Question 1

An older adult patient remarks that she has been experiencing constipation,which has never been a problem for her before now.What questions should the nurse ask? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

These questions are relevant to understanding potential causes of constipation in an older adult. Medications (A) can cause constipation as a side effect. Adequate fluid intake (B) is essential for preventing constipation. Dietary habits, particularly the intake of fruits and vegetables (D), can influence bowel movements due to their fiber content. Asking about the frequency of bowel movements (E) helps establish the severity and duration of the constipation. Rest (C) is less directly related to constipation, making it not a relevant choice in this context.

Question 2

A nurse is assessing an 85-year-old patient who presented to the emergency department with a complaint of "not feeling like myself." What should the nurse consider during this assessment?

Accepted Answer

In older adults, diseases often present with atypical symptoms, and the patient's complaint of "not feeling like myself" could indicate a variety of underlying issues. Aging does cause some decline in organ function, but sudden loss of function is not typical. While some older adults may not participate in activities to support wellness, this cannot be assumed as the cause of the patient's complaint. Also, not all 85-year-old patients live in institutional settings, and even those who do are not necessarily exposed to more communicable diseases.

Question 3

An older adult with osteoarthritis has been told that he cannot have his painful knee replaced because of his cardiac status.The patient is having progressive difficulty with normal self-care activities.The nurse should monitor this patient for which condition?

Accepted Answer

The patient's progressive difficulty with self-care activities may lead to feelings of hopelessness and despair, which could result in depression. Monitoring for signs of depression can help ensure proper treatment and support for the patient.

Question 4

An older adult is admitted to the emergency department (ED)after being the restrained front seat passenger in a motor vehicle accident.The nurse assessing this patient should consider that which physiologic response to hypovolemia is not as likely in an older adult?

Accepted Answer

Older adults may not exhibit tachycardia as a compensatory response to hypovolemia due to age-related changes in the heart's conduction system and potential medications that blunt heart rate responses.

Question 5

The nurse manages an acute care unit that is beginning to provide care for more and more older adults after surgery.The nurse manager would encourage nurses to add which interventions to the plan of care for these patients?

Accepted Answer

Early return to ambulation and self-care activities is important in the postoperative care of older adults. This helps to prevent complications such as pneumonia, delirium, and pressure ulcers. Restraints should be avoided whenever possible as they can increase agitation and confusion in older adults. While getting patients out of bed is important, it should be done gradually and with assistance to prevent falls and further injury. Keeping patients on complete bedrest can lead to muscle weakness, respiratory complications, and decreased mobility.

Question 6

An older adult has been prescribed medication to control hypertension.Today she says,"I took this same medication years ago,but I'm having more side effects this time." What should the nurse consider before replying?

Accepted Answer

As people age, changes occur in the blood-brain barrier, which controls what substances can enter the brain. This can make older patients more sensitive to some side effects of medications, especially those that affect brain function. Therefore, it is important for the nurse to consider this before replying to the patient about her side effects.

Question 7

An older adult patient tells the nurse that she is "tired" of having her medication doses changed so many times and wants to find a doctor who "knows what he's doing." How should the nurse respond to this patient?

Accepted Answer

It is important for the nurse to explain that frequent dose changes are necessary until the correct dose for the patient is determined. This will help the patient understand the importance of medication adjustments and trust the healthcare provider's decisions. Cutting pills or changing providers may not be the best solutions and may further complicate the patient's healthcare. The nurse should also use therapeutic communication and show empathy towards the patient's frustration.

Question 8

An older adult says,"I cannot believe that I have had a heart attack.I thought I had stomach flu and a backache." What nursing response is indicated?

Accepted Answer

The correct response acknowledges that the symptoms of a heart attack can vary, especially as people age, and may include back pain or stomach problems, which can be confusing and easily mistaken for other conditions. Option A may come across as dismissive and unsupportive. Option B is incorrect as not all patients have chest and arm pain during a heart attack. Option D is also incorrect as it suggests that a backache and stomach ache are rare symptoms of a heart attack, when in fact they can occur.

Question 9

The primary nurse reports to the team caring for an older adult that the patient has a low Braden Scale score.The nurse would instruct the team to start interventions to prevent which complication?

Accepted Answer

A low Braden Scale score indicates that the patient is at risk for developing pressure ulcers or skin breakdown, so interventions should be taken to prevent this complication.

Question 10

An older adult being treated for a burn on his lower leg and foot is surprised at its severity.He says,"It really didn't hurt very badly when I did it." What should the nurse consider before responding?

Accepted Answer

Aging can lead to decreased sensitivity in the feet and lower legs, which might explain why the burn did not feel very painful to the patient.

Question 11

The nurse has assessed that an older adult patient is at risk for impaired skin integrity.Which interventions are indicated? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

Securing IV catheters with paper tape reduces skin damage risk. Transparent film dressings protect pressure-prone areas. Keeping the patient warm promotes circulation and skin health. Monitoring IV sites for infiltration prevents skin damage. Pulling the patient up in bed can cause shear and friction, increasing skin damage risk.

