Gero. Exam 2
What order should the 4 laxative classes be administered? (first to last resort)
1. Bulk forming (Psyllium) 2. Docusate (Emollients) 3. Osmotic laxatives (Milk of mag, lactulose) 4. Stimulant laxatives (Bisacodyl)
What is the recommendation for getting "enough" exercise?
2.5 hours of moderate intensity exercise and muscle strengthening activities on 2 or more days that work all major muscle groups (legs, hips, abdomen, chest, shoulders, arms).
All of the following are symptoms of UTI's in the older adult except A. High fever B. Incontinence C. Decreased appetite D. Change in mental status
A. High fever may not be present. The older adult won't have the classic signs of frequency, urgency, & dysuria.
What are three NX considerations for giving an enema?
A. alteration of fluid/electrolyte balance B. Teach pt. not to use on regular basis (r/t the risk of body's dependence on enema for BM) C. Sodium phosphate enemas are CONTRAINDICATED in older adults. Should be just water.
All of the following are consequences of using restraints except: A. Improved patient outcomes B. Do not effectively prevent falls, wandering or removal of medical equipment. C. Exacerbation of problem D. Restraint related death: asphyxiation (cutting off airway from Vest restraint. E. Increased risk of pressure ulcers, agitation, COG decline, and depression.
A. using restraints does not improve patient outcomes.
Which of the following are risk factors for hypothermia? (Select all that apply) A. Select Impaired circulation B. Diabetes C. Adrenal or thyroid dysfunction D. Malnutrition E. Excessive alcohol use F. Inadequate housing or supervision G. Use of sedatives, anxiolytics, antidepressants.
All are risk factors for hypothermia. Remember that alcohol and inadequate housing are RF's for both hyper/hypothermia.
All of the following are interventions to improve nutritional status except A. Restrictive diet to prevent further damage to CV system. B. Consider ethnic food choices C. Use nutrient dense supplements with medications D. Include family when possible E. Incorporate favorite foods.
Answer: A B, C, D, E are all appropriate.
The Mini-Cog combines a short term memory test (from MMSE) with the Clock Test and has been found to be as reliable as MMSE but less biased, and more sensitive to dementia. -Say 3 unrelated words -Ask pt to repeat words -Ask pt to draw clock -Ask pt to recall 3 words How is this test scored? (select all that apply) A. All 3 words remembered means dementia unlikely B. None remembered menas dementia unlikely C. One or two recalled then consider results of CDT.
Answer: A, B False: C
Edna is a 83 year old woman living in her own home. What are appropriate interventions to keep her safe when managing the MAIL & LAUNDRY? (Select all that apply) A. Easy to access laundry, stool to access clothes in dryer, good lighting, folding laundry while sitting at able, carry laundry in bag on stairs, use cart or laundry services. B. Easy to access mailbox, mail basket at door. C. Have key ready when approaching front door. D. Protect valuables by keeping money and securities in the bank.
Answer: A, B False: C, D These are crime reducing interventions
Blanche is a 77 year old woman living in her home of 20 years. What are appropriate interventions to keep her safe in the KITCHEN? (Select all that apply) A. Substitute microwave or electric toaster for gas stove/burners (open flame). B. Place commonly used items in easy-to-reach areas; adjustable-height counters, cupboards, and drawers. C. Adequate lighting; utensils with brightly colored handles. D. Remove door and use curtain; leave wheelchair at door and use walker.
Answer: A, B, C, False: D "Remove door and use curtain; leave wheelchair at door and use walker." is an intervention for the bathroom.
Allen comes into the ER and has a temperature of 35C or 95F. He is confused and disoriented. What are appropriate nursing interventions? (Select all that apply). A. Monitor body temp against baseline B. To prevent future problems establish a system for when Allen goes back into the community. C. Contact social services for possible assistance with heating/electrical bills. D. Perform depression screening.
Answer: A, B, C, False: D
Which of the following interventions for urinary incontinence are appropriate for Poppy? (Select all that apply). A. Scheduled voiding B. Kegels C. Thorough assessment: how long, when did it start, night/day? D. Avoiding caffeine, smoking cessation, increase exercise E. Medications: anticholinergics F. Permanent urinary catheter as first line of treatment because she will never regain full control.
