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Which nursing actions will the nurse take to assess for possible malnutrition in an older-adult patient?
- A. Observe for depression.
- B. Review laboratory results.
- C. Assess teeth and oral mucosa.
- D. Ask about transportation needs.
- E. Determine food likes and dislikes.
Correct Answer: A,B,C,D
Rationale: The laboratory results, especially albumin levels, may indicate persistent poor protein intake. Transportation impacts patients' ability to shop for groceries. Depression may lead to decreased appetite. Oral sores or teeth in poor condition may decrease the ability to chew and swallow. Food likes and dislikes are not necessarily associated with malnutrition.
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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.
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 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 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 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.