Chapter 31

Question 1

1.	A student nurse visiting a senior center says, “It’s depressing to see these old people. They are weak and frail. I doubt any of them can engage in a discussion.” The student is expressing
a.
reality.
b.
ageism.
c.
empathy.
d.
vulnerability.

Answer 1

ANS: B
Ageism is a bias against older people because of their age. None of the other options applies to the ideas expressed by the student.

Question 2

2. A nurse plans an educational program for staff of a home health agency specializing in care of the elderly. Which topic is the highest priority to include?
   a.
   Pain assessment techniques for older adults
   b.
   Psychosocial stimulation for those who live alone
   c.
   Preparation of psychiatric advance directives in the elderly
   d.
   Ways to manage disinhibition in elderly persons with dementia

Answer 2

ANS: A
The topic of greatest immediacy is the assessment of pain in older adults. Unmanaged pain can precipitate other problems, such as substance abuse and depression. Elderly patients are less likely to be accurately diagnosed and adequately treated for pain. The distracters are unrelated or of lesser importance.

Question 3

3. Select the best comment for a nurse to begin an interview with an elderly patient.
   a.
   “I am a nurse. Are you familiar with what nurses do?”
   b.
   “Hello. I am going to ask you some questions to get to know you better.”
   c.
   “You look comfortable and ready to participate in an admission interview. Shall we get started?”
   d.
   “Hello. My name is _______ and I am a nurse. How you would like to be addressed by staff?”

Answer 3

ANS: D
The correct opening identifies the nurse’s role and politely seeks direction for addressing the patient in a way that will make him or her comfortable. This is particularly important when a considerable age difference exists between the nurse and the patient. The nurse should address patients by name and not assume patients want to be called by a first name. The nurse should always introduce self.

Question 4

4.	Which information is most important to obtain during assessment of an older adult diagnosed with health problems?
a.
Functional ability and emotional status
b.
Chronological age and sexual function
c.
Economic status and sources of income
d.
Developmental history, interests, and activities

Answer 4

ANS: A
Information related to functional ability and emotional status provides an overview of a patient’s problems and abilities. It guides selection of interventions and services to meet identified needs. The distracters reflect information of relevance, but are not of highest priority.

Question 5

5. A 75-year-old patient comes to the clinic reporting frequent headaches. As the nurse begins the interaction, which action is most important?
   a.
   Complete a neurological assessment.
   b.
   Determine whether the patient can hear as the nurse speaks.
   c.
   Suggest that the patient lie down in a darkened room for a few minutes.
   d.
   Administer medication to relieve the patient’s pain before continuing the assessment.

Answer 5

ANS: B
Before proceeding with any further assessment, the nurse should assess the patient’s ability to hear questions. Impaired hearing could lead to inaccurate answers.

Question 6

6. Which statement about aging provides the best rationale for focused assessment of elderly patients?
   a.
   The elderly are usually socially isolated and lonely.
   b.
   Vision, hearing, touch, taste, and smell decline with age.
   c.
   The majority of elderly patients have some form of early dementia.
   d.
   As people age, thinking becomes more rigid and learning is impaired.

Answer 6

ANS: B
Only the key is a true statement. It cues the nurse to assess sensory function in the elderly patient. Correcting vision and hearing are critical to providing safe care. The distracters are myths about aging.

Question 7

7. A nurse assesses an elderly patient. The nurse should complete the Geriatric Depression Scale if the patient answers which question affirmatively.
   a.
   “Would you say your mood is often sad?”
   b.
   “Are you having any trouble with your memory?”
   c.
   “Have you noticed an increase in your alcohol use?”
   d.
   “Do you often experience moderate to severe pain?”

Answer 7

ANS: A
Feeling low may be a symptom of depression. Low moods occurring with regularity should signal the need for further assessment for other symptoms of depression. The other options do not focus on mood.

Question 8

8.	A health care provider writes these new prescriptions for a resident in a skilled nursing facility: 2 g sodium diet, restraint as needed, limit fluids to 1800 mL daily, continue antihypertensive medication, milk of magnesia 30 mL PO once if no bowel movement for 3 days. The nurse should
a.
question the fluid restriction.
b.
question the order for restraint.
c.
transcribe the prescriptions as written.
d.
assess the resident’s bowel elimination.

Answer 8

ANS: B
Restraints may be imposed only on a written order of the health care provider that specifies the duration during which the restraints can be used. The Joint Commission guidelines and Omnibus Budget Reconciliation Act regulations also mandate a number of other conditions that must be considered and documented before restraints are used. The other prescriptions are appropriate.