Answer: A, B, C, D, E False: F: catheter is the ABSOLUTE last resort.
Which of the following GENERALLY happen to the feet as a result of age? (Select all that apply.) A. Skin becomes drier, less elastic, & colder (r/t decreased perfusion) B. SQ fat tissue on dorsum/side foot thins (less cushion on side/bottom of foot). C. Toenails become brittle, thick, increasing risk for fungal infection. D. Routine presence of eschar/necrotic tissue near toenail beds. E. Degenerative joint disease decreasing ROM
Answer: A, B, C, E False: D eschar/necrotic tissue is NOT an expected finding.
Which of the following are RF for changes in fluid balance/hydration status? (Select all that apply.) A. Physiological changes in body water content, and functional impairments B. Impaired thirst sensation C. Medications D. Lack of access to well water E. Chronic illness or emotional illness. F. High environmental temperature.
Answer: A, B, C, E, F False: D access to well water
Which of the following questions are representative of the Geriatric Depression Scale (Short Form). Select all that apply. A. Do you feel that your life is empty? B. Are you in good spirits most of the time? C. Do you feel full of energy D. What do you fear most about your sickness? E. How would you describe the problem that has brought you here?
Answer: A, B, C, F False: D, E Rationale: D & E are part of a cultural assessment Remember on scale: Each number with an asterisk counts as 1 point; a score >5 indicates need for further eval.
Which of the following are consequences of falls? (Select all that apply). A. Hip fractures B. Traumatic brain Injury C. Hendrich syndrome D. Fallophobia
Answer: A, B, D False: C
Which of the following are factors that make older adults susceptible to impaired thermoregulation? A. Neurosensory/physiological changes, medications that impair vasomotor response. B. When an older person can't afford proper heating/air conditioning. C. Adaptive listening devices D. Safety concerns prompting them to bolt doors/windows shut. E. Stage IV pressure ulcer opening up the body to intense temperatures.
Answer: A, B, D False: C, E
Which of the following are accurate about obesity in older adults: A. Recent sharp rise in obese/overweight younger adults. B. 1/3 of the 65+ are obese C. Overweight/obesity is equally dangerous in younger adults and older adults. D. Healthy weight throughout life is the best intervention for obesity.
Answer: A, B, D False: C. Obesity paradox: obesity may be protective in adults >70. (however many obese people don't make it to 70).
All of the following are issues that accompany limited access to safe transportation except: A. Social Isolation B. Poor nutrition C. Problems with thermoregulation. D. Neglect of health (and mental health) E. Increased depression/anxiety F. Increased risk of NX home placement and decreased quality of life.
Answer: A, B, D, E, F False: C
Which of the following are interventions appropriate for Purpura (thin fragile skin w purple splotches on arms aka bruise)? (Select all that apply). A. Wear long sleeves B. Massage bruised area C. Protect from trauma D. Increase fluid intake
Answer: A, C False: B, D (for Xerosis)
Which of the following are interventions appropriate for Xerosis (Dry cracked, itchy skin)? (Select all that apply) A. Increase fluid intake B. Reposition every hour C. Use gentle moisturizing soaps D. Wear long sleeves
Answer: A, C, False: B (for pressure ulcers), D (for purpura)
Dorothy is a 83 year old living in her own home. What are appropriate interventions to keep her safe in the LIVING ROOM? A. Board under cushion; pillow or folded blanket to raise seat; blocks or platform under legs; good armrests to push up on; back seat and cushions. (Select all that apply) B. Encourage her to wear small police whistle around neck or carry mace in case of intruders. C. Block motion of swivel/rocking chairs D. Relocate/remove obstructing furniture to clear paths E. Run extension cords along walls, eliminate unnecessary cords, place under sturdy furniture and use power strips with breakers.
Answer: A, C, D False: B This is a suggestion to reduce crime against older adults.
