneumonia.
A nurse is caring for an older adult client who has a new onset of type 2 diabetes mellitus. Which of the following physiologic changes contribute to the development of type 2 diabetes?
Decreased sensitivity to the circulating insulin Rationale: The pancreas in older adult clients demonstrates reduced tissue sensitivity to circulating insulin, leading to an increased risk of developing type 2 diabetes mellitus.
A nurse is assisting with the admission of an older adult client who fell at home 3 days go. The client has a fractured hip, malnutrition, and dehydration. Which of the following laboratory values, noted on admission, should indicate to the nurse prolonged malnutrition?
Decreased albumin Rationale: Decreased albumin is indicative of inadequate protein intake, which is a common finding in a client who has prolonged malnutrition.
A nurse is collecting data from an older adult client for signs of dehydration. Which of the following findings should the nurse consider an expected part of the aging process?
Decreased creatinine clearance Rationale: Creatinine clearance declines with age and, therefore, the kidneys have a decreased ability to concentrate urine. This expected part of the aging process places the client at risk for dehydration.
A nurse is reinforcing teaching with an older adult client who has anemia. Which of the following foods should the nurse recommend to increase the client's iron intake?
Dried fruit Rationale: The nurse should recommend the client eat more dried fruit to increase iron in the diet.
A nurse is collecting data from an older adult client who states he is homeless. Which of the following findings should the nurse document as comorbidities for this client?
Dementia and tuberculosis Rationale: The term comorbidity refers to medical conditions know to co-exist in a client. The number of comorbid conditions present in a client is used to provide an indication of his health status and risk of death. Dementia and tuberculosis occurring in an individual client is an example of comorbidity and increases the client's risk.
A nurse in the clinic is assessing an older adult client for the second time this week. The client reports a decreased energy level, insomnia, and anorexia. Diagnostic tests are within the expected reference ranges. For which of the following conditions should the nurse screen the client?
Depression Rationale: Depression, an altered mood state characterized by decreases every levels, insomnia, anorexia, and sadness, is a common condition among older adult clients. Depression can be a response to an acute or chronic illness. Depression in older adult clients can also be the result of medications such as analgesics, antihypertensives, steroids, and cardiovascular agents.
A nurse at an ophthalmology clinic is collecting data from a client referred by the provider for a potential cataract. Which of the following client reports should the nurse recognize is consistent with cataracts?
Halos when looking at lights Rationale: A cataract is a cloudy or opaque area in the lens of the client's eye. Cataracts in adults usually develop with advancing age and can be hereditary. Cataracts develop slowly and painlessly with a gradual onset of difficulty with vision. Visual problems include difficulty seeing at night, halos around lights or glare sensitivity, and decreases visual acuity, even in daylight. Cataracts are accelerated by environmental factors, such as cigarette smoke or other toxic substances, or in response to metabolic diseases, such as diabetes mellitus.
A nurse is caring for an older adult client who has gout and refuses to eat. The client's provider has approved the family to bring food from home. Which of the following foods should the nurse recommend that the client not eat?
Lentil soup Rationale: The nurse should encourage the client to eat a purine-restricted diet to declare she elevated uric acid levels. The diet is used for clients who have gout, renal calculi, or both in conjunction with medication therapy. Whole grain breads and cereals, oatmeal, wheat bran, meat gravies, fresh and saltwater fish, beans, organ meats, mushrooms, green peas, spinach, asparagus, cauliflower, and baker's and brewer's yeast are all high in purine. Lentils, which are legumes, are a risk source of purines.
A nurse is reinforcing teaching with a group of older adult female clients who are postmenopausal about dietary requirements. Which of the following statements about the role of folic acid should the nurse make?
"Adequate folic acid intake is associated with a reduced risk for heart disease." Rationale: Client who are postmenopausal and consume the recommended daily intake of 400 mcg of folic acid have significantly lower levels of homocysteine, a risk factor for heart disease, than those who do not. Older adult female clients need to improve their daily folic acid intake, which can be accomplished by increasing daily dietary intake of foods such as orange juice, beans, legumes, and green leafy vegetables, as well as foods enriched with folic acid, such as breads and pastas.
