Care Of The Older Adult > Fundamentals
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Showing 39 questions, Sign in for moreA nurse is reviewing the medication list of an older adult client who takes several medications for different health problems.
The nurse recognizes that polypharmacy in older adults can increase the risk of which of the following?
Explanation
The correct answer is A.
Adverse drug reactions.
Polypharmacy, which refers to the effects of taking multiple medications concurrently to manage coexisting health problems, is common among older adults.
It is defined as the regular use of at least five medications.
Polypharmacy can lead to an increase in geriatric syndromes, decrease in functional outcomes, and increased mortality.
One of the major risks of polypharmacy is adverse drug reactions, which are harmful or unintended effects of a medication that occur at normal doses.
Adverse drug reactions can result from drug-drug interactions, drug-disease interactions, drug-age interactions, or inappropriate prescribing.
Adverse drug reactions can cause symptoms such as confusion, dizziness, falls, bleeding, or organ damage.
They can also lead to hospitalizations, increased health care costs, and reduced quality of life.
Choice B is wrong because medication adherence, which is the extent to which patients take medications as prescribed by their health care providers, can actually decrease with polypharmacy.
This is because taking multiple medications can be complex, costly, and burdensome for older adults, especially if they have cognitive impairment or low health literacy.
Medication adherence can also be influenced by patients’ beliefs, preferences, and expectations about their medications.
Choice C is wrong because drug-drug interactions are not a risk of polypharmacy per se, but rather a cause of adverse drug reactions.
Drug-drug interactions occur when two or more drugs affect each other’s pharmacokinetics (absorption, distribution, metabolism, excretion) or pharmacodynamics (mechanism of action, efficacy, toxicity).
Drug-drug interactions can alter the therapeutic effects or safety of a medication.
Choice D is wrong because therapeutic effects are the intended or desired effects of a medication that benefit the patient’s health condition.
Therapeutic effects can decrease with polypharmacy due to drug-drug interactions that reduce the efficacy of a medication.
Therapeutic effects can also be diminished by prescribing cascade, which is a phenomenon where a new medication is prescribed to treat a symptom that is actually an adverse drug reaction of another medication.
Normal ranges for blood pressure are.
≤120/80.
mmHg for normal,.
120−129/80.
mmHg for elevated,.
130−139/80−89.
mmHg for stage 1 hypertension, and.
≥140/90.
mmHg for stage 2 hypertension.
A nurse is assessing an older adult client who has a history of falls.
Which of the following findings should the nurse identify as a risk factor for falls in older adults?
Explanation
The correct answer isD.
All of the above.All of these findings are risk factors for falls in older adults, according to the literature.
Some explanations for why each choice is a risk factor are:.
A. Orthostatic hypotension: This is a condition where blood pressure drops too much when getting up from lying down or sitting, causing dizziness, lightheadedness, or fainting.This can affect balance and increase the chance of falling.
B. Urinary frequency: This is a condition where one needs to urinate often, sometimes urgently.This can cause rushed movement to the bathroom, especially at night, which can lead to tripping, slipping, or losing balance.
C. Visual impairment: This is a condition where one has reduced or distorted vision, such as due to cataracts, glaucoma, macular degeneration, or diabetic retinopathy.This can affect depth perception, contrast sensitivity, and ability to detect obstacles or hazards in the environment.
Some normal ranges for these conditions are:.
• Orthostatic hypotension: A normal blood pressure change when standing up is less than 20 mmHg systolic (top number) or 10 mmHg diastolic (bottom number).
Orthostatic hypotension is defined as a drop of at least 20 mmHg systolic or 10 mmHg diastolic within 3 minutes of standing.
• Urinary frequency: A normal urinary frequency is about 4 to 6 times per day, depending on fluid intake and other factors.
Urinary frequency is considered abnormal if it is more than 8 times per day or more than 2 times per night.
• Visual impairment: A normal visual acuity is 20/20 or better with or without correction.
Visual impairment is defined as a visual acuity of 20/40 or worse in the better-seeing eye with best correction possible.
A nurse is providing discharge instructions to an older adult client who had a hip replacement surgery.
Which of the following statements by the client indicates a need for further teaching?
Explanation
The correct answer is A.
“I will use a walker until I can walk without pain.” This statement indicates a need for further teaching because the client should use a walker or other assistive device until they have regained their balance, flexibility and strength, not just until the pain subsides.Using a walker too long or too little can affect the healing process and the stability of the new hip joint.
Choice B is correct because the client should avoid crossing their legs or bending their hip more than 90 degrees to prevent dislocating the new hip joint.
Choice C is correct because the client should sleep on their back with a pillow between their legs to keep the hip in a neutral position and prevent excessive internal or external rotation.
Choice D is correct because the client should apply ice to their hip if it becomes swollen or inflamed to reduce pain and inflammation.The client should also elevate their leg and notify their healthcare provider if they notice any signs of infection, such as fever, chills, redness, warmth or drainage from the incision site.
Normal ranges for hip replacement surgery recovery vary depending on the individual and the type of surgery, but some general guidelines are:.
• The client should be able to walk with a cane or crutches within 2 to 4 weeks after surgery.
• The client should be able to resume most daily activities within 6 to 12 weeks after surgery.
• The client should avoid high-impact activities, such as running, jumping or contact sports, for at least 6 months after surgery.
• The client should have regular follow-up visits with their healthcare provider and physical therapist to monitor their progress and adjust their treatment plan as needed.
The nurse is caring for an elderly patient who has been admitted with pneumonia.
The nurse knows that elderly patients are at increased risk for respiratory infections because of which of the following factors?
(Select all that apply.).
Explanation
The correct answer is A, B and C.
These are the factors that increase the risk of respiratory infections in elderly patients:.
• Decreased immune response: Elderly patients have a weaker immune system that makes them more susceptible to viral and bacterial infections.They also have a poor response to respiratory vaccines.
• Decreased chest wall compliance: Elderly patients have reduced elasticity of the lungs and chest wall, which makes it harder for them to breathe and expel mucus.
• Decreased alveolar surface area: Elderly patients have fewer and larger alveoli, which reduces the gas exchange area and oxygen diffusion capacity.
Choice D is wrong because decreased oxygen saturation is not a risk factor, but a consequence of respiratory infections.
Choice E is wrong because decreased bronchial dilation is not a specific factor for elderly patients, but a common feature of obstructive lung diseases.
Normal ranges for oxygen saturation are 95-100% and for bronchial dilation are variable depending on the type and severity of the disease.
The nurse is assessing an elderly patient’s skin turgor and notes that it is poor.
The nurse understands that this finding may be due to which of the following reasons?
Explanation
The correct answer is A.
Dehydration.
Poor skin turgor means that the skin takes longer to return to its normal position after being pinched or pulled.
This is a sign of dehydration, which means the body does not have enough fluid.
Dehydration can be caused by not drinking enough water, vomiting, diarrhea, fever, diabetes, or other conditions that affect fluid balance.
Choice B is wrong because malnutrition does not directly affect skin turgor.
Malnutrition means the body does not get enough nutrients from food.
This can cause various problems, such as weight loss, muscle wasting, poor wound healing, and infections.
However, malnutrition does not cause the skin to lose its elasticity.
Choice C is wrong because loss of subcutaneous fat does not cause poor skin turgor.
Subcutaneous fat is the layer of fat under the skin that helps insulate the body and store energy.
As people age, they tend to lose some subcutaneous fat, especially in the face and hands.
This can make the skin look thinner and more wrinkled, but it does not affect how quickly the skin snaps back after being pinched.
Choice D is wrong because reduced collagen fibers do not cause poor skin turgor.
Collagen is a protein that gives the skin its strength and structure.
As people age, they produce less collagen, which can make the skin sag and lose firmness.