Question 9

9. An elderly patient must be physically restrained. Who is responsible for the patient’s safety?
   a.
   The nurse assigned to care for the patient
   b.
   Unlicensed assistive personnel who apply the restraint
   c.
   Family member who agrees to application of the restraint
   d.
   Health care provider who prescribed application of restraint

Answer 9

ANS: A
Although restraint is prescribed by a health care provider, the restraint is a measure carried out by nursing staff. The nurse caring for the patient is responsible for safe application of restraining devices and for providing safe care while the patient is restrained. Nurses may delegate the application of restraining devices and the care of the patient in restraint, but the nurse remains responsible for outcomes. Even when family agree to restraint, nurses are responsible for providing safe outcomes.

Question 10

10. A new nurse asks, “My elderly patient’s CT scan of the head shows many Lewy bodies are present. What should I do about assessing for pain?” Select the best response from the nurse manager.
    a.
    “Ask the patient’s family if they think the patient is experiencing pain.”
    b.
    “Use a visual analog scale to help the patient determine the presence and severity of pain.”
    c.
    “There are special scales for assessing patients with dementia. Let’s review how to use them.”
    d.
    “The perception of pain is diminished by this type of dementia. Focus your assessment on the patient’s mental status.”

Answer 10

ANS: C
Lewy bodies associated with dementia [Faculty note: Lewy bodies are defined and addressed in Chapter 23]. There are special scales to assess the presence and severity of pain in patients with dementia. The Pain Assessment in Advanced Dementia Scale evaluates breathing, negative vocalizations, body language, and consolability. A patient with dementia would be unable to use a visual analog scale. The family may be able to help the nurse gain perspective about the pain, but this strategy alone is inadequate. The other distracters are myths.

Question 11

11. An advance directive gives legally binding direction for health care interventions when a patient
    a.
    has a new diagnosis of cancer.
    b.
    is diagnosed with Parkinson’s disease.
    c.
    is unable to make decisions for self because of illness.
    d.
    diagnosed with amyotrophic lateral sclerosis is unable to speak.

Answer 11

ANS: C
Advance directives are invoked when patients are unable to make their own health care decisions. The correct response is the most global answer. A diagnosis of cancer or Parkinson’s disease does not mean the patient is unable to make a decision. For a patient with amyotrophic lateral sclerosis, there are other ways to communicate beyond speaking.

Question 12

12. A patient asks, “What advantage does a durable power of attorney for health care have over a living will?” The nurse should reply, “A durable power of attorney for health care
    a.
    gives your agent authority to make decisions during any illness if you are incapacitated.”
    b.
    can be given only to a relative, usually the next of kin, who has your best interests at heart.”
    c.
    can be used only if you have a terminal illness and become incapacitated.”
    d.
    cannot be implemented until 30 days after the documents are signed.”

Answer 12

ANS: A
A durable power of attorney for health care is an instrument that appoints a person other than a health care provider to act as an individual’s agent in the event that he or she is unable to make medical decisions. No waiting period is required for it to become effective, and the individual does not have to be terminally ill or incompetent for the person appointed to act on the individual’s behalf.

Question 13

13.	A physically frail elderly patient with mild cognitive impairments needs services of a facility that can provide supervision and safety as well as recreation and social interaction. The family cares for this patient during the evening and night. Which type of facility should the nurse suggest to meet this patient’s needs?
a.
Adult day care program
b.
Skilled nursing facility
c.
Partial hospitalization
d.
Group home

Answer 13

ANS: A
A day care program provides recreation and social interaction as well as supervision in a safe environment. Nursing, medical, and rehabilitative care are usually not provided. Skilled nursing facilities go beyond meeting recreational and social needs by providing medical interventions and nursing and rehabilitation services on a 24-hour basis. Partial hospitalization provides acute psychiatric hospital programs. A group home is inappropriate and would not meet the patient’s needs.

Question 14

14.	A 79-year-old white male tells a nurse, “I have felt very sad lately. I do not have much to live for. My family and friends are all dead, and my own health is failing.” The nurse should analyze this comment as
a.
normal pessimism of the elderly.
b.
evidence of risks for suicide.
c.
a call for sympathy.
d.
normal grieving.

Answer 14

ANS: B
The patient describes loss of significant others, economic security, and health. He describes mood alteration and voices the thought that he has little to live for. Combined with his age, sex, and single status, each is a risk factor for suicide. Elderly white males have the highest risk for completed suicide.

