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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.
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The admissions department at a local hospital is registering an elderly man for an outpatient diagnostic test. The admissions nurse asks the man if he has an advanced directive. The man responds that he does not want to complete an advance directive because he does not want anyone controlling his finances. What would be appropriate information for the nurse to share with this patient?
- A. Advance directives are not legal documents, so you have nothing to worry about.
- B. Advance directives are limited only to health care instructions and directives.
- C. Your finances cannot be managed without an advance directive.
- D. Advance directives are implemented when you become incapacitated, and then you will use a living will to allow the state to manage your money.
Correct Answer: B
Rationale: An advance directive is a formal, legally endorsed document that provides instructions for care (living will) or names a proxy decision maker (durable power of attorney for health care) and covers only issues related specifically to health care, not financial issues. They do not address financial issues. Advance directives are implemented when a patient becomes incapacitated, but financial issues are addressed with a durable power of attorney for finances, or financial power of attorney.
A 47-year-old patient who has come to the physicians office for his annual physical is being assessed by the office nurse. The nurse who is performing routine health screening for this patient should be aware that one of the first physical signs of aging is what?
- A. Having more frequent aches and pains
- B. Failing eyesight, especially close vision
- C. Increasing loss of muscle tone
- D. Accepting limitations while developing assets
Correct Answer: B
Rationale: Failing eyesight, especially close vision, is one of the first signs of aging in middle life. More frequent aches and pains begin in the early late years (between ages 65 and 79). Increase in loss of muscle tone occurs in later years (ages 80 and older). Accepting limitations while developing assets is socialization development that occurs in adulthood.
Falls, which are a major health problem in the elderly population, occur from multifactorial causes. When implementing a comprehensive plan to reduce the incidence of falls on a geriatric unit, what risk factors should nurses identify? Select all that apply.
- A. Medication effects
- B. Overdependence on assistive devices
- C. Poor lighting
- D. Sensory impairment
- E. Ineffective use of coping strategies
Correct Answer: A,C,D
Rationale: Causes of falls are multifactorial. Both extrinsic factors, such as changes in the environment or poor lighting, and intrinsic factors, such as physical illness, neurologic changes, or sensory impairment, play a role. Mobility difficulties, medication effects, foot problems or unsafe footwear, postural hypotension, visual problems, and tripping hazards are common, treatable causes. Overdependence on assistive devices and ineffective use of coping strategies have not been shown to be factors in the rate of falls in the elderly population.
After a sudden decline in cognition, a 77-year-old man who has been diagnosed with vascular dementia is receiving care in his home. To reduce this mans risk of future infarcts, what action should the nurse most strongly encourage?
- A. Activity limitation and falls reduction efforts
- B. Adequate nutrition and fluid intake
- C. Rigorous control of the patients blood pressure and serum lipid levels
- D. Use of mobility aids to promote independence
Correct Answer: C
Rationale: Because vascular dementia is associated with hypertension and cardiovascular disease, risk factors (e.g., hypercholesterolemia, history of smoking, diabetes) are similar. Prevention and management are also similar. Therefore, measures to decrease blood pressure and lower cholesterol levels may prevent future infarcts. Activity limitation is unnecessary and infarcts are not prevented by nutrition or the use of mobility aids.
The presence of a gerontologic advanced practice nurse in a long-term care facility has proved beneficial to both the patients and the larger community in which they live. Nurses in this advanced practice role have been shown to cause what outcome?
- A. Greater interaction between younger adults and older adults occurs.
- B. The elderly recover more quickly from acute illnesses.
- C. Less deterioration takes place in the overall health of patients.
- D. The elderly are happier in long-term care facilities than at home.
Correct Answer: C
Rationale: The use of advanced practice nurses who have been educated in geriatric nursing concepts has proved to be very effective when dealing with the complex care needs of an older patient. When best practices are used and current scientific knowledge applied to clinical problems, significantly less deterioration occurs in the overall health of aging patients. This does not necessarily mean that patients are happier in long-term care than at home, that they recover more quickly from acute illnesses, or greater interaction occurs between younger and older adults.