Period: FINALS

Schedule:
Consultation time:
Course content:
 Musculoskeletal Function
 Hip Fracture
 Arthritis
 Osteoporosis
 Foot problems
o Corn
o Calluses
o Bunions
o Hammertoe
o Nail disorders
 Urinary Function
 Acute & Chronic Incontinence
 Renal Failure
 Urinary Tract Infection
 Benign Prostatic hypertrophy
 Cognitive & Neurologic Function
 Delirium & Dementia
 Parkinson’s Disease
 Cerebrovascular Attack
 Integumentary Function
 Common skin growth
 Melanoma
 Ulcer
 Sensory Function
 Cataract
 Glaucoma
 Cataract
 Dysequilibrium
 Hearing loss
 Changes in sense of smell and taste
INTENDED LEARNING OUTCOMES:
After the designed activities, the student will be able to:
1. Discuss common Cognitive, Neurologic, Integumentary and sensory disorders
common among elderly.
2. Identify nursing care management effective to Cognitive, Neurologic,
Integumentary and Sensory problem.
3. Explain the current trend and issues in the care of the older person.

SPECIFIC ACTIVITIES:
1. Reading and comprehension of the concept.
2. Critical Thinking Exercises:
 Case Analysis
 Multiple Choice type of Examination
MUSCULOSKELETAL

-Physical activity aids respiratory, circulatory, digestive, excretory, and

musculoskeletal functions. Mental acuity and mood are enhanced by the
physiological effects of exercise. Physical activity can be a means to engage in social
activity; a physically fit state supports older adults in participating in social events.
Multiple health problems, such as atherosclerosis, obesity, joint immobility,
pneumonia, constipation, pressure ulcers, depression, and insomnia, can be avoided
when an active state is maintained.

EFFECTS OF AGING ON MUSCULOSKELETAL FUNCTION:

-An increasing challenge associated with the decreased muscle mass and/or
function facing individuals as they age is sarcopenia—a decline in walking
speed or grip strength. It can be caused by disease, immobility, decreased
caloric intake, poor blood flow to muscle, mitochondrial dysfunction, a decline
in anabolic hormones, and an increase in proinflammatory cytokines (Morley,
Anker, & von Haehling, 2014).
-When added to the impaired capacity for muscle regeneration that occurs in
late life, this can lead to disability, particularly in patients with diseases or
organ impairment. In addition to the effects of aging and disease, activity can
be impacted by psychosocial factors. The loss of one’s spouse and/or friends
can limit the older adult’s participation in social and recreational activities,
thereby reducing opportunities for physical activity. Retirement is often
accompanied by reduced activity as one no longer has to prepare for, travel
to, and engage in work; social and recreational activities that could offer
opportunities for some exercise may be restricted due to financial limitations
or poor health. The relocation from the house in which the older person
raised his or her family to a smaller home, apartment, or retirement
community reduces housekeeping and maintenance functions that provided
some opportunity for movement.
-Educating and encouraging persons of all ages to exercise regularly is an
important way that gerontological nurses can influence the health of today’s
and future generations of older people. All exercise programs should address:
o Cardiovascular endurance. The ability of the heart, lungs, and blood
vessels to deliver oxygen to all body cells is enhanced by aerobic
training. Aerobic exercises include walking, jogging, cycling,
swimming, rowing, tennis, and aerobic dancing
o Flexibility. The ability to freely move muscles and joints through their
range of motion is another part of physical fitness. Gentle stretching
exercises help maintain flexibility of joints and muscles; stretching
exercises for about 5 to 10 minutes before and after other exercises
can reduce muscle soreness.
o Strength training. Strength and endurance are enhanced by exercises
that challenge muscles. Key elements of strength training are
resistance and progression. Resistance is achieved by lifting weights
and the use of weight machines; isometric exercises or the use of
one’s own body weight through calisthenics, such as push-ups and
pull-ups, are also good means of strength training.

Guidelines for Exercise Programs for Older Adults:

 • Ensure that a recent physical examination has been done to detect
conditions that could affect or be affected by an exercise program
(e.g., heart disease and diabetes). If health conditions are present,
consult with the physician as to restrictions or modifications to the
exercise program.
• Assess the older adult’s current activity level, range of motion, muscle
strength and tone, and response to physical activity. In collaboration
with the patient, develop an exercise program that recognizes
interests, capacities, limitations, and realistic potential.
• Emphasize exercises that focus on good speed and rhythm (e.g., low
weights and high repetitions). Keep resistance exercises at a low level
and avoid isometric exercises.
• Determine the training heart rate and evaluate heart rate during
exercise to ensure that the rate stays within a safe range.
• To determine an age-adjusted training heart rate, subtract the
person’s age from 220 and multiply that answer by 70% (Centers for
Disease Control and Prevention, 2011). This calculates the maximum
rate that will provide vascular and other benefits without causing
deleterious effects. The resting heart rate can serve as the lower level
and the training heart rate as the upper level for a safe heart rate
range during exercise.
• Monitor pulse during exercise and reduce intensity and length of
exercise if heart rate is more than 10 beats above the target heart
rate.
• Consult the physician as to the appropriateness of the exercise
program for persons who have a resting heart rate exceeding 100
beats per minute.
• Advise the older adult to wear proper-fitting shock-absorbing shoes
with traction soles.
• Encourage warm-up exercises (e.g., gentle stretching and flexing) for
at least 10 minutes before the person engages in the full exercise
program.
• Provide for a period of cooling down after exercises.
• Begin with a conservative exercise program and gradually increase
activity. Monitor vital signs and symptoms at various activity levels.
Note arrhythmias, significant changes in blood pressure, dyspnea,
shortness of breath, fatigue, angina, and intermittent claudication.

COMMUNICATION TIP: When discussing exercise with older adults, better

results may be achieved if a plan is built on individual interests and needs
rather than a standardized exercise program. Instead of offering literature
about exercises or presenting recommendations to older adults, ask if they
have a history of exercising and what they think the likelihood of their
adhering to an exercise plan is. If they acknowledge that they don’t like or
adhere to exercise plans, review their interests and activities to explore how
these can be used to promote physical activity. Engage older adults in
designing exercise plans, ask their reaction to the plans, and aid them in
exploring options to overcome obstacles. Plans that are realistic and
acceptable to older individuals are more likely to be implemented and
sustained than ideal exercise recommendations prescribed by their providers
that are inconsistent with individuals’ interests and preferences.
-Some older individuals may be unable to participate in formal exercise
programs. For these persons, it can be beneficial to build less aggressive
exercises into their daily activities and promote maximum activity during
routine care activities. For example:
• Suggest that the patient do foot, leg, shoulder, and arm
circling while watching television.
• Instruct the patient to do deep-breathing and limb exercises in
the period between awakening and rising from bed.
• Encourage the patient to wash dishes or light laundry by hand
to exercise the fingers with the benefit of warm water.
• When greeting a patient in the hall, ask the person to raise
both arms as high as possible and wave.
• When giving a medication, ask the patient to bend each
extremity several times.
• During bathing activities, ask the patient to flex and extend all
body parts.

-People who are unable to participate in an aggressive exercise program can

stretch and exaggerate movements during routine activities to promote joint
mobility and circulation.
-The nurse or other caregivers will find it useful to remember the following
points:
• Exercise all body joints through their normal range of motion
at least three times daily.
• Support the joint and distal limb during the exercise.
• Do not force the joint past the point of resistance.
-Prevention of Inactivity:
For a person of any age, maintaining an active state can be
challenging. For older adults, age-related changes in muscle strength
and endurance, reduced opportunities for activity, and fatigue, pain,
dizziness, dyspnea, and other symptoms associated with health
problems prevalent in later life can further reduce activity levels.
• Deleterious Effects of Inactivity:
o Changes in physiologic function
o Reduced pulse rate Increased cardiac workload
o Decreased aerobic capacity
o Decreased chest expansion and ventilation
o Reduced muscle strength, tone, and endurance
o Demineralization of bones, increased ease of fractures
o Slower gastrointestinal motility
o Slower metabolism and lymphatic circulation Increased
risk of complications
o Postural hypotension
o Hypostatic pneumonia
o Pressure ulcers
o Poor appetite
o Obesity
o Constipation
o Fecal impaction
o Incontinence
 o Renal stone formation
o Urinary tract infection
o Joint stiffness, limited range of motion
o Changes in mood and self-concept Increased feelings
of helplessness, depression
o Perception of self as incapable, frail Increased
dependency
o Reduced opportunities for socialization
-Those caring for older people can enhance motivation by demonstrating a sincere
interest in their activities, for example, asking how they spent their day, admiring
crafts they made, or listening to the details of a trip.
-Recognizing housekeeping efforts, using their handmade gifts, and commenting on
a well-groomed appearance are small but meaningful ways to reinforce the older
person’s efforts to be active. Nurses can inform older adults about local resources
that can promote activity, such as senior centers, exercise classes, educational and
recreational programs at local schools or colleges, volunteer opportunities, and local
clubs. In addition, they can promote activity by arranging transportation for older
adults to and from activities.

SELECTED MUSCULOSKELETAL CONDITIONS:

• Fractures
o Trauma, cancer metastasis to the bone, osteoporosis,
and other skeletal diseases contribute to fractures in
older persons. The neck of the femur is a common site
for fractures in older people, especially in older women,
and most of these fractures result from falls. Colles’
fracture (break at the distal radius) is one of the most
frequent upper extremity fractures and often occurs
when attempting to stop a fall with an outstretched
hand. Older adults are also at risk for compression
fractures of the vertebrae, resulting from falls or lifting
heavy objects. The more brittle bones of older persons
not only fracture more easily but also heal at a slower
rate than in younger persons, potentially predisposing
older adults to the many complications associated with
immobility.
o Knowing that the risk of fracture and its multiple
complications is high among older adults, the
gerontological nurse must aim toward prevention,
drawing on the effectiveness of basic common sense
measures.
-The absence of typical signs of fracture does not guarantee that a bone is
not broken; therefore, close nursing observation is essential whenever a bone
has been subjected to trauma.
o Fractures heal more slowly in older adults, and the risk
of complications is greater. Pneumonia, thrombus
formation, pressure ulcers, renal calculi, fecal
impaction, and contractures are among the
complications that special nursing attention can help
prevent.
 o Activity within the limits determined by the physician
should be promoted, including deep-breathing and
coughing exercises, isometric and range-of-motion
exercises, and frequent turning and position changes.
o Fluids should be encouraged and the characteristics of
urine output noted.
o Good nutrition will facilitate healing, increase resistance
to infection, and decrease the likelihood of other
complications. Joint exercise and proper positioning can
prevent contractures.
o Correct body alignment can be maintained with the use
of foot boards, trochanter rolls, and sandbags.
o Keeping the skin dry and clean, preventing pressure,
stimulating circulation through massage, and frequently
turning the patient may reduce the risk of decubiti.
o Sheepskin, water beds, and alternating pressure
mattresses are beneficial, but they are not substitutes
for good skin care and frequent position changes.
o The patient should be mobilized as early as possible.

 Osteoarthritis
o is the progressive deterioration and abrasion of joint
cartilage, with the formation of new bone at the joint
surfaces. This problem occurs increasingly with
advanced age and affects most persons over age 55 to
some extent. It occurs in women more than in men
and is the leading cause of physical disability in older
adults.
o Disequilibrium between destructive (matrix
metalloproteinase enzymes) and synthetic (tissue
inhibitors of matrix metalloproteinase) elements leads
to a lack of homeostasis necessary to maintain
cartilage, causing the joint changes.
o Excessive use of the joint, trauma, obesity, low vitamin
D and C levels, and genetic factors may also predispose
an individual to this problem. Patients with acromegaly
have a high incidence of osteoarthritis. Usually,
osteoarthritis affects several joints rather than a single
one.
o Weight-bearing joints are most affected, the common
sites being the knees, hips, vertebrae, and fingers.
o Crepitation on joint motion may be noted, and the
distal joints may develop bony nodules (i.e., Heberden
nodes).
o The patient may notice that the joints are more
uncomfortable during damp weather and periods of
extended use.
o Isometrics and mild exercises are beneficial, excessive
exercise will cause more pain and degeneration.
o Acetaminophen is the first drug of choice because of its
safety over nonsteroidal anti-inflammatory drugs.
 o Rest, heat or ice, t’ai chi, aquatherapy, ultrasound, and
gentle massage help relieve joint aches.
o Acupuncture has been shown to bring about shortterm
relief. Splints, braces, and canes provide support and
rest to the joints.
o The nurse should emphasize the importance of
maintaining proper body alignment and using good
body mechanics when educating the patient.
o Cold water fish and other foods high in the essential
fatty acids have anti-inflammatory effects and should
be abundant in the diet.
o Vitamins A, B, B6 , C, and E and zinc, selenium,
niacinamide, calcium, and magnesium are among the
nutritional supplements that could prove useful in
controlling symptoms.
o Arthroplasty, or joint replacement, can be done to
restore joint motion, improve function, and reduce
pain.

 Rheumatoid Arthritis
o affects many persons, particularly those aged 20 to 40 years;
it is a major cause of arthritic disability in later life as a result.
Fortunately, the incidence decreases after 65 years of age;
most older patients with this disease developed it earlier in life.
Specifically, the deformities and disability associated with this
disease primarily begin during early adulthood and peak during
middle age; in old age, greater systemic involvement occurs.
This disease occurs more frequently in women and in persons
with a family history of the problem.
o In rheumatoid arthritis, the synovium becomes hypertrophied
and edematous with projections of synovial tissue protruding
into the joint cavity. The affected joints are extremely painful,
stiff, swollen, red, and warm to the touch. Joint pain is present
during rest and activity. Subcutaneous nodules over bony
prominences and bursae may be present, as may deforming
flexion contractures. Systemic symptoms include fatigue,
malaise, weakness, weight loss, wasting, fever, and anemia.
o Encouraging patients to rest and providing support to the
affected limbs are helpful measures.
o Limb support should be such that pressure ulcers and
contractures are prevented.
o Splints are commonly made for the patient in an effort to
prevent deformities.
o Range-of-motion exercises are vital to maintain
musculoskeletal function; the nurse may have to assist the
patient with active exercises.
o Physical and occupational therapists can provide assistive
devices to promote independence in self-care activities, and
heat, gentle massage, and analgesics can help control pain.
o Patients with rheumatoid arthritis may be prescribed anti-
inflammatory agents, disease-modifying antirheumatic drugs
 (e.g., methotrexate), corticosteroids, and immunosuppressive
drugs.
o The nurse should be familiar with the many toxic effects of
these drugs and detect them early if they occur. If function
becomes significantly impaired or pain severe, joint
replacement surgery may be recommended.
 Osteoporosis
o Demineralization of the bone occurs, evidenced by a decrease in
the mass and density of the skeleton. Any health problem
associated with inadequate calcium intake, excessive calcium loss,
or poor calcium absorption can cause osteoporosis.
o Risk Factors for Osteoporosis
 Advanced age (women over 65 years, men over
80 years)
 Ethnicity White women with a northwestern
 European or British Isles background
 Asian women
 Calcium deficiency
 Vitamin D deficiency
 Small-framed, thin women
 History of early menopause
 Estrogen deficiency
 History of multiple pregnancies
 Cigarette smoking
 High alcohol consumption
 Prolonged immobility
 Diseases or chronic use of drugs that increase
bone loss (e.g., corticosteroids, thyroid
hormones, and anticonvulsants)
 Family history of osteoporosis
o Many of the following potential causes are problems
commonly found among older persons:
- Inactivity or immobility. A lack of muscle pull on
the bone can lead to a loss of minerals,
especially calcium and phosphorus. This
particularly may be a problem for limbs in a
cast.
- Diseases. Cushing’s syndrome, an excessive
production of glucocorticosteroids by the
adrenal gland, is believed to inhibit the
formation of bone matrix. The increased
metabolic activity of hyperthyroidism causes
more rapid bone turnover, and the faster rate of
bone resorption to bone formation causes
osteoporosis.
- Reduction in anabolic sex hormones. Decreased
production or loss of estrogens and androgens
may be responsible for insufficient bone
calcium; therefore, postmenopausal women are
at high risk.
- Diet. An insufficient amount of calcium, vitamin
D, vitamin C, protein, and other nutrients in the
 diet can cause osteoporosis. Excessive
consumption of caffeine or alcohol decreases
the body’s absorption and retention of calcium
- Drugs. Heparin, furosemide, thyroid
supplements, corticosteroids, tetracycline, and
magnesium-and aluminum-based antacids can
lead to osteoporosis.

 Gout
o is a metabolic disorder in which excess uric acid accumulates in
the blood. As a result, uric acid crystals are deposited in and
around the joints, causing severe pain and tenderness of the joint
and warmth, redness, and swelling of the surrounding tissue.
o During an acute attack, the pain can be quite severe; the person
may not be able to bear weight or have a blanket or clothing rest
on the affected joint. Attacks can last from weeks to months, with
long remissions between attacks possible.
o Treatment aims to reduce sodium urate through a low-purine diet
(e.g., avoidance of bacon, turkey, veal, liver, kidney, brain,
anchovies, sardines, herring, smelt, mackerel, salmon, and
legumes) and the administration of drugs.
o Alcohol should also be avoided because it increases uric acid
production and reduces uric acid excretion. Colchicine or
phenylbutazone can be used to manage acute attacks; long-term
management could include colchicine, allopurinol, probenecid, or
indomethacin.
o Gout attacks can be precipitated by the administration of thiazide
diuretics, which raise the uric acid level of the blood. Vitamin E,
folic acid, and eicosapentaenoic acid can be useful dietary
supplements. Herbs such as yucca and devil’s claw reduce
symptoms in some persons.
o Nurses should monitor pain and encourage a good fluid intake to
prevent the formation of renal stones.

 Podiatric Conditions
o Calluses -(plantar keratoses) are caused by friction and
irritation on the feet that create layers of thickened skin.
Reduced fat padding of the foot, dryness of the skin,
decreased toe function, and poor fitting shoes contribute to
callus formation. They usually appear on the heels and soles
and, although not painful, can be unsightly. There is the risk
that people will attempt to shave or cut off calluses from their
feet and risk injuring their skin. Massaging the feet with lotions
and oils can aid in preventing calluses.
o Corns- are cone-shaped layers of thick, dry skin that form over
a bony prominence. Pressure on the area causes discomfort as
the tip of the cone presses into the tissue. Additional pressure
increases the size of the corn and, consequently, the pain. U-
shaped corn pads and loosely wrapping the toe in lamb’s wool
are superior to oval or round corn pads, which can restrict
 circulation. As with calluses, patients should be advised not to
attempt to remove corns on their own.
o Bunions (Hallux Valgus) A bunion or bursa is a bony
prominence over the first metatarsal head .
 There is a medial deviation of the first
metatarsal with abduction of the great toe
in relation to that metatarsal. Bunions occur
more often in women—not surprising
considering women’s shoe styles that
commonly have tight toe fit and the tight
hosiery that pull toes together.
 Some bunions are hereditary in nature. The
increased width of the foot caused by the
bunion can cause difficulty in finding
properly fitting shoes. Shoe repair shops can
stretch shoes to accommodate bunions;
custom-made shoes are also beneficial.
Surgery may be indicated for some cases.
o Hammer Toe - (Digiti Flexus) is a hyperextension at the
metatarsophalangeal joint with flexion and often corn
formation at the proximal interphalangeal joint. The toe
begins to resemble the shape of the hammers inside a
piano, thus its name.
o Plantar Fasciitis - A common cause of heel pain, often
mistaken for a spur, is plantar fasciitis.
 The plantar fascia is a thick ligamentous
band in the bottom of the foot that runs
from the ball of the foot to the heel, where
it is attached. Poor alignment of the foot
that causes pronation or supination of the
foot during walking results in stretching and
stress of the plantar fascia.
 Plantar fasciitis is an inflammation of this
band at its heel attachment. Pain is the
primary symptom and occurs in the center
or the inner side of the heel.
 Pain is worse after a period of rest; most
people experience the most pain in the
morning. After walking, the pain may
subside but tends to increase as pressure is
put on the heel from walking or standing.
Pain can radiate to the ankle or arch of the
foot if nerves become irritated secondary to
the swollen plantar fascia.
o Infections - Housing of the foot in shoes, particularly the
ones made from synthetic materials, creates a warm, moist
environment that facilitates fungus and bacterial growth.
 Onychomycosis is a fungal infection of the
nail or nail bed in which the toenail appears
enlarged, thick, brittle, and flaky. As the
fungus forms under the nail and displaces it
 up, the sides of the nail are pushed into the
skin and cause pain.
 Antifungal preparations assist in eliminating
the infection, but these infections are
stubborn to treat.
 Tinea pedis, better known as athlete’s foot,
is a fungal infection of the foot that can
cause burning and itching; the skin surface
will peel, crack, and be red, often with
vesicle eruptions. The breaks in the skin
surface provide easy entry for bacteria.
o Ingrown Nails (Onychocryptosis)- Ingrown nails can occur
due to tight-fitting shoes or cutting the nail excessively
short.
 As the nail grows, its edge cuts into
the tissue, leading to inflammation.
Soaks and topical antibiotics may be
prescribed; usually, a podiatrist can
correct this problem by removing the
ingrown portion and cleaning the
area.

