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Based on a patients vague explanations for recurring injuries, the nurse suspects that a community-dwelling older adult may be the victim of abuse. What is the nurses primary responsibility?
- A. Report the findings to adult protective services.
- B. Confront the suspected perpetrator.
- C. Gather evidence to corroborate the abuse.
- D. Work with the family to promote healthy conflict resolution.
Correct Answer: A
Rationale: If neglect or abuse of any kind including physical, emotional, sexual, or financial abuse is suspected, the local adult protective services agency must be notified. The responsibility of the nurse is to report the suspected abuse, not to prove it, confront the suspected perpetrator, or work with the family to promote resolution.
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Mrs. Harris is an 83-year-old woman who has returned to the community following knee replacement surgery. The community health nurse recognizes that Mrs. Harris has prescriptions for nine different medications for the treatment of varied health problems. In addition, she has experienced occasional episodes of dizziness and lightheadedness since her discharge. The nurse should identify which of the following nursing diagnoses?
- A. Risk for infection related to polypharmacy and hypotension
- B. Risk for falls related to polypharmacy and impaired balance
- C. Adult failure to thrive related to chronic disease and circulatory disturbance
- D. Disturbed thought processes related to adverse drug effects and hypotension
Correct Answer: B
Rationale: Polypharmacy and loss of balance are major contributors to falls in the elderly. This patient does not exhibit failure to thrive or disturbed thought processes. There is no evidence of a heightened risk of infection.
For several years, a community health nurse has been working with a 78-year-old man who requires a wheelchair for mobility. The nurse is aware that the interactions between disabilities and aging are not yet clearly understood. This interaction varies, depending on what variable?
- A. Socioeconomics
- B. Ethnicity
- C. Education
- D. Pharmacotherapy
Correct Answer: A
Rationale: Large gaps exist in our understanding of the interaction between disabilities and aging, including how this interaction varies, depending on the type and degree of disability, and other factors such as socioeconomics and gender. Ethnicity, education, and pharmacotherapy are not identified as salient influences on this interaction.
An 84-year-old patient has returned from the post-anesthetic care unit (PACU) following hip arthroplasty. The patient is oriented to name only. The patients family is very upset because, before having surgery, the patient had no cognitive deficits. The patient is subsequently diagnosed with postoperative delirium. What should the nurse explain to the patients family?
- A. This problem is self-limiting and there is nothing to worry about.
- B. Delirium involves a progressive decline in memory loss and overall cognitive function.
- C. Delirium of this type is treatable and her cognition will return to previous levels.
- D. This problem can be resolved by administering antidotes to the anesthetic that was used in surgery.
Correct Answer: C
Rationale: Surgery is a common cause of delirium in older adults. Delirium differs from other types of dementia in that delirium begins with confusion and progresses to disorientation. It has symptoms that are reversible with treatment, and, with treatment, is short term in nature. It is patronizing and inaccurate to reassure the family that there is nothing to worry about. The problem is not treated by the administration of antidotes to anesthetic.
You are the nurse planning an educational event for the nurses on a subacute medical unit on the topic of normal, age-related physiological changes. What phenomenon would you include in your teaching plan?
- A. A decrease in cognition, judgment, and memory
- B. A decrease in muscle mass and bone density
- C. The disappearance of sexual desire for both men and women
- D. An increase in sebaceous and sweat gland function in both men and women
Correct Answer: B
Rationale: Normal signs of aging include a decrease in the sense of smell, a decrease in muscle mass, a decline but not disappearance of sexual desire, and decreased sebaceous and sweat glands for both men and women. Cognitive changes are usually attributable to pathologic processes, not healthy aging.
A gerontologic nurse is overseeing the care that is provided in a large, long-term care facility. The nurse is educating staff about the significant threat posed by influenza in older, frail adults. What action should the nurse prioritize to reduce the incidence and prevalence of influenza in the facility?
- A. Teach staff how to administer prophylactic antiviral medications effectively.
- B. Ensure that residents receive a high-calorie, high-protein diet during the winter.
- C. Make arrangements for residents to limit social interaction during winter months.
- D. Ensure that residents receive influenza vaccinations in the fall of each year.
Correct Answer: D
Rationale: The influenza and the pneumococcal vaccinations lower the risks of hospitalization and death in elderly people. The influenza vaccine, which is prepared yearly to adjust for the specific immunologic characteristics of the influenza viruses at that time, should be administered annually in autumn. Prophylactic antiviral medications are not used. Limiting social interaction is not required in most instances. Nutrition enhances immune response, but this is not specific to influenza prevention.