TEST BANK for Evidence-Based Geriatric Nursing Protocols for Best Practice 6th Edition by Marie Bolt by ACADEMIAMILL

Evidence Based Geriatric Nursing Protocols for Best Practice 6th Edition Boltz Test Bank Chapter 1: Developing and Evaluating Clinical Practice Guidelines: A Systematic Approach Multiple Choice Test Questions 1. Models of evidence-based practice (EBP) involve which of the following steps when determining the process of developing protocols? Select all that apply. *a. Develop an answerable question b. Compare the evidence to what one feels to be true

*c. Critically appraise the evidence *d. Locate the best evidence Rationale: Evidence-based practice (EBP) involves five steps: 1. Develop an answerable question 2. Locate the best evidence 3. Critically appraise the evidence 4. Integrate evidence into practice using clinical expertise with attention to patient’s values and perspectives; and 5. Evaluate the outcome(s) Comparing the evidence to what one feels to be true is not a part of evidence-based practice. 2. When critically evaluating level of evidence is at the t h e e v nc)ehiuesreadrcihnyapsyturadm y,idw?hich bottom of the level of evidence (LidOeE *a. Opinions of respected authorities b. Systematic reviews of Clinical Practice Guidelines (CPGs) c. Single experimental studies (Randomized Controlled Trials) d. Nonexperimental studies

Rationale: The level of evidence (LOE) hierarchy pyramid highlights six levels of evidence. Opinions of respected authorities, internationally or nationally known, based on their clinical experience or the opinions of an expert committee, including regulatory or legal opinions, form the lowest level of evidence (i.e., Level VI, at the bottom of the LOE pyramid). The highest level of evidence, at the top of the pyramid, is comprised of systematic reviews, meta-analyses, or structured integrative reviews of evidence. Evidence judged to be at Level II comes from a single randomized controlled trial. Nonexperimental studies are considered Level IV evidence.

3. Which of the following questions are based on the PICO format? Select all that apply. *a. In patients with osteoarthritis of the knee, is hydrotherapy more effective than traditional physiotherapy in relieving pain? *b. For obese children, does the use of community recreation activities compared to educational programs on lifestyle changes reduce the risk of diabetes mellitus? *c. For deep vein thrombosis, is D-dimer testing or ultrasound more accurate for diagnosis? d. Do adults who binge drink have higher mortality rates?

Rationale: PICO stands for: P - Population or patient problem I - Intervention C - Comparison group or standard practice O - Outcomes PICO format is used to frame the research question and facilitate literature search. Each research question is narrowed down to clearly state the population or the patient problem, the intervention being studied, the comparison group, and the outcome measures. In the question “In patients with osteoarthritis of the knee, is hydrotherapy more effective than traditional physiotherapy in relieving pain?”, patients with osteoarthritis form the population, hydrotherapy is the intervention that is being compared with traditional physiotherapy, and pain relief is the expected outcome. In the question “For obese children, does the use of community recreation activities compared to educational programs on lifestyle changes reduce the risk of diabetes mellitus?”, obese children form the study popTuElaStiT onB,AuN seKoSf E coLmLm ityCO reM creation services is the EuRn. intervention, being compared to educational programs on lifestyle changes, and reducing the risk of diabetes mellitus is the expected outcome. In the question “For deep vein thrombosis, is Ddimer testing or ultrasound more accurate for diagnosis?”, deep vein thrombosis is the patient problem, D-dimer testing is the intervention, being compared to ultrasound for accuracy of diagnosis, that is the expected outcome. The question “Do adults who binge drink have higher mortality rates?” does not follow the PICO format. In this question, adults form the population being studied, binge drinking is the intervention, and higher mortality rate is the outcome being studied. However, the comparison group is not defined and stated in the question.

4. Which of the following statements regarding the AGREE II instrument are true? Select all that apply. *a. The AGREE instrument has 6 quality domains with 23 items divided among these domains. *b. Each domain is rated on a 4-point Likert-type scale from “strongly disagree” to “strongly agree” by a number of appraisers. c. The six domain scores are aggregated into a single quality score. d. The reliability of the AGREE instrument is decreased when each guideline is appraised by more than one appraiser.

Rationale: The AGREE II instrument has six quality domains: scope and purpose, stakeholder involvement, rigor of development, clarity and presentation, application, and editorial independence. A total of 23 items are divided into these domains. Each domain is rated on a 4point Likert-type scale from “strongly disagree” to “strongly agree” by a number of appraisers. Appraisers evaluate how well the guideline they are assessing meets the criteria of the six quality domains. The six domain scores are independent and should not be aggregated into a single quality score. The reliability of the AGREE instrument is increased, not decreased, when each guideline is appraised by more than one appraiser. 5. Four appraisers give the following scores, as shown in the table below, for domain 1 (Scope & Purpose) in the AGREE II instrument. What will be the scaled domain score?

Appraiser 1 Appraiser 2 Appraiser 3 Appraiser 4

Item 1

Item 2

Item 3

5 6 2 3 16

6 TESTB 6 4 3 19

N 6 KSELL R 17.COM 7 3 2 18

Item 4 19 9 8 53

a. 53%

*b. 57% c. 47% d. 19%

Rationale: Maximum possible score = 7 (strongly agree) × 3 (items) × 4 (appraisers) = 84 Minimum possible score = 1 (strongly disagree) × 3 (items) × 4 (appraisers) = 12 The scaled domain score will be: Obtained score − Minimum possible score Maximum possible score −Minimum possible score 53 − 12 × 100 = 41 × 100 = 0.5694 × 100 = 57% 84 − 12 72

6. A 59-year-old patient is diagnosed with acute biliary pancreatitis and noninfected pancreatic necrosis on contrast enhanced computed tomography scan. The clinician plans to start a course of prophylactic antibiotics. Which study design is appropriate to evaluate if antibiotics prevent infection of noninfected pancreatic necrosis and decrease mortality? a. Case-controlled study b. Randomized controlled trial *c. Systematic review and meta-analysis d. Prospective cohort study Rationale: Systematic review and meta-analysis of previous randomized control trials to evaluate use of antibiotics in preventing infection of noninfected pancreatic necrosis and decreasing mortality will be the appropriate study design in this case. Systematic reviews and meta-analysis constitute the highest level of evidence (Level I according to the level of evidence hierarchy pyramid). Case-control studies are observational studies used to identify factors that may contribute to a medical condition by comparing subjects who have that condition/disease (the “cases”) with subjects who do not have the condition/disease but are otherwise similar (the “controls’). Casecontrol studies require fewer resources but more time; also the evidence obtained is inferior to other types of study designs (Level IV on the level of evidence hierarchy pyramid). Thus, this will not be an appropriate study design in this case. A randomized control trial is a study design with two study groups: the experimental group, where the intervention being studied is applied; and the control group, where no intervention is used or a placebo is used instead. A randomized TES control trial can be used in this case toTeB vaAluNaK teSifEaLnL tibEiR ot. icC sO prM event infection of noninfected pancreatic necrosis and decrease mortality. However, it will be difficult to find matching controls (with the same stage and severity of disease, and other matching demographic characteristics). Also, the study will require significant time, as the two study groups will have to be followed up for a significant period of time to see results. The evidence obtained from a single randomized control trial will still be inferior (Level II on the level of evidence hierarchy pyramid) as compared to that from meta-analysis and systematic review. A prospective cohort study follows over time a group of similar individuals (cohorts) who differ with respect to certain factors under study to determine how these factors affect rates of a certain outcome. Such studies are important for research on the etiology of diseases. In a prospective cohort study, at the time of enrolling subjects and collecting baseline exposure information, none of the subjects have developed any of the outcomes of interest. After baseline information is collected, subjects are followed “longitudinally,” i.e., over a period of time, usually for years, to determine if and when they become diseased and whether their exposure status changes outcomes. Thus, this will not be an appropriate study design to assess impact of an intervention.

7. In a study, patients with arthritic knee pain were identified and randomly allocated to two groups. One group of patients was given Ibuprofen for control of pain, and the other group was given a placebo. According to the level of evidence (LOE) hierarchy pyramid, what level of evidence will the results from this study generate?? a. Level VI b. Level V *c. Level II d. Level III Rationale: The study is a randomized control trial with two study groups: the experimental group, where the intervention—in this case Ibuprofen—is given; and the control group, where a placebo is used instead. Thus, this study will generate Level II evidence according to the level of evidence (LOE) hierarchy pyramid. Level VI is the lowest level of evidence in the LOE hierarchy pyramid and is made up of the opinions of respected authorities based on their clinical experience or the opinions of an expert committee, including regulatory or legal opinions. Level V evidence includes narrative literature reviews, case reports that are systematically obtained and of verifiable quality, or program evaluation data. A quasi-experimental study, such as a nonrandomized controlled single group pretest/posttest, time series or matched case-controlled study, is considered Level III evidence. 8. In a randomized double-blind trial to compare a new analgesic with a placebo for control of pain in arthritis, subjects report less pain while using the analgesic. The “p” value for the difference in pain scores between the two regimes is 0.002. What conclusions can be drawn from this study? Select all thatTEST applyB . *a. The drug is an effective analgesic. *b. There is evidence that the drug reduces pain in arthritis. c. The drug is better than currently prescribed analgesics. d. There is a 2% probability that the difference in pain scores is obtained only due to chance. Rationale: The results of the study show a “p” value of 0.002 for difference in pain scores between the two regimes. It can be concluded that the drug is an effective analgesic and provides evidence that the drug reduces pain in arthritis. It is not possible to conclude whether the new analgesic is better than the currently prescribed analgesics as the study does not compare it with the current regime, but rather uses a placebo. The “p” value for difference in pain scores between the two regimes is 0.002. This means there is a probability of 0.2% that this difference is obtained only due to chance (and 99.8% probability that the difference is not due to chance).

9. A study is conducted to compare chemotherapy given at home with outpatient treatment for rectal cancer. The study enrolls 97 patients. Of these patients, 42 are treated at an outpatient clinic and 45 are treated at home. Treatment related toxicity in both groups is obtained and compared. What is the study design in this case? a. Randomized control trial *b. Observational study c. Case-control study d. Quasi-experimental study Rationale: This study is an observational study design where two methods of providing treatment are being compared: chemotherapy given at home versus outpatient treatment for patients with rectal cancer. No intervention is applied in this study. A randomized control trial is comprised of two study groups: the experimental group, where the intervention being studied is applied; and the control group, where no intervention is used or a placebo is used instead. Case– control studies are observational studies used to identify factors that may contribute to a medical condition by comparing subjects who have that condition/disease (the "cases") with subjects who do not have the condition/disease but are otherwise similar (the "controls"). A quasiexperimental study is a non-randomized experimental study that can be used to assess causal impact of an intervention on a population. 10. A hospital patient care program specifies use of the STRATIFY instrument to measure the risk of falls in older adult inpatients. What is this an example of? a. A guideline

*b. A protocol c. A standard of practice d. A recommendation Rationale: A protocol is a detailed guide for approaching a clinical problem and is tailored to a specific situation. It is specific and rigid, not leaving much room for adjustment and change. Use of the STRATIFY instrument to measure the risk of falls in older adult patients is an example of a protocol. A guideline is a general rule or a principle that is more flexible and can be adapted within a large variety of settings. Standards of practice are not specific or necessarily evidencebased; rather these are generally accepted, formal, and published frameworks of practice. A recommendation is a suggestion for practice, not necessarily sanctioned by a formal, expert group.

Chapter 2: Measuring Performance and Improving Quality Multiple Choice Test Questions 1. The Institute of Medicine defines “quality” as: a. Increase in the number of individuals receiving correct and safe medications, and receiving them in a timely manner b. Improved effectiveness of treatment and medications derived from evidence-based medicine *c. The degree to which health services for individuals and populations increase[s] likelihood of desired health outcomes and are consistent with the current professional knowledge d. Improved efficiency of medical services in providing treatment and medications Rationale: The National Academy of Medicine (NAM) defines quality of care as the degree to which health services for individuals and populations increase[s] likelihood of desired health outcomes and are consistent with the current professional knowledge. 2. What do regulatory and accrediting bodies expect organizations to do with data obtained through measuring the quality of outcomes? Select all that apply. *a. Identify and prioritize processes that support clinical care *b. Demonstrate an attempt to improve performance *c. Benchmark their results with results from similar organizations d. Identify the best performiT ngEeSmTpB loAyN eeKs SELLER.COM Rationale: The data obtained through measuring the quality of outcomes must be used to identify and prioritize processes that support clinical care, demonstrate efforts to improve performance, and benchmark and share results with similar organizations. The data is not used to assess the performance of employees. 3. If a performance measure is measuring what it is supposed to, it is said to have a high a. Sensitivity b. Specificity *c. Validity d. Reliability Rationale: Validity refers to whether the performance measure actually measures what it says. Sensitivity of a performance measure refers to its ability to identify true cases (i.e., determine the likelihood of a positive test when a condition is present). Specificity of a performance measure is the likelihood of a negative test when the parameter is not present. Reliability refers to reproducibility of results (i.e., the indicator measures the same attribute consistently across the same patients and across time).

4. A checklist to identify injury due to fall in postoperative patients is found to be 99% sensitive. Given this information, which of the following statements about the checklist are true? Select all that apply. *a. The checklist identifies most of the cases of injury due to fall in postoperative patients. b. The number of false positives reported is high. c. The checklist has a high specificity.

*d. The number of false negatives reported is low. Rationale: The checklist has a sensitivity of 99%, which means that it correctly identifies most of the cases of injury due to fall in postoperative patients. Since the test has a high sensitivity, false negatives reported will be low. From the information provided, assessment of specificity of the checklist is not possible. The number of false positives reported will depend on the specificity of the test; since information regarding specificity is not provided, it is not possible to assess the number of false positives. 5. During an accreditation audit, the surgical postoperative ward of a hospital is found to have inadequate nursing staff. This indicates lack of which of the nursing-sensitive indicators of quality care? *a. Structure b. Process c. Outcome d. Competence

Rationale: The nursing sensitiveTinEdS icTatBoA rsNoK fS quEaL litL yEcaRr. eC inO clM ude structure, process, and outcome. Structure relates to supply of nursing staff and their skill level. Process indicators measure aspects if nursing care, like assessment and intervention. Outcome indicators refer to patient outcomes that are nursing care sensitive, and include pressure ulcers, falls, intravenous infiltrations, etc. Competence indicators include collaboration with other professionals, decisionmaking, and the ability to practice ethically.

6. Performing a fall risk assessment on a patient at the time of admission can reduce fall rates. What is the process measure and the outcome measure in this statement? a. Performing fall risk assessment (outcome measure); reduction in fall rates (process measure) b. Time of admission (process measure); performing fall risk assessment (outcome measure) *c. Performing fall risk assessment (process measure); reduction in fall rates (outcome measure) d. Time of admission (outcome measure); performing fall risk assessment (process measure) Rationale: Outcome measures are a change in the health of an individual or a group of individuals that are attributable to an intervention. In this case, fall rates are outcomes indicators. Other examples of outcome indicators are mortality rates, readmission, and patient satisfaction. Process measures capture aspects of care provision like performing the fall risk assessment for patients at the time of admission. Time of admission is not a performance measure. 7. A geriatric care hospital has initiated the process of establishing standards of excellence in care for older adults and comparing its existing geriatric care process with these standards. What are the advantages of this process? Select all that apply. *a. Helps set performance expectations *b. Identifies performance gaps *c. Leads to technological upgradation *d. Develops a standardized set of procedures Rationale: The process of establiT shEinSgTsBtaAnN daKrdSsEoL fL exEcR el. leC ncOeM(using performance standards of the leading organizations in the field) and comparing existing processes with these standards is known as benchmarking. The process helps set performance standards or the outcome measures to be achieved, helps identify performance gaps, develops a standardized set of procedures, and leads to technological upgradation, as required to meet set standards.

8. Which of the following are qualities of a good performance measure? Select all that apply. *a. Validity *b. Clearly defined *c. Reliability *d. Sensitivity Rationale: Validity, a clear definition, reliability, and sensitivity are all qualities of a good performance indicator. Validity refers to whether the performance measure actually measures what it says. A performance measure must have a clear definition that specifies what data elements have to be collected. Reliability refers to reproducibility of results (i.e., the indicator measures the same attribute consistently across the same patients and across time). Sensitivity of a performance measure refers to its ability to identify true cases (i.e., determine the likelihood of a positive test when a condition is present). 9. Which of the following are the 4Ms of a friendly health system? Select all that apply. a. Money *b. Medication *c. Mentation *d. Mobility Rationale: The four elements or the 4Ms of a friendly health system are medication (i.e., use of medication that does not interfere with mentation, mobility, and what matters); mentation (i.e., prevention, identification, and management of delirium, dementia, and depression across care settings); mobility (i.e., ensuring T olE deSrTaB duAltNs K caSnEmLoLvE eR sa. feClyOtM o maintain function and do what matters); and what matters (i.e., alignment of patient goals with preferences). Money is not included as an element of a friendly health system. 10. Which of the following are important steps while developing in-house performance measures of quality care? Select all that apply. *a. Identify the population to be included *b. Identify and define data elements c. Reinvent performance measures *d. Test the data collection process Rationale: Identification of the population, identification and defining of data elements, and testing the data collection process are important steps in developing in-house performance measures of quality care. Reinventing performance measures, especially when good reliable performance measures are already available, is not recommended.

Chapter 3: Informational Technology: Embedding Geriatric Clinical Practice Guidelines Multiple Choice Test Questions 1. Electronic health record (EHR) is defined as: a. a portable, handheld computer with the ability to document patient details directly on the screen with a stylus. b. a software capable of voice recognition systems to document patient details. c. a record of prescriptions provided by the clinician.

*d. a software with a full range of functionalities to store, access, and use medical information. Rationale: Electronic health record (EHR) is a systemized collection of all patients’ information and data, using a software that stores all the information, and makes it easily accessible and retrievable for use. EHR is not a portable handheld computer; it is a software that can be accessed through any computer or mobile device by authorized personnel. Electronic health record software may have a voice recognition property; however, it also has many other features for documenting, storing, analyzing, and easy accessibility of medical information. Clinician prescriptions are a part of the data stored by EHR; it is a complete software for storing all patient-related information in a digital format. 2. Which of the following statements regarding computerized provider order entry (CPOE) are correct? Select all that apply. *a. CPOE ensures prescribing providers have access to patients’ allergy information. *b. CPOE supports providers in judicious use of medications potentially inappropriate for older adults. c. CPOE guides the care provider in differential diagnosis of the patient’s condition.

*d. CPOE ensures patients receive appropriate dosage of medications. Rationale: Computerized provider order entry (CPOE) is defined as "the provider’s use of computer assistance to directly enter medication orders from a computer or mobile device." It is an important component of electronic health records (EHRs). CPOE ensures prescribing providers have access to patients’ allergy information, and supports providers in judicious use of medications potentially inappropriate for older adults. CPOE also ensures that patients receive appropriate dosage of medications based on their weight, renal function, and other clinical situations. CPOE has no role in diagnosis of the patient's condition.