GENERAL NURSING CONSIDERATIONS FOR MUSCULOSKELETAL

CONDITIONS
 Managing Pain
o Pain relief is essential in promoting optimal physical, mental,
and social function. Unrelieved pain can interfere with older
persons’ abilities to engage in self-care, manage their
households, and maintain social contact.
o To enrich the quality of life, every effort should be made to
minimize or eliminate pain.
o Heat relieves muscle spasms; a warm bath at bedtime and
keeping the extremities warm with blankets and clothing can
reduce spasms and cramps throughout the night and promote
uninterrupted sleep. Because older adults are at high risk for
burns, care must be taken to avoid injury if heat applications
or soaks are used.
o Passive stretching of the extremity can be helpful in controlling
muscle cramps.
o Excessive exercise and musculoskeletal stress should be
avoided, as well as situations known to cause pain, such as
heavy lifting or damp weather
o Back rubs using slow, long, rhythmic strokes can promote
relaxation and comfort
o Pain in the weight-bearing joints can be alleviated by resting
those joints, supporting painful joints during transfers, and
using a walker or cane
o Correct positioning, whereby all body parts are in proper
alignment, can help prevent and manage pain.
 o Accidental bumping against the patient’s bed or chair and
rough handling of the patient during care activities must be
prevented.
o Nurses may also need to emphasize to other caregivers the
need for extra gentleness in turning and lifting older patients.

 Preventing Injury
o Safety considerations are essential for all older persons
because of their high incidence of accidents and
musculoskeletal injuries and the prolonged time required for
healing.
o Prevention includes paying attention to the area where one is
walking; climbing stairs and curbs slowly; using both feet for
support as much as possible; using railings and canes for
added balance; wearing properly fitting, safe shoes for good
support; and avoiding long trousers, nightgowns, or robes.
o The importance of the safe use of heat has already been
mentioned; it is useful for patients to learn how to measure
water temperature and use hot-water bottles and heating pads
safely.
o Patients with peripheral vascular disease must be warned that
the local application of heat can cause circulatory demands
that their body will be unable to meet; other means of pain
relief may be more beneficial to them. Warm baths can reduce
muscle spasm and provide pain relief, but they can also cause
hypotensive episodes leading to dizziness, fainting, and serious
injury.
o Carelessly turning patients so that legs hit the bed rail,
dropping them into a chair during a transfer, restraining them
in an unaligned position, roughly handling a limb, or
attempting to use force to straighten a contracture can lead to
muscle strain and fractures.
o Gentle handling will prevent unnecessary musculoskeletal
discomfort and injury.

 Promoting Independence
o Any loss of independence associated with the limitations imposed
by musculoskeletal problems has a serious impact on physical,
emotional, and social well-being.
o Nurses must explore all avenues to help patients minimize
limitations and strengthen capacities, thereby promoting the
highest possible level of independence.
o Canes, walkers, and other assistive devices can often provide
significant aid in compensating for handicaps and should be used
when feasible. Physical and occupational therapists can be
valuable resources in determining appropriate assistive devices for
use with specific deficits.

5. URINARY SYSTEM

EFFECTS OF AGING ON URINARY ELIMINATION

  Age-related changes in the urinary tract may cause various elimination
problems. One of the greatest annoyances is urinary frequency, caused
by hypertrophy of the bladder muscle and thickening of the bladder,
which decreases the ability of the bladder to expand and reduces storage
capacity. In addition to frequency during the day, nighttime urinary
frequency (nocturia) can be a problem.
-Often, kidney circulation improves when the person assumes a
recumbent position, so voiding may be required a few hours after the
individual lies down and at other times during the night. Age-related
changes in cortical control of micturition also contribute to nocturia; this
problem, along with incontinence (which is not a normal consequence of
aging), can be noted in persons with dementia or other conditions
affecting the cerebral cortex. Nurses should advise older adults and their
caregivers that long-acting diuretics, such as the thiazides, even when
administered in the morning, can also cause nocturia. If multiple episodes
of nocturia occur, a medical evaluation may be warranted to ensure that
no urinary tract problem is present.

 Inefficient neurologic control of bladder emptying and weaker bladder

muscles can promote the retention of large volumes of urine. In women,
the most common cause of urinary retention is fecal impaction; prostatic
hypertrophy, present to some degree in most older men, is the primary
cause in men.

 Symptoms of retention include urinary frequency, straining, dribbling,

palpable bladder, and the sensation that the bladder has not been
emptied. Retention can predispose older individuals in the development of
urinary tract infections (UTIs).

 The filtration efficiency of the kidneys decreases with age, affecting the
body’s ability to eliminate drugs. The nurse should observe the patient for
signs of adverse drug reactions resulting from an accumulation of toxic
levels of medications. Higher blood urea nitrogen levels may occur due to
reduced renal function, causing lethargy, confusion, headache,
drowsiness, and other symptoms.

 The decreased tubular function may cause problems in the concentration

of urine; the maximum specific gravity at 80 years of age is 1.024,
whereas, at younger ages, it is 1.032. Reduced ability to concentrate and
dilute urine in response to water or sodium excess or depletion occurs.

 Decreased reabsorption from the filtrate makes proteinuria of 1.0 usually

of no diagnostic significance in older adults. An increase in the renal
threshold for glucose is a serious concern because older individuals can
be hyperglycemic without evidence of glycosuria. False-negative results in
diabetic urine testing can occur for this reason.

Changes in the renal threshold for glucose cause older adults to be hyperglycemic
without having any evidence of glycosuria.

 URINARY SYSTEM HEALTH PROMOTION:

Basic health practices, which are easily incorporated into the daily schedule,
 can prevent a variety of urinary tract problems. For instance, a good fluid
intake can reduce the number of bacteria in the bladder.
- Acidic urine, beneficial in preventing infection, can be enhanced by the
intake of vitamin C and foods such as cranberries, prunes, plums, eggs,
cheese, yogurt, fish, and grains.
-Catheterization significantly increases the risk of infection and should be
avoided.
-The activity can eliminate urinary stasis, and frequent toileting can prevent
urinary retention. The nurse can teach older adults specific efforts to enhance
voiding and prevent retention, including the following:

 Voiding in an upright position 

 Massaging bladder area 
 Rocking back and forth 
 Running water 
 Soaking hands in warm water

 The reduced bladder capacity of older adults should be kept in mind when
individuals who are unable to ambulate independently are placed in
wheelchairs; they will not be able to sit all day without needing to void, and
unnecessary incontinence may result if toileting assistance is not provided.
Trips and activities should be planned to allow bathroom breaks at frequent
intervals.
-For older adults experiencing nocturia, nurses can implement measures to
promote patients’ safety. Because older adults’ increased threshold for light
perception makes night vision difficult, nocturia could predispose them to
accidents when attempting to walk to the bathroom in the dark. Nightlights
should be used to improve visibility during trips to the bathroom, and any
clutter or environmental hazards that could cause a fall should be removed.
Reducing fluids immediately before bedtime may help, although they should
not be significantly restricted.

URINARY FUNCTION ASSESSMENT:

The interview should include a review of function, signs, and symptoms. Ask
questions pertaining to the following:

 Frequency of voiding. “How often do you need to urinate during the day and
during the night? Has there been any recent change in that pattern?” 
 Continence. “Do you ever lose control of your urine? Do you experience a
steady stream of urine dribbling at all times or at certain times? Is urine
released when you cough or sneeze? How soon do you need to toilet after
getting the urge to void before you lose control?” 
 Retention. “Do you ever feel that you have not fully emptied your bladder
after you have voided? Do you have a sense of fullness in your bladder after
voiding?” 
 Pain. “Does it burn when you void? Do you experience pain in your lower
abdomen or anywhere else? Is there any tenderness, discomfort, itching, or
pain anywhere along your genital area?” 
  Urine. “Have you ever seen crystals or particles in your urine? Is your urine
ever pink, bloody, or discolored? Is it as clear as tap water or as dark as rusty
water? Does your urine ever have a strong odor? If so, what is that odor
like?”
 Medications. “Do you take any prescription or nonprescription medications? If
so, which ones? Do you use any herbal preparations?”

PHYSICAL EXAMINATION 

 Inspect, percuss, and palpate the abdomen for bladder fullness, pain, or
abnormalities. 
 Test women for stress incontinence by doing the following: Have the patient
drink at least one full glass of fluid and wait until she senses fullness of the
bladder.
-Instruct the patient to stand. If this is not possible, have her sit as upright as
possible.
-Ask the patient to hold a 4 × 4 gauze at her perineum.
-Instruct the patient to cough vigorously.
-The test is negative if no leakage or leakage of only a few drops occurs. If
residual urine is a the problem, a postvoid residual may be ordered in which
the patient is catheterized within 15 minutes of voiding to determine the
volume of urine remaining in the bladder.
 If incontinence is present, refer the patient for a comprehensive evaluation; it
can prove useful to maintain a record or have the patient maintain a diary of
each occurrence of incontinence and factors associated with these incidents.

Urinary Tract Infection

 UTIs are the most common infection of older adults and increase in
prevalence with age. Although UTIs occur more frequently in women than in
men at younger ages, the gap between the sexes narrows in late life, which
is attributable to reduced sexual intercourse in women and a higher incidence
of bladder outlet obstruction secondary to benign prostatic hyperplasia in
men. Organisms primarily responsible for UTIs are Escherichia coli in women
and Proteus species in men.

 The presence of any foreign body in the urinary tract or anything that slows
or obstructs the flow of urine (e.g., immobilization, urethral strictures,
neoplasms, or a clogged indwelling catheter) predisposes the individual to
these infections.

 UTIs can result from poor hygienic practices, improper cleansing after bowel
elimination, a predisposition created by low fluid intake and excessive fluid
loss, and hormonal changes, which reduce the body’s resistance. Persons in a
debilitated state or who have neurogenic bladders, arteriosclerosis, or
diabetes also have a high risk of developing UTIs. Of major consideration are
catheter-associated UTIs, which are the single most common type of
healthcare-associated infection.
UTIs can result from poor hygienic practices, prostate problems, catheterization,
dehydration, diabetes, arteriosclerosis, neurogenic bladders, and general debilitated
states.

Diagnosis:

 The gerontological nurse should be alert to the signs and symptoms of UTIs.
Early indicators include burning, urgency, and fever. Some older adults
develop incontinence and delirium with UTIs. Awareness of the patient’s
normal body temperature helps the nurse recognize the presence of fever—
for instance, 99°F (37°C) in a patient whose normal temperature is 96.8°F
(35°C). Some urologists believe that many UTIs in older adults seem
asymptomatic due to lack of awareness of elevations in normal temperature
from the baseline norm.
-The nurse can significantly facilitate diagnosis by informing the physician of
temperature increases from the patient’s normal level. Bacteriuria greater
than 105 CFU/mL confirms the diagnosis of UTI. As a UTI progresses,
retention, incontinence, and hematuria may occur.

Treatment:
 establish adequate urinary drainage and control the infection through
antibiotic therapy. The nurse should carefully note the patient’s fluid intake
and output. Forcing fluids is advisable, provided that the patient’s cardiac
status does not contraindicate this action. 
 Observation for new symptoms, bladder distention, skin irritation, and other
unusual signs should continue as the patient recovers.
 Cranberry juice has long been promoted as a means to reduce UTIs; research
now supports this belief. A study conducted at the Harvard Medical School
demonstrated a reduction in the frequency of bacteria and white blood cells
in the urine of women who regularly consumed cranberry juice (Bass-Ware,
Weed, Johnson, & Spurlock, 2014 ; Fiore & Fox, 2014 ). The gerontological
nurse may want to promote the daily inclusion of cranberry juice in the diet
of older adults. (It may be best to use forms such as capsules that have no
sugar added to avoid the high sugar content of some commercial brands;
these capsules and other freeze-dried forms of cranberry juice is available at
most health food stores.)
 Nurses should question the rationale for orders for indwelling catheters and
consider other options. The convenience of staff (e.g., reducing the need to
change soiled linens or to toilet a person) is not justification for inserting an
indwelling catheter and exposing the individual to the risk of UTI. Early
removal of the catheter should be encouraged as this has been found to
reduce the risk of UTI.

 Prostatitis is the most common UTI among older men. Although nonbacterial
prostatitis is responsible for some cases, most infections are bacterial in
origin. Acute bacterial prostatitis is characterized by the systemic symptoms
of fever, chills, and malaise, whereas these symptoms are uncommon with
chronic bacterial prostatitis. Both types will present urinary symptoms of
frequency, nocturia, dysuria, and varying degrees of bladder obstruction
secondary to an edematous, enlarged prostate, as well as lower back and
perineal pain.
URINARY INCONTINENCE:

GENERAL NURSING CONSIDERATIONS FOR URINARY CONDITIONS

 Nurses need sensitivity in dealing with patients’ urinary problems. In addition

to being areas that are uncomfortable for discussion for some persons, these
disorders may raise fears and anxieties that tales of becoming incontinent in
old age perhaps are valid. Realistic explanations and a committed effort to
correcting these disorders are vital. All levels of staff need to remember the
importance of discretion and dignity in managing these problems. Staff
members should not check to see if a patient’s pants are wet in front of
others, allow someone to sit on a bedside commode in a hallway, bring in a
group of students without the patient’s permission to observe a
catheterization, or scold the patient for having an accident in bed. Every
effort should be made to minimize embarrassment and promote a positive
self-concept.

6. COGNITIVE & NEUROLOGIC FUNCTION

EFFECTS OF AGING ON THE NERVOUS SYSTEM:

 The number of nerve cells declines, each cell has fewer dendrites, and some
demyelination of the cells occurs. These changes slow nerve conduction.
Response and reaction times are slower; reflexes become weaker.
 Plaques, tangles, and atrophy occur in the brain to varying degrees; there is
not always a relationship between these changes and cognitive function. 
 Free radicals accumulate with age and may have a toxic effect on certain
nerve cells. Cerebral blood flow decreases about 20% as fatty deposits
gradually accumulate in the blood vessels, and decreases are even greater in
persons with small-vessel cerebrovascular disease due
to diabetes and hypertension; this contributes to an increased risk of strokes.
-The brain has a greater ability to compensate after injury than does the
spinal cord, but this ability to compensate declines with age.
 Intellectual performance tends to be maintained until at least age 80,
although a slowing in central processing delays the time required to perform
tasks.
-Verbal skills are well maintained until age 70, after which there is a gradual
reduction in vocabulary, a tendency to make semantic errors, and abnormal
prosody (rhythm and intonation).
 The number and sensitivity of sensory receptors, dermatomes, and neurons
decrease, resulting in dulling of tactile sensation. There is also some decline
in the function of cranial nerves mediating taste and smell. Increased levels
of taste, sound, scents, touch, and lighting are required for perception by
older persons as compared with younger adults.

Subtle Indications of Neurologic Problems:

 New headaches that occur in the early morning or interrupt sleep 

 Change in vision (e.g., sudden decreased acuity, double vision, and blindness
in portion of visual field)
  Sudden deafness, ringing in ears
 Mood, personality changes
 Altered cognition or level of consciousness
 Clumsiness, unsteady gait
 Numbness, tingling of extremity
 Unusual sensation or pain over nerve

Assessment Guide: NEUROLOGIC FUNCTION

 Keen observation while interviewing the patient can aid in detecting a variety
of neurologic problems:
 On initial inspection of the patient, observe for asymmetry, deformity,
weakness, paralysis, tremors, and other abnormalities.
 Explore the presence of symptoms of neurologic disorders, such as pain,
tingling sensations, numbness, blackouts, headaches, twitching, seizures,
sleep disturbances, dizziness, distortions of reality, weakness, and changes in
mental status.
 If clinical abnormalities or symptoms are identified, inquire into their origin,
length of time present, and resulting limitations or problems.

SPEECH ASSESSMENT

 During something as basic as simple introductions, speech disorders can

become evident. If speech problems exist, it is important to differentiate
problems with articulation (i.e., dysarthria) and problems with the use of
symbols (i.e., dysphagia):

o With dysarthria, the symbols (in this case, words) are used
correctly, but speech may be slurred or distorted as a result of
poor motor control. Subtle dysarthrias can be disclosed by asking
the patient to pronounce the following syllables: me, me, me (to
test the lips)la, la, la (to test the tongue)ga, ga, ga (to test the
pharynx)
o Dysphasia can be receptive, expressive, or a combination of both:
To test for receptive aphasia, ask the patient to follow a command
(e.g., pick up the pencil); the patient’s inability to understand
what these symbols mean will prevent the command from being
followed.
o The patient with expressive aphasia will be able to understand
commands but will not be able to put symbols together into an
intelligent speech form. Point to several objects and ask the
patient to name them; mild dysphasia (i.e., paraphasia) may be
noted if the patient substitutes a close, although inaccurate, word
for the right one, such as calling a shoe a boot or a watch a clock. 
o The ability to understand and express oneself through the written
word is important to evaluate also. Ask the patient to write a short
sentence that you dictate and to read a sentence from a
newspaper. Ensure that the patient has the educational and visual
abilities to fulfill these demands.
PHYSICAL EXAMINATION:
-Sensation Ask the patient to close his or her eyes and to describe the sensations
felt. To help document areas where problems are identified, a figure drawing may
prove useful.

 Touch various parts of the body (e.g., forehead, cheeks, arms, hands, legs,
and feet) lightly with your finger or a cotton wisp and note if the patient is
able to feel the sensations. Compare analogous areas on both sides of the
body and distal and proximal areas on the same extremity. 
 If these primary sensations are intact, test the patient’s ability to identify two
simultaneous stimuli (e.g., touch the right cheek and the left forearm).
 To test cortical sensation (i.e., stereognosis), have the patient, again with
closed eyes, identify various objects placed in each hand (e.g., key, marble,
and coin). The inability to sense these objects is known as astereognosis.

Coordination and Cerebellar Function:

 Hold up your finger and ask the patient to touch it and then touch his or her
nose; have the patient continue this action as you move your fingers to
different areas. Do this point-to-point testing with both arms of the patient,
and note uneven, jerking movements and the inability to touch your finger or
his or her nose. 
 To test coordination in the lower extremity, have the patient lie down and run
the heel of one foot against the shin of the other leg.
 Test the ability to make rapid alternating movements by having the patient
rapidly tap his or her index finger on the thigh or a table surface.
 Tandem walking, in which the patient walks heal to toe as though walking a
tightrope, also tests coordination; patients with arthritic deformities may not
be able to perform this test. Have weak or poorly coordinated patients hold
your hand during the tandem walking test.

Reflexes :
Nurses can perform some tests of reflexes:

 To test the corneal reflex, gently touch the cornea with a wisp of clean
cotton. Tissue and gauze are too rough and can cause corneal abrasions.
Normally, the eye should blink.
 Test the Babinski reflex (i.e., plantar response) by stroking the sole of the
patient’s foot. Normally,the toes should flex; an abnormal response is
extension and fanning of the toes.

