SATA
1. The nurse is assessing an older patient with elevated plasma triglyceride levels. What other assessment finding leads the nurse to suspect metabolic syndrome? (Select all that apply.)
a. Blood pressure of 148/90 mm Hg
b. A fasting blood glucose of 109 mg/dL
c. Reports of frequent urination
d. Weight measurement of 50 inches
e. HDL level of 52 mg/dL
ANS: A, B, D, E The clinical criteria for metabolic syndrome includes increased waist circumference (population specific) plus any two of the following: (1) blood pressure greater than 129/84 mm Hg or taking hypertension medication, (2) plasma triglyceride levels over 149 mg/dL or taking triglyceride medication, (3) high-density lipid levels less than 40 mg/dL in men or less than 50 mg/dL in women or taking HDL-C medication, (4) fasting glucose greater than 99 mg/dL (including patients with diabetes).
An older patient is admitted for bacterial pneumonia. The only abnormal assessment values include a heart rate of 102 beats per minute, slight cyanosis of the nail beds, and mild confusion. The patients daughter questions the possibility of pneumonia stating, He isnt coughing or having any difficulty breathing. The nurse responds most appropriately by saying:
a. We are lucky to determine the problem in its early stage.
b. Respiratory problems develop only after the infection is well established.
c. People your dads age often lack the muscular strength to cough.
d. Older adults frequently lack the typical signs of a respiratory infection.
ANS: D The characteristic presentation of illness in older adults is more commonly one of blunted or atypical signs and symptoms. Stating, we are lucky to determine the problem does not give any useful information. Respiratory problems are often present early on in younger people. The lack of coughing is not caused by weakness.
An older adult patient reports losing urine when she bends over or gets out of a chair. What type of incontinence does the nurse plan interventions for?
a. Overflow
b. Urge
c. Functional
d. Stress
ANS: D Stress incontinence is commonly seen in older women who involuntarily lose urine as the result of a sudden increase in intraabdominal pressure. Overflow incontinence consists of frequent involuntary losses of small amounts of urine. Functional incontinence is manifested by loss of large volumes of urine because of a lack of awareness of the need to void or a mobility problem. Urge incontinence is accompanied by a sudden urge to void.
The nurse is assessing patients diagnosed with chronic disease processes for the probability of hospitalization because of the exacerbation of related symptoms. The nurse recognizes that the patient with the highest probability is a(n):
a. 72-year-old male with congestive heart failure (CHF).
b. 82-year-old male with type 2 diabetes.
c. 72-year-old female with chronic bronchitis.
d. 82-year-old female with osteoporosis.
ANS: A Individuals with chronic conditions typically have repeated hospitalizations to treat exacerbations of their illness. The most common reasons for hospitalization in older patients are heart disease, cancer, pneumonia, and stroke. The 72-year-old with CHF is at highest risk.
3. The geriatric nurses decision to identify a specific patient as a falls risk is primarily based on the:
a. presence of visual deficiencies and musculoskeletal weakness.
b. results determined by cognitive and physiologic assessment tools.
c. degree of frailty and functional limitation observed.
d. inability to follow instructions and communicate effectively.
ANS: C Research has shown that the individual with frailty and physical functional limitations is at greatest risk for falling.
3. What assessment findings support a diagnosis of hyperthyroidism in the older adult? (Select all that apply.)
a. Tremors
b. Heat intolerance
c. Tachycardia
d. Palpable goiter
e. Atrial fibrillation
ANS: A, D, E The classic geriatric presentation of hyperthyroidism includes tachycardia, fatigue, tremors, and nervousness in contrast to tachycardia, heat intolerance, and fatigue in younger patients. An enlarged, palpable goiter is present in 60% of older adults with hyperthyroidism. The most common complication, occurring in 27% of geriatric hyperthyroid patients, is atrial fibrillation that does not convert back to sinus rhythm when a euthyroid state has been achieved.
A 76-year-old postsurgical diabetic patient has reported feeling dizzy and clammy. The daily serum glucose level shows the patients levels to be within normal limits. The geriatric nurse shows an understanding of established health norms for the older adult when stating:
a. This patients normal may not be within the typical lab norms.
b. Ill ask the lab to rerun the test so we can double-check the results.
c. There must be another reason for the symptoms.
d. Ill compare the patients baseline lab work with todays results.
ANS: A Relying on established norms for laboratory values when analyzing the assessment data of older adults could lead to incorrect conclusions. The nurse should try to determine what the patients normal range is after stabilizing the patient.
A patient has a glomerular filtration rate (GFR) of 19 mL/min/1.73m2 . What assessment findings correlate with this condition? (Select all that apply.)
a. Fatigue
b. Weakness
c. Edema
d. No specific symptoms
e. Headaches
ANS: A, B, C This patient is in stage 4 of chronic kidney disease. Expected assessment findings include weakness, edema, fatigue, hypertension, heart failure, impaired cognition and immune function, dry skin and pruritus, anorexia, nausea, malnutrition, increased bleeding, anemia, peripheral neuropathy, and an overall decreased quality of life. In stages 1 and 2, patients are asymptomatic. Headache is not a finding.