However, collagen does not affect the skin’s ability to retain water and return to its normal shape after being stretched.
Normal ranges for skin turgor vary depending on the age and location of the skin.
In general, healthy skin should return to its normal position within 2 seconds after being pinched.
In children and young adults, skin turgor can be tested on the abdomen or forearm.In elderly people, skin turgor can be tested on the clavicle (collar bone), sternum (breastbone), forehead, or inner thigh.These sites are less affected by skin wrinkling and aging.
The nurse is teaching an elderly patient about nail care and hygiene. The nurse should instruct the patient to do which of the following?
(Select all that apply.).
Explanation
The correct answer isA, B, and E.
The nurse should instruct the patient to do the following:.
• Trim nails straight across and file edges smoothly.
• Soak nails in warm water before trimming to soften them.
• Report any signs of infection or inflammation around nails.
These are good practices for nail hygiene and health, especially for the elderly who may have dry, brittle or thickened nails.Trimming nails straight across and filing them prevents ingrown nails and reduces the risk of injury or infection.Soaking nails in warm water makes them easier to cut and less likely to crack or split.Reporting any signs of infection or inflammation around nails is important to prevent complications and get appropriate treatment.
Choice C is wrong because using a metal nail file or scissors to cut nails can damage the nail plate and cause splitting or tearing.Choice D is wrong because applying a clear nail polish to protect nails from cracking is unnecessary and may worsen nail health by trapping moisture and bacteria under the polish.
To maintain healthy nails, the elderly should also scrub the underside of their nails with soap and water, moisturize their nails and cuticles, avoid biting or chewing their nails, eat nutritious foods rich in calcium and vitamins B and C, and use sterilized nail grooming tools.
:Fingernail Care for the Elderly - assisting hands-il-wi.com:Fingernails: Do’s and don’ts for healthy nails - Mayo Clinic:Nail Hygiene | CDC - Centers for Disease Control and Prevention.
A nurse is planning care for an older adult client who has constipation due to decreased intestinal motility.
Which of the following interventions should the nurse include in the plan?
Explanation
Encourage fluid intake of at least 2 L/day.
This is because adequate hydration can help soften the stool and facilitate its passage through the intestines.Fluid intake should be increased gradually to avoid fluid overload or electrolyte imbalance.
Choice B is wrong because alow-fiber dietcan contribute to constipation by reducing the bulk and water content of the stool.
Fiber helps retain water in the stool and stimulate peristalsis.A high-fiber diet is recommended for clients who have constipation.
Choice C is wrong because astimulant laxativeshould not be used daily or for a long period of time, as it can cause dependence, dehydration, electrolyte imbalance, and damage to the intestinal mucosa.Stimulant laxatives should be used only as a last resort when other measures fail.
Choice D is wrong becausephysical activitycan help prevent constipation by increasing intestinal motility and blood flow.Physical activity should be encouraged for clients who have constipation, unless contraindicated by other conditions.
Normal ranges for fluid intake are about 2 to 3 L/day for adults, depending on age, weight, activity level, and climate.Normal ranges for fiber intake are about 25 to 38 g/day for adults, depending on age and sex.
A nurse is evaluating a client who is 70 years old for signs of dehydration.
Which of the following findings should the nurse expect?
Explanation
The correct answer is D.
Decreased mental status.Dehydration in elderly people can cause confusion, disorientation, or drowsiness due to the loss of water and electrolytes from the body.
These symptoms can affect the cognitive function and alertness of the client.Dehydration can also lead to complications such as kidney problems, electrolyte imbalances, or low blood pressure.
Choice A is wrong because increased skin turgor is not a sign of dehydration.
Skin turgor is the ability of the skin to return to its normal shape after being pinched or pulled.Dehydration causes decreased skin turgor, meaning the skin stays tented or wrinkled after being pinched.
Choice B is wrong because decreased pulse rate is not a sign of dehydration.Dehydration causes increased pulse rate, as the heart has to work harder to pump blood to the vital organs when there is less fluid in the body.
Choice C is wrong because increased urine output is not a sign of dehydration.Dehydration causes decreased urine output, as the kidneys try to conserve water and produce more concentrated urine.
The urine may also be darker in color than normal.
Normal ranges for fluid intake and output vary depending on age, weight, activity level, and health status.
However, a general guideline is to drink at least eight 8-ounce glasses of water per day and produce at least 30 mL of urine per hour.
A nurse is educating a client who is 60 years old about strategies to prevent orthostatic hypotension. Which of the following instructions should the nurse include?
(Select all that apply.).
Explanation
The correct answer is A, B, and D.These are some of the strategies to prevent orthostatic hypotension, which is a sudden drop in blood pressure caused by a change in posture, such as when a person stands up quickly.
Some explanations for the other choices are:.
• Choice C is wrong because drinking caffeinated beverages can cause dehydration, which can worsen orthostatic hypotension by reducing the fluid volume in the blood vessels.
• Choice E is wrong because increasing salt intake can raise blood pressure, but it can also cause fluid retention, which can strain the heart and kidneys.People with hypertension, heart failure, or kidney disease should limit their salt intake.
Some normal ranges for blood pressure are:.
• Systolic blood pressure (the top number) should be less than 120 mmHg for most adults.
• Diastolic blood pressure (the bottom number) should be less than 80 mmHg for most adults.
• Orthostatic hypotension is diagnosed when there is a drop of 20 mmHg or more in systolic blood pressure or 10 mmHg or more in diastolic blood pressure within 2 to 5 minutes of standing.
A nurse is caring for an older adult client who reports feeling cold most of the time.
The nurse knows that this is most likely due to which of the following physiological changes with aging?
Explanation
The correct answer is A.
Decreased metabolic rate.This is because the metabolic rate is the amount of energy that the body uses to maintain its functions, and it tends to decline with age due to various factors, such as loss of muscle mass, reduced activity, hormonal changes, and decreased thyroid function.
A lower metabolic rate means that the body produces less heat and therefore feels colder more easily.
Choice B is wrong because increased blood pressure is not a normal physiological change with aging, but rather a risk factor for cardiovascular diseases that can be influenced by lifestyle, genetics, and other factors.
Choice C is wrong because increased sweat gland activity is not a normal physiological change with aging, but rather a sign of hyperhidrosis, which is a condition that causes excessive sweating due to overactive sweat glands.Sweat glands actually decrease in number and function with age, which can impair thermoregulation and increase the risk of heat-related illnesses.
Choice D is wrong because decreased body fat is not a normal physiological change with aging, but rather a result of malnutrition, illness, or other causes.Body fat actually tends to increase with age, especially in the abdominal region, due to hormonal changes, reduced physical activity, and lower metabolic rate.
Body fat can act as an insulator and help maintain body temperature.
Normal ranges for metabolic rate vary depending on age, sex, body size, activity level, and other factors.
A general estimate for resting metabolic rate (RMR) is 10 calories per kilogram of body weight per day for men and 9 calories per kilogram of body weight per day for women.
However, this may not reflect the actual metabolic rate of an individual, as it does not account for the effects of food intake, exercise, or environmental factors.
Therefore, it is better to measure metabolic rate using indirect calorimetry or other methods that can capture these variables.
A nurse is assessing an older adult client who has sarcopenia.
The nurse knows that this condition is characterized by which of the following?
Explanation
The correct answer isB.
Loss of muscle mass and strength.Sarcopenia is a condition that affects older adults and causes a progressive decline in skeletal muscle mass, strength, and function.This can lead to an increased risk of falls, fractures, disability, and mortality.
Choice A is wrong because the loss of bone mass and strength is calledosteoporosis, not sarcopenia.Osteoporosis is a condition that affects the density and quality of bones, making them more prone to fracture.