Additional Tests:Each of the cranial nerves can be tested to identify further

problems. Lumbar puncture, cerebral angiography, pneumoencephalography, and
computed tomography scans are among other screening devices used to evaluate
neurologic problems. A review of mental status is included in the assessment of the
nervous system.
SELECTED NEUROLOGIC CONDITIONS:

Cerebrovascular Accidents
-Older persons with hypertension, severe arteriosclerosis, diabetes, gout, anemia,
hypothyroidism, silent myocardial infarction, TIAs, and dehydration and those who
smoke are among the high-risk candidates for a CVA.
-. The major types of CVA are ischemic, usually resulting from a thrombus or
embolus, and hemorrhagic, which can occur from a ruptured cerebral blood vessel.
-Most CVAs in older individuals are ischemic, caused by partial or complete cerebral
thrombosis. Light-headedness, dizziness, headache, drop attack (feeling of being
strongly and suddenly pulled to the ground), and memory and behavioral changes
are some of the warning signs of a CVA
-CVAs can occur without warning, however, and show highly variable signs and
symptoms, depending on the area of the brain affected. Major signs tend to include
hemiplegia, aphasia, and hemianopsia.
-Good nursing care can improve the patient’s chance of survival and minimize the
limitations that impair a full recovery.
-In the acute phase, nursing efforts have the following aims:

 Maintain a patent airway.

 Provide adequate nutrition and hydration.
 Monitor neurologic and vital signs.
 Prevent complications associated with immobility

 The eyes of the unconscious patient may remain open for a long time,
risking drying, irritation, and ulceration of the cornea.
-Corneal damage can be prevented by eye irrigations with a sterile saline
solution followed by the use of sterile mineral oil eye drops.
-Eye pads may be used to help keep the eyelids closed; these are
changed daily and frequently checked to make sure the lids are actually
closed.
-Regular mouth care and range-ofmotion exercises are also standard
measures.
 When the patient regains consciousness and stabilizes, more active
nursing efforts can focus on rehabilitation
-Attention span is reduced, and long, complicated directions may be
confusing.
-Memory for old events may be intact, whereas recent events or
explanations are forgotten, a characteristic demonstrated by many older
persons without a history of CVA.
 Patients may have difficulty transferring information from one situation to
another.
 Confusion, restlessness, and irritability may arise from sensory
deprivation. Emotional lability may also be a problem.

 To minimize the limitations imposed by these problems, the nurse may

find the following actions helpful:

 Talk to the patient during routine activities.

 Briefly explain the basics of what has occurred, the procedures being
performed, and the activities to expect.
 Speak distinctly but do not shout.
  Devise an easy means of communication, such as a picture chart to
which one can point.
 Minimize environmental noise, traffic, and clutter.
 Aim for consistency of those providing care and of care activities.
 Use objects familiar to patients (e.g., their own clothing and clock).
 Keep a calendar or sign in the room showing the day and date.
 Supply sensory stimulation through conversation, radio, television,
wall decorations, and objects for patients to handle.
 Provide frequent positive feedback; even a minor task may be a major
achievement for the patient. 
 Expect and accept errors and failures.

 For patients who have suffered speech impairments as a result of their

stroke, it is important to identify the type of impairment that is present.
Patients with dysarthria usually are able to understand speech but experience
difficulty speaking due to poor motor control, whereas patients with a
dysphasia have problems understanding words and/or expressing themselves
verbally. 

 Caregivers and family members need to understand the type of impairment

that is present so they can communicate effectively. Treating people with
dysarthria as though they don’t understand can be frustrating and insulting to
those people, whereas assuming that people with a dysphasia can
understand because they can pronounce words can be frustrating and unsafe
to those people.

 To prevent unnecessary frustration for all parties, it is  important for the
nurse to provide a realistic explanation of the speech disorder and to discuss
with those who need to communicate with the patient effective ways to do
so.

PARKINSON’S DISEASE
 affects the ability of the central nervous system to control body movements
as a result of impaired function of basal ganglia in the midbrain. It occurs
when neurons that produce dopamine in the substantia nigra die or become
impaired.
 Dopamine is necessary for smooth motor movement and has a role in
emotions. With the damage of a significant number of these dopamine-
producing cells, the symptoms of Parkinson’s disease appear. By the time
motor symptoms appear, nearly 80% of the dopamine neurons have been
lost.
 Parkinson’s disease is more common in men and occurs most frequently after
the fifth decade of life. The incidence rises with age, although most cases
have been diagnosed by the time people reach their seventh decade of life.
Although its exact cause is unknown.
 The death of substantia nigra cells within the basal ganglia leads to a
significant reduction in dopamine, which is responsible for the symptoms.
 The tremor is reduced when the patient attempts a purposeful movement.
Muscle rigidity and weakness develop, evidenced by drooling, difficulty in
swallowing, slow speech, and a monotone voice. The patient’s face assumes
a masklike appearance, and the skin is moist.
  Bradykinesia (slow movement) and poor balance occur.
 Appetite frequently increases, and the person may demonstrate emotional
instability.
 Postural instability is present. A characteristic sign is a shuffling gait while
leaning forward at the trunk. The rate of movement increases as the patient
walks, and the patient may not be able to voluntarily stop walking.
 As the disease progresses, the patient may become entirely unable to
ambulate. Secondary symptoms include depression, anxiety, sleep
disturbances, dementia, forced eyelid closure, decreased blinking, drooling,
dysphagia, constipation, shortness of breath, urinary hesitancy, urgency, and
reduced interest in sex.
 Carbidopa/levodopa in the form of Sinemet combines levodopa, which
converts to dopamine, and carbidopa, which reduces adverse effects and is
the most widely used and effective drug for Parkinson’s disease.
 Anticholinergics  may be prescribed to decrease the amount of acetylcholine
in the brain to restore the normal neurotransmitters’ balance; the effects of
these drugs need to be closely monitored because they can exacerbate
glaucoma and cause temporary anuria.
 Amantadine, mono oxidase inhibitors, and catechol-Omethyltransferase
inhibitors also can be prescribed to control symptoms.
 Close monitoring of drug therapy is important.  While they are taking
levodopa, patients should avoid foods that are high in vitamin B6 , such as
avocados, lentils, and lima beans, because they will counteract the drug;
dietary restrictions are not necessary if the patient is taking carbidopa–
levodopa (Sinemet).
 Active and passive range-of-motion exercises maintain and improve joint
mobility; warm baths and massage may facilitate these exercises and relieve
muscle spasms caused by rigidity.
 Contractures are a particular risk of older persons with Parkinson’s disease.
 Tension and frustration will aggravate the patient’s symptoms; therefore, it is
important for the nurse to offer psychological support and minimize emotional
upsets.
 The nurse should emphasize that the disease progresses slowly and that
therapy can minimize the disability.
 Intellectual functioning may be impaired as the disease progresses, the
person with Parkinson’s disease cannot be assumed to be cognitively
impaired; it is important that others do not underestimate the mental
abilities of the patient due to the speech problems and helpless appearance,
as this can be extremely frustrating and degrading to the patient, who may
react by becoming depressed or irritable.
 Continuing support by the nurse can help the family maximize the patient’s
mental capacity and understand personality changes that may occur.
 Communication and mental stimulation should be encouraged on a level that
the patient always enjoyed.

DEMENTIA & DELIRIUM

DELIRIUM -A variety of conditions can impair cerebral circulation and cause

disturbances in cognitive function.
  Sometimes the history, physical examination, or laboratory tests will indicate
the presence of an organic factor that has caused the disturbance; however,
without such evidence, the diagnosis of delirium can be established by the
symptoms and lack of any nonorganic mental disorder that could cause them.
 The onset of symptoms with delirium tends to be rapid and can include
disturbed intellectual function; disorientation of time and place but usually
not of identity; altered attention span; worsened memory; labile mood;
meaningless chatter; poor judgment; and altered level of consciousness,
including hypervigilance, mild drowsiness, and semicomatose. status.
 Significant perceptual changes can occur, such as hallucinations (usually
visual) and illusions (e.g., misinterpreting caregivers as police guards).
 Disturbances in sleep-wake cycles can occur; in fact, restlessness and sleep
disturbances may be early clues.
 The patient may be suspicious, have personality changes, and experience
illusions more often than delusions.
 Physical signs, such as shortness of breath, fatigue, and slower psychomotor
activities, may accompany behavioral changes.
 Any change in behavior or cognitive pattern warrants an evaluation. There is
the risk that delirium may not be recognized if persons unfamiliar with the
patient assume that poor cognition is normal for him or her.
 
Assessment Guide: MENTAL HEALTH GENERAL OBSERVATIONS 
-Assessment of mental status actually begins the moment the nurse meets the
patient. Upon initial observation, pay attention to the following indicators
of mental health:

 Grooming and dress: Is clothing appropriate for the season, clean and
presentable, appropriately worn? Is the patient clean? Is the hair clean and
combed? Are makeup and accessories excessive or bizarre?
 Posture: Does the patient appear stooped and fearful? Is body alignment
normal? 
 Movement: Are tongue rolling, twitching, tremors, and hand wringing
present? Are movements hyperactive or hypoactive?
 Facial expression: Is it masklike or overly dramatic? Are there indications of
pain, fear, or anger? 
 Level of consciousness: Does the patient drift into sleep and need to be
aroused (i.e., lethargic)? Does the patient offer only incomplete or slow
responses and need repeated arousal (i.e., stuporous)? Are painful stimuli the
only thing the patient responds to (i.e., semiconscious)? Is there no
response, even to painful stimuli (i.e., unconscious)? While observing the
patient, general conversation can aid in evaluating mental status.

Note the tone of voice, rate of speech, ability to articulate, use of unusual words or
combinations of words, and appropriateness of speech. Also, evaluate mood during
this time.

INTERVIEW:
- Effective questioning can reveal much about the patient’s mental health. Ask
direct questions to unveil specific problems, such as the following:
  “How do you feel about yourself? Would you say others would say you are a
good or bad person?” 
 “Do you have many friends? How do you get along with people?” 
 “Has anyone harmed you or do you feel that anyone is trying to harm you?
Who? Why?” 
 “Are you moody? Do you quickly go from laughing to crying or from being
happy to sad?” 
 “Do you have trouble falling asleep or staying asleep? How much sleep do
you get? 
 Do you use any drug or alcohol to help you sleep?” 
 “How is your appetite? How do your appetite and eating pattern change
when you are sad or worried?”
 “Do you ever have feelings of being nervous, such as palpitations,
hyperventilating, and restlessness?” 
 “Are there any particular problems in your life or anything you are concerned
about now?”
 “Do you see or hear things that other people do not? Have you ever heard
voices? If so, how do you feel about them?”
 “Does life bring you pleasure? Do you look forward to each day?”
 “Have you ever thought about suicide? If so, what were those ideas like?
How would you do it?” 
 “Do you feel you are losing any of your mental abilities? If so, describe how.” 
 “Have you ever been hospitalized or had treatment for mental problems? Has
any member of your family?”

Listen carefully to the answers and how they are given. It is important to pick up
nonverbal clues.

COGNITIVE TESTING:
-Even without the use of a tool, the nurse can assess basic cognitive function in the
following ways:

 Orientation: Ask the patient his or her name, where he or she is, the date,
time, and season. 
 Memory and retention: At the beginning of the assessment, ask the patient to
remember three objects (e.g., watch, telephone, and boat). First, ask the
patient to recall the items immediately after being told; then, after asking
several other questions, ask for a recall of the three items again; near the
end of the assessment, ask what the three items were one last time. 
 Three-stage command: Ask the patient to perform three simple tasks (e.g.,
“Pick up the pencil, touch it to your head, and hand it to me.”).
 Judgment: Present a situation that requires basic problem solving and
reasoning (e.g., “What is meant by the statement ‘A bird in the hand is worth
two in the bush’?”). 
 Calculation: Ask the patient to count backward from 100 by increments of 5;
if this is difficult, ask the patient to count backward from 20 by increments of
2. Simple arithmetic problems may also be asked, if they are within the realm
of the patient’s educational experience.

Whenever a cognitive function is tested, consider the unique experiences,

educational level, and cultural background of the patient, as well as the role of
sensory deficits, health problems, and the stress associated with being examined.

Persons with Alzheimer’s disease or other cognitive deficits may become

overwhelmed by the assessment and react with anger, tears, or withdrawal. This is
referred to as a catastrophic reaction. The assessment may need to be discontinued
temporarily and the patient reassured and comforted.

PHYSICAL EXAMINATION
- Physical health problems are often at the root of many cognitive disturbances
-A complete review of known diagnoses and medications being used is crucial. In
addition, a variety of laboratory tests may be conducted, including the following:
complete blood count

 serum electrolytes
 serologic test for syphilis
 blood urea nitrogen
 blood glucose
 bilirubin
 blood vitamin level
 sedimentation rate
 urinalysis

 Delirium is reversible in most circumstances, and prompt care, treating this

condition as a medical emergency, can prevent permanent damage.
 Treatment depends on the cause (e.g., stabilizing blood glucose, correcting
dehydration, and discontinuing a medication).
 Treating the symptoms rather than the cause or accepting the symptoms as
normal and failing to obtain treatment can result not only in worsened mental
status but also in the continuation of a physical condition that could be life-
threatening.
 During the initial acute stage, establishing medical stability and minimizing
stimulation are primary goals.
 Consistency in care is important; thus, the patient benefits from interaction
with only a limited number of people.
 Providing frequent orientation and explanations fosters function and
reduces anxiety and stress.
 Controlling environmental temperature, noise, and traffic flow are important.
 Placing this patient in a quiet area away from the mainstream activity is
beneficial.
 Bright lights should be avoided, but ample lighting is needed to enable the
patient to adequately visualize the environment.
 The nurse should ensure that the patient does not harm himself or herself or
others and that physical care needs are met.
 Regardless of the level of intellectual function or consciousness, it is
important to speak to the patient and offer explanations of activities or
procedures being done. Approach from the front, make eye contact and
speak in a calm manner.
  While keeping explanations and questions simple, it is important to avoid
addressing the person as a child or ignoring the person while discussing
him or her with others who are in the person’s presence.

 Avoid rushing and overwhelming the patient. If the person becomes

agitated or combative during the communication, remain calm and
relaxed. If the patient is in an area with other people, attempt to guide
him or her to a quieter area.

 Use gentle touch (e.g., stroking the arm) unless the person appears
threatened or agitated by the contact. If the patient becomes combative,
keep a safe distance between you and the patient.

 Avoid asking questions or arguing, and offer simple, reassuring

comments. Try to divert the patient’s attention (e.g., pointing out a new
card that the patient received or a picture on the wall).

 Any information the nurse gleans concerning factors that trigger agitation
for this patient and measures that can facilitate communication with him
or her should be documented in the patient’s record and shared with
others who have contact with the patient.

DEMENTIA
-is an irreversible, progressive impairment in cognitive function affecting memory,
orientation, judgment, reasoning, attention, language, and problem-solving. It is
caused by damage or injury to the brain.

Alzheimer’s Disease
-Alzheimer’s disease is the most common form of dementia
-Alzheimer’s disease is characterized by two changes in the brain:

 The first is the presence of neuritic plaques, which contain deposits of β-

amyloid protein (excess amounts of this are found in persons with Alzheimer’s
disease and Down’s syndrome). β-Amyloid protein is a fragment of amyloid
precursor protein that helps the neurons grow and repair. The β-amyloid
fragments clump together into plaques that impair the function of nerve cells
in the brain. It is unclear at this point if the plaques are a cause or by-product
of the disease.

 The second characteristic brain change is neurofibrillary tangles in the cortex.

Microtubules, structures within healthy neurons, are normally stabilized by a
special protein called tau. In Alzheimer’s disease, tau is changed and begins
to pair with other threads of tau that become tangled. This causes the
microtubules to disintegrate and collapse the neuron’s transport system.

 There are also changes in neurotransmitter systems associated with

Alzheimer’s disease, including reductions in serotonin receptors, serotonin
uptake into platelets, production of acetylcholine in the areas of the brain in
 which plaque and tangles are found, acetylcholinesterase (which breaks down
acetylcholine), and choline acetyltransferase.

 The transitional stage between normal cognitive aging and dementia in which
the person has short-term memory impairment and challenges with complex
cognitive functions are referred to a mild cognitive impairment.

 Possible Causes:

o Although environmental factors play a role, genetic factors do

increase the risk of Alzheimer’s disease

o Chromosomal abnormalities have been identified. A strong argument

for the genetic formulation of the disease stems from its connection
with Down’s syndrome.

o Chromosomes 14 and 1 have also been found to have mutations

within families who have a high prevalence of Alzheimer’s disease;
these mutations cause abnormal proteins to be produced.

o There is some investigation into the role of free radicals in the

development of Alzheimer’s disease. Free radicals are molecules that
can build up in neurons, resulting in damage (called oxidative
damage). The damage blocks substances from flowing in and out of
the cell, leading to brain damage. Higher than normal levels of
aluminum and mercury have been found in the brain cells of
Alzheimer’s disease patients, causing some speculation regarding the
role of environmental toxins in the disease.

 SIGNS & SYMPTOMS:

The greatest risk of suicide for a person with dementia is in the early stage of the
disease when an individual is aware of the changes experienced.

Treatment:
  There has been interest in estrogen’s role in enhancing cognitive function,
with speculation that estrogen has a role in protecting postmenopausal
women from developing Alzheimer’s disease or another age-related cognitive
decline; however, research has produced conflicting results as the women’s
Health Initiative Memory Study demonstrated an increased risk of dementia
in postmenopausal women in women taking estrogen with progestin (Barron
& Pike, 2012)

 Antioxidants, anti-inflammatory agents, supplements (folic acid and vitamins

B6 and B12 ), a gene therapy that adds a nerve growth factor to the aging
brain and the development of a vaccine are among the other areas being
investigated in clinical trials (Université, 2013).

 Acetylcholine falls sharply in people with Alzheimer’s disease, medications

that stop or slow the enzyme (acetylcholinesterase) that breaks down
acetylcholine have been developed to help people with Alzheimer’s disease;
these drugs include donepezil (Aricept), rivastigmine (Exelon), and
galantamine (Reminyl).

Other Dementias:
 In addition to Alzheimer’s disease, a variety of other pathologies can cause
dementia:

 Vascular dementia results from small cerebral infarctions. Damage to the

brain tissue can be diffuse or localized, the onset is more rapid, and the
disease progresses more predictably than Alzheimer’s disease. It is associated
with risk factors such as smoking, hypertension, hyperlipidemia, inactivity,
and a history of stroke or cardiovascular disease.
 Frontotemporal dementia is characterized by neuronal atrophy affecting the
frontal lobes of the brain rather than by neurofibrillary tangles and plaques as
in Alzheimer’s disease. A unique characteristic of this dementia is the
appearance of behavioral rather than cognitive abnormalities in the early
stage. Also, rather than poor memory, early cognitive changes can include
impairments in abstract thinking and speech and language skills. Pick’s
disease is the most common form of frontotemporal dementia.

 Lewy body dementia is also known as cortical Lewy body disease, is

associated with subcortical pathology and the presence of Lewy body
substance in the cerebral cortex. People with this dementia have fluctuations
in mental status, decompensate rapidly when they experience a medical
condition, and often have idiosyncratic reactions to cholinergic-type
medications (e.g., sedatives and antipsychotics). About one-fourth of the
people diagnosed with this dementia have a history of a family member with
dementia. Lewy body dementia is often misdiagnosed as other forms of
dementia.

 Creutzfeldt-Jakob disease is an extremely rare brain disorder that causes

dementia. It has a rapid onset and progression and is characterized by severe
neurological impairment that accompanies dementia. It is believed that this
disease can be transmitted through a slow virus; a familial tendency toward
the disease is possible. The pathological process displays destruction of
neurons in the cerebral cortex, overgrowth of glia, the abnormal cellular
 structure of the cortex, hypertrophy, and proliferation of astrocytes, and a
sponge-like appearance of the cerebral cortex. Symptoms are more varied
than with Alzheimer’s disease and include psychotic behavior, heightened
emotional lability, memory impairment, loss of muscular function, muscle
spasms, seizures, and visual disturbances.

 Wernicke’s encephalopathy and Parkinson’s disease are responsible for a

small percentage of dementias. 
 AIDS may lead to the development of dementia in the final phase of the
disease. 
 Trauma and toxins are among the other causes of dementia.