Question 15

15. In a sad voice, an elderly patient tells the nurse of the recent deaths of a spouse and close friend. The patient has no other family and only a few acquaintances in the community. The nurse’s priority is to determine whether which nursing diagnosis applies to this patient?
    a.
    Risk for suicide related to recent deaths of significant others
    b.
    Anxiety related to sudden and abrupt lifestyle changes
    c.
    Social isolation related to loss of existing family
    d.
    Spiritual distress related to anger with God

Answer 15

ANS: A
The patient appears to be experiencing normal grief related to the loss of her family, but because of age and social isolation, the risk for suicide should be determined and has high priority. No defining characteristics exist for the diagnoses of anxiety or spiritual distress. The patient’s social isolation is important, but the risk for suicide has higher priority.

Question 16

16. When making a distinction as to whether an elderly patient has confusion related to delirium or another problem, what information would be of particular value?
    a.
    Evidence of spasticity or flaccidity
    b.
    The patient’s level of motor activity
    c.
    Medications the patient has recently taken
    d.
    Level of preoccupation with somatic symptoms

Answer 16

ANS: C
Delirium in the elderly produces symptoms of confusion. Medication interactions or adverse reactions are often a cause. The distracters do not give information important for delirium.

Question 17

17. An 85-year-old has difficulty walking after a knee replacement. The patient tells the nurse, “It’s awful to be old. Every day is a struggle. No one cares about old people.” Select the nurse’s best response.
    a.
    “Everyone here cares about old people. That’s why we work here.”
    b.
    “It sounds like you’re having a difficult time. Tell me about it.”
    c.
    “Let’s not focus on the negative. Tell me something good.”
    d.
    “You are still able to get around, and your mind is alert.”

Answer 17

ANS: B
The nurse uses empathetic understanding to permit the patient to express frustration and clarify her “struggle” for the nurse. The distracters block communication.

Question 18

18.	A 76-year-old is indifferent and responds to others only when they initiate an interaction. What form of group therapy would be most useful to promote resocialization?
a.
Orientation
b.
Activity group
c.
Psychotherapy
d.
Reminiscence

Answer 18

ANS: D
Reminiscence therapy in a group setting can help to resocialize regressed and apathetic patients. The nurse can encourage discussion about past pleasant events or memories: first car, favorite memory from school, favorite band or song, seasonal activities growing up, etc. Assisting to evoke pleasant feelings or memories is an effective method to improve mood particularly in those with memory impairment. Group psychotherapy would not be effective for this patient. An activity group does not address the patient’s problem. Orientation groups can exacerbate a patient’s distress.

Question 19

19. A nurse assesses four patients between the ages of 70 and 80. Which patient has the highest risk for alcohol abuse? The patient who
    a.
    consumes 1 glass of wine nightly with dinner.
    b.
    began drinking alcohol daily after retirement and says, “A few drinks keep my mind off my arthritis.”
    c.
    drank socially throughout adult life and continues this pattern, saying “I’ve earned the right to do as I please.”
    d.
    abused alcohol between the ages of 25 and 40 but now abstains and occasionally attends Alcoholics Anonymous (AA).

Answer 19

ANS: B
Alcohol abuse and dependence can develop at any age, and the geriatric population is particularly at risk. Losses, such as retirement, widowhood, and loneliness, are often related. The distracters describe patients with a lower risk for alcohol abuse.

Question 20

20. A nurse wants to assess for suicidal ideation in an elderly patient. Select the best question to begin this assessment.
    a.
    “Are there any things going on in your life that would cause you to consider suicide?”
    b.
    “What are your beliefs about a person’s right to take his or her own life?”
    c.
    “Do you think you are vulnerable to developing a depressed mood?”
    d.
    “If you felt suicidal, would you tell someone about your feelings?”

Answer 20

ANS: B
This question is clear, direct, and respectful. It will produce information relative to the acceptability of suicide as an option to the patient. If the patient deems suicide unacceptable, no further assessment is necessary. If the patient deems suicide as acceptable, the nurse can continue to assess intent, plan, means to carry out the plan, lethality of the chosen method, and so forth. The other options are less direct, may produce responses that may be unclear, or are appropriate for later in this discussion.