Choice C is wrong because loss of joint flexibility and range of motion is calledarthritis, not sarcopenia.
Arthritis is a term that refers to inflammation of the joints, which can cause pain, stiffness, swelling, and reduced mobility.
Choice D is wrong because loss of skin elasticity and moisture is calledskin aging, not sarcopenia.
Skin aging is a process that involves changes in the structure and function of the skin, such as wrinkles, sagging, dryness, and decreased wound healing.
Normal ranges for muscle mass and strength vary depending on age, sex, body size, and physical activity level.However, some general indicators of sarcopenia include:.
• A muscle mass index (muscle mass divided by height squared) below 7.26 kg/m2 for men and 5.45 kg/m2 for women.
• A handgrip strength below 30 kg for men and 20 kg for women.
• A gait speed below 0.8 m/s for both sexes.
A nurse is planning care for an older adult client who has impaired tactile sensation due to aging.
Which of the following interventions should the nurse include?
(Select all that apply.).
Explanation
The correct answer isA, B, and C.
These interventions are appropriate for a client who has impaired tactile sensation due to aging.
• Ais correct because monitoring the client’s skin for signs of injury or infection can help prevent complications such as pressure ulcers, burns, or infections that might go unnoticed by the client due to reduced sensitivity.
• Bis correct because teaching the client to avoid exposure to extreme temperatures can protect the client from thermal injuries such as frostbite or heatstroke that might not be felt by the client due to diminished thermoreception.
• Cis correct because encouraging the client to use assistive devices for mobility and balance can enhance the client’s safety and independence by compensating for the loss of proprioception and kinesthesia that might impair the client’s coordination and stability.
• Dis wrong because providing the client with sensory stimulation such as massage or music is not directly related to impaired tactile sensation due to aging.While sensory stimulation might have other benefits for the client’s well-being, it does not address the specific problem of reduced touch perception.
• Eis wrong because advising the client to wear loose-fitting clothing and shoes is not helpful for a client who has impaired tactile sensation due to aging.In fact, loose-fitting clothing and shoes might increase the risk of falls or injuries by creating friction or slipping off the client’s body.
Normal ranges for tactile sensation vary depending on the type of stimulus, the location of the skin, and the method of testing.
However, some general guidelines are:.
• Vibration sense: normal threshold is less than 10 μm at 30 Hz on the fingertip.
• Temperature sense: normal threshold is less than 1°C difference between two stimuli on the forearm.
• Pressure sense: normal threshold is less than 10 g/mm2 on the fingertip.
• Pain sense: normal threshold is less than 0.5 g/mm2 on the fingertip.
The nurse is caring for an older adult client who has been diagnosed with benign prostatic hyperplasia (BPH). The client asks the nurse what causes this condition.
What is the best response by the nurse?
Explanation
The correct answer is B.
It is caused by a hormonal imbalance that stimulates the growth of prostate tissue.
• Choice A is wrong because BPH is not caused by an infection of the prostate gland.Prostate infections are called prostatitis and have different symptoms and treatments than BPH.
• Choice C is wrong because BPH is not caused by a genetic mutation that triggers abnormal cell division in the prostate.Prostate cancer is a malignant condition that involves uncontrolled cell growth in the prostate, but it is not the same as BPH.
• Choice D is wrong because BPH is not caused by an autoimmune disorder that attacks and damages the prostate tissue.Autoimmune disorders are conditions where the immune system mistakenly attacks healthy cells in the body, but they are not known to cause BPH.
The exact cause of BPH is unknown, but it is believed to be related to aging and hormonal changes in older men.The prostate gland grows throughout a man’s life, but it usually does not cause problems until later in life.Some factors that may increase the risk of BPH include family history, diabetes, heart problems, obesity, and prostate cancer.
BPH can cause symptoms such as difficulty urinating, frequent or urgent urination, weak or interrupted urine stream, dribbling at the end of urination, incomplete bladder emptying, nocturia (urination at night), urinary incontinence (leakage of urine), urinary retention (inability to urinate), blood in urine, and painful urination.These symptoms can affect the quality of life and lead to complications such as urinary tract infections, bladder stones, bladder damage, kidney problems, and acute urinary retention.
BPH can be diagnosed by a physical exam, medical history, and various tests such as urinalysis, urodynamic test, prostate-specific antigen (PSA) test, post-void residual test, and cystoscopy.
The treatment options depend on the severity of symptoms, the size of the prostate, and other health conditions.They include medications, surgery, and other procedures such as laser therapy or microwave therapy.Some natural treatments such as lifestyle changes, dietary supplements, and herbal remedies may also help with mild symptoms of BPH.
Normal ranges for some tests related to BPH are:.
• PSA test: The normal range for PSA levels is 0 to 4 nanograms per milliliter (ng/mL) of blood.
However, this range may vary depending on age, race, and other factors.Higher PSA levels may indicate prostate cancer or other prostate problems such as BPH or prostatitis.
• Post-void residual test: The normal range for post-void residual volume is less than 50 milliliters (mL) of urine.Higher volumes may indicate urinary retention or bladder dysfunction due to BPH or other causes.
• Urodynamic test: The normal range for urodynamic parameters such as bladder pressure, urine flow rate, and bladder capacity may vary depending on age, gender, and other factors.Abnormal values may indicate bladder obstruction or dysfunction due to BPH or other causes.
References:.
:What is Benign prostatic hyperplasia and its possible symptoms ….
The nurse is teaching an older adult client who has menopause about hormone replacement therapy (HRT). The client asks about the benefits and risks of HRT.
What should the nurse include in the teaching?
Explanation
The correct answer is A.
HRT can relieve hot flashes, vaginal dryness and mood swings, but it can also increase the risk of breast cancer, stroke and blood clots.This answer is based on the evidence from various studies that have shown the benefits and risks of HRT.
Choice B is wrong because HRT cannot prevent osteoporosis, heart disease and dementia, and it does not cause weight gain, acne and hair loss.These are common misconceptions about HRT that are not supported by scientific research.
Choice C is wrong because HRT does not have a significant effect on sexual function, skin elasticity and memory, and it does not lower the immune system, blood pressure and blood sugar.These are also myths about HRT that have no basis in reality.
Choice D is wrong because HRT can improve sleep quality, energy levels and mood, but it can also cause or worsen headaches, nausea and bloating.These are some of the possible side effects of HRT that vary depending on the type, dose and duration of the therapy.
Normal ranges for estrogen and progesterone levels depend on the stage of menopause, the type of HRT and the individual factors of each woman.
Generally, estrogen levels range from 10 to 50 pg/mL (picograms per milliliter) and progesterone levels range from 0.1 to 25 ng/mL (nanograms per milliliter) in postmenopausal women.
The nurse is reviewing the laboratory results of an older adult client who has a urinary tract infection (UTI).
Which of the following findings should alert the nurse to a possible complication of UTI in older adults?
(Select all that apply.).
Explanation
The correct answer isA, D, and E.
Here is why:.
A. Elevated white blood cell count.
This is a sign of infection and inflammation in the body, which can be caused by a UTI.An elevated white blood cell count can also indicate a complication of UTI such as pyelonephritis (kidney infection) or sepsis (blood infection).
D. Altered mental status.
This is a common symptom of UTI in older adults, especially those with dementia or other cognitive impairments.UTIs can cause confusion, agitation, delirium, or behavioral changes in the elderly due to the effects of infection and inflammation on the brain.
E. Positive urine culture.
This is the definitive test to diagnose a UTI, as it identifies the type and number of bacteria present in the urine.A positive urine culture confirms the presence of a UTI and guides the appropriate antimicrobial treatment.
The other choices are wrong because:.
•.
B. Decreased serum creatinine level.
This is not a sign of UTI or its complications.