3. An algorithm for risk assessment for developing pressure ulcers in geriatric patients is embedded in the nursing assessment part of the EHR. This is an example of a: a. Computerized provider order entry

*b. Clinical decision support system c. Dashboard d. Electronic medical record

Rationale: A clinical decision support system (CDSS) is a feature of electronic health records (EHRs) that helps clinicians analyze and reach a diagnosis based on patient data. It provides direction to the clinician regarding what needs to be assessed. Embedding an algorithm for risk assessment of pressure ulcers in the EHR is an example of CDSS, as this ensures that none of the patients are missed and the information obtained guides the clinician in decision-making. Computerized provider order entry (CPOE) is a component of EHRs and is defined as "the provider’s use of computer assistance to directly enter medication orders from a computer or mobile device." Instructions regarding medications, laboratory, and radiology investigations are sent via a computer application rather than paper, fax, or telephone. A dashboard is a system homepage that provides a holistic view of the entire system. It can be customized to summarize information relevant to a particular clinical situation, and provide quick access to the required data. Dashboards can also represent information in a tabulated or graphical manner. Electronic medical record is a digital version of a patient’s medical information from one provider. 4. Which of the following are advantages of implementing electronic health records? Select all that apply. *a. Promotes legible, complete documentation of patient information *b. Includes a clinical decision support system that assists in diagnosis *c. Provides electronic alerts for appropriate medication dosage based on patient-specific conditions *d. Enables quick access to patients’ records for more coordinated, efficient care Rationale: An electronic health record (EHR) is a systemized collection of all patients’ information and data, using software that stores all the information, and makes it easily accessible for use. It provides legible, complete documentation of patient information. The clinical decision support system (CDSS) is a feature of the EHR that helps clinicians analyze and reach a diagnosis based on patient’s data and provides direction to the clinician regarding what needs to be assessed. Electronic reminders through EHR can identify and present appropriate medicine dosage recommendations based on patient-specific conditions and characteristics at the time of ordering. EHR enables storage of all patient data in an electronic form, enabling quick access and retrieval of this data when required.

5. The geriatric nurse consultant of a hospital notices that data regarding different assessments of a patient, conducted at the time of admission, are presented in a fragmented manner at different locations in the electronic health record (EHR). Which of the following would be an effective solution for this problem? a. Periodic training of staff who uses EHR b. Set up EHR electronic alerts *c. Create a dashboard d. Update EHR software Rationale: The problem of data being presented in a fragmented manner in the EHR can be solved by creating a dashboard, which is a customized user interface that summarizes information relevant to a particular clinical situation and provides quick access to the required data. In this case, the dashboard can be customized to show results of all assessments of a patient done at the time of admission, on the main system homepage. Periodic training of the staff will not help solve the issue of fragmented data presentation. Setting up EHR electronic alerts will not be helpful in this case; alerts or reminders can be set up to ensure no assessment is missed by the nursing staff. Updating EHR software will not solve the issue of fragmented data presentation; a new customized user interface or dashboard needs to be created for this purpose. 6. The geriatric care unit of a hospital decides to set up a comprehensive geriatric care dashboard as a part of the EHR system. Who should be part of the multidisciplinary team to create this dashboard? Select all that apply. *a. Clinicians and nursing professionals *b. Clinical informaticists *c. Clinical documentation specialists d. Application developer

Rationale: The clinicians and nursing professionals will be a part of the team to create the dashboard, as they will be using the dashboard on a daily basis; and thus their inputs are important. Clinical informaticists and clinical documentation specialists must be included in the team for development of an EHR dashboard. Clinical informaticists are specialists in information technology and its application in the field of healthcare. They ensure that medical records and data are structured in an effective manner and can be easily retrieved and used, as and when required. Clinical documentation specialists are responsible for organization and management of clinical data and documents. They ensure organization, accuracy, and quality in documentation of medical records. An application developer creates and tests application software for computers. The multidisciplinary team to create an EHR dashboard does not usually require an application developer.

7. Which of the following information can be found in a patient’s Electronic Health Record (EHR)? Select all that apply. *a. Allergies *b. Family history *c. Present medications *d. Last time the patient visited the hospital Rationale: An electronic health record (EHR) is a systemized collection of all patient information and data using a software that stores all information, and makes it easily accessible for use. Information regarding allergies, family history, present medications, and details of the patient's last visit to the hospital can all be found in the patient’s EHR. 8. Which of the following are disadvantages of implementing electronic health records (EHRs)? Select all that apply. *a. Cost of implementation *b. Ongoing maintenance cost c. Decreased communication between the provider and the patients

*d. Risk of patient privacy violation Rationale: The cost of EHR adoption and implementation, involving a high upfront initial investment, is one of the major drawbacks of EHR. Maintenance cost of EHR is also high, as the hardware must be replaced and the software must be upgraded on a regular basis. Risk of patient privacy violations is a major disadvantage of EHR. Implementation of EHR improves communication between the healT thE caSreTpBrA ovNidKeS rsEaL ndLE thR e. paCtiO enMts. 9. What are the major steps in the development of an EHR dashboard? Select all that apply. *a. Identification of the problem *b. Identification of the key stakeholders *c. Discussion and finalization of specific components of display of the dashboard d. Obtaining and saving patient-related data

Rationale: A dashboard is a system homepage that provides a holistic view of the entire system. It can be customized to summarize information relevant to a particular clinical situation and provide quick access to the required data. Major steps in the development of a dashboard include identification of the problem and identification of key stakeholders such as end-users or personnel who would use the dashboard, a clinical informaticist, and a clinical documentation specialist. The next step involves discussion among stakeholders to finalize specific components of the dashboard display. Obtaining patient data is not required for development of the EHR dashboard. It is required to assess the functionality of the dashboard once the initial version is finalized and put to use.

10. Some studies have found implementation of EHR to be associated with increased medical errors. What could be the major reasons for this? Select all that apply. a. Poor internet connectivity *b. Poorly designed EHR system interface *c. Lack of end-user training d. Decreased doctor–patient communication Rationale: A poorly designed EHR system interface may lead to problems like improper workflow, inability to view or share patient information, and incorrect drug alerts, which may result in medical errors. Lack of end-user training also affects proper and correct use of EHR, leading to errors. Poor internet connectivity may affect access to EHR data but should not cause medical errors. EHR improves doctor–patient communication; thus, this should not be a reason for increased medical errors.

Chapter 4: Organizational Approaches to Promote Person-Centered Care Multiple Choice Test Questions 1. Which of the following are essential elements of person-centered care? Select all that apply. *a. Preference-based, holistic care plan including personal and social goals *b. Open dialogue between patients, families, and providers *c. Evolving caregiver team including the patient and the family *d. Identifying a primary contact person and team leader to ensure continuity of care Rationale: There are eight essential elements of person-centered care: a personalized care plan, care plan assessment, interdisciplinary team-based care, a team leader, care coordination, constant communication, continuing education, and measurable outcomes. A personalized care plan includes a preference-based, holistic plan including personal and social goals. Constant communication means an open dialogue between patients, families, and providers in person and through the electronic health record. An interdisciplinary team-based care comprised of an evolving caregiver team, including the patient and family members, is also an important element of person-centered care. A team leader and a primary contact person are identified to ensure continuity of care. 2. Which of the following is an example of shared decision-making? .eCnOt M a. The nurse and primary caT reEsS taT ffBfoArN mK ulS atE eL aL trE eaRtm plan for the patient. *b. The clinician explains the risks and benefits of a procedure to the patient and the family members. c. The patient selects and approves a treatment option based on the patient’s preferences and personal beliefs. d. The multidisciplinary team of medical experts decides on the intervention and communicates it to the patient and family members Rationale: Shared decision-making is a process whereby clinicians collaboratively help patients reach evidence-informed and value-congruent medical decisions. It is a process in which clinicians and patients work together to make decisions and select tests, treatment, and care plans based on clinical evidence, balancing risks, and expected outcomes with patient preferences and values. The clinician explaining the risks and benefits of a procedure to the patient and the family members constitutes shared decision-making. The nurse and primary care staff formulating a treatment plan for the patient, the patient selecting a treatment option based on his or her preferences and beliefs, and a team of medical experts deciding on an intervention and communicating it to the patient and family members are all scenarios that are not examples of shared decision-making.

3. Which of the following nursing strategies represent patient-centered care? Select all that apply. *a. Assessment of patient preferences *b. Engaging the patient in assessment, planning, and evaluation of treatment/care plan *c. Knowing the patient by using the “all about me” approach d. Encouraging caregivers to make decisions for the patient Rationale: The assessment of patient preferences and promoting congruence between preferences and care provided; involving the patient in assessment, planning, and evaluation; and knowing the patient by using the “all about me” approach are nursing strategies based on patientcentered care. The family members and caregivers must be encouraged to participate in the treatment plan; however, making decisions on behalf of the patient does not represent patientcentered care. 4. The Eden Alternative model, which is a culture change model of long-term care, involves which of the following strategies? a. Transformation of primary care toward improving patient and informal caregiver experiences, outcomes, and interactions with the healthcare system *b. Improving lives of older adults by decreasing loneliness, helplessness, and boredom by creating elder-centered communities c. Transformation of long-term and postacute care settings to smaller scale, homelike settings focused on improving quality of life and engaging in meaningful relationships d. Shifting long-term care to person-directed practices Rationale: The Eden AlternativeTmEoSdT elBaA imNsKtoSE imLpL roEvR e. thC eO liM ves of older adults by decreasing loneliness, helplessness, and boredom by creating elder-centered communities. The Patientcentered Medical Home Model of care is aimed at transformation of primary care toward improving patient and informal caregiver experiences, outcomes, and interactions with the healthcare system. The Green House project is based on transformation of long-term and postacute care settings to smaller scale, homelike settings focused on improving quality of life and engaging in meaningful relationships. The Pioneer Network, recognized as the national leader of the culture change movement in long-term care, is based on shifting long-term care to person-directed practices. 5. Which of the following are recommended for providing patient-centered care to people with dementia? Select all that apply. *a. Knowing and understanding the person with dementia b. Building authentic relationships by doing all tasks for the person with dementia *c. Creating and maintaining a supportive community for individuals and families *d. Evaluating care practices regularly and making appropriate changes Rationale: Knowing and understanding the person with dementia, creating and maintaining a supportive community for individuals and families, and evaluating care practices regularly and making appropriate changes are recommendations for providing patient-centered care to people with dementia. To build and nurture authentic, caring relationships with a person with dementia, it is important to focus on doing all tasks “with” the patient rather than doing all tasks “for” the patient. Thus, the focus should be on interaction with the patient, rather than mere completion of tasks. 20

6. A 68-year-old male patient is diagnosed with Type 2 diabetes. His HbA1C index is 7.5%. The clinician prescribes Metformin and educates the patient regarding importance of lifestyle changes (dietary modifications and physical activity) in diabetes control. The patient insists that he does not want to take medications and wants to control blood sugar levels with lifestyle modifications. What should be the clinicians next steps based on person-centered care? Select all that apply. a. Convince the patient to start Metformin by explaining the risks b. Counsel the family members on the importance of medication, and ask them to convince the patient

*c. Conduct an evidence-based review of whether proceeding with only lifestyle modifications is acceptable *d. Ensure the patient and family members are educated regarding the risks involved Rationale: An important aspect of person-centered care is to respect patient choices and preferences. In this case, an evidence-based review must be conducted to assess if the patient’s preference of avoiding medication and incorporating only lifestyle modifications for diabetes control can be accepted. The results of the evidence-based literature review must be shared with the patient, and any risks involved must be explained to the patient and the family members. Convincing the patient to start medications by merely explaining the risks, or asking the family members to convince the patient is not appropriate person-centered care. 7. Which of the following are essential domains of person-centered care? Select all that apply. *a. Engagement facilitators *b. Enacting humanistic valueTsESTBANKSELLER.COM *c. Communication *d. Living environment Rationale: The essential domains of person-centered care include engagement facilitators, like family and friends involvement in care and activities; enacting humanistic values, which means supporting autonomy and empowering individuals; communication; and a homelike living environment. 8. Which of the following are examples of the progressive patient care model? Select all that apply. *a. Assigning levels of care to patients using a numerical rating scale b. Improving patient flow by redefining roles of healthcare team members

*c. Grouping patients as outpatient and inpatient surgical cases *d. Stratifying inpatient surgical candidates based on expected length of stay Rationale: Assigning levels of care to patients using a numerical rating scale, grouping patients as outpatient and inpatient surgical cases, and stratifying inpatient surgical candidates based on expected length of stay in the hospital are all examples of the progressive patient care model. Improving patient flow by redefining roles of healthcare team members is an example of the lean approach.

9. Which of the following changes are essential to move acute care facilities toward personcentered care? Select all that apply. *a. Organizational models of care delivery *b. Patient care needs *c. Physical space *d. Nursing model of care delivery Rationale: Changes required to modify acute care facilities and move these toward personcentered care include organizational and nursing model of care delivery, patient-care needs, and appropriate physical space. 10. Which of the following are Eden domains of well-being? Select all that apply. *a. Security *b. Identity c. Financial independence d. Empathy Rationale: The Eden alternative is shaped by a framework of seven domains of well-being: security, identity, growth, autonomy, connectedness, meaning, and joy. Financial independence and empathy are not included in the Eden domains of well-being.

Chapter 5: Environmental Approaches to Support Aging-Friendly Care Multiple Choice Test Questions 1. Which of the following are examples of suffering due to improper physical environment in hospitalized older adults? Select all that apply. *a. Sleep disturbances b. Delirium *c. Falls *d. Infection Rationale: Hospitalized older adults can suffer from sleep disturbances, falls, and infections due to inappropriate physical environment in hospitals. Delirium is not caused by an improper physical environment; however, the physical environment can ease or aggravate the condition. 2. Which of the following is an intrinsic risk factor that can lead to falls in older adults? a. Nursing practices b. Medication *c. Mobility d. Environment Rationale: Mobility of a hospitalized older adult is an intrinsic factor that can lead to fall accidents. Nursing practices, medTicEaS tioTnB ,A anNdKeS nvEirLoL nm arO eM extrinsic factors that can also lead EeRn.t C to fall incidents in hospitalized older adults. 3. Which of the following are physical environmental strategies that are effective in preventing infection transmission? Select all that apply. *a. Single occupancy rooms *b. Electronic reminders for hand cleaning *c. Air filtering d. Installation of grab bars Rationale: Single occupancy rooms, electronic reminders for hand cleaning, and air filtering are physical environmental strategies effective in preventing transmission of infection. Installation of grab bars is a physical environmental measure to prevent falls.

4. Which of the following are examples of positive distraction therapy? Select all that apply. *a. Windows of hospitalized patients overlooking a garden *b. Nature sounds before, during, and after a bronchoscopy procedure *c. Exposure to bright sunlight after a surgical procedure *d. Involvement in a gardening activity Rationale: Positive distraction therapy refers to the predisposition of human beings to respond well to natural surroundings. Positive distractors are defined as environmental or social conditions marked by a capacity to restore mental health by distracting an individual’s attention away from internal and external stressors to a more restorative state of mind. Thus, windows of hospital patients overlooking a garden; nature sounds before, during, and after a bronchoscopy procedure; exposure to bright sunlight after a surgical procedure; and involvement in a gardening activity are all examples of positive distraction therapy. 5. Which of the following interventions are recommended to minimize disturbance due to sound in the hospital room of an older adult? Select all that apply. *a. Applying wall and door insulation *b. Using sound-absorbing finished surfaces c. Issuing a quiet protocol for staff conversations d. Providing ear plugs to patients Rationale: Applying door and wall insulation and using sound-absorbing finished surfaces are effective interventions that can be used to minimize disturbances due to sound in the hospital rooms. A quiet protocol for staff T coEnS v eTrsBaA tioNnKs SanEdLuLsE eR of.eC arOpMlugs are only secondary solutions and are not effective in the long term as these add additional steps for staff and patients and potentially interfere with care. 6. Which of the following nursing care factors can enhance a patient’s perception of dignity, respect, and identity? Select all that apply. *a. Allowing patients to put up personal photographs in the room *b. Allowing personal belongings in hospital/facility care rooms c. Enforcing strict visiting hours for family members *d. Allowing personal furniture items in rooms in a care facility Rationale: Environments that encourage personalization also facilitate dignified care. Interventions like allowing patients to decorate their rooms with personal photographs and allowing personal belongings and furniture, especially in long-term care facilities, can enhance the patient’s sense of dignity and identity and also lead to better connection between the staff and the patients. Strict visiting hours for family members can lead to anxiety and loneliness.

7. Which of the following is the most fundamental need of a hospitalized older adult? a. Respect b. Dignity c. Relief from symptoms *d. Safety Rationale: Safety is the most fundamental need of a hospitalized older adult. This includes fall reduction, infection prevention, security, and reduced errors in treatment. Management of symptoms is the next fundamental need; this includes pain management, anxiety management, and improving sleep and mobility. The most complex needs are a sense of dignity and respect, including privacy, sense of self-worth, and meaningful experiences. 8. Which of the following are clinical factors that can influence patient outcome? *a. Medical care b. Sensory function c. Genetics d. Duration of hospital stay Rationale: Medical care is a clinical factor that can influence patient outcome. Sensory function, genetics, and attitude are individual personal characteristics that also influence patient outcome. Duration of hospital stay is not a clinical factor, but an indicator of the clinical factors affecting patient outcome. 9. Which of the following intervTeE ntS ioT nsBcAaN nK reSdE ucLeLinEcR id. enCtsOoMf falls in hospitalized older adults? Select all that apply. *a. Eliminating flooring material transitions *b. Installing handrails and grab bars *c. Providing open circulation pathways *d. Minimizing site tripping obstacles Rationale: Adopting aging friendly design strategies like eliminating flooring material transitions, installing handrails and grab bars, providing open circulation pathways, and minimizing site tripping obstacles can reduce incidents of falls in hospitalized older adults. 10. Which of the following indicators can be used to assess clinical factors influencing patient outcomes? Select all that apply. *a. Use of medications b. Blood pressure *c. Duration of stay in the hospital d. Pain Rationale: Use of medications and duration of stay in the hospital are indicators of clinical factors influencing patient outcomes. Blood pressure indicates a physiological factor, whereas pain is an indicator of experiential factors of patient outcome.

Chapter 6: Age-Related Changes in Health Multiple Choice Test Questions 1. A 76-year-old male patient visits the clinician with complaints of fatigue, weakness, weight loss, and difficulty in climbing stairs. He has difficulty using scissors and holding coffee mugs and other items in his hands, with a tendency to drop these. The patient appears emaciated with loss of muscle mass. The clinician suspects this to be: a. Osteoporosis. b. Osteoarthritis. *c. Sarcopenia. d. Kyphosis. Rationale: Sarcopenia is defined as reduced muscle mass, decreased physical performance, and a weak grip strength, which occur due to a decline in size, number, and quality of skeletal muscle fibers with aging. As seen in this case, the patient has lost weight, is weak, and has difficulty holding objects in his hands. These symptoms raise suspicion of sarcopenia. Osteoporosis is a condition characterized by decreased bone density that results in bones becoming porus and weak, increasing the risk of fractures. Osteoarthritis is a chronic degenerative disease caused by loss of cartilage in joints, resulting in joint pain and stiffness. Kyphosis is a condition that results in an abnormal forward curvature of the spine. 2. A 91-year-old female patient T viEsiS tsTtB heAcNliK niS ciE anLw ithRc.oC mOpM laints of dizziness, abdominal pain, LE decreased appetite, and increased urinary frequency especially in the night, with urinary incontinence. On examination, she is found to be mildly dehydrated and confused in conversation. She has a history of coronary artery disease, hypertension, and arthritis and is on Tablet Tylenol and Aspirin 81 mg daily. The clinician’s next action should be: a. Conduct the Dipstick test. *b. Attempt to improve hydration and observe for 24–48 hours. c. Start empiric antibiotic treatment. d. Send urine sample for urine culture and urinalysis. Rationale: The symptoms of dizziness, abdominal pain, decreased appetite, and increased urinary frequency in an elderly female raise suspicion of a urinary tract infection (UTI) as UTI in older adults may present with these atypical symptoms. She is also found to be dehydrated and confused. Since typical symptoms of UTI are not seen in this case, the clinician should attempt to improve hydration, as acute changes in mental status like confusion could be due to dehydration. Thus, oral or intravenous fluids are given, and the patient is observed for 24–48 hours. The urine dipstick test is not immediately recommended. If symptoms of confusion and change in urinary characteristics persist after 24–48 hours, a dipstick test is performed. If change in urinary characteristics and mental confusion does not improve after attempting rehydration, urine culture and urinalysis are conducted. If urine culture is positive, antibiotic treatment is recommended.

