Question 1

During a morning assessment,the nurse notices that an older patient is less attentive and is unable to recall yesterday's events.Which test is appropriate for assessing the patient's mental status?&#10;A) Geriatric Depression Scale, Short Form&#10;B) The Physical Performance Test&#10;C) Mini-Cog&#10;D) The Get Up and Go Test

Accepted Answer

For nurses in various settings,cognitive assessments provide continuing comparisons to the individual's baseline to detect any acute changes in mental status.The Mini-Cog is a mental status test that tests immediate and delayed recall and visuospatial ability.The Geriatric Depression Scale,Short Form assess for depression and changes in the level of depression,not mental status.The Physical Performance Test assesses activities such as eating,dressing,transferring,and stair climbing,but not mental status.The Get Up and Go Test assesses functional mobility,not mental status.

Question 2

During a functional assessment of an older person's home environment,which statement or question by the nurse is most appropriate regarding common environmental hazards?&#10;A) &#34;These low toilet seats are safe because they are nearer to the ground in case of falls.&#34;&#10;B) &#34;Do you have a relative or friend who can help to install grab bars in your shower?&#34;&#10;C) &#34;These small rugs are ideal for preventing you from slipping on the hard floor.&#34;&#10;D) &#34;It would be safer to keep the lighting low in this room to avoid glare in your eyes.&#34;

Accepted Answer

Environmental hazards within the home can be a potential constraint on the older person's day-to-day functioning.Common environmental hazards including inadequate lighting,loose throw rugs,curled carpet edges,obstructed hallways,cords in walkways,lack of grab bars in tub and shower,and low and loose toilet seats are hazards that could lead to an increased risk of falls and fractures.Environmental modifications can promote mobility and reduce the likelihood of the older adult falling.

Question 3

The nurse is assessing the forms of support an older patient has before she is discharged.Which of these examples is an informal source of support?&#10;A) The local senior center&#10;B) Her Medicare check&#10;C) Meals on Wheels meal delivery service&#10;D) Her neighbor, who visits with her daily

Accepted Answer

Informal support includes family and close long-time friends and is usually provided free of charge.Another example of informal support is a neighbor who has daily contact with the client and shares food and company.Formal supports include programs such as social welfare and other social service and health care delivery agencies such as home health care.Semiformal supports such as church societies,neighborhood groups,and senior centers also form an important role in social support.

Question 4

The nurse is preparing to use the Lawton IADL instrument as part of an assessment.Which statement about the Lawton IADL instrument is true?&#10;A) The nurse uses direct observation to implement this tool.&#10;B) It is designed as a self-report measure of performance rather than ability.&#10;C) It is not useful in the acute hospital setting.&#10;D) It is best used for those residing in an institutional setting.

Accepted Answer

The Lawton IADL instrument is designed as a self-report measure of performance rather than ability.Direct testing is often not feasible,such as demonstrating the ability to prepare food while a hospital inpatient.Attention to the final score is less important than identifying a person's strengths and areas where assistance is needed.The instrument is useful in acute hospital settings for discharge planning and continuously in outpatient settings.It would not be useful for those residing in institutional settings because many of these tasks are already being managed for the resident.

Question 5

An elderly patient has been admitted to the intensive care unit (ICU)after falling at home.Within 8 hours,his condition has stabilized and he is transferred to a medical unit.The family is wondering whether he will be able to go back home.Which assessment instrument is most appropriate for the nurse to choose at this time?

A) The Lawton IADL instrument
B) Hospital Admission Risk Profile (HARP)
C) The Mini-Cog
D) The NEECHAM Confusion Scale

Accepted Answer

Hospital-acquired functional decline may occur within two days of a hospital admission.The HARP helps to identify older adults who are at greatest risk for loss of ADLs or mobility at this critical time.The Lawton IADL measures instrumental activities of daily living,which may be difficult to observe in the hospital setting.The Mini-Cog is an assessment of mental status.The NEECHAM Confusion Scale is used to assess for delirium.

Question 6

The nurse is preparing to assess an older adult and discovers that the older adult is in severe pain.Which statement about pain and the older adult is true?&#10;A) Pain is inevitable with aging.&#10;B) Older adults with cognitive impairments feel less pain.&#10;C) Alleviating pain should be a priority over other aspects of the assessment.&#10;D) The assessment should take priority so that care decisions can be made.

Accepted Answer

If the older adult is experiencing pain or discomfort,then the depth of knowledge gathered through the assessments will suffer.Alleviating pain should be a priority over other aspects of the assessment.It is paramount to remember that older adults with cognitive impairment do not feel less pain.

Question 7

An 85-year-old man has been hospitalized after a fall at home,and his 86-year-old wife is at his bedside.She tells the nurse that she is his primary caregiver.The nurse should assess the caregiver for signs of possible caregiver burnout,such as:

A) depression.
B) weight gain.
C) hypertension.
D) social phobias.

