Health Assessment EAQs Ch. 32

Which action by the nurse during the assessment prevents frustration for the older adult patient with altered cognition?

Ask the patient yes or no questions during the assessment.

Which would the nurse assess for during a home visit for an older patient who requires 24-hour care and whose spouse is also elderly?

Caregiver burnout

Which would the nurse assess before determining functional ability for an older adult patient who underwent joint replacement surgery the previous day?

Pain level

Which assessment tool would the nurse use to determine mild deficits when the family reports occasional periods of confusion in a patient?

Montreal Cognitive Assessment

Which instruction regarding exercise in would the nurse include in the care plan of the older adult patient, according to the World Health Organization (WHO)?

Perform muscle strengthening activities at least twice a week

Which discipline would the nurse refer an older patient to in order to determine functional decline during a long hospitalization?

Physical therapist

The nurse is caring for a geriatric patient who reports insomnia. Which would the nurse suggest to promote sleep in the patient?

"Avoid working or watching television in the bedroom."

Which suggestion to ensure proper sleep would the nurse provide to the aging patient who states, "I think my age is catching up with me; I am unable to sleep properly at night"?

"Consume a light snack with milk before going to bed."

Which questions would the nurse ask the patient to obtain a spiritual assessment?

"How does spirituality relate to your concept of health?"

Which is the nurse observing in the older adult patient when asking the patient to rise from a chair, walk 10 feet, turn, walk back to the chair, and sit down?

Timed Up and Go (TUG) Test

Which statement made by the patient indicates effective teaching about dietary modifications to promote sleep?

"I can have milk and crackers at bedtime."

Which information would the nurse provide to promote health in the patient with cardiovascular disease who has difficulty ambulating? Select all that apply.

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

Which interventions made by the nurse ensure proper assessment in the older adult patient? Select all that apply.

- 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.

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 some degree of cognitive impairment. Which cognitive tests would be used for further assessment? Select all that apply.

- Montreal Cognitive Assessment (MoCA) - Mini-Mental State Examination

Which activities are monitored in the instrumental activities of daily living (IADL) in an older adult patient? Select all that apply.

- Shopping - Cooking - Counting

Which are the advantages of the Katz Activity of Daily Living (ADL) scale? Select all that apply.

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

In the assessment of older adults, which activities may be considered activities of daily living (ADLs)? Select all that apply.

- Walking - Dressing - Using the stairs

An older adult patient states, "I have difficulty breathing during the night to the point where it suddenly wakes me up, and I also wake up drenched with sweat." Which further question would the nurse ask the patient to obtain more information about this condition?

- "Do you drink any alcohol before going to bed?"

Which side effects would the nurse include in the teaching plan for an older adult patient who has been prescribed hypnotics and sedatives for insomnia? Select all that apply.

- "You may increase the risk of delirium." - "You may have an increased risk of falls."

Which parameters are included in the Lawton Independent Activities of Daily Living (IADL) scale? Select all that apply.

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

Which factors would the nurse include in the assessment of an older adult patient who reports difficulty sleeping? Select all that apply.

- Depression - Medications - Cardiovascular disease

Which patient findings suggest altered cognition? Select all that apply.

- Difficulty finding words - Difficulty in naming objects

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

- Diuretics - Corticosteroids - Beta-blockers

Which interventions would the nurse expect the health care provider to prescribe for an older adult patient who is experiencing depression related to changes in mobility related to aging? Select all that apply.

- Initiate psychotherapeutic treatment for the patient. - Instruct the patient to perform regular active exercises.

Who would participate in a team to perform a comprehensive assessment of older adults? Select all that apply.

- Social workers - Speech therapist - Primary health care provide

Which conditions might the nurse identify as being responsible when the patient says, "I've had several injuries from frequent falls in the past?" Select all that apply.

-Syncope - Dementia - Diabetic neuropathy - Insomnia

Which result indicates the patient is at a high risk for falls when using the Timed Up and Go (TUG) Test to assess the patient's mobility?

16 sec

In which unit would an older patient be placed after presenting to the emergency department with increased confusion related to an infection?

Acute Care for Elders (ACE) unit

When using the Geriatric Depression Scale (Short Form), which does a score of 1 to 5 indicate?

No evidence of depression

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

Timed Up and Go Test

Which is the purpose for assessing whether the patient is grooming and walking on a daily basis?