3. Which of the following conditions can result from age-related changes to the renal system? Select all that apply. a. Increase in glomerular filtration rate *b. Hypovolemia and dehydration c. Decrease in serum creatinine *d. Impaired electrolyte and water management Rationale: The normal aging process results in the decline of the kidney mass with a loss of functional glomeruli and tubules, and a reduction in blood flow. Sodium wasting or excess sodium excretion can occur with diarrhea, resulting in hypovolemia and dehydration. Diminution in maximal urine concentrating ability and blunted thirst sensation and total body water together lead to dehydration and hypernatremia, thus increasing the risk of impaired electrolyte and water management in older adults. Reduction in kidney mass along with changes in the activity of regulatory hormones like vasopressin, atrial natriuretic hormone, and the renin–angiotensin– aldosterone system results in decreased glomerular filtration rate. Serum creatinine levels remain unchanged despite an age-associated decline in glomerular filtration rate because of the parallel decrease in older adults’ skeletal muscle mass, which produces creatinine and glomerular filtration rate for creatinine elimination. 4. A 70-year-old male patient visits the clinician for a routine medical check-up. During auscultation, an extra heart sound is heard immediately before the normal S1 and S2. What could be the reason for this extra heart sound? a. Right ventricular and atrial hypertrophy b. Sclerosis of atrial and mitT raE l vSaT lvBeA s NKSELLER.COM c. Arterial wall thickening and stiffening *d. Atrial contractions in diastole Rationale: An extra heart sound, S4, is heard immediately before the normal heart sounds S1 and S2 in the elderly; this is due to atrial contractions in diastole. S4 heart sound does result from right atrial and ventricular hypertrophy. Sclerosis of atrial and mitral valves causes improper closure of these valves resulting in aortic regurgitation or mitral stenosis, which present as heart murmurs. Arterial wall thickening and stiffening can result in occlusive arterial disease, resulting in a bruit on examination.

5. A 75-year-old male patient visits the clinician with complaints of increasing fatigue, shortness of breath on walking but not on rest, and sleepiness for the past several months. Physical examination shows a diminished chest wall movement, and his abdomen does not rise on inspiration. Pulmonary function tests show a reduced lung volume and inability to sustain a maximal breathing effort. Blood carbon dioxide is high and blood oxygen is low. The clinician concludes this to be: a. Heart failure. *b. Chronic respiratory failure. c. Angina pectoris. d. Emphysema. Rationale: The symptoms of the patient are typical of chronic respiratory failure, probably due to neuromuscular weakness as indicated by diminished chest wall movement and failure of the abdomen to rise, which indicates diaphragmatic weakness. Inability to sustain a maximal breathing effort indicates respiratory muscle weakness. Heart failure is associated with a sudden severe shortness of breath, chest pain, and palpitations. The patient, in this case, has diminished chest wall movement and diaphragmatic weakness, which raises suspicion of respiratory failure. Further investigations including chest radiograph, electrocardiogram, and blood investigations are required to reach a final diagnosis. Angina is characterized by chest pain with a pressure, squeezing, or heaviness in the chest, with the pain radiating to the arms, neck, jaw, and/or the back. Emphysema is a type of chronic obstructive lung disease, involving loss of elasticity and enlargement of the air sacs in the lungs. Main symptoms in emphysema are chronic cough and shortness of breath; however, diminished chest wall movement and diaphragmatic weakness are usually not present. 6. Which of the following cognitive abilities decrease with age? Select all that apply. a. Crystallized intelligence *b. Declarative memory *c. Fluid intelligence *d. Divided attention Rationale: Declarative memory is associated with learning new information, and it decreases with age. Fluid intelligence also decreases with age; it is related to creative reasoning and problem-solving. Divided attention, or the ability to concentrate on multiple tasks concurrently, decreases with age. Crystallized intelligence refers to information and skills acquired from experience, and it largely stays intact with age.

7. Age-related diminished gastric motility contributes to which of the following conditions in older adults? Select all that apply. *a. Altered oral drug passage time and absorption in the stomach *b. Decreased postprandial hunger *c. Elevated risk of gastroesophageal reflux d. Diverticulitis Rationale: Age-related diminished gastric motility leads to delayed emptying of the stomach, resulting in altered oral drug passage time and absorption in the stomach, decreased postprandial hunger, and elevated risk of gastroesophageal reflux. Diverticulitis is caused by decreased motility of the large intestine and is not due to diminished gastric motility. 8. A 79-year-old male patient is brought to the emergency department of a hospital by his daughter, who found him lying on the floor, confused and incontinent of urine. She reveals that the patient had productive cough and weakness for the past three days, but is otherwise independent with activities of daily living and is ambulatory. There is no history of any such episode in the past. On examination, he is found to be severely dehydrated, and auscultation reveals rales and wheeze. Chest x-ray appears normal. He has a history of rheumatoid arthritis and hypertension and takes 325 mg Tylenol and 81 mg Aspirin daily. Which of the following is the most appropriate initial treatment? a. Assess mental status using Mini-Mental State Examination (MMSE) b. Administer intravenous antibiotics *c. Administer intravenous fluids to improve hydration TE d. Start 1 mg Ativan three tim esSaTdBayANKSELLER.COM Rationale: The patient has a history of cough, and examination reveals rales and wheezing; these symptoms raise suspicion of pneumonia or respiratory tract infection. The patient is found to be severely dehydrated. In older adults, pneumonia may present as lethargy, dehydration, and newonset confusion. Chest x-ray may not show infiltrates or consolidation, and these findings may appear only after hydration. Thus, appropriate initial treatment in this case is to administer intravenous fluids to improve hydration. Once hydration improves, cognitive assessment using Mini-Mental State Examination (MMSE) can be done. Intravenous antibiotic should be given only after diagnosis is established. Ativan should not be started immediately; any decision to administer Ativan should be taken after a detailed neurological examination and after obtaining details of existing illnesses and medications.

9. The clinician is examining a geriatric patient who is brought to the hospital after a fall from stairs. He appears confused and is unable to recall any details about the accident, nor does he remember how he reached the hospital. He is unable to provide any family or health history and refuses to eat or take any fluids. What should the clinician assess for in this patient? Select all that apply. *a. Decreased level of consciousness *b. Irritability *c. Personality changes d. Unilateral rhinorrhea Rationale: Older adults are at an increased risk of subdural hematoma from any head trauma, which may cause tearing of small vessels leading to the formation of a subdural hematoma. This patient has been brought to the hospital after a fall from stairs, thus subdural hematoma should be suspected. Signs of an acute or slow-developing hematoma include irritability, decreased level of consciousness, and personality changes. Unilateral rhinorrhea occurs only with skull fracture. 10. How should fever be assessed in older adults? a. Assess for a temperature of at least 101°F, caused by natural increase in basal body temperature b. Measure body temperature against the standard measurement of 98.6°F *c. Determine the baseline and monitor for changes of 2°F to 2.4°F above the baseline d. Assess for axillary temperature of more than 98.6°F Rationale: In older adults, fever T isEaS ssT esBseAdNbK ySdE etL erL mEinRin.gCtO heMbaseline body temperature and then monitoring for changes 2°F to 2.4°F above the baseline. Considering fever as a temperature of at least 101°F or measuring body temperature against the standard measurement of 98.6°F are not correct techniques. Axillary temperature does not provide an accurate estimate of the core body temperature; thus should be avoided for assessing fever in older adults. Measuring body temperature against the standard measurement of 98.6°F is not the correct technique.

Chapter 7: Healthcare Decision-Making Multiple Choice Test Questions 1. Beneficence is one of the core ethical principles underlying the healthcare decision process. It is defined as: a. supporting and facilitating the capable patient’s exercise of self-determination regarding healthcare. b. avoiding actions likely to cause harm to the patient. *c. promoting the patient’s best interest and well-being and protecting the patient from harm. d. allocating fairly the benefits and burdens related to healthcare delivery. Rationale: The core ethical principles underlying the healthcare decision process and giving rise to clinical obligations include beneficence, respect for autonomy, nonmaleficence, and justice. Beneficence is defined as promoting the patient’s best interest and well-being and protecting the patient from harm. Respect for autonomy is supporting and facilitating the capable patient’s exercise of self-determination regarding healthcare. Nonmaleficence is avoiding actions likely to cause harm to the patient. Justice means allocating fairly the benefits and burdens related to healthcare delivery and ensuring that decisions are based on clinical need, rather than ethically irrelevant characteristics. 2. A 79-year-old male patient reports to the hospital’s emergency department disoriented, yelling, and rambling. He is bTroEuS ghTtBtoAtN heKhSoEspLiL taE l bRy.hCisOw Mife, who found him lying on the floor, unable to answer any questions, and confused. In this condition, the patient is not capable of making decisions about his treatment. How should treatment decisions be made for this patient? a. The required treatments to sustain the patient’s life are pursued in spite of the risks, burdens, and benefits. b. Social services are contacted, and someone not related to the patient is appointed as the patient’s guardian to make rational decisions on the patient’s behalf. *c. The patient’s wife must make decisions for the patient based on what is determined to be in the patient’s best interests. d. The matter must be referred to the hospital’s ethics committee. Rationale: Capacity is a clinical determination that a person has the ability to understand, make, and take responsibility for the consequences of healthcare decisions. When patients are not capable of making decisions regarding their treatment, the authority to act on their behalf is vested in others, like family members or surrogates. In this case, the patient’s wife must make decisions for the patient based on what is determined to be in the patient’s best interest. The required treatments are continued only after an informed consent is obtained from the patient’s family or surrogate. In this case, the patient is accompanied by his wife, so social services need not be contacted for the purpose of making decisions on the patient’s behalf. The matter need not be referred to the hospital’s ethics committee.

3. A 65-year-old diabetic patient is brought to the emergency department of a hospital with severe hypoglycemia after taking an overdose of insulin. A detailed history reveals that he lives alone, and often forgets to take his diabetes medication. On a Mini Mental Status Examination he scored 17 out of 30. Which tool should be used to assess the decisional capacity of this patient? a. Assessment of Capacity for Everyday Decision Making (ACED) *b. Short Portable Assessment of Capacity for Everyday Decision Making (SPACED) c. Confusion Assessment Method (CAM) d. St. Louis University Mental Status (SLUMS) Rationale: The patient is a diabetic who lives alone and often forgets to take his medication. The Mini Mental Status Examination score of 17 is well under the cut-off score of 24 and indicates that the patient has a possible cognitive impairment. The Short Portable Assessment of Capacity for Everyday Decision Making (SPACED) can be used to assess the decisional capacity of this patient. This instrument helps to assess the capacity to solve functional problems of older adults with mild to moderate cognitive impairment. SPACED is a shorter version of Assessment of Capacity for Everyday Decision Making (ACED) and allows the examiner to interview a patient with a functional problem that has at least one possible solution (like in this case, the patient forgets to take his medication and home care can provide a weekly pill box). Assessment of Capacity for Everyday Decision Making (ACED) is an instrument used to assess the capacity to solve functional problems of older adults with mild to moderate cognitive impairment. In this case, ACED can be used; however SPACED is a better tool as the patient has a specific functional problem of forgetting to take his diabetes medication. Confusion Assessment Method (CAM) is used to assess for DelirT iuEmS; T itBisAnNoK t rSeE quLirLedER in.thCiO s cMase as the patient shows no symptoms of confusion and Mini Mental Status Examination has already been done to assess cognitive functioning. St. Louis University Mental Status (SLUMS) is a screening and staging tool used for assessment of dementia, and is not required in this case. 4. Which of the following statements describing the relationship between risk attached to a decision and capacity required to make a decision are true? Select all that apply. *a. The greater the risk attached to a decision, the higher is the level of capacity required to make a decision that will be honored. b. The greater the risk attached to a decision, the lower is the level of capacity required to make a decision that will be honored. c. The lower the risk attached to a decision, the higher is the level of capacity required to make a decision that will be honored. *d. The lower the risk attached to a decision, the lower is the level of capacity required to make a decision that will be honored. Rationale: Accurate and useful capacity assessment depends on the recognition that capacity is decision specific and works on a sliding scale based on the notion of risk. The greater the risk attached to a decision, the higher is the level of capacity required to make a decision and will be honored. Similarly, the lower the risk attached to a decision, the lower is the level of capacity required to make a decision and will be honored.

5. Which of the following questions are useful in assessing the degree to which the patient has the skills necessary to make an informed healthcare decision? Select all that apply. *a. “What do you think you will gain by refusing this surgical intervention?” *b. “Why is this decision so difficult for you?” *c. “Tell me what the physician explained to you regarding the treatment option.” d. “What do you think your daughter would want you to do?” Rationale: In order to assess the degree to which the patient has the skills necessary to make an informed healthcare decision, it is imperative to assess the patient's understanding relative to that particular decision. The probes and questions asked must be very specific, keeping in mind the medical intervention that is required. The questions “What do you think you will gain by refusing this surgical intervention?” “Why is this decision so difficult for you?” and “Tell me what the physician explained to you regarding the treatment option” all relate directly to the patient’s understanding of the intervention. A question like “What do you think your daughter would want you to do?” is inappropriate, as it is not specific for any particular intervention. 6. A 90-year-old male patient with advanced dementia is admitted to the hospital, as he has stopped eating. On examination, the patient is found to respond to painful stimuli but does not interact, nor does he appear to recognize his family members. A decision regarding placement of a percutaneous endoscopic gastrostomy tube to provide him nutrition has to be taken. His family members do not support this decision because they feel he would never want to be dependent on artificial nutrition and hydration. This kind of decision-making on behalf of the patient due to a lack of capacity to decide medical care for himself is referred to as: a. advanced directive. *b. substituted judgment. c. best interest standard. d. instruction directive. Rationale: In this case, the patient is not capable of making decisions regarding his health. In the absence of any advanced directive, decisions are made by his family members based on the fact that they are close to the patient, so they are aware of and can infer the patient’s wishes based on his characteristic behavior and decision-making. This is known as substituted judgment. Advanced directive is of two types: an instruction directive (a list of interventions the patient does or does not want in specified circumstances) or an appointment directive (a health proxy or durable power of attorney for healthcare is identified with the same decision-making authority as the patient.) In a case, where the patient’s wishes are not known and cannot be inferred, best interest standard is applied. This is a decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred. Instruction directive, also known as a living will, is a list of interventions the patient does or does not want in specified circumstances.

7. Which of the following are important steps in obtaining an informed consent? Select all that apply. *a. Disclosure of sufficient material information relevant to the decision in question b. Emphasis on distinctions about efficacy of treatment *c. Understanding the information provided *d. Consent or refusal to the proposed intervention Rationale: Informed consent requires disclosure of sufficient information to the patient (or to surrogates on behalf of patients without decisional capacity), understanding of the information provided, voluntary choosing among the options, and consent or refusal to the proposed intervention. Emphasis on distinctions about efficacy of treatment, whether it would be curative or palliative, can influence a patient’s decision. This is referred to as “framing” and must be avoided during the process of obtaining an informed consent. 8. Which of the following are core ethical principles that give rise to clinical obligations? Select all that apply. a. Allocating clinical resources to patients who are likely to obtain greatest benefit from them. *b. Promoting the patient’s best interest and well-being and protecting the patient from harm. *c. Supporting and facilitating the capable patient’s exercise of self-determination regarding healthcare. *d. Avoiding actions likely to cause harm to the patient. Rationale: The core ethical princTipEleSsTinBcA luN dK eS reE spLeL ctEfoRr.aC utO onMomy, which means supporting and facilitating the capable patient’s exercise of self-determination regarding healthcare; beneficence, which means promoting the patient’s best interest and well-being and protecting the patient from harm; and nonmaleficence, which means avoiding actions likely to cause harm to the patient. Allocating clinical resources to patients likely to obtain greatest benefit from them is not a core ethical principle.

9. Which of the following are components of Advanced Care Planning (ACP)? Select all that apply. a. Best interest standard *b. Instruction directive c. Substituted judgment *d. Appointment directive Rationale: Advanced Care Planning (ACP) is a process to enable individuals with decisional capacity to prospectively articulate their health goals, values, and treatment preferences so that they can be communicated and honored when the ability to make and communicate decisions is lapsed. Instruction directives and appointment directives are important components of Advanced Care Planning. An instruction directive includes a list of interventions the patient does or does not want in specified circumstances. An appointment directive is the legal designation of a healthcare agent with the same decision-making authority as the patient. In case of absent explicit instructions from the patient, either verbally or in an advanced directive, decisions by others are based on either substituted judgment or best interest standard. Best interest standard is a decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred. Substituted judgment is a decision by others based on the formerly capable person’s wishes that are known or can be inferred from prior behaviors or decisions. 10. A 74-year-old female patient needs to undergo an emergency surgical procedure to relieve intestinal obstruction. When the procedure is explained to the patient to obtain an informed LaEkR consent, she replies, “Talk to T mEySdT auBgA htNerK. S ShEeLm es.aC llOmMy decisions about important things. Just do whatever she thinks is right.” The patient is alert and capable of making decisions for herself. What should be the clinician’s next step? a. Refer the matter to the hospital’s ethics committee. b. Explain to the patient that she has to make decisions pertaining to her own health. *c. Respect the patient’s preference and talk to her daughter about obtaining an informed consent. d. Proceed with the best interest standard. Rationale: The decision of the patient to delegate her daughter to be the decision-maker is an autonomous decision; thus it must be respected. The patient’s daughter should be involved and asked to make an informed decision regarding the surgical procedure required for the patient. Since the patient has delegated a trusted person to be the decision-maker, the matter need not be referred to the ethics committee. Best interest standard (decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred) is not required in this case, as the patient has delegated her daughter to make decisions on her behalf. The patient need not be further coaxed to change her decision.

Chapter 8: Sensory Changes in the Older Adult Multiple Choice Test Questions 1. Presbycusis is a condition characterized by which of the following features? Select all that apply. a. Low frequency sensorineural hearing loss *b. Impaired processing of high-pitched sounds *c. Difficulty understanding speech in noisy surroundings *d. Increased hearing thresholds Rationale: Presbycusis is a condition characterized by age-related progressive and irreversible, bilateral, symmetrical, sensorineural hearing loss that results from degeneration of cochlea or associated structures of the inner ear, or the auditory nerves. It is characterized by impaired processing of high-pitched sounds, difficulty in understanding speech in noisy environments, and increased hearing thresholds. Presbycusis is a high-frequency sensorineural hearing loss, not a low-frequency sensorineural hearing loss. 2. A 68-year-old female patient has a best corrected visual acuity of 20/60. What kind of visual impairment does she have? a. Mild vision impairment *b. Moderate visual impairment c. Severe visual impairment d. Normal vison Rationale: The patient has moderate visual impairment, which is defined as a visual acuity of 20/60 to 20/160. Mild vision impairment is defined as best corrected visual acuity of 20/25 to 20/50. Severe visual impairment is a best corrected visual acuity of 20/200 to 20/400. Normal vision is defined as a visual acuity of 20/20 or better. 3. An 85-year-old male patient visits a clinician complaining of blurred vision in the right eye. Ophthalmoscopic fundus examination of the eye reveals a dark shadow in the anterior portion of the lens in front of the retina. Which of the following is the most appropriate treatment? a. Laser trabeculoplasty b. Photodynamic therapy *c. Surgical extraction and lens implantation d. Corticosteroids Rationale: A dark shadow in the anterior portion of the lens in front of the retina on ophthalmoscopic fundus examination indicates a diagnosis of cataract, which results in blurred, hazy vision with gradual, painless loss of vision. Surgical extraction of the affected lens followed by lens implantation is done for treatment of cataract. Laser trabeculoplasty is conducted for the treatment for open-angle glaucoma. Photodynamic therapy is used for treatment of age-related macular degeneration (ARMD). Corticosteroids are used in the treatment of diabetic retinopathy and do not have any role in management of cataract.

