Chapter 04: Gerontologic Assessment My Nursing Test Banks

Chapter 04: Gerontologic Assessment

Meiner: Gerontologic Nursing, 5th Edition

MULTIPLE CHOICE

1. The geriatric nurse recognizes that the bodys homeostatic mechanisms may be compromised in the:

a.

79-year-old with moderate Alzheimer disease who requires assistance with all activities of daily living (ADLs).

b.

73-year-old with a history of chronic bronchitis who lives with family.

c.

86-year-old who lost a spouse and is moving into an assisted living facility.

d.

69-year-old with peripheral vascular disease who is visited by home health care weekly.

ANS: C

Declining physiologic function and increased prevalence of disease, particularly in the old-old (age 85 or older), are in part a result of a reduction in the bodys ability to respond to stress through all of its homeostatic mechanisms. The important point is that older adults often encounter profound and repeated losses; the time between the occurrences of these losses is often short, resulting in an inadequate period for resolution and return to a baseline state, thus putting them at risk for illness. Although the other patients may have compromised homeostatic mechanisms, the 86-year-old patient is most likely to exhibit this phenomenon.

DIF: Analyzing (Analysis) REF: N/A OBJ: 4-2

TOP: Nursing Process: Diagnosis MSC: Physiologic Integrity

2. To best minimize patient anxiety and help ensure a successful history assessment interview, the geriatric nurse first:

a.

asks whether the patient has any questions about the interview.

b.

makes sure the interview area is comfortable and private.

c.

explains the reason for asking the questions.

d.

assures the patient that all answers will be kept confidential.

ANS: C

To ensure a successful interview, the nurse should explain the reason for the interview to the patient followed by a brief overview of the format to be followed. This helps alleviate anxiety and uncertainty, and the patient can then focus on providing the information. The other options are all important actions during the assessment interview, but they will not diminish anxiety as much as an explanation of the purpose.

DIF: Applying (Application) REF: N/A OBJ: 4-1

TOP: Nursing Process: Implementation MSC: Emotional Needs Related to Health Problems

3. 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.

DIF: Understanding (Comprehension) REF: Page 57 OBJ: 4-2

TOP: Teaching-Learning MSC: Physiologic Integrity

4. A nurse aide working in the geriatric units dining room tells the nurse that a patient who was oriented to time and place this morning is now confused about what day it is and why shes here. The nurse appropriately directs the nurse aide to:

a.

take the patient back to her room and put her safely in bed.

b.

place a falls risk identification bracelet on the patient and add the status care plan.

c.

immediately take the patients vital signs and report them to her.

d.

reorient the patient to time and place frequently and document the patients response.

ANS: C

A sudden change in an older adult patients cognitive status is likely a symptom of a physiologic stressor such as an infection. The vital signs will allow the nurse to determine the presence of a fever or other deviation from the patients baseline vitals. The patient may or may not need or wish to go to bed, but this does not provide any data for the nurse to evaluate. An ill patient may need to be on fall precautions, but again this does not provide data. Reorientation may be necessary, but if the patient has an illness, this needs to be taken care of.

DIF: Applying (Application) REF: N/A OBJ: 4-2

TOP: Nursing Process: Implementation MSC: Physiologic Integrity

5. The nurse most effectively implements guided reminiscence during a patient interview by:

a.

reminding the patient to share important memories of the past.

b.

scheduling several short interviews rather than one long one.

c.

controlling the interview by selecting the memories to be discussed.

d.

encouraging the patient to relive his or her memories while maintaining focus.

ANS: D

This goal-directed interviewing process helps the patient share pertinent information through remembering. The tendency to reminisce may make it difficult for the patient to stay focused on the topic, so it is the nurses responsibility to refocus the interview when necessary. Reminding the patient to share memories, using several short interviews, and controlling the interview do not make best use of this technique.

DIF: Applying (Application) REF: N/A OBJ: 4-4

TOP: Nursing Process: Implementation MSC: Psychosocial Integrity

6. To establish a mutually respectful relationship with an older adult patient being admitted to a skilled nursing unit, the nurse first introduces himself and then asks:

a.

how the patient would like to be addressed.

b.

if the patient has any specific requests to make of the staff.

c.

the patient to share a little about his or her personal likes and dislikes.

d.

the patient to read the orientation materials that the facility provides.

ANS: A

Respect is shown best by acquiring knowledge regarding the preferences held by a patient; using the patients surname is preferred unless the patient directs the staff to do otherwise. The other options are too narrow in focus to establish a mutually respectful relationship.

DIF: Applying (Application) REF: N/A OBJ: 4-4

TOP: Integrated Process: Caring MSC: Psychosocial Integrity

7. The nurse showing the best understanding of how personal attitude affects the interview process during a health assessment of an older adult patient is one who:

a.

proceeds with the interview as if the patient were not an older adult.

b.

incorporates therapeutic communication into the assessment process.

c.

treats all patients with respect regardless of age.

d.

has self-reflected on his or her own feelings regarding aging.

