ch10.doc

[Osborn] chapter 10

Learning Objectives [Number and Title] Learning Objective 1 Identify normal age-related changes of the head, neck, respiratory,

cardiovascular, gastrointestinal, genitourinary, musculoskeletal, integumentary, and neurological systems when completing a nursing assessment.

Learning Objective 2 Explain the rationale for recommended immunizations and screening exams as proposed by the U.S. Preventive Services Task Force and as stated in the chapter for the patient over 65 years of age.

Learning Objective 3 Discuss medications contraindicated in the aging patient as identified by the Beers criteria.

Learning Objective 4 Recognize signs and symptoms of elder mistreatment to determine appropriate referrals.

Learning Objective 5 Differentiate between residential, assisted living, and skilled nursing care in accordance with the type of patient care services provided.

Learning Objective 6 Provide direction and advice to the elderly by describing available innovative housing options.

Learning Objective 7 Explain the implications of technological advancements in providing care to the elderly.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for PracticeCopyright 2010 by Pearson Education, Inc.

1. The results of a 78-year-old patient’s respiratory vital capacity are decreased. The nurse realizes this finding is consistent with:

1. A normal finding in an elderly person.2. Chronic respiratory disease.3. Neurological deterioration.4. Cardiac insufficiency.

Correct Answer: A normal finding in an elderly person.

Rationale: Structural changes of the thoracic cavity are often seen with aging and can affect respiratory function. Kyphosis, which gives the patient a “stooped over” appearance, is caused by osteoporosis and collapse of vertebrae. The chest wall becomes less compliant, and changes in the breathing pattern are seen. Inspiration tends to be shallower, and expiration requires the use of accessory muscles. As a result, the measured vital capacity is decreased, and increased residual capacity will be seen if pulmonary function tests are conducted. There is not enough information to determine if this patient has chronic respiratory disease, neurological deterioration, or cardiac insufficiency.

Cognitive Level: ApplyingNursing Process: Assessment Client Need: Health Promotion and MaintenanceLO: 1


2. An elderly female patient tells the nurse that she is having trouble “holding her water” and doesn’t want to drink fluids anymore. Which of the following does this information provide to the nurse?

1. The patient is experiencing incontinence.2. The patient has a urinary tract infection.3. The patient has a reduced thirst reflex.4. The patient needs estrogen cream.

Correct Answer: The patient is experiencing incontinence.

Rationale: One common disorder seen in the genitourinary tract of the elderly is incontinence. Incontinence occurs when urine exceeds the bladder’s capacity. There is not enough evidence to support the patient having a urinary tract infection. The patient states that she does not want to drink fluids, which would not support a reduced thirst reflex. The use of estrogen cream would be indicated for atrophic vaginitis or a decrease of estrogen in the vaginal tissues.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 1


3. An elderly female patient has a sudden onset of delirium during the first night of hospitalization. This episode suggests to the nurse:

1. The cause has to be determined immediately because it can signal another health problem.2. The patient has Alzheimer’s disease.3. The patient is dehydrated.4. The patient has an infection.

Correct Answer: The cause has to be determined immediately because it can signal another health problem.

Rationale: The patient’s onset of delirium should be investigated because it can signal another health problem. Delirium is a sudden, fluctuating, and usually reversible cognitive disorder characterized by a disturbance in consciousness that develops over a short period of time. It is an abnormal mental state, not a disease, and usually a sign of a newly developed disorder that affects about one-third of hospitalized people over the age of 70. There is not enough evidence to suggest that the patient has Alzheimer’s disease or is dehydrated or has an infection.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Health Promotion and MaintenanceLO: 1


4. The nurse is planning care for a 70-year-old patient. Which of the following screenings should be included in this patient’s care?

1. Annual PSA test and digital rectal exam 2. Biannual eye examinations3. Hearing test every 5 years4. Testing for fecal occult blood every 5 years

Correct Answer: Annual PSA test and digital rectal exam

Rationale: The USPSTF recommends a yearly prostate surface antigen (PSA) test and a digital rectal exam (DRE) in males age 65 and older. The USPSTF recommends visual screening and full eye exam on an annual basis for all individuals age 65 and older. Hearing loss is the most common sensory impairment in the older adult. The USPSTF recommends hearing impairment screening on a yearly basis for all individuals age 65 and older. For those age 65 and older, fecal occult blood testing is recommended yearly, sigmoidoscopy every 5 years, and colonoscopy every 10 years.

Cognitive Level: ApplyingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 2


5. A 68-year-old female patient has had a complete hysterectomy including the removal of the cervix. The nurse realizes that long-term screening of this patient would include:

1. Pap smears no longer needed.2. Annual Pap smears.3. Pap smears every 3 years.4. Annual Pap smears until a negative and then every 3 years.

Correct Answer: Pap smears no longer needed.

