Emotional (Psychological Abuse)
Using words or actions to control, frighten, isolate, or erode a person's self-respect
What are some examples?
Fead or coercion, threatening, insulting, lying, not keeping promises, humiliation, blaming, puttig someone down
What may be some indicators? Ho
First-line Treatment for RLS
Dopamine agonists such as pramipexole or ropinirole
RLS can have an underlying cause such as
IDA(iron deficiency anemia), uremia(high urea in the blood), or peripheral neuropathy
The restless feeling in the legs is usually associated with
uncomfortable paresthesia(burning or prickling) of the legs.
Diagnosis of RLS is based on history, WHEREAS PLMD
PLMD requires BOTH history and overnight PSG
diff between true apnea and periodic bretahing
Periodic breathing is clusters of breaths separated by intervals of apnea or near apnea. Periodic breathing is defined as three or more episodes of central apnea lasting at least four seconds separated by no more than 30 seconds of normal breathing.
Apprx � dementia clients experience sleep dysregulation associated with:
agitation, wandering, comorbid illness, primary sleep disorders, or medications used to treat dementia
Insomnia
Dx based on sleep history, sometimes with sleep diary, PSG
Can include one or more of the following:
Difficulty falling asleep
Difficulty staying asleep
Waking up too early
Poor quality
What should you do when you notice a sleep problem
Initial evaluation of sleep focuses on medical conditions, substance abuse, mental health problems, and medications
Identify recent stressors and symptoms of depressions, anxiety, and other psychiatric disorders need to be identified
Referral for overnigh
Consequences of age-related sleep changes
Longer time needed to fall asleep
Frequent arousals during the night
More time in bed to achieve some quantity of sleep
Diminished quality of sleep (less dreaming and deep sleep)
Health consequences w lack of sleep
Increased risk for stroke, cancer, obesity, diabetes, depression, and substance abuse
Arthritis and sleep
Chronic pain and discomfort interferes with sleep
COPD and sleep
Awakening from periods of apnea
Sleep quality with age
Length of the lightest sleep stage increases gradually throughout adulthood, older adults experience longer periods of drowsiness without actual sleep during the early part of the night
Shift more frequently in/out of lighter sleep stages
Proportion of de
Sleep quantity with age
Sleep efficiency
Diminishes to 50-70% for older adults (from 80-90% for younger)
Due to prolonged sleep latency (time to get to sleep - increased wakening)
Day time naps - compensation
Melanocyte production with age
decreases
Epidermis - barrier changes with age
cells enlarge and reproduction decreases, melanocyte production decreases
Dermis changes with age
temperature regulation, sensory perception & nourishment for all layers
Subcutaneous skin with age
storage of calories, insulation, and regulation of heat loss
Sweat and sebaceous glands
Sweat (Eccrine/apocrine glands) - secretion - decreases age
Sebaceous - dermis helps stop water loss - dry skin
Nails
become thinner, fragile, brittle and prone to splitting
Hair
loss of body hair (trunk, axillae, pubic), graying and balding
Shingles
viral disease that affects the peripheral nerves and causes blisters on the skin that follow the course of the affected nerves
Post herpetic neuropathy PHN
...
prevention against shingles
Vaccination - less likely to get shingles- recommended to people >60 Zostavax (not recommended for immunosuppressed, TB, allergy to neomycin, or any immunosuppressant meds)
Focus of treatment is medical, antiviral medications, pain management, topical ATB
Keratosis
any skin growth, such as a wart or a callus, in which there is overgrowth and thickening of the skin
excessive growth of keratin, a skin protein, on skin, variety of causes leads to several different types of keratosis
Actinic keratosis
a precancerous skin growth that occurs on sun-damaged skin
face, lips, hands, forearms
can turn into cancer
Seborrheic keratosis
trunk, face, neck, scalp
chicken skin
Candidiasis - yeast
cause: Infection that gets in through cracks in your nail or cuts in skin
Warm damp toes great opportunity for growth
Nails thicker than normal, oddly shaped, yellow, white dots, loosen/separate from bed
Can also spread
More common in men, diabetics, weak
PAD (arterial insufficiency)
Improper functioning of one way valves
Poor blood circulation to lower leg and foot atherosclerosis
Diabetic (combination/arterial blockage and nerve damage)
Age over 60
Cardiac risk factors
Intermittent claudication
Pale, waxy, hairless ulcers
Pain with
Arterial insufficiency
inadequate blood flow through the arteries
Venous insufficiency
Veins not working - 80% of leg ulcers
Valves not working - b/c of clots - interfere with blood flow
High pressure in veins damages the skin
Chronic Vein Insufficiency
Caused by vein wall or valve weakness
Over 50 years old
Risk factors: family history, DVT history
SS: pain, swelling of legs, spider veins, varicose veins, skin discoloration, pruritis, stasis ulcers, pain relief with elevation
Treatment: elevate legs, co
Age/liver spot, senile freckle
Pale dark brown, macules, occurring in exposed areas
Senile purpura
discoloration due to increasing capillary fragility
Areas of brown or bluish discolouration - bruising like
Sebaceous hyperplasia
raised yellow papules with a central depression
Yellowish/doughnut shaped elevations, common on face (mostly men)
Senile/cherry angioma
Bright, ruby-red pinpoint, superficial elevations of small blood vessels
Spider angiomas
Tiny, red papules radiating arms (could indicate pathology)
Venous lakes
Bluish papules with sharp borders, appearing mainly on lips/ears
Acrochordon, skin tags
Flesh coloured , starlike lesions
Xanthelasma
Fatty deposits, usually around eyes
Skin cancer: abnormal growth of skin cells
Age-related changes & long-term sun exposure
Basal cell carcinoma
Squamous cell carcinoma
Melanoma
Basal cell carcinoma
malignant tumor of the basal cell layer of the epidermis
Most common malignant skin cancer 60%
Slow-growing and metastasis is rare
Pearly papule with prominent telangiectasis (blood vessels) or as a scar-like area with no Hx of trauma
Early detection/Tx n
Squamous cell carcinoma
malignant tumor of the squamous epithelial cells in the epidermis
2nd most common skin Ca
Aggressive, high incidence of metastasis (if not identified/treated promptly)
More prevalent in fair-skinned, elderly men who live in sunny climates
head, neck, or h
Melanoma
black tumor
neoplasm of melanocytes
Least common skin Ca
High mortality rate b/c of rapid metastasize
multicolour, raised appearance - asymmetrical, irregular border
Treatable prior to invasion of surrounding tissue
Abcde of cancer.
cancer of melanocytes.
ABCDE of cancer
Asymmetry
Border
Color
Diameter
Elevation
Skin tears
traumatic wounds b/t dermis &/or epidermis cause: friction, rubbing, shearing force - very common in frail elderly
Pressure injuries
localized to skin over bony prominence d/t pressure or with shearing
Various medical devices associated with increased risk for developing pressure injuries
Masks, orthotics, tubing, stockings, boots, nasogastric tubes, cervical collars or braces, tracheostomy tubes & ties
Mandate to document presence of skin breakdown on admission & during hospitalization
Hospital-acquired pressure injury
Reduce mobility, hydration causes skin ulcers.
Functional consequences of pressure injuries
Pain, loss of function, decreased quality of life
Pressure injury classification 1
non-blanchable erythema
Pressure injury classification 0
normal skin
Stage 2 pressure injury
partial thickness
Stage 3 pressure injury
full-thickness skin loss
Stage 4 pressure injury
full-thickness tissue loss
Stage X pressure injury
full-thickness skin or tissue loss�depth unknown (sometimes stage X)
Functional Consequences Affecting Skin Wellness
Delayed wound healing & increased susceptibility to skin problems
Increased risk for postoperative wound disruption, decreased tensile strength of healing, increased risk of secondary infections
Regeneration of healthy skin takes 2x's as long for 80-year-
Examination of the skin
Colour - areas of discolouration
Irregular pigmentation
Areas of sunburn or tan
Indicators of poor circulation
Skin temperature and extremity difference
Skin moisture - oily, dry, clammy
Texture - smooth/rough
Tissue appearance - paper thin (translucent)
Examination of hair and nails
Colour/texture/ general condition of hair
Distribution of hair
Dandruff, scaling
Colour, length, cleanliness, angle, dry/cracked general condition of nails and nail beds
Personal Care practices - part of assessment
person's overall appearance with regard to grooming & attention to personal attractiveness
grooming poor, does person express concern about this and provide explanation
psychosocial factors influencing care practices (socially isolated, limited functional
Nursing Diagnoses skin
Impaired skin integrity: altered epidermis and/or dermis
Risk for impaired skin integrity: at risk for alteration in epidermis and/or dermis
Related to factors: medications, incontinence, dehydration, limited mobility, and nutritional deficits (low albumi
Interventions - promoting healthy skin
Fluid in diet
Humidifiers
Apply moisturizer (use mineral oil or petrolatum)
Avoid massaging bony areas
Avoid products with perfumes/alcohols
Avoid multiple ingredient products (allergic reactions)
Inspect skin regularly
With bathing use less soap
Water te
Evaluating Effectiveness of Nursing Interventions skin
Alleviation of concerns: dry or itching skin
Evaluate response to interventions
Effectiveness of interventions for pressure injury by rate of healing & prevention of complications
Epworth Sleepiness Scale
Determines how likely PT will Fall asleep in a given scenario, 0-3 scale. Score of 9or< is high index for sleep.
