Question 1

When using the various instruments to assess an older person's ADLs, the nurse needs to remember that a disadvantage of these instruments includes:

Accepted Answer

A disadvantage of many of the ADL and IADL instruments is the self- or proxy reporting of functional activities.The other responses are not correct.

Question 2

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?

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 assesses immediate and delayed recall and visuospatial abilities.The Geriatric Depression Scale, short form, assesses for depression and changes in the level of depression, not mental status.The Rapid Disability Rating Scale-2 measures what the person can actually do versus what he or she could do, but not mental status.The Timed Up and Go Test assesses functional mobility, not mental status.

Question 3

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?

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 for falls and fractures.Environmental modifications can promote mobility and reduce the likelihood of the older adult falling.

Question 4

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?

Accepted Answer

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

Question 5

The nurse is preparing to perform a functional assessment with an older patient and knows that a good approach would be to:

Accepted Answer

Two approaches are used to perform a functional assessment: (1) asking individuals about their ability to perform the tasks (self-reports), or (2) actually observing their ability to perform the tasks.For persons with memory problems, the use of surrogate reporters (proxy reports), such as family members or caregivers, may be necessary, keeping in mind that they may either overestimate or underestimate the person's actual abilities.

Question 6

A 68-year-old patient with dementia is requesting information about medical assistance in dying.The nurse informs the patient that to be eligible for medical assistance in dying, the individual must: (Select all that apply.)

Accepted Answer

To be eligible for medical assistance in dying, an individual must be eligible for government health care coverage (not a visitor to Canada), be at least 18 years old, have a grievous and irremediable medical condition (be actively dying), make a voluntary request for medical assistance in dying, and be able to give informed consent.

Question 7

When beginning to assess a person's spirituality, which question by the nurse would be most appropriate?

Accepted Answer

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

Question 8

The nurse is assessing an older adult's advanced activities of daily living (AADLs), which would include:

Accepted Answer

AADLs are activities that an older adult performs, for example, occupational and recreational activities.Self-grooming activities are basic ADLs; meal preparation and balancing the chequebook are considered IADLs.

Question 9

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?

Accepted Answer

Informal support includes family and long-time close friends and is usually provided free of charge.Formal supports include programs, such as social welfare and other social services, and health care delivery agencies, such as home health care.

Question 10

An older 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.The nurse will need to complete a comprehensive assessment of the patient's: (Select all that apply.)

Accepted Answer

A comprehensive assessment incorporates both the physical examination and assessments of an individuals' mental, functional, social, and economic status; pain; and the physical environment for safety concerns.

Question 11

The nurse is assessing an older adult's functional ability.The nurse will need to determine the patient's:

Accepted Answer

Functional ability refers to one's ability to perform activities necessary to live in modern society and can include driving, using the telephone, or performing personal tasks, such as bathing and toileting.

Question 12

The nurse is working with the older adult population and recognizes that polypharmacy can increase the risk for the older adult for:

Accepted Answer

Polypharmacy is the prescription and use of multiple medications (usually five or more) to deal with concomitant multiple diseases and can lead to adverse drug events, such as medication interactions, decreased functional status, cognitive impairment, and falls.

Question 13

The nurse is preparing to use the Lawton IADL instrument as part of an assessment.Which statement about the Lawton IADL instrument is true?

Accepted Answer

The Lawton IADL instrument is designed as a self-report measure of performance rather than ability.Direct testing, such as demonstrating the ability to prepare food while a hospital inpatient, is often not feasible.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 14

During a health history interview with an 88-year-old female patient and daughter who is the caregiver, the nurse notes that the daughter appears stressed and her responses are abrupt.The nurse uses STOPHARM to:

Accepted Answer

• The mnemonic (STOP HARM) can help detect, diagnose, and manage elder abuse:
o Screen for abuse in all older adult patients
o Think about risk factors
o Ominous danger signs present?
o Physical findings
o History
o Address issue of elder abuse
o Report to adult protective services
o Manage with prevention and risk factor modification
• The Physical, Intellectual, Emotional, Capabilities, Environment and Social (PIECES) program was developed for all health care providers to enhance understanding of and care for patients with complex physical and cognitive/mental health needs and behavioural changes.
• The Katz Index of ADL is based on the concept of physical disability and was intended to measure physical function in older adults and chronically ill patients.
• The Duke Social Support and Stress Scale is a measure of a patient's perceptions of support and stress in family and nonfamily relationships.

Question 15

The nurse needs to assess a patient's ability to perform activities of daily living (ADLs) and should choose which tool for this assessment?

Accepted Answer

The Barthel Index is used to assess ADLs.The other options are used to measure IADLs.

Question 16

The nurse is assessing the abilities of an older adult.Which activities are considered IADLs? (Select all that apply.)

Accepted Answer

Typically, IADL tasks include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation.The other options listed are ADLs related to self-care.

Question 17

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 safely outside alone.The nurse will perform which test to assess this?

Accepted Answer

The Timed 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 safely outside alone.The Performance 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, balance, mobility, coordination, and endurance.The Tinetti Gait and Balance Evaluation assesses gait and balance and provides information about fall risk.In a review of 17 functional balance tests, Langley and Mackintosh recommended the Timed Up and Go Test as valid and reliable for the older adult population.

Question 18

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 screen the wife using the:

Accepted Answer

The Modified Caregiver Strain Index is specifically designed to assess the level of burden and strain experienced by caregivers. As the wife has identified herself as the patient's primary caregiver, it is important to assess her level of strain and identify any potential issues that may impact the patient's care. The other screening tools listed may be appropriate in different contexts, but are not as directly related to the caregiver's current situation.

Quiz 31: Functional Assessment of the Older Adult