Health Assessment for Older Adults
Which assessment tool is most highly regarded and often used to determine the mental status of the older adult?
a. SPICES Assessment Tool
b. The Mini-Cog
c. Short Test for Dementia
d. MDS 3.0
Correct answer: b
Many assessment tools are available to assist nurses in assessing mental status in older adults. Although others are also well known, the easiest and most highly regarded is the Mini-Cog.
Which of the following factors can contribute to the development of hypothermia in older adults. (Select all that apply.)
a. Decreased muscle tissue
b. Decreased sensory perception of cold
c. Decreased subcutaneous fat
d. Increased metabolism
e. Increased muscle activity
Correct answers: a, b, c
Older adults are highly susceptible to hypothermia for several reasons. Normal changes that occur with aging affect the body’s ability to regulate temperature. Changes in the skin reduce the older person’s ability to perceive dangerously hot or cold environments. Decreased muscle tissue, diminished peripheral circulation, reduced subcutaneous fat, and decreased metabolic rate affect the amount of heat produced and retained by the body.
What action(s) can the nurse take to help increase self-esteem in older adults? (Select all that apply.)
a. Remind the older adult that their life wasn’t as hard as they remember.
b. Schedule time to sit and listen to older adults talk about their concerns.
c. Develop activities that allow older adults to reminisce about their lives.
d. Provide as much help with ADLs as possible to ensure that your patients feel some sense of control.
e. Allow older adults to make choices during the day regarding their schedule and ADLs.
Correct answers: b, c and e
Scheduling time to list to concerns, reminiscence and allowing choices are all interventions to help increase self-esteem. Stories of other patients minimize the older adult’s feelings. Overhelping with ADLs minimizes their independence which can impact self-esteem.
An older woman was widowed about a year ago. What would normal expected behavior at this stage of grieving include?
a. Loss of appetite, sleep changes, and difficulty making decisions
b. Improved energy, interest in new activities and goals
c. Restlessness, poor memory, and irritability
d. Crying, social isolation, lack of concentration
Correct answer: b
A woman widowed about a year ago is most likely in the reorganization stage of grieving. Behaviors for this stage include renewed energy, reorganization of eating and sleeping habits, improved judgment, and renewed interest in activities and goals for the future.
Correct answer: b
A woman widowed about a year ago is most likely in the reorganization stage of grieving. Behaviors for this stage include renewed energy, reorganization of eating and sleeping habits, improved judgment, and renewed interest in activities and goals for the future.
When assessing an older adult, the nurse suspects an increased level of stress while observing which physiologic data? (Select all that apply.)
a. Increased urine production with retention
b. Hyperventilation
c. Warm hands and feet with sweating
d. Headache
e. Elevated pulse and blood pressure
Correct answers: b, d, e
When assigned an older adult, physiologic data observations that would indicate stress include hyperventilation, headache, rapid pulse, elevated blood pressure, loss of appetite, and nausea. Urine production would be decreased, but increased urinary frequency would be seen. The hands and feet of the older adult would be cold and clammy.
When assessing the respiratory system of an older adult, the nurse hears continuous, coarse, low-pitched sounds. How would these sounds be reported?
a. Rales (crackles)
b. Wheezes
c. Friction rub
d. Gurgles (low-pitched wheezes)
Correct answer: d
Gurgles (low-pitched wheezes) are adventitious lung sounds characterized by continuous low-pitched sounds with a coarse snoring quality. They are cleared by coughing and are heard over the trachea and bronchi.
Which of the following manifestations indicate serious heat-related problems? (Select all that apply.)
a. Cramps in the legs
b. Vomiting
c. Heavy perspiration
d. Profound weakness
e. Mental changes
f. Throbbing headache
Correct answers: b, d, e, f
Symptoms of hyperthermia are progressive. Mild, early signs of heat stress include feeling hot, listless, or uncomfortable. Cramps in the legs, arms, and abdomen are early indicators of elevated body temperature. Serious indications of heat-related problems include hot, dry skin without perspiration; tachycardia; chest pain; breathing problems; throbbing headache; dizziness; profound weakness; mental or perceptual changes; vomiting; abdominal cramps; nausea; and diarrhea.