Caring for Persons with Dementia:

-The irreversible nature of dementia and its progressive deteriorating course can
have devastating effects on affected individuals and their families. A majority of the
care required by persons with dementia falls within the scope of nursing practice.

1. Ensuring Patient Safety
-Their poor judgment and misperceptions can lead to serious behavioral
problems and mishaps. A safe, structured environment is essential. The
persons and components of the environment should be consistent
-Items to trigger memory are useful to include, such as photographs of the
patient or a consistently used symbol (e.g., flower or triangle) on the
bedroom door or personal possessions. Noise, activity, and lighting levels can
overstimulate the patient and further decrease function; thus, they need to
be controlled. This is particularly useful in preventing and managing
sundowner syndrome.
Sundowner Syndrome:
-Individuals with cognitive impairments may experience a nocturnal
confusion, named sundowner syndrome due to its presentation “after the sun
goes down.” Some of the factors that increase the risk of this condition
include unfamiliar environment (e.g., recent admission to a facility), disturbed
sleep  patterns (e.g., from sleep apnea), use of restraints, excess sensory
stimulation, sensory deprivation, or change in circadian rhythms.
-Nurses can prevent and manage sundowner syndrome by, placing familiar
objects in the person’s room, providing physical activity in the afternoon to
help the person expend energy, adjusting the lighting in the environment to
prevent the room from becoming dark in the evening, keeping a night-light
on throughout the night, having frequent contact with the person to offer
reassurance and orientation, using touch to provide human contact and calm
the person, ensuring the environmental temperature is within a comfortable
range for the person, controlling noise and traffic flow in the evening,
ensuring the person’s basic needs are met (e.g., adequate fluids, toileting,
and dry clothing).
2. Promoting Therapy and Activity
-Various therapies and activities can be offered to the patient with dementia,
depending on the patient’s level of function.
-Occupational therapy and expressive therapies can benefit those with early
dementia. Various degrees of reality orientation, ranging from daily groups to
reminding the patient who he or she is during every interaction can be used.
-Even the most regressed patient can maintain contact and derive stimulation
 through activities, such as listening to music, petting an animal, and touching
various objects. Being touched is also a pleasurable and stimulating
experience
-Modified communication techniques can facilitate activity. Some useful
strategies include the following:  Using simple sentences that contain only
one idea or instruction, Speaking in a calm manner using an adult tone (not
baby talk), Avoiding words or phrases that can be misinterpreted or sarcasm
Offering opportunities for simple decisions, Avoiding arguments (distractions
can help), Recognizing efforts with positive feedback, Observing nonverbal
expressions and behaviors.
3. Providing Physical Care
-The physical care needs of patients with dementia must not be overlooked.
These individuals may not complain that they are hungry, so no one may
notice that they have consumed less than one-quarter of the food served;
they may not remember to drink water, so they can become dehydrated;
they may fight their bath so strongly that they are left unbathed, and
pressure ulcers on their buttocks may go unnoticed.
-These patients need close observation and careful attention to their physical
needs. Consideration must be given to their potential inability to
communicate their needs and discomforts; a subtle change in behavior or
function, a facial grimace, or repeated touching of a body part may give clues
that a problem exists.
-Consistency in caregivers allow the caregivers to become familiar with a
patient’s unique behaviors and more quickly recognize a deviation from that
individual’s norm.
4. Using Complementary and Alternative Therapies
- A variety of alternative medical therapies are being used to treat dementias.
Nutritional supplements that have been used include vitamins B6 , B12 , C,
and E; folic acid; zinc; and selenium.
5. Respecting the Individual
-As patients regress, their dignity, personal worth, freedom, and individuality
may be jeopardized. Loved ones may view the demented family member as a
stranger living inside the body that once housed the person they knew.
-Special attention must be paid to maintaining and promoting the following
qualities:
a. Individuality. The nurse should learn the personal history and uniqueness
of the patient and incorporate this into caregiving activities.
b. Independence. Even if it takes three times longer to guide patients
through dressing than it would take to dress them, they should be afforded
every opportunity for self-care.
c. Freedom. As major freedoms become limited, minor choices and control
become especially important. Nurses must be careful that, in the name of
efficiency and safety, such severe restrictions to freedom are not imposed
that the quality of life becomes minimal.
d. Dignity. To become angry or laugh at the behaviors of a demented person
is no less cruel than reacting in a similar fashion to a stroke victim who falls
during ambulation. These patients should be afforded the respect given to
any adult, including attractive clothing, good grooming, adult hairstyles, use
of their names, privacy, and confidentiality.
e. Connection. Persons with dementia continue to be valued human beings
who are members of families, communities, and the universe. Interaction and
 connection with other people and nature show recognition and respect for
the spiritual beings that live within the altered bodies and minds.
6. Supporting the Patient’s Family
-Assistance and support to the families of patients are integral parts of
nursing care for persons with dementia. The physical, emotional, and
socioeconomic burden of caring for a cognitively impaired relative can be
immense. It should not be assumed that family members understand basic
care techniques. The nurse needs to review basic, specific care techniques,
including lifting, bathing, and managing inappropriate behaviors. The nurse
can also help prepare families for the guilt, frustration, anger, depression,
and other feelings that normally accompany this responsibility.
-Helping families plan respite, network with support groups, and obtain
counseling may be beneficial.

INTEGUMENTARY FUNCTION

EFFECTS OF AGING ON THE SKIN

Lines and wrinkles, thicker nails, and graying hair are constant reminders of the
aging process. These result from common aging changes to the integumentary
system that include flattening of the dermal–epidermal junction, reduced thickness
and vascularity of the dermis, decreased rate of epidermal turnover, degeneration of
elastic fibers, increased coarseness of collagen, and reduction in melanocytes.

The increased fragility of the skin poses challenges to older adults and their
caregivers in that there are heightened risks for skin tears, bruising, pressure injury,
and skin infections. In addition, the effects of this system’s aging on appearance are
highly visible signs of the aging process, potentially affecting body image, self-
concept, reactions from others, socialization, and other psychosocial factors.

Assessment Guide for skin status:

GENERAL OBSERVATIONS
- Much of the status of the integumentary system is evident to the naked eye. A
quick observation can assist in evaluating skin color, moisture, and cleanliness, and
the presence of lesions. Signs such as pallor or flushing can provide clues to health
problems.

INTERVIEW
-Ask the patient about itching, burning sensations on the skin surface, and other
symptoms associated with skin problems. Also use this opportunity to review bathing
and shampooing practices.

PHYSICAL EXAMINATION

Skin surface.
-Examine the entire skin surface from head to toe, including behind the ears, within
skin folds, under the breasts, and between the toes. Bathing and massages are good
opportunities to inspect the skin in the course of patient care. Note moles, skin tears,
bruises, discoloration, and any other unusual finding. Be aware that areas of
pressure may be difficult to detect in dark skinned persons.
Lesions.
-Describe any lesions as specifically as possible in regard to their color (e.g., purple,
black, and hypopigmented), configuration (e.g., linear, separate, confluent, and
annular), size (e.g., measurement of depth and diameter), drainage, and type.
Terms used to describe the types of lesions include the following:

Macule: a small nonpalpable spot or discoloration

Papule: a discoloration less than ½ cm in diameter with palpable elevation
Plaque: a group of papules
Nodule: a lesion ½ to 1 cm in diameter with palpable elevation; the skin may
or may not be discolored
Tumor: a lesion greater than 1 cm with palpable elevation; the skin may or
may not be discolored
Wheal: a red or white palpable elevation that may occur in variable sizes
Vesicle: a lesion less than ½ cm in diameter that contains fluid and has a
palpable elevation Bulla: a lesion greater than ½ cm in diameter that
contains fluid and has a palpable elevation Pustule: a lesion containing
purulent fluid; of variable size and palpable elevation
Fissure: a groove in the skin Ulcer: an open depression in the skin that may
occur in variable sizes

Mongolian spots. Consider that many persons of African, Asian, or Native American
backgrounds have Mongolian spots. These are irregular, dark areas (resembling
bruises) that may be found on the buttocks, lower back, and to a lesser extent on
the arms, abdomen, and thighs.

Skin turgor. Test skin turgor by gently pinching various areas of the skin. Skin turgor
tends to be poor in most older adults; however, the areas over the sternum and
forehead do experience less of an age-related reduction in turgor and are good areas
for turgor assessment.

Pressure tolerance. Assess pressure tolerance by inspecting a pressure point after

the patient has been in the same position for half an hour; if redness is present, the
patient must be on a turning schedule of every half an hour. If redness is not
present, allow the patient to remain in the same position for 1 hour and inspect; if
redness is not apparent, increase increments by half an hour up to 2 hours.

Temperature. Obtain a gross assessment of skin temperature by using the back of

the hands and touching various areas. Note coldness or temperature inequalities
between the extremities.

SELECTED SKIN CONDITIONS

 Pruritus
-The most common dermatologic problem among older adults is pruritus. Although
atrophic changes alone may be responsible for this problem, pruritus can be
precipitated by any circumstance that dries the person’s skin, such as excessive
bathing and dry heat.
-Diabetes, arteriosclerosis, hyperthyroidism, uremia, liver disease, cancer, pernicious
anemia, and certain psychiatric problems can also contribute to pruritus. If not
corrected, the itching may cause traumatizing scratching, leading to breakage and
infection of the skin. Prompt recognition of this problem and implementation of
corrective measures are, therefore, essential. If possible, the underlying cause
should be corrected.
-Careful assessment is required to assure conditions, such as scabies, that demand
special precautions are not present. Bath oils, moisturizing lotions, and massage are
beneficial in treating and preventing pruritus. Vitamin supplements and a high-
quality, vitamin-rich diet may be recommended.
-Topical application of zinc oxide is effective in controlling itching in some individuals.
Antihistamines and topical steroids may also be prescribed for relief.

Keratosis
-Keratoses, also referred to as actinic or solar keratoses, are small, light-colored
lesions, usually gray or brown, on exposed areas of the skin. Keratin may be
accumulated in these lesions, causing the formation of a cutaneous horn with a
slightly reddened and swollen base.
-Freezing agents and acids can be used to destroy the keratotic lesions, but
electrodesiccation or surgical excision ensures a more thorough removal.
-Close nursing observation for changes in keratotic lesions is vital because these
lesions are precancerous.
Skin Cancer
-There are three major skin cancers that are common in late life: basal cell
carcinoma, squamous cell carcinoma, and melanoma. Basal cell carcinoma, the most
common form of skin cancer, grows slowly and rarely metastasize.
-Risk factors for its development include advanced age and exposure to the sun,
ultraviolet radiation, and therapeutic radiation. It commonly occurs on the face,
although it can erupt anywhere on the body.
-The growths tend to be small, dome-shaped elevations covered by small blood
vessels that often resemble benign, flesh-colored moles with a “pearly” surface. The
surface sometimes is dark, rather than shiny, if the growth contains melanin
pigments.

Vascular Lesions
-Age-related changes can weaken the walls of the veins and reduce the veins’ ability
to respond to increased venous pressure. '
-Obesity and hereditary factors compound this problem. Weakened vessel walls
cause varicose veins. The poor venous return and congestion that result lead to
edema of the lower extremities, which leads to poor tissue nutrition. As the poorly
nourished legs accumulate debris, inadequately carried away with the venous return,
the legs gain a pigmented, cracked, and exudative appearance.
-Stasis dermatitis, an inflammatory condition associated with chronic venous
insufficiency, can result. Subsequent scratching, irritation, or other trauma (which
can result from tight elastic-band stockings) that occurs with stasis dermatitis can
then easily lead to the formation of leg ulcers. These ulcers, known as stasis ulcers,
often appear on the medial aspect of the tibia above the malleolus and, prior to skin
breakdown, present as a dark discoloration of the skin. Stasis ulcers need special
attention to facilitate healing.
-Infection must be controlled, and necrotic tissue removed before healing will occur.
Good nutrition is an important component of the therapy, and a diet high in vitamins
and protein is recommended. Once healing has occurred, the concern should be
given to avoiding situations that promote stasis dermatitis.
- The patient may need instruction regarding a diet for weight reduction or the
planning of high-quality meals. Venous return can be enhanced by elevating the legs
several times a day and by preventing interferences to circulation, such as standing
for long periods, sitting with legs crossed, and wearing garters.
-Elastic support stockings may be prescribed and, although effective, can be a the
challenge for some older adults to apply.
-The nurse needs to assess the older adult’s ability to properly put on these
stockings and provide instruction as needed. Some patients may require ligation and
stripping of the veins to prevent further episodes of stasis dermatitis.

Pressure Injury
-Tissue anoxia and ischemia resulting from pressure can cause necrosis, sloughing,
and ulceration of tissue. This is commonly known as a pressure injury, previously
called pressure ulcer.
Stages:
-In addition to developing more easily in older persons, pressure injuries require a
longer period to heal than in younger people. Therefore, the most important nursing
measure is to prevent their formation; to do this, it is essential to avoid unrelieved
pressure. Encouraging activity or turning the patient who cannot move independently
is necessary.
-a turning schedule of every 2 hours may not be sufficient for every patient, and
pressure injuries can develop under that turning schedule. Shearing forces that
cause two layers of tissue to move across each other should be prevented by not
elevating the head of the bed more than 30 degrees, not allowing patients to slide in
bed, and lifting instead of pulling patients when moving them. Use of pillows,
floatation pads, alternating pressure mattresses, and water beds can disperse
pressure from bony prominences.
-A high-protein, vitamin-rich diet to maintain and improve tissue health is also
essential to avoid formation of pressure injury.
-Good skincare is another essential ingredient in prevention.
-The skin should be kept clean and dry; blotting the patient dry will avoid irritation
from rubbing the skin with a towel. Bath oils and lotions, used prophylactically, help
keep the skin soft and intact. Massage of bony prominences and range-of-motion
exercises promote circulation and help keep the tissues well nourished.
-The person who is incontinent should be thoroughly cleansed with soap and water
and dried after each episode to avoid skin breakdown from irritating excreta
-Treatment measures depend on the state of the pressure injury as identified by the
following signs: 

 Hyperemia. Redness of the skin appears quickly and can disappear quickly if
pressure is removed. There is no break in the skin, and the underlying tissues
remain soft. Relieving the pressure by the use of a square of adhesive foam
is useful; it is advisable to protect the skin with a product such as DuoDerm
(Squibb) or Tegasorb (3M) before applying the adhesive.
 Ischemia. Redness of the skin develops from up to 6 hours of unrelieved
pressure and is often accompanied by edema and induration. It can take
 several days for this area to return to its normal color, 1033 during which the
epidermis may blister. Skin should be protected with Vigilon, which contains
water and is soothing to the area. If the skin surface is broken, it should be
cleansed daily with normal saline or the product suggested by your agency.
 Necrosis. Unremitting pressure extending over 6 hours can cause ulceration
with a necrotic base. This type of sore requires a transparent dressing that
protects from bacteria but is permeable to oxygen and water vapor.
Thorough irrigation is essential during dressing changes. Sometimes topical
antibiotics are used. It may take weeks to months for full healing to occur.
 Deep tissue damage. If pressure is not relieved, necrosis will extend through
the fascia and potentially to the bone. Eschar, a thick, coagulated crust, is
frequently present, and bone destruction and infection may occur. Unless
eschar is removed, the underlying tissue will continue to break down, so
debridement is essential.

GENERAL NURSING CONSIDERATIONS FOR SKIN CONDITIONS

Promoting Normalcy:
-Psychological support can be especially important to the patient with a dermatologic
problem. Unlike respiratory, cardiac, and other disorders, dermatologic problems are
often visibly unpleasant to the patient and others.
-Visitors and staff may unnecessarily avoid touching and being with the patient in
reaction to his or her skin problems. -The nurse can reassure visitors regarding
the safety of contact with the patient and provide instruction for any special
precautions that must be followed.
-The most important fact to emphasize is that the patient is still normal, with normal
needs and feelings, and will appreciate normal interactions and contact. Many older
adults are distressed at the visible signs of aging reflected in wrinkles.
-Persons of all ages need to be advised that wrinkles can be prevented by avoiding
excess sun exposure and using sunscreen. There are topical products (e.g., α- or β-
hydroxy acids) that can reduce wrinkling.
-With cosmetic surgery advertisements being widespread, this option for gaining a
more youthful-looking skin may be considered by some older persons; advise
individuals to seek reputable providers who are experienced in these procedures.

Using Alternative Therapies

-Today, the use continues, as evidenced by creams, lotions, and shampoos
containing aloe, chamomile, and other plant products.
-Aloe vera has emollient properties when used externally, and many people find it
useful for treating minor cuts and burns. The external application of chamomile
extract is used for skin inflammation.
-Witch hazel has long been used for its astringent effects and is applied externally for
the treatment of bruises and swelling.
-Essential oils are also increasingly used for the prevention and treatment of skin
problems, including thyme oil as an antiseptic, thyme linalool and rosewood oil for
topical acne, rosemary oil for cell regeneration, and the oils of basil, cinnamon,
garlic, lavender, lemon, sage, savory, and thyme for insect bites or stings.
-Topical application of peppermint oil can have an anti-inflammatory effect and
speed the healing of wounds and mild burns. Some homeopathic and naturopathic
remedies are being used to treat skin eruptions, as is acupuncture.
- Biofeedback, guided imagery, and relaxation exercises can help control the
symptoms of some dermatologic disorders.
-There is a belief that nutritional supplements can also be beneficial for skin
disorders; those most commonly recommended are zinc, magnesium, essential fatty
acids, and vitamins A, B complex, B6 , and E. Nurses should urge patients to discuss
the use of alternative therapies with their physicians.

SENSORY FUNCTION

Effects of Aging on Vision and Hearing

- The reduced elasticity and stiffening of the muscle fibers of the lens of the
eye that begins in the fourth decade of life interferes with the ability to
adequately focus and is the factor responsible for most older people requiring
some form of corrective lenses; this condition is known as presbyopia.
-Visual acuity progressively declines due to reduced pupil size, opacification of
the lens and vitreous, and loss of photoreceptor cells in the retina. The light
perception threshold decreases causing difficulty with vision at night and in
dimly lit areas. Dark and light adaptation takes longer. Sensitivity to glare
increases due to cataract formation.
- Visual changes cause depth perception to become distorted, making the
ability to judge the height of walking surfaces more challenging. Visual fields
become smaller reducing peripheral vision. The eyes produce fewer tears and
are drier.
-Approximately half of all individuals who are identified as legally blind each
year are 65 years of age or older. Visual limitations can make communication
problematic because facial expressions and gestures, which are as important
as the words themselves, may be missed or misinterpreted. Lip reading to
compensate for hearing deficits may be difficult, and written correspondence
may be limited because independent reading and writing become almost
impossible tasks. Remaining aware of current events through newspapers
and socialization through playing cards and other games may be hampered.
-Hearing changes are also common and may negatively impact
communication. Presbycusis (age-related sensorineural hearing loss) reduces
the ability to hear s, sh, f, ph, and w sounds and may cause speech to be
inaudible or distorted, as can impacted cerumen, which is a common problem
in older adults.
-Older people may be self-conscious of this limitation and avoid situations in
which they must interact. In turn, others may avoid them because of this
difficulty. Telephone conversations can be affected by this problem, limiting
social contact even further for the individual who may be socially isolated for
other reasons.
-Approximately 10% of the older population has some difficulty hearing
telephone conversations. Assessing the underlying cause of a hearing
problem through professional evaluation, including an audiometric
examination, is the first step in the management or correction of the
problem.