An older adult client tells a nurse at a health fair "I am always forgetting things. I cannot even remember where I parked my car! Do you think I have Alzheimer's disease?" Which of the following is a therapeutic response by the nurse?
"That must be very upsetting. Can you tell me about your forgetfulness?" Rationale: This statement is an example of the therapeutic communication technique of empathy and clarification. The client has stated has stated a problem with forgetfulness, so the nurse empathizes with the client's concern and seeks additional information with which to counsel the client.
A nurse is reinforcing teaching with an older adult client who has osteoarthritis of the right hip and lower lumbar vertebrae. Which of the following statements by the client indicates an understanding of the teaching?
"To relieve the pressure on my hip, I can use a cane while ambulating." Rationale: Using a. Cane as an assistive device enables the client to compensate for weakness in the spine by providing some relief of hip pressure. Use of a cane can provide joint support and safety for self-care activities.
A nurse is collecting data from an older adult client. Which of the following actions should the nurse take to collect subjective data?
Allow sufficient time for the client to respond to the questions Rationale: The nurse should recognize that it might take an older adult client longer than other clients to process and respond to questions. Consequently, the nurse shoulda low adequate for the client to respond without appearing rushed. The client's verbal responses formulate the subjective data of the health history.
A nurse is caring for a client who has Alzheimer's disease and refuses to take her morning antihypertensive medication. The client is oriented to name and place and is able to perform ADLs with minimal supervision. Which of the following actions should the nurse take?
Ask the client to express her reasons for refusing the medication and document the event Rationale: Before interviewing or making a judgement about the client's competence, the nurse should evaluate the client. The nurse should then determine if the client's reason for refusal can be addressed.
A nurse is collecting data from an older adult client during an annual physical. Which of the following findings should the nurse report to the provider?
Fasting blood glucose level 160 mg/dL Rationale: The nurse should recognize that a fasting blood glucose level of 160 mg/dL is elevated. The nurse should report this values to the provider for further evaluation, as the client might be showing early signs of diabetes mellitus.
A nurse in a long-term care facility is promoting reminiscence among older adult clients. Which of the following actions should the nurse take?
Institute a daily storytelling hour Rationale: A storytelling hour is an example of reminiscence therapy, which allows clients to share stories of their past and reminisce with others who might have similar or shared memories. According to Erikson's physiological theory, reminiscence is an important action for older adult clients
A nurse is reinforcing dietary teaching with an older client who is on bedrest following development of deep vein thrombosis (DVT) about methods to increase peristalsis. Which of the following high-fiber choices should the nurse recommend?
Navy bean soup Rationale: An older adult client who is on bedrest has an increased risk for constipation due to the decreased peristalsis associated with the aging process. Increasing dietary fiber by adding foods like legumes to the diet, as well as ensuring adequate fluid intake, will promote bowel regularity.
A nurse is assisting with planning care for an older adult client following abdominal surgery for a bowel obstruction. Which of the following information about pain management should the nurse include in the plan of care?
Older adult clients are sensitive to the analgesic effect of opiates Rationale: An older adult client is likely to require a decreased dose of opiates to provide the same level of analgesia as a younger client, with a reduced risk of side effects, because he metabolizes opiates more slowly.
A nurse is assisting with the care of an older adult client who has dementia. The client becomes agitated and confused at night and wanders into the hallway. Which of the following actions should the nurse take?
Place the client's mattress on the floor Rationale: To ensure the client's safety and prevent falls when he is confused at night, the nurse should place his mattress on the floor.
A nurse is contributing to the plan of care for a client who had a stroke. Which of the following goals should the nurse identify as the priority for this client?
The client's airway will remain clear, as evidenced by clear breath sounds Rationale: The nurse should apply the ABC priority-setting framework when caring for this client. This framework emphasizes the basic core of human functioning; having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority-setting framework because adequate ventilatory effect is essential in order for oxygen exchange to occur. Circulation is the third highest priority in the ABC priority-setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. The priority nursing action is to promote pulmonary hygiene as evidenced by clear breath sounds.
A nurse is reinforcing teaching with a group of healthy older adult clients about health screenings after age 50 years. Which of the following health screenings should the nurse recommend that the clients complete annually?
Visual acuity Rationale: The nurse should recommend an annual visual acuity screening for all clients over 50 years of age.
