Gerontological Nursing 8th Edition by Charlotte Eliopoulos – Test Bank A+

Description

2.1•A nurse assists a geriatric client to discuss the desire to complete advanced directives with the client’s adult children. This is an example of

1. collaboration with the interdisciplinary team.
2. facilitation of palliative care.
3. engagement in professional development.
4. accountability to protect client’s rights and autonomy.

Answer: 4

Rationale: The nurse demonstrates accountability in supporting the client in exercising control over end-of-life decisions and communicating client wishes to family members. This is included in the knowledge and skills of gerontological nurses. Collaboration with the interdisciplinary team would involve the nurse working with other professionals who provide care to clients. Palliative care alleviates pain and suffering. Professional development activities include continuing education and being part of professional organizations.

Implementation

Safe, Effective Care Environment

Analysis

2.2•The nurse is supportive of an elderly client’s decision to stop further chemotherapy treatments after diagnostic testing shows a recurrence of the malignancy. The basic ethical principle involved is

Answer: 3

Rationale: The principle of autonomy involves respect for the client’s need for self-determination and the right to accept or refuse a treatment. Justice involves fairness and equal distribution of resources to all in need. Beneficence is the principle of doing good and not doing harm to clients. Nondisclosure is an ethical issue when persons who care about a client, such as family, do not want a client to be told the entire facts of a negative prognosis in order to protect the client from anxiety and fear.

Implementation

Safe, Effective Care Environment

Knowledge

2.3•The major focus of nursing assessments based on functional health patterns is

1. effects of diseases.
2. client disabilities.
3. potential for rehabilitation.
4. client interaction with his or her environment.

Answer: 4

Rationale: The assessment framework of functional health patterns (Gordon, 1994) is based on the client’s interaction with the environment, including client assessment of health status, lifestyle, activities, life demands, support systems, and the ability to function within the client’s environment. Effects of diseases are viewed within the context of the individual client’s ability to function with a disease that affects his or her life. Disability and the potential for rehabilitation are aspects of the functional assessment.

Assessment

Safe, Effective Care Environment

Application

2.4•An example of a gerontological nurse acting as a manager is

1. arranging respite care in a local nursing home for a client while the adult child caregiver recovers from surgery.
2. performing blood pressure screenings at a senior citizen health fair.
3. participating in a skin assessment survey of clients in a nursing home.
4. writing a letter of support for a client who is seeking custody of a grandchild.

Answer: 1

Rationale: The nurse functions as a manager by connecting a client to community resources and coordinating the transfer of care of the client needing respite care. Participating in the blood pressure screening and skin assessment surveys are within the traditional nursing role of clinical practitioner. The nurse is in an advocacy role by supporting the client to obtain custody of a grandchild.

Intervention

Health Promotion and Maintenance

Application

2.5•A nurse is conducting an interview with a resident who has just moved to a retirement community. The client discusses her volunteer activities in the past mayoral election. In an assessment based on functional health patterns, this information would be included under which category?

1. cognitive and perceptual
2. self-perception and self-concept
3. coping and stress tolerance
4. values and beliefs

Answer: 1

Rationale: The functional health pattern assessment consists of 11 health patterns. The cognitive–perceptual pattern includes how the client thinks and perceives the world and current events. The client’s campaign activities would be part of this assessment. Self-perception and self-concept include how a person sees and values him- or herself. Coping and stress tolerance include the ways and effectiveness of coping strategies. The values and beliefs category includes the client’s beliefs, values, and perceptions about the meaning of life.

Assessment

Psychosocial Integrity

Application

2.6•A client’s religious affiliation and participation in the local parish would be included in which of the functional health pattern assessment categories?

1. cognitive and perceptual
2. self-perception and self-concept
3. coping and stress tolerance
4. values and beliefs

Answer: 4

Rationale: The functional health pattern assessment consists of 11 health patterns. The values and beliefs category includes beliefs, values, and perceptions about the meaning of life. A client’s participation in a religion would be part of this assessment. Self-perception and self-concept include how a person sees and values him- or herself. Coping and stress tolerance include the ways and effectiveness of coping strategies. Cognitive-perceptual includes ways of perceiving the world.

Assessment

Psychosocial Integrity

Application

2.7•A client’s family member asks a nurse what is the significance of being a certified nurse. He has noticed that some of the nurses caring for the client in a long-term care facility are certified gerontological nurses and others are registered nurses. Certification in gerontological nursing means that

1. the nurse must have a master’s degree in nursing.
2. the nurse works in administration at the nursing home.
3. the nurse has completed a process of formal validation of clinical competence in gerontological nursing.
4. the nurse has worked full time at least 2 years in gerontological nursing.

Answer: 3

Rationale: Certification is the process of validation of clinical competence through which a nurse successfully completes an examination in a specialty area of nursing practice. Master’s degreed nurses may be certified, but nurses with associate or baccalaureate degrees or diploma certificates may also be certified but at a generalist level. Certified nurses may work in administration but also function in direct care and case management. In order to qualify to take the certification examination, the nurse must have practiced the clinically equivalent of 2 years full time or minimally 2,000 hours over the past 3 years.

Implementation

Safe, Effective Care Environment

Analysis

2.8•Select the statement that provides correct information about nursing homes in the United States.

1. The major fee source for nursing home care is Medicare.
2. Clients in nursing homes have more diverse and complex clinical needs than in the past.
3. Nursing homes employ the greatest percentage of nurses.
4. About 25% of persons age 65 or older live in nursing homes.

Answer: 2

Rationale: Many older clients requiring hospitalization stay in the hospital for shorter periods of time and recuperate in nursing homes or at home. Thus, the clients receiving care in the nursing home have a great variety of conditions that require complex care. Medicaid, the federal and state program for low-income persons, is the largest funding source of long-term care. Medicare accounted for about 14% of long-term care funding in 2000. Hospitals are still the major employers of nurses, at 59% of registered nurses in 2000. Approximately 5% of the population over age 65 live in nursing homes as of 2001.

Implementation

Safe, Effective Care Environment

Knowledge

2.9•During a health fair for older adults, a healthy woman tells the nurse that she thinks she has been losing weight unintentionally during the past 6 weeks. The nurse should

1. instruct the woman to add protein rich, low-fat snacks between meals and at bedtime.
2. encourage the woman to purchase a scale with a digital readout to accurately measure her weight on a daily basis.
3. explain to the client that the loss of muscle mass that occurs with aging could account for the weight loss.
4. ask the client to describe her eating habits and when she last had a checkup by her healthcare provider.

Answer: 4

Rationale: Asking about a client’s eating habits and when the client last saw her healthcare provider is part of the assessment process, the first step of the nursing process. The other answers are all interventions to solve or reasons to explain the weight loss without adequate assessment.

Assessment

Physiological Integrity

Application

2.10•Which of the following statements is correct in describing nursing care plans for older adults?

1. Standardized care plans are more effective in goal attainment than individualized care plans.
2. Care plans are controlled by the nurses caring for the client; other members of the interdisciplinary team should develop their own specific plans of care.
3. The first step of creating a nursing care plan is a systematic assessment using a functional health pattern framework.
4. Older adults often have multiple nursing diagnoses and each diagnosis should be addressed at once.