Serum creatinine is a measure of kidney function, and it usually increases when the kidneys are damaged or impaired.A decreased serum creatinine level may indicate other conditions such as liver disease, muscle wasting, or malnutrition.
•.
C. Increased urine specific gravity.
This is not a sign of UTI or its complications.
Urine specific gravity is a measure of urine concentration, and it usually increases when the body is dehydrated or has high levels of solutes in the urine.An increased urine specific gravity may indicate other conditions such as diabetes mellitus, heart failure, or dehydration.
Normal ranges for some of these tests are:.
• White blood cell count: 4,000 to 11,000 cells per microliter (mcL) of blood.
• Serum creatinine: 0.6 to 1.2 milligrams per deciliter (mg/dL) for men and 0.5 to 1.1 mg/dL for women.
• Urine specific gravity: 1.005 to 1.030.
The nurse is caring for an older adult client who has an infection and a fever of 38°C (100.4°F).
The nurse should monitor the client for which of the following complications?
Explanation
The correct answer is D.
Delirium.
The nurse should monitor the client for delirium, which is a state of acute mental confusion that can be caused by fever, infection, dehydration, or medications.
Delirium can affect the client’s cognition, attention, orientation, memory, and behavior.It can also increase the risk of falls, complications, and mortality.
Choice A is wrong because dehydration is not a complication of fever, but rather a possible cause of fever.
Dehydration occurs when the body loses more fluid than it takes in, and it can impair the body’s ability to regulate its temperature.Dehydration is more common and dangerous in older adults because they have a lower volume of water in their bodies, a weaker thirst response, and may have conditions or medications that increase fluid loss.
Choice B is wrong because hypothermia is not a complication of fever, but rather a condition of abnormally low body temperature.
Hypothermia can occur when the body loses heat faster than it can produce it, such as in cold weather or water exposure.Hypothermia can affect the brain, heart, and other organs, and can lead to death if not treated promptly.
Choice C is wrong because seizures are not a common complication of fever in older adults.
Seizures are sudden episodes of abnormal electrical activity in the brain that can cause changes in movement, sensation, behavior, or consciousness.
Seizures can have various causes, such as head injury, stroke, infection, or epilepsy.
Fever-induced seizures are more likely to occur in young children than in older adults.
The nurse is providing discharge instructions to an older adult client who has diabetes mellitus and is taking oral hypoglycemic agents.
The nurse should advise the client to do which of the following?
Explanation
The correct answer is D.
Report any signs of infection or delayed wound healing.
This is because oral hypoglycemic agents lower the blood glucose level, but they do not prevent the complications of diabetes mellitus, such as impaired wound healing and increased susceptibility to infections.Therefore, the client should be advised to monitor for any signs of infection, such as fever, redness, swelling, or pus, and report them to the health care provider promptly.
Choice A is wrong because checking blood glucose levels at least four times a day is not necessary for most clients who are taking oral hypoglycemic agents.
The frequency of blood glucose monitoring depends on the type and dose of medication, the level of glycemic control, and the presence of other factors that may affect blood glucose, such as illness or stress.The client should follow the individualized plan prescribed by the health care provider regarding blood glucose monitoring.
Choice B is wrong because drinking plenty of fluids and avoiding caffeine is not specific to clients who are taking oral hypoglycemic agents.
This is a general recommendation for all clients who have diabetes mellitus, as dehydration and caffeine can worsen hyperglycemia and increase the risk of diabetic ketoacidosis or hyperosmolar hyperglycemic state.However, this alone is not sufficient to manage diabetes mellitus and prevent complications.
Choice C is wrong because eating small, frequent meals and avoiding simple sugars is also a general recommendation for all clients who have diabetes mellitus, as this can help to maintain a stable blood glucose level and prevent hypoglycemia or hyperglycemia.
However, this alone is not sufficient to manage diabetes mellitus and prevent complications.The client should also follow a balanced diet that includes complex carbohydrates, protein, fiber, and healthy fats, and consult with a dietitian or a diabetes educator for individualized dietary guidance.
The nurse is assessing an older adult client who has osteoporosis and reports frequent falls.
The nurse should ask the client about which of the following factors that could contribute to falls?
(Select all that apply.).
Explanation
The correct answer isA, B, C, and E.
The nurse should ask the client about medications, vision problems, home environment, and urinary incontinence as these are all factors that could contribute to falls in older adults.
• Medicationscan increase the risk of falls because they can cause side effects such as drowsiness, dizziness, confusion, or low blood pressure.Some medications that can increase the risk of falls include sedatives, antidepressants, antihypertensives, diuretics, and anticholinergics.
• Vision problemscan impair the ability to see obstacles, judge depth and distance, or adjust to changes in light.Some vision problems that can increase the risk of falls include cataracts, glaucoma, macular degeneration, and diabetic retinopathy.
• Home environmentcan pose safety hazards that can cause tripping, slipping, or losing balance.Some home hazards that can increase the risk of falls include loose rugs, clutter, poor lighting, slippery floors, uneven surfaces, and lack of handrails or grab bars.
• Urinary incontinencecan lead to rushed movements to the bathroom or frequent nighttime trips that can increase the risk of falls.Urinary incontinence can be caused by various factors such as bladder infections, prostate problems, pelvic floor weakness, or medication side effects.
Choice D is wrong because thyroid function is not a direct factor that contributes to falls in older adults.However, thyroid disorders such as hyperthyroidism or hypothyroidism can affect other factors such as muscle strength, bone density, heart rate, or blood pressure that can indirectly increase the risk of falls.
Normal ranges for thyroid function tests vary depending on the laboratory and the method used.However, a common reference range for thyroid-stimulating hormone (TSH) is 0.4 to 4.0 mIU/L and for free thyroxine (FT4) is 0.8 to 1.8 ng/dL.
A nurse is reviewing the results of a functional status assessment for an older adult client using the Katz Index of Independence in Activities of Daily Living (ADLs). The nurse notes that the client scored 4 out of 6 on this tool.
What does this score indicate?
Explanation
The correct answer is B.
The client needs assistance with two ADLs.This is because the Katz Index of Independence in Activities of Daily Living (ADLs) is a tool that measures the client’s ability to perform six basic ADLs independently: bathing, dressing, toileting, transferring, continence, and feeding.The score ranges from 0 to 6, with 6 indicating complete independence, 4 indicating moderate impairment, and 2 or less indicating severe dependence.The score is based on the number of ADLs that the client can perform without supervision, direction, personal assistance, or total care.
Therefore, a score of 4 out of 6 means that the client needs assistance with two ADLs.
Choice A is wrong because it implies that the client is independent in all ADLs, which would require a score of 6 out of 6.
Choice C is wrong because it implies that the client is dependent on others for all ADLs, which would require a score of 0 out of 6.
Choice D is wrong because it implies that the client has difficulty with four ADLs, which would require a score of 2 out of 6.
The normal range for the Katz Index of Independence in Activities of Daily Living (ADLs) depends on the setting and population of the client.For example, one study found that the average score for residents in skilled nursing facilities was 3.1 out of 6.Another study found that the hierarchy of difficulty of the six ADLs from least to greatest was: eating, maintaining continence, transferring, toileting, dressing, and bathing.
A nurse is conducting a functional status assessment for an older adult client using the Lawton Instrumental Activities of Daily Living (IADLs) Scale. The nurse asks the client about his ability to use transportation.
Which of the following questions is appropriate for this domain?
Explanation
The correct answer is A.“Do you drive your own car or use public transportation?.” This question is appropriate for the domain ofmode of transportation, which is one of the eight areas of occupational performance assessed by the Lawton Instrumental Activities of Daily Living (IADLs) Scale.The scale evaluates a person’s ability to engage in more complex activities thought necessary for functioning in community settings.