A 73-year-old patient has been diagnosed with congested heart failure (CHF). The nurse provides the greatest support for this patients positive view of self-wellness by presenting information regarding:
a. how to minimize the exacerbation of symptoms.
b. locally available supportive services.
c. the importance of adherence to medical treatment.
d. the need to report symptoms promptly.
ANS: A Many older adults now seek education about health promotion and management of their illness. The nurse can support older adults by teaching self-care management in these areas. The other actions are also valued, but learning how to control symptoms gives patients the feeling of accomplishment
7. An older patient diagnosed with dementia has begun behaviors that increase the risk of falling. The patients son tells the nurse that physical restraints may be used. The nurse responds:
a. Ill document that, so that the staff can use them when necessary.
b. Physical restraints are seldom effective on patients with dementia.
c. The staff will use physical restraints only as a last resort.
d. There are more effective methods to use to help ensure her safety.
ANS: D Physical restraint use does not prevent falls and therefore should never be employed for safety precautions. This is the best explanation because the nurse will then need to explain the other measures that will be taken to keep the patient safe.
2. The nurse working with older adults knows which facts about age-related musculoskeletal changes? (Select all that apply.)
a. Muscle mass decreases, causing atrophy.
b. Myocytes are replaced by fibrous tissue.
c. Vertebral spaces enlarge with fluid retention.
d. Posture and gait change, leading to fall risk.
e. Men become bowlegged and waddle.
ANS: A, B, D With age, muscle mass decreases, myocytes are replaced with fibrous tissue, and posture and gait change. Vertebral spaces narrow, leading to shrinkage. Women become bowlegged and develop a waddling gait.
An older patient is reluctant to report multiple vague signs and symptoms, including lethargy, incontinence, and weight loss that have persisted for 6 weeks. The nurse recognizes that such symptoms place the patient at great risk for:
a. viral infection.
b. disorientation.
c. malnutrition.
d. physical frailty.
ANS: D Self-reported vague signs and symptoms such as lethargy, incontinence, decreased appetite, and weight loss can be indicators of functional impairment. Ignoring older adults vague symptoms exposes them to an increased risk of physical frailty (impairments in the physical abilities).
A male patient has benign prostatic enlargement. He is at risk for what type of acute kidney injury?
a. Prerenal
b. Intrarenal
c. Postrenal
d. Combined form
ANS: C BPH would place this patient at risk for postrenal failure. Prerenal failure is often the result of decreased cardiac output or acute fluid volume loss. Intrarenal failure consists of damage to the actual nephrocytes.
To best assist an older adult patient to cope with a new diagnosis of chronic renal failure, the nurse:
a. asks the patient to describe her usual coping strategies.
b. provides the patient with descriptions of new coping strategies.
c. initiates discussions with the patient to explain the disease.
d. offers to arrange a meeting with another patient with the diagnosis.
ANS: C Understanding the illness and what to expect is directly related to the ability to cope. After the patient has information, the nurse can then assess psychosocial systems.
A cognitively impaired older adult patient is a resident at a skilled nursing facility. The nurse acting as the patients advocate will consistently address the patients risk for injury issues based on:
a. preferences generally expressed by cognitive patients.
b. professional nursing knowledge.
c. implementation of the less restrictive intervention.
d. established facility policies and procedures.
ANS: D If patients are unable to make informed choices and no family members are available, the nurse must use nursing judgment and follow an acceptable standard of care to promote safety and security that are defined and described in official policies and procedure manuals. The preferences of other patients do not indicate this patients preferences. Professional nursing knowledge can be used but must remain within the policies. Less restrictive interventions are preferable, but again actions need to conform to policy.
To assess for osteoarthritis in an older adult patient, the nurse asks which of the following questions? (Select all that apply.)
a. Do you have pain in your finger joints?
b. Do your knees crackle when you bend down?
c. Does you get dizzy when you turn your head?
d. Does it hurt when you get up from a chair?
e. Does your back creak when you bend over?
ANS: A, B, D, E The distal interphalangeals, proximal interphalangeals, knees, hips, and spine are the joints most commonly affected by osteoarthritis. These would be the questions most likely to suggest osteoarthritis. Getting dizzy is not a manifestation of this disorder.
The nurse admitting a debilitated patient to a long-term care facility initially assesses the patient using the Katz Index. The student asks why the nurse chose that tool. What answer by the nurse is best?
a. It is quick and simple for a baseline.
b. The Katz Index is mandated by Medicare.
c. It is comprehensive in nature.
d. It shows functioning in 12 areas.
ANS: A The Katz Index takes only about 5 minutes to complete and rates patients as to whether they are totally independent or dependent in six basic functions. For the debilitated patient who will tire easily, this is the best choice. It is not mandated by Medicare, it is not as comprehensive as other tools, and it only shows functioning in 6 areas.
A patient treats chronic kidney failure with peritoneal dialysis. The patient notes the fluid draining out of the abdomen is cloudy and foul smelling. What action by the nurse is best?
a. Assess the patient for other signs of infection. b. Document the findings in the patients chart.
c. Call the rapid response team immediately.
d. Request a prescription for an antibiotic.