Answer: 3

Rationale: Assessment must form the basis for determining problem areas (nursing diagnoses) of the client. The functional health pattern framework provides a systematic approach that includes the current level of functioning and self-concept of the client. The care plan should address problems or potential problems, some of which may be referred to and addressed by other members of the interdisciplinary team caring for the client. Many clients have multiple nursing diagnoses. The diagnoses need to be prioritized so that those diagnoses considered serious and of concern to the client are addressed initially.

Assessment

Safe, Effective Care Environment

Application

2.11•A client is talking to the nurse and begins to cry when he mentions the death of his daughter 20 years earlier. The most appropriate initial response by the nurse is

1. touching the client’s arm and listening in silence.
2. explaining to the client that crying is an effective means to express emotions.
3. asking the client to describe the details of the death so the nurse can understand more completely.
4. asking the client if he thinks he could be suffering from depression.

Answer: 1

Rationale: Active listening is the key to effective communication, and the most appropriate response is to demonstrate empathy and support for the client in the expression of strong feelings. Appropriate touching and silence best meet this objective. Giving explanations, asking for clarifications, or focusing on depression are not appropriate. Asking about depression could give the client the impression that the expression of feelings of grief is not normal or healthy.

Intervention

Psychosocial Integrity

Application

2.12•The nurse assesses an older postoperative client and determines constipation is an appropriate nursing diagnosis. A goal for this nursing diagnosis is

1. knowing the importance of hydration and activity in regard to constipation.
2. decreasing the frequency of pain medication.
3. evacuating a formed bowel movement at least every 2 days with minimal distress.
4. drinking at least 1,500 ml of noncaffeinated and nonalcoholic beverages each day.

Answer: 3

Rationale: The goal should be linked to the nursing diagnosis; be measurable, realistic, and achievable; and include a time frame for attainment. The type and frequency of bowel movement is directly connected to the nursing diagnosis. Knowing is not a measurable verb. Indirectly, the client’s frequency of bowel movement may be improved by decreasing pain medication and increasing fluids and activity. Pain control also must be addressed.

Implementation

Physiological Integrity

Application

2.13•During a home visit, an older client recovering from cardiac valve replacement surgery states to the nurse, “I am so weak that I will never be able to dance with my wife again.” An appropriate statement for the nurse to reply is

1. “It’s okay, honey, in time your strength will return.”
2. “What type of dancing do you want to do, some are more strenuous than others?”
3. “Do you think you are pushing yourself enough to return to that type of activity in the near future? Is your wife encouraging you?”
4. “Tell me more about not feeling able to do what you want to do.”

Answer: 4

Rationale: It is important that the nurse use attentive listening in communication. An open-ended statement will encourage the client to continue talking thus helping him clarify concerns and formulate solutions. “Honey” could be demeaning to the client. In the other answers, the nurse is giving advice and solutions without hearing the client’s specific concerns.

Implementation

Psychosocial Integrity

Application

2.14•A student nurse asks the gerontological clinical nurse specialist to explain evidence-based practice. The nurse correctly states that this practice includes interventions that

1. are stated specifically in the policy and procedures manual of the healthcare facility.
2. have been included in research studies with supportive evidence of a cause-and-effect relationship between the intervention and a positive client outcome.
3. have been highly effective in the nurse’s own practice and experience.
4. reflect methods that were previously effective for a particular client.

Answer: 2

Rationale: Evidence-based practice involves using interventions that have been studied through the research process. Research has shown a link between the prescribed intervention and the desired outcome of care. These interventions are considered to be more strongly linked to positive outcomes than interventions that have not been researched. Those interventions that are not evidenced based may be supported by nursing experience, client case, or institutional policy.

Evaluation

Safe, Effective Care Environment

Analysis

2.15•It is important that the nurse communicates effectively when caring for older adult clients. Which of the following guidelines promote effective communication?

1. avoiding periods of silence while communicating
2. changing the subject if the nurse begins to feel emotional about a subject
3. speaking loudly because most older clients are hard of hearing
4. asking for clarification if what the client is trying to say is not understandable

Answer: 4

Rationale: Active listening includes asking for clarification if the client is not clearly communicating to the nurse. Silence and pauses in conversations are often opportunities for the client to think out his or her feelings, and breaking the silence will stop the contemplative process. Nurses should acknowledge the clients feelings, and changing the subject will stop communication. It is not necessary to talk loudly to all older persons because all are not hard of hearing, and if the client is wearing a hearing aid, the loudness may be distressing.

Intervention

Psychosocial Integrity

Application

2.16•The family members of a hospitalized older adult contact social services concerning plans after discharge. The family members report intentions to take the client home with them after discharge but indicate a need for assistance during the day while they are at work. Based upon your understanding, what referral information should be provided?

1. A skilled nursing facility
2. A retirement community
3. An adult day care service
4. Community nursing care services

Answer: 3

Rationale: The family is in need of assistance to provide a supervised environment for their loved one during their work hours. A skilled nursing care facility would not be appropriate for the older adult living at home. The retirement community is indicated for older adults planning to live in their own quarters. Community nursing care services provide nursing care in the home for specific tasks.

Assessment; Safe, Effective Care Environment; Application

2.17•A client hospitalized for a hip replacement is discussing discharge options with the nurse. The client states she is interested in having a visiting nurse come to the home to assist with her meals and housekeeping duties. What response is indicated by the nurse?

1. “You should discuss this referral with your physician.”
2. “I will contact representatives from the agency to meet with you before discharge.”
3. “You will need to determine if the agency fees will be covered by your insurance.”
4. “The visiting nurse is used to provide a more skilled type of care for you.”

Answer: 4

Rationale: The types of duties the client is interested in having the “nurse” provide are not consistent with home health nursing responsibilities. The misconceptions should be pointed out to the client. Referrals are generated after approval by the physician, but the nurse has the responsibility to ensure the client has an understanding of the concepts.

Implementation; Safe Effective Environment; Application

2.18•The daughter of a 67-year-old client hospitalized for pneumonia voices concerns to the nurse about the hospital bills. The daughter asks if her mother is old enough to qualify for Medicaid. What information should the nurse provide to the client?

1. Medicaid is available to individuals once they reach the age of 65.
2. Medicaid is intended to assist low-income individuals over the age of 65.
3. Older adults are eligible for Medicaid if they are planning to enter a long-term care facility.
4. Eligibility for Medicaid is based upon income, not age.

Answer: 4

Rationale: Medicaid is a joint federal and state program for low-income individuals. Age is the primary criteria. Income is the greatest determinant.

Implementation; Psychological Integrity; Application

2.19•A 70-year-old client hospitalized after a CVA is preparing for transfer to a long-term care facility that offers rehabilitation care services. It is estimated the client will be at the new facility for at least 4 weeks. When considering payment for the services, the nurse understands:

1. Medicaid is not an option for this client because the age criteria have not been met.
2. Medicaid will not be available to assist with the medical bills, as the client is planning to return home after leaving the rehabilitation facility.
3. Medicare may likely cover the rehabilitation as long as the appropriate documentation is submitted.
4. Medicare will cover only the acute care services, as the client is planning to return to home after leaving the rehabilitation facility.