Choice B is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofability to use a telephone.The scale asks about the person’s ability to operate a telephone, dial numbers, and answer calls.
Choice C is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofshopping.The scale asks about the person’s ability to take care of all shopping needs independently, shop for small purchases, or need assistance with shopping.
Choice D is wrong because it is not related to the domain of mode of transportation, but rather to the domain ofmobility.The scale does not assess mobility directly, but it may be inferred from the person’s ability to travel by public transportation or car.
The Lawton IADLs Scale has a summary score that ranges from 0 (low function, dependent) to 8 (high function, independent) for women, and 0 to 5 for men.The score identifies areas of need in regard to care and support.
A nurse is implementing interventions to improve the functional status of an older adult client who has diabetes and hypertension.
Which of the following interventions should the nurse include?
(Select all that apply.).
Explanation
The correct answer isA, B, C and E.These interventions are consistent with the best practices for optimizing functional status in the elderly.
Some explanations for the choices are:.
• Choice A is correct because physical activity and exercise can help maintain muscle strength, joint mobility, balance and coordination, which are essential for functional independence and quality of life.
• Choice B is correct because adequate nutrition and hydration can prevent malnutrition, dehydration and electrolyte imbalance, which can impair physical and cognitive function and increase the risk of complications.
• Choice C is correct because managing chronic diseases and medications can prevent complications, adverse effects and polypharmacy, which can affect functional status and increase the need for health care services.
• Choice D is wrong because providing assistive devices and adaptive equipment is not an intervention to improve functional status, but rather to enhance mobility, safety and independence for patients who already have functional limitations.
The question asks for interventions to improve functional status, not to compensate for it.
• Choice E is correct because modifying the environment can reduce hazards, improve accessibility and facilitate self-care, which can promote functional independence and prevent injuries or falls.
The normal ranges for blood glucose and blood pressure for older adults with diabetes and hypertension are:.
• Blood glucose: 80-130 mg/dL before meals and less than 180 mg/dL after meals.
• Blood pressure: less than 140/90 mmHg or individualized based on comorbidities and risk factors.
A nurse is reviewing the medication list of an older adult client who has delirium.
Which of the following medications can contribute to delirium in older adults?
Explanation
The correct answer is B.
Diphenhydramine.Diphenhydramine is an antihistamine and sedative medication that can causedeliriumin older adults, especially when used in high doses or for a long time.Delirium is a serious change in mental abilities that results in confused thinking and reduced awareness of the surroundings.It can be caused by various factors, such as infections, medications, surgery, or alcohol or drug use or withdrawal.Delirium can have serious consequences, such as increased risk of falls, complications, and death.
Choice A is wrong because acetaminophen is a pain reliever and fever reducer that does not usually cause delirium in older adults.
However, acetaminophen overdose can cause liver damage and altered mental status.
Choice C is wrong because metformin is an oral medication that lowers blood sugar levels in people with type 2 diabetes.
Metformin does not typically cause delirium in older adults.
However, metformin can cause a rare but serious condition called lactic acidosis, which can cause confusion and other symptoms.
Choice D is wrong because lisinopril is an angiotensin-converting enzyme (ACE) inhibitor that lowers blood pressure and prevents heart failure.
Lisinopril does not usually cause delirium in older adults.
However, lisinopril can cause a rare but serious condition called angioedema, which can cause swelling of the face, tongue, or throat and difficulty breathing.
Normal ranges for some relevant laboratory tests are:.
• Albumin: 3.5-5.0 g/dL.
• Potassium: 3.5-5.0 mEq/L.
• Total cholesterol: <200 mg/dL.
• Hemoglobin: 13.5-17.5 g/dL for men; 12.0-15.5 g/dL for women.
A nurse is performing a mental status examination on an older adult client who has delirium.
Which of the following tools can the nurse use to assess the client’s attention span and concentration?
Explanation
The correct answer is D.
Digit Span Test (DST).
The DST is a tool that can be used to assess the client’s attention span and concentration by asking them to repeat a series of digits forward and backward (Martin, 1990).
The DST is part of the Mini-Mental State Examination (MMSE), which is a broader tool that covers other domains of cognitive functioning, such as orientation, memory, language, and visuospatial skills (Folstein et al., 1975).
Choice A is wrong because the MMSE is not a specific tool for attention span and concentration, but rather a general screening tool for cognitive impairment.
Choice B is wrong because the Confusion Assessment Method (CAM) is a tool that can be used to diagnose delirium, but not to assess attention span and concentration.
The CAM focuses on four features of delirium: acute onset and fluctuating course, inattention, disorganized thinking, and altered level of consciousness (Inouye et al., 1990).
Choice C is wrong because the Clock Drawing Test (CDT) is a tool that can be used to assess visuospatial skills and executive function, but not attention span and concentration.
The CDT requires the client to draw a clock face with numbers and hands indicating a specific time (Shulman et al., 1986).
Normal ranges for the DST vary depending on the age and education level of the client, but generally a score of 5 or more digits forward and 4 or more digits backward is considered normal (Martin, 1990).
A nurse is providing discharge instructions to an older adult client who has recovered from delirium and their family caregiver.
Which of the following recommendations should the nurse make to prevent recurrence of delirium?
(Select all that apply.).
Explanation
The correct answer isA, B and D.
Here is why:.
• Following up with the primary care provider regularly can help detect and treat any medical conditions that may cause or contribute to delirium, such as infections, electrolyte imbalances, or medication side effects.
• Avoiding alcohol and tobacco use can prevent delirium caused by intoxication or withdrawal, as well as improve overall health and cognitive function.
• Engaging in physical and mental activities daily can help maintain brain health, prevent cognitive decline, and reduce stress and boredom that may trigger delirium.
Choice C is wrong because taking over-the-counter sleeping pills as needed can increase the risk of delirium, especially in older adults.Sleeping pills can cause confusion, drowsiness, memory impairment, and falls that may lead to delirium.Instead of sleeping pills, it is better to have good sleep habits such as uninterrupted sleep, avoiding caffeine and naps, and having a regular bedtime routine.
Choice E is wrong because wearing glasses and hearing aids if prescribed can help prevent delirium, not cause it.Sensory impairment such as poor vision and hearing can make a person more prone to delirium, as they may feel disoriented, isolated, or misunderstood.Wearing glasses and hearing aids can help improve communication, orientation, and awareness of surroundings.
Delirium is a serious change in mental abilities that results in confused thinking and a lack of awareness of one’s surroundings.It usually comes on fast and can be caused by various factors such as fever, infection, surgery, medication, or emotional distress.
Delirium can often be prevented.
The nurse is caring for a patient who has had a spinal cord injury at level C5-C6 as a result of an automobile accident. The patient suddenly develops severe hypertension, throbbing headache, blurred vision, and bradycardia.
What is the priority nursing intervention?
Explanation
The correct answer is C.
Check for bladder distention or fecal impaction.
Autonomic dysreflexia is a disorder of autonomic nervous system dysregulation that occurs in patients with a spinal cord injury above T6.
It is caused by an exaggerated reflex response of the sympathetic nervous system due to an irritating stimulus below the spinal cord injury.It leads to severe hypertension and is a medical emergency.
Bladder or bowel distension are the most common triggers of autonomic dysreflexia.
Therefore, the priority nursing intervention is to check for bladder distention or fecal impaction and relieve them as soon as possible.
This can help to eliminate the stimulus and lower the blood pressure.
Choice A is wrong because administering antihypertensive medication as prescribed may not be effective or appropriate for autonomic dysreflexia.
The hypertension is caused by a reflex mechanism and not by a primary cardiovascular disorder.Moreover, antihypertensive drugs may cause hypotension once the stimulus is removed.
