Nokea
The nurse is admitting an older-adult patient who has urinary urgency and a possible urinary tract infection (UTI). Which of the following actions should the nurse implement first?
- A. Assess the patient's orientation.
- B. Inspect for abdominal distension.
- C. Question the patient about hematuria.
- D. Invite the patient to use the bathroom.
Correct Answer: D
Rationale: Before beginning the assessment of an older patient with a UTI and urgency, the nurse should have the patient empty the bladder because bladder fullness or discomfort will distract from the patient's ability to provide accurate information. The patient may seem disoriented if distracted by pain or urgency. The physical assessment data are obtained after the patient is as comfortable as possible.
You may also like to solve these questions
The nurse is teaching an older-adult female patient about her new medications and the patient replies that she 'just can't remember all that information anymore.' Which of the following changes may interfere with the patients' ability to learn about the new medications?
- A. Intellectual ability declines with age.
- B. All mental abilities slow as individuals age.
- C. Declining physical health can impair cognitive function.
- D. Impaired vocabulary and verbal function decrease reasoning with age.
Correct Answer: C
Rationale: Declining physical health is an important factor in cognitive impairment. Intellectual ability does not decline with age. All mental abilities do not slow as an individual ages. Vocabulary and verbal function do not decrease with age.
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.
Findings from a health history indicate that the patient takes daily supplements of the antioxidants beta carotene, vitamin C, and vitamin E. This health practice reflects which of the following theories of biological aging?
- A. Free radicals
- B. Crosslinking
- C. Somatic mutation
- D. Telomere-telomerase depletion
Correct Answer: A
Rationale: Free radicals are natural by-products of many normal cellular processes and are also created under the influence of environmental factors such as smog, tobacco smoke, and radiation. Numerous natural protective mechanisms are in place to prevent oxidative damage. Recent research has focused on the roles of various antioxidants, including vitamins C and E, in slowing down the oxidative process and, ultimately, the aging process. The somatic mutation theory focuses on spontaneous mutations. The crosslinking theory is based upon lipids, proteins, CHO, and nucleic acid reactions. The telomere-telomerase depletion theory focuses on the loss of telomeres, repeated sequences at the ends of DNA.
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.
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.