Rationale: Women without a cervix should not have Pap smears. The USPSTF recommends a Pap smear at least every 3 years in women age 65 and older. However, Pap smears can be stopped after age 65 if there is one negative result at age 65 and the woman is considered at low risk.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 2


6. An 85-year-old male patient is aware of the need for a colonoscopy; however, he has a history of severe electrolyte imbalances associated with bowel preps for diagnostic tests. The nurse realizes that this patient should probably:

1. Talk to his doctor about not having the colonoscopy because the prep might be harmful.2. Have the colonoscopy and take medication afterward for the electrolyte imbalances.3. Wait a year and have the colonoscopy done then.4. Have a flexible sigmoidoscopy instead.

Correct Answer: Talk to his doctor about not having the colonoscopy because the prep might be harmful.

Rationale: The age to discontinue colorectal cancer screening is unknown; however, the burden of screening may outweigh the potential benefits in patients with advanced age and comorbid conditions that limit life expectancy. The patient should discuss the benefits and potential harms associated with the colonoscopy with his health care provider. There is not enough information to determine that the patient should have the colonoscopy and be treated for electrolyte imbalances afterward. It is not a recommendation to wait a year and have the colonoscopy done then. It is not a U.S. Preventive Services Task Force recommendation to substitute a flexible sigmoidoscopy for a colonoscopy.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Health Promotion and MaintenanceLO: 2


7. A 72-year-old patient wants to know where her digoxin pill is because she always takes it for her heart. Which of the following is the best response by the nurse?

1. “The health care provider will likely order a different heart medication pill.”2. “Digoxin doesn’t work as well as it used to.”3. “Digoxin is a bad medication to take.”4. “Digoxin is no longer manufactured.”

Correct Answer: “The health care provider will likely order a different heart medication pill.”

Rationale: The nurse should inform the patient that the health care provider will order a different heart pill than the digoxin. Digoxin is one of several medications or medication classes that should generally be avoided in persons 65 or older because the medications are ineffective or pose unnecessarily high risks for this group, and safer alternatives exist. While it is true that digoxin is not beneficial to a patient of the client’s age, telling the patient that the medicine does not work as well as it used to does not address what will be done to replace the medication. The nurse should not tell the patient that digoxin is a bad medication to take, nor that digoxin is no longer manufactured.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 3


8. An elderly patient with arthritis is admitted to the unit with acute gastrointestinal bleeding. Which of the following medications taken by the patient is known to cause this type of bleeding?

1. Naproxen2. Clonidine3. Doxazosin4. Amitriptyline

Correct Answer: Naproxen

Rationale: Long-term use of a nonsteroidal anti-inflammatory medication such as Naproxen has the potential to induce gastrointestinal bleeding. Clonidine, Doxazosin, and Amitriptyline do not have the potential to cause gastrointestinal bleeding in the elderly.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Physiological IntegrityLO: 3


9. The nurse is caring for an elderly patient with a history of blood clots. Which of the following medications would be the most effective for this patient?

1. Aspirin2. Ticlopidine3. Amiodarone4. Amitriptyline

Correct Answer: Aspirin

Rationale: Aspirin is better to prevent clotting than ticlopidine in the elderly and is less toxic. Amiodarone is a cardiac medication and is not used to prevent blood clots. Amitriptyline is an antidepressant and is not used to prevent blood clots.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 3


10. A 75-year-old female has been brought into the emergency department. She tells the nurse that her son, who has taken care of her, said he would “be right back,” but she has not seen him for weeks. The nurse realizes this patient is describing:

1. Abandonment.2. Neglect.3. Physical abuse.4. Self-neglect.

Correct Answer: Abandonment.

Rationale: Abandonment is defined as desertion of an elderly person by an individual deemed responsible for the elder’s care. An example is a caregiver leaving a dependent elderly person alone for a week while the caregiver takes a vacation out of town. Neglect is the refusal or failure to fulfill duties to an elder including failing to provide necessary personal care. Physical abuse is the use of force that may result in injury, pain, or impairment. Self-neglect is the refusal or failure of an elderly person to provide him- or herself with adequate food, water, shelter, and health care to the point that personal health or safety is threatened.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Psychosocial Integrity LO: 4


11. A patient tells the nurse that she does not bother to bathe anymore and has no appetite so only eats a few times a week. The nurse realizes this patient is demonstrating signs of:

1. Self-neglect.2. Abandonment.3. Emotional abuse.4. Physical abuse.

Correct Answer: Self-neglect.