Answer: 3

Rationale: Medicare is available to older adults and younger disabled individuals. It will cover rehabilitation or skilled care services as long as there is a 3-day qualifying stay in a hospital. Documentation must also be submitted for precertification.

Assessment; Safe Effective Care Environment; Application

2.20•A student nurse questions the nursing instructor about the constant information being relayed in reports about the client’s method of payment. The student reports not understanding why this is being emphasized, as it is not the real focus of the nurse. What response by the nursing instructor is indicated?

1. “Since pay status is a concern of the client, it must be considered by nurses as well.”
2. “Understanding healthcare reimbursement is important for nurses to best be able to manage resources.”
3. “That information is just intended to be relayed to the case manager.”
4. “We listen to that information so we understand how many days the client will be allowed to remain in the hospital.”

Answer: 2

Rationale: The cost and management of cost of healthcare is the responsibility of all members of the healthcare team. Understanding the manner of payment is also important. A working knowledge of Medicare and Medicaid is needed to work with the older adult population.

Implementation; Safe, Effective Care Environment; Application

2.21•A registered nurse is planning an educational program for peers to discuss the current and anticipated nursing staffing needs of the future. Which of the following should be included in the presentation? Select all that apply.

1. The number of nurses employed in hospital settings has increased since 1980.
2. More complex nursing skills are needed to provide care in long-term care and rehabilitative care facilities.
3. The number of nursing homes has begun to increase over the last 10 years.
4. More nurses will be needed to work in assisted living care settings.

Answers: 2, 4

Rationale: The acuity of clients in hospital settings is increasing. The length of hospital stay is decreasing. These factors require the nurse to care for clients who are more and more ill each day. The number of nurses working in the acute care setting declined between 1980 and 2007. There is an increase in assistive care settings in the United States. This is accompanied by a reduction in number of and beds within nursing homes.

Planning; Safe, Effective Care Environment; Application

2.22•The nurse observes that a client under her care does not feel comfortable with the care choices planned by her family and the social services department. The client appears coherent. What action by the nurse is indicated?

1. Contact the family and organize a conference.
2. Notify the physician.
3. Consult with the unit’s educator.
4. Discuss the matter with the unit’s nurse manager.

Answer: 4

Rationale: The role of a unit manager is to ensure the rights of the client are being met. The unit manager can review the concerns of the nurse and provide guidance. It is important to follow the chain of command. The nurse manager is the first step along this path. Contact with the physician and arranging a conference are premature. The role of the traditional unit educator does not include matters of this nature.

Implementation; Psychological Integrity; Application

2.23•A newly licensed registered nurse is working with a preceptor on the acute care unit. He is developing the nursing care plan for a newly admitted client. The primary nursing diagnosis is knowledge deficit related to pre- and postoperative care. After developing goal statements for the plan, the preceptor reviews them. Which of the goal statements is most appropriate?

1. The client will understand the prescribed medications.
2. The nurse will administer the prescribed medications.
3. The client will be afibrile during the postoperative period.
4. The client will verbalize understanding of the preoperative medications prior to surgery.

Answer: 4

Rationale: Goal statements must be specific to the nursing diagnosis. Goal statements must be client focused. Time frames for attainment should also be included.

Planning; Psychological Integrity; Analysis

2.24•During a routine physical examination, the client reports feeling increasingly unable to maintain his home. He states he is looking for other options. The nursing assessment reveals a well-nourished male, age 66. His medical history is essentially negative except a mild myocardial infarction 10 years ago. He has significant financial resources. Which of the following will likely best meet the client’s needs?

1. Skilled-nursing facility
2. Retirement community
3. Adult day care
4. Residential care facility

Answer: 2

Rationale: The client is likely a candidate for a retirement community. He does not appear to need the nursing services associated with a skilled or residential care facility. He appears independent and would not benefit from an adult day care.

Assessment; Psychological Integrity; Application

2.25•The nurse is assigned to provide care for a client recently admitted to a rehabilitation care facility. The client was severely injured in an automobile accident and requires assistance with the activities of daily living and occupational and physical therapy. The nurse notices the client is tearful one evening. When questioned, the client reports feeling “lonely” and “sad.” What initial action by the nurse is indicated?

1. Ask the client what is wrong.
2. Sit with the client and encourage a discussion of feelings.
3. Obtain a referral for a psychological consult.
4. Offer to call the client’s family members.

Answer: 2

Rationale: The client’s demeanor is consistent with sadness after a traumatic injury and continued hospitalization. Encouraging verbalization of feelings may reduce feelings of isolation. Simply asking what is wrong may infer to the client that his or her feelings are “wrong.” Sitting with the client provides additional support. There is not an indication that a psychological consult is needed. It would be premature to contact the family members without first determining what is troubling the client.

Implementation; Psychological Integrity; Application

Chapter 12

The Integument

12.1•A nurse aide reports to the nurse that a 94-year-old client’s rectal temperature is 35.8C. The nurse interprets this value as

1. a sign of infection.
2. a normal value for older clients.
3. an inaccurate reading by the nurse aide.
4. a sign of anemia.

Answer: 2

Rationale: Body temperature in the elderly is usually lower than the baseline of 37C. Therefore, this is a normal value for this client. Signs of infection result in an elevated temperature and anemia would not be reflected by a low temperature. The inaccurate reading could be questioned but the rectal temperature is the most accurate method for measuring the temperature.

Assessment

Physiological Integrity

Analysis

12.2•A 75-year-old client is recovering from surgery to remove a tumor in the abdomen. When planning care for this client, the nurse would consider that the skin of an older person would require

1. increased healing time.
2. decreased healing time.
3. a need to keep the wound edges taped.
4. skin near the wound to be massaged to increase blood flow.

Answer: 1

Rationale: Epidermal mitosis slows 30% after the age of 50, resulting in longer healing time for older persons. Additional changes place the client at risk for infection and skin tears. Taping the wound edges and massaging the skin would cause further damage to skin.

Planning

Physiological Integrity

Analysis

12.3•The nurse is completing a home care visit of an 86-year-old client. The client lives alone and is independent in activities of daily living. During your visit, you notice a red mark on the arm of the client. The client states she was unaware of the injury and it may have occurred from hot water when cooking. Your interpretation of this finding is that the client is

1. losing short-term memory.
2. experiencing friction tears of the skin.
3. at risk for further injury.
4. experiencing senile purpura in the skin.

Answer: 3

Rationale: Normal changes in the skin result in a decline of both touch and pressure sensations placing them at risk for burns and pressure sores. Clients are to be cautioned to prevent this type of injury. There is no indication the client has memory loss. A skin tear is a dramatic separation of the dermis, and a bruised or discolored appearance is seen in senile purpura.

Assessment

Physiological Integrity

Analysis

12.4•An 82-year-old client is admitted for a hip fracture. During the postoperative recovery, the nurse notices a stage I pressure ulcer forming on the client’s sacrum. To reduce the progression of this stage of ulcer, the nurse would

1. maintain the head of the bed at 45.
2. apply a dry dressing to pressure ulcer.
3. maintain the head of the bed at 30 positioned on the right or left side.
4. apply a heat lamp to the area to increase circulation.