ANS: A One of the complications of peritoneal dialysis is infection in the peritoneal space, or peritonitis. The nurse should fully assess the patient for infection and notify the provider. Documentation should occur, but the nurse needs to take action first. The rapid response team is not needed. Antibiotics will probably be used to treat the infection.
2. The student learning about chronic disease and illness in the older population learns which facts about this situation? (Select all that apply.)
a. One in two adults, or more than 133,000 Americans, has a chronic condition.
b. Chronic disease is the leading cause of death in those over 65.
c. About 75% of medical costs each year are spent on managing chronic disease.
d. Formerly acute conditions are now manageable chronic diseases..
e. The focus of Americas health care services is now on chronic illness
ANS: A, B, C, D One in two adults has a chronic illness, and these problems are the leading cause of death in those over 65 and the largest cost to our health care system. One reason for this is that formerly acute, possibly fatal, conditions are now manageable as chronic conditions. Americas health care system continues to be focused on acute care.
A patient is brought to the emergency department after an unexplained fall. What actions by the nurse are most appropriate? (Select all that apply.)
a. Placing the patient on a cardiac monitor
b. Obtaining a urine sample for cultures
c. Checking a quick bedside blood glucose
d. Assessing the patient for asthma
e. Performing tests for orthostatic vital signs
ANS: A, B, C, D Common causes of falls include cardiac dysrhythmias, urinary tract infection, hypoglycemia, and dehydration, so the nurse assesses for these conditions. Asthma most likely is not an issue.
A client who is found unresponsive has arterial blood gases drawn and the results indicate the following: pH is 7.12, Pco2 is 90 mm Hg, and HCO3- is 22 mEq/L. The nurse interprets the results as indicating which condition?
1. Metabolic acidosis with compensation
2. Respiratory acidosis with compensation
3. Metabolic acidosis without compensation
4. Respiratory acidosis without compensation
4-Rationale: The acid-base disturbance is respiratory acidosis without compensation. The normal pH is 7.35 to 7.45. The normal Pco2 is 35 to 45 mm Hg. In respiratory acidosis the pH is decreased and the Pco2 is elevated. The normal bicarbonate (HCO3-) level is 22 to 27 mEq/L. Because the bicarbonate is still within normal limits, the kidneys have not has time to adjust for this acid-base disturbance. In addition, the pH is not within normal limits. Therefore the condition is without compensation. The remaining options are incorrect interpretations.
2. The nurse using the SPICES model to assess older patients collects data on which topics? (Select all that apply.)
a. Sleep disorders
b. Problems with eating
c. Incontinence
d. Falls
e. Social situations
ANS: A, B, C, D SPICES stands for sleep disorders, problems with eating or feeding, incontinence, confusion, evidence of falls, and skin breakdown.
When preparing educational information regarding benign prostatic hyperplasia (BPH) for a group of older male patients, the nurse includes which of the following? (Select all that apply.)
a. Eighty percent of males experience the symptoms by age 80.
b. Diabetes mellitus is a risk factor.
c. It is only as the prostate enlarges that symptoms occur.
d. The resulting urinary retention can cause urinary tract infections.
e. Symptoms are a result of urethral obstruction.
ANS: A, C, D, E Approximately 80% of men may be diagnosed with BPH by the age of 80. In early prostatic enlargement, the patient may be asymptomatic because the muscles may initially compensate for increased urethral resistance. As the prostate gland enlarges, the patient begins to manifest symptoms of an obstructive process. The symptoms may include hesitancy, a decrease in the force of the urinary stream, terminal dribbling, a sensation of a full bladder after voiding, and urinary retention. Urethral obstruction may cause urinary stasis, UTIs, hydronephrosis, and renal calculi. Diabetes is not a risk factor
3. The nurse understands what about the Americans with Disabilities Act? (Select all that apply.)
a. It outlaws discrimination on the job because of disabilities.
b. It requires state governments to fund disability services.
c. It prohibits discrimination in government services to the disabled.
d. It requires all buildings to be retrofitted to allow access.
e. It provides funding for barrier-free buildings and parks.
ANS: A, C The ADA outlawed discrimination on the basis of disability in employment, in programs and services provided by state and local governments, and in the provision of goods and services provided by private companies and commercial facilities. It does not mandate government payment for disability services, require buildings to be retrofitted, or provide funding for barrier-free facilities.
When assessing an older adult for intrinsic risk factors for falls, the nurse is particularly interested in which of the following? (Select all that apply.)
a. An unsteady gait when asked to walk without assistance
b. The presence of throw rugs in the living room of the home
c. The patients report that he wears corrective lenses
d. An inability to see changes in height because of poor lighting
e. Evidence of short-term memory deficiency
ANS: A, C, E The most salient observations for intrinsic risk factors for falls relate to gait, balance, stability, and cognition. Intrinsic risk factors are a combination of age-related changes and concurrent disease. The other two options are extrinsic factors, which relate to the environment.