Rationale: Self-neglect is the refusal or failure of an elderly person to provide him- or herself with adequate food, water, shelter, and health care to the point that personal health or safety is threatened. This patient is demonstrating signs of self-neglect. Abandonment is defined as desertion of an elderly person by an individual deemed responsible for the elder’s care. Emotional abuse involves inflicting pain or distress through verbal or nonverbal means and includes insults, threats, or forced social isolation. Physical abuse is the use of physical force that may result in injury, pain, or impairment.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Psychosocial IntegrityLO: 4


12. An elderly patient tells the nurse that her son cashes her Social Security checks but tells her he does not have enough money to buy her medications. The nurse should investigate this situation because it could be which of the following?

1. Financial exploitation2. Emotional abuse3. Physical abuse4. Neglect

Correct Answer: Financial exploitation

Rationale: Financial exploitation is defined as misuse of an elder’s money, property, or assets. The patient’s son is cashing the Social Security check but telling her he does not have the money to buy her medications. Emotional abuse involves inflicting pain or distress through verbal or nonverbal means such as insults, threats, or forced social isolation. Physical abuse is the use of physical force that may result in injury, pain, or impairment. Neglect is the refusal or failure to fulfill duties to an elder.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Psychosocial IntegrityLO: 4


13. A patient says that she cannot go home until she can walk independently because she might get “kicked out” of the apartment. The nurse realizes this patient is describing which type of living facility?

1. Assisted living facility2. Adult day care3. Residential living facility4. A skilled nursing care facility

Correct Answer: Assisted living facility

Rationale: Assisted living facilities also are licensed as residential care facilities, but tend to be larger in size, often with 50 to 200 residents. Most require individuals to be ambulatory, use a walker, or be able to propel their wheelchairs to a common dining area. These facilities cannot accommodate individuals who are bedbound. If an individual requires daily nursing care for problems such as pressure ulcers or an indwelling urinary catheter, the facility must apply for a special waiver to allow the person to remain in the facility. Adult day care is a type of program that focuses on socialization among elderly people. A residential living facility, also termed a “board and care” facility, is where care is provided by unlicensed personnel and services such as meals, social activities, housekeeping, laundry, and limited transportation are provided. A skilled nursing care facility provides care for a short period of time to recover from an acute illness or injury after a hospitalization. Care is provided by licensed nurses, and many individuals in this type of facility receive daily physical therapy.

Cognitive Level: ApplyingNursing Process: AssessmentClient Need: Safe Effective Care EnvironmentLO: 5


14. A patient tells the nurse he does not want to go to a nursing home and knows that he needs some help with preparing meals and transportation but does not want to be with “a lot of sick people.” Which of the following should the nurse suggest to this patient?

1. Residential care facility2. Assisted living facility3. Intermediate care facility4. Skilled nursing care facility

Correct Answer: Residential care facility

Rationale: A residential care facility is another term for a facility that offers “board and care” to the residents. Services typically include meals, social activities, housekeeping, laundry services, and limited transportation. This patient is a candidate for a residential care facility. Assisted living facilities have 50 to 200 residents and the residents need to be ambulatory to be able to arrive independently to the dining area. The patient does not want to be with a large number of people, so this type of facility would not be to the patient’s liking. Intermediate care and skilled care facilities are sometimes referred to as “nursing homes.” The patient does not need intermediate or skilled care and is therefore not a candidate for either of these types of facilities.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Physiological IntegrityLO: 5


15. A patient who was a resident at an assisted living facility now has an indwelling urinary catheter. The nurse realizes that which of the following will need to be done to help this patient with living needs?

1. Find out if the facility can apply for a special waiver to permit the patient to return to the assisted living facility.

2. Explain to the patient that he cannot return to the assisted living facility and plan to transfer him to a skilled nursing facility.

3. Explain to the patient that he cannot return to the assisted living facility and plan to transfer him to an intermediate care facility.

4. Ask the patient if any family members would be willing to have him live with them because there is no other facility where he can live.

Correct Answer: Find out if the facility can apply for a special waiver to permit the patient to return to the assisted living facility.

Rationale: Assisted living facilities cannot typically accommodate individuals who need daily nursing care such as an indwelling urinary catheter unless the facility applies for a special waiver to allow the person to remain in the facility. The nurse should find out if the facility can obtain such a waiver. The nurse should not tell the patient that he needs to live in an intermediate care or skilled nursing care facility. The nurse should also not ask the patient if there are any family members he can live with since there is no other place for him to reside.

Cognitive Level: AnalyzingNursing Process: PlanningClient Need: Physiological IntegrityLO: 5


16. A patient adamantly refuses to go to a nursing home. The nurse asks if the patient would be willing to live in a place that has a doctor’s office and other health care providers as well as a place for all residents to congregate and socialize. This nurse is describing which of the following housing options?