ANS: D

The nurses own anxiety and fear of personal aging as well as a lack of knowledge regarding older people contribute to commonly held negative attitudes, myths, and stereotypes about older people that interfere with a successful, effective assessment interview. The nurse must acknowledge the age-related differences in this patient. The nurse does use therapeutic communication, but this may be hampered by unrealized stereotypes. The nurse should treat all patients with respect, but this statement does not give specific information on how to do so.

DIF: Applying (Application) REF: N/A OBJ: 4-4

TOP: Nursing Process: Assessment MSC: Communication and Documentation

8. An older patient is being admitted to a long-term care facility. The nurse recognizes that the primary purpose of the initial geriatric health assessment is to:

a.

identify the patients physiologic baselines.

b.

ultimately create a plan of care that prevents disability and dependence.

c.

initiate the therapeutic nurse-patient relationship.

d.

document self-care deficiencies that the patient exhibits.

ANS: B

Specifically, the purpose of older adult assessment is to identify patient strengths and limitations so that effective and appropriate interventions can be delivered to support, promote, or restore optimum function and to prevent disability and dependence. Physiologic baseline, therapeutic nurse-patient relationship, and self-care deficits are all important aspects of the assessment but not the major purpose for it.

DIF: Remembering (Knowledge) REF: Page 55 OBJ: 4-8

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

9. 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.

DIF: Understanding (Comprehension) REF: Page 56 OBJ: 4-1

TOP: Nursing Process: Evaluation MSC: Physiologic Integrity

10. A patient is being admitted after a fall that has caused a painful leg injury. In preparing to interview the patient for a health history, the nurse is initially concerned that:

a.

the family should be present to help answer questions.

b.

a therapeutic nurse-patient relationship should be established.

c.

the patient should be free of hearing and vision barriers.

d.

the patients pain should be effectively managed.

ANS: D

The acute pain the patient is experiencing will have the greatest impact on the success of the health assessment interview and must be removed as a barrier for the assessment to be successful. The other factors are important too, although depending on the cognitive status of the patient, the family may or may not need to be present.

DIF: Application (Apply) REF: N/A OBJ: 4-5

TOP: Nursing Process: Implementation MSC: Physiologic Integrity

11. The nurse has administered the Apgar screen tool to assess an older patients family function status. Upon determining that the family functions at a 4, the nurse:

a.

prepares to administer a more detailed tool.

b.

prepares to report reasonable suspicion of elder abuse.

c.

asks the patient to identify specific family members to include in care planning sessions.

d.

notifies social services that the family is not likely to be of much support to the patient.

ANS: D

An Apgar score of 4 to 6 suggests a moderately dysfunctional family, one that should not be depended on to provide physical, financial, or emotional support to the patient.

DIF: Analysis (Analyze) REF: N/A OBJ: 4-9

TOP: Nursing Process: Assessment MSC: Psychosocial Integrity

12. The geriatric nurse admitting a patient to an assisted living facility recognizes the importance of tools such as the Katz and the Barthel indexes because of the impact they have on:

a.

planning the amount of help the patient will need with ADLs.

b.

the patients ability to be realistic about achieving independence.

c.

creating an appropriate, patient-specific nursing care plan.

d.

appropriate staffing to ensure the safety needs of the patients are met.

ANS: C

These assessment tools are designed to assess a patients levels of function, particularly related to ADL. Determination of the degree of functional independence in these areas can identify a patients abilities and limitations, leading to appropriate interventions presented in the patients nursing care plan. It provides more information than just how much help the patient needs, it is not related to being realistic, and it is not designed to be used for staffing purposes.

DIF: Analysis (Analyze) REF: N/A OBJ: 4-9

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

13. 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).

DIF: Remembering (Knowledge) REF: Page 56 OBJ: 4-7

TOP: Nursing Process: Assessment MSC: Health Promotion and Maintenance

14. An older patient is hospitalized after a fall that resulted in a fractured left ankle. By day 4 of the hospitalization, which includes reduction of the fracture and analgesic drug therapy, the patient has become mildly disoriented and is incontinent of urine. The nurse explains to the family that these symptoms reflect the:

a.

relationship between aging and both physical and psychosocial responses to trauma.

b.

response exhibited by many older adults who are hospitalized.

c.

effects of stress-induced perceptual deficits often seen in the hospitalized older adult.

d.

results of the pharmacologic pain control therapy.

ANS: A

Many serious consequences are the result of the interaction of physical and psychosocial factors in the older patient. Although the other options have some degree of truth to them, the most comprehensive answer is the one that relates aging to response to trauma.