Choice B is wrong because elevating the head of bed to 90 degrees may not be enough to lower the blood pressure.It may also increase the risk of orthostatic hypotension once the stimulus is removed.However, sitting the patient upright and loosening any tight clothing are recommended as initial steps to reduce the blood pressure.
Choice D is wrong because applying a cooling blanket to lower body temperature is not indicated for autonomic dysreflexia.There is no evidence that body temperature is elevated or contributes to the hypertension in this condition.A cooling blanket may also cause vasoconstriction and worsen the hypertension.
Normal ranges for blood pressure vary depending on age, sex, and other factors.
However, a general guideline is that systolic blood pressure should be less than 120 mm Hg and diastolic blood pressure should be less than 80 mm Hg for most adults.
Normal ranges for heart rate also vary depending on age, activity level, and other factors.
However, a general guideline is that resting heart rate should be between 60 and 100 beats per minute for most adults.
References:.
The nurse is assessing a patient who has been diagnosed with multiple sclerosis (MS).
Which of the following findings is most consistent with this condition?
Explanation
Intention tremors and nystagmus.These are some of the common symptoms of multiple sclerosis (MS), a condition that affects the central nervous system and causes communication problems between the brain and the rest of the body.Intention tremors are involuntary shaking movements that occur when a person tries to perform a precise action, such as reaching for an object or writing.Nystagmus is a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception.
Choice A is wrong because muscle atrophy and fasciculations are more typical of motor neuron diseases, such as amyotrophic lateral sclerosis (ALS), which affect the nerve cells that control voluntary muscle movements.
Choice C is wrong because flaccid paralysis and areflexia are signs of lower motor neuron lesions, which can be caused by spinal cord injuries, peripheral nerve disorders, or Guillain-Barré syndrome.
Choice D is wrong because hyperactive reflexes and spasticity are signs of upper motor neuron lesions, which can be caused by stroke, traumatic brain injury, or cerebral palsy.
Normal ranges for some of the symptoms mentioned are:.
• Intention tremors: none or minimal.
• Nystagmus: none or minimal.
• Muscle atrophy: none or minimal.
• Fasciculations: none or minimal.
• Flaccid paralysis: none or minimal.
• Areflexia: absent or reduced reflexes.
• Hyperactive reflexes: normal or slightly increased reflexes.
• Spasticity: normal or slightly increased muscle tone.
A. Muscle atrophy and fasciculations B.
Intention tremors and nystagmus C.
Flaccid paralysis and areflexia D.
Hyperactive reflexes and spasticity
A nurse is providing discharge teaching for a patient who had a seizure disorder and is prescribed phenytoin (Dilantin).
Which of the following instructions should the nurse include?
(Select all that apply.).
Explanation
The correct answer is B, C, and E.
Phenytoin (Dilantin) is an anticonvulsant medication that is used to control seizures.
It can have several side effects, some of which are serious and require medical attention.
Here are some explanations for each choice:.
A. Avoid drinking grapefruit juice while taking this medication.
This iswrongbecause grapefruit juice does not interact with phenytoin.However, grapefruit juice can affect the levels of other medications, such as statins, calcium channel blockers, and some antidepressants.
B. Brush your teeth gently with a soft-bristled toothbrush.This isrightbecause phenytoin can causegingival hyperplasia, which is an overgrowth of the gums that can lead to bleeding, infection, and difficulty chewing.
To prevent this, patients should practice good oral hygiene, avoid alcohol and tobacco, and see a dentist regularly.
A. Avoid drinking grapefruit juice while taking this medication B.
Brush your teeth gently with a soft-bristled toothbrush C.
Wear a medical alert bracelet or necklace at all times D.
Stop taking this medication if you develop a rash or fever E.
Have your blood levels checked regularly as directed by your provider
A nurse is caring for an older adult client who has depression and reports having chronic pain in his lower back.
Which of the following actions should the nurse take?
Explanation
The correct answer isD.
All of the above.
The nurse should take all of the actions listed to provide effective pain management for the older adult client who has depression and chronic pain in his lower back.
• Choice Ais correct because assessing the pain using a valid and reliable pain scale is essential for determining the severity and impact of pain, as well as monitoring the response to treatment.
• Choice Bis correct because administering analgesic medications as prescribed can help reduce pain and improve function.
The nurse should also monitor for effectiveness and side effects, especially in older adults who may have altered drug metabolism, polypharmacy, and increased risk of adverse events.
• Choice Cis correct because providing non-pharmacological interventions can enhance pain relief, reduce medication use, and address the biopsychosocial aspects of pain.
Massage, heat or cold therapy, relaxation techniques, and distraction are some examples of non-pharmacological interventions that can be used for chronic pain in older adults.
• Choice Dis correct because it includes all of the above actions, which are part of a multimodal approach to pain management that is recommended by clinical guidelines.
4 7 A multimodal approach can improve pain outcomes, reduce side effects, and address the complex needs of older adults with chronic pain.
A. Assess the location, intensity, quality and duration of the pain using a pain scale B.
Administer analgesic medications as prescribed and monitor for effectiveness and side effects C.
Provide non-pharmacological interventions such as massage, heat or cold therapy, relaxation techniques or distraction D.
All of the above
A nurse is evaluating an older adult client who has depression after four weeks of treatment with an antidepressant medication.
Which of the following findings would indicate that the medication is effective?
Explanation
The correct answer is D.
All of the above.
This is because all of these findings indicate that the client has experienced an improvement in mood, energy, appetite, sleep, interest and participation in social activities and hobbies, which are common signs of depression recovery.
Choice A is wrong because it only covers some of the symptoms of depression, such as mood, energy, appetite and sleep, but not others, such as interest and participation in social activities and hobbies.
Choice B is wrong because it only measures the client’s depression level using standardized scales, such as the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9), but not their actual functioning and quality of life.
Choice C is wrong because it only reflects the client’s interest and participation in social activities and hobbies, which are important aspects of depression recovery, but not their mood, energy, appetite, sleep or depression level.
The GDS and the PHQ-9 are both valid and reliable tools for screening and measuring depression in older adults.
The GDS is a 15-item questionnaire that asks the client to answer yes or no to questions about their mood, satisfaction, hopelessness, helplessness, worthlessness, guilt, agitation, withdrawal and suicidal thoughts.
The PHQ-9 is a 9-item questionnaire that asks the client to rate how often they have experienced symptoms of depression in the past two weeks, such as depressed mood, anhedonia, insomnia or hypersomnia, fatigue, appetite or weight changes, concentration problems, feelings of worthlessness or guilt.
A. The client reports an improvement in mood, energy, appetite and sleep B.
The client scores lower on the Geriatric Depression Scale (GDS) or the Patient Health Questionnaire (PHQ-9) C.
The client shows more interest and participation in social activities and hobbies D.
All of the above
A nurse is educating an older adult client who has depression about the benefits of physical activity and exercise.
Which of the following statements should the nurse include?
(Select all that apply.).
Explanation
The correct answer isA, B, C, D and E.
All of these statements are true and should be included in the nurse’s education.
Physical activity and exercise have many benefits for older adults with depression, such as:.
• Increasing the levels ofserotonin and endorphins, which are natural mood boosters that can help reduce depression symptoms.
• Improvingcardiovascular health, muscle strength, balance and flexibility, which can prevent or delay chronic diseases, reduce the risk of falls and injuries, and enhance functional ability.
• Reducingstress, anxiety, pain and inflammation, which can worsen depression and affect physical health.
• Enhancingself-esteem, confidence and sense of accomplishment, which can improve self-image, social interaction and coping skills.
• Helping tosleep better at night and feel more refreshed in the morning, which can improve mood, energy and cognitive function.