Promoting Vision

- Routine and thorough eye examinations, including tonometry, by an

ophthalmologist are important in detecting and treating eye problems early in
older individuals. The nurse should stress the importance of an annual eye
examination, to detect vision changes and needs not only for alterations in
 corrective lenses but also for early discovery of problems, such as cataracts,
glaucoma, and other disease processes.
-Annual eye examinations, prompt evaluation is required for any symptom
that could indicate a visual problem, including burning or pain in the eye,
blurred or double vision, redness of the conjunctiva, spots, headaches, and
any other change in vision.
-Nutrients Beneficial to Vision:
o Essential Fatty Acids: Important to healthy retinal function.
o Flavonoid: Improves night vision and adaptation to dark;
promotes visual acuity; improves capillary integrity to reduce
hemorrhage risk in diabetic retinopathy.
o Vitamin A: Maintains healthy rods and cones in retina.
o Vitamin B complex: May prevent elevated levels of
homocysteine, which is associated with vascular problems
affecting the retina.
o Vitamin C: Promotes normal vision; supplementation may
reduce the risk of cataracts.
o Vitamin E: May aid in preventing cataracts; supplementation in
large doses can prevent macular degeneration.
o Selenium: May aid in preventing cataracts; supplementation
with vitamin E can reduce visual loss in macular degeneration.
o Zinc: Promotes normal visual capacity and adaptation to dark;
supplementation can reduce visual loss in macular
degeneration; deficiency can facilitate cataract development.
Promoting Hearing

-Some hearing deficits in old age can be avoided by good care of the ears
throughout the life. Such care should include prompt and complete treatment
of ear infections, prevention of trauma to the ear (e.g., from a severe blow or
a foreign object in the ear), and regular audiometric examinations.
-The nurse should examine an older adult’s ears frequently for cerumen
accumulation. Cerumen removal can be aided by gentle irrigation of the
external auditory canal with warm water or a hydrogen peroxide and water
solution; commercial preparations are also available.
-A forceful stream of solution should not be used during this procedure
because it can cause perforation of the eardrum. It is wise for older persons
to have assistance when irrigating ears because dizziness often occurs during
the procedure. Even allowing water to run in the ears during showers or
shampoos can aid in loosening cerumen.
-Avoid the use of cotton-tipped applicators for cerumen removal, because
they can push the cerumen back into the ear canal and cause an impaction.
Hairpins or similar devices should never be used.
-Protection from exposure to loud noises, such as those associated with
factory and construction work, vehicles, loud music or drums, and explosions,
is important throughout the life; earplugs or other sound-reducing devices
should be used when exposure is unavoidable.

Assessment Guide VISION AND HEARING

-GENERAL OBSERVATIONS
During interactions with the patient, note the signs of hearing deficits
such as missed communication, requests to have words repeated,
 reliance on lip reading, and cocking of the head to one side in an
effort to hear better. Identify eye problems by noticing if the patient
uses eyeglasses, demonstrates difficulty seeing (e.g., bumping into
objects and unable to see small print), or possesses eye abnormalities
such as drooping eyelids, discolored sclera, excess tearing, discharge,
and unusual movements of the eyes. Foul odors (e.g., associated
with incontinence or vaginitis) that do not seem to bother the patient
could reflect diminished olfactory function; cigarette burns on finger
or unrecognized pressure ulcers may indicate that the patient has
reduced ability to sense pressure and pain.
-INTERVIEW
o Ask the patient about the date and type of the last ophthalmic
and audiometric examinations (e.g., Where was the
examination done? Was an ophthalmologist or optometrist
seen? Did the eye examination include tonometry? Was a full
audiometric evaluation or basic hearing screening done?).
o If eyeglasses or hearing aids are used, ask questions about
where, when, and how these appliances were obtained (e.g.,
reading glasses purchased from the local pharmacy versus
prescription glasses; hearing aid obtained via television
advertisement).
o Ask questions such as the following to disclose the presence of
sensory problems:
 “Has there been any change in your vision?
Please describe.”
 “Are your glasses as useful to you as they were
when you first obtained them?”
 “Do you experience pain, burning, or itching in
the eyes?”
 “Do you ever see spots floating across your
eyes? How often does this happen and how
large and numerous are the spots?”
 “Do you ever see flashes of light or halos?”
 “Are your eyes ever unusually dry or watery?”
 “Do you have difficulty with vision at night, in
dimly lit areas, or in bright areas?”
 “Does anyone in your family have glaucoma or
other eye problems?”
 “Have you noticed any change in your ability to
hear? Please describe.”
 “Are certain sounds more difficult for you to
hear than others?” “Do you ever experience
pain, itching, ringing, or a sense of fullness in
your ears?”
 “Do your ears accumulate a lot of wax? How do
you manage this?”
 “Is there ever drainage from your ears?”
-PHYSICAL EXAMINATION
Eyes
o Inspect the eyes for unusual structure, drooping eyelids, discoloration,
and abnormal movement.
 o Loss of elasticity around the eyes, indicated by bags, is a common
finding. Black-skinned persons may normally have a slight yellow
discoloration of the sclera. Note any lesions on the eyelids.
o Palpation of the eyeballs with the eyelids closed can reveal hard-
feeling eyes with extremely elevated intraocular pressure (IOP) and
spongy-feeling eyes with fluid volume deficits.
o Perform a gross evaluation of visual acuity by having the patient read
a Snellen chart or various sized lettering on a newspaper. If the
patient is unable to see letters on the chart or newspaper, estimate
the extent of the visual limitation by determining if the patient is able
to see fingers held up before him or can merely make out figures.
o To perform a gross test of the visual field, have the patient focus
straight ahead. While facing the patient, bring your finger into the
field of view. Note when the patient indicates seeing your finger
compared with when you are able to see it. If the patient has
restrictions in seeing all portions of the visual field, review the exact
nature of this problem. A blind spot in the visual field (i.e., scotoma)
can occur with macular degeneration, a narrowing of the peripheral
field may be associated with glaucoma, and blindness in the same half
of both eyes (i.e., homonymous hemianopia) can be present in
persons who have experienced a cerebrovascular accident.
o Test extraocular movements by having the patient follow your finger
as you move it to various points, horizontally and vertically. Irregular,
jerking eye movements can result from disturbances in cranial nerves
III, IV, or VI.

Ears
o Inspection of the ears commonly shows cerumen accumulation,
increased hair growth, and atrophy of the tympanic membrane, which
causes it to appear white or gray.
o Cerumen impactions should be noted and removed.
o A small, crusted, ulcerated lesion on the pinna can be a sign of basal
or squamous cell carcinoma.
o Perform a gross evaluation of hearing by determining the patient’s
ability to hear a watch ticking. Check both ears.
o Weber and Rinne tests can be performed to assess sounds at different
frequencies. These tests involve placing a vibrating tuning fork next to
the ear or against the skull; this will stimulate the inner ear to vibrate.
The Rinne tuning fork test helps evaluate a patient’s hearing ability by
air conduction compared with that of bone conduction. The Weber
tuning fork test helps determine a patient’s hearing ability by bone
conduction only, and this test is useful when hearing loss is
asymmetrical.
o In addition to presbycusis and conductive hearing losses, ear or upper
respiratory infections, ototoxic drugs, and diabetes can be responsible
for diminishing hearing.

Selected Vision and Hearing Conditions

Cataracts
 is a clouding of the lens or its capsule that causes the lens to lose its
transparency. Cataracts are common in older people because everyone
develops some degree of lens opacity with age.
 Everyone develops some degree of lens opacity with age, although it is more
severe in persons who have had significant exposure to sunlight.
 Exposure to ultraviolet B increases the risk of developing cataracts,
emphasizing the importance of wearing proper sunglasses to protect the
eyes.
 Diabetes, cigarette smoking, high alcohol consumption, and eye injury are
also contributing factors.
 Symptoms:
o No discomfort or pain is associated with cataracts
o visual acuity is not affected, but as opacification continues, vision is
distorted, night vision is decreased, and objects appear blurred.
o Glare from sunlight and bright lights is extremely bothersome to the
affected person; this is due to the cloudy lens causing light to scatter
more than it would in a clear lens.
o Nuclear sclerosis develops, causing the lens of the eye to become
yellow or yellow-brown; eventually the color of the pupil changes from
black to a cloudy white.
 Treatment and Cataract Surgery
o Patients with a single cataract may not necessarily undergo surgery if
vision in the other eye is good, and these individuals should
concentrate on strengthening their existing visual capacity, reducing
their limitations, and using the safety measures applicable to any
visually impaired person
o Sunglasses, sheer curtains over windows, furniture placed away from
bright light, and several soft lights instead of a single bright light
source minimize annoyance from glare. It is beneficial to place items
within the visual field of the unaffected eye, a consideration when
preparing a food tray and arranging furniture and frequently used
objects.
o Measures to Compensate for Visual Deficits in Older Adults:
 Face the person when speaking.
 Use several soft indirect lights instead of a single glaring one.
 Avoid glare from windows by using sheer curtains or stained
windows.
 Use large print reading material.
 Place frequently used items within the visual field.
 Avoid the use of low-tone colors and attempt to use bright
ones.
 Use contrasting colors on doorways and stairs and for changes
in levels.
 Identify personal belongings and differentiate the room and
wheelchair with a unique design rather than by letters or
numbers
o Cataract surgery is an outpatient procedure and older people usually
withstand it well. Gerontological nurses are in a position to reassure
older patients and their families that age is no deterrent to cataract
surgery.
 o Two types of surgical procedures are used:
 Intracapsular extraction is the surgical procedure of choice for
the older patient with cataracts and consists of removing the
lens and the capsule.
 Extracapsular extraction is a simple surgical procedure in
which the lens is removed and the posterior capsule is left in
place. A common problem with extracapsular extraction is that
a secondary membrane may form, requiring an additional
procedure for discission of the membrane.

Glaucoma

 a is a degenerative eye disease in which the optic nerve is damaged from an

above-normal intraocular pressure (IOP).
 the exact cause is unknown, glaucoma can be associated with increased size
of the lens, iritis, allergy, endocrine imbalance, emotional instability, and a
family history of this disorder
 An increase in IOP occurs rapidly in acute glaucoma and gradually in chronic
glaucoma.
o Acute Glaucoma
 also called closed-angle or narrow-angle glaucoma, the patient
experiences severe eye pain, headache, nausea, and vomiting,
rapid increased tension within the eyeball, edema of the ciliary
body and dilation of the pupil occur.
 Vision becomes blurred, and blindness will result if this
problem is not corrected within a day, emphasizing that this is
a medical emergency demanding prompt attention.
 diagnostic test (i.e., gonioscopy) uses a contact lens and a
binocular microscope to allow direct examination of the
anterior chamber and differentiate closed-angle from open-
angle glaucoma.
 medications are now effective in treating the acute attack
(e.g., carbonic anhydrase inhibitors, which reduce the
formation of aqueous solution; mannitol, urea, and glycerin,
which reduce fluid because of their ability to increase osmotic
tension in the circulating blood).
 An iridectomy may be performed after the acute attack to
prevent future episodes of acute glaucoma.
o Chronic Glaucoma
 or open-angle, glaucoma is more common than acute
glaucoma.
 It often occurs so gradually that affected individuals are
unaware that they have a visual problem.
 Peripheral vision becomes slowly but increasingly impaired so
that people may not realize for a long time why they bump or
knock over items at their side.
 As the impairment progresses, central vision is affected.
People may complain of a tired feeling in their eyes,
headaches, misty vision, or seeing halos around lights—
symptoms that tend to be more pronounced in the morning.
  The cornea may have a cloudy appearance, and the iris may
be fixed and dilated.
 Treatment, aimed toward reducing the IOP, may consist of a
combination of a miotic and a carbonic anhydrase inhibitor or
of surgery to establish a channel to filter the aqueous fluid
(e.g., iridectomy, iridencleisis, cyclodialysis, and corneoscleral
trephining).
 Care and Prevention of Complications:
o Vision lost due to glaucoma cannot be restored.
o Physical straining and emotional stress should be prevented
o Miotics may be instilled into the eye; acetazolamide may be used.
Mydriatics, stimulants, and agents that elevate the blood pressure
must not be administered.
o It may benefit patients to carry a card or wear a bracelet indicating
their problem to prevent administration of these medications in
situations in which they may be unconscious or otherwise unable to
communicate.
o Abuse and overuse of the eyes must also be prevented.
o Nurses need to teach patients about the disease and its care and
counsel them about the importance of compliance

Macular Degeneration

 the most common cause of blindness in people over age 65, involves damage
or breakdown of the macula, which results in a loss of central vision.
 most common form is involutional macular degeneration, which is associated
with the aging process, although macular degeneration can also result from
injury, infection, or exudative macular degeneration.

Left upper – Normal Vision, Right Upper – Cataract,

Left Lower Macular Degeneration, Right Lower - Glaucoma

 Routine ophthalmic examinations can identify macular degeneration and

promote treatment that can prevent additional vision loss.
  Laser therapy has been used for the treatment of some forms of macular
degeneration, but the involutional type does not respond well to this
procedure.
 Magnifying glasses, high-intensity reading lamps, and other aids can prove
helpful to patients with this condition.

Corneal Ulcer

 Inflammation of the cornea, accompanied by a loss of substance, causes the

development of a corneal ulcer, a problem more common in older adults than
in younger-aged individuals.
 Febrile states, irritation, dietary deficiencies, lowered resistance, and
cerebrovascular accident tend to predispose the individual to this problem.
 Corneal ulcers, which are extremely difficult to treat in older persons, may
scar or perforate, leading to destruction of the cornea and blindness.
 The affected eye may appear bloodshot and show increased lacrimation. Pain
and photophobia are also present.
 Nurses should advise patients to seek prompt assistance for any irritation,
suspected infection, or other difficulty with the cornea as soon as it is
identified.
 Early care is often effective in preventing the development of a corneal ulcer
and preserving visual capacity.
 Cycloplegics, sedatives, antibiotics, and heat may be prescribed to treat a
corneal ulcer.
 Sunglasses will ease the discomfort associated with photophobia. It is
important that the underlying cause be treated—an infection, abrasion, or
presence of a foreign body. Corneal transplants are occasionally done for
more advanced corneal ulcers

Hearing Deficits

 Exposure to noise from loud music, jets, traffic, heavy machinery, and guns
cause cell injury and loss.
 The higher incidence of hearing loss in men may be associated with their
more frequent employment in occupations that subject them to loud noises
(e.g., truck driving, construction work, heavy factory work, and military
service).
 Recurrent otitis media and trauma can damage hearing. Certain drugs may
be ototoxic, including aspirin, bumetanide, ethacrynic acid, furosemide,
indomethacin, erythromycin, streptomycin, neomycin, karomycin, and
Rauwolfia derivatives; the delayed excretion of these drugs in many older
persons may promote this effect.
 Diabetes, tumors of the nasopharynx, hypothyroidism, syphilis, other disease
processes, and psychogenic factors can also contribute to hearing
impairment.
 In otosclerosis, an osseous growth causes fixation of the footplate of the
stapes in the oval window of the cochlea. This may be a middle ear problem;
it is more common among women and can progress to complete deafness.
 Tinnitus, a ringing or other sound in the ear, can be associated with age-
related hearing loss, ear injury, medications, or cardiovascular disease.
 Infections of the middle ear are less common in older individuals; they
usually accompany more serious disorders, such as tumors and diabetes. The
external ear can be affected by dermatoses, furunculosis, cerumen impaction,
cysts, and neoplasms.
o Patient Care
 The first action in caring for someone with a hearing deficit
should be to encourage audiometric examination. Hearing
impairment should not be assumed to be a normal
consequence of aging and ignored.
 sometimes the underlying cause of the hearing problem can be
corrected, frequently, older persons must learn to live with
varying degrees of hearing deficits.
 It is not unusual for individuals with a hearing impairment to
demonstrate emotional reactions to their hearing deficits.
 Unable to hear conversation, patients may become suspicious
of those around them and accuse people of talking about
them. Anger, impatience, and frustration can result from
repeatedly unsuccessful attempts to understand conversation.
 Patients may feel confused or react inappropriately on
receiving distorted verbal communications.
 Limited ability to hear danger and protect themselves may
make them feel insecure.
 Being self-conscious of their limitation may make them avoid
social contact to escape embarrassment and frustration.
 Social isolation can be a serious threat; people sometimes
avoid an older person with a hearing deficit because of the
difficulty in communication.
 People with hearing loss should be advised to request
explanations and instructions in writing so that they receive
the full content.
 Hearing Aids
o A variety of styles of hearing aids are available, including in the ear,
behind the ear, over the ear, and in the ear canal.
o hearing aid should never be purchased without being specifically
prescribed. Sometimes older persons will attempt to improve hearing
by purchasing an aid through a private party or a mail-order catalog,
which often results in disappointment and a waste of money from an
already limited budget.
o Patients must understand that, even with a hearing aid, their
problems will not be solved. Although hearing will improve, it will not
return to normal.
o Speech may sound distorted through the aid because when speech is
amplified, so are all environmental noises, which can be most
uncomfortable and disturbing to the individual.
o Hearing Aid Care
 Turn the aid off or remove the battery when the aid is not
being worn. Store it in a safe, padded container.
 Clean the aid at least weekly. Wipe the aid off and use a
toothpick, pipe cleaner, or pick that may have come with the
aid to clean the channel. Do not use alcohol to clean the aid as
 this can cause drying and cracking. Avoid having hairspray,
gels, or other chemicals come in contact with the aid.
 Protect the aid from exposure to extreme heat (e.g., hair
dryers), cold weather, or moisture.
 When changing the battery, turn off the aid first.
 Keep several new batteries available. Typically, a battery will
last about 80 hours.
o When used appropriately, hearing aids may correct hearing problems
and allow older individuals to maintain communication and social
relationships.

General Nursing Considerations for Visual and Hearing Deficits

 To compensate for the multiple sensory deficits older persons may
experience, special attention must be paid to stimulation of all the senses
during routine daily activities.
 The diet can be planned to include a variety of flavors and colors. Perfumes,
fresh flowers, and scented candles, safely used, can provide interesting
fragrances.
 In an institutional setting, having a pot of fresh coffee brewing in the
patients’ area can provide a pleasant and familiar aroma during the early
morning hours; likewise, a tabletop oven can allow for cookie baking and
other cooking activities in the patients’ area, providing a variety of stimuli.
 Different textures can be used in upholstery and clothing fabrics. Clocks that
chime, music boxes, and wind chimes can vary environmental sounds. The
design of facilities for older people should take into consideration the use of
different shapes and colors. Intellectual stimulation, through conversation,
music, and books, for instance, is also vital.
 To compensate for visual limitations, one should face the individual and
exaggerate gestures and facial expressions when speaking.
 To compensate for poor peripheral vision, which is common in older people,
one should approach these individuals from the front rather than the side
where their vision is limited and ensure that seating allows for full sight of
persons or objects with which they are interacting.
 Ample lighting is important and should be provided by several soft indirect
lights rather than a single, bright, glaring source.
 Using large print games and playing cards and telephone dials with enlarged
numbers that glow in the dark can promote interaction.
 Books and magazines with large print and recordings of current events and
popular literature can provide a source of recreation and a means of keeping
informed.
 COMPREHENSION ASSESSMENT (QUIZ)

General Instructions:
• BE SURE NOT TO SKIP the lecture. Read and understand before answering
this self-assessment exercise. The purpose of this exercise is for you to have
a better retention of concepts as well as to evaluate your understanding on
the topics discussed.
• Read the instructions carefully and write your answers on the answer sheet
provided.
• Compile your outputs in your Learning Portfolio to be submitted on the date
set by your teacher.

PRELIM
MULTIPLE CHOICE
Instructions:
• Read each item carefully and answer the question by writing the letter in the
answer sheet provided.
• Use permanent ink in writing your answer
• Over imposition and erasure is not acceptable.