Pittsburgh Sleep Quality Index (PSQI)
Pittsburgh Sleep Quality Index (PSQI) is a self-report questionnaire that assesses sleep quality over a 1-month time interval
True or False
Age-related changes have little impact on the overall quantity of sleep of older adults, but they do have a significant impact on the quality of sleep and the quantity of rest
true
True or False
The sleep-wake circadian rhythm generally causes adults to become sleepy between 8pm and 10pm and to wake feeling rested between 7 and 9 am.
6 am and 8 am in the morning not 7=9 so false
What is one of the most effective health promotion interventions to support healthy sleeping patterns for the older adult.
Educations about age-related changes in sleep patterns
Encouragement of daytime napping
Suggesting herbal remedies for sleep
Increas
Educations about age-related changes in sleep patterns
Elder abuse is
`Elder abuse/mistreatment is defined by intentional actions causing harm or create serious risk of harm, whether or not intended to vulnerable older adult by a caregiver or other person who stands in a trusting relationship, or failure by the caregiver to
Prevalence of abuse
1 in 4 vulnerable older adults:
Vulnerable by virtue of the fact that they are physically or psychologically impaired or subjugated
Canada - 4% (at least but many go unreported)
Least likely to suffer from a violent crime but the most likely to suffer vio
Most common perpetrators of abuse.....
Relatives are the most common (Ha, Department of Justice, 2013)
32% of cases - relative
In those cases financial was the greatest
Elderly are reluctant to lay charges against their children
Also happens in nursing homes
Three Basic Categories of abuse
Three Basic Categories
Physical Abuse
Using physical force against a person without their consent
What are some Indicators? How can we tell abuse is going on?
The person may look skinny, hair brittle, guarded, looking at the ground, dehydrated.
Neglect
Failing to adequately provide necessities or care for a dependent older person.
Examples:
Failing to provide adequate nutrition, personal care, or a clean, warm, safe environment
Withholding medical services or treatments
Failing to provide proper needed
financial abuse
Acting without the older persons consent in a way that benefits the abuser at the expense of the older person through threats, intimidation, or deceit. Most forms of financial abuse are crimes.
What are the examples?
Shopping for someone and buying your o
Vulnerability and abuse
Vast majority of cases go unreported.
Social, personal, situational and environmental factors associated with vulnerability. Language
Older adults may have less contact with the outside world.
Older adults reluctant to admit to abuse/neglect
Significant p
Caregiver
Caregivers may abuse due to
Life stresses: role overload, burnout, work,
Pathologic characteristics: narcissist, anti social
Personality characteristics,
Insufficient resources, they are broke
Lack of understanding of older adult's condition: they lack ed
Questions to ask when assessing suspected abuse.
Examples - please refer to your policies at your work environment
Physical Abuse
Do you feel safe at home?
Has anyone tried to hurt you in any way?
Have you had any recent injuries?
Has anyone ever touched you or tried to touch you without permission?
Hav
Nursing Diagnosis for abuse
Compromised Family Coping
Disabled Family Coping
Caregiver Role Strain
Risk for Injury
Decisional Conflict
Goal is toward wellness
Understand that it is complex
Support for caregiver
Need to consider this for nursing homes as well - BIG picture
Help for v
Residents' Bill of Rights
Prevention of Abuse and Neglect
� Every resident has the right to be protected from abuse.
� Every resident has the right not to be neglected by the Home or staff.
Nociception
Processing of pain signals in the brain that gives rise to the feeling of pain.
Transduction
Tissue damage by thermal (burns) chemical (chemotherapy) or mechanical stimuli (cuts)- secretion of prostaglandin, bradykinin, histamine, serotonin, substance P (
Neuropathy
Originates from abnormal processing of sensory stimuli by the central or peripheral NS
Can occur in the absence of immediate tissue damage or inflammation
Does not serve any purpose
Can be brought on by mechanical, thermal, chemical stimuli
Viruses, infec
Acute pain
Sharp - immediate pain from injury
Triggered by physiologic malfunction
Normal predictive response to chemical, thermal or mechanical stimulus
Purposeful - resolution focus
Burns, trauma, medical/surgical procedures, cancer
Time limited
Responds to anti-i
Chronic pain
Last longer than 3-6 months beyond expected healing
Increases with age (Canadian women over 65)
Perception involves many neurotransmitters/receptors
Combination of nociception and neuropathic
Causes - injury, medical Tx, surgical Tx, inflammation/neuropat
Misconceptions held by health care professionals about pain
Older adults have higher tolerance (false)
People with dementia do not experience pain (false)
People who are sleeping do not experience pain (false)
Chronic pain not as painful as acute (false)
Behavioral manifestations more reliable than self-report (fa
Factors to Consider when Assessing Pain in Older Persons
Function (cognitive &physical)
Expression of pain (are they able to express their pain? Language barriers? Pain tolerance level)
Social support (do they have money? Family knows they are in pain but doesn't want to tell the provider, don't want to be a bu
Questions to Assess Pain in Older Adults
Are you experiencing pain, discomfort, aching right now?
Have you had this before or is it new?
Characteristics: frequency, duration, precipitating & alleviating factors
QOL: ADL's, relationships, emotions, cognitive abilities, enjoyable hobbies
Analgesic
Assessment in Older Adults who are Cognitively Impaired
Pain transmission process is unaltered in older adults who have dementia
Cognitive processing & interpretation of pain - impaired
Importance of recognizing signs
Team approach & family
Pain Cues in Persons with Communication Difficulties
Behavioral Changes (DEMENTIA PATIENTS CAN BE AGRRESSIVE OR PACING BACK AND FORTH)
Activity Changes (More disinterested in usual activities
Vocalization Changes (they can express to you how they feel)
Physical Changes
Potential causes of pain:
Skin infecti
Wellness oriented approach
pain management
Wellness oriented approach
Physical:
Reflexology, heat and cold, mild exercise, physical therapy, TENS
Cognitive-behavioural:
Relaxation, distraction, hypnosis, guided imagery, music, spiritual & religious coping strategies
Patient/family education:
Addre
Pain ladder
WHO's pain ladder for cancer pain relief in adults
1- mild pain- nonopioid - adjuvant therapy
2- mild to moderate pain - weak opioid, non opioid and adjuvant therapy
3- moderate to severe pain - strong opioid, non opioid, adjuvant therapy
Misconceptions about drugs
Tolerance
Physiologic protective mechanism that helps the body become accustomed to the side effects - adverse effects diminish
Dependence
Normal physiologic response manifested by withdrawal symptoms when opioid suddenly discontinued - not necessarily an
physiological triad frailty
sarcopenia, immune, neuroendocrine dysregulation
Geriatric syndromes: conditions that do not fit a specific disease category
Falls, frailty, malnutrition, urinary incontinence, functional decline, pressure ulcers, cognitive impairment and delirium
Diminish older adult's ability to adapt to stressors associated with poor outcomes
Nonfatal chronic illness
Osteoarthritis
Hearing or Vision Problems
Contribute to increase HC costs & disabilities
Serious, eventually fatal chronic conditions
Cancers, organ system failures, dementia, strokes
Frailty
A fatal, chronic condition in which the body has few reserves left, and any disturbance can cause multiple health conditions and costs.
