Exam 1 - Chapter 9

Question 1

Factors that affect the pharmacokinetics of lipophilic medications in older adults include:

a. greater adipose tissue ratio to body mass.
b. decreased total body water.
c. increased glomerular filtration rate.
d. increased creatinine clearance.

Answer 1

A - Older adults have a higher ratio of adipose (fat) tissue where lipophilic (fat-soluble)
medications can be stored thus resulting in a potential for an accumulation of the medication
and potentially fatal overdoses. Older adults have a decrease in lean body mass and an
increase in fat. An increased body mass would not affect lipophilic medication absorption.
Older adults have a decreased glomerular filtration rate, which begins to decline as early as
age 25. Older adults have a decrease in overall kidney function.

Question 2

Which pharmacokinetic/pharmacodynamic parameter does the aging process least affect?

a. Absorption
b. Distribution
c. Metabolism
d. Excretion

Answer 2

A - There is no conclusive evidence that the absorptive process is changed appreciably in older
adults. Distribution, metabolism, and excretion are all affected significantly by aging.

Question 3

What factor is an important contribution to polypharmacy in older adults?

a. Inadequate communication among medical care providers
b. Implementation of Medicare Part D prescription drug benefit
c. Use of generic medications
d. Increasing popularity of dietary and herbal supplements

Answer 3

A - Polypharmacy is often the result of inadequate communication among specialists or between
specialists and primary care providers. Medicare Part D prescription drug benefits influence
the financing of medication but are not directly related to polypharmacy. Generic medications
are a way to keep medication costs down. The use of herbal supplements is an important
factor when examining drug interactions or adverse reactions but is not a direct factor related
to polypharmacy.

Question 4

The area in which nurses have the greatest effect on the safe, effective medication therapy of
an older client is:
a. educating the client to all aspects of the medication.
b. assessing for adverse reactions to the medication.
c. monitoring overall health of the client as it is affected by the medication.
d. evaluating the outcomes resulting from the medication.

Answer 4

A - Nurses have the greatest opportunity to impact medication use and improve treatment
outcomes through patient education. Assessing for reactions, monitoring effects, and
evaluation of outcomes all depend on the client’s understanding and compliance with the
medication therapy (i.e., are affected by client education).

Question 5

When developing a teaching plan for an older, newly diagnosed diabetic client, the nurse best
ensures an understanding of oral hypoglycemic medications when providing:
a. the package insert and assessing the client’s reading skills.
b. the client with the website address for the American Diabetes Association.
c. oral explanations and sending the client home with a written copy.
d. the information in paragraph form as opposed to numbered line fashion

Answer 5

C - Providing memory aids, such as written information including charts, is effective in
reinforcing teaching. Package inserts are not always written in lay language that is
understandable and appropriate to the reading level of the older adult. The font size of the
print may be too small for aging eyes. Not all older adults are computer literate or comfortable
with the use of the computer. This method may be more effective for younger clients. A more
effective manner in which to provide written information to older adults is in the form of lists
using a large-size font

Question 6

The nurse suspects that a client is experiencing tardive dyskinesia when observing that:

a. the client can’t seem to stop moving.
b. the client’s facial muscles are twisting involuntarily.
c. the client not able to get up out of a chair.
d. the client’s hand tremors so much that drinking from a cup is difficult.

Answer 6

B - Facial movements and involuntary twisting of the limbs, trunk, neck, and face is the definition
of tardive dyskinesia. A compulsion to be in motion is the definition of akathisia. An inability
to move is the definition of akinesia. A bilateral tremor and rigidity reflects Parkinsonian
symptoms

Question 7

The Beers Criteria is an effective tool for health care professionals prescribing and/or
managing the medication therapy of older adults since it identifies medications that for this
population:
a. are not typically covered by drug benefit plans.
b. have a higher than usual risk for injury.
c. are likely to be abused.
d. generally cause allergic reactions.