Choice A is correct because physical activity and exercise can increase the levels of serotonin and endorphins, which are natural mood boosters that can help reduce depression symptoms.
Choice B is correct because physical activity and exercise can improve cardiovascular health, muscle strength, balance and flexibility, which can prevent or delay chronic diseases, reduce the risk of falls and injuries, and enhance functional ability.
Choice C is correct because physical activity and exercise can reduce stress, anxiety, pain and inflammation.
A. Physical activity and exercise can increase your levels of serotonin and endorphins, which are natural mood boosters B.
Physical activity and exercise can improve your cardiovascular health, muscle strength, balance and flexibility C.
Physical activity and exercise can reduce your stress, anxiety, pain and inflammation D.
Physical activity and exercise can enhance your self-esteem, confidence and sense of accomplishment E.
Physical activity and exercise can help you sleep better at night and feel more refreshed in the morning
According to Erikson’s psychosocial theory, what is the main developmental task of older adults?
Explanation
The correct answer is C.
Ego integrity vs despair.
According to Erikson’s psychosocial theory, older adults face the challenge of looking back on their lives and evaluating their accomplishments and failures.
If they feel satisfied with their life course, they achieve a sense of ego integrity, which is a feeling of wholeness and coherence.
If they feel regretful or dissatisfied, they experience despair, which is a sense of hopelessness and bitterness.
Choice A is wrong because trust vs mistrust is the first stage of Erikson’s theory, which occurs in infancy.
It involves developing a basic sense of trust in oneself and others based on the quality of caregiving.
Choice B is wrong because generativity vs stagnation is the seventh stage of Erikson’s theory, which occurs in middle adulthood.
It involves contributing to society and the next generation through work, parenting, or other activities.
Choice D is wrong because identity vs role confusion is the fifth stage of Erikson’s theory, which occurs in adolescence.
It involves developing a stable and coherent sense of self and one’s role in society.
Normal ranges for Erikson’s stages are:.
• Trust vs mistrust: birth to 18 months.
• Autonomy vs shame and doubt: 18 months to 3 years.
• Initiative vs guilt: 3 to 6 years.
• Industry vs inferiority: 6 to 12 years.
• Identity vs role confusion: 12 to 18 years.
• Intimacy vs isolation: 18 to 40 years.
• Generativity vs stagnation: 40 to 65 years.
• Ego integrity vs despair: 65 years and older.
What are some of the environmental factors that can influence the psychosocial changes in older adults?
Explanation
The correct answer is C.
Living arrangements and social support.
This is because living arrangements and social support are some of the environmental factors that can influence the psychosocial changes in older adults.Psychosocial changes refer to the changes in mental and emotional well-being, social relationships, and roles that occur as people age.Environmental factors are the external conditions or circumstances that affect a person’s life.
Choice A is wrong because physical health and functional status are not environmental factors, but rather biological factors that affect the aging process.Physical health and functional status can influence the psychosocial changes in older adults, but they are not part of the environment.
Choice B is wrong because cognitive conditions and memory loss are also not environmental factors, but rather neurological factors that affect the brain function of older adults.Cognitive conditions and memory loss can also influence the psychosocial changes in older adults, but they are not part of the environment.
Choice D is wrong because hormonal changes and sensory impairments are also not environmental factors, but rather physiological factors that affect the body function of older adults.Hormonal changes and sensory impairments can also influence the psychosocial changes in older adults, but they are not part of the environment.
Living arrangements and social support are environmental factors because they depend on the availability, accessibility, and quality of housing, transportation, community services, family networks, and social interactions that older adults have in their surroundings.Living arrangements and social support can influence the psychosocial changes in older adults by affecting their sense of independence, identity, belonging, security, and satisfaction.
Therefore, living arrangements and social support are some of the environmental factors that can influence the psychosocial changes in older adults.
A nurse is conducting a psychosocial assessment of an older adult client who has recently retired from work.
Which of the following questions should the nurse ask?
(Select all that apply.).
Explanation
The correct answer isA, B, C, D, and E.
All of these questions are relevant for conducting a psychosocial assessment of an older adult client who has recently retired from work.A psychosocial assessment is a process for learning about a client’s problems and needs, so that together you can create therapy goals and a plan for recovery.The information-gathering process should allow you to learn more about the client as a person, beyond just a diagnosis.
• Choice A is correct because it explores how the client feels about their retirement, which can be a major life transition that affects their identity, self-esteem, and sense of purpose.
• Choice B is correct because it assesses the client’s interests and hobbies, which can provide sources of enjoyment, stimulation, and meaning in their life.
• Choice C is correct because it evaluates the client’s social support network, which can influence their mental health, well-being, and coping skills.
• Choice D is correct because it identifies the client’s stressors and challenges, which can affect their mood, functioning, and quality of life.
• Choice E is correct because it examines the client’s physical and mental health issues, which can impact their ability to perform daily activities, manage their emotions, and adhere to treatment plans.
A comprehensive geriatric assessment is a multidimensional process designed to assess the functional ability, health (physical, cognitive, and mental), and socioenvironmental situation of older people.The comprehensive geriatric assessment specifically and thoroughly evaluates functional and cognitive abilities, social support, financial status, and environmental factors, as well as physical and mental health.Ideally, a regular examination of older patients incorporates many aspects of the comprehensive geriatric assessment, making the two approaches very similar.
A nurse is teaching an older adult client about the benefits of social interaction for health and well-being.
Which of the following statements by the client indicates a need for further teaching?
Explanation
The correct answer is D.
“Social interaction can help me avoid stress and anxiety.” This statement indicates a need for further teaching because social interaction does not necessarily help older adults avoid stress and anxiety.
In fact, some social situations may cause or increase stress and anxiety for some people, especially if they are negative, unpleasant, or conflictual.
Therefore, the nurse should explain to the client that social interaction can help them cope with stress and anxiety, but not avoid them altogether.
Choice A is correct because social interaction can help lower blood pressure and cholesterol levels by reducing the effects of stress hormones and promoting physical activity.
Choice B is correct because social interaction can help boost the immune system by enhancing positive emotions, increasing antibody production, and reducing inflammation.
Choice C is correct because social interaction can help improve memory and learning ability by stimulating brain regions involved in cognition, communication, and social perception.
Normal ranges for blood pressure are less than 120/80 mmHg for adults, and normal ranges for cholesterol are less than 200 mg/dL for total cholesterol, less than 100 mg/dL for LDL cholesterol, and more than 40 mg/dL for HDL cholesterol.
A nurse is assessing an older adult client who has been diagnosed with depression and social isolation.
Which of the following questions should the nurse ask to determine the possible causes of the client’s condition?
Explanation
The correct answer is D.
All of the above.
The nurse should ask all of these questions to assess the possible causes of the client’s condition.
Depression and social isolation in older adults can be triggered by various factors, such as:.
• Losses or changes in life, such as death of a spouse, retirement, relocation, or chronic illness.
• Lack of social support or contact with family, friends, or neighbors, which can lead to loneliness and reduced self-esteem.
• Decreased engagement or interest in activities or hobbies that provide meaning, pleasure, or stimulation, which can affect mood and cognitive function.
By asking these questions, the nurse can identify the specific factors that contribute to the client’s depression and social isolation, and provide appropriate interventions to address them.
For example, the nurse can:.
• Provide emotional support and empathy to the client and help them cope with their losses or changes.
• Encourage the client to maintain or increase their social interactions and connections with others who share similar interests or experiences.
• Assist the client to resume or find new activities or hobbies that suit their abilities and preferences, and provide positive feedback and reinforcement.
A nurse is implementing interventions to prevent or reduce social isolation in older adult clients who live in a long-term care facility.
Which of the following interventions are appropriate for this setting?