4. Perception of sound without an external source is known as a. Ménière’s disease b. Speech paucity *c. Tinnitus d. Central auditory processing disorder Rationale: Tinnitus or ‘ringing in the ear’ is a condition characterized by perception of sound without any external source. Ménière’s disease is characterized by fluctuating hearing loss, dizziness, vertigo, tinnitus, and a sensation of pressure in the affected ear. Speech paucity is a condition with decreased attempts to have meaningful conversations because of the difficulty in getting the message through to a hearing impaired loved one. Central auditory processing disorder is characterized by difficulties in perceptual processing of auditory information in the central nervous system and the neurobiological activity that underlies the processing and gives rise to electrophysiological auditory potentials. 5. An 81-year-old female patient visits a clinician complaining of dry mouth, reduced salivary flow, discomfort in chewing and swallowing, and an unpleasant taste in the mouth for the past two days. History reveals that she visited a hospital three days prior with complaints of vomiting with decreased urine output and fatigue, for which she was prescribed tablet metronidazole, tablet furosemide, and vitamin supplements. Which of the following is an appropriate treatment for her present complaints? a. No treatment required, symptoms are due to aging *b. Discontinue tablet metronTidEaS zoTleBANKSELLER.COM c. Discontinue tablet furosemide d. Increase vitamin supplements Rationale: The symptoms of dry mouth, reduced salivary flow, discomfort in chewing and swallowing, and an unpleasant taste in the mouth indicate a diagnosis of xerostomia or dry mouth. Xerostomia is common in aging adults; however, in this case, the patient has been on tablet metronidazole for the past three days, which is known to cause xerostomia. Thus, tablet metronidazole should be discontinued to relieve symptoms of dry mouth. Furosemide is a diuretic, not known to cause symptoms of dry mouth. Xerostomia is also caused by deficiency of vitamins B and D; however, in this case, the symptoms started acutely after the patient was prescribed tablet metronidazole, which is known to cause dry mouth. Thus, discontinuing metronidazole is the appropriate treatment in this case. 6. Which of these disorders increase the risk of peripheral neuropathy? Select all that apply. *a. Infections *b. Vitamin B12 deficiency *c. Hypertension *d. Diabetes Rationale: Infections, vitamin B12 deficiency, hypertension, and diabetes are all conditions that increase the risk of peripheral neuropathy.

7. A 75-year-old female patient reports to the emergency department of a hospital with swelling and numbness in the right lower leg. She has a history of diabetes and hypertension, and her medications include Metformin 1500 mg daily and Lisinopril 40 mg daily. Which of the following tests should be done in this patient? Select all that apply. a. Ankle-brachial index *b. Vibratory sense with a tuning fork *c. Ultrasonography of the leg *d. Semmes–Weinstein monofilament test Rationale: The symptoms of swelling and numbness in the lower leg raise suspicion of peripheral neuropathy and diabetic neuropathy (the patient has a history of diabetes). Vibratory sense using a tuning fork should be assessed, using a 128-Hz vibrating tuning fork, on the lower extremity bony prominence. Ultrasonography or venous ultrasound of the affected leg should be done; this is the standard imaging test to assess flow of blood in the veins and diagnose deep vein thrombosis. A Semmes–Weinstein monofilament test should be done to screen for decreased sensation on several plantar sites on the foot. The Semmes–Weinstein monofilament is placed against the sole of the foot in eight different areas on the foot. The patient is asked to report when he or she perceives any sensations. Loss of sensation indicates a risk for neuropathic ulcer development. An ankle-brachial index score is used to diagnose peripheral arterial disease, so it is not recommended in this patient. 8. A clinician is examining a 79-year-old male patient. The clinician asks the patient to close his eyes and holds the right large toe of the patient on the sides, moves the toe up, and asks the EaLsLmEoRve.dC. O patient to identify in which diT reEctSioTnBthAeNtK oeSw WMhat is the clinician assessing for in this patient? a. Decreased plantar sensation b. Vibratory sense *c. Proprioception d. Peripheral arterial disease Rationale: The clinician is assessing the patient for proprioception, which is the ability to determine where one is in space. Decreased plantar sensation is assessed using the Semmes– Weinstein monofilament test. The Semmes–Weinstein monofilament is placed against the sole of the foot in eight different areas on the foot. The patient is asked to report when he or she perceives any sensations. Loss of sensation indicates a risk for neuropathic ulcer development. Vibratory sense is assessed using a 128-Hz tuning fork. The vibrating tuning fork is placed on the lower extremity bony prominence, and the patient is asked if he or she can feel the vibration. Older adults should be able to feel the vibration. Peripheral arterial disease is caused by narrowing of blood vessels resulting in decreased blood supply to the affected limb. Tests to detect peripheral arterial disease include an examination of arterial pulse below the affected area, ultrasonography of the affected limb, and detection of ankle-brachial index score.

9. A 70-year-old male patient has a pin-hole visual acuity of less than 20/60. It can be concluded that: a. the individual’s visual impairment is correctable with glasses. *b. the individual’s visual impairment is not correctable with glasses. c. he has severe visual impairment. d. he has normal vision. Rationale: A pin-hole visual acuity test identifies refractive error of the peripheral cornea of the lens of the eye by allowing only perpendicular light into the lens. A pin-hole visual acuity of less than 20/60 indicates that the individual’s visual impairment is not correctable with glasses. If the individual can read farther down the Snellen’s chart with the pin hole, vision may be improved with better refraction of the eyeglasses; or if he or she does not wear glasses, vision could be improved with eyeglasses. Severe visual impairment is a best corrected visual acuity of 20/200 to 20/400. Normal vision is defined as visual acuity of 20/20 or better. 10. During a routine examination of a 76-year-old male patient with a history of Alzheimer’s disease, the clinician uses three bags: one filled with coffee, one filled with baby powder, and one filled with peppermint candies. What is the clinician assessing in this patient? a. Color contrast *b. Olfactory sense c. Sense of taste d. Peripheral sensations

AiNthKcSoE Rationale: The clinician uses bagTsEfiSllT edBw ffL eeL, E baRb. yC poOwMder, and peppermint candies to assess for any olfactory disorders. The patient has a history of Alzheimer's disease, which can negatively impact the sense of smell. Color contrast or contrast sensitivity is measured using the Pelli–Robson Contrast Sensitivity Chart. Disorders of taste are assessed using electrophysiological and reflex tests to identify abnormalities in the nerve brainstem pathway, or through imaging to investigate any lesions in the taste pathway. Peripheral sensations are assessed through Semmes–Weinstein monofilament test, vibratory sense using a tuning fork, and by tests for proprioception.

Chapter 9: Assessing Cognitive Function in the Older Adult Multiple Choice Test Questions 1. Which of the following instruments to assess cognitive functioning would take the shortest amount of time to administer? a. Folstein’s Mini-Mental State Examination b. The Montreal Cognitive Assessment *c. The Mini-Cog d. The Delirium Observation Screening Scale Rationale: The Mini-Cog is a brief four-item screening test consisting of a three-item recall and one clock-drawing item, that takes approximately 3–5 minutes to administer.The Folstein’s Mini-Mental State Examination consists of 11 items assessing orientation, attention, memory, concentration, language, and constructional ability; and takes approximately 10–15 minutes to administer.The Montreal Cognitive Assessment assesses attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation; and takes about 15–20 minutes to administer.The Delirium Observation Screening Scale is useful to determine the nature of impairment and to rule out reversible and treatable conditions like delirium and depression; and takes around 15 minutes to administer. 2. Which of the following are red flags for potential delirium? Select all that apply. *a. Chronic illness *b. Dementia *c. Dehydration *d. Recent surgery Rationale: Chronic illnesses like diabetes, hypertension, and arthritis are red flags for potential delirium. Dementia is a risk factor for developing delirium and the two may co-exist. Dehydration and any recent surgical intervention are potential risk factors for developing delirium, especially in elderly patients.

3. An 85-year-old man, with a history of mild dementia and stable chronic heart failure, is brought to the hospital by his wife. Since morning, he has been intermittently sleepy, confused in conversation, does not seem to recognize his wife, and also has uncharacteristic urinary incontinence. The clinician suspects his symptoms are related to which of the following conditions? a. Depression b. A progression in dementia *c. Delirium d. Stroke Rationale: The patient has an acute, sudden onset of symptoms with disorientation, confusion, and urinary incontinence. He has a previous history of dementia and heart failure. In such a case, the clinicain should suspect delirium; as advanced age, chronic illnesses, and dementia are risk factors for developing delirium. Depression is charcterized by loss of interest or pleasure, which causes clinically significant distress and leads to a decline from previous functioning; these symptoms cannot be attributed to direct physiological effects of a substance or a general medical condition. Dementia is chronic and is characterized by a significant cognitive decline from a previous level of performance in at least one of the cognitive domains. There is no fluctuation in symptoms. Dementia is a risk factor for developing delirium in older adults. Stroke is caused by reduced blood supply to a part of the brain or by hemorrhage due to rupture of a clot. Speech may become slurred and incoherant, and the patient may be unconscious or incoherent. However, stroke is also associated with drooping of one side of the face, and weakness of arms. There is no fluctuation of symptoms in stroke.

4. A 79-year-old male reports to the emergency department of a hospital disoriented, yelling, rambling, striking out, and attempting to jump out of the stretcher. He was brought to the hospital by his daughter, who found him lying on the floor, confused and incontinent of urine. She revealed that the patient had a fever and cough for the past three days, but is otherwise independent with activities of daily living and is ambulatory. There is no history of any such episode in the past. On examination, he was found to be mildly dehydrated and his behavior kept fluctuating. He has history of rheumatoid arthriris and hypertension; and takes 325 mg of Tylenol and 81 mg of Aspirin daily. What tool can be used to assess the patient’s condition? a. St. Louis University Mental Status (SLUMS) b. Montreal Cognitive Assessment (MoCA) *c. Confusion Assessment Method (CAM) d. AD8 Rationale: The patient has an acute onset of symptoms of confusion and disorientation, with no past history of such episodes. He has a respiratory infection as indicated by cough and fever and is mildly dehydrated. These symptoms and history indicate a possible diagnosis of delirium. The Confusion Assessment Method (CAM is a suitable quick and simple tool that can be used to assess for Delirium in this patient. St. Louis University Mental Status (SLUMS)is a screening and staging tool used for assessment of Dementia. Montreal Cognitive Assessment (MoCA) assesses attention and concentration, executive functions, memory, language, visuoconstructional skills, conceptual thinking, calculations, and orientation. It is very sensitive to mild cognitive impairment and nonBaAnNt-K Alzheimer’s Dementia. AD8 is anTE inS foTrm baSsE edLqLuE esRti. onCnO aiMre used for screening of dementia.

5. Which of the following represents a modest cognitive decline from a previous level of performance in at least one cognitive domain that does not interfere with capacity for independence in everyday activities? a. Depression b. Delirium c. Dementia *d. Mild cognitive impairment Rationale: Mild cognitive impairment is a modest cognitive decline from a previous level of performance in at least one cognitive domain. Patients with this decline are independent in everyday activities. Depression is a disorder represented by several symptoms; one symptom that must be present is depressed mood or loss of interest or pleasure during a 2-week period, which causes clinically significant distress and leads to a decline from previous functioning. These symptoms cannot be attributed to direct physiological effects of a substance or a general medical condition. Delirium is disturbance in attention and awareness that develops over a short period of time and tends to fluctuate in severity during the course of a day, combined with a disturbance in cognition that is not better explained by another neurocognitive disorder. Dementia is a significant cognitive decline from a previous level of performance in at least one cognitive domain that interferes with independence in everyday activities if the decline is not exclusively present in the context of a delirium or attributable to another mental disorder. 6. An 85-year-old man is brought to the hospital after a fall from the stairs. On examination he is found to have a dislocated shoulder that is reduced under anesthesia. He is unable to recall any details about the accident, nor does he remember how he reached the hospital. He is unable to provide any family or health history, refuses to eat or take any fluids, and has difficulty responding to simple directions. On a Mini Mental Status Examination he scored 17 out of 30. The clinician’s next actions should be (Select all that apply.) a. Start 1 mg Ativan three times a day *b. Elicit a detailed history from the family members and caregivers *c. Administer AD8 and GP-Cog Informant component *d. Refer the patient for a detailed neurological evaluation Rationale: The Mini Mental Status Examination score of 17 is well under the cutoff score of 24. This indicates that the patient has possible cognitive impairment. Further cognitive assessment using AD8 and GP-Cog Informant component to assess for dementia. A detailed history should be elicited from the family members and care providers, and the patient should be referred for a detailed neurological evaluation. Ativan should not be started immediately; any decision to administer Ativan should be taken after a detailed neurological examination, and after obtaining details of existing illnesses and medications.

7. A 65-year-old diabetic patient was brought to the emergency department of a hospital with confusion and a severe hypoglycemic episode after taking an overdose of insulin. The patient has experienced six similar episodes of hypoglycemia in the past 18 months. He is a college professor and lives alone after his wife passed away three years ago. The clinician should assess the patient for which of the following? Select all that apply. *a. Depression b. Mild Cognitive Impairment c. Delirium *d. Dementia Rationale: Previous six similar episodes of hypoglycemia due to insulin overdose raise suspicion of a suicidal attempt and depression. Dementia or severe cognitive impairment is also suspected as it may interfere with the patient’s ability to conduct activities of daily living. Mild cognitive impairment usually does not affect activities of daily living. Delirium is disturbance in attention and awareness that develops suddenly over a short period of time and tends to fluctuate in severity during the course of a day, combined with a disturbance in cognition like disorientation, or memory deficit. 8. A 78-year-old woman is brought to a clinician with complaints of memory loss and difficulty in communicating and finding words. She has a history of hypertension and coronary artery disease (with a normal stress test, six months ago). Which of the following tools can be used to assess and diagnose the patient’s condition? a. Glassgow Coma Scale AM NK *b. Mini-Mental State ExamiT naEtiS onTB (M SES)E c. Confusion Assessment Method (CAM) d. UB-2 Rationale: The patient has memory loss with difficulty in finding words and communicating; thus indicating towards a possible cognitive impairment. Mini-Mental State Examination (MMSE) should be used in this patient to assess cognitive impairment; it is comprised of 11 items to assess orientation, attention, memory, concentration, language, and constructional ability. Each question is scored as either correct or incorrect; the total score ranges from 0 to 30, reflecting the number of correct responses. A score less than 24 is considered demonstrative of impaired cognition. Glasgow Coma Scale is a neurological scale used to assess the level of consciousness in a patient. Confusion Assessment Method (CAM) is a questionnaire to assess delirium by looking for evidence of an acute change, inattention, disorganized thinking, and altered level of consciousness. UB-2 is a two-item Ultra-Brief Delirium screen (UB-2) to detect delirium.

9. A 65-year-old woman was brought to a clinician by her husband who informed that she feels weak and also has had pain in her back and shoulders for the past several weeks. She is a teacher by profession, but has stopped going to work due to the pain. She is unable to sleep at night, appears restless most of the time, and has gradually stopped speaking with other family members. She has crying spells and feels lethargic all the time. She had visited a few doctors previously and was prescribed medication for anxiety, but she refused to take these medicines. The clinician suspects this condition to be: a. Alzheimer’s disease. b. Dementia. C. Delirium. *d. Depression. Rationale: The patient has been experiencing symptoms of lack of interest in work, with crying spells, and feeling low for several weeks. Distress accompanying these symptoms is causing deficits in social, occupational, and other areas of functioning, indicating a diagnosis of Depression. Alzheimer’s disease is charcterized by memory loss and other cognitive impairments interfering with activities of daily living. Dementia is a significant cognitive decline from a previous level of performance in at least one cognitive domain that interferes with independence in everyday activities. Delirium is disturbance in attention and awareness that develops over a short period of time and tends to fluctuate in severity during the course of a day, combined with a disturbance in cognition like disorientation, or memory deficit. 10. A 60-year-old woman is brouT ghEtStoTaBcAliN nK icS iaE nL byLhEeR r. soCnOwMho informs that she has difficulty recalling where she has placed objects, does not recall recent converstaions, and is increasingly relying on written reminders for everyday tasks. The symptoms started three years ago and have been increasing in severity since then. She is otherwise independent with activities of daily living. Her MMSE score was found to be 23/30. There is no history of any other medical illness or condition. The clinician suspects this condition to be which of the following? a. Depression b. Delirium c. Dementia *d. Mild cognitive impairment Rationale: Mild cognitive impairment is a modest cognitive decline from a previous level of performance in at least one cognitive domain that does not interfere with capacity for independence in everyday activities. In this case, the patient has difficulty recalling recent conversations and forgets where she has placed objects and relies on written notes. She is, however, independent with her activities of daily living. These factors and a MMSE score of 23/30 indicate a possible diagnosis of mild cognitive impairment. Depression is a disorder represented by several symptoms; one symptom that must be present is depressed mood or loss of interest or pleasure during a 2-week period, which causes clinically significant distress and leads to a decline from previous functioning. These symptoms cannot be attributed to direct physiological effects of a substance or a general medical condition. Delirium is disturbance in attention and awareness that develops over a short period of time and tends to fluctuate in

severity during the course of a day, combined with a disturbance in cognition that is not better explained by another neurocognitive disorder. Dementia is a significant cognitive decline from a previous level of performance in at least one cognitive domain that interferes with independence in everyday activities if the decline is not exclusively present in the context of a delirium or attributable to another mental disorder.

Chapter 10: Assessment of Physical Function in the Older Adult Multiple Choice Test Questions 1. Why is it important to include critical components of functional assessments into the routine assessments in acute care settings? Select all that apply. *a. To obtain baseline information to benchmark patients’ response to treatment as they move along the continuum from acute care to rehabilitation or to subacute care *b. To determine care needs and eligibility for services, including safety, physical therapy, and posthospitalization needs *c. To plan continuity of care from other healthcare providers *d. To obtain an objective measurement of the outcome of care Rationale: It is important to include critical components of functional assessments into routine assessments in acute care settings because functional assessment helps in obtaining baseline information to benchmark patients’ responses into treatment at various stages of care and rehabilitation. Functional assessments also help to determine care needs and eligibility for various services like safety, physical therapy, and posthospitalization needs and help in planning continuity of care from other healthcare providers. Functional assessments also provide an objective measurement of the outcome of care. 2. An 85-year-old male patient with a history of Alzheimer’s disease visits a clinician for a routine check-up. Which of thTeEfoSlT loB wA inNgKteSstEs LshLoE ulRd.bC eO usMed for assessment of ADL (activities of daily living) function in this patient? *a. Barthel Index b. Mini-Cog c. “Get up and Go” Test d. AD8 Rationale: The Barthel Index is an ordinal scale that measures performance in activities of daily living (ADL) and the degree of assistance required by an individual. It should be used for functional assessment of this patient. The Mini-Cog is a brief four-item screening test used to detect cognitive impairment, and differentiates individuals with dementia from those who do not have dementia. It is not used for functional assessment, and thus not required in this case. “Get up and Go” test is a performance-based measure of ambulation, balance, and gait; it does not assess ADL performance. AD8 is an informant-based questionnaire used for screening of dementia. It does not assess functional status, and thus not recommended in this patient.