Answer 7

B - Drugs on the Beers’ list are those that have been identified to have a higher than usual risk
when used in older adults. The Beers Criteria have no relation to medication financing. There
is no evidence that the drugs are likely to be abused by older adults. There is no greater
likelihood of these drugs causing allergic reactions

Question 8

When performing the initial assessment on a new client in a geriatric outpatients practice, the
most effective method the nurse can implement to elicit an accurate medication assessment is
to ask that the client:
a. make a list of all her current medications.
b. Work with a family member to make a new list of medications
c. bring in all of the medications that she is currently taking.
d. allow her previous primary care provider to provide a list of medications.

Answer 8

C - The gold standard is to use the “brown bag” approach. The patient is asked to bring all
medications including prescription drugs, OTC drugs, and herbal and dietary supplements.
The patient may not remember all of the medications that are being taken. As each medication
is removed from the bag, necessary information is obtained. A complete medication
assessment includes OTC drugs, as well as herbal and dietary supplements, not just
prescription medications. Your primary source of information should be the patient if she is
able to provide the information; the previous provider may not be able to provide information
on supplements or OTC and herbal medications. The nurse needs to include more than just
prescription medications. In addition, prescribed medications do not always reflect what is
being taken

Question 9

When discussing pharmacological considerations, a 68-year-old client asks, “Why do
medications seem to act differently than they did when I was younger?” The nurse bases the
response on the concept that:
a. age-related changes affect the way drugs are metabolized by older adults.
b. Over-the-counter (OTC) drugs have standardized dosages that are appropriate for
all ages.
c. older adults may need larger doses of medication to bring about the desired effects.
d. adverse drug reactions occur with similar frequency in older adults as the general
population.

Answer 9

A - Age-related pharmacokinetic and pharmacodynamic changes explain why older adults react
differently to medications. OTC drugs can result in altered drug outcomes since that relates to
the individual’s response to the medication. Age-related changes may require smaller doses of
medication in older patients than in younger patients. The rule is to “start low and go slow.”
The older a person is, the more likely he or she is to have an adverse drug reaction.

Question 10

The nurse’s first response when told by a client during an assessment interview that he “can’t
take furosemide (Lasix)” is to ask:
a. “Is your health care provider aware that you are allergic to Lasix?”
b. “Can you describe what happened when you took Lasix?”
c. “When was the last time you took Lasix?”
d. “Have you any questions regarding your reaction to Lasix?”

Answer 10

B - It is important to document the type of allergic reaction, when the patient had it, how long it
lasted, and how it was treated. Determining whether the health care provider is aware of the
allergic reaction or when the medication was last taken does not have precedence over
assessing the client’s reaction to the medication since neither has a direct bearing on the
management of a similar reaction. Evaluating the client’s understanding of the reaction is
appropriate but not as an initial response.

Question 11

An 81-year-old patient is being discharged from the hospital to home. She is on seven
different medications, which are to be taken at four different times during the day. What
would be most useful in helping this patient manage her medications?
a. The package inserts from all of the medications for the client to read
b. A pillbox with compartments for each day and each of the doses
c. A written list of all the client’s medications and administration routine
d. A suggestion that the client’s daughter administer the medications

Answer 11

B - Providing a pillbox is an effective method to reinforce exactly which medications are to be
given at what times. It also serves as an effective method to remind patients when they have
missed a dose. Package inserts are often written in language that is not easy for patients to
understand. Another consideration is that the size of the print in package inserts may be too
small for aging eyes. Although providing a written list of the medications is appropriate, it
does not make as much of an impact on the overall management of this patient’s medications
as other options. There is no indication that this patient cannot self-administer the
medications.

Question 12

A 77-year-old Hispanic Catholic nun (retired) who immigrated to the United States 15 years
ago lives alone but in an apartment complex where her biological sister lives as well. She is
being discharged home after a hospitalization for congestive heart failure with prescriptions
for eight different medications. She is considered at risk for noncompliance due to
contributing factors that include: (Select all that apply.)
a. language barrier.
b. living alone.
c. large number of medications.
d. ethnic background.
e. religious background

Answer 12

A,B,C - Language barriers, living alone, and a large number of medications are all factors that have
been shown to contribute to noncompliance in older adults. There is no evidence that ethnic or
religious background contributes to noncompliance.