Common Chronic Health Problems
Cardio-vascular and respiratory problems
Parkinson's
Cognitive impairment
Diabetes
Bone and joint disorders
Special Considerations in Chronic Illness
Fatigue
Grieving
Fostering Self-Care
Rehabilitation and Restorative Care
Prevention of Iatrogenic Disturbances
Assistive Technology
Symptoms of Frailty
3 or More of these conditions:
Unplanned weight loss of 10 or more pounds/year
Fatigue or poor endurance
Muscle weakness (low grip strength)
Slow or unsteady gait
Decline in general activity
Addressing the needs of Caregivers
Major focus of intervention
Review Modified Caregiver Strain Index
80% of people who care for an older adult are family members - most often child of older adult
High level of stress associated with caring for an older adult
In hospital settings this is d
Implications for Gerontological Nursing
Assessment
Selection of appropriate tools
Ongoing evaluation of responses and outcomes
Careful observation
Periodic monitoring
Alert watchfulness
Discussion and collaboration with older adults about their perceptions and the meaning their illness has for
Nursing Diagnoses
Readiness for Enhanced Knowledge
Impaired Comfort
Ineffective self-health management
Stress overload
Ineffective role performance
Impaired social interaction
Planning outcomes
Addressing needs related to physical health, functioning, emotional & spiritual well-being
Promoting personal responsibility for health through self-care measures & management of chronic conditions
Help identify personal strengths
Identify goals for quali
Protein-Calorie Malnutrition (PCM) aka Protein-Energy Malnutrition (PEM
Most common form of malnutrition in older adults
Characterized by presence of clinical signs (ex: wasting, low BMI) & biochemical indicators (ex: albumin, cholesterol, or other protein changes) indicative of insufficient intake
Syndrome characterized by a
Marasmus
Marasmus: the PCM/PEM syndrome that develops gradually over months or years when energy intake is insufficient. Skeletal muscle, rather than plasma proteins or visceral protein, is metabolized, and this there is generally a normal serum albumin level.
Kwashiorkor
more acute or subacute PCM/PEM and is frequently superimposed on marasmus, the precipitant being the stress of an acute illness; it may develop over weeks but is often more acute. Due to elevated hormones, monokines, and tumor necrosis factor (TNF), serum
Oral health changes
Enamel less permeable�teeth more brittle
Tooth colour change
Dry mouth
Loss of submucosal elastin in oral mucosa
Loss of connective tissue (collagen)
Decrease in number of quality of blood vessels and nerves
Nutrition Screening & Assessment
Nutrition screening is the first step to identifying patients who are at risk for nutrition problems or who have undetected malnutrition
Several screening and assessment tools specific to population and can be completed in any setting
Screening includes t
Nutrition Screening & Assessment
Nutrition assessments are more comprehensive than nutrition screens and are generally completed by a registered dietitian
Pneumonic ABCD = Anthropometric, Biochemical, Clinical, and Dietary. Next slide summarizes the most common data collected during a nu
Mini Nutritional Assessment Questionnaire (MNA)
an evaluation tool using 19 items to assess the malnutrition risk of an older adult. Also been shown to predict morbidity and mortality. Only use in adults >65years. See Brightspace for details.
Popular Screening Tools
Other tools include:
Nutritional Risk Index
Nutritional Risk Score
Nutritional Risk Assessment Scale
Prognostic Nutritional Index
Subjective Global Assessment
Depression screening: adults
The USPSTF recommends screening for depression in the general adult population, including pregnant and postpartum women. Screening should be implemented with adequate systems in place to ensure accurate diagnosis, effective treatment, and appropriate foll
An 80-year-old is seen in the emergency department for a fall. The client has bruises on the upper arms and appears depressed. The client is accompanied by a grandchild, who is unkempt, glassy-eyed, and whose breath smells of alcohol. Which of the followi
A
The first priority should be to see whether the older adult is safe and then determine his competency. Legal intervention can be pursued after safety and competency are determined. The degree of frailty and chronic health problems is assessed with safet
Which of the following is true about cognitive impairment and abuse of older adults?
Older adults who live alone are always willing to acknowledge their impairments.
Cognitively impaired older adults are usually able to meet minimum standards of care.
Whe
D
When the older adult denies cognitive impairment, the risk for abuse increases. Older adults who are cognitively impaired are not able to meet minimal standards of care. Older adults who live alone may be afraid to acknowledge their impairments.
A neighbor notices an 81-year-old getting water from someone's outside faucet. The neighbor notices that this person's ankles are very swollen and there is an open wound on her left leg. The older adult says, "I stopped taking my pills because the water d
Ans: A
Feedback:
Because the older adult is not in immediate danger, the first step is to determine her competency and the ability to make decisions for herself.
Which of the following statements is true about the laws of mandatory abuse reporting?
A) Government agencies, not individual nurses, are responsible for reporting abuse.
B) Mandatory reporting laws require reporters to know whether abuse or neglect has o
Ans: D
Feedback:
In all states within the United States, individual nurses are responsible for reporting abuse. Mandatory reporters are required to report the suspicion of abuse or neglect. Protocols do not replace individual responsibility. Protocols cla
A 30-year-old grandchild lives with and provides care for the 75-year-old grandparent. The grandparent has congestive heart failure, hypothyroidism, and chronic pain from a compression fracture and osteoporosis. The grandchild supervises the older adult's
Ans: B
Feedback:
Physical neglect can arise from the caregiver's lack of knowledge. It is important to assess the caregiver's understanding of the dependent person's needs before drawing other conclusions.
A nurse who works with the older population is aware that elder abuse takes many forms. Which of the following examples most clearly constitutes elder abuse?
A paid caregiver cleans and assists with shopping for an older adult who lives alone.
An older ad
D
Feedback:
Allowing an older adult to remain in soiled clothing as a way of preserving financial assets is a form of elder abuse. Power of attorney confers legitimate financial control to an individual and this is not necessarily coercive or abusive. Fai
7. A nurse who provides care in a clinic comes into contact with numerous older adults, many of whom have bruises of various sizes and stages on their body. What pattern of bruising is most suggestive of possible abuse?
A) Significant bruising on the shin
Ans: B
Feedback:
Bruising on the neck and ears is not typically accidental. Conversely, bruising on the backs of the hands, elbows, and shins is more common and less likely to raise the suspicion of abuse.
8. An 81-year-old has been living for the past 2 years in a long-term care facility. However, financial pressures have required that the resident move in with the oldest child and spouse. Which of the following statements if made by the child's spouse sho
Ans: C
Feedback:
It is normal and reasonable to be somewhat overwhelmed with the prospect of providing care for an older adult. However, a suggestion that the older adult may have to go without care is problematic and a potential precursor to elder abuse
A wound care nurse is assessing a 76-year-old client. The client has intimated to the nurse that her son sometimes "flies off the handle and gets rough with me." Which response made by the nurse is the best response?
A) "When you say 'gets rough,' what do
Ans: A
Feedback:
Safety is the first priority in cases of elder abuse and prompt action is often necessary. However, gathering additional information, detail, and context is appropriate when a threat is not immediate. Speculating about a perpetrator's mot
10. An older adult who appears to be between 85 and 95 has been brought to the emergency department by emergency medical services after being found wandering in the street. The older adult is filthy, confused, and exhibits numerous bruises to the face and
Ans: C
Feedback:
Nursing guidelines emphasize that interventions related to hydration status are higher priority than most other problems, including hygiene, and malnutrition; elder abuse is not an immediate threat when the older adult is in a health care
11. A nurse in a hospital setting assesses an older adult and is unsure if the assessment data warrant notification to the authorities for elder abuse. Which action is most appropriate for the nurse at this time?
A) Determine if the person has dementia.
B
Ans: C
Feedback:
The nurse is a mandatory reporter for potential elder abuse; the authorities can make the final determination if abuse has occurred or not. Nurses assess all potential contributing conditions but the immediate responsibility is to follow
12. A nurse prepares a presentation regarding elder abuse and neglect. Which of the following types of abuse should the nurse include? (Select all that apply.)
A) Alcohol (substance)
B) Financial
C) Mandatory
D) Physical
E) Psychological
F) Sexual
Ans: B, D, E, F
Feedback:
The National Center on Elder Abuse (2013a) recognizes seven major types of abuse: physical, sexual, emotional or psychological, neglect, abandonment, financial or material exploitation, and self-neglect.
13. A nurse assesses an 85-year-old client and finds bruises on the arms and shins and a skin tear on the right hand. Which action is the priority for further nursing assessment?
A) Consider the family as a reliable source of information.
