Exam 2: Chapter 15 Flashcards
An older woman asks a nurse, “You always seem to be telling me that I need to drink more water. How much water do I really need to drink?” The nurse bases her response on the knowledge that older adults should consume at least:
a. 1000 mL of fluid per day.
b. 1500 mL of fluid per day.
c. 2000 mL of fluid per day.
d. 2500 mL of fluid per day.
ANS: B
Older adults, with the exception of those who require a fluid restriction, should consume at least 1500 mL of fluid per day.
A nurse administers hypodermoclysis (HDC) to an older nursing home resident. The purpose of hypodermoclysis is:
a. to rehydrate an individual with severe dehydration.
b. to quickly administer 4-5 L of fluid within a 24-hour period.
c. to rehydrate an individual with mild to moderate dehydration.
d. as a supplement to IV hydration to expedite rehydration.
ANS: C
HDC is an infusion of isotonic fluids into the subcutaneous space. It is an alternative to IV administration for individuals with mild to moderate dehydration. It cannot be used in individuals with severe dehydration or for any situation requiring more than 3 L over 24 hours.
Which of the following statements describing oral care for the older population is correct? a. Regular dental examinations can prevent tooth loss and improve the ability to chew healthful foods.
b. Losing one’s teeth is considered a normal part of the aging process.
c. Oral malignancies seldom occur in older adults so oral examinations are of low priority.
d. Preventative dental care is covered under Medicare.
ANS: A
Regular dental care is essential and can prevent tooth loss. Losing one’s teeth is not a normal part of aging; about one-quarter of adults over age 65 are edentulous. Oral cancers occur more often in older individuals. The median age at diagnosis is 61. Oral examinations can assist in early identification and treatment. Medicare does not provide any coverage for oral care services.
In a long-term care facility, a nurse is having a discussion with the nurse aides about ways to deal with dementia clients who are uncooperative with mouth care. Appropriate methods to use include:
a. speaking to the client sternly and instructing the client to open the mouth and cooperate immediately.
b. having another nurse aide assist in holding the client’s mouth open with a tongue depressor.
c. involving the client in the process of oral hygiene, such as using the hand over hand technique to brush the client’s teeth.
d. quickly performing oral hygiene without explanation since the client is
uncooperative.
ANS: C
With uncooperative individuals, it is important for the caregiver to be at eye level and explain all actions with step-by-step instructions. Speaking to the client sternly, having another nurse aide hold the patient’s mouth open, or performing oral hygiene without an explanation will only serve to agitate the patient. Involving the client and having the client participate to the
extent possible is important. Using a hand over hand technique is effective.
A nurse is observing a nurse aide perform denture care for a resident in the nursing home. The nurse recommends that the nurse aide receive additional education on denture care when the nurse observes which of the following?
a. The nurse aide places a face cloth in the sink and fills the sink half full with water. b. The nurse aide uses toothpaste to clean the dentures.
c. The nurse aide utilizes a specially designed denture brush to clean the dentures. d. The nurse aide stores the dentures in a denture cup filled with denture cleansing solution.
ANS: B
Toothpaste is not used to clean dentures since it abrades denture surfaces. All of the other options are correct steps in the process to cleanse dentures.
Which of the following are age-related changes that affect hydration status? (Select all that apply.)
a. Decrease in thirst sensation
b. Decrease in total body water
c. Decrease in ability of kidneys to maximally concentrate urine
d. Decrease in bone marrow mass
e. Decrease in bladder capacity
ANS: A, B, C
As one ages, thirst sensation decreases and is not proportional to metabolic needs in response to dehydrating conditions. There is a decrease in total body water. The kidneys are less able to maximally concentrate urine resulting in a loss of water. While there is a decrease in bone marrow mass, this does not impact hydration status. Also, as one ages, bladder capacity decreases; however, this does not directly impact hydration status.
A nurse is performing an admission assessment on an older patient who presented with a high fever and cough, reduced oral intake for 3 days, and lower extremity weakness. The patient has sunken eyes, and the patient’s skin turgor over the sternum is poor. The nurse suspects that the patient is dehydrated. Which of the following are indicators of dehydration in this patient? (Select all that apply.)
a. Poor skin turgor over the sternum
b. Lower extremity weakness
c. High fever
d. Sunken eyes
e. Cough
ANS: B, D
Older adults often present atypically when dehydrated. Skin turgor over the sternum is not a reliable marker in older adults due to the loss of subcutaneous tissue with aging. Lower extremity weakness and sunken eyes may indicate dehydration. High fever and cough can be associated with many other conditions and are not typically signs of dehydration.
Which of the following nursing interventions should be implemented to prevent dehydration in hospitalized older adults? (Select all that apply.)
a. Implementing intake and output recording for any patients with fever, diarrhea, vomiting, or an infection
b. Limiting duration of NPO requirements for diagnostic tests and procedures c. Administering IV fluids to all hospitalized older adults
d. Limiting the use of diuretic medications in hospitalized older adults
e. Making sure that hospitalized patients have easy access to fluids
ANS: A, B, E
In order to prevent dehydration, it is essential to closely monitor hospitalized older adults. Any individual who develops fever, diarrhea, vomiting, or an infection should be monitoring closely by implementing intake and output records and providing additional fluids. NPO requirements for diagnostic tests and procedures should be as short as possible. It is not appropriate to administer IV fluids to all hospitalized older adults. IV fluids are administered when there is a clinical indication. It is not appropriate to limit the use of diuretics. Diuretics are an important treatment for many older patients. Hydration management involves acute and ongoing management of oral intake. Oral hydration is the first line of treatment for dehydration prevention.
An older adult complains of xerostomia. Which of the following interventions should the nurse implement for this patient? (Select all that apply.)
a. Encourage the patient to brush and floss teeth regularly.
b. Encourage the patient to have regular dental screenings.
c. Provide antiseptic mouthwash (e.g., Listerine) for the patient.
d. Encourage adequate intake of water.
e. Provide saliva substitutes.
ANS: A, B, D, E
Individuals with xerostomia should have regular dental screenings and be encouraged to practice good oral hygiene. Adequate intake of water is important, as is avoidance of alcohol and caffeine. Saliva substitutes may be helpful. Antiseptic mouthwashes usually contain alcohol, which can further dry the mouth
A nurse is caring for an older adult who has a gastrostomy tube. The nurse is developing a care plan related to oral care. Which of the following should the nurse consider for this patient? (Select all that apply.)
a. Oral care should be provided every four hours.
b. Teeth should be brushed with a toothbrush after each tube-feeding.
c. Lemon glycerin swabs should be used in between feedings to keep the mouth moist.
d. Foam swabs should be used in place of a toothbrush to clean the teeth after each tube-feeding.
e. Oral care should be provided only twice daily if the older adult is edentulous.
ANS: A, B
Tube-feeding is associated with significant pathologic contamination of the mouth, greater than in individuals who receive oral feeding. Oral care should be provided every 4 hours for patients with gastrostomy tubes and teeth should be brushed with a toothbrush after each feeding to decrease the risk of aspiration pneumonia. Lemon glycerin swabs should never be used for oral care, as they dry and inhibit saliva production. Foam swabs do not remove plaque as well as toothbrushes. Oral care is required even if the individual is edentulous.