Question 13

An older client prescribed a transdermal morphine patch for severe chronic pain is being
educated on the appropriate administration of the medication. The nurse shows an
understanding of essential information regarding this route of drug administration when
stating: (Select all that apply.)
a. “This is an effective route for delivering small doses of medication over long
periods of time.”
b. “Since you have problems with digestion, this is a good way to take your
medication.”
c. “Please show me how you would apply your patch.”
d. “Be careful to put the patch only on your chest but change locations with each
application.”
e. “Be sure to avoid placing the patch on injured skin.”

Answer 13

A,B,C,E - Aging does increase the risk of developing an allergic reaction due to its effect on the immune
system and decreased gastric motility. Transdermal medications bypass the gastrointestinal
tract and so do not cause digestion problems, and their effectiveness is not affected by
digestive problems. Demonstrating the application process is an excellent way to evaluate the
client’s understanding and technique. Transdermal patches can be applied to areas other than
the chest, such as the arms, backs, legs, and abdomen, but damaged skin should be avoided

Question 14

An antihypertensive medication has been prescribed for an older patient with hypertension.
The patient tells a clinic nurse that he would like to take an herbal substance to help lower his
blood pressure instead of the prescription medication. Which of the following should the
nurse do? (Select all that apply.)
a. Tell the patient that herbal substances are less effective than prescription
medications
b. Encourage the patient to discuss the use of an herbal substance with his primary
care provider
c. Explore with the patient which herbal substance he is planning on taking
d. Educate the patient on possible interactions of the herbal substance with his other
medications
e. Instruct the patient not to take the herbal substance, as it is dangerous

Answer 14

B,C,D - The popularity of medicinal herbs and supplements continues to rise. A major concern with
the use of herbs and supplements is the potential interactions with prescribed medications. It is
important that the patient share his or her use of herbs and substances with all providers and
that the provider review the herbs and the prescribed medications to ensure compatibility.

Question 15

An older patient is prescribed warfarin for stroke prevention. A nurse is providing patient

education. Which of the following foods should the patient be taught to avoid? (Select all that
apply. )
a. Milk
b. Whole grains
c. Kale
d. Spinach
e. Red meats

Answer 15

C,D - It is important to avoid “leafy green vegetables” when taking Coumadin.

Question 16

The nurse is preparing to apply a topical cream on the arm of a cognitively impaired, anorexic older adult patient in the terminal stage of lung cancer. The nurse carefully monitors the effectiveness of the medication because its effectiveness will be most negatively impacted by the patients:

a. age.
b. cognitive limitations.
c. nutritional status.
d. cancer diagnosis.

Answer 16

A - Topical drugs face barriers to absorption because the aged skin has decreased water content, a relative decrease in lipid content, and a decrease in tissue perfusion. These changes may result in impaired absorption of some medications that are administered via lotions, creams, ointments, and patches. The other options are not related to medication effectiveness in this situation.

Question 17

When administering medications to older adults, the nurse shows an understanding of the effect of aging on drug distribution by monitoring the patients:

a. cardiac function.
b. liver function.
c. red blood cell count.
d. plasma albumin levels.

Answer 17

D - With age, particularly for malnourished or frail adults, plasma albumin levels may drop and therefore should be monitored. As a result of decreased sites for protein binding, the activity of highly protein bound drugs, and any side effects caused by these drugs may be increased. The other options may be appropriate for specific drugs, but not in general.

Question 18

An older adult patient has been prescribed warfarin (coumadin). The nurses primary intervention involves daily review of the patients:

a. prothrombin time.
b. body for bruising.
c. serum creatinine level.
d. reflex tone.

Answer 18

A - Warfarin therapy is monitored by the international normalized ratio (INR) or INR with prothrombin time.

Question 19

A patient with diabetes and hypothyroidism is being admitted to an assisted living facility. During the admission assessment, the patient reports difficulty falling asleep. The nurse shows an understanding of sleep dysfunction and the older patient when asking:

a. Have you ever been prescribed a sleeping medication?
b. How do you feel about leaving your home to live here?
c. How long have you been a diabetic?
d. Are you taking medication for your thyroid problem?

Answer 19

D - Insomnia and anxiety are problems that commonly plague older adults. Because insomnia and anxiety often occur secondary to medication side effects or secondary to medical conditions such as dementia, thyroid abnormalities, or depression, proper diagnosis and treatment of any underlying causes of insomnia or anxiety can help this condition. The other questions are appropriate for an intake interview, but not specifically related to the insomnia.