Answer: 3

Rationale: Keeping the head of the bed at 30 or less decreases pressure on the sacrum. Dry dressings are not indicated with this stage pressure wound. Heat lamp is a method no longer used, as it does not provide therapeutic benefit.

Implementation

Physiological Integrity

Analysis

12.5•The nurse is reviewing the care of an 89-year-old client who has a stage I decubiti on the coccyx and right heel. The nurse provides instruction to the nurse aide assigned to care for the client. What would the nurse include in the instruction to the nurse aide?

1. keep the bed elevated 45 or higher
2. turn the client on the side to remove sheets and clothing
3. use dry dressings to the heels
4. use soap to cleanse the skin

Answer: 2

Rationale: Friction occurs with lateral movement of pulling sheets or clothing from under a person’s weight, causing removal of the stratum corneum. This could disrupt the epidermis and lead to further breakdown of the skin. Elevating the head of the bed at 45 increases pressure on the sacral area, and dry dressings are not indicated for use for pressure ulcers. Soap can be a skin irritant that will remove sebum that normally protects the skin.

Planning

Physiological Integrity

Application

12.6•The nurse is assessing the client’s stage III decubiti of the coccyx. In measuring the depth and width of the wound, the nurse notes that the wound is beefy red and grainy, and the depth has decreased by 2 mm but the width has not changed. The nurse interprets this finding as the wound

1. progressing positively toward healing.
2. not healing properly.
3. no longer at risk for infection.
4. about to slough off tissue.

Answer: 1

Rationale: Healing of a decubitus fills from the wound bottom so the depth decreases before the wound width decreases. The beefy red and grainy appearance is evidence of granulation tissue as the capillary bed builds. These are all indicators of good wound healing. Any open tissue is at risk for infection.

Assessment

Physiological Integrity

Analysis

12.7•The nurse is caring for a client who has previously had a sacral decubiti that has completely healed. In developing the risk profile for skin breakdown, the nurse recognizes that a prior pressure ulcer would

1. heal faster with reinjury.
2. break down faster with reinjury.
3. have no sensation in the injured area.
4. be at risk for infection even with intact skin.

Answer: 2

Rationale: Scarred wounds never reach their prewound strength and, therefore, are more prone to reinjury than normal tissue. Sensation does return, and even though there is risk for breakdown, intact skin does not increase risk for infection.

Assessment

Psychosocial Integrity

Analysis

12.8•The nurse is providing care for an elderly client who has been diagnosed with a hip fracture. The client underwent surgery to repair the hip. Which of the following assessments would indicate a risk for delayed wound healing?

1. client participation in activity
2. low levels of calcium
3. low levels of serum transferrin
4. serous sanguinous drainage from the wound

Answer: 3

Rationale: Many older persons have protein-energy malnutrition where the intake of protein and energy is inadequate to meet the client demands. Serum transferrin levels are an accurate indicator of protein stores. When protein stores are depleted, wound healing is delayed. Client activity is helpful as an extrinsic factor but does not directly affect the healing of the wound. Calcium is not an indicator of wound healing, and serous sanguinous drainage is a normal finding for a surgical wound.

Assessment

Physiological Integrity

Application

12.9•Which of the following over-the-counter skin preparations should the nurse instruct the elderly to use with caution?

1. superfatted soaps
2. emollients that keep the skin moist
3. steroid-based ointments and creams
4. sunblock

Answer: 3

Rationale: Older persons have a high rate of adverse reactions to both corticosteroids and antihistamines. Long-term use may cause systemic absorption. Superfatted soaps and emollients are appropriate treatments for dry skin. Sunblock is appropriate to protect for UV exposure to the sun.

Implementation

Physiological Integrity

Analysis

12.10•A nurse is preparing to complete wound dressings for a client who has a large abdominal surgical wound. What solution would provide the most benefit for cleansing the wound?

1. Dakins^® solution
2. hydrogen peroxide
3. providine iodine
4. isotonic saline

Answer: 4

Rationale: The safest, most cost-effective cleansing agent is isotonic saline. Topical antiseptics, such as Dakins^® solution, hydrogen peroxide, and providine iodine, should not be used because these products have been found to be toxic to the wound fibroblasts and macrophages.

Planning

Psychosocial Integrity

Application

12.11•An African American client reports plans to bask in the sun on an upcoming vacation. When questioned about the use of sunscreen, which of the following responses by the client indicates the need for further education?

1. “The melanocytes in my subcutaneous tissue will protect me from sun damage.”
2. “I will avoid the sun between the peak hours of 10 am and 4 pm.
3. “Sunscreen is important to wear during all daytime hours.”
4. “I can still experience sun damage despite my dark skin tones.”

Answer: 1

Rationale: Melanocytes are located in the epidermal skin layers. The remaining client responses are correct.

Evaluation; Health Promotion and Maintenance; Analysis

12.12•While performing a physical assessment, the nurse notes the client has multiple brown and black bands on the finger nails of the thumbs and index fingers. The nurse recognizes which of the following statements about this finding to be most correct?

1. These findings are associated with damage to the nail matrix.
2. This is an indication the finger nails are going to split in response to recent trauma.
3. These findings are indicative of a fungal infection.
4. These benign findings are often seen in African Americans.

Answer: 4

Rationale: Longitudinal pigmented bands are single or multiple brown or black bands on the nails of the thumb and index finger. They are seen in the majority of African Americans older than age 20. Damage to the nail matrix is manifested as longitudinal striations. There are no facts to support the presence of nail matrix damage or fungal infections.

Assessment; Physiological Integrity; Application

12.13•A client questions the nurse concerning her dry skin. The client reports she has not changed her skin care regimen but notices increasing dryness. A review of the medical records notes the client is 55 years of age. Which of the following statements best explains the experiences of the client?

1. There is an increase in the number of sweat glands present as the individual ages.
2. There is a reduction in sebum production as the body ages.
3. There is an increase in body core temperature with aging, resulting in skin drying.
4. There is a decrease in the number of sweat glands in the body with aging.

Answer: 2

Women demonstrate a reduction in sebum production after the onset of menopause. There is an increase in the number of sweat glands, but this has little impact on the dryness of skin being reported. Changes in body temperature are not implicated in this client’s scenario. The number of sweat glands does decrease with aging but does not have a role in the reduction of the production of sebum.

Implementation; Physiological Integrity; Application

12.14•A client has recently been diagnosed with skin cancer. When discussing the diagnosis with the nurse, the client tearfully asks why she could have gotten skin cancer, as she has never sunbathed in her life. What response by the nurse is indicated at this time?

1. “We frequently never find out why cancer strikes.”
2. “Sun exposure can happen as we carry out our daily activities.”
3. “This is unusual, as skin cancer normally only occurs in sunbathers.”
4. “Can you tell me more about your feelings?”

Answer: 2

Rationale: Sun exposure occurs as we carry out our daily activities. Riding in the car, going in and out of buildings, and so on permits sun exposure. The client is asking for information; the other options do not provide adequate or correct information.