Which behavioral change does the nurse identify that may indicate a patient is depressed? (Select all that apply.)
a. Increased alcohol consumption
b. Changes in daily routines
c. Agitation and irritability
d. Isolation and withdrawal
e. More frequent calls to family
f. Reports of palpitations, trembling, and dry mouth
Correct answers: a, b, c, d
Careful assessment is necessary to recognize problems with depression before they result in other—even more serious—problems. Some changes that warrant further investigation include increased use of alcohol or mood-altering drugs, changes in daily routines, agitation, irritability, isolation, and withdrawal. Complaints of palpitations, trembling and dry mouth suggest anxiety or fear. Calls to the family can be for a variety of reasons but do not necessarily signal depression.
Correct answers: a, b, c, d
Careful assessment is necessary to recognize problems with depression before they result in other—eve
Correct answers: a, b, c, d
Careful assessment is necessary to recognize problems with depression before they result in other—even more serious—problems. Some changes that warrant further investigation include increased use of alcohol or mood-altering drugs, changes in daily routines, agitation, irritability, isolation, and withdrawal. Complaints of palpitations, trembling and dry mouth suggest anxiety or fear. Calls to the family can be for a variety of reasons but do not necessarily signal depression.
n more serious—problems. Some changes that warrant further investigation include increased use of alcohol or mood-altering drugs, changes in daily routines, agitation, irritability, isolation, and withdrawal. Complaints of palpitations, trembling and dry mouth suggest anxiety or fear. Calls to the family can be for a variety of reasons but do not necessarily signal depression.
How do roles change as a person ages? (Select all that apply.)
a. Communication becomes less important as older adults become more dependent on others for care.
b. Relocation to new environment may separate friends, family, and possessions.
c. Roles are lost with the death of spouse or family members.
d. Isolation is a common expected outcome with aging.
e. Retirement brings the loss of one’s previous professional roles or status.
Correct answers: b, c, e
Roles change in many ways as one grows older. Family members may die, and one often loses his or her peer group one by one; retirement and completion of child rearing duties necessitate a change in the career and parenting roles that were once so very important. Although isolation sometimes happens, it is not an expected outcome of aging.
What is the drug most commonly abused by older adults?
a. Cocaine
b. Marijuana
c. Heroin
d. Alcohol.
Correct answer: d
The substances most commonly abused by older adults include tobacco, alcohol, and prescription drugs. Some older adults also abuse illicit street drugs, and this number increasing. Because alcohol is legal, socially acceptable, and readily available, it is the most often abused substance.
When taking a radial pulse of an older adult, the nurse finds it difficult to count a weak and thready pulse. What should the nurse do?
a. Gently apply more pressure with three fingers to obtain a stronger pulse.
b. Take the person’s blood pressure to get the heart rate reading from the machine.
c. Take an apical pulse instead.
d. Document, “Weak, thready pulse, rate N/A.”
. Correct answer: c
Weak, thready pulses are often seen in individuals with fluid volume deficits or electrolyte imbalances; full or bounding pulses may indicate excessive fluid volume. Weakness of a radial pulse may make palpation impossible and necessitate use of the apical route.
The nurse should instruct the nursing assistant who is caring for a patient who is receiving antihypertensive medication to
a. Have at least 2 people assist with ambulation
b. Encourage the patient to stand up slowly from a sitting or lying position
c. Take the blood pressure if the patient complains of diplopia
d. Provide additional salt with the patient’s meals
Correct answer: b
Medications often contribute to falls, and because older adults commonly take one or more medications, their risk for untoward effects is increased. Common types of hazardous medications include sedatives, hypnotics, tranquilizers, diuretics, antihypertensives, and antihistamines. Antihypertensive medications can cause dizziness or fainting with position changes caused by a sudden drop in blood pressure (orthostatic hypotension). Therefore, the patient receiving an antihypertensive should be encouraged to change to a standing position slowly to avoid symptoms of orthostatic hypotension.
Which is true of suicide risk in the older adult?
a. Older adults complete suicide less frequently and less violently than people in other age groups.
b. Women over the age of 80 with chronic illness have the highest suicide risk.
c. Older adults attempt suicide at a higher rate than those in other age groups but are less successful.
d. Suicide is often triggered by pain, a recent loss, or a stressful life event affecting the older adult.
Correct answer: d
Triggers for suicide can include severe emotional or physical pain or a recent loss or stressful event (such as the diagnosis of a terminal disease). Such triggers are present in a large percentage of those who attempt suicide.