B) Determine if
Ans: D
Feedback:
The nurse has not yet gathered enough data to determine whether elder abuse is a potential factor. The client/family may not know the source of the bruises, and in fact may provide inaccurate information if they contribute to an abusive s
14. A home health nurse visits a client who has a history of alcoholism and dementia. The client's words are incoherent, and the client's clothes are filthy. The client is unsteady and leaning to the right, and the room in the rooming house is in disarray
Ans: B
Feedback:
Victims of self-neglect are likely to have the following characteristics: older age; chronic illness; functional limitations; solo living arrangements; social isolation; inadequate economic resources; and dementia, mental illness, substan
1. A nurse is teaching health interventions to an older adult with osteoarthritis. Which of these statements indicates that the individual needs additional teaching?
A) "I will avoid high-impact exercises."
B) "I will get adequate intake of calcium and vi
Feedback: C
Walkers and other assistive devices help relieve stress on weight-bearing joints and improve balance. Individuals with osteoarthritis need to participate in supervised, low-impact exercises and avoid high-impact activities. Vitamin D is essent
Origin: Chapter 22- Mobility and Safety, 2
2. A nurse is teaching older adults at a senior center how to reduce the incidence of falls. Which of the following statements indicates that the nurse's teaching has been effective?
A) "Benadryl is a safe medica
Ans: D
Feedback:
Numerous prescription and over-the-counter medications are implicated in falls. Benzodiazepines have been studied, and it is suggested that their effect on psychomotor function increases the incidence of falls. Benadryl (diphenhydramine)
3. A 99-year-old resident has fallen. Which of the following functional consequences of this fall most strongly impacts the plan of care?
A) A 99-year-old is at much higher risk of a fracture from a fall than a younger person.
B) A 99-year-old is more lik
Ans: A
Feedback:
The functional consequence of the fall is risk for future falls which may include a risk for fractures. Osteoporotic fractures occur with little or no trauma to the older adult, and risk of fractures increases in direct relation to age. W
4. Which of the following nursing interventions should be the priority for a nurse working in a retirement community?
A) Using restraints to keep nursing home residents from getting out of chairs unattended
B) Establishing a fall-prevention program for re
Ans: B
Feedback:
Formal fall-prevention programs are implemented in home care and health care settings. These programs can address multiple risk factors, focusing on those who are at risk for falls and the consistent implementation of preventive measures.
5. Which of the following older adults is most at risk to develop osteoporosis?
A) A 65-year-old white woman with chronic obstructive pulmonary disease who takes corticosteroids
B) A 65-year-old white man with rheumatoid arthritis
C) A 70-year-old African
Ans: A
Feedback:
White non-Hispanic women have a higher incidence of osteoporosis. Corticosteroids and antiseizure medications are most frequently associated with secondary osteoporosis. White men and African Americans of both genders have a lower inciden
6. A 79-year-old woman is scheduled to undergo hip replacement surgery after a fracture that was caused by a fall. Which of the following age-related changes may have contributed to the woman's susceptibility to bone fracture?
A) Increased protein synthes
Ans: D
Feedback:
The process of bone resorption accelerates with age, resulting in lower bone density. Changes in various aspects of the nervous system accompany the aging process, but a loss of neural control of balance is not normally among these. Infec
7. A nurse was recently assisting an 84-year-old resident of a nursing home with the resident's biweekly bath. While the nurse was helping the resident transfer out of the bathtub, the resident grabbed on to the nurse forcefully, became rigid, and exclaim
Ans: C
Feedback:
The fear of falling, which is the most common reported fear among older adults, has been identified as a public health problem that is of equal importance to falls. This fear goes beyond prudent safety measures and is not a normal, age-re
8. An 82-year-old client walked 2 miles last week to enjoy the spring weather. The client says since that time, "I haven't been doing very much, I'm afraid it will hurt." Which action by the nurse is most appropriate?
A) Discuss moderation in activity, en
Ans: A
Feedback:
Practices that are recommended for self-care of osteoarthritis include using moist heat and analgesics for pain, regular low impact exercise, and balancing weight-bearing activities with rest periods. Walking 2 miles is too far for this c
9. A 70-year-old woman has expressed interest in preventing osteoporosis as a result of the high prevalence of the disease in her peer group. What dietary measures should the nurse recommend?
A) High intake of salmon and fortified cereals
B) A high-protei
Ans: A
Feedback:
Nurses can also teach older adults and their caregivers about the importance of adequate intake of calcium and vitamin D in the prevention of osteoporosis. Salmon, fortified cereals, and orange juice are sources of both. Measures such as
10. A nursing home has been the site of numerous falls by residents in recent months. Which of the following environmental factors should the nurse manager change? (Select all that apply.)
A) The hallways that lead to the dining room and common areas do n
Ans: A, C
Feedback:
Keeping bedrails raised can constitute a falls risk when residents attempt to leave their bed to go to the washroom and are forced to scale the bedrails. Long hallways, shared bathing facilities, and the particular skills mix of the fa
11. The nurse cares for a client with advanced Alzheimer disease who is not mobile. The nurse has assessed the client as high risk for falls. Which of the following should be included in the fall-prevention program? (Select all that apply.)
A) Bright oran
Ans: A, B, D, F
Feedback:
Bright ID stickers, padded mattress on the floor, frequent assessment, and a bed alarm are all appropriate interventions; lights on and use of restraints are not.
12. The 64-year-old client who went rock climbing last week and snowboarding this week is at risk for broken bones. Which functional consequence of aging most strongly increases this risk?
A) A strong musculoskeletal system helps to protect bones.
B) Redu
Ans: B
Feedback:
A strong musculoskeletal system helps to protect bone. Weight-bearing activities decrease the risk of injury by strengthening the bone. Blood flow doesn't change. There is impaired bone formation secondary to reduced osteoblastic producti
13. The home nurse assesses a frail older adult for fall risk using the Timed Up and Go (TUG) test. Which score places this client at high risk for falls in his home?
A) 6
B) 9
C) 12
D) 15
Ans: D
Feedback:
The TUG test is a reliable measure of gait speed, as well as an indicator of fall risk and ability to safely perform ADLs. Higher scores (i.e., longer time to complete the tasks) are associated with increased risk for falls. Cutoff scores
14. The nurse presents at a conference regarding aging and mobility. Which age-related changes should the nurse include?
A) Bones decrease resorption due to decreased parathyroid hormone
B) Diminished positioning sensations in the lower extremities
C) Out
Ans: B
Feedback:
Diminished positioning sensations in the lower extremities increase risk for falls. With older adults: bones increase resorption due to increased parathyroid hormone, there is degeneration of collagen and elastin cells, and the number of
15. Which of the following hospitalized older adults is at greatest risk for in-hospital hip fractures from a fall?
A) A 79-year-old client
B) A client receiving numerous cardiac medications
C) A client with a history of hip fractures from a fall
D) A cli
Ans: C
Feedback:
Prior fracture almost doubles the risk for another fracture. The older the client, the higher the risk. Medications with adverse reactions do increase the risk, and dementia especially moderate to severe increases risk.
1. A client is unresponsive, the skin is usually dry, confined to bed, with limited mobility and contractures, and the nutrition is less than adequate. Using the Braden score, which score will be assigned to this client's risk for pressure ulcers?
A) 8, v
Ans:
Feedback:
The nurse uses the Braden score to determine the plan of care. The lower the Braden score, the greater the risk. Scores of 9 or less are considered to be at very high risk, and additional pressure relieving surface and treatment of nutritio
2. A nurse teaches older adults about skin care and aging. Which of the following would be appropriate to include in this teaching? (Select all that apply.)
A) Avoid sunscreens with a sun protection factor (SPF) higher than 14.
B) Gently apply rubbing alc
Ans: C, E, F
Feedback:
Older adults need an adequate intake of calories, nutrients, and hydration. Older adults should use a gentle, patting motion when drying their skin ensuring dry skin between toes. Older adults need to use a sunscreen with an SPF of
3. The nurse assesses the fluid volume status of a 72-year-old client who takes Lasix (furosemide) and Pacerone (amiodarone). Which of the following is the most reliable method for assessing this client's skin turgor?
A) Ask the client to open the mouth a
Ans: C
Feedback:
Skin turgor should be checked over protected areas, such as the sternum or abdomen. The use of diuretics can exacerbate xerosis that older adults may have. Diuretics and amiodarone increase the risk for photosensitivity.
4. A nurse notes a 2-mm open shallow ulcer with a red wound bed on the great toe where shoe touched the skin. Which of the following should the nurse document?