Implementation; Psychological Integrity; Application

12.15•A client is preparing for discharge. When planning the information that will be provided prior to leaving the hospital, which of the following medications should be accompanied with a warning to avoid extended sun exposure?

1. Ibuprofen
2. Tylenol
3. Aspirin
4. Vicodin

Answer: 1

Rationale: Ibuprofen is associated with sun sensitivity. Tylenol, aspirin, and vicodin are not associated with sun sensitivity.

Planning; Physiological Integrity; Application

12.16•The nurse is collecting data from a client who is being seen at the ambulatory care clinic for a routine physical examination. While listening to the client’s lungs, the nurse notes a small, indurated, scaled spot on the client’s upper chest. The nurse records the findings. Based upon your knowledge, which of the following diagnoses most closely resembles the nurse’s findings?

1. Squamous cell carcinoma
2. Basal cell carcinoma
3. Malignant melanoma
4. Actinic keratosis

Answer: 1

Rationale: Squamous cell carcinoma most often appears as a flesh-colored, erythematous, indurated scaly plaque. Basal cell carcinoma presents as a small fleshy bump. Malignant melanoma manifests as black, brown, or multicolored nodules or plaques. Actinic keratosis is a precancerous condition. The lesion appears as a sore, rough, scaly plaque.

Diagnosis; Physiological Integrity; Application

12.17•A hospitalized client requests a small inflated donut to sit on to relieve pressure. The client explains having used one during a previous illness. What response by the nurse is most appropriate?

1. “I will obtain the device for you.”
2. “I will need to get an order from the physician.”
3. “Using the donut can cause skin breakdown.”
4. “You will need to wait until discharge and use this at home.”

Answer: 3

Rationale: The use of a donut applies pressure and results in tissue anoxia. The client may indeed feel that pressure is lessened, but this is due to the loss of sensation. The use of the devices should be avoided.

Implementation; Health Promotion and Maintenance; Analysis

12.18•A client’s spouse reports the presence of a reddened area on her husband’s coccyx. She feels a massage would be helpful in promoting circulation to the area. What response by the nurse is indicated?

1. “Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care.”
2. “I will record these findings in the medical record.”
3. “Massaging the area may actually cause more harm to a potentially compromised area of skin.”
4. “I will need to obtain an order from the physician to perform a massage.”

Answer: 3

Rationale: The presence of redness may indicate the presence of a Stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted. Massages, when therapeutic, do not require a physician’s order.

Implementation; Health Promotion and Maintenance; Analysis

12.19•The nurse is performing an assessment on a dark-skinned individual. After completing the assessment, the nurse records the findings. Which of the findings indicates a problems requiring further action?

1. Bluish gums
2. Bluish tones noted on the soles of the feet
3. Freckle-like spots on the borders of the tongue
4. Bluish tones to the lips

Answer: 2

Rationale: The presence of bluish tones on the soles or heels is indicative of cyanosis in the darker-skinned individual and should be investigated further. Bluish gums or lips are potentially normal findings in the darker-skinned client. Freckle-like spots on the tongue may also be found in the healthy individual.

Evaluation; Physiological Integrity; Analysis

12.20•A client is admitted to the long-term care facility after a brief hospitalization. The Braden Scale is completed to assess the client’s risk for the development of pressure ulcers. After completion of the assessment, the nurse notes the clients has a score of 18. Based upon your understanding, what is the best interpretation of this finding?

1. This client is at a low risk for the development of a pressure ulcer.
2. This client is at a high risk for the development of a pressure ulcer.
3. This client’s score is inconclusive and does not reflect a significant risk for the development of a pressure ulcer.
4. The client’s score is inconclusive, indicating the need for a repeated assessment using the Braden Scale within the next 3 days.

Answer: 2

Rationale: The Braden Scale is used to evaluate a client’s risk for the development of pressure ulcers. The completed assessment may score between 6 and 23 points. Scores of 16 or greater indicate a significant risk for the development of pressure ulcers.

Evaluation; Health Promotion and Maintenance; Analysis

12.21•The nurse is caring for a client who has been undergoing treatment for a Stage II pressure ulcer. When changing the dressing, which of the following products will likely be used to clean the wound?

1. Povidone-iodine
2. Hydrogen peroxide
3. Dakin’s solution
4. Saline

Answer: 4

Rationale: Saline solution is isotonic. Topical antiseptics including povidone-iodine, hydrogen peroxide, and Dakin’s solution are contraindicated with wounds, as they may be toxic to wound fibroblasts and macrophages.

Planning; Safe, Effective Care Environment; Application

12.22•A client has been treated for a skin tear. Which of the following dietary selections contains ingredients that will be most favorable to wound healing?

1. Bacon, toast, and coffee
2. Cereal, milk, and toast
3. Eggs, toast, and orange juice
4. Ham slices, milk, and applesauce

Answer: 3

Rationale: Protein and vitamin C are useful for tissue healing. Eggs and orange juice contain both. The remaining menu selections do not contain the same amount of “healing” foods.

Assessment; Physiological Integrity; Application

12.23•The nurse is assisting a graduate nurse to develop a plan of care for a newly admitted client. The client has been diagnosed with pneumonia and has a Stage II pressure ulcer. Which of the following nursing diagnoses will be of the greatest initial importance when planning care?

1. Potential for infection related to impaired skin integrity
2. Pain related to destruction of tissue
3. Knowledge deficit related to care of skin disorder
4. Risk for infection related to impaired skin integrity

Answer: 2

Rationale: The question is seeking the most immediate client care concern. Pain is the most significant problem initially. All of the diagnoses are appropriate and have importance. Once pain has been addressed and managed, the remaining diagnoses can be prioritized and interventions planned.

Planning; Physiological Integrity; Analysis

12.24•You are acting as a preceptor for a newly hired graduate nurse. The graduate has been assigned to care for a client with a Stage III pressure ulcer. The graduate nurse voices questions about infections and pressure ulcers. Which of the following statements should be included in your response?

1. Topical antibiotic therapy is used for long-term prophylactic pressure ulcer management.
2. Silver sulfadiazine is the antimicrobial of choice for wounds with high bacterial counts.
3. Nanocrystalline silver dressings are effective against gram-positive bacteria.
4. Caution must be used with cadexomer iodine dressings, as they have been shown to disrupt granulation activity.

Answer: 2

Rationale: Silver sulfadiazine is the preferred topical antimicrobial treatment for wounds with high bacteria levels. Long-term antibiotic use should not be instituted unless a bacterial infection is diagnosed. Overuse or inappropriate use of antibiotic therapy may result in bacterial resistance. Nanocrystalline silver dressings are used in the treatment of gram-negative bacterial infections. Cadexomer iodine dressings are supportive of granulation activity.

Implementation; Physiological Integrity; Application

12.25•A nurse is planning a program to teach participants measures to prevent skin damage from sun exposure. What concepts should be included in the program?

