Nokea
The home health nurse suspects elder mistreatment of the 93-year-old client by the live-in caregiver. Which findings support the nurse’s conclusion? Select all that apply.
- A. Client has urine burns
- B. Client has wrist bruises
- C. Client states there have been some unexplained financial expenditures
- D. Client is more talkative than during previous home visits
- E. Smell of alcohol noted on live-in caregiver’s breath
Correct Answer: A;B;C;E
Rationale: Urine burns (neglect), wrist bruises (physical abuse), unexplained expenditures (financial abuse), and caregiver alcohol use (abuser characteristic) support mistreatment. Increased talkativeness suggests comfort, not abuse.
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The nurse completes teaching for the 80-year-old female client. Which statement made by the client indicates further teaching is needed?
- A. Instead of using sodium seasonings, I plan to try one with herbs and lemon.'
- B. Although I find my lavender-scented hand cream relaxing, I should not use it.'
- C. I should place a towel on the floor outside my shower so I don’t slip when getting out.'
- D. Rather than relying on laxatives, I should increase my intake of fruits and vegetables.'
Correct Answer: C
Rationale: Placing a towel on the floor increases fall risk; a slip-resistant mat is needed. Nonsodium seasonings, avoiding scented lotions, and increasing roughage are correct.
After performing an assessment and determining that there are no other causes, the nurse concludes that the older adult’s recent hearing loss in one ear may be from cerumen accumulation from age-related changes. The nurse’s conclusion was based on which age-related changes that contribute to the cerumen accumulation?
- A. Reduced sweat gland activity; thinning and drying of the skin lining the ear canal
- B. Ossicular bone calcification; longer and thicker hair growth in the ear canal
- C. Degenerative structural changes of the eardrum preventing cerumen passage
- D. Over activity of the sweat glands contributing to the development of presbycusis
Correct Answer: A
Rationale: Reduced sweat gland activity and thinning/drying of the ear canal skin cause cerumen buildup, affecting sound perception. Ossicular calcification, eardrum changes, and presbycusis are unrelated.
The nurse is reviewing a laboratory report for a 61-year-old client. Which finding is most important for the nurse to address with the HCP?
- A. Total cholesterol 180 mg/dL; was 140 at age 50
- B. Erythrocyte sedimentation rate (ESR) increased
- C. Alkaline phosphatase increased
- D. AST, ALT, and serum bilirubin increased
Correct Answer: D
Rationale: Elevated liver function tests (AST, ALT, bilirubin) are not age-related and suggest liver pathology, requiring immediate HCP notification. Cholesterol, ESR, and alkaline phosphatase increases are normal with aging.
Pre-hospital admission medications for the older adult client include warfarin and atenolol. Which statement made by the client should prompt the nurse to initiate a referral to a social worker?
- A. I crush my medications and take them with applesauce because they are hard to swallow.'
- B. I stopped taking my blood pressure pill; I can’t afford it, and my blood pressure is normal.'
- C. I feel more alert after starting to take ginkgo, but I forgot to ask my doctor if it were okay.'
- D. I have my daughter set up my medications for two weeks at a time in a medication bar.'
Correct Answer: B
Rationale: Stopping medication due to cost indicates a financial concern, warranting a social worker referral. Swallowing issues, ginkgo use, and medication setup require different interventions.
The nurse assesses the 75-year-old client and concludes that some findings are not age-related changes and require further follow-up. Which report by the client represents a non-age-related finding that requires additional investigation?
- A. Reports a decreased ability to see at night
- B. Reports seeing halos around lights
- C. Reports difficulty distinguishing some colors
- D. Reports diminished visual acuity
Correct Answer: B
Rationale: Seeing halos is a symptom of glaucoma, not an age-related change, requiring investigation. Night vision, color distinction, and acuity changes are normal with aging.