Question 21

21. A community health nurse visits an elderly person whose spouse died 6 months ago. Two vodka bottles are in the trash. When the nurse asks about alcohol use, this person says, “I get lonely and drink a little to help me forget.” Select the nurse’s most therapeutic intervention.
    a.
    Assess whether this patient is drinking and driving.
    b.
    Advise the person not to drink alone because the risks for injury increase.
    c.
    Teach the person about risks for alcoholism and suggest other coping strategies.
    d.
    Arrange for the person to attend an AA meeting for older adults.

Answer 21

ANS: D
This person needs help with alcohol abuse as well as social involvement. An AA meeting for older adults will provide an opportunity for peer bonding as well as strategies for coping with stress without abusing alcohol. The distracters will not be therapeutic in this instance.

Question 22

22.	Discharge planning begins for an elderly patient hospitalized for 2 weeks diagnosed with major depressive disorder. The patient needs ongoing assessment and socialization opportunities as well as education about medication and relapse prevention. The patient lives with a daughter, who works during the week. Select the best referral for this patient.
a.
Behavioral health home care
b.
A skilled nursing facility
c.
Partial hospitalization
d.
A halfway house

Answer 22

ANS: C
Partial hospitalization will provide services the patient needs as well as give supervision and meals to the patient while the daughter is at work. Home care would not provide socialization. The patient does not need the intensity of a skilled nursing facility. A halfway house provides 24-hour care and usually expects involvement in off-campus programs.

Question 23

23.	A patient living in community housing for the elderly says, “I don’t go to the senior citizen’s club. They play cards and talk about the past because that’s all they can do.” The nurse analyzes these remarks to represent
a.
failure to achieve developmental tasks.
b.
thinking associated with ageism.
c.
hypercritical behavior.
d.
paranoid thinking.

Answer 23

ANS: B
Ageism is negative stereotyping and devaluation of people based on their age. Older adults might be as guilty of ageism as younger individuals. The other options are not substantiated by the information given in the scenario.

Question 24

24.	A nurse plans a staff education program for employees of a senior living community. Which topic has priority?
a.
Late-onset schizophrenia
b.
Depression and suicide
c.
Dementia
d.
Delirium

Answer 24

ANS: B
Older Americans frequently experience undiagnosed depression and are disproportionately more likely to commit suicide. Educating staff about signs and symptoms of high-risk patients and early intervention strategies will decrease morbidity and mortality. The other conditions have a lower prevalence.

Question 25

25. An older adult patient was diagnosed with schizophrenia at age 18. A nurse at the outpatient medication clinic interviews this patient. Which communication strategy will be most helpful?
    a.
    Ask questions that can be answered with “yes” or “no.”
    b.
    Ask clear, simple questions using concrete language.
    c.
    Use silence often and let the patient take the lead.
    d.
    Use open-ended, indirect questions.

Answer 25

ANS: B
Communication with individuals with a long history of schizophrenia might be difficult because of the individual’s various thought disorders. The nurse can be most effective by using simple language, keeping to concrete concepts, and clarifying and validating as needed. The nurse needs more information than “yes” or “no” questions will provide.

Question 26

26. An elderly patient brings a bag of medications to the clinic. The nurse finds bottles of medications as well as assorted pills in no containers in the bag. What is the nurse’s priority action?
    a.
    Dispose of all medications that are not in properly labeled bottles.
    b.
    Confer with a family member about the patient’s management of medication.
    c.
    Engage the patient in education about safe storage and labeling of medication.
    d.
    Ask the patient to name the purpose and date of expiration of each medication not in a bottle.

Answer 26

ANS: C
The patient needs medication education and help with proper, safe, and consistent labeling of medications. There is no evidence that the patient cannot self-administer medication. The nurse does not have the authority to dispose of the patient’s property. The nurse would first need to obtain the patient’s consent to confer with family. While the patient may be able to name the purpose of each unbottled medication, naming the expiration date is unlikely and may frustrate the patient.

Question 27

27. The highest priority for assessment by nurses caring for older adults who self-administer medications is
    a.
    use of multiple drugs with anticholinergic effects.
    b.
    overuse of medications for erectile dysfunction.
    c.
    missed doses of medications for arthritis.
    d.
    trading medications with acquaintances.

Answer 27

ANS: A
Anticholinergic effects are cumulative in older adults and often have adverse consequences related to accidents and injuries. The distracters may be relevant but are not the highest priority.