DIF: Understanding (Comprehension) REF: Page 56 OBJ: 4-2

TOP: Teaching-Learning MSC: Physiologic Integrity

15. When unsure about how to address older patients with advanced stage Alzheimer disease, the nurse recognizes that it is best to address the patient by:

a.

a pet name, because the patients are not likely to respond to their given names.

b.

the first name, to foster a friendly, relaxed atmosphere.

c.

the full name, to show respect for the patients as individuals.

d.

a childhood nickname, because long-term memory will likely still be intact.

ANS: C

Nurses should address all older patients by their full name, including Mr. Mrs., or Miss, to show respect, unless the patient specifically requests being called something else.

DIF: Application (Apply) REF: N/A OBJ: 4-4

TOP: Caring MSC: Psychosocial Integrity

16. A nurse is working with an older patient in the gerontology clinic. The patient reports a vague decline in function and says, I guess Im just getting older. What action by the nurse is best?

a.

Help the patient find ways to cope with the changes.

b.

Assess the patient for an undetected illness.

c.

Ask if the patient needs any home health services.

d.

Find out what the patient thinks of these changes.

ANS: B

Vague changes and declining function are often attributed to aging but can be the only signs of illness. The nurse should perform a thorough assessment to look for any possible ailments. If the findings are normal and the changes are age related, the nurse can help the patient find ways to cope, ask about home health care services, and determine the patients thoughts on the matter.

DIF: Applying (Application) REF: N/A OBJ: 4-2

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

17. 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.

DIF: Understanding (Comprehension) REF: Page 71 OBJ: 4-9

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

18. A nurse assesses a patient using the Barthel Index and scores the patient as a 98. What inference does the nurse draw from this assessment?

a.

The patient is nearly dependent in all areas measured.

b.

The patient is able to live independently.

c.

The patient is close to independent in the areas measured.

d.

The patients cognitive status impaired the assessment.

ANS: C

The Barthel Index has a maximum score of 100, with the higher the score meaning more independent functioning. However, the tool developers do not state that a high score equals being able to live independently. This tool does not measure cognitive functioning.

DIF: Applying (Application) REF: N/A OBJ: 4-9

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

19. The staff members in a long-term care facility have noted a decline in cognitive function in one of the residents; however, each time the resident is given the Short Portable Mental Status Questionnaire (SPMSQ), the score does not change. What action by the nursing manager is best?

a.

Provide in-service education on using this tool.

b.

Conduct the assessment him- or herself

c.

Switch to a different screening tool

d.

Determine that no changes have occurred.

ANS: C

The SPMSQ is given orally, and because it is short, it is easy to memorize. The manager should use a different tool.

DIF: Applying (Application) REF: N/A OBJ: 4-10

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

20. The nurse has used the Yesavage Geriatric Depression Scale (short form) and scored the patient at a 1. What is the nurses best action?

a.

Refer the patient to a mental health practitioner.

b.

Assess the patient further for depression.

c.

Ask the patient about using antidepressant medications.

d.

Document findings in the patients medical record.

ANS: D

A score of 5 or more indicates possible depression that should be assessed further. A score of 1 indicates no or little depression risk. The nurse should document the findings. No other action is needed.

DIF: Applying (Application) REF: N/A OBJ: 4-10

TOP: Nursing Process: Assessment MSC: Psychologic Integrity

21. A nurse is conducting an admission interview with an older patient admitted to a long-term care facility. When the nurse asks about the patients former occupation, the patient states, What do you care? I am long retired! What response by the nurse is best?

a.

Your job may have exposed you to some health hazards.

b.

It helps me get to know you and your background better.

c.

We have several clubs here you might be interested in.

d.

No real reason, its just part of our admission interview.

ANS: A

Previous occupations may have exposed the patient to health hazards that might be important. The question does help the nurse get to know the patient and maybe offer some activities he or she would most likely be interested in, but thats not the main reason for the question. Saying there is no reason to ask the question puts the entire admission interview under suspicion for being irrelevant.

DIF: Understanding (Comprehension) REF: Page 66 OBJ: 4-6

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

MULTIPLE RESPONSE

1. A nurse who cares for older adults recognizes which of the following clinical features associated with dementia? (Select all that apply.)

a.

Failing to remember his or her room number

b.

Becoming increasingly disoriented at night

c.

Working on jigsaw puzzles for hours at a time

d.

Often referring to a cup as a canyon

e.

Misunderstanding when told its raining cats and dogs

ANS: A, D, E

Clinical features of dementia are associated with cognitive deficiencies such as forgetfulness, lack of inquiry, inability to correctly associate proper words to objects, and concrete thinking.

DIF: Remembering (Knowledge) REF: Page 57|Page 59

OBJ: 4-3 TOP: Nursing Process: Assessment MSC: Psychosocial Integrity

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.

DIF: Remembering (Knowledge) REF: Page 70 OBJ: 4-12

TOP: Nursing Process: Assessment MSC: Physiologic Integrity

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