Which of the following are appropriate interventions to implement sleep hygiene? (Select all that apply). A. Avoid stimulants and alcohol B. Eat snacks in the bedroom to ensure falling asleep on a full stomach. C. Avoid screen time just before bed. D. If you can't fall asleep go to another room until feeling sleepy. E. Manage GERD Symptoms
Answer: A, C, D, E False: B
To reduce risk of fires in the home what are appropriate tips to share for best practice? (Select all that apply). A. Contact local Fire Dep. non-emergency line and explain special needs. B. Bedside light, night lights, flashlight attached to walker/cane C. In high rise apartment, remain in the room with doors and hall vents closed unless smoke is in apartment; open/break window to get fresh air D. Rehears what to do if clothing catches on fire (stop, drop, roll). E. In multistory home, arrange to sleep on ground floor near an exit.
Answer: A, C, D, E False: B Bedside light, night lights, flashlight attached to walker/can is an intervention for to keep older adults safe in the BEDROOM
Which of the following are accurate regarding pressure ulcers? (Select all that apply.) A. Hospitalized or institutionalized older adults are at greater risk. B. Those who have undergone orthopedic procedures (hips, knees, long surgeries etc) are at lesser risk. C. Increases risk of mortality r/t infectoin D. High prevalence of healthcare litigation (lawsuits) E. If a person develops a pressure ulcer in the facility insurance WILL NOT pay for it.
Answer: A, C, D, E False: B (orthopedic procedures and long surgeries increase the risk of pressure ulcers).
To prevent fires and burns what are appropriate tips to share for best practice? (Select all that apply) A. Identify emergency exists in public buildings B. Keep second walker or wheelchair at top or bottom of stairs. C. In boarding or foster home, check to see that it has smoke detectors/sprinkler system, and fire extinguishers. D. Wear clothing that is nonflammable or treated with a permanent fire-retardant finish. E. Use several electrical outlets rather than overloading one outlet.
Answer: A, C, D, E, False: B is an intervention for safety in the home when using stairs.
Maude is an 89 year old woman living alone in her home of 20 years. What are appropriate interventions to keep her safe in the BATHROOM? (Select all that apply) A. Raised toilet seat w side bars B. Cordless phone, cell phone, with in reach C. Bath (transfer) bench, hand held shower nozzle, rubber mat, hydraulic lift bath seat. D. Check water temperature before bath (set hot water thermostat to 120F or less, using bath thermometer). E. Remove door and use curtain; leave wheelchair at door and use walker.
Answer: A, C, D, E, False: B Rationale: Cordless phone etc. are interventions for Maude's problems with the telephone
Which of the following is/are appropriate interventions for fungal infections (yellow, brown nail, flaking/erythema of skin and feet). A. Keep foot clean/dry B. Use padding and avoid sharp tools to remove nail C. Custom shoes and socks E. HOB in upright position
Answer: A. Keep foot dry/clean.
All of the following are components of proper foot care except A. Swimming can improve foot hygiene by letting the feet breathe. B. Yearly foot exam by HCP (especially for those with DM) C. Proper are of toenails D. Propper fitting footwear E. Orthotic shoes PRN.
Answer: A. Swimming has nothing to do with foot hygiene. Proper care of toenails includes: -knowing nails are best cut after soaking for 30 minutes. -clip straight across (not curved)
Which of the following is the most appropriate intervention for hammer toe (permanently flexed toe)? A. Custom shoes or surgery B. Keep feet clean/dry C. Copious amounts of lotion D. Elevate legs to promote venous return.
Answer: A. custom shoes or surgery is the most appropriate intervention for hammer toe.
Which of the following are risk factors for falls: A. Orthostatic hypotension B. Cognitive Impairment C. Impaired vision/hearing D. Medications E. Environmental factors F. Weakness and frailty.
Answer: ALL are RF for falls.
Which of the following are interventions to prevent hyperthermia? (Select all that apply). A. Drink 2-3 L of water B. Minimize exertion, stay in air conditioned places/use fans C. Take tepid baths/showers D. Wear hats/loose clothing, remove clothing when indoors. E. Apply cold, wet compresses, or immerse hands/feet in cool water. F. Avoid alcohol, and evaluate medications for risk of hyperthermia.