1.The practitioner who believes in the free radical theory of aging is likely to
recommend that the older adult
A. avoid excessive intake of zinc or magnesium.
B. supplement his or her diet with vitamins C and E.
C. increase intake of complex carbohydrates.
D. avoid the use of alcohol or tobacco.
2.To provide effective care to the older adult, the nurse must understand that
A. older adults are not a homogeneous sociologic group.
B. little variation exists in cohort groups of older adults.
C. health problems are much the same for similar age groups of older adults.
D. withdrawal by an older adult is a normal physiologic response to aging.
3.The nurse is helping an older adult male client identify aspects of his work,
recreation, and family life that describe his personal identity. According to the Eight
Stages of Life theory, this activity facilitates
A. body transcendence.
B. ego transcendence.
C. ego differentiation.
D. generativity.
4. A 76-year-old client is recovering from a mild cerebral vascular accident (stroke).
The home care nurse notes that he is talking about updating his will and planning
funeral arrangements with his partner. Which of the following responses is most
appropriate for the nurse to make?
A. “You seem to be preoccupied with dying.”
B. “You seem to be concerned about completing these tasks.”
C. “How have you been doing with your physical exercises lately?”
D. “Let’s focus on how you are recovering rather than on your dying.”
5.Your 68-year-old client’s husband died recently. She is a retired nurse who cared
for her husband during an extended illness. She is now depressed and withdrawn
and verbalizes feeling useless. Which action would be most beneficial to the client at
this time?
A. Encouraging her to take up a hobby such as gardening
B. Explaining that activity such as volunteering at a hospital would make her
feel better
C. Informing her that her feelings will pass with time
D. Asking her to share some of her nursing experiences
6.A 62-year-old African American female client has recently been diagnosed with
end-stage renal disease. The client has cried often throughout your shift today. The
client confided in you during a conversation and stated, “I am going home to be with
my Lord.” Your best response as a nurse caring for this patient would be
A. I will let your doctor know right away
B. Would you like for me to call your family
C. Would you like to see the chaplain or a spiritual advisor
D. I think the Lord will welcome you home.
7.You are a new nurse caring for 20 older adults in a nursing facility on Hall B. The
patients range in age from 64 years to 104 years. The individuals are from different
cultures and include both men and women. You are aware that similarities exist
among all the patients and that
A. the patients will be cared for in exactly the same manner.
B. the patients are individuals.
C. the youngest patient is just like the oldest patient.
D. being fearful is best until you gain all the needed information.
8.An 87-year-old Asian man hospitalized for reoccurring shoulder pain tells you, the
nurse, “ I worked in the field for years; I think I have just worn my shoulder out.”
You realize that the patient is voicing a belief congruent with what theory?
A. Error theory
B. Cross-linkage theory
C. Wear-and-tear theory
D. Immunity theory
9. Knowing the difference between normal age-related changes and pathologic
findings is very important. Which finding should the nurse identify as pathologic in a
72-year-old client?
A. Increase in the number of infections
B. Increase in residual volume
C. Increase in response to touch, heat, and pain
D. Increase in sphincter bladder control
10. A 71-year-old widowed client is hospitalized for dehydration. During his
admission interview he repeatedly talked about how he wished he was as energetic
and strong as he was when he was younger. In planning the care for this client, the
nurse should include which of the following?
A. Changing the topic
B. Interject a little humor
C. Help the patient confront his peers
D. A “life review”
11. A standard of care is a guideline for nursing practice which establishes an
expectation for the nurse to provide the older adult client with care that is
A. within the client’s financial resources.
B. in accordance with established facility policies and procedures.
C. based on orders by the attending physician.
 D. reasonably expected to be safe and appropriate.
12. The most important reason for nurses to be legally informed about the rights of
older adults is so that the nurse can
A. preserve the rights of the older adult.
B. serve as an expert witness in trials.
C. assist older adults in filing lawsuits.
D. assist with creating new laws for older adults.
17. Your client is a 97-year-old man who has severe coronary artery disease. His
daughter informs you that he has a living will and durable power of attorney. A living
will differs from a durable power of attorney in that a living will
A. is an example of an advance medical directive.
B. allows designated person to make decisions if the client becomes
incompetent.
C. provides a written expression of a client’s wishes in the event of terminal
illness.
D. is rarely honored because it is not a legal document.
18. The nurse is caring for a 67-year-old client who has terminal cancer. The client is
having difficulty making a decision about signing an advance medical directive. The
primary responsibility of the nurse in relation to the patient’s advance medical
directive is to make certain that the client
A. signs the advance directive before her condition deteriorates.
B. discusses her prognosis with her physician so that she can make an
informed decision.
C. understands it is not necessary if she has a durable power of attorney.
D. understands the information contained in the advance directive.
19. The Ethical Code for Nurses and Standards and Scope of Gerontological Nursing
Practice are similar in that they both
A. serve to regulate nursing practice from within the profession.
B. serve as guidelines for legal action against nurses.
C. ensure legal conduct in the professional setting.
D. are of little value when dealing with ethical dilemmas.
20. The Joint Commission on Accreditation Healthcare Organizations (JCAHO) is a
well-known organization established to review health care facilities. As a nurse in a
JCAHO-certified hospital, you are aware that the role of JCAHO is
A. as a trend setter.
B. as a respected friend.
C. to set the industry standard.
D. as a valued colleague.
21. An 89-year-old client has been experiencing restlessness; you are assigned to
care for him tonight during the 11 PM to 7 AM shift. The patient has often been found
by nursing staff wandering in and out of other clients' rooms during the night. He
also has an antipsychotic ordered for combative behavior. As the nurse caring for the
client, you are aware that you can
A. give him PRN.
B. give the medication so that you free up staff.
C. tie the patient to his bed.
D. only give the PRN medication as it is prescribed by the physician.
22. An alert and oriented 84-year-old client is receiving home care services after a
cerebrovascular accident that has left her with left-sided hemiparesis. She lives with
her middle-aged son and daughter-in-law. The nurse suspects she being physically
abused by her son. To elicit information effectively, the nurse should do which of the
following?
 A. Interview neighbors to gain information
B. Confront the son regarding the suspicion
C. Confront the daughter-in-law with the suspicion
D. Directly ask the client if she has been physically struck or hurt by anyone
23. Your older adult client has signed the consent form for a research study but has
changed her mind. The nurse tells the client that she has changed her mind based
on which of the following principles?
A. Autonomy and informed consent
B. Advanced medical directives and designation of health care
C. Justice and right to know
D. Living wills and durable power of attorney

24. The nurse is caring for an 86-year-old man who has terminal end-stage renal
failure. The patient requested that the nurse give him an extra dose of pain
medication so that he can "go ahead and die." The nurse is aware of the code of
ethical conduct for nurses and that
A. she is free to assist the patient in the suicide.
B. she must get an order from the doctor.
C. she is prohibited from participating in assisted suicide.
D. she must review the will before continuing care.
25. An older adult client you are caring for is offered the opportunity to participate in
research on a new therapy for arthritis. The researcher asks the nurse to obtain the
client’s consent. What is the most appropriate action for the nurse to take?
A. Be sure the client can read the consent
B. Read the consent form to the client and allow him or her to ask questions
C. Leave the consent at the bedside so that the client’s daughter can read it
D. Refuse to be the one to obtain the client’s consent
26. An 80-year-old client is confused after undergoing surgical repair of a fractured
hip. Her health history reveals that she takes digitalis (Digoxin) for congestive heart
failure. This client’s confusion is most likely
A. a sign of early dementia that often occurs after a stress event.
B. the result of toxicity from the Digoxin and unrelated to her surgery.
C. the consequences of interacting physical and psychosocial factors.
D. an acute medical problem that requires immediate attention.
27. A 71-year-old man is admitted to the acute care facility with suspected lung
cancer. On the third day after his admission, the nurse notes that his blood pressure
is 164/92 mm Hg. Considering the client’s age, the nurse should
A. report the abnormal blood pressure to the client’s physician.
B. ask another nurse to take the client’s blood pressure.
C. compare the blood pressure reading with his past readings.
D. ignore it because it is within the normal range for older adults.
28. Today is the sixth postoperative day for an 88-year-old client who underwent
bowel surgery. He was alert and oriented until the evening, when he became
confused and incontinent of urine and stool. The nurse should suspect which factor
as the most likely cause of the client’s acute confused state?
A. The client’s age
B. The client’s family history of dementia
C. The client’s preadmission medication profile
D. The presence of a urinary tract infection
29. Any nurse who cares for older adult clients should understand the clinical
features associated with dementia, such as
A. loss of intellectual functions.
 B. increased disorientation during the night.
C. sudden, abrupt onset of disorientation.
D. impairment of recent memory.
30. While assessing an older adult client, the nurse notes that the client’s head and
shoulders are drooping and she is slow to respond to questions. Based on this
observation, the nurse should
A. allow the client to lie down and then continue with the interview.
B. document observations of the behavior and continue with the interview.
C. stop the interview and continue the assessment at another time.
D. increase the pace of the interview so that it can be completed quickly.
31. The nurse notices that her older adult client is restless and agitated. He does not
speak or understand English, and an interpreter is not available. What approach
would be most effective to assess the client for his current problem?
A. Speak in a loud voice and ask, You aren’t in pain, are you
B. Look directly at him and whisper, Are you uncomfortable
C. Deliberately and slowly repeat the word pain.
D. Point to his incision, grimace, and ask, Are you in pain
32. Which question, when conducting a health history on an older adult, best
addresses the client’s present health status?
A. “When did you receive your last tetanus/diphtheria immunization?”
B. “Who is your current health care provider?”
C. “Do you get around in your house easily, or are you concerned about
falling?”
D. “Have you had any hospitalizations, surgeries, or traumatic injuries?”
33. The nurse is admitting a 70-year-old client to the hospital for treatment of severe
dehydration. The client is weak and confused. The nurse should understand
that
A. a head-to-toe assessment should be immediately performed.
B. assessing the client at this time would deplete her energy reserves.
C. the physical assessment should be postponed until after the client is
hydrated.
D. the client should first be assessed for fluid volume deficit.
34. An 80-year-old client is being treated in an acute care setting. His nurse needs to
assess his functional level this morning to determine the effects of the last week’s
treatments intended to restore his function. In this case, which of the following is the
most useful tool for the nurse to use?
A. Instrumental Activities of Daily Living Scale
B. The Katz Index of Activities of Daily Living
C. Short Portable Functional Status Questionnaire
D. The Braden Scale of Functional Status
35. You note on your older adult’s medical record that she has undergone the Beck
Depression Inventory. You recognize that this test
A. describes a variety of symptoms and attitudes associated with depression.
B. examines the cognitive aspects of mental function, such as orientation
and depression.
C. attempts to detect the presence and degree of intellectual depression.
D. is a 30-question instrument designed to screen for depression.
36. An 81-year-old white man is scheduled for a physical exam in the outpatient
clinic in which you work. You should be aware and anticipate
A. a short, easy procedure.
B. little interaction between client and nurse because he is hard of hearing.
C. the client will have a lot of energy.
 D. ensuring that the client is comfortable.
37. A 97-year-old African American woman was recently diagnosed with ovarian
cancer. As the nurse caring for the patient, you are aware that you can
assess the older person’s social function by using what assessment tool?
A. Interrelationship Score
B. Functional Status
C. Tailoring Test
D. APGAR
38. As a nurse providing care to older people, you realize that nursing-focused
assessments occur in traditional settings of the hospital, home, and long-term care
facility as well as in nontraditional living units, hospice facilities, and independent
living units. The setting dictates
A. documentation.
B. only an understanding of potential problems.
C. the way data collection and analysis should be managed to serve clients
best.
D. application of understanding of needs.
39. An 81-year old patient presented to the emergency department with a self-report
of multiple vague signs and symptoms, including lethargy, incontinence, and weight
loss. You understand that physical frailty and impairments affect the ability of an
older patient to live independently. This is a major contributor to the need for
A. acute care.
B. independent living.
C. hospice care.
D. long-term care.
40. You are working in an outpatient clinic caring for geriatric clients. Your 68-year-
old female client arrived 1 hour late for her appointment and is noticeably shaking
and perspiring. She reports missing her bus, causing her to be late for her
appointment. You realize that several factors influence the client’s ability to
participate meaningfully in the interview. What factor may affect this interview?
A. Anxiety
B. Pain
C. Sensory perceptual deficits
D. Reduced energy level

 CASE ANALYSIS:
Seventy-nine-year-old Mr. J has been diagnosed with a rare liver cancer. The
oncologist informs Mr. J that although he is willing to attempt a round of
chemotherapy, no treatment has been effective in extending life for more
than a few months for this aggressive type of cancer. Mr. J and his 66-year-
old wife are devastated by this information and look to the Internet for help.
They read testimonials of patients who have had similar liver cancers whose
lives allegedly were extended for several years with an alternative treatment
offered by a hospital in Germany. They make contact with the hospital and
learn that Mr. J qualifies for their treatment, which consists of a 2-weeklong
stay at the hospital in Germany, every 2 months. Each of the hospitalizations
costs 25,000 plus the couple’s travel expenses. The couple has no savings but
owns a very modest house; they have no children. The couple discusses this
option with the oncologist, who discourages the alternative treatment,
stating, “Your time and money would be better spent in enjoying the
remaining time you have together and making preparations for Mr. J’s
declining health and ultimate death.” Despite the physician’s discouraging
 remarks, Mr. J wants to mortgage the house to pay for the alternative
treatment. Mrs. J wants to help her husband extend his life but is concerned
that she will face the prospect of losing the house or being required to pay
off the mortgage on her limited Social Security check long after Mr. J dies.
She is not comfortable with the idea, but feels that if she voices her concerns,
her husband, friends, and family will consider her uncaring.

THINK CRITICALLY:
o Does Mr. J have the right to deplete the couple’s resources for a
questionable treatment that may only extend his life for a few
months?
o Does Mrs. J have the right to oppose this plan?
o Does Mr. J’s physician have the right to dash Mr. J’s hopes?
o How could you assist the couple?

ANSWER SHEET FOR PRELIM QUIZ

MULTIPLE CHOICE
1. 11. 21. 31.
2. 12. 22. 32.
3. 13. 23. 33.
4. 14. 24. 34.
5. 15. 25. 35.
6. 16. 26. 36.
7. 17. 27. 37.
8. 18. 28. 38.
9. 19. 29. 39.
10. 20. 30. 40.

CASE ANALYSIS:

MIDTERM
MULTIPLE CHOICE
 Instructions:
• Read each item carefully and answer the question by writing the letter in the
answer sheet provided.
• Use permanent ink in writing your answer
• Over imposition and erasure is not acceptable.

MULTIPLE CHOICE
Instructions:
• Read each item carefully and answer the question by writing the letter in the
answer sheet provided.
• Use permanent ink in writing your answer
• Over imposition and erasure is not acceptable.

1. A client is newly diagnosed with cancer and is beginning a treatment plan.

Which of the following nursing interventions will be most effective in helping the client
cope?
A. Assume decision making for the client.
B. Encourage strict compliance with all treatment regimens.
C. Inform the client of all possible adverse treatment effects.
D. Identify available resources.
2. A daughter is concerned that her mother is in denial when discussing her diagnosis
of breast
cancer because she sometimes says that breast cancer isn't that serious and changes
the subject.
The nurse informs the daughter that denial can be a healthy defense mechanism if it is
used:
A. To permit her mother to seek unconventional treatments.
B. When making decisions about her care.
C. Alone and not in combination with other defense mechanisms.
D. To allow her mother to continue in her role as a mother.
3. A 45-year-old single mother of three teenaged boys has metastatic breast cancer.
Her parents
live 750 miles (1,207 km) away and have only been able to visit twice since her initial
diagnosis
14 months ago. The progression of her disease has forced the client to consider high-
dose
chemotherapy. She is concerned about her children's welfare during the treatment.
When
assessing the client's present support systems, the nurse will be most concerned about
the
potential problems with:
A. Denial as a primary coping mechanism.
B. Support systems and coping strategies.
C. Decision-making abilities.
D. Transportation and money for the boys.
4. Which of the following characteristics displayed by the wife of a 36-year-old man
with
pancreatic cancer suggests that she may be at risk for negative bereavement
outcomes?
A. She is preparing for her husband's death.
B. Her high socioeconomic status.
 C. Her strong family support.
D. She blames herself for her husband's cancer.
5. Which of the following factors assists a person to achieve positive bereavement
outcomes?
A. Young age.
B. History of anxiety.
C. History of depression.
D. Higher socioeconomic status.
6. Which of the following nursing interventions will be most effective when caring for a
client who
is experiencing powerlessness?
A. Make certain that all staff members focus only on the client's capabilities.
B. Encourage family members to become more responsible for the client's care.
C. Request a referral to a psychologist.
D. Include the client in decision making whenever possible.
7. During the initial stage of adaptation to the diagnosis of cancer and its treatment,
the nurse
can facilitate the client's adaptation by:
A. Encouraging the client to maintain her usual role.
B. Facilitating family-related disagreements and conflicts.
C. Supporting the client in her use of denial as a coping strategy.
D. Arranging transportation and child care on treatment days.
8.When explaining hospice care to a client, which of the following statements is most
appropriate?
A. “Hospice care uses a team approach to direct hospice activity.”
B. “Clients and their families are the focus of care.”
C. “The client's physician coordinates all the care.”
D. “All hospice clients will die at home.”
9. A client's husband expresses concern that his dying wife keeps saying, “I have to go
to the
store.” Which of the following statements by the nurse will be most effective in
assisting the
husband to understand the dying process?
A. “Many dying clients are restless and can be treated with sedatives.”
B. “The client may be fighting death, and you should leave her alone.”
C. “Comments related to going somewhere or leaving on a trip are common in
dying clients.”
D. “Decreased circulation and lack of oxygen to the brain often causes
delirium.”
10.The wife of a terminally ill client asks the nurse, “Why is my husband having
frequent bowel
movements if he is not eating?” Which of the following responses by the nurse best
informs the
wife about the client's condition?
A. “I know he is having frequent loose stools and it is distressing for you, but
that's just the way it is.”
B. “I don't know when the bowels will shut down, but they will eventually.”
C. “The pain medication will eventually help to slow the process of bowel
function.”
D. “The intestines still produce some waste products even when a person is not
eating.”
11.The client who is in end stages of cancer is requesting spiritual support. The nurse
should:
A. Tell the client to start attending religious services.
B. Call a chaplain and set up an appointment for spiritual guidance.
C. Help the client reflect on past accomplishments.
D. Ask the client what spiritual activities would be most helpful.
12. A 72-year-old client with end-stage cancer needs assistance with arranging for
end-of-life
home care. The nurse should refer the client to:
A. The client's oldest child.
B. Social worker.
C. Physician.
D. The executor of the client's will.

