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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.
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The nurse suspects that elder abuse may be occurring when a frail older-adult patient with a broken arm is brought to the emergency department by a family member. Which of these actions should the nurse take first?
- A. Notify an elder protective services agency about the possible abuse.
- B. Make a referral for a home assessment visit by the home health nurse.
- C. Have the family member stay in the waiting area while the patient is assessed.
- D. Ask the patient how the injury occurred and observe the family member's reaction.
Correct Answer: C
Rationale: The initial action should be assessment and interviewing of the patient. The patient should be interviewed alone because the patient will be unlikely to give accurate information if the abuser is present. If abuse is occurring, the patient should not be discharged home for a later assessment by a home health nurse. The nurse needs to collect and document physiological data before notifying the elder protective services agency.
The nurse is caring for patients in a geriatric family practice clinic with a primary health care provider. Which of the following actions should the nurse do when caring for older persons who live in rural areas?
- A. Assess the patient for persistent diseases that are unique to rural areas.
- B. Ensure transportation to appointments with the health care provider.
- C. Schedule appointments for the patient in an urban area for better health care.
- D. Obtain adequate medications for the patient to last for 4-6 months.
Correct Answer: B
Rationale: Transportation can be a barrier to accessing health services in rural areas. There are no persistent diseases unique to rural areas. Because medications may change, the nurse should help the patient plan for obtaining medications through alternate means such as the mail or delivery services, not by purchasing large quantities of the medications. The patient living in a rural area may lose the benefits of a familiar situation and social support by moving to an urban area.
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.
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.
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.