1. Wetting fabrics when the sun is hot will reduce the amount of radiation that is able to damage the skin through the clothing.
2. The key times to avoid the sun are between noon and 2 pm.
3. Wearing navy or black is safer than wearing lighter colors.
4. The use of sunscreen with a sun protection factor of 10 is needed to provide safety.

Answer: 3

Rationale: The wearing of darker colors is safer than lighter colors. Wet fabrics transmit ultraviolet waves more than dry fabrics. The peak times to avoid sun damage are between 10 am and 4 pm. A sunscreen should have a sun protection factor of at least 15 to provide some degree of protection against damaging sun rays.

Planning; Health Promotion and Maintenance; Application

Chapter 24

Multisystem Problems:Caring for Frail Elders WithComorbidities

24.1•Which clinical manifestation would the nurse expect to find when assessing a frail older client?

1. weight gain
2. generalized weakness
3. increased endurance and energy
4. increased ability to do all activities of daily living (ADL)

Answer: 2

Rationale: Generalized weakness is the correct answer because frail elders are usually diagnosed with chronic illness, loss of organ function, or recurrent acute illnesses, which all contribute to weakness. Weight gain is incorrect because most frail elders have a loss of appetite, eat less, and lose weight, which they do not plan. Increased endurance and energy is incorrect because both endurance and energy decrease with age, chronic illnesses, loss of organ function, recurrent acute illnesses, and loss of muscle mass with loss of appetite. Increased ability to do all the activities of daily living is an incorrect answer because frail elders become more dependent and less able to do ADL for themselves as they increase in age.

Assessment

Health Promotion and Maintenance

Comprehension

24.2•An 85-year-old client is admitted to the emergency department with a major burn. Which physician order would the nurse question?

1. administer narcotics intramuscularly as needed for pain
2. insert Foley catheter for hourly output measurements
3. take vital signs every 5 to 15 minutes
4. apply topical antimicrobial ointment to wounds

Answer: 1

Rationale: Administer narcotics intramuscularly as needed for pain is the correct answer but an incorrect intervention because pain medications should be administered intravenously for better absorption and control of pain. Insert Foley catheter for hourly output measurement is incorrect but it is a correct intervention because it is used as the indicator of effective fluid resuscitation and assessment of kidney function. Take vital signs every 5 to 15 minutes is an incorrect answer but correct intervention because it is required to assess hemodynamic stability in the emergency department. Apply topical antimicrobial ointment to wounds is an incorrect answer but correct intervention because it is used to prevent or eliminate infection on the surface of the burn wound.

Diagnosis

Safe, Effective Care Environment

Application

24.3•According to the Agency for Health Care Research and Quality, which drug event committed by nurses has the highest percentage of error to the elderly?

1. inadequate monitoring
2. drug–drug interaction
3. preparation error
4. missed dose

Answer: 4

Rationale: Missed dose is the correct answer because in 7% of errors committed clients do not get the prescribed medications. Drug–drug is an incorrect answer because drug interaction occurs with 5% of drug events. Inadequate monitoring and preparation error are incorrect answers because AHCRQ states that these drug events occur in 1% of the cases.

Evaluation

Physiological Integrity

Knowledge

24.4•A nurse is caring for an elderly client who is in palliative care only. Which intervention would have the highest priority?

1. aggressive chemotherapy
2. pain management
3. invasive testing
4. aggressive invasive surgery

Answer: 2

Rationale: Palliative care provides comfort measures at the end of life. Aggressive chemotherapy, invasive testing, and aggressive invasive surgery are used when the goal is cure of the disease.

Intervention

Physiological Integrity

Analysis

24.5•An 86-year-old client is admitted to the emergency department from a long-term facility. The client has Alzheimer’s disease, a history of falls with injury, atrial fibrillation, and a fever of unknown origin. The chest x-ray reveals a possible area of consolidation in the right lower lobe. The client is restless, irritable, and agitated. For best practice, prioritize the actions the nurse would take. (Prioritize sequence.)

1. review drugs and doses
2. serve as client advocate
3. communicate with long-term facility
4. assess for comfort and safety
5. investigate vague signs and symptoms

Answer: 4, 5, 3, 1, 2

Rationale: Assess for comfort and safety is the first priority because the nurse needs to establish a baseline to compare with later assessments and to determine the priority of interventions; attempt to find out the cause of the client’s restlessness, irritability, and agitation; and prevent medication errors, injuries, and falls. Second, investigate vague signs and symptoms to find the cause because the nurse knows that presentation of illness is less dramatic, and signs and symptoms of heart disease, infection, gastrointestinal problems, depression, and cancer may not be accompanied by the classic signs and symptoms seen in younger adults. Third, communicate with the long-term facility to obtain the client’s usual behavior, request information regarding client’s medications and dietary preferences, and establish a rapport with the facility for future client needs. Fourth, review drugs and dosages to find out client’s prescriptions, when the last doses were administered, and the interactions of drugs prescribed to prevent medication errors and risk of injury. Fifth, serve as client advocate by practicing ethically according to professional standards; establishing directives and identifying end-of-life preferences; and educating and empowering client and family so that they can make informed decisions, avoid futile care, and refuse interventions that are excessively burdensome, painful, and invasive.

Analysis

Safe, Effective Care Environment

Application

24.6•Which statements would indicate the frail older clients are more at risk for poor treatment outcomes than younger clients? (Select all that apply.)

1. diagnoses of vague symptoms and problems
2. nosocomial infections
3. assessment of the effects of acute illness on diagnosed chronic illnesses
4. iatrogenesis of therapeutic interventions

Answer: 2, 4

Rationale: Nosocomial infection is a correct answer because frail elders are at an increased risk of decreased organ function. Iatrogenesis of therapeutic interventions is a correct answer because frail older clients are at a higher risk for adverse outcomes and complications from medical and surgical interventions. Diagnoses of vague symptoms and problems is an incorrect answer because the earlier the problems are identified the better the outcome. Assessment of the effects of acute illness on diagnosed chronic illnesses is an incorrect answer because the earlier the treatment, the better the outcome.

Analysis

Health Promotion and Maintenance

Application

24.7•A frail older cognitively impaired client has developed a urinary tract infection. Which signs and symptoms would the nurse expect to find?

1. hypertension
2. flank pain
3. increased confusion
4. high fever

Answer: 3

Rationale: Increased confusion is the correct answer because it is a symptom that results from the infection and the cognitively impaired client’s inability to state feelings correctly. Hypertension is an incorrect answer because it is not a sign or symptom of a urinary tract infection but of chronic renal failure, medication, arteriosclerosis, and so on. Flank pain is an incorrect answer because this type of pain occurs with pyelonephritis. Pain with urinary tract infection occurs with urination. High fever is an incorrect answer because, with urinary tract infection, the fever is usually low grade, and elderly’s fever usually is low grade rather than high with other diseases.

Assessment

Physiological Integrity

Application

24.8•Which is a lifestyle change that can help promote clients living to a healthy old age?