A) 2-mm stage II pressure ulcer
B) Stage III pressure ulcer on great toe
C) 2-mm skin tear with
Ans: A
Feedback:
The wound described is a pressure ulcer, and Pressure Ulcer Scale for Healing (PUSH) staging should be used to document all pressure ulcers. Wound documentation should also include size of wound bed. Stage II ulcers are partial thickness
5. Which of the following functional consequences of skin changes will impact the nursing care of older adults?
A) Older adults have an increased incidence of moles requiring intervention.
B) There is a decreased incidence of skin cancer in older adults b
Ans: D
Feedback:
There is less tensile strength of the skin because of collagen changes, which predisposes the older adult to abrasive and tearing skin damage. There is a decreased incidence of moles after 40 years of age. There is an increased incidence
6. A gerontological nurse is aware of the changes in the structure and function of the skin and accessory glands that occur with aging. Which of the following changes is a normal accompaniment to the aging process?
A) Thickening of collagen in the dermal
Ans:D
Feedback:
The dermal vascular bed decreases by about one-third with increased age; this contributes to the atrophy and fibrosis of hair bulbs and sweat and sebaceous glands. However, sweat glands do not wholly stop functioning. Collagen tends to thi
7. A nurse is participating in a health fair that is being sponsored by a local seniors' center, discussing healthy skin and aging. Which of the following teaching points should the nurse emphasize?
A) "You should limit your sun exposure to a small amount
Ans: A
Feedback:
Current recommendations emphasize the importance of a balanced approach that encourages small amounts of sun exposure each day for adequate vitamin D synthesis, but not so much that would lead to increased skin cancer risk. Many medicatio
8. One of the functional consequences of age-related changes to the skin is an increased susceptibility to injury. Which of the following factors contributes to this susceptibility? (Select all that apply.)
A) Decreased sensation of cutaneous pain and dis
Ans: A, C, D
Feedback:
A muted pain response, increased healing time, and decreased resistance to shearing all contribute to older adults' susceptibility to injury. Changes in vitamin D may occur with age, but these changes do not constitute a risk for in
9. A nurse on an acute care unit is disturbed by the increasing incidence of pressure ulcers among older adults. Which of the following measures should the nurses on the unit prioritize in order to prevent the formation of pressure ulcers?
A) Apply emolli
Ans: B
Feedback:
Frequent repositioning is an important measure in prevention. Lotions should be applied; relief of pressure is the highest priority. Nurses should ensure that those at risk for pressure ulcers do receive enough calories, vitamins, and pro
10. A nurse in a long-term care facility teaches aides to assist several older adults with bathing each day. Which of the following interventions should the nurse include in the teaching?
A) Apply perfumed products after bathing to promote hygiene and sel
Ans: C
Feedback:
Skin need to be dried thoroughly but gently, particularly between the toes and other areas where skin touches. Perfumed products and alcohol should be avoided. Water temperatures for bathing should be about 90�F to 100�F.
11. A nurse monitors a group of older adults in the long-term care facility's kitchen. Which of the following actions would cause the nurse to intervene?
A) Sharing perfumed hand soap
B) Using hand lotion after washing dishes
C) Using hot water to rinse t
Ans: C
Feedback:
Older adults are more susceptible to scald burns because of their diminished ability to feel dangerously hot water temperatures. Perfumed hand soap, dish washing liquid, and lotion are acceptable.
12. A nurse evaluates the healing of a full-thickness skin tear on a 92-year-old resident of a long-term care facility. Which of the following would support the continuation of the current treatment plan?
A) The wound with redness surrounding at 12 days
B
Ans: C
Feedback:
About 50% healing at 16 days is acceptable. Full-thickness skin tears take an average of 21 days to healing in older adults. The treatment plan needs to be changed if there is redness (at 12 days), pain (at 19 days), or draining plasma (a
13. A nurse monitors older adults at an assisted living facility for pressure ulcers. Which of the following older adult is at highest risk for a pressure ulcer?
A) The obese older adult with continuous positive airway pressure (CPAP) mask
B) The frail ol
Ans: A
Feedback:
Medical devices that are commonly associated with increased risk for pressure ulcers include masks, orthotics, tubing, immobilizers, stockings or boots, nasogastric tubes, cervical collars or braces, and tracheostomy tubes and ties. Peopl
14. A nurse assesses residents of the acute care facility for pressure ulcers. Which older adult should the nurse monitor closely for pressure ulcers?
A) The Asian with multiple nevi on extremities
B) The Ethiopian former store clerk
C) The fair-skinned C
Ans: B
Feedback:
Persons with darkly pigmented skin have a higher incidence of serious pressure ulcers. Nevi, sun exposure, and fail skin are related to cancer, not pressure ulcers.
15. A nurse assesses older adults at risk for pressure ulcers. Which of the following assessment tools should the nurse use to identify those who might benefit from interventions? (Select all that apply.)
A) Braden Scale
B) Norton Scale
C) PUSH Scale
D) R
Ans: A, B, E
Feedback:
Braden Scale has been recommended for identifying older adults who are at risk for the development of pressure ulcers. The Norton and Waterloo scales are also commonly used, with reviews of studies indicating that all three of these
16. A nurse at the dermatology office triages calls. Which of the following clients is the highest priority to follow up?
A) A 2-year-old with diaper rash
B) A 20-year-old with red sunburn on the chest and arms
C) A 78-year-old with a lesion that is black
Ans: C
Feedback:
In general, the following characteristics of a skin lesion warrant medical evaluation: redness, swelling, dark pigmentation, moisture or drainage, pain or discomfort, raised or irregular edges around a flat center.
1. A nurse presents at a conference about the concept of sleep. Which of the following statements should the nurse include in the teaching?
A) "Increased sleep efficiency is considered a normal, age-related change."
B) "Sleep efficiency is quite consisten
Ans: C
Feedback:
Age-related changes and pathologic conditions together contribute to the decreased sleep efficiency associated with older age. Sleep efficiency tends to decrease, not increase, with increasing age and is not generally consistent with that
2. A nurse is responsible for the care of group of older adults on an acute medical unit. Which of the following clients should the nurse monitor closely at night for worsening symptomatology?
A) A client with a diagnosis of chronic obstructive pulmonary
Ans: A
Feedback:
The symptoms of individuals with COPD are often exacerbated during sleep, because of both positioning and decreased oxygen saturation that occurs during sleep. Clients with osteoarthritis, cellulitis, or anemia would not be as likely to h
3. A nurse plans the care for an older adult man who consumes two alcoholic beverages each evening. Which of the following should be included in the plan of care?
A) Allow for a later bedtime.
B) Encourage the client to cease all alcohol intake.
C) Monito
Ans: C
Feedback:
Alcohol consumption is associated with both initial drowsiness and increased numbers of awakenings during the night, as well as overall decreases in both total sleep time and REM sleep. Individuals who are accustomed to the depressant eff
4. A nurse counsels an older adult with chronic insomnia. Which of the following statements should the nurse include in the teaching?
A) "Consider making your environment more conducive to sleep."
B) "Continuing with the hypnotic medications you've been p
Ans: A
Feedback:
Environmental modification can be a useful intervention in promoting sleep in older adults. While age-related changes do influence sleep in older adults, this does not mean that interventions and strategies are unnecessary in mitigating t
5. A nurse teaches a nursing student about pharmacologic interventions for the treatment of sleep problems among older adults. Which of the following statements by the student shows understanding of the care of those with sleep disturbances?
A) "Behaviora
Ans: A
Feedback:
In general, behavioral therapies are preferable to hypnotics and other drugs for the treatment of sleep disorders. Benzodiazepines are the drug category with the greatest risk of adverse effect, and L-tryptophan is found in foods rather t
6. A nurse orients a graduate nurse to a gerontology unit. Which of the following statements, if made by the graduate nurse, shows understanding of normal age-related changes of sleep patterns?
A) Older adults need for 10% to 20% more sleep than younger a
Ans: D
Feedback:
Older adults typically spend less time in deep sleep than do younger adults, though the overall quantity of sleep required remains fairly static throughout the adult life span. Older adults usually experience more sleep cycles during the
7. A nurse in a long-term care facility has noticed that many residents of the facility spend a large amount of time in bed yet frequently complain of fatigue and sleep deprivation. What change in the facility's environment is most conducive with helping
Ans: B
Feedback:
It is important not to schedule the time for awakening clients/residents based on the most efficient use of nursing and dietary time that require clients/residents to adjust their sleep routines accordingly. Lighting should be bright duri
8. An older adult with restless legs syndrome (RLS) has sought advice from the nurse in an effort to ease the problem. Which of the following statements should the nurse include in the plan?
