Deck 4: Assessment of the Older Adult

Question 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)Slow,insidious onset of manifestations

Answer 1

Failing to remember his or her room number
Often referring to a cup as a canyon
Slow,insidious onset of manifestations

Question 2

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.

Answer 2

It is quick and simple for a baseline.

Question 3

The gerontologic 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 which of the following?

A)Planning the amount of help the patient will need with ADLs.
B)The patient's 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.

Answer 3

Creating an appropriate,patient-specific nursing care plan.

Question 4

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 about which of the following?

A)Having the family present to help answer questions.
B)Establishing a therapeutic nurse-patient relationship.
C)Ensuring the patient is free of hearing and vision barriers.
D)Effectively managing the patient's pain.

Question 5

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 patient's daughter questions the possibility of pneumonia stating,"He isn't coughing or having any difficulty breathing." The nurse responds most appropriately with which comment?

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 dad's age often lack the muscular strength to cough."
D)"Older adults frequently lack the typical signs of a respiratory infection."

Question 6

The registered nurse in a long-term care facility has administered the Montreal Cognitive Assessment (MoCA)to a new resident.Before documenting the resident's score,what action by the nurse is best?

A)Ask the resident about years of schooling completed.
B)Perform an assessment of the resident's cranial nerves.
C)Determine if the resident is literate.
D)Assess the resident's hand strength.

Question 7

A 76-year-old postsurgical diabetic patient has reported feeling dizzy and clammy.The daily serum glucose level shows the patient's levels to be within normal limits.The gerontologic nurse shows an understanding of established health norms for the older adult when stating

A)"This patient's normal may not be within the typical lab norms."
B)"I'll ask the lab to rerun the test so we can double-check the results."
C)"There must be another reason for the symptoms."
D)"I'll compare the patient's baseline lab work with today's results."

Question 8

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.

Question 9

The nurse has used the Yesavage Gerontologic Depression Scale (short form)and scored the patient at a 1.What is the nurse's 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 patient's medical record.

Question 10

A nurse is conducting an admission interview with an older patient admitted to a long-term care facility.When the nurse asks about the patient's 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,it's just part of our admission interview."

Question 11

The gerontologic unit nursing manager evaluates that which nurse shows the best understanding of how personal attitude affects the interview process during a health assessment of an older adult patient?

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.

Question 12

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 the older adult which of the following?

A)How the patient would like to be addressed.
B)If the patient has any specific requests to make of the staff.
C)If the patient will share a little about his or her likes and dislikes.
D)If the patient understood the orientation materials to the facility.

Question 13

A nurse is working with an older patient in the gerontology clinic.The patient reports a vague decline in function and says,"I guess I'm 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.

Question 14

To best minimize patient anxiety and help ensure a successful history assessment interview,the gerontologic nurse does which of the following 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.

Question 15

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

A)identify the patient's 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.

Question 16

Which action by the nurse most effectively implements guided reminiscence during a patient interview?

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.

Question 17

An older patient is hospitalized after a fall that resulted in a fractured left ankle.By day 4 of the hospitalization,which included 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.

Question 18

A nurse aide working in the gerontologic unit's 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 she's "here." The nurse appropriately directs the nurse aide to do which of the following?

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 patient's vital signs and report them to her.
D)Reorient the patient to time and place and document the patient's response.

Question 19

The gerontologic nurse recognizes that which patient is at highest risk for a decline in functional ability?

A)79-year-old,moderate Alzheimer's disease,requires assistance with all activities of daily living (ADLs).
B)73-year-old,history of chronic bronchitis,lives with family.
C)86-year-old,lost a spouse recently,is moving into an assisted living facility.
D)69-year-old,peripheral vascular disease,visited by home health care weekly.

Question 20

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