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The nurse is admitting an acutely ill older-adult patient to the hospital. Which of the following interventions should the nurse implement during the admission process?
- A. Speak slowly and loudly while facing the patient.
- B. Obtain a detailed medical history from the patient.
- C. Interview the patient before the physical assessment.
- D. Determine whether the patient uses glasses or hearing aids.
Correct Answer: D
Rationale: Assistive devices should be in place before assessing the patient to minimize anxiety and confusion. When a patient is acutely ill, the physical assessment should be accomplished first to detect any physiological changes that require immediate action. Not all older patients have hearing deficits, and it is insensitive of the nurse to speak loudly and slowly to all older patients. To avoid tiring the patient, much of the medical history can be obtained from medical records.
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The nurse is caring for an older-adult patient with multiple health problems who states that who reports having 'no energy' and feeling increasingly weak. The patient has had a 5 kg weight loss over the last year. Which of the following interventions should the nurse implement initially?
- A. Ask the patient about daily dietary intake.
- B. Schedule regular range-of-motion exercise.
- C. Discuss long-term care placement with the patient.
- D. Describe normal changes with aging to the patient.
Correct Answer: A
Rationale: In the frail elderly patient, nutrition is frequently compromised, and the nurse's first action should be to assess the patient's nutritional status. Active range of motion may be helpful in improving the patient's strength and endurance, but nutritional assessment is the priority because the patient has had a significant weight loss. The patient may be a candidate for long-term care placement, but more assessment is needed before this can be determined. The patient's assessment data are not consistent with normal changes associated with aging.
Which of the following actions should the nurse consider when developing the plan of care for an older adult who is hospitalized for an acute illness?
- A. Use a standardized geriatric nursing care plan.
- B. Minimize activity level during hospitalization.
- C. Plan for transfer to a long-term care facility after the hospitalization.
- D. Consider preadmission functional abilities when setting patient goals.
Correct Answer: D
Rationale: The plan of care for older persons should be individualized and based on the patient's current functional abilities. A standardized geriatric nursing care plan will not address individual patient needs and strengths. A patient's need for discharge to a long-term care facility is variable. Activity level should be designed to allow the patient to retain functional abilities while hospitalized and also to allow any additional rest needed for recovery from the acute process.
Which information obtained by the home health nurse when making a visit to a frail older-adult patient with mild forgetfulness is of concern?
- A. The patient tells the nurse that a close friend recently died.
- B. The patient has lost 4.5 kg during the last month.
- C. The patient is cared for by a daughter during the day and stays with a son at night.
- D. The patient's son uses a marked pillbox to set up the patient's medications weekly.
Correct Answer: B
Rationale: A 4.5 kg weight loss may be an indication of elder neglect or depression and requires further assessment by the nurse. The use of a marked pillbox and planning by the family for 24-hour care are appropriate for this patient. It is not unusual that an elderly adult would have friends who have died.
The nurse is admitting an older-adult patient who is hospitalized with an acute illness. Which of the following interventions should the nurse do first?
- A. Orientate the patient to their room.
- B. Administer the prescribed PRN sedative medication.
- C. Ask the health care provider to order a vest restraint.
- D. Place the patient in a 'geri chair' near the nurse's station for observation.
Correct Answer: A
Rationale: The older adult who moves to a different location needs a thorough orientation to the environment. The nurse should repeatedly reassure the patient that he or she is safe and attempt to answer all questions. The unit should foster patient orientation by displaying large-print clocks, avoiding complex or visually confusing wall designs, clearly designating doors, and using simple bed and nurse-call systems. Physical or chemical restraints may be necessary, but the nurse's first action should be to provide an ongoing and clear physical orientation. There is no indication that the patient needs observation at this time.
The nurse is assessing the nutritional status of an older-adult patient using the SCALES acronym. Which of the following should the nurse assess when completing the 'S'?
- A. Serum potassium level
- B. Sadness or mood change
- C. Social support
- D. Sexual intimacy
Correct Answer: B
Rationale: The acronym SCALES can be used to remind the nurses to assess important nutritional indicators. In the case of the 'S,' the nurse is to assess sadness or mood changes.