A) "There are new, over-the-counter medications that can probabl
Ans: C
Feedback:
Risk factors for RLS include genetic predisposition, iron deficiency, chronic renal failure, peripheral neuropathy, and adverse effects of certain medications. RLS is considered a neuromuscular disorder, not an age-related change. It is m
9. A nurse plans care for an older adult with insomnia. The client's medication list includes zolpidem, potassium, and omeprazole. Which of the following diagnoses should the nurse include in the plan of care?
A) Risk for falls
B) Risk for suicide
C) Risk
Ans: A
Feedback:
Fractures and falls are a risk of nonbenzodiazepine agents. Powerlessness, incontinence, and suicide are not increased with these medications.
10. An older adult client states that he has lately been taking up to 2 hours to fall asleep at night, despite avoiding caffeine during the day and going for a brisk walk after lunch each day. Which of the following statements by the nurse is most appropr
Ans: C
Feedback:
Older adults experiencing sleep problems should attempt to awaken, rest, and go to bed at a consistent time each day. Hypnotics should be a temporary measure of last resort, and alcohol and exercise should be avoided around bedtime.
11. A nurse discusses sleep patterns with an older adult. The client states, "I feel like all I do is lie in bed awake each night." Which response by the nurse is most appropriate?
A) "How long do you lie there each night?"
B) "Describe your pillow and ma
Ans: C
Feedback:
Older adults have more diminished sleep efficiency secondary to prolonged sleep latency, and an increased number of awakenings during the night. How long he lies there is not as important as the fact that he feels like it is all night. Th
12. A nurse presents an overview of sleep to older adults at an activity center. Which of the following risk factors for sleep problems should the nurse include in the presentation? (Select all that apply.)
A) Boredom
B) Chronic discomfort
C) Dehydration
Ans: A, B, F
Feedback:
Boredom, chronic discomfort, and RLS are all treatable risk factors that can interfere with sleep patterns. Dehydration, exercise, and lack of light do not decrease sleep.
13. A nursing supervisor in the long-term care facility implements changes to improve environmental conditions. Which of the following should be included in these changes? (Select all that apply.)
A) Assist residents to bed at 7 PM each day.
B) Build part
Ans: B, C, E
Feedback:
More time in bed does not mean more time sleeping. Partitions can increase the sleeping privacy of residents; bright lights at night interfere with sleep but are helpful during the day. Temperature that is too hot or too cold interf
14. A 64-year-old obese man is admitted to the hospital for treatment of heart failure secondary to alcoholism. For which of the following negative consequences should the nurse assess?
A) Chronic pain
B) Obstructive sleep apnea
C) Parkinson disease
D) RL
Ans: B
Feedback:
Factors associated with increased risk for obstructive sleep apnea include obesity, diabetes, stroke, Parkinson disease, congestive heart failure, genetic predisposition, craniofacial anatomic features, and the use of alcohol or medicatio
15. An older adult at home uses earplugs to diminish street noise at night. Which of the following statements by the nurse is appropriate?
A) "Using earplugs during sleep can damage your hearing."
B) "I suggest a smoke alarm with blinking lights."
C) "You
Ans: B
Feedback:
People who live alone should be cautioned about the danger of blocking out the sound of a smoke alarm; one that has lights increases the safety. Earplugs at night do not damage hearing.
1. Which of the following statements best captures the typical character of health problems in the lives of older adults?
A) Older adults' lives are dominated by the increasing number of acute health problems due to age-related changes.
B) Most older adul
Ans: B
Feedback:
The interplay between chronic and occasional acute conditions is typical of the health trajectory of many older adults. The most salient factor is not acute problems alone, nor are health problems necessarily attributable to age-related c
2. During assessment of an older adult, the nurse discovers that the individual has been reluctant to divulge recent losses in activities of daily living to his primary care provider. Which of the following factors has been demonstrated to contribute to s
Ans: A
Feedback:
Many older adults have been shown to fear losing their independence or becoming institutionalized if they divulge health problems. It has not been demonstrated that age-related changes and psychosocial problems are not treatable, nor that
3. A nurse is teaching new graduates about the nature of palliative care on her unit. Which of the following statements by a new nurse indicates a need for further teaching?
A) "I can see how important it is for us to educate patients and their families a
Ans: B
Feedback:
While the focus of palliative care is not on curing disease, this does not mean that treatments of all kinds are absent. Distressing symptoms are addressed from both a nursing perspective and a medical perspective. Education is a key comp
4. A nurse is teaching an older adult's family about the concept of caregiver burden. Which of the following points is priority for the nurse to communicate to the family?
A) "Don't feel guilty about having to hire help. Most older Americans' care is curr
Ans: C
Feedback:
A strong support system is a prerequisite for anyone who is planning to become a caregiver for a friend or family member. Most care is provided by friends and family, not professionals. It has been shown that moving a loved one to a nursi
5. Which of the following statements by the new nurse best conveys an understanding of diabetes in older adults?
A) "A combination of lifestyle factors and age-related changes contributes to high rates of diabetes among older adults."
B) "Development of d
Ans: A
Feedback:
The high prevalence and incidence of diabetes among older adults is attributable to lifestyle, genetic, and age-related factors. Ethnicity is a valid variable that needs to be considered, given that some minority groups have significantly
6. An 81-year-old client was diagnosed with colon cancer several months ago. Both the patient and the family have been made aware of the potential for metastasis and the poor prognosis associated with this disease. At what point in the client's disease tr
Ans: B
Feedback:
The principles and practices of palliative care should not be exclusively reserved for late in a disease trajectory. It is applicable early in the course of an illness and should be offered as needs develop and before they become unmanage
7. A 66-year-old has been conscientious about health as an adult and is disappointed at having been recently diagnosed with type 2 diabetes. The client had been unwilling to discuss this new diagnosis for the past several weeks but has now begun asking th
Ans: A
Feedback:
An expressed willingness to know more about how a health problem is diagnosed and managed suggests a nursing diagnosis of readiness for enhanced knowledge. This is not synonymous with enhanced self-care, but is a likely precursor. The cli
8. A 68-year-old client has a long history of poor eating habits and low activity levels. The client now has a diagnosis of type 2 diabetes mellitus. Which of the following nursing interventions should be the priority?
A) Adherence to diabetes screen prot
Ans: D
Feedback:
The care of older adults with diabetes should prioritize self-care measures such as diet, exercise, medications, and glucose monitoring. Screening is not relevant since the client has already been diagnosed with the disease in question. E
9. A palliative care team has taken over primary responsibility for the care of an older adult who has recently experienced a stroke. A visitor asks, "What is palliative care?" Which of the following is the best response by the nurse?
A) "Spiritual and ps
Ans: D
Feedback:
Palliative care is a holistic approach to care that may be applied during complex and/or declining health states. It is not necessarily limited to the end of life and does not involve a rejection of biomedical interventions. The wishes of
10. An older adult with a diagnosis of heart failure has been admitted to the hospital with an exacerbation of this condition. Which of the following are consequences of heart failure for which the nurse must monitor? (Select all that apply.)
A) Arrhythmi
Ans: A, C, D, E
Feedback:
Common consequences of heart failure in older adults include increased likelihood for developing arrhythmias, increased risk for hypotension and falls, increased risk for drug interactions, and high incidence of sleep disorders.
11. A nurse in the long-term care facility assesses an 86-year-old woman who has recently become lethargic and difficult to arouse. Her vital signs are all stable and within normal limits. Her breath sounds are diminished. Which action by the nurse should
Ans: C
Feedback:
Atypical presentation is especially common in those who are older than 85 years. Changes in behavior or functioning and increased fatigue are common atypical presentations of infection (e.g., pneumonia or urinary tract infection). In addi
12. A wellness center nurse teaches a class of older adults about healthy habits. Which of the following interventions will make a difference in the clients' lives and as such be included by the nurse?
A) Avoid alcohol consumption.
B) Avoid fried foods an
Ans: C
Feedback:
Nurses must not be influenced by ageist attitudes suggesting that older adults are too old to change behaviors and to benefit from improved health behaviors. Health promotion behaviors include the following: avoid secondhand smoke; limit
13. A nurse cares for an older adult in a residential care program. The client has multiple chronic conditions. The client has developed dyspnea and has lost 105 lb of body weight. Which of the following statements by the nurse is most appropriate?