Question 28

28. A nurse and social worker co-lead a reminiscence group for eight old-old and centenarian adults. Which activity is appropriate to include in the group?
    a.
    Mild aerobic exercise
    b.
    Singing a song from World War II
    c.
    Discussing national leadership during the Vietnam War
    d.
    Identifying the most troubling story in today’s newspaper

Answer 28

ANS: B
Old-old adults and centenarians are persons 85 to 104 years of age. They were young people during World War II. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group or reminiscence.

Question 29

29. A nurse and social worker co-lead a reminiscence group for eight young-old adults. Which activity is most appropriate to include in the group?
    a.
    Mild aerobic exercise
    b.
    Singing a song from World War II
    c.
    Discussing national leadership during the Vietnam War
    d.
    Identifying the most troubling story in today’s newspaper

Answer 29

ANS: C
Young-old adults are persons 65 to 75 years of age. These adults were attuned to conflicts in national leadership associated with the Vietnam War. Reminiscence groups share memories of the past. The incorrect options are less relevant to this age group or reminiscence.

Question 30

1. A nurse leads a staff development session about ageism among health care workers. What information should the nurse include about the consequences of ageism? (Select all that apply.)
   a.
   Failure of the elderly to receive necessary medical information
   b.
   Development of public policy that discriminates against the elderly
   c.
   Staff shortages because caregivers prefer working with younger adults
   d.
   The perception that elderly consume a smaller share of medical resources
   e.
   More ancillary than professional personnel discriminate with regard to age

Answer 30

ANS: A, B, C
Because of society’s negative stereotyping of the elderly as having little to offer, some staff persons avoid working with older patients. Staff shortages in long-term care are common. Elderly patients are often provided less information about their conditions and fewer treatment options than younger patients are because some health care staff members perceive them as less able to understand. This problem exists among both professional and ancillary personnel. Public policy discriminates against programs for the elderly. Anger exists because the elderly are perceived to consume a disproportionately large share of medical resources.

Question 31

2.	A nurse assessing an elderly patient for depression and suicide potential should include questions about mood as well as (Select all that apply.)
a.
personal hygiene.
b.
increased appetite.
c.
sleep pattern changes.
d.
evidence of grandiosity.
e.
increased concerns with bodily functions.

Answer 31

ANS: A, C, E
The correct responses relate to symptoms often noted in elderly patients with depression. Somatic symptoms are often present but missed by nurses as related to depression. Anorexia, rather than hyperphagia, occurs in major depression. Grandiosity is associated with bipolar disorder.

Question 32

3.	Which assessment findings would alert the nurse that an older patient may have an increased risk for development of geriatric alcohol abuse? (Select all that apply.)
a.
Mild recent memory impairment
b.
Eighth grade education
c.
Death of spouse
d.
Retirement
e.
Loneliness

Answer 32

ANS: B, C, D, E
The geriatric problem drinker begins drinking in later life, often in response to stressors such as retirement, loss of spouse, and loneliness. Once the demands of job, career, and care of a family and household are gone, the structure of daily life is disrupted. Mild cognitive impairment is not a predisposing factor in the development of geriatric problem drinking. Other risk factors include less than a high school education, smoking, low income, and male gender.

Question 33

4. Which remarks by a 72-year-old patient should prompt the nurse to assess for depression? (Select all that apply.)
   a.
   “Lately I have had a lot of aches and pains and just haven’t felt very well.”
   b.
   “People are in and out of my room all day and all night taking my things.”
   c.
   “Don’t ask me to eat. I can’t because my stomach is upset all the time.”
   d.
   “I’m eating more than usual, and I am sleeping about 6 hours a night.”
   e.
   “Life seems more organized now that I don’t live in my own home.”

Answer 33

ANS: A, B, C
Any of the remarks listed as correct should be enough to trigger use of an assessment tool for depression. Somatic symptoms, delusions of persecution, and nihilistic delusions are more common in late-onset depression than in early-onset depression. The distracters do not suggest symptoms of depression.

Question 34

5. Which beliefs by a nurse facilitate provision of safe, effective care for older adult patients? (Select all that apply.)
   a.
   Sexual interest declines with aging.
   b.
   Older adults are able to learn new tasks.
   c.
   Aging results in a decline in restorative sleep.
   d.
   Older adults are prone to become crime victims.
   e.
   Older adults are usually lonely and socially isolated.

Answer 34

ANS: B, C, D
Myths about aging are common and can negatively impact the quality of care older patients receive. Older individuals are more prone to become crime victims. A decline in restorative sleep occurs as one ages. Learning continues long into life. These factors affect care delivery