What characteristics place an older adult at increased risk for social isolation? (Select all that apply.)
a. Sensory changes
b. Decreased physical mobility
c. Advanced age
d. Limited financial resources
e. Incontinence
f. Physical deformity
g. Belonging to an ethnic minority group
Correct answers: a, b, c, d, e, f
Loneliness, the sense of being alone, is a common problem among older adults. Decreased physical mobility and limited finances can result in potential for social isolation. Those of advanced age may have simply outlived family and friends. Physical changes can restrict an older adult’s ability to move about and make social contacts. Older adults who experience changes in body image from medical issues and/or deformity are also likely to isolate themselves from others. Older adults with cognitive or perceptual problems may isolate themselves because they do not understand what is going on around them.
An older adult tells the nurse that visiting her primary care provider is very stressful for her. What is the best response?
a. Suggest that she postpone the visit and go when she is more relaxed.
b. Tell her that she needs to work on changing her attitude.
c. Help her develop strategies for dealing with her concerns.
d. Stress that it is important and she needs to go and get it over with.
Correct answer: c
People differ in their abilities to cope with stress. Many different coping or defense mechanisms are used as part of day-to-day living. Coping mechanisms are neither good nor bad; they become dysfunctional only when used excessively or inappropriately as a way of avoiding dealing with the stressors. When stressors cannot be avoided, such as visiting a care provider, then confrontational, cognitive, and problem-solving methods of coping can be used. These methods provide effective means of dealing with these types of stressful situations. By helping the older adult develop strategies for dealing with his or her concerns regarding visiting the provider, the nurse is using the problem-solving method. This method helps the person retain control and make a choice that helps reduce stress levels.
When performing an assessment of the gastrointestinal system of an older adult, the nurse would proceed in what order? Place the parts of a gastrointestinal system assessment in sequence from first to last.
a. Palpate abdomen.
b. Observe abdomen for scars.
c. Obtain a health history.
d. Inspect the oral cavity.
e. Auscultate bowel sounds.
Correct answers: c, d, b, e, a
Before starting a physical assessment, the nurse will use interviewing techniques to obtain a health history. Once the history is obtained, the nurse is then ready to proceed to the physical assessment. Complete physical assessment should be done in an orderly manner so that no important observations are missed. Assessment should begin with an overview of the person and proceed with more focused assessments. The most common method of physical assessment is a head-to-toe approach in which the entire body is assessed systematically. An assessment of the gastrointestinal system of an older adult would begin with the health history and then proceed from head to toe, starting with inspection and progressing to auscultation and lastly palpation.
The nurse is aware that the best predictor of an older adult falling is
a. A history of previous falls
b. Use of multiple medications
c. Sensory deficits
d. Alterations in balance
Correct answer: a
Falls are the most common safety problems in older adults. Any fall is the best predictor of future falls. Falling doubles the chance of someone falling again.
Which phrase spoken by an older adult warrants further assessment by the nurse of their self-perception or self-esteem?
a. “I need help now.”
b. “I can’t do anything right anymore.”
c. “I wish I were young again.”
d. “I can’t do things like I used to.”
Correct answer: b
Those who have low self-esteem are likely to display certain characteristic behaviors. These individuals are likely to speak of themselves in negative terms. Statements, such as “Don’t waste your time on me” or “I can’t do anything right”, are indicative of low self-esteem.
Correct answers: a, b, c, d, e, f
Loneliness, the sense of being alone, is a common problem among older adults. Decreased physical mobility and limited finances can result in potential for social isolation. Those of advanced age may have simply outlived family and friends. Physical changes can restrict an older adult’s ability to move about and make social contacts. Older adults who experience changes in body image from medical issues and/or deformity are also likely to isolate themselves from others. Older adults with cognitive or perceptual problems may isolate themselves because they do not understand what is going on around them.
Correct answer: c
Relationships are connections formed by the dynamic interaction of individuals who play interrelated roles. Roles and relationships are maintained through communication with others. Therefore, a person who prefers solitary activities and states that he or she “likes to be left alone” would, most likely, experience relationship issues. The more people are separated from family and friends, the greater the potential for social isolation will be.