3. The clinician is assessing a 75-year-old female patient with dementia. The Katz ADL Index score is 2. This indicates which level of functional impairment in the patient? a. No functional impairment b. Mild functional impairment c. Moderate functional impairment *d. Severe functional impairment Rationale: The Katz Index of Independence in Activities of Daily Living assesses independence of a patient in conducting activities of daily living. It is a dichotomized tool with independent versus dependent variable of each task; and can be used as an observational or self-reported measure of level of independence. A score of 2 or less than 2 on the Katz Index indicates severe functional impairment. A score of 4 indicates moderate impairment, and a score of 6 indicates full function or no functional impairment. Mild functional impairment is not defined by the Katz Index. 4. An 85-year-old patient with a history of mild degenerative dementia and stable chronic heart failure is brought to the hospital complaining of abdominal pain. Which of the following instruments should be used for functional assessment of instrumental activities of daily living (IADL) in this patient? a. Older American Resources and Services-IADL Scale b. Lawton IADL Scale c. Barthel Index *d. Direct Assessment of Functional Abilities (DAFA) Rationale: The patient has a history of mild degenerative dementia, thus Direct Assessment of Functional Abilities (DAFA) should be used for functional assessment of instrumental activities of daily living (IADL). This is a 10-item observational measure of IADL that is useful in assessment of function in older adults with dementia. The Lawton IADL scale and the Older American Resources and Services-IADL Scale are instruments to measure IADL; however, in patients with dementia, DAFA is used. The Barthel Index is an ordinal scale that measures performance in activities of daily living (ADL) and the degree of assistance required by an individual. It does not measure IADL. 5. Frailty is characterized by which of the following? Select all that apply. *a. Walking speed *b. Weight loss c. Mental acuity *d. Fatigue handgrip Rationale: Frailty is characterized by five components: weight loss, fatigue, handgrip, physical activity, and walking speed. Baseline frailty is an important predictor of functional decline during acute illness and hospitalization that necessitates early aggressive interventions to maintain mobility and nutrition. Mental acuity is not a component of frailty.

6. A 74-year-old patient with a history of mild dementia is being discharged from the hospital after recovering from an episode of pneumonia. Which of the following instruments can be used to assess critical needs of the patient after discharge? Select all that apply. a. SF 36v2 *b. Katz ADL Index *c. Direct Assessment of Functional Abilities (DAFA) *d. Lawton IADL Scale Rationale: The Katz Index of Independence in Activities of Daily Living (commonly called the Katz ADL Index) assesses the independence of a patient in conducting activities of daily living. This instrument can be used to assess and detect problems performing daily activities at the time of discharge to plan for appropriate measures and assistance that may be required at home. Direct Assessment of Functional Abilities (DAFA) is a 10-item observational measure of IADL that is useful in assessment of function in older adults with dementia. This instrument can be used to assess in performing instrumental activities of daily activities at the time of discharge and help plan for assistance required by the patient after discharge. The Lawton IADL scale is used to measure instrumental activities of daily living (IADL) and can also be used to assess patient’s level of independence at the time of discharge from hospital. SF 36v2 is an instrument that assesses the patient’s perception of his or her functioning and overall health. It will not be helpful in assessing the patient’s level of independence and assistance required after discharge from the hospital. 7. An older adult patient has a score of 8 on the Lawton IADL Scale. What assessment can be concluded about this patient? *a. Independent b. Dependent c. Low function d. Moderate function Rationale: The Lawton IADL scale is used to measure instrumental activities of daily living (IADL), which are considered to be more complex functions compared to the basic activities of daily living. Common IADL skills identified include using a phone, shopping, meal preparation, housekeeping, laundry, medication administration, transportation, and money management. These eight domains of function are measured by the Lawton IADL scale. A summary score ranges from 0 (low function, dependent) to 8 (high function, independent). A score of 8 indicates that the patient is independent. The patient does not have a low enough score to be considered dependent, low function, or moderate function.

8. Which of the following instruments can be used to assess a patient’s perception of their functioning and overall health? a. Direct Assessment of Functional Abilities (DAFA) *b. SF-6D c. Katz ADL Index d. Barthel Index Rationale: SF-6D is an instrument that assesses the patient’s perception of his or her functioning and overall health. Direct Assessment of Functional Abilities (DAFA) is a 10-item observational measure of IADL that is useful for assessment of function in older adults with dementia. DAFA does not assess the patient’s perception of his or her own health. The Katz Index of Independence in Activities of Daily Living assesses independence of a patient in conducting activities of daily living. The Barthel Index is an ordinal scale that measures performance in activities of daily living (ADL) and the degree of assistance required by an individual. 9. Which of the following are effective strategies to maximize the functional status of a patient? Select all that apply. *a. Encourage music therapy *b. Encourage socialization c. Encourage extended bed rest *d. Allow flexible visitation Rationale: Strategies that can help in maximizing functional status of a patient include relaxation and activities like musT icEthSeT raB pA y,NeK ncSoE urLagLiE ngRt. heCpOaM tient to socialize, and allowing flexible visitation hours. All these measures help to maintain the patient’s daily routine, and thus maximize function. The patient should be discouraged from remaining in bed for long periods of time; physical activity and ambulation should be encouraged to help improve functional status of the patient. 10. The clinician is assessing a 70-year-old patient and instructs the patient to get up from the chair, walk up to a point marked with a tape, turn around, walk back to the chair, and sit down. The clinician observes the patient during the process and gives a score of 5. Which of the following can be concluded regarding the patient’s condition? Select all that apply. a. Mildly abnormal balance and gait *b. Fall risk is high *c. Patient requires gait aid; cannot go out alone *d. Restorative therapies required to prevent fall and injuries Rationale: The clinician is conducting the “Get up and Go Test” that is an efficient performance-based measure of ambulation, balance, and gait can be observed during routine care of the hospitalized patient. Performance is scored from 1 (normal balance and steady gait) to 5 (abnormal balance and unsteady gait). A score of 5 indicates that the patient has a severely abnormal balance and gait and the fall risk is high. The patient requires a gait aid and should not be allowed to go out alone. Restorative therapies should be initiated to prevent fall and injuries.

Chapter 11: Oral Healthcare in the Older Adult Multiple Choice Test Questions 1. During a routine oral examination of an older adult patient, the clinician notices red, inflamed lesions on the gingival palate, tongue, and cheek tissues. The clinician concludes these to be caused by which of the following conditions? a. Pemphigus vulgaris *b. Cicatricial pemphigoid c. Lichen planus d. Angular cheilitis Rationale: Cicatricial pemphigoid is an oral mucosal disease that results in red, inflamed lesions on the gingival palate, tongue, and cheek tissues. Pemphigus vulgaris is an autoimmune disease that causes painful blisters on the mucous membrane, with red bleeding tissues that heal without scarring. Lichen planus appears as a white lacy coating on the tongue and cheek tissues. Angular cheilitis causes red and white cracked lesions in the inner corners of the mouth. 2. Oral assessment of an older adult patient reveals a score of 20 on the Kayser-Jones Brief Oral Health Status Examination. Which of the following conclusions can be made from the assessment results? Select all that apply. *a. The patient has very poor oral health. *b. The patient needs a detailT edEoSraTlBevAaNluKaS tioEnLbLyEaRd. enCtaOl M consultant. *c. The family members need to be educated regarding proper oral hygiene measures. d. The patient’s oral hygiene is satisfactory. Rationale: The Kayser-Jones Brief Oral Health Status Examination (BOHSE) is a 10-category screening tool that can be used in older adults for oral assessment. The 10 categories include lymph nodes, lips, tongue, gums, tissues, saliva, natural teeth, artificial teeth, pairs of teeth in chewing positions, and oral cleanliness. Total scores range from 0 (healthy) to 20 (unhealthy); the higher the score, the poorer is the oral health. The score for this patient is 20, which indicates very poor oral health. A detailed oral evaluation must be carried out by a dental consultant, and the patient as well as the family members must be educated regarding proper oral hygiene measures (as family members are usually involved in caregiving for older adult patients). The patient’s oral hygiene is not satisfactory.

3. A routine oral examination of a 74-year-old female patient reveals a white coating on the mucosal surface with intense erythema and scattered petechiae over the mucosa covered by the base of the upper denture. The mucosal surface below the lower denture appears normal. Which of the following is the appropriate treatment for this condition? Select all that apply. a. Prescribing oral antibiotics *b. Providing topical therapy with clotrimazole or nystatin lozenges *c. Applying nystatin powder/cream on tissue contacting surface of the denture *d. Soaking dentures overnight in chlorhexidine solution Rationale: The patient has a white mucosal coating with intense erythema and scattered petechiae on mucosa under the upper denture; these lesions point toward a diagnosis of denture stomatitis. Topical therapy with clotrimazole or nystatin lozenges is the first-line treatment of denture stomatitis. Application of nystatin powder/cream on tissue contacting surface of the denture is also recommended. Denture sanitation is an important element of treatment; dentures should be soaked overnight in chlorhexidine solution. Oral antibiotics have no role in the management of denture stomatitis unless there is a bacterial infection. In this case, antibiotics are not required. 4. During oral examination of an 80-year-old patient, white plaque is noted on the midline of the posterior dorsal surface of the tongue. The lesion cannot be removed by wiping or scraping. The patient reports that the lesion has been present for about two weeks, there is no pain or burning in the affected area, and the lesion does not appear to increase or decrease in size. The patient was on antibiotics recently for an upper respiratory tract infection. Which of the following is the most likeT lyEdS iaT gnBoAsiNs?KSELLER.COM a. Pemphigus vulgaris *b. Hyperplastic candidiasis c. Stomatitis d. Angular cheilitis Rationale: The white plaque on the posterior dorsal surface of the tongue that cannot be removed by wiping or scraping and is painless, points toward a possible diagnosis of hyperplastic candidiasis. The patient reports to have been on antibiotic treatment recently, which predisposes to oral candidiasis. Pemphigus vulgaris is an autoimmune disease that causes painful blisters on the mucous membrane, with red bleeding tissues that heal without scarring. Stomatitis refers to inflamed or sore mouth which can lead to aphthous ulcers and cold sores. Aphthous ulcer is a pale or yellow ulcer with an outer red ring. It may present as a single ulcer or a cluster, usually on the cheeks, tongue, or inside the lip. Cold sores occurring in stomatitis are fluid-filled sores that occur on or around the lips. These are usually associated with tingling, tenderness, or burning sensation in the affected area. Angular cheilitis is characterized by an erythematous, fissured area in the corner of the mouth involving one or both commissures. It involves only the commissure portion of the lip and adjacent skin and does not cross the mucosal surface. The tissues within the oral cavity are not involved.

5. Which of the following are effective oral care strategies in older adults? Select all that apply. *a. Using foam swabs to clean oral mucus b. Using lemon glycerin swabs *c. Regularly using an alcohol-free mouth rinse *d. Soaking dentures overnight in chlorhexidine solution Rationale: Effective oral care strategies in older adults include use of foam swabs for cleaning oral mucus in edentulous older adults, and use of an alcohol-free mouth rinse. In case of adults using dentures, it is recommended that dentures are removed, brushed, and soaked overnight in chlorhexidine solution to prevent any infections. Use of lemon glycerin swabs should be avoided as these can cause drying of the oral mucosa and also lead to erosion of tooth enamel. 6. Which of the following are side effects of chlorhexidine? Select all that apply. *a. Staining of teeth *b. Xerostomia c. Red cracked lesions on the angles of the mouth *d. Decreased taste sensation Rationale: Chlorhexidine is a component of mouth rinses used to treat gingivitis and other oral infections. The major side effects of chlorhexidine include staining of teeth and dentures, xerostomia or dry mouth, and a decreased taste sensation. Chlorhexidine is not known to cause red cracked lesions on the angles of the mouth.

EiLthLcEoR 7. A 76-year-old female patient T viEsiS tsTaBdAenNtK isS tw m. plC aiO nsMof a burning sensation in the mouth for the past two weeks. On examination, a lacy white appearance on the tongue and on the mucosa of the cheeks is observed. Which of the following is the most likely diagnosis? a. Candidiasis *b. Lichen planus c. Lupus erythematosus d. Canker ulcer Rationale: A burning sensation in the mouth with lacy white appearance on the tongue and mucosa of the cheeks indicates a diagnosis of lichen planus. It is a chronic inflammatory autoimmune disease that may cause lesions on the skin, scalp, and also on other parts of the body. Candidiasis is a fungal infection that usually results in white-to-yellow patches on the inner cheeks, tongue, and gums. It may also present as white plaque on the tongue or as dry, cracked skin at the corners of the mouth. Lupus erythematosus is a chronic autoimmune disease that causes oral ulcers that are red in color surrounded by a white halo with white radiating lines, and present usually inside the cheeks on the hard palate and on the lower lip. Canker ulcer, also known as aphthous ulcer, is a pale or yellow ulcer with an outer red margin. It may present as a single ulcer or as a cluster on the mucosa of cheeks, tongue, or inside the lip.

8. Which of the following are important aspects of oral health assessment? Select all that apply. *a. Assess the oral cavity for any dryness, swelling, sores, or ulcers *b. Assess presence or absence of natural teeth and dentures *c. Assess ability of the patient to speak, chew, and swallow d. Assess the nutritional status of the patient Rationale: The Oral health assessment involves examination of the oral cavity for any dryness, swelling, sores, or ulcers. Teeth should be checked (both natural and dentures, if any) for any tooth decay or broken teeth. Ability of the patient to speak, chew, and swallow is also assessed. Assessment of nutritional status of the patient is not a part of oral assessment. 9. A 69-year-old patient presents with a rhomboid lesion in the center of the tongue. The patient reports that it has been present for about a month and is not associated with any pain, but there is a slight bitter metallic taste in the mouth. On examination, the affected area, the tongue appears smooth, depapillated, and dark red. The patient has a history of asthma for which he has been taking inhaled corticosteroids for the past three years. Which of the following is the appropriate treatment for this condition? *a. Topical miconazole b. Oral antibiotics c. Prednisone d. Azathioprine therapy Rationale: The rhomboid painless lesion in the center of the tongue and a bitter metallic taste in the mouth point toward a possible diagnosis of oral candidiasis. The patient has been on inhaled corticosteroids for management of asthma, which can predispose to oral candida infection. Treatment should include topical antifungals like miconazole. Oral antibiotics have no role in treatment of oral candidiasis, unless there is a secondary bacterial infection. In this case, antibiotics are not required. Prednisone is a corticosteroid, which is not indicated in the treatment of candidiasis. Azathioprine is an immunosuppressant medication, not indicated in the treatment of oral candidiasis, thus not required in this case. 10. The clinician is educating an older adult patient with a diagnosis of xerostomia. What counsel should the clinician provide? Select all that apply. *a. Drink more water and fluids *b. Eat a low-sugar diet *c. Use topical fluorides and antimicrobial mouth rinses *d. Use bedside humidifiers at night Rationale: Xerostomia is a condition characterized by symptoms of dry mouth, reduced salivary flow, discomfort in chewing and swallowing, and an unpleasant taste in the mouth. Xerostomia is common in aging adults and is also caused by medications like anticholinergic drugs, tricyclic antidepressants, sedatives, and antihypertensives. The clinician should educate the patient with symptoms of dry mouth to drink more fluids; this will help alleviate symptoms of dry mouth. The patient should also be counselled regarding consuming a low-sugar diet and regular use of topical fluorides and antimicrobial mouth rinses to prevent dental caries, as patients with xerostomia are predisposed to dental infections. Use of humidifiers at bedtime is suggested to prevent discomfort and frequent sleep disturbances due to dry mouth.

Chapter 12: Managing Oral Hydration in the Older Adult Multiple Choice Test Questions 1. An 80-year-old patient with a history of dementia is brought to the hospital with severe dehydration. The family reports that he has been forgetting to drink water and eat his meals. Which of the following categories of hydration should the patient be categorized into? *a. “Can drink” b. “Cannot drink” c. “Will not drink” d. “End of life” Rationale: Older adults who forget to drink water secondary to cognitive impairment or may not know what is an adequate intake are categorized as ones who “can drink.” Older adults who “cannot drink” are those who are physically incapable of accessing or safely consuming fluids due to physical frailty or difficulty in swallowing. Older adults who will not drink are those who are capable of consuming fluids safely but do not do so because of the concerns about being able to reach the toilet with or without assistance or who relate that they have never consumed many fluids. Older adults who are terminally ill comprise the “end of life” category. Certain theories suggest that withholding fluids in patients with terminal illnesses lessens other noxious symptoms like excessive pulmonary secretions, nausea, edema, and pain. It does not apply to this patient as he does not suffer from any terminal illness. 2. Which of the following are reliable indicators of dehydration? Select all that apply. *a. Elevated serum sodium b. Decreased axillary sweat production *c. Elevated serum osmolality *d. Elevated BUN/creatinine ratio Rationale: Elevated serum sodium, serum osmolality, and BUN/creatinine ratio are reliable indicators of dehydration. Decreased axillary sweat production as a clinical sign is not a reliable indicator of dehydration. 3. Which of the following factors limit the use of urine color and specific gravity as a measure of dehydration? Select all that apply. *a. Certain medicines and foods can discolor urine. *b. Renal function deficiency can affect urine color and specific gravity. *c. Patient must be able to give a urine sample for color evaluation. *d. Urine color and specific gravity changes must be analyzed over a period of time. Rationale: Urine color and specific gravity are not reliable measures to assess dehydration, as urine color is affected by certain drugs and medications. Renal function deficiency can also alter the color of urine. Some older patients may find it difficult to collect a urine sample due to problems like urinary incontinence, physical disability, or frailty. In such cases, urine analysis for dehydration assessment is not possible. Moreover, a single reading of urine color and specific

gravity is not sufficient; the changes must be analyzed over a period of time with several readings. 4. An 85-year-old patient with a history of dementia is brought to the hospital by his son. Since morning, he has been intermittently sleepy, confused in conversation, and does not seem to recognize his family members. A urine analysis is done as part of routine examination; the urine color chart shows a score of 5. What is the hydration status of this patient? a. Hydrated b. Mildly dehydrated *c. Dehydrated d. Very dehydrated Rationale: A score of 5 on the urine color chart indicates that the patient is dehydrated. A score of 1–2 will indicate that the person is well hydrated. Urine is pale, odorless, and plentiful. A score of 3–4 indicates mild dehydration; urine is slightly darker in color in such a case. A score of 7–8 indicates that the person is very dehydrated; urine in this case is usually dark, strong smelling, and less in quantity. 5. A clinician is educating an 80-year-old patient regarding measures to prevent dehydration. What counsel should the clinician provide? Select all that apply. *a. Drink small quantities of water throughout the day rather than drinking large quantities at one time *b. Eat more foods like yogurt, soups, vegetables, and fruits *c. Avoid caffeine and alcohol d. Avoid physical activity Rationale: Older adults must be counselled to drink small quantities of water throughout the day rather than drinking large quantities at one time. They should be encouraged to eat foods high in water content like yogurt, soups, vegetables, and fruits. Caffeine and alcohol should be avoided, as these have a diuretic effect that may lead to dehydration (especially with low intake of water). Avoiding physical activity to prevent dehydration is not recommended. 6. Which of the following can be used as clinical signs of dehydration in older adults? Select all that apply. *a. Tongue furrows *b. Decreased urine output *c. Rapid pulse *d. Dry oral mucous membranes Rationale: Tongue furrows, decreased urine output, a rapid pulse, and presence of dry oral mucous membranes are all clinical signs indicating dehydration.