To assess the activities of daily living (ADL)

The nurse is using the Katz Index of Independence in ADL tool and finds that the patient performs dressing and feeding and transfers from bed without any assistance, but requires supervision while bathing, toileting, and with continence. What score would the nurse document in the patient's medical records? Record your answer using a whole number. ________ points

3

Which risk would the nurse expect in a patient who consumes excessive amounts of coffee in the day and evening hours?

Insomnia

The nurse advises an older adult patient with insomnia to have a glass of milk at bedtime to promote sleep. This action reduces which condition?

Hypoglycemia

Which would the nurse instruct a patient to do to promote sleep if the patient reports insomnia?

Consume a light bedtime snack

Which would the nurse include as a positive safety effect for a group of older adults who actively participate in a group exercise class?

Decreased falls

Which might the nurse expect to find in the older adult patient who is awake at night and has a difficult time staying awake during the day?

Delirium

During a home visit to assess the environment for safety and ability to remain living independently, which finding warrants further assessment?

Empty refrigerator

The nurse finds that the health care provider is gradually reducing the dose of a patient's psychotropic medications. Which risk would the nurse hope to minimize with this intervention?

Falls

After assessing a patient's ability to maintain independence with driving, which finding indicates a need to discuss driving cessation?

Finding dents and scrapes on the car

A geriatric patient who takes a diuretic follows the nurse's direction to restrict fluid intake before going to bed. Which condition is the patient attempting to avoid?

Insomnia

Which finding when assessing the environment for a patient could impede the functional ability of the patient and be a safety concern?

Loose throw rugs

Which action would best determine the patient's ability to perform self-care?

Observe patient perform own self-care

Which professional often performs the assessment of the advanced activities of daily living (AADLs)?

Occupational therapists

Which information provided by the student nurse about physical activity in the older adult needs correction?

Promotes napping

Which is the appropriate response when an older adult patient insists that the nurse delay a routine assessment until a member of the patient's family arrives at the appointment?

Respect the patient's wish by involving the family member in the assessment.

As the nurse assesses the environment during a home visit, which finding could contribute to isolation for an older adult who uses a wheelchair for mobility?

Stairs at points of egress

Which setting is desirable for assessing the functional abilities of the older adult patient?

The patient's home

Which is the optimal time for the nurse to assess an older adult's ability to transfer?

When patient needs to use bathroom

Which would the nurse include when asking a patient with cognitive deficits questions?

Ask "yes" or "no" questions

The nurse is caring for a patient with delirium and sleep disturbances. Which nonpharmacologic measures would the nurse take to promote proper sleep in the patient? Select all that apply.

- Keep a clock in the patient's room. - Darken the patient's room during night hours. - Open the drapes of the windows in the morning. - Play relaxing music at bedtime.

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 some degree of cognitive impairment. Which cognitive tests would be used for further assessment?

- Montreal Cognitive Assessment (MoCA) - Mini Mental State Exam

During the assessment of an older patient, which patient statement made during the health history will require further patient teaching?

"I walk about 20 minutes a day around the house."

Which parameters would the nurse assess while evaluating the Advanced Activities of Daily Living (AADL) on an older adult patient with a chronic illness? Select all that apply.

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

Which would the nurse consider to ensure that geriatric patients receive effective individualized care? Select all that apply.

- They have varied disabilities. - They will have varied independence.

Which abilities would the nurse evaluate during the Timed Up and Go Test? Select all that apply.

- Walks 10 feet - Maintains sitting balance - Sits back down in the chair - Transfers from sitting to standing

Which environmental modifications would the nurse suggest to an older patient to promote sleep? Select all that apply.

-"Do not watch television while lying on the bed." - "Control the noise level to prevent possible sleep interruptions." - "Obtain a minimum of a half an hour of sunlight exposure per day."

Which disease process, as documented in the patient's records, may make it difficult to complete discharge teaching?

Alzheimer dementia

Which intervention would the nurse include to prevent falls while assessing mobility in an older adult with diabetic neuropathy?

Assess the risk factors and take corrective actions.

During a home health nursing visit, an older adult patient reports having trouble seeing traffic signals and pavement markings clearly while driving, and the nurse observes many traffic tickets lying on the table. Which recommendation is appropriate for this situation?

Assisting the patient in exploring alternate means of transportation

Which instrument would the nurse use to assess the ability of a geriatric patient to bathe, dress, toilet, and transfer from bed to chair?

Katz index of activities of daily living