The nurse observes an older adult who saves unopened crackers, jelly, and juice packages from the meal tray. How does the nurse interpret this behavior?
a. The patient may want a snack later.
b. It is not appropriate to waste items that are good and useful.
c. Hoarding disorder is a likely diagnosis.
d. The behavior means nothing unless it becomes compulsive.
Correct answer: b
Many of today’s older adults were strongly affected by the depression of the 1930s, either by experiencing it themselves or being raised by parents who experienced the depression. They were taught the value of a dollar and to “waste not, want not.” Many older people are dismayed when nurses or family members throw away food or medical supplies and may attempt to retrieve these items. They may store an excessive number of personal belongings and clutter up their homes until these belongings become a safety hazard.
When performing an interview with an older adult, the nurse should consider physical environment factors by (Select all that apply.)
a. Explaining what will take place during the assessment
b. Ensuring privacy and minimal noise levels
c. Selecting a room with a comfortable temperature
d. Ensuring bright lighting to enable the older adult to see clearly
e. Having the interview done by a nurse of the same gender to build rapport
f. Seeking a location in close proximity to a restroom
Correct answers: a, b, c, f
When performing a patient interview, attention to making the older adult comfortable is important, including providing an environment that is properly illuminated, but not too brightly, as glare can be harsh on the older eyes. Temperature should be comfortable, and it is important to provide for physical needs (e.g., offering the bathroom before beginning) and privacy. One should begin the interview by explaining what to expect. Providing a nurse of the same gender is generally not required but should be accommodated if requested by the patient.
Your team is developing a fall reduction program on your unit. Which intervention(s) would be important to remember when developing such a program? (Select all that apply.)
a. Assess patients for for fall risk factors upon admission and any change in patient condition
b. Identify and remove environmental hazards.
c. Avoid placing signage identifying patient with fall risk to protect privacy.
d. Encourage patient participation in supervised group exercise program.
e. Perform regular medication reviews.
f. Use protective devices on patients with a high fall risk.
. Correct answers: a, b, d, e
Assessment for fall risk factors should be done upon initial assessment when being admitted to a facility, and any time there is a change in patient condition. Removing environmental hazards will help decrease falls caused by tripping. Placing signage indicating someone’s fall risk will help alert the team and visitors of the risk. Both medication reviews and supervised exercise groups have been shown to reduce one’s fall risk. Protective devices (formerly called restraints) should only be used as an intervention of last resort, as they can lead to patient injury or death.
Which intervention is appropriate for an older adult experiencing anxiety or fear?
a. Place the resident in a populated area to make sure that they are not alone.
b. Find a quiet activity in which to involve the person.
c. Discourage talking about their feelings so the anxiety does not get worse.
d. Identify coping strategies that have helped in the past.
e. Provide explanations of any procedures that are being done.
Correct answer: a, d, and e
Diversion by a quiet activity can help decrease anxiety. Identifying coping strategies and explaining procedures can also minimize fear and anxiety. Discouraging talking about their fears can minimize their feelings. Very busy areas can increase anxiety.
What intervention(s) should nurses consider when an older adult is grieving the loss of a role or relationship? (Select all that apply.)
a. Encourage communication with friends and family members.
b. Build a trusting relationship.
c. Assist with all day-to-day activities until grieving is improved.
d. Introduce a variety of new experiences each day to encourage social interaction.
e. Be available to discuss loss without stirring up deep emotions or feelings.
f. Identify support groups, counselors, spiritual advisors, and family members who can provide additional support.
Correct answers: a, b, e, f
Identifying deep feelings and emotions can help assist with the grieving process. Communication and building a trusting relationship are also important. Participation in day-to-day activities should be encouraged; structure is important.
The nurse is caring for a patient who has listed “atheist” on an intake form asking about a preferred religion. Which nursing response to this notation is appropriate?
a. “Do you have any spiritual practices we can assist you with?”
b. “Would you like me to ask our on-call priest to help you?”
c. “Although you don’t believe, I am still praying that a higher power will heal you.”
d. “I guess you won’t be needing the services of our spiritual care department.”
Correct answer: a
When someone has identified themself as an atheist, it is a mistake to assume that they are not spiritual simply because they are not religious. Persons who refuse to identify with religious beliefs may merely indicate that they do not subscribe to beliefs of recognized religious systems. Nurses must be aware of the personal nature of spirituality and respect patients’ choices.