older adults- adaptive quizzing
The home health care nurse visits an older adult couple living independently. The wife cares for the husband, who has dementia. Which interventions would the nurse implement for them? Select all that apply. One, some, or all responses may be correct. 1 Assess the wife for caregiver burden. 2 Arrange hospice care for the husband. 3 Make health care decisions for the couple. 4 Assess the husband for signs of physical abuse. 5 Identify social support within the community
Correct 1 Assess the wife for caregiver burden. Correct 4 Assess the husband for signs of physical abuse. Correct 5 Identify social support within the community. An older caregiver should be assessed for caregiver burden. Anxiety, depression, relationship tension, or health changes are indicators of caregiver burden. The nurse would assess the client for any unexplained bruises or skin trauma; these are signs of physical abuse. These findings must be reported to the state protective agencies. The nurse would also help the couple identify social support within the community. Terminally ill clients who need pain management require hospice care. The nurse need not arrange hospice care for a client with dementia. The nurse would not make health care decisions for the client. The client and spouse should be consulted in all health care decisions. Test-Taking Tip: Read the question carefully before looking at the answers: (1) determine what the question is really asking and look for key words; (2) read each answer thoroughly and see if it completely covers the material asked by the question; and (3) narrow the choices by immediately eliminating answers you know are incorrect.
An 85-year-old client has just been admitted to a nursing home. When designing a plan of care for this older adult, the nurse recalls which expected sensory losses associated with aging? Select all that apply. One, some, or all responses may be correct. 1 Difficulty in swallowing 2 Diminished sensation of pain 3 Heightened response to stimuli 4 Impaired hearing of high frequency sounds 5 Increased ability to tolerate environmental heat
Diminished sensation of pain Impaired hearing of high frequency sounds Increased ability to tolerate environmental heat Because of aging of the nervous system, an older adult has a diminished sensation of pain and may be unaware of a serious illness, thermal extremes, or excessive pressure. As people age, they experience atrophy of the organ of Corti and cochlear neurons, loss of the sensory hair cells, and degeneration of the stria vascularis, which affects an older person's ability to perceive high-frequency sounds. An interference with swallowing is a motor loss, not a sensory loss, and it is not an expected response to aging. There is a decreased, not heightened, response to stimuli in older adults. There is a decreased, not increased, ability to physiologically adjust to extremes in environmental temperature.
The nurse finds that an older adult has a new onset of decreased consciousness, fatigue, and hallucinations. Which condition would the nurse suspect in the client? 1 Delirium 2 Dementia 3 Depression 4 Alzheimer disease
Delirium Delirium is an acute confusion state in which the client has reduced or disturbed consciousness, fatigue, and distorted perceptions accompanied by delusions, hallucinations, and misperceptions. Clear consciousness exists and misconceptions are usually absent in clients with dementia. Clear consciousness exists and distortions and hallucinations are observed only in severe cases of depression. Alzheimer disease is a progressive cerebral deterioration that can occur in middle-aged or advanced age adults. Test-Taking Tip: Read the question carefully before looking at the answers: (1) Determine what the question is really asking; look for key words. (2) Read each answer thoroughly and see if it completely covers the material asked by the question. (3) Narrow the choices by immediately eliminating answers you know are incorrect.
The nurse is caring for an older adult with a hearing loss secondary to aging. Which would the nurse expect to identify when assessing this client? Select all that apply. One, some, or all responses may be correct. 1 Dry cerumen 2 Tears in the tympanic membrane 3 Difficulty hearing high pitched voices 4 Decrease of hair in the auditory canal 5 Overgrowth of the epithelial auditory lining
Dry cerumen Difficulty hearing high pitched voices Cerumen (ear wax) becomes drier and harder as a person ages. Generally, female voices have a higher pitch than male voices; older adults with presbycusis (hearing loss caused by the aging process) have more difficulty hearing higher-pitched sounds. There is no greater incidence of tympanic tears caused by the aging process. The hair in the auditory canal increases, not decreases. The epithelium of the lining of the ear becomes thinner and drier.