Question 20

A patient is receiving propranolol (Inderal) for hypertension. Which outcome is the best indicator of goal success when considering the drugs potential effect on the patients quality of life?

a. The patient verbalizes the importance of moderate exercise.
b. The patient experiences no injuries as a result of dizziness.
c. The patients blood pressure stays within normal limits.
d. The patient describes symptoms indicative of an adverse drug reaction.

Answer 20

B - The main concerns with the use of antihypertensive medications in older adults are an increased risk of orthostatic hypotension and dehydration. Exercising and maintaining the blood pressure within normal limits are treatment goals but do not impact quality of life like dizziness or fainting. Having an adverse drug reaction would not improve quality of life.

Question 21

The nurse responsible for administering medications to the residents of a long-term care facility shows an understanding of the risk of injury this population experiences when:

a. confirming the patients identity prior to providing the medication.
b. assessing the patient for a history of drug-related allergies.
c. implementing the 5 rights of medication administration routinely.
d. educating patients about the purpose and side efforts of their medications.

Answer 21

C - The Institute of Medicine (IOM) estimates that 1.5 million ADEs and 7000 deaths occur in the United States each year secondary to medication errors. Older adults are disproportionately affected; more than half of the medication errors occur in long-term care facilities and more than 500,000 occur among ambulatory Medicare patients. Some references use the 6 rights of medication administration.

Question 22

An older adult diabetic patient is mildly hypertensive. The nurse prepares to educate the patient regarding angiotensin II blocking agents. These drugs are especially useful in older adults because they:

a. protect the kidneys function.
b. have a well-defined therapeutic window.
c. are more effective than other drugs in the same class.
d. can be given when liver function is compromised.

Answer 22

A - The ACEIs and ARBs also have demonstrated value in decreasing the chance of cardiac mortality in patients with heart failure. They also confer renal protection, which is particularly beneficial for patients with diabetes. The other statements are not related to both the patients conditions.

Question 23

The nurse shows an understanding of medication-related risk factors common to older adults when asking:

a. Are you aware of the possible side effects of your medications?
b. Do you regularly take any dietary supplements?
c. How do you keep track of when your medications are due?
d. How many different physicians are prescribing medications for you?

Answer 23

B - About 52% of older adults living in the United States take some sort of dietary supplement on a regular basis in addition to prescription medications. This increases the potential for drug-drug interactions. The other questions are important assessment questions to include in a medication review.

Question 24

An older adult patient is having difficulty remembering when to take several of the prescribed medications. To improve the patients compliance with the medication regimen, the nurse:

a. asks the patients spouse to consistently administer the drugs.
b. checks the drug guide to see if decreasing the frequency if the drugs is possible.
c. informs the patients physician about the drug noncompliance.
d. teaches the patient to administer daily pills with a pill dispenser.

Answer 24

D - The regimen should be simplified as much as possible; using a drug dispenser could make the daily process less complicated. If the patient is still unable to manage this task, the nurse could consult with the provider about decreasing frequency or changing medications, or the nurse could ask the spouse to administer the medications if this were acceptable to the patient. But the easiest and most cost-effective action is to try a pill dispenser.

Question 25

The nurse is caring for an older adult who reports severe chronic pain. To best assess age-related physiologic changes that could influence plans for initiating an appropriate drug regimen, the nurse prepares the patient for which laboratory evaluation?

a. White blood count
b. Glomerular filtration rate
c. Serum complement level
d. Electroencephalogram

Answer 25

B -

Question 26

An older adult patient is being assessed for possible alcohol abuse. To best assess the patients risk potential, the nurse asks:

a. Have you ever experienced a memory loss as a result of consuming alcohol?
b. Would you drink to relax after a particularly stressful day?
c. Do you ever drink when you are alone?
d. How many alcoholic drinks do you consume each week?

Answer 26

D - The nurse should start the assessment for alcohol abuse by inquiring as to the number of drinks the patient consumes each week. The other questions can be part of an abuse assessment, but it is easiest to start with a simple, quantitative question to open the discussion.

