Nokea
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.
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The nurse is planning care for an alert and active older-adult patient who takes multiple medications for persistent cardiac and respiratory disease and lives with a daughter who works during the day. Which nursing diagnosis is most appropriate?
- A. Risk for injury as evidenced by exposure to toxic chemical (drug-drug interactions)
- B. Social isolation related to social behavior incongruent with norms (weakness and fatigue)
- C. Disabled family coping related to differing coping styles between support person and patient
- D. Caregiver role strain related to increase in care needs
Correct Answer: A
Rationale: The patient's age and multiple medications indicate a risk for injury caused by interactions between the multiple drugs being taken and a decreased drug metabolism rate. The patient data do not indicate problems with social isolation, caregiver role strain, or compromised family coping.
The nurse is visiting a homeless shelter for older persons to provide a health-promotion activity. Which of the following factors are associated with adult homelessness?
- A. Low income
- B. Reduced cognitive capacity
- C. Decreased health problems
- D. Abundance of affordable housing
- E. Living alone
Correct Answer: A,B,E
Rationale: Key factors associated with homelessness are low income, reduced cognitive capacity, and living alone. There is a shortage of affordable housing and homeless adults generally have an increase in health problems.
The home health nurse is caring for an older-adult patient who lives alone and is taking seven different prescribed medications for persistent health problems. Which of the following nursing interventions would be most appropriate to ensure medication regimen adherence?
- A. Use a marked pillbox to set up the patient's medications.
- B. Discuss the option of moving to an assisted-living facility.
- C. Remind the patient about the importance of taking medications.
- D. Visit the patient daily to administer the prescribed medications.
Correct Answer: A
Rationale: Since forgetting to take medications is a common cause of medication errors in older persons, the use of medication reminder devices is helpful when older persons have multiple medications to take. There is no indication that the patient needs to move to assisted living or that the patient does not understand the importance of medication regimen adherence. Home health care is not designed for the patient who needs ongoing assistance with activities of daily living (ADLs) or instrumental ADLs (IADLs).
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.
Which of the following actions would enable the nurse to obtain the most complete information when doing an assessment with an older-adult patient?
- A. Interview both the patient and the primary patient caregiver.
- B. Use a geriatric assessment instrument to evaluate the patient.
- C. Review the patient's chart for the history of medical problems.
- D. Ask the patient to write down medical problems and medications.
Correct Answer: B
Rationale: The most complete information about the patient will be obtained through the use of an assessment instrument specific to the geriatric population, which includes information about both medical diagnoses and treatments and about functional health patterns and abilities. A review of the chart, interviews of the patient and caregiver, and written information by the patient will all be included in a comprehensive geriatric assessment.