7. Laboratory reports of an 81-year-old patient show a serum osmolality of 297 mmol/kg. What can be concluded about the status of hydration of the patient? a. The patient has a normal status of hydration. b. The patient is mildly dehydrated. *c. The patient is in a state of impending dehydration. d. The patient is severely dehydrated. Rationale: A serum osmolality of 297 mmol/kg indicates that the patient is in a state of impending dehydration. Serum osmolality of less than 295 mmol/kg indicates a normal hydrated state. Serum osmolality of more than 300 mmol/kg indicates a state of dehydration. 8. Which of the following can be used as indicators of hydration in an older adult? Select all that apply. *a. Bioelectrical impedance analysis (BIA) *b. Urine color and specific gravity c. Serum osmolality *d. Salivary osmolality Rationale: Bioelectrical impedance analysis (BIA) is a measurement used to estimate body composition, including body mass index (BMI), total body water (TBW), and intracellular and extracellular water. Urine color and specific gravity have also been shown to be reliable indicators of hydration status in older adults with adequate renal function. Salivary osmolality is an emerging clinical indicator of status of hydration thT atEcS anTbBeAuNseKdStE oL asLseEsR s. hyCdO raM tion in older adults. Serum osmolality is an indicator of dehydration (and not hydration); elevated serum osmolality is one of the most reliable indicators of osmolality. 9. Which of the following strategies can be used to promote fluid intake in hospitalized older adults? Select all that apply. *a. Easy access to fluids all the time *b. Accommodating fluid references of the patient *c. Increasing fluids with each medication administration *d. Maintaining a beverage chart Rationale: Strategies like easy access to fluids all the time in a vessel that is easy to handle, assessing fluid preferences of patients and offering fluids of choice, increasing fluid intake with each medication administration, and maintaining a beverage chart (to document intake of fluids and beverages) can be used to promote fluid intake in hospitalized older adults.

10. Which of the following groups of patients is at risk of overhydration? a. Postsurgery patients *b. Chronic mentally ill patients c. End-of-life patients d. Patients who have suffered a stroke Rationale: Chronic mentally ill patients (individuals with schizophrenia, bipolar disorders, obsessive-compulsive disorders) are at an increased risk of overhydration. This can occur due to a combination of the drying effect of prescribed psychotropic medications and compulsive behaviors that can result in excessive fluid intake. Postsurgery patients, end-of-life patients, and patients who have suffered a stroke are at a greater risk of dehydration.

Chapter 13: Nutrition in the Older Adult Multiple Choice Test Questions 1. An 83-year-old male patient with a history of dementia and chronic obstructive pulmonary disease is admitted to the hospital with an upper respiratory tract infection. He stays alone after his wife passed away 2 years ago. He reports decreased appetite for the past several months. On examination, he has no problem with chewing and swallowing food, and oral health is fairly good. His score on Mini-Nutritional Assessment-Short Form (MNA-SF) is 9. What should be the clinician’s next step? a. Start the patient on parenteral nutrition *b. Perform the in-depth MNA assessment c. Start enteral feeding d. Conduct an abdominal ultrasound Rationale: The Mini-Nutritional Assessment (MNA) is a comprehensive, 18-item, two-level tool, used to screen and assess the older hospitalized patient by evaluating the presence of risk factors for malnutrition. The Mini-Nutritional Assessment-Short Form (MNA-SF) is based on the full MNA and consists of six questions. This is used as a screening tool. If the MNA-SF score is 11 or less, a full detailed MNA should be performed. In this case the patient has a MNASF score of 9; thus the next step should be to conduct a detailed, in-depth Mini-Nutritional Assessment (MNA) to assess the nutritional status of the patient. Since the patient has no problem chewing and swallowingTfEoS odTaBnA dN thKerSeEisLnLoEhR is. toCryOoMf vomiting, indicating that the digestive system is functional, the patient need not be started immediately on parenteral or enteral feeding. An abdominal ultrasound is not recommended as the patient has no complaints related to abdominal discomfort or pain. 2. Which of the following are laboratory indicators of nutritional status? Select all that apply. *a. Serum albumin b. Serum sodium *c. Serum transferrin *d. Serum prealbumin Rationale: Serum albumin, serum transferrin, and serum prealbumin are visceral proteins that can be used as laboratory indicators of nutritional status. Elevated serum sodium is an indicator of dehydration.

3. A 76-year-old female patient is brought to the emergency department of a hospital with complaints of repeated vomiting and diarrhea for the past day. Which of the following categories should the patient be categorized into? *a. “Cannot eat” b. “Should not eat” c. “Will not eat” d. “Should eat with personal assistance” Rationale: An older adult who is not able to digest food properly (which could be due to various factors affecting the gastrointestinal tract that limit one’s ability to digest and absorb food properly) is categorized as “cannot eat.” Since this patient is experiencing vomiting and diarrhea, she should be categorized as “cannot eat.” An older adult with a condition where eating is contraindicated is categorized as “should not eat.” An older adult who is not eating due to conditions like decreased appetite, or inability to cook and shop for food items is categorized as “will not eat.” An older adult with cognitive impairments or difficulty reaching out to and eating food on their own is categorized as “should eat with personal assistance.” 4. An 80-year-old male patient with a history of dementia is brought to the emergency department of the hospital as he has been forgetting to eat his meals; he even forgets to drink water. On examination, the patient is found to be moderately dehydrated, his oral health is good, and he does not appear to have any problems in chewing or swallowing food. What should be the clinician’s nextTaE ctS ioT nsB?ASN elK ecSt EalLl L thE atRa. ppClO y.M *a. Conduct a Mini-Nutritional Assessment-Short Form (MNA-SF) b. Start parenteral nutrition *c. Start oral liquid nutritional supplements d. Start enteral tube feeding Rationale: Patients with dementia are at risk for malnutrition. In this case, the patient has stopped eating, although his oral health appears good and he does not have any symptoms related to the gastrointestinal system. To assess the nutritional status of the patient, Mini-Nutritional Assessment-Short Form (MNA-SF) should be conducted and the patient should be started on oral liquid nutritional supplements. Since the functioning of the gastrointestinal system is intact, parenteral nutrition is not required in this case. The patient has no problem in chewing and swallowing food, and oral health is good; thus enteral tube feeding is not indicated.

5. Which of the following conditions can lead to decreased appetite in older adults? Select all that apply. *a. Xerostomia *b. Depression *c. Chronic illnesses *d. Gum diseases Rationale: Xerostomia or dry mouth, depression, chronic illnesses, and poor oral health with gum diseases are all conditions that can lead to poor appetite in older adults. 6. An 81-year-old male patient is brought to the hospital with loss of appetite. He has lost about 6 pounds of weight in the last 2 weeks. Examination reveals that the patient has severe denture stomatitis in both the upper and lower jaws. The mucosa below the dentures is red, swollen, and bleeding in places, causing a lot of pain and discomfort while chewing food. The patient is put off solid and semisolid foods to give time for the mucosa to heal. Which of the following is the appropriate technique to provide nutrition to the patient during this time? a. Start the patient on a pureed diet b. Start parenteral nutrition c. Start oral liquid nutritional supplements *d. Start enteral tube feeding Rationale: The patient has been put off solid and semisolid food so that the mucosa gets adequate time to heal. The functioning of the gastrointestinal system is intact, thus enteral tube feeding is the appropriate techniqT uE eS inTthBisAcNaK seS. E SiL ncLeEthRe.gCaO strMointestinal system is functioning adequately, parenteral nutrition is not required. Oral nutritional liquid supplements and pureed diets are not recommended in this case, as the oral mucosa, affected by denture stomatitis, requires time to heal properly. 7. Which of the following are risk factors for developing malnutrition in older adults? Select all that apply. *a. Isolation *b. Functional impairment *c. Physical disabilities *d. Inflammation Rationale: Isolation, functional impairments, physical disabilities, and inflammation are all risk factors for developing malnutrition in older adults. Isolation may lead to a loss of desire to cook and eat because of loneliness. Functional impairments increase risk of malnutrition as adequate functioning is imperative for securing and preparing food. Physical disabilities limit and hinder the ability to prepare and ingest food and also to move out of the house to obtain food, thus increasing the risk of malnutrition. Inflammation, acute and chronic, also increases risk of malnutrition in older adults.

8. An 81-year-old patient has a score of 12 on the Mini-Nutritional Assessment-Short Form (MNA-SF) tool. Which of the following is correct about the nutritional status of this patient? a. The patient is malnourished. b. The patient is at risk of malnutrition. *c. The patient has a normal nutritional status. d. The patient is severely malnourished. Rationale: The Mini-Nutritional Assessment-Short Form (MNA-SF) is based on the full MNA and consists of six questions. It is used as a screening tool to assess nutritional status of older adults. A score of 12 on the MNA-SF tool indicates a normal nutritional status. A score of 8–11 on the MNA-SF indicates that the patient is at risk of malnutrition. A score of 7–11 on the MNASF indicates that the patient is malnourished. The MNA-SF tool does not describe the category of severe malnourishment. 9. Which of the following parameters are assessed during a complete nutritional assessment of an older adult? Select all that apply. *a. Dietary intake *b. Risk assessment using MNA tool *c. Anthropometry *d. Functional status Rationale: Dietary intake, malnutrition risk assessment using the Mini-Nutritional Assessment (MNA) tool, anthropometric measurements, and assessment of functional status are conducted EeSnT during complete nutritional assesT sm t oBfAaN nK olS deErLaL duEltR .. OC thO erMparameters assessed include level of visceral proteins, transitional care needs, and a general assessment with detailed history of present and past illnesses. 10. Which of the following measures can improve oral intake in hospitalized older adults? Select all that apply. *a. Ask patient’s food preferences and honor them *b. Provide small frequent meals with adequate nutrients c. Discourage family members to visit during meal times *d. Limit staff breaks to before and after mealtimes Rationale: Measures to improve oral intake in hospitalized older adults include asking and honoring patient’s food preferences; providing small, frequent meals with adequate nutrition to help the patient regain and maintain weight; limiting staff breaks to before and after mealtimes to avoid disturbance; and encouraging, not discouraging, family members to visit during meal times.

Chapter 14: Family Caregiving Multiple Choice Test Questions 1. Which of the following is an example of a psychoeducational intervention? *a. A structured program to train caregivers to respond effectively to memory and behavior problems in patients with dementia and anger in patients with cancer b. Assistance in activities of daily living and skilled nursing care to give some time off to the caregiver c. An unstructured support group that is led by a professional and focuses on creating a space for caregivers to discuss problems and feelings d. Activity therapy programs to improve everyday competence of the care receiver Rationale: Psychoeducational interventions involve a structured program geared toward providing information about the care receiver’s disease process and about resources and services, and training caregivers to respond effectively to disease-related problems. Lectures, group discussions, and written material led by a trained leader, are used. Thus, training caregivers on how to respond to memory and behavior problems in patients with dementia and anger in patients with cancer is a psychoeducational intervention. Assistance in activities of daily living and skilled nursing care to give some time off to the caregiver is an example of respite care. An unstructured support group led by a professional (or by peers) focusing on creating a space for care givers to discuss problems and feelings is an example of a supportive intervention. Activity therapy programs to impTroEvS eT evBeA ryNdK ayScEoL mL peEteRn.ceCoOfMthe care receiver is an example of an intervention to improve care receiver’s competence. 2. Which of the following should be measured to assess the caregiver’s perceived quality of relationship with the care receiver? a. Affinity b. Reciprocity c. Interdependence *d. Mutuality Rationale: Mutuality is defined as the caregiver’s perceived quality of relationship with the care receiver, and is a key predictor of the presence or absence of strain from caregiving. This quality of relationship can be measured using a Mutuality Scale. Affinity is a natural likeness for someone or something; however, it is not an indicator of a caregiver’s perceived quality of relationship with the care receiver. Reciprocity refers to exchanging similar privileges and feelings; and interdependence means dependence of the caregiver and care receiver on each other. Reciprocity and interdependence are not indicators of a caregiver’s perceived quality of relationship with the care receiver.

3. An older adult woman has been providing care to her older adult husband for the past two years, after he was diagnosed with Alzheimer’s disease. She scored 60 on the Center for Epidemiological Studies—Depression Scale Revised (CESD-R Scale). Which of the following can be concluded regarding her mental health status? Select all that apply. *a. The caregiver has a high frequency of clinically relevant depressive symptoms. b. The caregiver has depressive symptoms but these are not clinically relevant. *c. The caregiver is experiencing most of the symptoms of depression almost every day. d. The caregiver is experiencing most of the symptoms of depression but the frequency is less than 1 day (in the last one week). Rationale: The CESD-R Scale is a self-administered instrument used to assess depression or other emotional distress in family caregivers. It contains 20 items. Participants rate frequency of occurrence during the past week on a 4-point scale from 0 (not at all or less than 1 day) to 3 (nearly every day for 2 weeks). Scores range from 0 to 60, with a higher score indicating presence of a greater number and frequency of depressive symptoms. In this case, the caregiver scores 60 on the CESD-R Scale, indicating that she has a high frequency of depressive symptoms that are clinically relevant. (A score of 16 or higher has been identified as discriminatory between groups with clinically relevant and nonrelevant depressive symptoms.) Since the caregiver has scored 60, which is the highest score on the CESD-R Scale, it indicates that she is experiencing most of the symptoms of depression almost every day. If she were experiencing most of the symptoms of depression, with the frequency of less than 1 day (in the past 2 weeks), the score would have been less than 60.

LsEwRi. 4. Which of the following is an T inE diS caTtoBrAoN fK prS obElL em thCtO heMquality of care provided by the caregiver that could potentially result in elder abuse? Select all that apply. *a. Inappropriate management of finances *b. Demonstration of a lack of respect for the older adult c. Request by the caregiver for respite to take a short vacation *d. Evidence of an unhealthy environment Rationale: Inappropriate management of finances, demonstration of lack of respect for the older adult, and evidence of an unhealthy environment are all indicators of problems with the quality of care provided by the caregiver, and could potentially result in elder abuse. A request by the caregiver for respite to take a short vacation does not indicate a problem of caregiving; in fact a short period of respite is expected to help maintain and improve physical and mental health of the caregiver.

5. Which of the following is an example of caregiving role transitions? Select all that apply. *a. An adult son who helped his older adult father with grocery shopping and paying bills, begins cooking and organizing medication for his father after his father is diagnosed with dementia. b. An adult daughter who has been caring for her older adult mother resumes care when her mother is discharged from the hospital after an episode of pneumonia. *c. An older adult woman assumes care of her older adult husband when he is discharged from the hospital following a stroke. *d. An adult daughter becomes the primary caregiver when her adult brother can no longer take care of their older adult parents. Rationale: Role transitions occur when a role is added or deleted from the role set of a person or when behavioral expectations for an established role change significantly, requiring acquisition of new knowledge and skills. An adult son who helped his older adult father with grocery shopping and paying bills begins cooking and organizing medication for his father after his father is diagnosed with dementia, an older adult woman assuming care of her older adult husband when he is discharged from the hospital following a stroke, and an adult daughter becoming the primary caregiver when her adult brother can no longer take care of their older adult parents are all examples of caregiving role transitions. An adult daughter who has been caring for her older adult mother resumes care when her mother is discharged from the hospital after an episode of pneumonia is not an example of caregiving role transitions as she resumes her same role and responsibilities as before, prior to the episode of pneumonia. There are no additions or deletions to her role as a caregiver for her mother. 6. The adult daughter and caregiver of a 70-year-old male patient with dementia is assessed using the Modified Caregiver Strain Index (MCSI). Positive responses are obtained to 12 items on the questionnaire. Which of the following can be concluded from the results of MCSI? Select all that apply. *a. The caregiver is experiencing high levels of strain. *b. Further in-depth assessment of the caregiver’s strain must be conducted. *c. The caregiver needs appropriate interventions to manage the burden and strain caused by caregiving. d. The results provide evidence of a high level of mutuality among the caregiver and the care receiver. Rationale: The Modified Caregiver Strain Index (MCSI) is a 13-item tool used to assess the burden or strain due to caregiving and identify families with potential caregiving concerns. Positive responses to seven or more items on the index indicate a greater level of strain. In this case, the caregiver has a positive response to 11 out of the 13 items on the index, indicating high levels of strain and burden due to caregiving. The results indicate need of a further in-depth assessment and appropriate interventions to manage the burden and strain. The MCSI does not provide evidence or measure of mutuality among the caregiver and the care receiver. Mutuality is measured using a Mutuality Scale.

7. Which of the following are some of the rewards of caregiving? Select all that apply. *a. Sense of accomplishment from helping a family member *b. Acquiring new skills and knowledge *c. Family members working together as collaborative family caregivers often grow closer in the process *d. Closer bond between the caregiver and the care receiver Rationale: Research shows that there are many positive aspects of providing care. A sense of accomplishment from helping a family member, and acquiring new knowledge and skills are some of the positive aspects of providing care. The family members working together as collaborative family caregivers often grow closer in the process; and a closer bond and relationship develops between the caregiver and the care receiver. 8. Which of the following are indicators of unhealthy caregiver transitions? Select all that apply. *a. Stress in caregiver and care receiver’s relationship *b. Lack of preparedness *c. Lack of well-being *d. Depression in the caregiver Rationale: Stress in the relationship between the caregiver and the care receiver, lack of preparedness (in terms of appropriate skill, time, or physical environment) to take on the responsibility of caregiving, lack of well-being, and presence of signs of depression in the caregiver are all indicators of unhTeE alS thT yB caArN egKivSeE r tLraLnE siR tio.nCs.OM 9. According to research, which of the following characteristics across interventions provides the most significant benefit to the caregivers? a. Caregiver training with focus on improving symptoms of the care receiver b. Respite care c. Group interventions *d. Multicomponent tailored interventions Rationale: According to research, multicomponent interventions—combining features of psychotherapy and knowledge with skill building—provide significant benefit to the caregiver and are effective in improving well-being, ability, and knowledge of the caregiver. Caregiver training that focuses only on improving symptoms of the care receiver will not be sufficient for improving the well-being of the care giver. Respite care refers to providing assistance to the care receiver in activities of daily living, and skilled nursing care to give some time off to the caregiver. Respite care is useful to provide some time off to the care provider, but respite care alone will not be sufficient for improving well-being of the care giver or improving the care provider’s knowledge and skills. Group interventions to improve everyday competence of the care provider are not very useful in improving the well-being of the care giver.

10. Which of the following nursing care strategies are useful and provide the best outcomes in situations requiring family caregiving? Select all that apply. *a. Identify skills required to increase preparedness for caregiving. *b. Assist the caregiver in identifying strengths in the care giving situation and how it can be rewarding. c. Perform regular evaluations of quality of care provided by the caregiver stressing importance of adhering to established standard practices. *d. Help caregivers identify and manage their physical and emotional responses to the caregiving situation. Rationale: Some strategies that can help obtain best outcomes in situations requiring family caregiving are identifying skills required to increase preparedness of the caregiver, assisting the caregiver in identifying strengths in the caregiving situation and how it can be a rewarding experience, and helping caregivers identify and manage their own physical and emotional responses to the caregiving situation. Performing evaluations of quality of care provided by the caregiver, with the aim to stress the importance of adhering to established standard practices, can add undue stress on the caregiver.