Question 12

A 68-year-old patient had a PCV13 pneumonia vaccination 2 years ago.Which information should the nurse provide about this vaccination?

Accepted Answer

The PCV13 vaccine protects against 13 types of pneumococcal bacteria, while the PPSV23 vaccine covers 23 types. Adults 65 years or older who have received PCV13 are also recommended to receive a dose of PPSV23 to broaden their protection against pneumococcal disease.

Question 13

An older adult patient's testing reveals decreased absorption of calcium,which is a common age-related change.The nurse would consider which nursing problem when creating a care plan for this patient?

Accepted Answer

Decreased absorption of calcium can lead to decreased bone density and an increased risk of osteoporosis. Constipation is a common occurrence in older adults and can be exacerbated by a decreased intake of calcium. Swallowing, incontinence, and activity intolerance are not directly related to decreased absorption of calcium.

Question 14

After being medicated for postoperative pain an older patient becomes agitated and combative.Since this behavior has not been previously demonstrated the nurse conducts additional assessment for which most likely condition?

Accepted Answer

The sudden onset of agitation and being combative after medication suggests delirium, which is an acute confusional state commonly seen in older adults who experience a medical illness or hospitalization. Other signs of delirium include altered consciousness, disorientation, and hallucinations. Depression, drug toxicity, and dementia do not typically cause sudden onset agitation and combative behavior. However, drug toxicity could be a contributing factor if the patient was prescribed a medication that interacted negatively with their current medication regimen.

Question 15

An older patient says,"I seem to get chest colds so often now." How should the nurse respond to this report?

Accepted Answer

As we age, our immune system weakens and becomes less efficient at fighting off infections, including colds. It is important for the nurse to educate the patient on this fact and suggest preventative measures that can be taken to reduce the risk of colds and infections.

Question 16

Results of the CAM-ICU testing reveal that an older adult hospitalized in the intensive care unit has delirium.Which nursing interventions should be instituted?

Accepted Answer

The best choice would be to manage the patient's pain effectively. Delirium can be caused or exacerbated by pain, so effectively managing pain can help alleviate the delirium. Increasing environmental stimuli may actually worsen the delirium, and limiting visiting hours or sedating the patient is not an appropriate or evidence-based intervention for delirium.

Question 17

The nurse is admitting an older adult female who uses two canes for ambulation.The patient is attended by her daughter,who quietly reorients her mother several times during the assessment process.The daughter reports that her mother was a smoker for many years,but has not smoked for the last 5 years.The patient wears incontinence underwear and has problems with constipation.The nurse would evaluate which of these findings as key risk factors from the Hendrich II Fall Risk Model? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

The Hendrich II Fall Risk Model identifies factors that increase a patient's risk of falling. In this scenario, the patient wearing incontinence underwear (C) indicates a higher risk due to the potential for urgent needs to use the bathroom, increasing the chance of falls. The need for frequent reorientation (D) suggests cognitive impairment, which is a recognized risk factor for falls. The use of a cane (E) indicates mobility issues, which also increases fall risk. Being female (A) and a history of tobacco use (B) are not identified as risk factors in the Hendrich II Fall Risk Model.

Question 18

The nurse has received emergency admission orders for an older adult patient who was severely injured in a fall.The nurse would question the use of which medication in this patient?

Accepted Answer

Diazepam is a benzodiazepine that can cause sedation and confusion in older adults, which may increase the risk of falls and injury. It should be used with caution in this population, especially with a history of recent fall and injury.

Question 19

The nurse suspects urinary tract infection in an older adult patient who has sudden onset of incontinence.Which symptoms,atypical in a younger adult,would the nurse assess for in this patient? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

Accepted Answer

In older adults, urinary tract infections (UTIs) can present atypically with symptoms such as confusion and vomiting, rather than the classic symptoms like chills, flank pain, and fever often seen in younger adults.

Question 20

The daughter of an older adult calls the emergency department (ED)triage nurse and reports that her father hit his head "very hard" while getting into the car about 10 minutes ago.There is no bleeding.The daughter asks what she should watch for in her father.How should the nurse respond?

Accepted Answer

Option D is the best choice as it provides the daughter with important information specific to older adults, that changes can be very subtle and may develop over several hours or even days. The nurse advises the daughter to bring her father to the ED if she has any concerns. This advice is in line with the principle of caution and safety in dealing with head injuries, especially among older adults who may have a higher risk for traumatic brain injury. Options A, B, and C are not specific to older adults and do not provide adequate guidance on what symptoms to watch out for or when to seek medical help.

Quiz 4: The Older Adult High-Acuity Patient

An older adult patient remarks that she has been experiencing constipation,which has never been a problem for her before now.What questions should the nurse ask? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.