1. PACE program2. Green House project3. Elder cohousing4. Team-based primary care in the home

Correct Answer: PACE program

Rationale: The Program of All-inclusive Care for the Elderly (PACE) is based on the British day hospital model of care. PACE programs provide preventive, primary, acute, and long-term services for their enrolled members all under one roof. With a nursing focus, PACE programs include the medical component of care, working from a clinic that is open 5 or 6 days a week, where participants receive care from a clinic provider. These services are offered along with an adult day care program, where participants gather for socialization, recreation, and nursing care. The Green House project describes a group of suburban homes used to house the elderly; meals are served at a community dining table. Elder cohousing is similar to a townhouse or condominium community where all residents enjoy living and doing things together. Team-based primary care in the home is an approach where the patient stays at home and receives health care provider care when needed. The goal is to reduce unnecessary and costly hospitalizations.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Safe Effective Care Environment LO: 6


17. A 76-year-old patient tells the nurse that she is “too young” to go to any kind of nursing home and just wants to live among other people of the same age and activity level to enjoy meals, activities, and social functions. The nurse realizes this patient would be an ideal candidate for which of the following housing options?

1. Elder cohousing2. Team-based primary care3. PACE program4. Green House project

Correct Answer: Elder cohousing

Rationale: Elder cohousing is a concept where elderly individuals live in townhouses or condominiums, with the goal being to encourage aging in the home. Residents enjoy living and doing things together. This patient would be a candidate for elder cohousing. Team-based primary care is an approach to care where health care providers provide 24-hour home visits to the patient when needed. The care is designed to improve the quality of care for those with chronic illnesses. The PACE program provides preventive, primary, acute, and long-term care all within the same location. The PACE program usually provides care in a clinic. The Green House project is a philosophy where elderly patients live in a community of suburban homes and helps reduce the fears of being institutionalized in a nursing home.

Cognitive Level: AnalyzingNursing Process: AssessmentClient Need: Safe, Effective Care EnvironmentLO: 6


18. An elderly patient is eligible for a PACE program. Which of the following should the nurse instruct this patient about the program?

1. Health services are provided in one location that also has social activities. Transportation is provided if you need it.

2. A doctor will come to your home if you become ill.3. It is a housing community where everyone eats their meals together.4. It is a townhouse community where everyone socializes together and you can get home care if

you need it.

Correct Answer: Health services are provided in one location that also has social activities. Transportation is provided if you need it.

Rationale: PACE programs provide health care services in addition to social activities all within one location. Transportation is provided. Health care providers who see patients in their own homes describes team-based primary care. A housing community where everyone eats their meals together describes the Green House project. A townhouse community where the residents socialize and receive home care if needed describes elderly cohousing.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Safe, Effective Care EnvironmentLO: 6


19. A patient tells the nurse that he is moving to a smaller apartment in an assisted living complex, but he has so many boxes of records and receipts that he does not think it will all fit. Which of the following could the nurse suggest to help this patient?

1. Computerize the records.2. Store the records in another facility.3. Discard the records.4. Contact a company to have the records destroyed.

Correct Answer: Computerize the records.

Rationale: Computers continue to offer an opportunity for seniors to apply technology in their lives to simplify record keeping, even when they are no longer able to live at home. Many seniors keep track of their medical care and health history using notebooks, filing systems, or, in some cases, no particular system. Even though storing the records in another facility appears to be an option, it might prove to be costly for the person in addition to not having access to the records when needed. While some of the records and receipts may no longer be needed, the patient may not want to discard them; computerizing the material allows the patient to maintain the information.

Cognitive Level: ApplyingNursing Process: ImplementationClient Need: Safe Effective Care Environment LO: 7


20. An elderly patient told the nurse that her daughter bought her a system that will call for help if she falls. The nurse realizes this patient is describing:

1. Continuous body monitoring.2. Direct dial to the local ambulance company.3. Computerized communication.4. A home alarm system.

Correct Answer: Continuous body monitoring.

Rationale: Continuous body monitoring is available in many different types. Most body monitoring systems include a device that the elderly person wears that communicates to an ambulance company or other family member that the patient needs help or assistance. There is no way of knowing if the patient has direct dialing to the ambulance company. Computerized communication would mean the patient has a computer at home and would need to access it to communicate health needs. The nurse has no way of knowing if the patient has a home alarm system.



21. An elderly female patient tells the nurse that her daughter bought her a small computer that she uses instead of a telephone because the conversation is “typed out in words” and she only has to read what everyone is saying instead of straining to hear the conversation. The nurse realizes this patient is using a:

1. Voice over Internet program.2. Cell phone.3. Smart phone.4. Continuous body monitoring device.

Correct Answer: Voice over Internet program.

Rationale: The patient is describing a Voice over Internet program. A Voice over Internet program involves the use of the Internet instead of a traditional phone line to carry voices. Through this program, communication can occur through either voice or text. This type of technology is not available through the use of a cell phone. A smart phone may or may not include the Voice over Internet technology. Continuous body monitoring devices do not typically include a phone to communicate in text mode.



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