Chapter 15: Issues Regarding Sexuality in Older Adults Multiple Choice Test Questions 1. Which of the following changes occur in women with loss of estrogen after menopause? Select all that apply. *a. Thinning of the vaginal walls b. Weaker but more frequent vaginal contractions c. Lengthening of the vagina *d. Downward descent of the cervix Rationale: After menopause, loss of estrogen in women results in thinning of the vaginal walls, fewer and weaker vaginal contractions during orgasm, shortening of the vagina, and downward descent of cervix into the vagina. Other changes include decreased or delayed vaginal lubrication and atrophy of labia. 2. Which of the following medications increases the risk of sexual dysfunction? *a. Paroxetine b. Bupropion c. Nebivolol d. Mirtazapine Rationale: Paroxetine is an antidT epErS esT saBnA t oNfKthSeEsL elL ecEtiR ve.sCeO roM tonin reuptake inhibitor (SSRI) class. It is associated with an increased risk of sexual dysfunction. Bupropion is used to treat major depressive disorders and is associated with a lower risk of sexual dysfunction. Nebivolol is a beta blocker that does not affect sexual function. Mirtazapine is an antidepressant drug that does not increase the risk of sexual dysfunction. 3. Which of the following statements are true regarding the impact of cognitive functioning on sexuality? Select all that apply. *a. Older adults engaging in sexual activity tend to have better overall cognitive function. *b. Problems with cognitive sequencing negatively affect sexual function. c. Hypersexuality is common among cognitively impaired older adults. *d. Apathy or indifference toward sexual activity is more prominent. Rationale: Reviews show that older adults engaging in sexual activity tend to have better overall cognitive function. Problems with cognitive sequencing and recall negatively affect sexual function. Apathy or indifference toward sexual activity is more prominent in older adults. Hypersexuality is rare among cognitively impaired older adults.

4. Which of the following questions should be asked during sexual assessment of an older adult? a. “Do you have any concerns about your sexuality?” *b. “How has your sexuality changed as you have aged?” c. “Have you noticed any changes in your sexuality since you were diagnosed with this condition?” d. “Do you have any thoughts about ways you could enhance your sexual health?” Rationale: Sexual assessments are most effective when open-ended questions are asked to elicit information about sexual health of the patient. The question “How has your sexuality changed as you have aged?” is an appropriate open-ended question. The questions “Do you have any concerns about your sexuality?”, “Have you noticed any changes in your sexuality since you were diagnosed with this condition?”, and “Do you have any thoughts about ways you could enhance your sexual health?” are all closed-ended questions, and thus should be avoided during sexual health assessment of older adults. 5. Which of the following are barriers to sexual health in older adults? Select all that apply. *a. Negative body image *b. Loss of spouse or partner *c. Cognitive impairment d. Hypersexuality Rationale: Negative body image is a barrier to sexual health in older adults, who may view normal changes of aging and theiT rE suS bsTeB quAeN ntKiS mE paLcL t oEnRa.pC peOaM rance as embarrassing or indicative of illness. This results in a negative body image and reluctance to pursue sexual health. Loss of spouse or partner and illnesses like cognitive impairment also act as barriers to sexual health in older adults. Hypersexuality is defined as extremely frequent or suddenly increased libido, which is rarely seen in older adults. Thus, it is not a barrier to sexual health in older adults. 6. Which of the following changes occur as a result of a decrease in testosterone levels in older adult males? Select all that apply. *a. Erectile dysfunction *b. Long refractory period between erections *c. Depression d. Excessive semen production Rationale: Changes occurring as a result of declining testosterone levels in older adult men include erectile dysfunction, a longer refractory period between erections, and depression. Semen production also decreases with decline in testosterone levels (thus, excessive semen production is usually not seen in older men).

7. Which of the following are preventive measures that older adults may undertake to reduce the impact of normal aging on sexual health? Select all that apply. *a. Continue to engage in sexual activity *b. Avoid smoking *c. Explore foreplay and masturbation *d. Use aids to increase stimulation Rationale: In order to reduce impact of normal aging on sexual health, older adults must continue to engage in sexual activity as it is associated with greater life fulfillment. Abstinence from smoking and eating healthy foods are also very important for sexual health. Exploring foreplay and masturbation, and using aids to increase stimulation are also techniques to maintain sexual health in older adults. 8. A 76-year-old male patient consults a clinician with complaints of erectile dysfunction, which is affecting his sexual health. He has no history of diabetes or cardiovascular disease. Which of the following drugs can be used to treat his condition? a. Nebivolol *b. Avanafil c. Paroxetine d. Bupropion Rationale: Avanafil is a phosphodiesterase-5 inhibitor (PDE5-1) used for treatment of erectile dysfunction that occurs with aging in older males. Thus, it can be used to treat erectile dysfunction in this patient. NebivT olEoS l iT sB aA beNtaKbSlE ocLkL erEuR se.dCfoOrMtreatment of hypertension and heart failure. It has no role in erectile dysfunction. Paroxetine is an anti-depressant of the Selective Serotonin Reuptake Inhibitor (SSRI) class; and Bupropion is used to treat major depressive disorders. These drugs have no role or impact in erectile dysfunction. 9. A 79-year-old male patient with mild cognitive impairment who is staying in a health facility is noticed making sexually explicit remarks regarding the facility staff on several occasions. What are appropriate measures to deal with this kind of behavior? Select all that apply. *a. Conducting a complete sexual assessment b. Questioning the patient regarding his inappropriate remarks in the presence of his family members *c. Using techniques of redirecting behavior *d. Using same-sex caregivers Rationale: The patient is an older adult with mild cognitive impairment. To understand his behavior, a complete sexual assessment using clear communication should be conducted. Redirecting behavior by expressing discontent can be used to discourage the inappropriate behavior. Using same-sex caregivers for the patient can also be helpful. Questioning the patient in the presence of his family members is not appropriate, as this will be embarrassing for both the patient and his family.

10. Which of the following are components of the PLISSIT Model? Select all that apply. *a. Seeking permission *b. Share limited information *c. Specific suggestions *d. Referral to intensive therapy Rationale: The PLISSIT model can be used for sexual health assessment in older adults. It begins by first seeking permission (P) to discuss sexuality with the older adult. The next step of the model affords an opportunity for the nurse to share limited information (LI) with the older adult. Specific suggestions (SS) and interventions to improve health are then provided. Referral to intensive therapy (IT) may be needed for those with more complex sexual problems.

Chapter 16: Elder Mistreatment Detection Multiple Choice Test Questions 1. What is the most common form of elder mistreatment? a. Physical abuse b. Financial exploitation *c. Neglect d. Sexual abuse Rationale: Neglect is recognized as the most common form of elder mistreatment. Financial exploitation and physical and sexual abuse are other forms of elder mistreatment, however, neglect (whether intentional or unintentional) is most common. 2. Which of the following examples illustrate likely perpetrators of elder mistreatment? Select all that apply. *a. An adult daughter with a long history of depression who moves in with her older adult mother after she is evicted from her apartment b. A neighbor who cooks lunch for an older adult woman recovering from hip surgery and helps her with household chores *c. A wife who is an alcoholic and sole caregiver for her husband, who is suffering from end-stage lung cancer *d. A husband, with a bipolarTdEisS orTdB erA ,N wK hoShEaL sL livEeR d.wCitO hM his wife for 40 years, and is experiencing tremendous difficulty in caring for her since she developed dementia Rationale: One of the theories explaining psychopathology of the abuser mentions that mistreatment stems from a perpetrator’s own battle with psychological illness such as substance use, depression, and other mental disorders. In the examples mentioned, an adult daughter with a long history of depression who moves in with her older adult mother after being evicted from her apartment, a wife who is an alcoholic and sole caregiver for her terminally ill husband, and a husband with bipolar disorder who is experiencing tremendous difficulty in caring for his wife for 40 years since she developed dementia are all examples where the caregiver is experiencing a mental health issue or substance abuse, and thus can be a likely perpetrator of elder mistreatment. A neighbor helping an older adult woman with household chores and cooking lunch for her is less likely to mistreat her.

3. A 79-year-old female patient with dementia visits the clinician for a routine examination. The clinician notes that she is shabbily dressed with uncombed hair. She appears malnourished and has an untreated ulcer on her right toe that appears to have been present for several weeks. She has been missing her regular appointments, is disturbed, and refuses to talk much. Physical examination is normal; however, her adult daughter does not allow the clinician to speak to the patient in private. What should the clinician suspect this to be? Select all that apply. a. Exacerbation of dementia *b. Caregiver neglect c. Physical abuse d. Self-neglect Rationale: The clinician should suspect this to be a case of caregiver-neglect. The patient is shabbily dressed with unkempt hair and is malnourished with an untreated ulcer on her right toe. She has been missing her appointments and appears disturbed. Her caregiver does not allow the clinician to speak with the patient in private. All these indicate a possible case of caregiver neglect and abuse of the patient. The patient’s symptoms do not point toward an exacerbation of dementia. Since the physical examination of the patient is normal, physical abuse is not likely. The patient’s caregiver does not allow the clinician to speak with the patient in private, thus it is most likely a case of caregiver neglect, not self-neglect. 4. Which of the following questions can be used to elicit information about possible emotional abuse of an older adult? Select all that apply. *a. “Has anyone been insultinTgEyS oT uB anAdNuK siS ngEdLeLgE raR di. ngCO laM nguage?” *b. “Does anyone care for you or provide regular assistance to you?” *c. “Are you being cared for by someone who abuses drugs or alcohol?” d. “Has anyone ever taken anything that was yours without asking?” Rationale: The questions that can be asked to elicit a possible emotional abuse include “Has anyone been insulting you and using degrading language?”, “Does anyone care for you or provide regular assistance to you?”, and “Are you being cared for by someone who abuses drugs or alcohol?” The question, “Has anyone ever taken anything that was yours without asking?” gathers information on financial abuse, not emotional abuse. 5. What are the reasons that older adults do not self-report mistreatment and abuse? Select all that apply. *a. Embarrassment *b. Fear of being placed in a nursing home *c. Uncertainty that they will get help after reporting abuse *d. Fear that the abuse might increase if reported Rationale: Some reasons that prevent older adults from reporting abuse and mistreatment include embarrassment, fear of being placed in a nursing home, uncertainty that will get help after reporting abuse, and fear that the abuse might increase if reported.

6. Which of the following statements are correct regarding elder mistreatment detection education and elder mistreatment (EM) reporting? Select all that apply. *a. Healthcare professionals educated about EM were more inclined to report detected cases of EM than those who had little or no education. b. Increased education on EM assessment increased the rate of false-positive cases being reported. *c. Healthcare professionals educated about EM were not more likely to detect EM cases. *d. Reporting of EM by healthcare professionals remains low due to a lack of education and training on the assessment, detection, and reporting of EM. Rationale: Research shows that healthcare professionals educated about EM were more inclined to report detected cases of EM than were those who had little or no education. However, healthcare professionals educated about EM were not more likely to detect EM cases. Overall, reporting of EM by healthcare professionals is low due to lack of education and training on the assessment, detection, and reporting of EM. Increased education on EM assessment has not resulted in any increase in the rate of false-positive cases being reported. 7. What factors can delay elder mistreatment (EM) detection and intervention? Select all that apply. *a. Refusal of services by the victim *b. Denial on the part of the perpetrator and older adult *c. Incorrect attribution of physical signs of EM to physiological changes or chronic diseases *d. Fears that reporting EM may worsen it Rationale: Factors that can delay elder mistreatment detection and intervention include refusal of services by the victim, denial on the part of the perpetrator and older adult, incorrect attribution of physical signs of EM to physiological changes or chronic diseases, and fear on the part of the older adult that reporting EM may actually worsen it.

8. A 68-year-old female patient is brought to the emergency department of the hospital with an injury on the forearm. Her daughter, who cares for her, states that the patient fell down in the bathroom and got injured. The Hwalek–Sengstock Elder Abuse Screening Test (HS-EAST) is administered and a positive result is obtained. What should be the clinician’s next steps? Select all that apply. *a. Administer the Geriatric Depression Scale (GDS) *b. Assess the caregiver using the Modified Caregiver Strain Index (CSI) *c. Counsel and educate the caregiver *d. Refer the patient to Adult Protective Services (APS) Rationale: A positive result on the Hwalek–Sengstock Elder Abuse Screening Test (HS-EAST) indicates that the patient has been experiencing mistreatment and abuse by the caregiver. Victims of elder abuse are more likely to suffer from depression, thus the patient should be assessed for depression using the Geriatric Depression Scale (GDS). The caregiver should be assessed using the Modified Caregiver Strain Index (CSI). This is a 13-question tool that measures the caregiver’s strain related to caregiving. There is at least one item in the questionnaire for each of the following major domains: financial, physical, psychological, social, and personal. Positive responses to seven or more items on the index indicate a greater level of strain. The caregiver should be appropriately counselled and educated. The patient should be referred to an Adult Protective Services (APS) for developing a plan for her safe discharge and care. 9. Older adults are often disfranchised in society as their prior responsibilities and even selfcare is shifted to others. This corroborates to which theory of elder mistreatment? a. Situational theory *b. Political economy theory c. Social exchange theory d. Social learning theory Rationale: The political economy theory mentions that older adults are often disfranchised in society as their prior responsibilities and even self-care is shifted to others. This leads to increase in elder abuse and mistreatment. The situational theory mentions that stressful family conditions contribute to mistreatment. Thus, elder mistreatment may be viewed as a consequence of caregiver strain resulting from the overwhelming task of caring for a vulnerable or frail older adult. The social exchange theory speculates that the long-established dependencies present in the victim–perpetrator relationship are responses developed within the family that then continue into adulthood. The social learning theory attributes mistreatment to learned behavior on the part of the perpetrator or victim from either his or her family life or the environment.

10. Which of the following factors put older adults with dementia at an increased risk for mistreatment by their caregivers? Select all that apply. *a. Cognitive deficits associated with dementia make screening for elder mistreatment difficult. *b. Older adults with dementia may not be able to provide a reliable history. *c. Signs of mistreatment may be masked by disease. *d. Higher levels of caregiver burnout Rationale: Older adults with dementia are at an increased risk of mistreatment and abuse by their caregivers; this is because cognitive deficits associated with dementia make screening for elder mistreatment difficult. Secondly, it is difficult to elicit a proper history as the older adult with dementia may not be able to provide reliable details. Signs of mistreatment may be masked by disease, which also delays or prevents detection of abuse. Those providing care for older adults with dementia are at particular risk for caregiver strain and burnout. High levels of caregiver burnout may lead to high levels of emotional exhaustion, depersonalization, and a sense of lack of personal achievement. These characteristics of the caregiver increase the risk of mistreatment of older adult by the caregiver.

Chapter 17: Advance Care Planning Multiple Choice Test Questions 1. Which of the following are included in advance care planning (ACP)? Select all that apply. a. Best interest standard *b. Instruction directive c. Substituted judgement *d. Appointment directive Rationale: Advance care planning (ACP) is a process to enable individuals with decisional capacity to prospectively articulate their health goals, values, and treatment preferences so that they can be communicated and honored when the ability to make and communicate decisions is lapsed. Instruction directives and appointment directives are important components of ACP. Instruction directive includes a list of interventions the patient does or does not want in specified circumstances. Appointment directive is the legal designation of a healthcare agent with the same decision-making authority as the patient. In case of absent explicit instructions from the patient, verbally or in an advanced directive, decisions by others are based on either substituted judgement or best interest standard. Best interest standard is a decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred. Substituted judgment is a decision by others based on the formerly capable person’s wishes that are known or can be inferred from prior behaviors or decisions. Substituted judgment aTnE dS beTsB t iA ntNerKeS stEstLanLdEaR rd.aC reOnMot a part of ACP, and are used when there is no ACP. 2. Which of the following statements is correct about an instruction directive? Select all that apply. *a. It is a written set of value-neutral instructions about specified interventions the individual would or would not want under certain circumstances. b. It enables a capacitated individual to legally appoint another person to make medical decisions on his or her behalf after decisional capacity is lost. c. It supports appointment of an alternate proxy in case the appointed agent is unavailable or unable to make decisions on the patient’s behalf. d. It enables greater flexibility in responding to unanticipated or rapidly changing medical conditions. Rationale: An instruction directive is a written set of value-neutral instructions about specified medical, surgical, or diagnostic interventions the individual would or would not want under certain circumstances, especially toward the end of life. Enabling a capacitated individual to legally appoint another person to make medical decisions on his or her behalf after decisional capacity is lost and appointment of an alternate proxy in case the appointed agent is unavailable or unable to make decisions are features of appointment directives (and not instruction directives). Flexibility in responding to unanticipated or rapidly changing medical conditions is obtained through appointment directives. There is not much flexibility in instruction directives because the individual is required to anticipate future medical conditions and determine the preferred treatment.

3. Which of the following are questions asked in the Five Wishes hybrid directive? Select all that apply. *a. “Who is the person I want to make decisions for me when I cannot?” *b. “What is the kind of medical treatment I do or do not want?” *c. “How do I want people to treat me?” d. “What type of place or hospital do I want to get treated at?” Rationale: The Five Wishes hybrid directive is a kind of advanced directive that provides an opportunity for patients to communicate decisions about (1) the person they want to make care decisions for them when they cannot, (2) the kind of medical treatment they do or do not want, (3) how comfortable they want to be, (4) how they want people to treat them, and (5) what they want their loved ones to know. It does not include a choice about the place (or hospital) of treatment. 4. A 75-year-old patient with dementia is diagnosed with kidney failure that requires him to be put on dialysis. He has no advance directive. His wife, who has been with the patient for the last 45 years, does not support the decision and states that the patient would never have wanted to be on dialysis. However, his son, who has the power of attorney and legal authority to take care of all the patient’s financial matters, insists on going ahead with dialysis. What should be the clinician’s next step? a. The clinician should go ahead with dialysis, based on the decision of the patient’s son, since he has the power of attorney. *b. The clinician should go ahTeE adST wiBthAtN heKdSeEciLsiL oE nR of.tC heOpMatient’s wife. c. The matter should be referred to the hospital’s ethics committee. d. The clinician should proceed with the best interest standard. Rationale: In this case, since the patient has no advance directive, the clinician should go ahead with the decision of the patient’s wife. She has been with the patient for the past 45 years and is aware of and can infer the patient’s wishes, based on his characteristic behavior and decisionmaking. The patient’s son has the power of attorney to make financial decisions on the patient’s behalf, and not decisions related to health. Thus, he cannot be considered as a legal proxy for health-related matters for the patient. The matter need not be referred to the hospital’s ethics committee, as the patient’s wishes can be inferred. Best interest standard (a decision based on what others judge to be in the best interest of an individual who never had or made known healthcare wishes and whose preferences cannot be inferred) is not required in this case, since the patient’s wife is aware of and can infer what the patient would have decided in such a scenario.

5. Which of the following are features of an appointment directive? Select all that apply. a. It provides a written set of instructions specifying medical interventions an individual would or would not want under particular circumstances, usually at the end of life. *b. It enables a capacitated individual to legally appoint another person to make medical decisions on his or her behalf in case the patient’s decisional capacity is lost. *c. It ensures the authority of the appointed proxy supersedes that of the next of kin of the patient. d. It requires the appointed proxy to honor the patient’s previously expressed care preferences in all circumstances. Rationale: An appointment directive enables a capacitated individual to legally appoint another person to make medical decisions on his or her behalf in case the patient’s decisional capacity is lost. The authority of the appointed agent supersedes that of anyone else (except a courtappointed guardian), including the next of kin. Although the agent is generally required to honor the patient’s previously expressed care preferences, if those instructions do not apply to or are inconsistent with the patient’s current health needs, the agent is empowered to exercise judgment and use his knowledge of the patient’s health goals, values, preferences, and decision history to make choices that promote the patient’s best interest. A written set of instructions specifying medical interventions an individual would or would not want under particular circumstances, usually at the end of life, is a feature of an instruction directive or a “living will,” not an appointment directive. 6. In which of the following scenarios must an individual decide what interventions they would TpBlA or would not want to receive T toEcS om etN eK anSaEdL vaLnE ceRd.dC irO ecMtive? Select all that apply. *a. Coma with virtually no chance of recovery *b. Coma with a small chance of recovery, but restored to an impaired physical or mental state *c. Advanced dementia and a terminal illness d. Stroke Rationale: While filling out an advanced directive, individuals must decide prospectively which interventions they would want in the context of four scenarios: coma with virtually no chance of recovery, coma with a small chance of recovery but restored to an impaired physical and mental state, advanced dementia and a terminal illness, and advanced dementia. Stroke is not included as a separate scenario.