Answer: ALL are appropriate to prevent heat stroke.
To prevent fires and burns what are appropriate tips to share for best practice? (Select all that apply) A. Do not smoke in bed or when sleepy B. When cooking do not wear loose-fitting clothes C. Set thermostats for water faucets so that it does not become too hot. D. Install a portable hand fire extinguisher in the kitchen E. Keep access to outside door(s) unobstructed.
Answer: ALL are correct
To reduce risk of fires in the home what are appropriate tips to share for best practice? (Select all that apply). A. Smell smoke, see flames, hear fire, evacuate everyone in the house FIRST B. Use normal exits, never use elevators C. Make sure smoke alarms are installed on each level of home and outside all sleeping areas. Replace batteries D. Know at least two exits from every room E. Make necessary accommodations like exit ramps and widening doorways
Answer: ALL are correct
Which of the following are appropriate interventions to implement sleep hygiene? (Select all that apply). A. Maximize comfort with pillows etc. B. Restrict bedroom for sleep/sex ONLY C. Avoid or limit naps (<30min) D. Exercise and go outdoors E. Institute a bedtime routine.
Answer: ALL are correct
When assessing the patient for Seborrheic Keratosis (waxy raised lesion), what will the NX be do? (Select all that apply). A. Knowing that in darker skinned people, the lesion looks darker than the skin tone B. Comparing findings to baseline C. Reassure patient that Seborrheic Keratosis is NON PREVENTABLE.
Answer: ALL are correct.
Which of the following are appropriate interventions to prevent falls? (Select all that apply). A. Fall prevention bundles (arm bands, signs, standardized edu., risk assessment, etc.) B. Environmental modifications C. Assistive devices, Wheelchairs D. Safe client handling E. Alarms/motion sensors as an alternative to restraints.
Answer: ALL of these are appropriate.
Which of the following are accurate concerning side rails?(Select all that apply). A. Research does not show side rails reduce falls/injury B. Need HCP order to put all 4 rails up. C. Climbing over side rails is a fall risk D. Medicare/Medicaid require documentation and need for side rails.
Answer: ALL of these are correct
Blanche is a 77 year old woman living in her own home. What are appropriate interventions for HOME SAFETY? A. Remote-controlled door lock, door wedge, hook/chain locks B. Automatic door openers; level doorknob handles, intercom at door. C. Lever and crank handles for windows. D. Blinking lights vibrating surfaces for alarms. E. Illumination 1-3 feet from object being viewed; change bulbs when dim; adequate lighting in stairways/hallways, use of night lights.
Answer: All are interventions that promote home safety.
In order to treat a heat stroke, what is the priority nursing intervention? A. Drink 2-3L of water to cool them down from the inside. B. Minimize exertion which could further raise HR C. Get them out of the heat D. Evaluate medications for the risk of hyperthermia. E. Avoid alcohol.
Answer: B Getting them out of the heat is the priority nursing intervention. Treat the underlying cause.
Which of the following is the most appropriate intervention for a bunion (bony deformity of foot)? A. Keep feet clean/dry B. Custom shoes, surgery or steroid injection C. Keep side rails up to decrease activity on bunion. D. Use copious amounts of lotion.
Answer: B custom shoes, surgery or steroid injections are appropriate for bunions.
Which of the following are interventions appropriate for Actinic Keratosis (precancerous skin lesion)? (Select all that apply). A. Keep skin dry and clean B. Use sunscreen C. Get HPV vaccination D. Protect from trauma
Answer: B use sunscreen False: A (for candidiasis), C, D (for purpura).
Which of the following are assessment tools used to measure fall risk? (Select all that apply). A. Braden's Scale B. Mores Scale C. Minimum Data Set (MDS 3.0) D. Hendrich II
Answer: B, C, D False: A
Estelle is a 79 year old living in her own home. What are appropriate interventions help her use the TELEPHONE? (Select all that apply) A. Never open the door automatically, use an optical viewer and confirm authenticity of a service person's ID. B. Cordless phone or cell, inform friends to let phone ring 10 times, answering machine and call back C. Use headset or speaker when she has trouble hearing. D. Preset numbers, have phone with large button numbers and voice activated dialing. E.