1. use preventive and screening services
2. increase physical inactivity
3. decrease nutritional intake
4. continue smoking

Answer: 1

Rationale: Use preventive and screening services is the correct answer because it increases clients’ awareness of changes needed in lifestyles to maintain or improve health. Continue smoking is an incorrect answer because smoking is an irritant and is linked to vasoconstriction, allergies, asthma, cancer, cardiovascular diseases, lung diseases, and strokes among other diseases and conditions. Increase physical inactivity is an incorrect answer because exercise is needed to increase capacity and ability to use oxygen to derive energy for work; decrease myocardial oxygen demands; alter lipid and carbohydrate metabolism; prevent cardiovascular disease; maintain or increase muscle tone and strength; and increase physical fitness. Decrease nutritional intake is an incorrect answer because poor nutrition increases fatigue, weakness, and loss of muscle mass.

Assessment

Health Promotion and Maintenance

Knowledge

24.9•An older client with diabetes is diagnosed with an acute illness and placed on high doses of antibiotics for a long period of time to eradicate the offending organism. For which clinical manifestation would the nurse monitor?

1. constipation
2. increased urine output
3. white blood cell count normal to granulocytopenia
4. clear vesicles with red base that rupture, weep, crust, and spread

Answer: 3

Rationale: WBC count normal to granulocytopenia is the correct answer because the elderly may not develop an increased WBC count even in the presence of a severe bacterial infection. Increased urine output is an incorrect answer because urine output will decrease with most antibiotics that affect the kidneys. Clear vesicles with red base that rupture, weep, crust, and spread is an incorrect answer because these lesions are cold sores caused by herpes simplex virus. Constipation is an incorrect answer because diarrhea is usually associated with antibiotic use.

Analysis

Physiological Integrity

Analysis

24.10•Which factor impacts on the chronic illness trajectory that causes some older adults with chronic conditions to remain active and independent, whereas others decline into frailty and dependence?

1. Cognitive impairment condition has less effect on an older client’s function than does osteoarthritis.
2. Older clients with health insurance and financial resources can better manage chronic conditions while maintaining functional ability.
3. Older clients cannot control or halt disabling effects and progression of symptoms.
4. Access to healthcare and social support has a negative impact on health outcomes.

Answer: 2

Rationale: Older clients with health insurance and financial resources can better manage chronic conditions while maintaining functional ability is the correct answer because clients without health insurance and financial resources wait until the condition is worse and the outcomes may be negative and more costly. Cognitive impairment condition has less effect on an older client’s function than does osteoarthritis is an incorrect answer because client’s who have cognitive impairment progress on a path of functional decline faster and tend to become dependent. Older clients cannot control or halt disabling effects and progression of symptoms is an incorrect answer because many chronic conditions can be controlled or halted with medications and changes in lifestyles. Access to healthcare and social support has a negative impact on health outcomes is an incorrect answer because it has positive impact on modifications designed to encourage and maintain functional independence.

Planning

Safe, Effective Care Environment

Knowledge

24.11•A very old, frail client’s family is in a client-centered interdisciplinary conference guided by the nurse. Which are key issues that should be addressed? (Select all that apply.)

1. client’s wishes
2. communications
3. goals and outcomes
4. identification of areas of conflict

Answer: 1, 2, 3, 4

Rationale: Client’s wishes is a correct answer because client’s wishes should be made known to healthcare providers and family so that they can better understand common reasons for withholding or withdrawing aggressive treatment. Communications is a correct answer because it is a key issue in clarifying statements and conditions, and avoiding misrepresentation. Goals and outcomes is a correct answer because family and healthcare providers must agree to avoid conflict, misunderstandings, and allegations. Identification of areas of conflict is a correct answer because the family needs to understand what healthcare providers are doing, how the client is responding, and what options are available for the client’s goals; and the healthcare providers need to clarify goals and misunderstandings.

Planning

Health Promotion and Maintenance

Application

24.12•An elderly client was given a nursing diagnosis of injury, risk for: related to disorientation. Which statement would be appropriate for an expected outcome? The client

1. maintains continence on four out of five voidings.
2. does not become lost or sustain injury during wanderings.
3. sleeps through the night and stays awake most of the day.
4. receives appropriate care consistent with his or her and family specific values and expected outcomes.

Answer: 2

Rationale: Client does not become lost or sustain injury during wanderings is the correct answer because it relates to the diagnosis and it is measurable. Client maintains continence on four out of five voidings is an incorrect answer because it does not relate to the diagnosis. Client sleeps through the night and stays awake most of the day is an incorrect answer because it does not relate to the diagnosis. Client receives appropriate care consistent with his or her and family specific values and expected outcomes is an incorrect answer because expected outcomes are unknown and not measurable.

Diagnosis

Safe, Effective Care Environment

Planning

24.13•An older client with early-stage dementia is admitted to the hospital with vomiting and diarrhea. Which symptoms of early-stage dementia would the nurse most likely observe during the hospitalization?

1. changes in mood or personality, withdrawal, or depression
2. anomia, agnosia, apraxia, aphasia
3. anxiety, restlessness, wandering, perseveration
4. inability to recognize family and friends, withdrawal

Answer: 1

Rationale: Changes in mood or personality, withdrawal, or depression is the correct answer because these are the earliest symptoms and progress as the illness gets worse. Anomia (inability to remember names of objects), agnosia (inability to recognize or comprehend sights, sounds, words, or other sensory information), apraxia (inability to perform purposive movements or use object properly), aphasia (impairment of the ability to communicate through speech or writing) is an incorrect answer because these become more evident in the mild stages of dementia. Anxiety, restlessness, wandering, perseveration is an incorrect answer because, as the client’s initial confusion gets worse, the client becomes more anxious. As the client gets lost, becomes more restless, and wanders the speech becomes more repetitive of words and phrases. Inability to recognize family and friends, withdrawal is an incorrect answer because this occurs in the late stages of dementia. There is a considerable overlap in symptoms between stages, but as dementia gets worse, so do the symptoms.

Analysis

Psychosocial Integrity

Analysis

24.14•The student nurse is preparing a presentation for her fellow students regarding

caring for elderly patients. Which of the following criteria would be used to define

frailty? Select all that apply.

1. Unplanned weight loss of at least 10 lbs in a year
2. Slowness
3. Low activity
4. Short-term memory loss

Answer: 1, 2, 3

Rationale: Options 1, 2, and 3 are correct answers to define frailty. Short-term memory loss is not a criteria used to define frailty.

Planning; Physiological Integrity; Application

24.15•The nurse is caring for an older patient recently diagnosed with diabetes. The

patient asks the nurse what she can do to keep from “becoming a burden on my children.”

Which of the following responses by the nurse would be most appropriate?

1. “We will all need some help as we get older.”
2. “I’m sure your children won’t mind helping you if you need help.”
3. “If you take care of yourself by taking your medication, exercising, and eating healthy, you can help yourself remain independent.”
4. “Chronic diseases like diabetes are a major cause of disability in late life; you will need to speak with your children regarding your concern.”

Answer: 3

Rationale: Good lifestyle choices such as exercise and healthy eating can help to promote functional dependence in later life. Options 1, 2, and 4 are all downplaying the patient’s concern and would be considered nontherapeutic communication techniques.

Intervention; Physiological Integrity; Application

24.16•The graduate nurse is caring for an elderly patient recently diagnosed with cancer.