A) "Ha
Ans: B
Feedback:
Unintentional weight loss, unstable medical conditions, and frequent hospitalizations indicate a need for discussion of palliative care services. The nurse uses open-ended assertive statements that teach the client. Saying we can't make y
14. A nurse discusses health promotion with a group of older adult women. The nurse suggests a Pap test every 2 years. One woman states, "I haven't had a Pap since the change, why would I do that now?" Which response by the nurse is best?
A) Annual checku
Ans: C
Feedback:
Cancers are found more often in older adults, functional consequences of many sequelae. The risk of death from ovarian cancer is twice as high among women aged 65 and older, compared with younger patients. Sexual relations do not cause ov
15. A nurse plans discharge instructions of a 78-year-old black client with newly diagnosed dilated heart failure. The client states, "Will I be going home on hospice now that my heart is failing?" Which of the following responses is most appropriate by t
Ans: A
Feedback:
The client with heart failure will need medications and will benefit from cardiac rehabilitation; however, these answers avoid the issue of lack of understanding of the type of disease heart failure is. Palliative care is not appropriate
16. A 73-year-old client is admitted to the hospital. A nurse assesses the client for frailty. Which of the following indicate frailty? (Select all that apply.)
A) Diminished handgrip strength
B) High level of physical activity
C) Intentional weight loss
Ans: A, D, E
Feedback:
Patients are considered fail when they have three or more of the following conditions: low level of physical activity, slow walking speed, unintentional weight loss (i.e., 10 lb or more during the past year), weakness (measured by d
1. A nurse assesses an older adult following the repair of an abdominal hernia. The older adult client states, "I really hate to take pain medication." Which response by the nurse is best?
A) "Early treatment of pain helps now and can reduce the incidence
Ans: A
Feedback:
Recent studies have focused on the complex mechanisms involved with the development of persistent postsurgical pain, finding that its incidence can be reduced with the use of aggressive and early analgesic therapy. The client does not exp
2. An 80-year-old black woman minimizes her pain in the joints and back as "normal aging." Which of the following actions by the nurse is most appropriate?
A) Address the client's concerns regarding addiction.
B) Allow the client to choose to minimize the
Ans: D
Feedback:
Racial and ethnic minorities and women are at high risk for receiving inadequate pain relief. The nurse must discuss nonpharmacologic interventions as well as dispelling myths regarding the functional consequences of aging and pain treatm
3. A nurse assesses the pain of an older adult. Which of the following findings indicates the presence of persistent pain?
A) The client's vital signs are unchanged.
B) The client is asleep in the chair.
C) The client has not reported pain to the nurse.
D
Ans: D
Feedback:
Essential assessment information is also obtained by observing for nonverbal indicators of pain, such as grimacing, muscle tension, rubbing, and protecting body parts. Relying on vital signs, presuming that sleeping clients are not experi
4. A nurse assesses an older adult client with confusion related to hyponatremia who reports pain. Which of the following data should the nurse use as a guide for choosing interventions?
A) Symptoms of hyponatremia do not include pain.
B) The client does
Ans: D
Feedback:
The client's subjective self-report of pain is the priority assessment finding and reflects the adage that pain is what the client says it is. The nurse should not discount the reports of clients based on medical diagnoses and expected fi
5. A nurse is teaching an older adult about some of the risks associated with using opioid analgesics. Which of the following statements best demonstrates the individual has gained a sound knowledge base?
A) "I know that if I become dependent on the drug,
Ans: D
Feedback:
Tolerance denotes a decreased response to a drug over time, a fact that may necessitate an increase in drug dosage. Dependence on a drug's effects is not an indication that the drug necessarily needs to be discontinued, but rather that th
6. A nurse in a postoperative unit educates peers to overcome myths about pain in older adults. Which of the following statements by a peer most clearly warrants further teaching?
A) "We have to be more conservative in the treatment of the older adults' p
Ans: A
Feedback:
The statement that warrants more teaching is that their pain should be treated more conservatively than younger clients. Studies have found no age-related difference in appropriate doses of postoperative morphine. Multimorbidities and chr
7. A 79-year-old woman had a total knee replacement yesterday; she has rung her call light to report pain. What consideration should the nurse prioritize when choosing an appropriate intervention?
A) The fact that the woman has a documented history of per
Ans: D
Feedback:
The need for adequate pain control is paramount in the care of older adults. The fact that the woman has a history of persistent pain has little bearing on her present complaint and the need for relief. Addiction to analgesics is a rare d
8. A 74-year-old client with a history of osteoarthritis is being treated in the hospital for pneumonia and malnutrition. The nurse administered 650 mg of acetaminophen 90 minutes ago and the client is now requesting another dose. The medication administr
Ans: D
Feedback:
Limit the amount of acetaminophen to 3,000 mg per day in the client with malnutrition to avoid hepatotoxicity. Pain medication, not normal saline, should be administered. While alternative approaches to pain relief may be warranted, this
9. A nurse who provides care in a large, inner-city hospital comes into contact with older adults from a wide variety of cultural groups. How is culture most likely to influence the assessment and management of pain?
A) Cultural differences affect the int
Ans: B
Feedback:
The most salient effect of culture on pain management involves the expression of pain. Culture can be a relevant influence on the subjective sensation of pain and clinicians' choice of analgesia, but this is typically less pronounced than
10. An older adult with pain is to be discharged home with a prescription for oral morphine (MSContin) daily for persistent pain. The client historically took an over-the-counter nonsteroidal anti-inflammatory drug (NSAID) for pain. Which statement by the
Ans: C
Feedback:
Long-term use of NSAIDs is associated with more severe and life-threatening adverse effects, whereas the most common adverse effect of opioids is constipation, which can be addressed by using laxatives (MiraLAX), stool softeners, fluid, a
11. An emergency department triage nurse receives a phone call from an older adult who states, "I am experiencing pain across my left side. It is tingling, and really hurts when it gets touched." Which of the following response by the nurse is most approp
Ans: C
Feedback:
Burning, shooting, knife-like, tingling, and pins and needles are common symptoms of neuropathic pain (in this case shingles). Over half of the cases of shingles occur in older adults. Peripheral neuropathy results in pain along the distr
12. A nurse administers IV pain medication to an older adult in the hospital. Which of the following actions by the nurse is the priority?
A) Encourage the family to leave.
B) Identify the client's expectations for relief.
C) Reassess the pain level.
D) R
Ans: D
Feedback:
In acute care settings, effectiveness of analgesics should be assessed 30 to 60 minutes after administration. Pain assessment should include open-ended questions to identify the person's expectations for relief before administering medica
13. A nurse plans care for an older adult with advanced dementia. Which of the following plans is most appropriate regarding the pain treatment plan?
A) Monitor assessment findings including vital signs for indications of pain.
B) Treat pain that is impli
Ans: B
Feedback:
Dementia does not directly affect one's experience of pain but it does alter the ability to express pain, as well as other needs. Disruptive behaviors that do not involve locomotion were more strongly correlated with pain in comparison to
14. A home care nurse notes in the assessment that an older adult expresses anxiety and fatigue. The client sleeps 3 hours at a time at maximum and has had a 10 lb weight loss. Which of the following interventions is priority?
A) Assess the client's level
Ans: A
Feedback:
The symptoms represented reflect functional consequences commonly experienced by older adults. The other assessments are not the priority reflected by these symptoms.
15. The process of nociception is important in determining the most appropriate analgesic. Place the processes in order:
A) Modulation
B) Perception
C) Transduction
D) Transmission
Ans: C, D, B, A
Feedback:
Nociception includes transduction, transmission, followed by perception, and finally modulation.
1. A nurse teaches an older adult about changes to nutritional requirements. Which of the following meal choices would give evidence that the older adult understands the teaching?
A) Baked chicken, carrots, and angel food cake
B) Green salad, mashed potat
Ans: A
Feedback:
Older adults need increased intake of foods with a high nutritional value and a concomitant decrease in the intake of foods containing little or no nutrients.
2. A nurse teaches older adults about nutrition. Which of the following statements shows the nurse that the older adult requires further teaching?
A) "Alcohol intake will interfere with absorption of B-complex vitamins and vitamin C."
