Geriatric Assessment
A comprehensive assessment of an older adult should consider physical health, cognition, mood, function, medications, and what additional factors?
What are social and environmental factors?
A patient reports pain that is sharp, aching, and located in the knee after a fall. What type of pain is most likely?
Somatic pain
What stage of pressure injury presents with intact skin and localized, non-blanchable redness?
Stage I
A CD4 count below what level indicates severe immunosuppression and increased risk for opportunistic infections?
Below 200 cells/mm³
A patient has a potassium level of 6.8 mEq/L. What major cardiac complication is the nurse concerned about?
Cardiac conduction abnormalities and dysrhythmias.
What do ADLs assess in an older adult?
Basic activities of daily living, such as bathing, dressing, toileting, eating, and transferring.
A patient reports cramping abdominal discomfort that is difficult to pinpoint to one specific location. What type of pain is most likely?
Visceral pain
What stage of pressure injury presents as partial-thickness skin loss with a pink or red wound bed?
Stage II
Which patient has the greatest risk for opportunistic infections: CD4 750, 600, 450, or 180 cells/mm³?
180 cells/mm³
What electrolyte imbalance is present when the serum sodium is 124 mEq/L?
Hyponatremia
What do IADLs assess?
More complex activities needed for independent living, such as managing medications, finances, shopping, transportation, and meals.
A patient with diabetes describes burning and shooting pain with numbness and tingling in both feet. What type of pain is most likely?
Neuropathic pain
What stage involves full-thickness skin loss with visible adipose tissue but no exposed muscle, tendon, cartilage, or bone?
Stage III
A patient with an indwelling urinary catheter develops a temperature of 38.5°C and suprapubic discomfort. What should the nurse assess first regarding the catheter?
Whether the catheter is still clinically necessary.
A patient with sodium of 124 mEq/L develops confusion and a headache. Why can these neurologic symptoms occur?
Low sodium can cause water to move into cells, resulting in cellular swelling, particularly in the brain.
An older adult has multiple chronic conditions, recent falls, difficulty managing medications, and lives alone. What areas should be assessed besides physical health?
Cognition/mood, functional status, medication use, and social/environmental factors.
Name several physical manifestations that may indicate prolonged or significant stress.
Tachycardia, muscle tension, headaches, and difficulty sleeping.
Which older adult is at greatest risk for a pressure injury: a healthy 65-year-old scheduled for elective surgery or an 80-year-old who is thin, confused, and has low albumin?
The 80-year-old who is thin, confused, and has low albumin.
Why should the nurse not obtain a urine culture specimen from the drainage bag?
The drainage bag may contain contaminated or colonized urine, making it inappropriate for obtaining a culture specimen.
What electrolyte imbalance is associated with cardiac conduction abnormalities and dysrhythmias and requires continuous ECG monitoring when severe?
Hyperkalemia
What is the overall goal of a comprehensive geriatric assessment?
To identify the older adult’s medical, functional, psychological, social, and environmental needs and guide an individualized care plan.
A patient reports persistent tachycardia, muscle tension, headaches, and insomnia related to ongoing stress. What does this indicate?
Stress is producing significant physiologic effects on the patient.
Name four factors that increase an older adult’s risk for developing a pressure injury.
Advanced age, immobility, poor nutrition/low albumin, and impaired cognition.
A catheterized patient develops a new fever and suprapubic discomfort. What should the nurse do after assessing the catheter?
Notify the provider of the findings and follow the appropriate evaluation/treatment plan.
Interpret the following arterial blood gas:
pH: 7.46
PaCO₂: 47 mmHg
HCO₃⁻: 31 mEq/L
Metabolic alkalosis with respiratory compensation