Answer: B, C, D False: A This choice is an intervention to reduce crime.
Betty is a 87 year old woman living alone in her home. What are appropriate interventions to keep her safe in the BEDROOM? (Select all that apply) A. Remove door and use curtain; leave wheelchair at door and use walker. B. Remove any wheels on bed, and use leg extensions/blocks or second mattress if bed is too low. Consider adjustable height hospital bed. C. Bedside light, night lights, flashlight attached to walker/cane D. Remove rugs and use nonskid wax (or no wax) on floors. Have Betty wear rubber sole footwear. E. Metal strop at edge of thick carpet or doorsill, tape down edge. F. Bedside (cordless) phone, cell phone, intercom, buzzer or lifeline.
Answer: B, C, D, E, F False: A Rationale: "Remove door and use curtain; leave wheelchair at door and use walker." is an intervention for the bathroom.
Which of the following are questions representative of a Culturally Sensitive Assessment? Select all that apply. A. Do you feel pretty worthless about the way you are now? B. How would you describe the problem? C. How long have you had the problem? D. What do you think is happening to you? E. Why has it happened to the involved part? F. What do you think will help this problem/Who else do you think can make you feel better?
Answer: B, C, D, E, F False: A, Rationale: A is from the Geriatric Depression Scale (Short Form). Remember: older adults are a different culture; ask them to ELABORATE
Which of the following are examples of INSTRUMENTAL Activities of Daily Living? (Select all that apply) A. Toileting, transferring, continence B. Ability to use telephone C. Dressing, feeding, bathing D. Shopping/Ability to Handle Finances E. Food prep., housekeeping, laundry F. Responsible for own medication, has mode of transportation
Answer: B, D, E, F False: A, C Remember: LAWTON is used to assess IADLs KATZ is used to assess ADLs
Which of the following is NOT a factor that makes older adults more susceptible to crimes? A. Living alone B. Memory impairments C. Protect valuables by keeping money and securities in the bank.
Answer: C
A student nurse deems that a falls assessment should be done on a patient who's gait is already notably unsteady. Which scale would work is appropriate (select all that apply) A. Henrich II B. Tinetti Balance & Gait C. Morse Fall Scale
Answer: C False: A, B Rationale: The Hendrich II and Tinetti Balance/Gait may not be the best choice if the pt gait is already unsteady and they're having trouble getting up.
Which of the following are most important intervention to preventing candidiasis (yeast infection found in the skin folds)? A. Turn every hour B. Use copious lotion C. Keep skin dry and clean D. Keep DM controlled.
Answer: C, D False: A (pressure ulcers), B (pruritis).
Which of the following are interventions appropriate for Pruritis (itchy skin). (Select all that apply). A. Use sun screen B. Don't pet animals if allergic C. Use fragrance free products D. Use lots of lotion
Answer: C, D False: A, B
Which of the following is the most appropriate intervention for Corns/Calluses (thick compacted skin). A. Let legs dangle at side of bed to promote arterial blood flow. B. Copious amounts of lotion C. Avoid sharp tools in OTC preparations to remove skin. D. Decrease activity to stop intermittent claudication.
Answer: C. Avoiding dangerous OTC preparations that include sharp tools is the priority NX intervention for geriatric patients with corns/calluses
All of the following are interventions to improve nutritional status except A. Finger foods B. Liberal diets C. Visually appealing foods D. Only yellow foods bc they're easier for the old people to see. E. Easy access to refreshment stations with juices, water, healthy snacks.
Answer: D A, B, C, E are all appropriate.
The nurse responds to an older client who is experiencing heat fatigue. What is the priority NX intervention? A. Place client in dorsal recumbent position B. Assess the last time the client urinated C. Assess the skin on head/chest for tenting D. Eliminate underlying cause, get them out of the heat.
Answer: D.Eliminate underlying cause, get them out of the heat.