Question 27

An older adult patient is currently undergoing detoxification for alcohol at a rehabilitation center. When assessing the patient using the Clinical Institute Withdrawal Assessment tool, the nurse determines the patients current score to be 23. The nurse:

a. immediately institutes seizure precautions.
b. monitors the patients vital signs every 2 hours.
c. arranges for the patient to be transferred to an acute care hospital.
d. shares with the patient that the detoxification process is almost complete.

Answer 27

C - The maximum score on this tool is 67, and patients who score higher than 20 should be admitted to a hospital. The other options are incorrect.

Question 28

A 68-year-old man with a history of alcohol abuse is admitted to the acute care facility for reports of abdominal pain. Based on your understanding of alcohol withdrawal, the nurse knows that if patient is currently abusing alcohol, he will most likely:

a. experience delirium tremors within 4 hours of hospitalization.
b. develop withdrawal symptoms 48 to 72 hours after the last intake of alcohol.
c. receive 1 ounce of alcohol every 4 hours while awake.
d. be prescribed oxazepam (Serax).

Answer 28

B - Symptoms tend to peak 48 to 72 hours after a patients last drink, although they may occur within 4 to 12 hours. The patient may or may not have DTs. The patient should not receive alcohol and may or may not need medication.

Question 29

When working with a patient suspected of substance abuse, the nurse is particularly interested in determining the cause of a patients:

a. acute abdominal pain.
b. recurring insomnia.
c. extensive history of falls.
d. chlordiazepoxide (Librium) prescription.

Answer 29

C - Frequently, the symptoms of substance abuse are subtle or atypical, or they mimic symptoms of other age-related illnesses and remain undiagnosed. Patients presenting symptoms may be erratic changes in affect, mood, or behavior; malnutrition; bladder and bowel incontinence; gait disturbances; and recurring falls, burns, and head trauma. Acute abdominal pain, insomnia, and prescriptions for Librium may or may not be related to substance abuse, but falling is.

Question 30

A 67-year-old woman presents at the emergency department with symptoms that suggest possible abuse of a narcotic analgesic. To best assure the patients safe care, the nurse asks:

a. When did you first start using the analgesic?
b. Have you experienced withdrawal symptoms before?
c. Why did you initially need an analgesic?
d. What prescribed drugs are you currently taking?

Answer 30

D - First, if prescription drug abuse is suspected, the nurse should ask the patient or a family member to identify all medications that the patient is currently using. The nurse and physician can then plan for safe detoxification. In addition, the physician can try to prevent any untoward drug interactions resulting from prescribing a new medication that is contraindicated because of an existing prescription.

Question 31

Your patient reports frequent constipation as a result of prescription medications and asks the nurse for advice about using a daily over-the-counter laxative. The most appropriate response by the nurse is to:

a. tell the patient to consult the health practitioner before using nonprescription drugs.
b. educate the patient about the side effects of regular laxative use.
c. tell the patient to avoid laxatives because they can interfere with medications already being taken.
d. tell the patient to consult a dietician about ways to correct chronic constipation.

Answer 31

A - Education regarding the importance of contacting the health practitioner (physician or pharmacist) before taking nonprescription medication is essential for reducing the number of unintentional medication interactions. Educating the patient on side effects and teaching the patient nonpharmaceutical ways to manage constipation are also appropriate.

Question 32

When initially planning care for the older adult patient who is prescribed clonidine patches as part of a smoking cessation program, the nurse:

a. assesses the patient for any skin disorders on the upper arms and back.
b. determines how many cigarettes or cigars the patient smokes per day.
c. asks if the patient is currently taking any antihypertensive medications.
d. educates the patient to the possible side effects of clonidine therapy.

Answer 32

C - Clonidine is an antihypertensive, so knowledge of the patients medication history is vital to avoid inducing hypotension. The other assessments are not related to patient safety.

Question 33

The nurse explains to ancillary staff that caffeine abuse is difficult to diagnose in the older adult patient because caffeine intoxication symptoms:

a. can be confused with normal effects of aging.
b. often mimic those of some cardiac disorders.
c. produce fewer symptoms in older adults than in younger adults.
d. resemble the side effects of several antihypertensive drugs.