Accepted Answer

Caregiver burden is the perceived strain by the person who cares for an elderly,chronically ill,or disabled person.Caregiver burnout is linked to the caregiver's ability to cope and handle stress.Signs of possible caregiver burnout include multiple somatic complaints,increased stress and anxiety,social isolation,depression,and weight loss.Screening caregivers for depression may also be appropriate.

Question 8

A patient will be ready to be discharged from the hospital soon,and the patient's family members are concerned about whether the patient is able to walk outside alone safely.The nurse will perform which test to assess this?

A) The Get Up and Go Test
B) The Performance Activities of Daily Living
C) The Physical Performance Test
D) Tinetti Gait and Balance Evaluation

Accepted Answer

The Get Up and Go Test is a reliable and valid test to quantify functional mobility.The test is quick,requires little training and no special equipment,and is appropriate to use in many settings including hospitals and clinics.This instrument has been shown to predict a person's ability to go outside alone safely.The Performance of Activities of Daily Living test has a trained observer actually observing as a patient performs various ADLs.The Physical Performance Test assesses upper body fine motor and coarse motor activities,as well as balance,mobility,coordination,and endurance.The Tinetti Gait and Balance Evaluation assesses gait and balance and provides information about fall risk.

Question 9

When beginning to assess a person's spirituality,which question by the nurse would be most appropriate?&#10;A) &#34;Do you believe in God?&#34;&#10;B) &#34;How does your spirituality relate to your health care decisions?&#34;&#10;C) &#34;What religious faith do you follow?&#34;&#10;D) &#34;Do you believe in the power of prayer?&#34;

Accepted Answer

Open-ended questions provide a foundation for future dialog.The other responses are easily answered by one-word replies,and they are closed questions.

Question 10

The nurse is assessing the abilities of an older adult.Which of these following activities are considered instrumental activities of daily living? Select all that apply.&#10;A) Feeding oneself&#10;B) Preparing a meal&#10;C) Balancing a checkbook&#10;D) Walking&#10;E) Toileting&#10;F) Grocery shopping

Accepted Answer

Typically,instrumental activities of daily living tasks include shopping,meal preparation,housekeeping,laundry,managing finances,taking medications,and using transportation.The others listed are activities of daily living related to self-care.

Question 11

The nurse is administering a test that is timed over 15 minutes and assesses a patient's upper body fine motor and coarse motor activities,balance,mobility,coordination,and endurance.During this test,activities such as dressing and stair climbing are timed.Which test is described by these activities?

A) The Get Up and Go Test
B) The Performance Activities of Daily Living
C) The Physical Performance Test
D) Tinetti Gait and Balance Evaluation

Accepted Answer

The answer of The nurse is administering a test that...

Question 12

The nurse is assessing an older adult's advanced activities of daily living,which would include:&#10;A) recreational activities.&#10;B) meal preparation.&#10;C) balancing the checkbook.&#10;D) self-grooming activities.

Accepted Answer

The answer of The nurse is assessing an older adult's...

Question 13

When using the various instruments to assess an older person's activities of daily living (ADLs),the nurse needs to remember that a disadvantage of these instruments includes:&#10;A) the reliability of the tools.&#10;B) self or proxy report of functional activities.&#10;C) lack of confidentiality during the assessment.&#10;D) insufficient detail about the deficiencies identified.

Accepted Answer

The answer of When using the various instruments to assess...

Question 14

The nurse is assessing an older adult's functional ability.Which definition correctly describes one's functional ability? Functional ability:&#10;A) is the measure of the expected changes of aging that one is experiencing.&#10;B) refers to the individual's motivation to live independently.&#10;C) refers to the level of cognition present in an older person.&#10;D) refers to one's ability to perform activities necessary to live in modern society.

Accepted Answer

The answer of The nurse is assessing an older adult's...

Question 15

The nurse needs to assess a patient's ability to perform activities of daily living and should choose which tool for this assessment?&#10;A) Direct Assessment of Functional Abilities (DAFA)&#10;B) Lawton IADL&#10;C) Barthel Index&#10;D) Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL (OARS-IADL)

Accepted Answer

The answer of The nurse needs to assess a patient's...

Question 16

The nurse is preparing to perform a functional assessment of an older patient and knows that a good approach would be to:&#10;A) observe the patient's ability to perform the tasks.&#10;B) ask the patient's wife how he does when performing tasks.&#10;C) review the medical record for information on the patient's abilities.&#10;D) ask the patient's physician for information on the patient's abilities.

Accepted Answer

The answer of The nurse is preparing to perform a...

Deck 30: Functional Assessment of the Older Adult