(Select all that apply.).
Explanation
These interventions are appropriate for reducing social isolation in older adult clients who live in a long-term care facility because they provide opportunities for social interaction, support, comfort and familiarity.
Choice A is correct because group activities such as games, music, art or exercise can foster a sense of belonging, enjoyment and engagement among older adults.Group activities can also improve physical and mental health, cognitive function and well-being.
Choice B is correct because encouraging family members or volunteers to visit or call the clients regularly can enhance the quality and quantity of social relationships, which can reduce loneliness and isolation.Family members or volunteers can also provide emotional support, companionship and practical assistance to the clients.
Choice C is correct because creating a homelike environment that promotes comfort, safety and privacy can increase the clients’ satisfaction, autonomy and dignity.A homelike environment can also facilitate social interactions among the clients and the staff by providing common areas, personal belongings and familiar objects.
Choice D is correct because assigning consistent staff members who are familiar with the clients’ needs and preferences can improve the continuity and quality of care, as well as the trust and rapport between the clients and the staff.Consistent staff members can also recognize and respond to the clients’ social needs and preferences, and provide personalized interventions.
Choice E is incorrect because providing feedback or recognition for the clients’ achievements or contributions may not be effective in reducing social isolation, unless it is combined with other interventions that promote social interaction and support.Feedback or recognition alone may not address the underlying causes of social isolation, such as lack of meaningful relationships, low self-esteem or poor health.
Normal ranges for social isolation and loneliness are difficult to define, as they depend on various factors such as individual characteristics, cultural norms and measurement tools.However, some indicators of social isolation include having few or no social contacts, participating in few or no social activities, feeling disconnected from others or society, and having low levels of perceived social support.Some indicators of loneliness include feeling unhappy about one’s social situation, feeling left out or unwanted, lacking companionship or intimacy, and having low levels of perceived belongingness or connectedness.
A nurse is providing education to a group of older adults about sexuality and aging.
Which of the following information should the nurse include?
Explanation
The correct answer is B.
Older adults may experience changes in sexual response or function due to physiological factors.This is because aging can affect the sex organs, hormones, blood flow, and nerve signals that are involved in sexual arousal and performance.These changes do not mean that older adults cannot enjoy a satisfying sex life, but they may require some adjustments or treatments to overcome any difficulties.
Choice A is wrong because older adults have the same need for intimacy and affection as younger adults, and sexuality is an important component of emotional and physical intimacy that can enhance well-being and quality of life.
Choice C is wrong because older adults with chronic diseases or disabilities can still have sexual activity, as long as they are comfortable and safe.They may need to consult with their health care providers about any precautions or modifications they should make to accommodate their conditions.
Choice D is wrong because older adults are not at lower risk for sexually transmitted infections (STIs) than younger adults.In fact, older adults may be more vulnerable to STIs due to lower immune function, thinner vaginal tissues, lack of condom use, and other factors.
Therefore, older adults should practice safe sex and get tested regularly for STIs.
Normal ranges for sexual response or function vary widely depending on the individual, the partner, the situation, and other factors.
There is no one standard or ideal way to experience sexuality and intimacy in older adulthood.The most important thing is to communicate openly with one’s partner and health care provider about any concerns or preferences, and to seek help if needed.
A nurse is caring for an older adult client who has erectile dysfunction due to diabetes mellitus.
The client asks the nurse what he can do to improve his sexual function.
Which of the following responses should the nurse give?
Explanation
You can do any of the above options, depending on your preference and medical condition.
Erectile dysfunction (ED) is the inability to get and maintain an erection for sexual activity.
It can be caused by physical or psychological factors, or both.
ED can affect your self-esteem, stress level and relationship quality.
There are different treatment options for ED, and they work in different ways.
Some of the most common ones are:.
• Oral medicationssuch as sildenafil (Viagra), tadalafil (Cialis), vardenafil (Levitra) or avanafil (Stendra).
These drugs enhance the effects of nitric oxide, a chemical that relaxes the muscles in the penis and increases blood flow.
You need to take them before sexual activity, and they only work if you are sexually stimulated.
They are not safe for everyone, especially if you have heart problems, low blood pressure, liver disease or certain eye conditions.They can also cause side effects such as headache, flushing, nasal congestion or indigestion.
• Penile self-injectionssuch as alprostadil (Caverject, Edex) or papaverine (OraVerse).
These are shots of medicine that you inject into the base or side of your penis with a fine needle.
They cause an erection by dilating the blood vessels in the penis.
The erection lasts about 20 to 30 minutes, and you need to use them only when needed.They can cause side effects such as bleeding, pain, priapism (a prolonged and painful erection) or fibrous tissue formation.
• Alprostadil urethral suppository(Muse).
This is a tiny pellet of medicine that you insert into your urethra (the tube that carries urine out of the body) with a special device.
It works by expanding the blood vessels in the penis and causing an erection.
The erection lasts about 30 to 60 minutes, and you need to use it only when needed.It can cause side effects such as burning, pain, bleeding or infection.
• Vacuum erection device(VED).
This is a plastic tube that you place over your penis and pump out the air to create a vacuum.
This draws blood into the penis and causes an erection.
You then slide a rubber ring around the base of your penis to keep the blood in place.
The erection lasts as long as the ring is on, up to 30 minutes.
You need to use it only when needed.It can cause side effects such as bruising, numbness, pain or difficulty ejaculating.
• Penile implant surgery.
This is a procedure where inflatable or bendable devices are surgically placed on both sides of your penis.
You can control when and how long you have an erection by inflating or deflating the devices with a pump or a switch.This is a permanent solution for ED, but it requires surgery and has risks of infection, mechanical failure or erosion.
Other treatment options for ED include hormone therapy, psychotherapy, lifestyle changes and natural remedies.
However, these may not be as effective or safe as the ones mentioned above.
The best treatment option for you depends on your personal preference, medical condition, cost and availability.
You should talk to your doctor about the benefits and risks of each option and choose the one that suits you best.
A nurse is assessing the risk factors for sexually transmitted infections (STIs) in older adult clients.
Which of the following factors should the nurse consider?
(Select all that apply.).
Explanation
The correct answer isA, B, C and D.
These are all factors that can increase the risk of sexually transmitted infections (STIs) in older adult clients.
A. Decreased immune system function with aging.This can make older adults more susceptible to infections and less able to fight them off.
B. Lack of knowledge or awareness about STIs.
Older adults may not have received adequate education or information about STIs, their symptoms, prevention and treatment.They may also have misconceptions or stigma about STIs that prevent them from seeking help or testing.
C. Reduced use of condoms or other barrier methods.
Older adults may not perceive themselves as at risk of STIs or may not know how to use condoms correctly or consistently.They may also face barriers such as cost, availability, embarrassment or partner resistance to using condoms.
D. Increased number of sexual partners or casual encounters.
Older adults may have more opportunities for sexual activity due to factors such as divorce, widowhood, online dating, travel or retirement.They may also engage in sexual behaviors that expose them to multiple or unknown partners, such as sex work, drug use or group sex.
Choice E is wrong becauseincreased vaginal dryness or atrophy with menopauseis not a risk factor for STIs in older adult clients.
While this condition can cause discomfort, pain or bleeding during sexual intercourse, it does not increase the likelihood of acquiring or transmitting an STI.However, it may affect the quality of life and sexual satisfaction of older women and their partners, and may require medical attention or lubrication products.
: Johnson BK.
Sexually transmitted infections and older adults.J Gerontol Nurs 2013;39(11):53-60.: World Health Organization (WHO).
Sexually transmitted infections (STIs).2022 Aug 22.: Journal of Gerontological Nursing (JGN).
Sexually Transmitted Infections and Older Adults.
2013 Sep 18.
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