13. The family members caring for a client who is near death from colon cancer are
concerned
about dehydration. What should the nurse tell them about dehydration at end of life?
A. The physician will make the decision regarding hydration therapy.
B. Dehydration may prolong the dying process.
C. Hydration is used only in extreme situations of dehydration.
D. Dehydration is expected during the dying process.
14. Which of the following actions should the nurse plan to do first when caring for a
client who is
experiencing spiritual distress?
A. Make a referral to a member of the clergy.
B. Explain the major beliefs of different religions.
C. Suggest reading material.
D. Help the client explores his or her own values and beliefs.
15. A nurse is caring for a client at home on hospice care for terminal renal cancer.
People are
calling the nurse to inquire about the client's condition. The nurse should tell the
callers:
A. “Please call the oncologist.”
B. “The client is in a coma now.”
C. “Please call the client's sister”
D. “The client is not expected to live much longer.”
16. A 42-year-old client with breast cancer is concerned that her husband is depressed
by her
diagnosis. Which of the following changes in her husband's behavior may confirm her
fears?
A. Increased decisiveness.
B. Problem-focused coping style.
C. Increase in social interactions.
D. Disturbance in his sleep patterns.
17. The most cost-effective suggestion for bereavement support for the hospice nurse
to give a
woman whose husband died 3 months ago and her three young children would be to:
A. Seek group counseling support for the three children.
B. Request individual counseling and medication to manage depression.
C. Remind her gently that bereavement care before death minimizes grieving.
D. Continue bereavement support offered through hospice.
18.Which of the following interventions will be most effective in improving transcultural
communications with clients with cancer and their families?
A. Use touch to show concern and caring for the client.
B. Focus attention on verbal communication skills only.
C. Establish a rapport and listen to their concerns.
D. Maintain eye contact at all times.
19.A client with cancer is uncertain about how to cope with all the issues that will
arise. The
nurse can best support the coping behaviors of a client with cancer by:
A. Helping the client identify available resources.
B. Encouraging compliance with treatment regimens.
C. Relieving the client of decision making as much as possible.
D. Assisting the client to prepare for adverse treatment effects.
20.Which of the following is an expected outcome of a nursing referral to a cancer
support
group? The client can:
A. Choose the best treatment options.
B. Find financial help.
C. Obtain home health care.
D. Cope with cancer.
21.A cancer survivor feels guilty when attending a cancer support group meeting. The
nurse can
help the client manage feelings of guilt by pointing out that:
A. These actually are feelings of anger at the terminally ill clients in the group.
B. It is an unexpected response to volatile emotions.
C. This is a spiritual response to the client's own illness.
D. This is a normal reaction when surviving a life-threatening experience.
22. A 68-year-old client with colon cancer experiences an increase in feelings of
anxiety and
depression and has suicidal ideation. The nurse realizes that these feelings occur
during which
stage of the disease?
A. Initiation of definitive treatment.
B. End of the first course of treatment.
C. End stage of the disease.
D. Recurrence of the disease.
23. The 65-year-old widower whose only son is 500 miles (805 km) away is at higher
risk for
psychosocial distress because the client:
A. Has been successful in dealing with stress all his life.
B. Does not have to deal with other stressors right now.
C. Is able to use denial as a coping mechanism.
D. Perceives he has minimal social support.
24. A client with a diagnosis of cancer is frequently disruptive and challenges the
nurse. This
behavior may be caused by:
A. Uncertainty and an underlying fear of recurrence.
B. The usual trajectory of a short-term illness.
C. A history of a behavioral illness.
D. The one-time crisis from learning of the diagnosis.
25. A 42-year-old husband and father of a 7-year-old girl and a 10-year-old boy is
concerned
about what he should tell his children regarding his wife's impending death from
aggressive
breast cancer. The nurse should first:
A. Refer the family to pastoral care services.
B. Encourage the husband to come to terms with his own grief first.
C. Suggest that the children be told nothing until after death occurs.
D. Begin education about strategies for communication with his children.
26. While talking to her husband, who is caring for their children, a 52-year-old client
slams the
phone down. She begins to cry and states that she is feeling guilty for being
hospitalized. Which
of the following will best support the client emotionally?
A. Call the physician and ask for a psychiatry consultation.
B. Call the physician and request an antidepressant medication.
C. Sit with the client and help her acknowledge and discuss her feelings.
D. Sit with the client and encourage her to see the good side of the situation.
27. A 56-year-old female who is receiving radiation therapy tells the nurse that she
feels
inadequate as a wife and mother because she can no longer carry out her usual duties
with the
same energy as before. What recommendations should the nurse make to help the
client cope
with this situation?
A. Suggest that she reassign all household chores to other members of the
family.
B. Suggest that she prioritize her activities and ask for help from friends and
family.
C. Suggest that she ignore the household chores during the crisis period.
D. Tell her not to worry so much because everyone gets a little tired at this
phase of the therapy.

28. A 66-year-old female who is usually meticulous about her appearance and dress
arrives today
for her 23rd day of radiation therapy. She appears disheveled and emotionally labile,
and her
responses to the usual questions are a little inappropriate. Her heart rate is 124 bpm,
her
respirations are 32 breaths/min, and her skin is cold and clammy. These findings
would suggest
that the nurse should further assess the client for which of the following conditions?
A. Schizophrenia.
B. Panic disorder.
C. Depression.
D. Delirium.
29.A client has undergone surgical resection for lung cancer. Which of the following
will promote
adaptation and rehabilitation?
A. Arranging a visit from a member of the Philippine Cancer Society Lost Chord
Club .
B. Planning a progressive activity regimen with the client.
C. Teaching tracheostomy care.
D. Planning a vigorous exercise program.
30. Which of the following activities indicates that the client with cancer is adapting
well to body
image changes?
A. The client names his brother as the person to call if he is experiencing
suicidal ideation.
B. The client discusses changes in body structure and function.
C. The client discusses the date of his return to work.
D. The client serves as a volunteer in a client-to-client visitation program.
31. The family of a hospitalized client demonstrates understanding of the teaching
about advance
directives when they make which of the following statements? Select all that apply.
A. “Advance directives give instructions about future medical care and
treatment.”
B. “If people are not capable of communicating their wishes, health care
providers and family together can agree on measures or actions that
will be taken.”
C. “Ethics experts agree that the family is the sole deciding factor when the
client is competent.”
D. “Medical power-of-attorney gives primarily financial access to the designee.”
E. “Medical power-of-attorney or durable power-of-attorney for health care is a
document that
lists who can make health care decisions should a person be unable to make an
informed decision
for himself or herself.”
F. “Advance directives give details about the client's past medical history.”
32. The nurse can be an important advocate for the client who is considering an
alternative
method of cancer treatment. Which of the following statements best demonstrates the
nurse as
client advocate? The nurse will:
A. Provide the information about standard therapies.
B. Monitor blood tests as indicated by the alternative therapy.
C. Document the client's desire to try an alternative therapy.
D. Allow the client to make health care choices but will assist in ensuring the
client is fully
informed when making those decisions.
33. After completing the nursing assessment for a client and family entering the
palliative care
program, the nurse should develop a teaching plan that includes an understanding of
which of
the following outcomes? Select all that apply.
A. Alteration in the family's usual coping strategies.
B. Achievement of a dignified and respectful death.
C. Improvement in the client's quality of life.
D. Provision of comfort during the dying process.
E. Provision of support for client and family.
F. Advocation for prolonging life while curing the disease
34. When a client and family receive the initial diagnosis of colon cancer, the nurse can
act as an
advocate by:
A. Helping them maintain a sense of optimism and hopefulness.
B. Determining their understanding of the results of the diagnostic testing.
 C. Listening carefully to their perceptions of what their needs are.
D. Providing them with written materials about the cancer site and its
treatment.
35. A client who is dying of acquired immunodeficiency syndrome (AIDS) is admitted
to the
inpatient psychiatric unit because he attempted suicide. His close friend recently died
of AIDS.
The client begins to talk about his feelings related to his illness and the loss of his
friend. He
begins to cry. Which of the following responses by the nurse would be most
appropriate?
A. Give the client some tissues and tell him it is okay to cry.
B. Tell the client to stop crying and that everything will be okay.
C. Sort the client's mail to distract the client.
D. Change the subject.
36. The wife of an older adult who has been admitted to the hospital with kidney
failure tells the
nurse, “I know he doesn't want to die in a hospital, but it is so hard for me to take
care of him at
home. He said he doesn't want any more treatment, but I'm not ready to let him go.
We have so
many arrangements to decide before he dies.” Which of the following statements by
the nurse to
the client's wife would be most appropriate? Select all that apply.
A. “He's not going to die that soon judging by his current symptoms.”
B. “What are your fears about your husband dying?”
C. “I can imagine that it is hard for you to care for him at home.”
D. “What do you and your husband know about advance directives?”
E. “We can discuss types of hospice and home care available.”
F. “What kind of arrangements do you think need to be made before he dies?”
37. A terminally ill client's husband tells the nurse, “I wish we had taken that trip to
Europe last
year. We just kept putting it off, and now I'm furious that we didn't go.” The nurse
interprets the
husband's statement as indicating which of the following stages of adaptation to
dying?
A. Anger.
B. Denial.
C. Bargaining.
D. Depression
38. Which of the following philosophies should the nurse integrate into the plan of care
for a
client and family to help them best cope during the final stages of the client's illness?
A. Living each day as it comes as fully as possible.
B. Reliving the pleasant memories of days gone by.
C. Expecting the worst and being grateful when it does not happen.
D. Planning ahead for the remaining good times that will be spent together.
39. A client who is in the end stages of cancer is increasingly upset about receiving
chemotherapy. Which of the following approaches by the nurse would likely be most
helpful in
gaining the client's cooperation?
A. Telling the client how the treatment can be expected to help.
 B. Describing the probable effect on that missing a treatment would have.
C. Saying “Be a good client and not make the treatment any harder for
yourself.”
D. Promising to give a backrub when the treatment is completed.
40. A client suspects that he will not live. However, others talk about only pleasant
matters with
him and maintain a persistently cheerful facade around him. The nurse anticipates that
the client
will most likely feel which of the following as a result of such behavior?
A. Relief.
B. Isolation.
C. Hopefulness.
D. Independence.

CASE ANALYSIS:

Seventy-two-year-old Mrs. W has been widowed for 8 months. She is an attractive,

active woman who desired to break up her lonely days by joining a local senior
center, where she met Mr. R, a handsome 75-year-old widower. In short time, they
began dating, and recently, Mr. R has asked Mrs. W to join him for a long weekend
at a romantic vacation spot. Mr. R has openly shared that he has had frequent
sexual partners and that he envisions initiating a sexual relationship with Mrs. W
during their weekend. Mrs. W is interested in taking the relationship to this new level
but is nervous about the fact that she and her husband did not have intercourse
during the last 8 years of his life due to his poor health, and she now wonders how
much discomfort she will experience. She discusses this with a nurse friend and
expresses concerns about having a new sexual partner for the first time in over 50
years, Mr. R’s possible reactions to seeing her “naked old body,” and what her
children and grandchildren would think if they found out about her weekend.

THINK CRITICALLY:

What advice would be helpful for the nurse friend to offer?

What are some of the challenges and risks that Mrs. W could face?

ANSWER SHEET FOR PRELIM QUIZ

MULTIPLE CHOICE
1. 11. 21. 31.
2. 12. 22. 32.
3. 13. 23. 33.
4. 14. 24. 34.
5. 15. 25. 35.
6. 16. 26. 36.
7. 17. 27. 37.
8. 18. 28. 38.
9. 19. 29. 39.
10. 20. 30. 40.

CASE ANALYSIS:
 SEMI FINALS
MULTIPLE CHOICE
Instructions:
• Read each item carefully and answer the question by writing the letter in the
answer sheet provided.
• Use permanent ink in writing your answer
• Over imposition and erasure is not acceptable.

1. The effects of normal physiologic aging on the cardiovascular system are most
readily noted in older adults when they are
A. sleeping.
B. exercising.
C. eating.
D. lying in a supine position.
2. Cigarette smokers are four times as likely to die of sudden cardiac death than
nonsmokers because smoking
A. promotes the development of anemia.
B. produces coronary artery stricture.
C. results in carbon monoxide poisoning.
D. increases platelet aggregation.
3 When assessing the older adult’s blood pressure, the nurse recognizes that
secondary hypertension may exist if the client
A. consumes a diet high in saturated fats.
B. leads a sedentary lifestyle.
C. has diabetes mellitus.
D. is of African American decent.
4 When administering a β-blocker such as Lopressor to an older adult client
with hypertension, the nurse should monitor for
A. episodes of dizziness or syncope.
B. signs and symptoms of thromboembolism.
C. muscle weakness and dry mouth.
D. increases in serum potassium.
5 When teaching older adult clients about hypertension, of importance is
information about
A. signs and symptoms associated with heart attacks.
B. the need for restricting sodium and potassium intake.
C. the need for yearly blood pressure monitoring.
D. the benefit of relaxation techniques.
6 An older client reports dizziness and becomes disoriented during a treadmill
test for cardiac endurance. The nurse recognizes this response as a(n)
A. normal age-related response.
B. early indication of ischemia.
C. atypical response for this age group.
D. indication of cerebral compromise.
7 Which point about exercise should receive special emphasis when teaching a
68-year-old male client who has unstable angina after an acute myocardial
infarction? Exercise should
A. be gradually increased during recovery.
B. include walking and swimming.
C. build endurance.
 D. be avoided.
8 The nurse may accurately conclude that the older client with coronary artery
disease has achieved an important outcome of care when the client is able to
A. discuss the need for resuming former activities.
B. return to her usual activities of daily living.
C. identify at least two of her modifiable risk factors.
D. lower her blood pressure by 10%.
9 The nurse must initiate which independent nursing activity for the older client
who is in the acute phase of recover after a myocardial infarction?
A. Assisting with ambulation
B. Applying oxygen during activity
C. Administering prescribed morphine sulfate to prevent angina
D. Encouraging active and passive range-of-motion exercises
10 A hospitalized older adult client has been diagnosed with sick sinus
syndrome. She has an intermittent saline lock and is receiving oral
isoproterenol (Isuprel). On entering her room, the nurse finds the client on
the bathroom floor and notes her pulse is 42 beats/min. The nurse’s first
action should be to
A. call the client’s family.
B. prepare for cardioversion.
C. administer intravenous atropine as ordered.
D. administer the prescribed isoproterenol (Isuprel) early.
11 Which nursing activity is important to add to the plan of care for the older
adult client suspected of having orthostatic hypotension?
A. Assessing skin turgor and oral mucous membranes
B. Monitoring all blood pressure readings when the client is lying down
C. Taking blood pressure readings from both arms
D. Teaching the client about the use of sublingual nitroglycerin
12 A 77-year-old client is being discharged after the insertion of a permanent
pacemaker for a bradyarrhythmia. It is set to fire at 80 beats/min. The client
should be taught to notify her practitioner if
A. her urine output increases significantly.
B. she experiences fatigue or dizziness.
C. her radial pulse goes below 80 beats/min.
D. she feels a sudden increase in energy.
13 A 72-year-old client underwent an aortic valve replacement 4 days ago. He is
currently alert and oriented, and his incision is dry and intact. His cardiac
monitor shows atrial fibrillation. Which nursing diagnosis takes priority at this
time?
A. High risk for injury related to altered tissue perfusion
B. Knowledge deficit: disease process and follow-up care
C. Pain related to surgical incision
D. Activity intolerance related to fatigue
14 A 68-year-old client is being treated for congestive heart failure secondary to
long-standing renal disease. The nurse recognizes that because of his age
and renal disease, he is most likely exhibiting signs and symptoms of
A. right-sided heart failure.
B. right- and left-sided heart failure.
C. acute chronic heart failure.
D. systolic heart failure.
15 An older adult male has been recently diagnosed with hypertension. He is
being treated with a thiazide diuretic and dietary management along with
 lifestyle modifications. The nurse knows that he understands the treatment if
he makes which of the following statements?
A. “I will use a large amount of salt substitute.”
B. “I have stopped smoking, so the damage is reversed.”
C. “I will exercise to reduce my blood pressure.”
D. “I need to cut back to two 4-ounce glasses of wine a day.”
16 A 76-year-old client is being assessed in the emergency department for
cardiovascular problems. The nurse understands that some of the common
symptoms associated with cardiovascular disease are
A. chest discomfort and increased sputum production.
B. weight changes and mood swings.
C. headaches and fainting.
D. shortness of breath and chest discomfort.
17 Teaching older adult clients measures to prevent respiratory infection is
based on the understanding that older adults
A. retain greater amounts of carbon dioxide, so they exhibit respiratory
acidosis.
B. tend to be hypoxic because of ineffective breathing patterns.
C. have difficult clearing secretions because of reduced ciliary function.
D. have fewer alveoli available for effective gas exchange.
18 An older adult’s pulmonary function studies indicate that his vital capacity is
reduced and his residual volume is increased. The nurse recognizes that
these test results reflect
A. deeper breathing patterns related to an older age.
B. altered inspiratory and expiratory capabilities.
C. significant airway obstruction.
D. bronchopulmonary infection.
19 Before administering the drug theophylline to the older adult who has a
respiratory problem, the nurse should determine whether the client
A. smokes cigarettes.
B. has an elevated serum potassium level.
C. has shortness of breath.
D. has chest pain.
20 Which of the following nursing diagnoses is most appropriate for the older
adult after having general surgery?
A. Airway clearance, ineffective related to narcotic administration
B. Incontinence, functional related to anesthesia
C. Sleep pattern disturbance related to frequent position changes
D. High risk for aspiration related to diminished cough reflex
21 The nurse suspects that an older adult client has asthma. Which clinical
finding, if noted, best supports the nurse’s suspicion?
A. Use of accessory muscles with respiration
B. Bilateral lower lung crackles
C. Decreased respiratory depth and rate
D. Client report of chest pain
22. Emphysema differs from asthma and chronic bronchitis in that emphysema
results in
A. an FEVa1 or peak expiratory flow rate ≥80% predicted.
B. hypertrophy of the bronchial mucous glands.
C. enlarged alveoli distal to the terminal bronchioles.
D. airway inflammation and hypersensitivity.
23 Which finding in the darkly pigmented older adult should alert the nurse to
the presence of cyanosis?
A. Decreased respiratory rate
B. Dark color around the mouth
C. Nasal flaring
D. Bradycardia
24 When teaching older adults about lung cancer, they should be taught that a
primary risk factor is
A. excessive intake of vitamin A.
B. folic acid deficiency.
C. use of tobacco.
D. exposure to hairspray.
25 An older client is admitted to the hospital with reports of recent weight loss
and a chronic cough. His practitioner orders a tuberculin skin test, the results
of which are negative. The most appropriate conclusion is that the
A. technique used was probably inaccurate.
B. test results were false-negative and the client has tuberculosis.
C. client does not have tuberculosis.
D. test should be repeated.
26 An older adult client who has tuberculosis is being treated with the drugs
isoniazid 300 mg daily, rifampin 600 mg daily, and pyrazinamide 1500 mg
daily. Which signs or symptoms warrant reporting because they indicate an
adverse drug reaction?
A. Decreased uric acid and liver function studies
B. Chronic cough, fever, and weakness
C. Anemia, hypersensitivity, and seizures
D. Red-orange urine and burning on urination
27 An 88-year-old client is being treated for dehydration and confusion. Her
chest radiograph study shows consolidation in the left lower lobe. Her vital
signs are respirations, 28 breaths/min; temperature, 99˚ F; blood pressure,
118/62 mm Hg; and pulse, 88 beats/min. She is very weak and has no
cough. Which nursing diagnosis is most appropriate for this client on the
basis of these data?
A. Self-care deficit related to weakness and confusion
B. Ineffective airway clearance related to perceptual impairment and absent
cough
C. Activity intolerance related to fatigue and confusion
D. Altered oral mucous membranes related to dehydration and mouth
breathing
28 During morning rounds, the nurse notes that a 76-year-old client with
pneumonia is restless. Assessment reveals crackles in the left lower lung lobe.
On the basis of the client’s data, the nurse should first
A. position the client on the right side.
B. obtain a sputum specimen for culture.
C. administer the prescribed sedative.
D. call for stat arterial blood gases.
29 An older client has just had arterial blood gases drawn. The nurse knows
A. arterial PH is the same unless influenced by an acute illness.
B. to gently shake the collection syringe.
C. to vigorously shake the collection syringe.
D. to aspirate 0.1 mL of saline into the syringe.
30 A 66-year-old woman is admitted to the hospital. She has smoked three
packs per day for 40 years. While providing her history, she becomes
breathless, pauses frequently between words, and appears extremely
anxious. She has a cough with thick white sputum production. Her chest is
barrel-shaped and she is cyanotic. On the basis of these data, the nurse will
need to develop a plan of care for a client with
A. tuberculosis.
B. chronic obstructive pulmonary disease.
C. asthma.
D. pneumonia.
31 The nurse is checking tuberculin skin test results at a long-term care facility.
One client has an area of indication measuring 12 mm in diameter. The nurse
is aware that this finding indicates
A. inactive tuberculosis.
B. a normal reading.
C. a positive reaction that can indicate exposure to tuberculosis.
D. the client needs to be rechecked in 3 days.
32 The nurse should understand that the primary difference between type 1 and
type 2 diabetes in the older adult is that type 1 diabetic clients
A. retain their ability to produce small to moderate quantities of insulin.
B. can generally control their diabetes through diet and exercise.
C. demonstrate more insulin resistance than loss of secretion.
D. always require insulin administration to control their blood glucose.
33 You note that your older adult client with diabetes mellitus is running a higher
than usual blood glucose level. On further investigation, you determine that
he is also receiving Cardizem (a calcium-channel blocker), consumes a 1200
calorie/day diet, drinks approximately 4 cups of caffeinated coffee each day,
and eats fruit at bedtime. The most appropriate advice to give the client is
that he should
A. increase his morning dose of insulin by 5 units.
B. switch to decaffeinated coffee or tea.
C. decrease his daily intake from 1200 to 1000 calories.
D. refrain from eating a nighttime snack.
34 You have just completed teaching your older adult diabetic client about the
disease, its treatment, and complications. Which statement, if made by the
client, indicates that she needs further teaching?
A. “If I start feeling unusually tired, I should notify my health care provider.”
B. “I need to perform foot care daily to prevent ulcer formation.”
C. “I should regulate my insulin intake according to how I feel.”
D. “I may develop infections more easily than I used to.”
35 You are responsible for teaching a newly diagnosed diabetic about his diet,
oral hypoglycemic agent, and home care. Therefore it is very important to
teach the client that
A. alcohol intake is contraindicated for persons taking oral hypoglycemic
agents.
B. dietary intake is not a consideration when taking oral hypoglycemic
agents.
C. oral hypoglycemic agents are similar to insulin in that hyperglycemia is a
complication of both.
D. few, if any, side effects are associated with oral hypoglycemic agents.
36 You are caring for several older adult clients. Which client is more likely to
have a normal decrease in thyroid function?
 A. A 65-year-old woman who has diabetes mellitus
B. A 79-year-old woman who is generally healthy
C. A 67-year-old woman who has mild rheumatoid arthritis
37 You are caring for an older adult client who recently underwent abdominal
surgery for which the prognosis is very good. However, you are concerned
that your client may have hypothyroidism on the basis of other signs and
symptoms. Which problems should be reported because they often indicate
hypothyroidism in the older adult?
A. Heat intolerance, low-grade fever, and patchy hair loss
B. Polycythemia, tachycardia, and oral candidiasis
C. Bradycardia, decreased appetite, and cold intolerance
D. Increased blood pressure, postural hypotension, and blurred vision
38 Your 76-year-old female client is being treated for hypothyroidism. Which
nursing diagnosis is most appropriate considering her age and medical
diagnosis?
A. Constipation related to decreased metabolic function
B. Self-care deficit related to restlessness and agitation
C. Depression related to organic brain deterioration secondary to thyroid
dysfunction
D. Heat intolerance related to metabolic dysfunction
39 When evaluating the older adult client, data may indicate that the client has
hypothyroidism. The clinical signs may include
A. blurred vision.
B. dizziness when rising from a lying position.
C. not feeling hungry.
D. anorexia, weight loss, and falls.
40 Teaching for the older adult client with newly diagnosed hyperthyroidism
should include information about the need for
A. decreasing his or her intake of foods high in calories or fat.
B. maintaining a vigorous daily exercise program.
C. monitoring daily blood thyroid levels for at least 1 year.
D. monitoring for clinical manifestations of hypothyroidism.