All of the following are interventions to improve nutritional status except A. Establish a routine for meals/snacks B. Visual cues and hand over hand assistance PRN C. Appropriate utensils and dinnerware D. Offer fluids in between bites E. Don't include family they're a distraction. F. Allow time to enjoy and complete meal.
Answer: E family should be included, distractions excluded.
Rose is a 72 year old woman living in her own home. What are appropriate interventions to keep her safe when using STEPS? (Select all that apply) A. If steps can't be tolerated use stair glide, lift, elevator ramp B. Install at least one hand rail C. Remove or nail down rugs to wooden steps. E. Keep second walker or wheelchair at top or bottom of stairs.
Answer: all choices are correct.
Which of the following are factors that affect fulfillment of nutritional needs in the 65+? (Select all that apply.) A. Age associated changes in taste/smell B. Oral health status, chronic disease C. Side effects of medications D. Socialization, anorexia of aging, income, transportation, housing. E. Prolonged NPO status, severely restricted diets, insufficient time for feeding assistance.
Answer: all these are factors that affect the fulfillment of nutritional needs.
Lucy an 89y/o female is admitted to the hospital with a DX of pneumonia and no fever. 4 hours later the CNA takes her temperature and reports 38.8 C or 101 F. The nurse knows that A. This is a normal finding for Lucy, her body is fighting the infection and she is making excellent progress B. Her fever should be reported because and should be taken seriously because older adults have a lower resting temperature.
B. Older adults have a lower resting temperature.
All of the following are S/S associated with sleep apnea except A. Excessive daytime sleepiness r/t lack of restful sleep. B. Sleepwalking C. Snoring, gasping, chocking during the night D. Waking up with H/A or being irritable.
B. Sleep walking is not associated with sleep apnea. Obstructive Sleep Apnea is caused by a decline in tone of upper airway muscles; sometimes tongue slips back.
All of the following are treatments for constipation except: A. Increase physical activity B. Lean the patient back and hurry them to create a sense of urgency. C. Toilet regimen (ex. 30 minutes after a meal or after breakfast). D. Increase fluid & fiber intake
B. The patient should squat, lean forward and be told to take their time (at least 10 minutes).
All of the following are sleep issues associated with sleep except: A. Decreased sleep quality and increase in disorders like apnea/insomnia etc. B. Circadian rhythm response diminished (less REM) C. Doesn't take long to fall asleep D. Frequent awakenings E. Increased day-time napping
C. It takes a longer time to fall asleep
The nurse performed a geriatric depression assessment on a Erwin a 76 year old and suspects positive screen for depression and SI. What is the priority NX intervention? A. Take his Vital signs. B. Call the HCP C. Administer lithium D. Ask if he's planning to hurt himself.
D. Ask if he's planning to hurt himself.
Which of the following are RF for Obstructive Sleep Apnea? (Select all that apply). A. ETOH use B. Sedatives C. Being overweight D. Having a dog that barks in the middle of the night E. Smoking
D. having a dog that barks does not contribute to sleep apnea. Treatments include: CPAP machine, and stopping contributing factors
All of the following are appropriate interventions to prevent pressure ulcers EXCEPT: A. Eliminate friction/irritation B. Reduce moisture C. Turning D. Put side rails up E. Propping (with pillows etc.) F. Promote nutrition
D: is not appropriate to prevent pressure ulcers.
Delirium, thromboembolism (clot), infection, renal failure, kidney stones, constipation are all complications of
Dehydration: reduction in total body water (geriatric syndrome) often associated with a disease process like DM, HF (where the treatment is fluid restriction), respiratory disease, frailty;
June is a 93y/o female who is exhibiting malaise, urinary retention, incontinence, cognitive decline, constipation and reduced BM frequency (although small amounts of stool seep out on occasion). The nurse suspects June has a fecal impaction. How will the nurse treat the fecal impaction?
Digital removal of hard stool from rectum. 1. use LOADS of LUBE 2. May take several days. 3. Don't dis-impact too much bc it is painful and can cause vagus nerve stimulation (bradycardia/hypotension).
The nurse performed a geriatric depression assessment on a 76 year old and suspects positive screen for depression and SI. What is the priority NX intervention?