What signs or symptoms would be present to support the diagnosis of frailty in this

patient?

1. Serum albumin greater than 2.5 g/100dl
2. Serum albumin less than 2.5 g/100dl
3. Hemoglobin 23 g/dl
4. Hemoglobin 12 g/dl

Answer: 2

Rationale: A serum albumin level of 2.5 g/100dl is considered a symptom of frailty in an older patient. A hemoglobin level of 12 g/dl would be considered normal in an older patient. A hemoglobin level of 23 g/dl would be considered high. Neither hemoglobin levels would be indicative of frailty.

Assessment; Physiologic Integrity; Application

24.17•A nurse is preparing a community education program regarding cardiovascular

disease in the older patient. Which of the following information should the nurse include?

1. Cancer kills more women than heart disease.
2. Women are more likely than men to develop heart disease in their middle years.
3. A woman of 70 is as likely as a man to develop heart disease.
4. For most women, heart disease is a greater problem before they reach menopause.

Answer: 3

Rationale: Heart disease is a problem in women. A woman’s risk increases as she ages, especially after menopause. Men are more likely to develop cardiovascular disease in their middle ages, but by the 70s, the risk is the same for men and women.

Planning; Health Promotion and Maintenance; Application

24.18•A student nurse is assigned to care for an older patient diagnosed with frailty and

cardiovascular disease. While reviewing the patient’s chart, which of the following lab

values would the student expect to find?

1. Digoxin level 1.8 ng/mL
2. Digoxin level 3.0 ng/mL
3. Digoxin level 0.2 ng/mL
4. Digoxin level 1.5 ng/mL

Answer: 2

Rationale: Symptoms of frailty in an older patient with cardiovascular disease can include toxic levels of needed medications. A normal digoxin level is 0.5 to 2.0 ng/mL.

Assessment; Physiological Integrity; Analysis

24.19•When caring for a frail older patient with diabetes who has recently been

diagnosed with a UTI, the nurse will expect the physician to prescribe antibiotics

1. at a higher dose and for a longer period of time.
2. at a lower dose for a longer period of time.
3. at a higher dose for a shorter period of time.
4. at a lower dose for a shorter period of time.

Answer: 1

Rationale: When antibiotics are used in older persons with diabetes, they are usually prescribed at higher doses for longer periods of time to ensure complete eradication of the offending organism.

Assessment, Physiological Integrity; Application

24.20•A graduate nurse is working with her preceptor in a long-term care facility. The

graduate nurse asks her preceptor to list the most serious problems that she must watch

out for in patients with dementia. Which of the following is the most appropriate

response by the preceptor?

1. “Patients with dementia need assistance with everything; make sure that your nursing assistants are doing everything for them.”
2. “Patients with dementia may have become aggressive, so you need to make sure that you medicate them when they act out.”
3. “Patients with dementia may have problems with overmedication and polypharmacy; you need to really pay attention to the medications the patients are taking and their responses to those medications.”
4. “Patients with dementia may need their schedules adjusted each day depending on how they are acting.”

Answer: 3

Rationale: Polypharmacy and overdosing are serious problems inherent in the care of the older person with dementia. In caring for patients with dementia, one of the goals is to reinforce the patient’s independence. This can be done by allowing patients to handle as much of their own care as possible. One way to help this is to keep their schedules as predictable as possible. Aggression is a problem in patients with dementia, but medication should be used as a last resort.

Assessment; Physiological Integrity; Application

24.21•A nurse is preparing an educational program for her peers. The presentation is

about palliative care. Which of the following information does the nurse need to include?

Select all that apply.

1. Palliative care focuses on patients who are close to death.
2. Palliative care focuses on alleviation of pain and management of troublesome symptoms.
3. Palliative care can be delivered for extended periods of time and throughout all phases of the treatment process.
4. Palliative care can provide respite care for family members.

Answer: 2, 3, 4

Rationale: Palliative care can be provided to seriously ill older persons at any time during the disease process. It focuses on alleviation of pain and management of troublesome symptoms and can provide respite care for families. Palliative care is not limited to those close to death.

Planning; Physiological Integrity; Application

24.22•A nurse is caring for an elderly patient. The patient’s daughter has been reading on

the Internet about a hospitalized patient who was given the wrong medication and

subsequently died. The daughter asks the nurse how the hospital can prevent errors like

that in the future. Which of the following is the best response by the nurse?

1. “The hospital could install a bar-code system to identify patients and medications.”
2. “Errors like that are bound to happen, given the shortage of nurses.”
3. “Most physicians’ handwriting is so bad that it’s hard to figure out what medications they really want. It’s no wonder more people aren’t killed by medication errors.”
4. “Errors like that are bound to happen when nurses have too many patients assigned to their care.”

Answer: 1

Rationale: Identification of the correct patient and drug using bar-code technology is one method that has been shown to decrease the frequency of medication errors. Options 2, 3, and 4 are not statements that should be made to a patient or family members.

Assessment; Physiological Integrity; Application

24.23•A nurse working on a medical/surgical unit is preparing to admit an elderly patient

from a nursing home. What information does the nurse need to obtain from the family

and nursing home during the admission process? Select all that apply.

1. Code status
2. Goals of treatment
3. Current medications
4. Past surgeries

Answer: 1, 2, 3, 4

Rationale: All answers are information that the nurse needs to gather during the admission history and communicate to the entire treatment team.

Assessment; Physiologic Integrity; Application

24.24•A nurse is participating in a committee planning to implement an acute care of the

elderly (ACE) unit within the hospital. A coworker asks her what makes an ACE unit

different from any other unit in the hospital. Which of the following is the best response

by the nurse?

1. “Some of the key concepts of an ACE unit are to promote safety, include patient-centered interdisciplinary care, and discharge planning with the goal of returning the patient to his or her former living status.
2. “An ACE unit isn’t any different than any other unit in the hospital. except for the age of the patients.”
3. “The key concept of an ACE unit is to return the patients to their nursing homes as quickly as possible.”
4. “An ACE unit will be run just like a nursing home, except it’s located in the hospital.”

Answer: 1

Rationale: ACE units are based on four key concepts: having a safe environment, including patient-centered interdisciplinary care, discharge planning with a goal to return the patient to previous living status, and careful medical and nursing interventions to prevent adverse outcomes. ACE units are set up differently than a “normal” hospital unit.

Planning; Safe, Effective Care Environment; Application

24.25•A nurse is preparing an educational program on planning for a hospitalization for

residents of an assisted living community. What information does the nurse need to

include? Select all that apply.

1. Bring a list of your current medication and current labs.
2. Bring several changes of clothing so that you won’t have to wear a hospital gown.
3. Bring a copy of any advanced directives that you have in place.
4. Bring good walking slippers, a bathrobe, and a book if you are a reader.

Answer: 1, 3, 4

Rationale: Patients are encouraged to bring a current list of medications, copies of their medical records, and copies of advanced directives when they are admitted to a hospital. Comfort items such as slippers, bathrobes, and books are also encouraged. Patients are discouraged from bringing large amounts of clothing or valuables due to storage and safety concerns.

Planning; Safe, Effective Care Environment; Application

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