CASE ANALYSIS:

Seventy-nine-year-old Mr. B, who has chronic obstructive pulmonary disease, lives at

home with his 80-year-old wife, who has Alzheimer’s disease. Mrs. B is able to
ambulate and perform activities of daily living with guidance from Mr. B; however,
Mrs. B displays poor judgment and requires close supervision. Recently, Mr. B was
hospitalized for pneumonia and discharged with home oxygen. His wife, who stayed
with a friend during Mr. B’s hospitalization, has returned home. Mr. B desires to care
for his wife at home but finds his energy reserves are low and has difficulty tracing
her steps throughout the house while attached to his oxygen. The couple
desperately wants to stay in their home but have no family in the area and receive
only limited assistance from friends and neighbors.

THINK CRITICALLY:

o What are the risks faced by this couple and how can they be minimized?
o What assistance could be provided to the couple?

ANSWER SHEET FOR PRELIM QUIZ

MULTIPLE CHOICE
1. 11. 21. 31.
2. 12. 22. 32.
3. 13. 23. 33.
4. 14. 24. 34.
5. 15. 25. 35.
6. 16. 26. 36.
7. 17. 27. 37.
8. 18. 28. 38.
9. 19. 29. 39.
10. 20. 30. 40.

CASE ANALYSIS:

FINALS
MULTIPLE CHOICE
Instructions:
 • Read each item carefully and answer the question by writing the letter in the
answer sheet provided.
• Use permanent ink in writing your answer
• Over imposition and erasure is not acceptable.

1. Which age-related change is the nurse most likely to encounter when assessing
the older adult client’s musculoskeletal system?
A.Increased muscle mass in the legs and torso
B.Shorter height compared with that of younger years
C.Hyperextension of the spine
D.Increased bone density of the spine and long bones
2.When caring for the older adult client who has had a hip fracture, the nurse must
take measures to prevent the occurrence of which common complication?
A.Chronic renal failure
B.Immobility
C.Hypoglycemia
D.Pressure ulcers
3.An effective nursing activity to reduce or control pain in the older adult client who
has a hip fracture is for the nurse to
A.administer higher dosages of the ordered pain medication initially.
B.administer ordered pain medication with aspirin or acetaminophen.
C.elevate the client’s knee on the affected side with a pillow.
D.keep the affected limb in alignment during turning.
4.An older adult client is 8 days post-op after surgical pinning of a hip fracture. Plans
are being made for his discharge to home. Which of the following findings, if noted,
is evidence that expected outcomes are being met?
A.The client is eating well and has no elimination problems.
B.The client can transfer independently from his bed to the chair.
C.The client requests pain mediation every 4 to 6 hours.
D.The client states that he will have someone at home to help care for him.
5.Your older adult client has been diagnosed with osteoarthritis, a condition in which
articular cartilage thins. Based on your understanding of the client’s disease process,
you recognize that the client most likely has
A.severe flexion and fixation of the spine.
B.joint stiffness when rising in the morning.
C.joint swelling without redness or pain.
D.aching pain that is not relieved by rest or application of heat.
6.Which of the following objective findings, if noted, supports the nursing diagnosis
of self-care deficit for the older adult client with osteoarthritis?
A.Client has a weight loss of 10 lb over a 2-month period.
B.Client reports inability to wash or brush hair.
C.Client takes frequent rest periods during bath time.
D.Client spills food when attempting to feed self.
7.You are assisting a 65-year-old female client with planning an appropriate exercise
program to prevent osteoporosis. Of the exercises she enjoys, which will benefit her
the most?
A.Swimming
B.Bicycling
C.Walking
D.Rowing
8.Your older adult female client has been given a prescription for alendronate sodium
(Fosamax) to retard the progression of her osteoarthritis. Important teaching
regarding this drug is that it should be
A.taken daily, 30 minutes before the intake of food or fluids.
B.taken with as little water as necessary to swallow the pill.
C.followed by 1 hour of rest in a reclining position.
D.followed with 8 oz of milk or a milk substitute such as soy protein.
9.An older adult client has been admitted to the hospital with suspected Paget’s
disease. What clinical manifestation will the nurse want to monitor for in an attempt
to differentiate Paget’s disease from other types of musculoskeletal diseases?
A.Red, swollen upper and lower extremity joints
B.Pain on awakening that subsides with activity
C.Headache and/or mild hearing loss
D.Back deformity in the absence of pain
10.A patient is recovering from osteomyelitis. Which outcome is specific for this
condition as opposed to other forms of arthritis?
A.The client will correctly identify the need for antibiotic therapy.
B.The client will verbalize the necessity of follow-up care and monitoring.
C.The client will describe her pain as 1 on scale of 1 to 5.
D.report the presence of increased mobility.
11.A 94-year-old woman was found lying on the floor in the long-term care facility.
She was unable to move without severe pain in her left hip. She is admitted to the
orthopedic unit with a diagnosis of left hip fracture. Buck’s extension traction is used
before surgery. The nurse inspects the foot and notes the traction tapes are
lengthwise on opposite sides of the limb. The nurse’s response to the client is
A.“I can turn you for comfort.”
B.“I can lift your leg.”
C.“I’ll call your doctor.”
D.“How long has your foot been numb?”
12.An effective medicine for the treatment of pain and inflammation of acute gout is
A.colchicine (Novocholchine).
B.allopurinol (Zyloprim).
C.gentamicin (Garamycin).
D.linezolid (Zyvox).
13When caring for older adults, which problem should the nurse expect to encounter
because it represents a normal age-related change in the urinary system?
A.Urinary incontinence
B.Low-grade bladder infection
C.Nocturia
D.High incidence of urinary residual volume
14.An 87-year-old client who does not have a history of urinary incontinence has
suddenly become incontinent. In dealing with this problem, the nurse’s first action
should be to
A.review his medication record for medications that may be causing urinary
incontinence.
B.seek an order from the physician for an indwelling urinary catheter to
prevent skin breakdown.
C.limit his fluid intake to reduce his feeling of having to void so often.
D.remind him every 2 hours that he needs to void and assist him to a bedside
commode or toilet.
15.An older adult client reports “losing urine” when she bends over or gets out of a
chair. In light of her symptoms, which nursing diagnosis most accurately addresses
her problem?
A.Altered urinary function, overflow incontinence
B.Altered urinary function, urge incontinence
C.Altered urinary function, functional incontinence
D.Altered urinary function, stress incontinence
16.When assessing the client for urinary incontinence, which client symptom best
supports the nursing diagnosis of overflow incontinence?
A.“I have trouble starting my urinary stream.”
B.“It burns so badly after I urinate that I hold it as long as I can.”
C.“I can’t make it to the toilet when I feel the need to urinate.”
D.“I constantly dribble urine.”
17.An older adult client’s urinary incontinence is being addressed by prompted
voiding. An important aspect of this procedure is to
A.reprimand the client for urinating at times other than those scheduled.
B.keep the client on the toilet until voiding occurs.
C.allow the client to void at times other than those scheduled.
D.withhold fluids for 8 hours after incontinence occurs.
18.What factor, which often exacerbates the problem, can often be overlooked when
planning care for the incontinent older adult?
A.The presence of constipation or fecal impaction
B.The amount of diaphoresis the client has
C.The client’s ability to get to the commode
D.The amount of food the client is eating each day
19.Indwelling urinary catheters are often a source of infection for the older adult
client. Urinary catheterization is contraindicated in an older adult client who
A.has a deep, nonhealing coccygeal pressure sore.
B.has end-stage cancer.
C.is unable to void sufficiently and has urinary retention.
D.is cognitively impaired but voids when reminded to do so.
20.An older adult male client was in generally good health until yesterday, when he
received injuries from an automobile accident. The nurse should add the diagnosis of
high risk for renal dysfunction to his plan of care because
A.persons, regardless of age, commonly develop renal failure after sustaining
physical trauma.
B.older adults have less ability to maintain homeostasis when physiologically
stressed.
C.he will be receiving renally toxic drugs to protect him from secondary
infections.
D.he will require the use of an indwelling urinary catheter for several days.
21.An older adult woman has a resistant strain of pneumoniA. Which factor, if it
occurs, places her at increased risk for the development of acute renal failure?
A.Administration of intravenous narcotics
B.Administration of total parenteral nutrition
C.Inadequate fluid maintenance
D.Urinary incontinence
22.Of the many factors associated with the development of chronic renal failure,
which condition is least likely to promote its development in the older adult?
A.Long-term prostate enlargement
B.Diabetes mellitus
C.Polycystic kidney disease
 D.Coronary artery disease caused by atherosclerosis
23.You are a nurse working on a medical-surgical unit. A client is admitted with
acute renal failure. You must continually assess for
A.acid reflux.
B.decreased blood urea nitrogen and creatinine levels.
C.hypercalcemia.
D.hyponatremia and hyperkalemia.
24.The nurse is completing an admission assessment on a 69-year-old client who has
benign prostate hyperplasia. The nurse should obtain an in-depth assessment about
A.family history.
B.internal bleeding.
C.vital sign history.
D.urinary patterns.
25.The plan of care for an older adult client with seborrheic dermatitis of the scalp
and eyebrows should include
A.cleaning lesions with a weak hydrogen peroxide solution daily.
B.cleaning the eyebrows with soap and water.
C.applying hydrocortisone 10% to scalp lesions only.
D.applying selenium shampoo to scalp and eyebrows.
26.An older adult male client who has benign prostatic hypertrophy also has xerosis
with severe pruritus. Which nursing intervention is most appropriate for this client?
A.Teaching him to clean his perineal area frequently with mild soap
B.Encouraging him to take a warm shower daily
C.Calling his practitioner for an antihistamine order
D.Teaching him to avoid bath oils or emollient lotions after bathing
27.Which older adult client is at increased risk for developing impaired skin integrity
related to candidiasis?
A.A 60-year-old with a history of bacterial pneumonia
B.A 72-year-old with hyperglycemia and incontinence
C.A 58-year-old newly diagnosed with lung cancer
D.A 90-year-old emaciated client receiving antihypertensives
28.An 87-year-old client developed herpes zoster after surgical repair of a hip
fracture. Which nursing diagnosis should be given priority during the acute phase of
herpes zoster?
A.Social isolation related to isolation precautions
B.Self-care deficit related to severe pain and fatigue
C.Self-esteem disturbance related to presence of lesions
D.High risk for infection related to ruptured vesicles
29.The presence of which skin assessment finding, if noted on an older adult client,
should cause the nurse to suspect a premalignancy?
A.Numerous small red papules on the chest and back
B.An oozing, rough, reddish macule on the ear
C.An irregularly shaped mole on the face or shoulders
D.Brown, greasy lesions on the neck
30.An older adult client has been taught measures to prevent the development of
skin cancer. Which statement, if made by the client, indicates that he needs more
teaching?
A.“I will miss my gardening activities.”
B.“I should buy a sunscreen with an SPF of 15 or higher.”
C.“Now I have a good excuse to wear the straw hat my wife hates!”
D.“My cool long-sleeved shirts will work just fine while I’m golfing.”
31.When assessing the older adult client’s skin for indications of melanoma, the
nurse should inspect for a(n)
A.thick, adherent scale with a soft center.
B.small, inflamed lesion that bleeds easily.
C.irregularly shaped nevus (mole).
D.small, purple, hard nodule beneath the skin surface.
32.An older adult client with a history of peripheral vascular disease has been
admitted to the hospital for treatment of a leg ulcer. The nurse recognizes that the
client will most likely have
A.a deep, necrotic, painless wound on her affected leg.
B.shiny, dry, cyanotic skin on the affected leg.
C.multiple shallow, crusty lesions on the affected leg.
D.a pale, painful extremity with paresthesia.
33.You note that your older adult client has an open, draining wound on the medial
aspect of his right leg. The skin surrounding the wound is reddish-brown with
surrounding erythema and edemA. Based on this information, which nursing
diagnosis should you add to your client’s plan of care?
A.Impaired skin integrity related to altered venous circulation
B.Impaired skin integrity, peripheral related to arterial insufficiency
C.Impaired skin integrity related to diabetic neuropathy
D.Impaired skin integrity, open wound related to pressure ulcer
34.A home nurse is visiting a client who has a draining venous ulcer. Which
observation, if made by the nurse during the visit, indicates that the client needs
more teaching about the ulcers?
A.The client’s legs are elevated.
B.The client’s dressing is dry and intact.
C.The client’s compression stockings are off.
D.The client’s bed is elevated with 15-cm blocks.
35.A 65-year-old man is seen in the outpatient clinic for treatment of psoriasis. The
nurse should anticipate which of the following findings?
A.Increased bowel movements
B.Scant amount of urination
C.Discolored nails
D.Joint alignment
36.The nurse of a bedridden 74-year-old woman is evaluating whether the family
members understand how to position the client correctly. Which of the following
should the nurse observe?
A.Upper arms and legs should be supported by two pillows.
B.The family should change the position at least every 2 hours.
C.Moisture should be placed under the back of the neck.
D.The extremities should be extended to cause contractures.
37. A 69-year-old client is admitted and diagnosed with delirium. Later in the day, he
tries to get out of the locked unit. He yells, “Unlock this door. I've got to go see my
doctor. I just can't miss my monthly Friday appointment.” Which of the following
responses by the nurse is most appropriate?
A. “Please come away from the door. I'llshow you your room.”
B. “It's Tuesday and you are in the hospital. I'm Anne, a nurse.”
C. “The door is locked to keep you from getting lost.”
D. “I want you to come eat your lunch before you go the doctor.”
38. An 83-year-old woman is admitted to the unit after being examined in the
emergency department (ED) and diagnosed with delirium. After the admission
interviews with the client and her grandson, the nurse explains that there will be
more laboratory tests and x-rays done that day. The grandson says, “She has
already been stuck several times and had a brain scan or something. Just give her
some medicine and let her rest.” The nurse should tell the grandson which of the
following? Select all that apply.
A. “I agree she needs to rest, but there is no one specific medicine for your
grandmother's condition.”
B. “The doctor will look at the results of those tests in the ED and decide
what other tests are needed.”
C. “Delirium commonly results from underlying medical causes that we need
to identify and correct.”
D. “Tell me about your grandmother's behaviors and maybe I could figure out
what medicine she needs.”
E. “I'll ask the doctor to postpone more tests until tomorrow.”
39. The nurse is attempting to draw blood from a woman with a diagnosis of
delirium who was admitted last evening. The client yells out, “Stop; leave me alone.
What are you trying to do to me? What's happening to me?” Which response by the
nurse is most appropriate?
A. “The tests of your blood will help us figure out what is happening to you.”
B. “Please hold still so I don't have to stick you a second time.”
C. “After I get your blood, I'll get some medicine to help you calm down.”
D. “I'll tell you everything after I get your blood tests to the laboratory.”
40. A 90-year-old client diagnosed with major depression is suddenly experiencing
sleep disturbances, inability to focus, poor recent memory, altered perceptions, and
disorientation to time and place. Lab results indicate the client has a urinary tract
infection (UTI) and dehydration. After explaining the situation and giving the
background and assessment data, the nurse should make which of the following
recommendations to the client's primary health care provider?
A. A prescription to place the client in restraints.
B. A reevaluation of the client's mental status.
C. The transfer of the client to a medical unit.
D. A transfer of the client to a nursing home

CASE ANALYSIS:

A home health nurse is making an initial home visit to evaluate 69-year-old Mr. S,
who has Alzheimer’s disease, and to assist his wife in developing effective caregiving
plans. Mr. S was diagnosed approximately 1 year earlier as a result of an evaluation
initiated by the university where he taught. University sources stated that Mr. S was
behaving inappropriately: entering other professors’ classrooms and beginning to
lecture, forgetting to be present for classes and meetings, failing to bathe or change
his clothes for days, addressing his class in an incoherent manner, and asking
coworkers for assistance in operating office equipment that he had used for years
without difficulty. After observing Mr. S’s condition progressively worsen over time,
the dean of the university telephoned Mrs. S to discuss the situation. Mrs. S claims
that she noticed that her husband was acting unusually (forgetting names and
appointments, bouncing checks, arguing for no reason, making unkind comments to
friends, and confusing days off with workdays) but thought this could be related to
“getting older” and job stress. When the dean spoke with her, Mrs. S realized that a
serious problem might exist and accompanied her husband for an evaluation, the
result of which was the establishment of a diagnosis of Alzheimer’s disease. Mr. S
retired immediately from the university and has been with his wife for 24 hours each
day since. Mrs. S offered no complaints until this past month, when she repeatedly
called the physician to discuss the new problems of incontinence, eating difficulties,
and wandering that Mr. S was exhibiting. These new problems have devastated Mrs.
S; she looks fatigued and claims to be eating and sleeping poorly. She firmly states
that she “will never consider placing her husband in an institution” and that she’ll
take care of him at home even “if it kills her.”

THINK CRITICALLY:

o What needs do both Mr. and Mrs. S have at this time?

o What resources could be helpful to Mrs. S to assist her in coping with the
demands of caregiving?

ANSWER SHEET FOR PRELIM QUIZ

MULTIPLE CHOICE
1. 11. 21. 31.
2. 12. 22. 32.
3. 13. 23. 33.
4. 14. 24. 34.
5. 15. 25. 35.
6. 16. 26. 36.
7. 17. 27. 37.
8. 18. 28. 38.
9. 19. 29. 39.
10. 20. 30. 40.

CASE ANALYSIS:

End of Prelim Coverage

Before proceeding to the Midterms Coverage….

 Do not forget to write your reflective journal for this term regarding
your learnings, personal reflections and realizations of the different
concepts given. All written outputs should be compiled in your
learning portfolio to be submitted to the subject teacher as part of
the requirements of the course.

EVALUATION:
1. Critical thinking checkpoint.
2. Application (case analysis)
3. End of chapter tests in the form of:
 Identification
 Multiple choice questions
 True or False
 4. Self-Reflection question at the end of the term.

REQUIREMENTS:
After this module, you are expected to submit the following on the date given by
your instructor:

1. Learning Portfolio composed of:

 A copy of the answer sheet duly accomplished found at the last part
of each term.
 Your reflective journal in using the module.
2. Term examinations.