Answer 33

B - Caffeine stimulates the sympathetic nervous system, often producing the rapid pulse associated with cardiac disorders. Caffeine effects are not mistaken for normal signs of aging, produce fewer symptoms in older adults, or resemble side effects of antihypertensives.

Question 34

An older adult patient shares with the admitting nurse that she drinks one shot of whiskey nightly to help her sleep. The nurse documents the need to:

a. assess the patient for slurred speech, lack of coordination, and nystagmus.
b. address the effects of alcohol abuse with the patient.
c. provide the patient with an alcohol substitute.
d. assess the patient for signs of agitation, as well as anxiety and seizures.

Answer 34

D - It is important to assess older patients for the possibility of alcohol withdrawal if agitation, hallucinations, anxiety, or seizures develop. Because the patient admits to a shot a day, it is possible she drinks more or uses alcohol to self-medicate for problems other than insomnia. The nurse should monitor the patient for signs of withdrawal as a priority, because this is a medical emergency. Slurred speech, lack of coordination, and nystagmus are signs of overindulging. The nurse should not provide an alcohol substitute. It is appropriate to discuss the effects of alcohol, but safety comes first.

Question 35

The nurse is assessing patients for impending alcohol withdrawal. The nurse assesses the patient with which of the following conditions as a priority?

a. Pulse, 58 beats/min; and BP 100/60
b. Pulse, 118 beats/min; and BP 160/90
c. Dozing off in chair and not recognizing staff
d. Reporting muscle aches and frequent stumbling

Answer 35

B - Manifestations of alcohol withdrawal are elevated blood pressure, elevated pulse, and autonomic hyperactivity. In addition, fever; increased hand tremors; insomnia; nausea and vomiting; transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures may occur. The nurse should see the hypertensive, tachycardic patient as the priority.

Question 36

To minimize the possible complications of polypharmacy among older adult patients, the nurse assesses this population for which of the following? (Select all that apply.)

a. Number of physicians providing medical care
b. Location of pharmacies where prescriptions are filled
c. Presence of chronic illnesses
d. Tendency to borrow medication from family or friend
e. Use of over-the-counter medication to self-medicate

Answer 36

A,B,C,E - Older adults are especially vulnerable to polypharmacy because many have one or more chronic conditions requiring several medications for management. To complicate matters, patients may see more than one provider for the same health problem and may have prescriptions filled at more than one pharmacy. Additional contributors to polypharmacy include the use of over-the-counter and alternative medicines or supplements in the treatment of conditions. As a result, the patient may end up taking duplicate drugs, similar drugs from the same drug class, and drugs that are contraindicated when taken together. Borrowing medications is not usually an issue.

Question 37

The nurse must be able to distinguish between alcohol intoxication and alcohol withdrawal to intervene appropriately. The nurse suspects alcohol intoxication when the patient does which of the following? (Select all that apply.)

a. Slurs his speech when answering questions
b. Has difficulty remembering his address
c. Reports seeing snakes in the corner of the room
d. Documents his blood pressure as 168/90
e. Experiences difficulty when walking to the bathroom

Answer 37

A,B,E - Signs associated with alcohol intoxication include the scent of alcohol on the breath, slurred speech, lack of coordination, unsteady gait, nystagmus, impairment in attention or memory, and stupor or coma. Manifestations of alcohol withdrawal are elevated blood pressure, elevated pulse, and autonomic hyperactivity. In addition, fever; increased hand tremors; insomnia, nausea and vomiting; transient visual, tactile, or auditory hallucinations or illusions; psychomotor agitation; anxiety; and grand mal seizures may occur.

Question 38

A 69-year-old was prescribed a benzodiazepine 3 years ago. This medication regimen increases the patients risk for injury related to drug abuse and requires frequent patient assessment for which of the following? (Select all that apply.)

a. Daytime sleepiness
b. Unsteady gait
c. Shortness of breath
d. Easy bleeding
e. Forgetfulness

Answer 38

A,B,E - Benzodiazepines can cause excessive sedation, impaired memory, decreased psychomotor performance, and balance disturbances and may lead to drug dependence and should not be prescribed for extended periods of time. Shortness of breath and bleeding are not signs of side effects.