Which are extrinsic factors responsible for falls in older adults? Select all that apply. One, some, or all responses may be correct. 1 Impaired vision 2 Cognitive impairment 3 Environmental hazards 4 Inappropriate footwear 5 Improper use of assistive devices
Environmental hazards Correct 4 Inappropriate footwear Correct 5 Improper use of assistive devices Environmental hazards, inappropriate footwear, and improper use of assistive devices are extrinsic factors that are responsible for falls in older adults. Impaired vision and cognitive impairment are intrinsic factors that are responsible for falls in older adults.
Which age-related change would the nurse consider when formulating a plan of care for an older adult? Select all that apply. One, some, or all responses may be correct. 1 Difficulty in swallowing 2 Increased sensitivity to heat 3 Increased sensitivity to glare 4 Diminished sensation of pain 5 Heightened response to stimuli
Increased sensitivity to glare Diminished sensation of pain Heightened response to stimuli Changes in the ciliary muscles, decrease in pupil size, and a more rigid pupil sphincter contribute to an increased sensitivity to glare. Diminished sensation of pain may make an older adult unaware of a serious illness, thermal extremes, or excessive pressure. There should be no interference with swallowing in older adults. Older adults tend to feel the cold and rarely complain of the heat. There is a decreased response to stimuli in older adults.
Which intrinsic factor is associated with the fall of an older adult? 1 Wet floors 2 Poor lighting 3 Lack of exercise 4 Inappropriate footwear
Lack of exercise 4 Inappropriate footwear Intrinsic risk factors associated with the fall of an older adult may include a lack of exercise or deconditioning. Wet floors, poor lighting, and inappropriate footwear are extrinsic risk factors.
Which is the most important nursing intervention when working with an older adult client? 1 Encouraging frequent naps 2 Strengthening the concept of ageism 3 Reinforcing the client's strengths and promoting reminiscing 4 Teaching the client to increase calories and focusing on a high-carbohydrate diet
Reinforcing the client's strengths and promoting reminiscing Teaching the client to increase calories and focusing on a high-carbohydrate diet Reinforcing strengths promotes self-esteem; reminiscing is a therapeutic tool that provides a life review that assists adaptation and helps achieve the task of integrity associated with older adulthood. Frequent naps may interfere with adequate sleep at night. Reinforcing ageism may enhance devaluation of the older adult. A well-balanced diet that includes protein and fiber should be encouraged; increasing calories may cause obesity.
Outdated and leftover medications from previous prescriptions are discarded at the home of an older adult client. Which Quality and Safety Education for Nurses (QSEN) competency would this intervention involve? 1 Safety 2 Quality Improvement 3 Evidence-based practice 4 Teamwork and collaboration
Safety The nurse ensures the safety of the client by discarding medications that are outdated. It is important to prevent harm to the client who may unintentionally take a medication that is no longer required. Quality improvement requires the nurse to use data to monitor the outcomes of care processes. The nurse ensures evidence-based practice by integrating the best current evidence with clinical expertise, client, and family values for delivery of optimal health care. The nurse functions effectively within nursing and interprofessional teams to promote open communication and mutual respect while applying teamwork and collaboration competency. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options. Example: If the item relates to and identifies stroke rehabilitation as its focus and only one of the options contains the word stroke in relation to rehabilitation, you are safe in identifying this choice as the correct response.
The nurse is caring for an older adult client with dementia. Which client need would the nurse prioritize while providing care? 1 Safety 2 Self-esteem 3 Self-actualization 4 Love and belonging
Safety An older adult client with dementia has impaired cognition. The nurse would make arrangements such as applying bedside rails to ensure that the client's safety needs are met first. At this stage, self-esteem or factors that enhance confidence and self-worth are not as important as safety. Self-actualization is the ability to solve problems and being able to cope realistically, which is beyond the capacity of the client with dementia. All clients need to feel love and belonging; however, safety is the first priority for this client. Test-Taking Tip: Identifying content and what is being asked about that content is critical to your choosing the correct response. Be alert for words in the stem of the item that are the same or similar in nature to those in one or two of the options.