Do you have a plan to hurt yourself. Safety is a top priority
What does FANCAPES stand for?
F: Fluids A: Aeration N: Nutrition C: Communication A: Activity P: Pain E: Elimination S: Social Skills
True or False Older adults are NOT vulnerable to environmental risks and mistreatment by others because they are more irrelevant to society.
False: Older adults are INCREASINGLY vulnerable to physical/emotional assault therefore: a safe environment allows an older person to live w/o fear of attack, accident or imposed interference.
All of the following are true about malnutrition in older adults except: A. Geriatric syndrome: higher rates of malnutrition in LCR bc they can't feed themselves, chronic disease and functional impairments. B. Malnutrition increases the risk for infection, pressure ulcers, anemia, hip fractures, hypotension, impaired COG, morbidity/mortality. C. Comprehensive screening and assessment is critical to ID'ing older adults at risk for malnutrition. D. Nutrition is less important than making sure the CV meds are given on time.
False: D
True or False: The older adult's inability to maintain temperature is a myth made up by grandmas as an excuse to knit more sweaters.
False: inability to maintain temperature is an expected finding of aging, but having hypothermia/hyperthermia is not NORMAL but is an EXPECTED FINDING.
True or false? There is overwhelming evidence that restraints PREVENT falls, wandering, pulling out IVs/Monitors.
False: restraints can make the situation worse; at all cost do not use restraints.
Lucy an 89y/o comes into the ER complaining of a cough. She doesn't have a fever, but does have crackles in all lobes. The nurse knows that:
Frail older adults have lower baseline temperatures than younger adults and ABSENCE OF FEVER DOES NOT rule out infection.
An older client who is at risk for falling has multiple throw rugs in the home. The NX performs which action to best eliminate the risk of falling.
Get rid of the rug.
What is the #1 intervention for Herpes Zoster (painful vesicular rash over a dermatome)?
Get the vaccine at age 60
Deborah an 81 y/o female was admitted to you're floor 2 hours ago. Since then her temperature has spiked to 104F. She is HOT/DRY, has tachycardia, a mental status change, hypotension, hyperventilation, and looks flushed. What stage of hyperthermia is Deborah experiencing and why are you concerned about it?
Heat Stroke; you are afraid of cellular and organ damage in response to the high temperature HOT & DRY instead of cool/clammy. *Hyperthermia (3)
Pat is a 74 y/o male who's brought to the ER by his son. His son says he hasn't been "acting right" and upon assessment you find he's cool/clammy, has elevated HR, Nauseous, and has a mild increase of core body temperature (from baseline). You find these signs and his altered mental status concerning because you suspect Pat is experiencing
Heat exhaustion. Mild increase in temperature. Pat will be cool/clammy, have altered mental status, nauseous, tachycardia, and be thirsty. *Hyperthermia (2)
The first part is the fall risk portion (objectively) Older adult male gets point for being male (bc men fall more frequently than women.) The second part is the "get up and go test" These components are included in what assessment tool?
Hendrich II
Allen comes into the ER and has a temperature of 35C or 95F. He is confused and disoriented. What is Allen experiencing, and what temperature would be an appropriate goal?
Hypothermia. The goal is >97F
The nurse is interviewing Rosemary in order to compile the components of her health history. In addition to assessing her PMH, reviewing the systems/symptoms, and inquiring about social history, what should the nurse be sure to ask specifically about?
MEDICATIONS: -prescribed -Over the counter -Home Remedies -Herb/Dietary supplements.
Name is examination: Shorter exam that is less specific. What day is today/ What is this (point to eye)? Repeat-- "It's a lovely sunny day but too warm"
MMSE 2
Which examination is a 30 item test: gross screening for dementia. Rules out DX of dementia, but does not DX dementia. Negative: you can almost with certainty say they don't have dementia Positive: requires further investigation.
Mini-Mental State Examination (MMSE)
What Multi disciplinary Assessment tool looks at: Physical Therapy Social Work Nursing and includes resident interviews?