B) "Certain 'fluid'
Ans: D
Feedback:
Long-term beta-carotene use can cause vitamin E deficiency. Paralytic ileus can occur with anticholinergic medication. Nutritional supplements and herbal preparations can affect nutrients. Alcohol interferes with the absorption of B-compl
3. A 70-year-old client with urosepsis is admitted to a nursing unit. The labs include elevated sodium, blood urea nitrogen, hematocrit, and albumin. Which of the following nursing diagnoses is priority for this client?
A) Constipation
B) Fluid volume def
Ans: B
Feedback:
The appropriate nursing diagnosis is fluid volume deficit. Blood values that may be altered in dehydration include elevations in sodium, hematocrit, creatinine, osmolality, and blood urea nitrogen. While the client may develop constipatio
4. A nurse plans the diet for an older adult with congestive heart failure. Which of these nursing interventions would be most successful to encourage optimal nutrition?
A) Encourage calorie supplements.
B) Provide 55% of calories from complex carbohydrat
Ans: B
Feedback:
Dietary guidelines for older adults recommend a daily intake of five to nine servings of fruits and vegetables; 55% of calories need to come from complex carbohydrates. Older adults need fewer calories with increased quality of nutrients
5. A nurse teaches a health education class for older adults about constipation. Which of the following points should the nurse stress?
A) Older adults who do not have a daily bowel movement should use a laxative.
B) Older adults should limit their intake
Ans: D
Feedback:
A bulk-forming agent is least likely to have detrimental effects; providing fluid intake is adequate, if a medication is needed to promote regular bowel elimination. If at all possible, older adults should avoid laxatives. Older adults sh
6. A nurse assesses an older adult in the assisted living facility who has presbyphagia. Which of the following systems should the nurse auscultate?
A) Abdomen for bruit
B) Bowel sounds
C) Heart tones
D) Lung sounds
Ans: D
Feedback:
Swallowing difficulties create a risk of aspiration. Presbyphagia is unlikely to result in assessment changes to the abdomen or heart.
7. A nurse counsels an older adult regarding nutritional requirements. Which of the following teaching points is priority when discussing age-related changes in nutritional requirements?
A) "If possible, try to eliminate animal fats from your diet."
B) "Y
Ans: C
Feedback:
Caloric requirements for older adults are significantly less than those for younger adults. It is unnecessary to wholly eliminate animal fats from the diet, and protein intake should remain same as for younger adults. Complex carbohydrate
8. A nurse manager of the long-term care facility develops plans to reduce nutritional deficits. Which of the following interventions is appropriate to include in the plan?
A) Encourage residents to eat in their rooms to minimize distractions.
B) Offer fo
Ans: C
Feedback:
Adequate oral care is important in the promotion of adequate food intake, because it enhances chewing, eating, and swallowing. Eating alone is associated with lower caloric intake. Offering incentives may be construed as coercive or patro
9. A nurse evaluates the plan of care for a client who experienced an ischemic stroke. Which of the following assessment findings should signal the nurse to the possibility that the client has developed dysphagia?
A) The client complains of being excessiv
Ans: C
Feedback:
Pocketed food suggests dysphagia. Sitting upright after meals prevents, rather than indicates, dysphagia and neither hunger nor high fluid intake is indicative of dysphagia.
10. A nurse admits a 90-year-old client to the hospital with a diagnosis of failure to thrive. Which of the following laboratory data should the nurse expect?
A) Low albumin and red blood cells
B) Elevated white blood cells (WBCs) and low potassium
C) Low
Ans: A
Feedback:
Anemia and low serum albumin levels are consistent with malnutrition. Elevated WBCs, calcium, and magnesium and low platelets and PT are not characteristic of malnutrition.
11. A nurse assesses older adults at a senior center. One older adult, age 78, has a body mass index (BMI) of 15. Which response by the nurse is appropriate?
A) "You are too skinny."
B) "Have you been losing weight?"
C) "Have you tried to lose this extra
Ans: B
Feedback:
The nurse uses therapeutic communication to assess the weight loss. Unintentional weight loss is considered a significant indicator of poor nutrition. Healthy adult BMI is between 18 and 25 and may extend to 30 for older adults.
12. A nurse working for human services visits a long-term care facility. Which resident assessment finding indicates poor quality care?
A) BMI of 29
B) Indentured mouth
C) Serum albumin of 3.5
D) Unintentional weight loss
Ans: D
Feedback:
Healthy adult BMI is between 18 and 25 and may extend to 30 for older adults. Dentures are a common finding in older adults. Normal serum albumin is 3.5 to 5; unintentional weight loss is an indicator of quality of care provided by the fa
13. A nurse plans care for a client who states that food is no longer appealing. The nurse notes a dry mouth and teeth in poor condition. Which interventions should the nurse include in the plan of care? (Select all that apply.)
A) Eight-ounce bottle of w
Ans: A
Feedback:
Social isolation can lead to lack of appetite. Saliva-producing activities before each meal and 60 to 80 ounces of water a day are recommended to treat dry mouth. Iced drinks are less palatable to the older adult with poor oral condition.
14. A nurse at a rehabilitation unit assesses an 86-year-old woman with a BMI of 30 and a history of heart failure, whose oral intake is declining. Which of the following risk factors is related to this older adult's decline in appetite?
A) Diuretics
B) E
Ans: A
Feedback:
Diuretics decrease saliva, olfactory function, and gustatory functioning. Women have better olfactory and gustatory function than men; exercise increases appetite. Obesity is unrelated.
15. An older adult states, "I just feel so full so fast, I can't eat any more." Which of the following responses is most appropriate?
A) "All of us feel that way after a meal."
B) "Make an appointment with your health care provider."
C) "Slower emptying o
Ans: C
Feedback:
Slight slowing of gastric emptying in older adults after ingestion of large meals leads to early sensations of fullness. Gallstone symptoms include pain, not fullness. An emergent visit to the health care provider is not indicated.
16. An older adult develops diarrhea. Which of the following is the priority intervention for the nurse?
A) Assess for pancreatitis.
B) Determine the last bowel movement.
C) Review meal preparation techniques with the client.
D) Review the client's medica
Ans: D
Feedback:
A number of medications can cause diarrhea in the older adult (e.g., Cimetidine, laxatives, antibiotics, cardiovascular drugs, and cholinesterase inhibitors). Additionally, Clostridium difficile and its related diarrhea are related to ant
Bones - framework
Age related changes dependent upon type of bone involved - remodeling
Increased bone resorption
Diminished calcium absorption
Impaired regulation of osteoblast activity
Decreased estrogen in women and testosterone in men
Muscles
Decreased size and number of muscle fibers
Loss of motor neurons
Replacement of tissue by connective tissue and eventually by fat tissue
Deterioration of muscle cell membranes
Overall changes - SARCOPENIA
Loss of muscle mass, strength and endurance
Joints and connective tissue
Diminished viscosity of synovial fluid
Degeneration of collagen and elastin cells
Fragmentation of fibrous structures in connective tissue
Outgrowths of cartilaginous clusters because of continuous wear/tear
Formation of scar tissue/calcification in joint
Nervous System
Changes in central and peripheral nervous system - primary mechanism involved in diminished muscle function in older adult
Maintaining balance is influenced by age related changes in the NS
Altered visual acuity
Slower righting reflex
Impaired propriocept
Risk Factors Affecting Mobility
Being sedentary - catch 22
Nutrition - particularly vitamin D - often ordered as a supplement because it influences calcium absorption
Soy - controversial the impact but studies on Asian women have found that it is a marker for bone health
Also linked to
Falls - major focus for the elderly today
Philosophy in health care today - might surprise you "people have the right to fall"
Catch is - high rate of morbidity and mortality - prime focus of primary health promotion in Canada
RNAO - projects associated with reducing risk of falls
What is it - ev
Osteoporosis
Porous Bone"
Chronic, progressive metabolic bone disease that can strike at any age but affects one in four Canadian women and one in eight men over 50
Characterized by low bone mass (osteopenia) and structural deterioration of bone tissue
Increased bone
osteopenia
-1--2.5
-2.5
osteoporosis
above -1
healthy
Those over 50 or those younger adults at high risk (with osteoporosis, multiple fractures, or conditions affecting vitamin D absorption) should receive
800 - 2,000 IU daily.
Adults age 51 and older should aim for an intake of ____ mg of calcium every day, or 3 servings of milk and alternatives.
1200
anxiety test
gad7
depression test
phq9
PHQ9
Screens for depression in primary care populations with medical co-morbidities
GAD7
generalized anxiety 7 scale