Minimum Data Set 3.0 (MDS)
You are a RN who happens to be sitting next to nell Nell a 68 y/o female watching her grandson's coach pitch game outside. You notice that she becomes pale and sweaty, her daughter asks you to make sure she's okay. You find her pulse is 120 bpm, and her temperature (feels/is) normal. What do you suspect is happening to Nell?
Nell is experiencing heat fatigue. It's a phase of hyperthermia usually overlooked, but can quickly lead to heat exhaustion. You and her daughter take Nell to the shade and she recovers quickly. *Hyperthermia (1)
The nurse is interviewing Otis an 89 year old male. When she asks him a question Otis seems to take a while thinking about this answer to the question. Should the nurse move on to a different question?
No. The nurse ought to: -listen patiently -allow for pauses -don't be loud -allow extra time for thought process.
What Assessment tool has Five dimensions: (looking at overall health, broad/holistic assessment) 1. Social resources 2. Economic resources 3. Mental health 4. Physical health 5. ADL's
OARS Older Americans Resources and Services
What skin problem causes most of aging cosmetic problems and the #1 intervention is use of sunscreen?
Photo damage
These are the steps for what examination? 1. Provide a piece of paper (with a circle on it) 2. Choose 3 unrelated words Wall, sky, shoe (they are completely unrelated, not something like shirt, pants, shoes) 3. Tell them to remember those words. 4. Instruct them to draw a time.Ex. "draw on the click ten after eleven."
Remember must have manual dexterity and visual acuity. Scoring: A score of 1 or 2 is normal Anything >3 represents a cognitive deficit. (higher the score the worse).
What does SPICES stand for?
S: Sleep Disorders P: Problems w eating I: Incontinence C: Confusion E: Evidence of falls S: Skin breakdown Starting point for a more specific assessment.
This disorder is very common in older people. 70% of men and 56% of women 65+. Many don't have a DX but do snore.
Sleep apnea
Dr. Djibouti has prescribed Zolpidem (Ambien) for one of your home health clients. You are aware that this medication causes profound sleepiness and what other common side effect?
Sleep walking = Risk for falls.
List the stages of pressure ulcers I-IV. Unstageable?
Stage I: red non blanchable skin. Stage II: top layer of skin is gone Stage III: involvement of connective tissue. Stage IV: bone involved Unstageable: eschar/necrotic tissue that prevents visibility and must be debrided to be staged.
True or false: Yoga and tai chi exercises have been shown to benefit the 65+ in terms of improving flexibility/balance, pain reduction, enhancing psychological well-being. Tai chi can be adapted for level of function and mobility status; home-based balanced training exercise programs are available.
True
True or False: There are higher rates of depression and social isolation in older adults. Per Medicare all HCPs must now screen all older adults for for depression.
True.
True or false: 1/3 of those 65+ fall each year, and 10% sustain serious injury like a broken hip, head injury or death.
True. Falls are a symptom of a problem, usually caused by something else (geriatric syndrome).
True or false: More than 60% of people over 50 don't get enough exercise and about 90% over 75 don't get enough exercise.
True. Should get 2.5 hrs of moderate exercise weekly. Examples include: -brisk walking, swimming, muscle strength activities, using all major muscle groups.
True or false: More adults die from excessive heat than from all other natural disasters combined.
True. This heat is not in response to an infection.
Poppy is a 68 y/o who has the following S/S: -urge to go >8x/day -leakage of >50mL when laughing/coughing -can't get to the bathroom in time bc of her recent knee replacement. The nurse knows Poppy is experiencing all three types of
Urinary Incontinence
Which of the following are included in a complete assessment of the older adult? A. Physical data B. Biological data C. Cultural (religion, beliefs, practices) D. Psychosocial (family, social activities) E. Functional aspects (physiological and anatomical) F. Growth and Development
all of these components are assessed to provide holistic care.
Glen is a 97 y/o man who upon urinalysis is positive for bacteria. Upon urine culture, bacteria is present, but WBC are absent. The nurse knows this is:
asymptomatic uncomplicated bacteria in urine and should be reported but not treated. (bacteria adhering to bladder wall)