7. Which of the following are advantages of an advanced directive? Select all that apply. *a. Less likelihood that the patient is burdened with unwanted treatments like a respirator or feeding tube *b. Increased likelihood of the patient dying in his or her preferred location (at home or in a hospice) c. Higher chance of prolonged life with less discomfort *d. Fewer concerns about family being informed about what to expect Rationale: An advanced directive with instructions about treatments that the patient would want (or would not want) at the end of life ensures that there is less likelihood of a patient being burdened with unwanted treatments like a respirator or feeding tube. The patients are more likely to die at their preferred location with fewer concerns about family being informed about what to expect. An advanced directive does not ensure prolongation of life or less discomfort. 8. An 84-year-old male patient is brought to the emergency department of the hospital. He was found lying unconscious on the bathroom floor. The patient’s status is announced as “full code.” What should the clinician understand this to mean? a. The patient has no advance directive. *b. In the event of cardiopulmonary arrest, cardiopulmonary resuscitation (CPR) must be performed. c. The patient has a do-not-resuscitate (DNR) status. d. The patient has an advance directive but it does not specify the patient’s consent for cardiopulmonary resuscitation (CPR). Rationale: If the patient’s status is mentioned as “full code,” it means that in the event of cardiopulmonary arrest, cardiopulmonary resuscitation (CPR) must be performed. “Full code” does not refer to the presence or absence of an advance directive. “Full code” means that there is no do-not-resuscitate (DNR) order. “Full code” does not mean that the patient has an advance directive not specifying the patient’s consent for cardiopulmonary resuscitation (CPR). 9. Which of the following statements are true regarding Physician’s Orders for Life-Sustaining Treatment (POLST)? Select all that apply. *a. POLST is a consolidated set of medical orders that are immediately actionable. *b. POSLT is intended for individuals with a life-limiting illness. *c. POSLT is active from the moment it is signed. d. POSLT always includes a do-not-resuscitate (DNR) order. Rationale: Physician’s Orders for Life-Sustaining Treatment (POLST) is a consolidated set of medical orders that are immediately actionable. POSLT is intended only for a subsection of the population, individuals who have life-limiting illnesses, and are typically expected to live 1 year or less. POSLT is active from the moment it is signed. POSLT does not always include a do-notresuscitate (DNR) order.

10. When creating an advance directive, an individual must decide whether they would or would not want which of the following interventions? Select all that apply. *a. Cardiopulmonary resuscitation (CPR) *b. Artificial nutrition and hydration (ANH) c. Kidney transplant *d. Dialysis Rationale: Interventions included in an advance directive about which an individual must decide prospectively (i.e., whether he or she would want or would not want that intervention) include cardiopulmonary resuscitation (CPR), artificial nutrition and hydration (ANH), dialysis, invasive diagnostic tests, antibiotics, and blood transfusion. Kidney transplant is not one of the interventions included in advance directives.

Chapter 18: Preventing Functional Decline in the Acute Care Setting Multiple Choice Test Questions 1. Loss of physical function is associated with increased risk with which poor long-term outcomes? Select all that apply. *a. Discharge to a nursing home setting *b. Morbidity and mortality *c. Rehabilitation cost *d. Decreased long-term functional recovery Rationale: Loss of physical function correlates with poor long-term outcomes. These include increased likelihood of being discharged from a hospital to a nursing home setting, increased morbidity and mortality, increased rehabilitation costs, and decreased long-term functional recovery. 2. Which of the following are risk factors for functional decline? Select all that apply. *a. Presence of two or more comorbidities *b. Polypharmacy *c. Urinary incontinence *d. Cognitive impairment Rationale: The total number of cT om itiEoL nsLpEreRs. enCt O inMolder adults at the time of EoSrTbiBdAcoNnKdS admission determines the patient’s individual risk of functional decline. Additionally, polypharmacy, urinary incontinence, and cognitive impairment is associated with increased risk of functional decline that persists even 12 months after hospitalization. 3. Which of the following environmental aspects of a conventional patient room contribute to functional decline? a. Nonglare flooring b. Door levers c. Large print calendars *d. A lack of chairs, handrails, and adequate lighting Rationale: Nonglare flooring, door levers, handrails, and adequate lighting are the basic requirements in a patient’s room that promote safe mobility. Large-print calendars and clocks are the environmental enhancements required to promote orientation. Lack of chairs, handrails, and adequate lighting can therefore contribute to functional decline.

4. What are the benefits of mobility programs in promoting functional mobility? *a. Reduces depression, anxiety, and symptom distress *b. Reduces delirium, pain, urinary discomfort *c. Improves quality of life and independence *d. Improves organizational outcomes Rationale: Mobility programs provide benefits in four areas. First benefit is seen in psychological outcomes such as less of depression, anxiety, and symptom distress. Additionally, there is increased comfort and satisfaction. Second benefit is seen in physical outcomes such as less of delirium, pain, and urinary discomfort. The patient is also less likely to report the following conditions: difficulty voiding, urinary tract infection, deep vein thrombosis, fatigue, and pneumonia. Additionally, there is an increase in walking, ADL performance, and ventilatorfree days. Third benefit is seen in social outcomes. Patients report an improved quality of life and independence. Fourth benefit is seen in organizational outcomes. Patients have a decreased length of hospital stay, reduced mortality, and reduced cost of treatment. 5. Which of the following statements regarding ADL in hospitalized older adults are correct? a. ADL assessment should begin on the day of admission. *b. Post discharge rehabilitation strategy depends on ADL level before admission. c. ADL level declines after discharge from the hospital. d. Hospitalized older adults suffer functional decline and not ADL decline Rationale: For older adults with loss of ADL function prior to admission rehabilitation would be MDL decline from admission to as a goal of their hospital care. FoTrEthSoT seBpAaN tieKnS tsEwLhL oEaR cq.uC ireOA discharge, aggressive postacute rehabilitation plans with the goal of promoting return to baseline function will need to be mobilized. Many older adults with medical illness report a decline in ADL function between baseline (2 weeks before admission) and discharge. Hence, ADL level 2 weeks prior to admission should be assessed. ADL decline is a functional decline. 6. An older adult with a history of previous hospitalization for a cardiovascular event was readmitted to the hospital with a similar problem. Nursing care and patient management should be alert regarding which of the following problems? Select all that apply. *a. Falls *b. Infections c. Poor vision *d. Pressure ulcer Rationale: Cardiovascular disease in late life can cause functional decline, and readmissions are common this condition. Older adults with functional decline have various levels of immobility which is associated with increased risk of infections, pressure ulcers, and falls. Hence, patient management and nursing care should be alerted about these issues and measures should be used to prevent them. Poor vision can be a symptom of a cardiovascular event or can naturally be present in older adults and not the result of functional decline.

7. How can a nurse keep a hospitalized older patient mentally stimulated to prevent functional decline? Select all that apply. *a. Encourage visitors to bring familiar items from home *b. Reduce excessive noise and promote healthy sleeping c. Use activity kits *d. Encourage watching TV, playing games Rationale: Liberal visiting hours and bringing the patient familiar items from home such as photos or blankets can provide meaningful sensory inputs for mental stimulation. Function can be enhanced through interventions such as excessive noise control and attention to sleep hygiene. The mind can be kept active through diversional activities, such as TV, movies, and word games. These activities also improve engagement in self-care and physical activity in older adults patients. Activity kits can be used to improve cognition in older adults suffering from cognitive challenges such as dementia and are not used for mental stimulation in older adults without cognitive challenges. 8. How can a nurse motivate an older patient to remain physically and mentally active? Select all that apply. *a. Initiate meaningful communication b. Use activity kits *c. Use humor and verbal cues *d. Maintain activity diary Rationale: To motivate an older patient to remain physically and mentally active, a nurse will AiNthKtS need to strike a meaningful conveTrE saS tioTnBw heEpLaL tieEnR t..FC orOtM his, the nurse should understand the patient’s values, past experiences, and relationships. Using humor and verbal cues also supports communication. Functional outcome in older adults can be improved through individualized, graduated exercise, and mobility program. Maintaining an activity diary along with progressive encouragement of functional independence by nursing staff can motivate the patient toward physical independence. This along with cognitive stimulation sessions helps in keeping the patient mentally stimulated. Activity kits are used to improve cognition in older adults suffering from cognitive challenges such as dementia. 9. A 70-year-old man is admitted to the ICU with a respiratory ailment. His systolic blood pressure is greater than 200 mmHg. Which of the following actions should be taken regarding his mobility? a. Restrict him to bed until systolic BP normalizes b. Mobility is not important in ICU *c. Encourage mobility d. Focus on his BP and respiratory ailment Rationale: Mobility in respiratory intensive care unit (RICU) is usually safe. Mobility at systolic BP greater than 200 mmHg is safe and should be encouraged. Mobility should be encouraged even if patient has a systolic blood pressure less than 90 mmHg, or oxygen desaturation less than 80%. ICU patients with fall to knees, tube removal, and extubation should be encouraged to move around as per their capacity. Giving medications for BP and respiratory ailment is an important part of treatment, but its focus is on curing the disease and not mobility. Mobility should be encouraged in all ICU patients.

10. An older adult had a sudden fall and her family brought her to emergency department (ED). No fracture or head injury was found. She had very high blood pressure for which she was treated. She will be discharged soon. The family is concerned regarding allowing her to walk post discharge from the ED, although the patient carried out all activities of daily living (ADL) before the fall. What interventions can be used to assure and engage family? Select all that apply. *a. Function-focused care (FFC) *b. Family-centered FFC c. Nurse-led mobility protocols d. Functional mobility programs Rationale: The patient carried out ADL before the fall. She will be able to manage at home post discharge. The family needs to be reassured. FFC and family-centered FFC help prepare the family for discharge, assess risk factors, set goals, and help at various environmental and procedure levels to ensure mobility at home. Nurse-led mobility protocols and functional mobility programs help in critical care and hospitalized setting where patients are managed by the hospital staff.

Chapter 19: Late-Life Depression Multiple Choice Test Questions 1. The DSM-5 criteria for the diagnosis of a major depressive disorder require five criteria (or more) from a list of nine to be present nearly every day during the same 2-week period and must represent a change from previous functioning. Which of the following is one of those five criteria? Select all that apply. *a. Feelings of worthlessness, self-reproach, or excessive guilt *b. Suicidal thinking or attempts *c. Anhedonia d. Headache Rationale: Accoring to the Diagnostic and Statistical Manual of Mental Disorders 5th ed. (DSM-5), there are nine listed criteria for the diagnosis of major depressive disorder (MDD), which is the most severe form of depression. At least five of these nine listed criteria must be present nearly every day during the 2-week period and must represent a change from previous functioning. The nine criteria are: a) feelings of worthlessness, self-reproach, or excessive guilt; b) suicidal thinking or attempts; c) anhedonia or diminished pleasure in usually pleasurable people or activities; d) depressed, sad, or irritable mood; e) difficulty with thinking or diminished concentration; f) fatigue and loss of energy; g) changes in appetite and weight; h) disturbed sleep; and i) psychomotor agitation or retardation. Although headache is a somatic symptom of depression, it is not included as oT neEoSfTthBeAnN inKeScrEitL erLiaEuRn. deCrOthMe DSM-5 used for the diagnosis of MDD in older adults. 2. Which of the following categories define the treatment of depression in older adults? Select all that apply. *a. Lifestyle change (exercise and diet) *b. Somatic therapies (e.g., pharmacotherapy, ECT, and light therapy) *c. Psychosocial interventions (e.g., cognitive-behavioral, psychodynamic, social engagement, and reminiscence therapy) *d. Collaborative care interventions Rationale: Lifestyle change (physical exercise and diet) may be effective in reducing less severe depression, and carries less risk of adverse effects compared to pharmacological interventions. Somatic therapies like pharmacotherapy or ECT are efficacious and recommended for treating more severe depression. Pharmacotherapy and light therapy may also be recommended for older adults with less severe symptoms and for individuals who have not responded to nonpharmacological treatments. Bright white or pale blue light therapy can significantly reduce the severity of depression in older adults. There is growing evidence that psychosocial interventions such as cognitive/behavioral, psychodynamic, and reminiscence or life-review therapy help reduce geriatric depression. Collaborative depression care programs (incorporating scheduled patient follow-ups and intensified interprofessional communication) are effective in older adults with depression. These programs are carried out through multiprofessional teams that also include nurses trained as depression managers.

3. Which of the following are negative health consequences of geriatric depression? Select all that apply. *a. Lowered pain tolerance *b. Comorbidities (e.g., cardiovascular disease, musculoskeletal diseases, lung diseases, and cancer) *c. Poor decision-making capacity causing life-threatening behavior d. Fatigue and loss of energy Rationale: Negative health consequences of geriatric depression include lowered pain tolerance; increased risk of comorbidities like cardiovascular disease, musculoskeletal diseases, lung diseases, and cancer; anxiety; cognitive impairment; and increased health care use. Depression can affect a person's decision-making capacity, which may indiretly result in life-threating behaviors such as a refusal to eat, take medicines, or receive treatments. Fatigue and loss of energy is one of the crieria for diagnosing depression according to the Diagnostic and Statistical Manual of Mental Disorders 5th ed.(DSM-5). Thus, it is a symptom, not a consequence, of depression. 4. Comorbid anxiety and depression in older adults are associated with increased risk of which of the following? Select all that apply. *a. Decrease in memory *b. Suicide c. Paranoia *d. Poor treatment outcomes Rationale: Comorbid anxiety and depression in older adults are associated with decrease in memory, increased rates of suicidal ideation, and poorer treatment outcomes. Symptoms of depression in general are more severe and not paranoia in isolation. 5. A 70-year-old patient complains of many somatic symptoms. The nurse taking the patient’s history suspects the patient has depression. However, the nurse should be vigilant enough to correlate which somatic symptoms with which other comorbidities? Select all that apply. *a. Disturbed sleep and congestive heart failure *b. Increased lethargy and acute metabolic disturbance *c. Increased lethargy and drug response d. Increased breathlessness and chronic lung disease Rationale: Comorbidites are common in older adults suffering from depression. Their acute or chronic comorbidities may have some somatic symptoms in common with symptoms of depression. Older adults often report their somatic symptoms more often than their depressed mood. Symptoms of depression may be associated with many comorbid conditions in the patient. For example, a complaint of disturbed sleep may be related to chronic lung disease or congestive heart failure. An older adult reporting increased lethargy or diminished energy could be suffering from acute metabolic disturbance. The patient could also be experiencing diminished energy or increased lethargy in response to a drug the patient is taking. Although inreased breathlessness could be seen in untreated chronic lung disease, it is not a symptom of depression.

6. A 78-year-old patient has recently been admitted to a nursing home because her family lives far away and is unable to care for her at home. The medical officer finds the patient to be very meloncholic. After taking a detailed history, the medical officer runs some tests. The patient does not have any serious medical ailment as per routine investigations. The medical officer reaches a tentative diagnosis and feels the patient has had this condition for the last 5– 6 years. What could be the reason the patient was not diagnosed with this condition prior to her admission to the nursing home? Select all that apply. *a. She may not have reported symptoms due to social stigma. *b. She may have thought that her symptoms were normal for her age. *c. She dismissed her melancholic feeling as a reaction to the loss of her husband. *d. Her family physician thought that her mood was caused by not having family nearby. Rationale: There is a social stigma around depression and hence older adults often learn to live with their symptoms. A diagnosis of depression is often missed in older adults because most accept it as a feeling associated with aging, hence they do not report the symptoms. Often the individual or the healthcare provider associate the symptoms of depression as a normal response to medical illness, hospitalization, or other stressful life events (like the loss of a spouse or having no family nearby). 7. A 66-year-old African American patient was brought into the emergency room after a fall by a relative who suspects the patient has a leg fracture. The relative relayed that the patient often complained he wasn’t as able as his coworkers and that he did not socialize much with others. The healthcare providers in the emergency examined the patient, ran X-rays, and confirmed that there was no fT raE ctS urTeB . TAhNeKpS atE ieL ntL ’sEfR al. l rCesOuM lted in a muscle tear and he was advised treatment for this condition. However, the nurse felt that this patient had some other health problem for which he had not sought any treatment for years. What factors might have hindered this patient’s diagnosis and care? Select all that apply. *a. Patient’s inability to afford insurance b. Lack of doctors in the neighborhood *c. Patient’s inability to correctly express himself *d. Patient’s status as a minority Rationale: The African American community is a minority community in the United States. They suffer from inequities in healthcare access as compared to the white population. The patient has likely suffered from depression for years that went undiagnosed for several reasons. Minorities are less likely to have insurance coverage and often cannot afford treatment. Further, cultural and language barriers can make it difficult for minorities to correctly express themselves. There is not likely a lack of doctors in the area, although minorities may have trouble finding culturally competent doctors they can easily access and trust.

8. An older adult, living alone, is brought by her next-door neighbor to the community screening program for depression. The neighbor is concerned that the older adult often forgets to bring her lunch when they meet to play cards and eat on Fridays, forgets to lock her front door now and then, and sometimes forgets the route to their favourite coffee shop. Which assessment form should be used to screen the older adult for depression? a. The Patient Health Questionnaire-9 (PHQ-9) *b. The Geriatric Depression Scale—Short Form (GDS-SF) c. The Cornell Scale for Depression in Dementia (CSDD) d. Diagnostic and Statistical Manual of Mental Disorders 5th ed.(DSM-5) Rationale: The patient’s forgetfulness is indicative of mild cognitive impairment. The Geriatric Depression Scale—Short Form (GDS-SF)is a simple Yes/No form with 15 questions for easy screening of depression in older adults. A score of 5 or more is suggestive of depression. The Patient Health Questionnaire-9 (PHQ-9) is not indicated in older adults with cognitive impairment. The Cornell Scale for Depression in Dementia (CSDD) is useful for screening dementia and depression associated with it, but it not a useful screening tool for depression in older adults without dementia. The Diagnostic and Statistical Manual of Mental Disorders 5th ed.(DSM-5) is a tool for individual assessment and diagnosing depression, not a screening tool. 9. An older adult is suspected to be suffering from depression. The nurse taking the patient’s history notes that the patient also suffers from chronic allergies and has been on the same anti-allergic medications for almost a year. What could be the nurse’s immediate next steps? Select all that apply. *a. Change anti-allergic mediTcaEtiSoT nsBANKSELLER.COM *b. Run a few lab tests and ECG c. Refer the patient to a psychiatrist d. Refer the patient to a dermatologist Rationale: In older adults, many comorbid conditions or their treatments present with symptoms of depression, make the diagnosis and management of depression difficult. Hence, it is important to assess existing medications and rule out new comorbid conditions through proper laboratory tests and ECG. Many anti-allergics cause depression-like side-effects. This medication should be identified and changed. Where medically feasible, a more depressogenic medication should be subsituted with a less depressogenic one. Lab tests and ECG should be run and any comorbid condition identified will need to be treated, as comorbidities often contribute to depression.

10. A 75-year-old patient is brought to the psychiatry ward by his son. The son informs the nurse that the patient has been having suicidal thoughts for 2–3 days and even attempted to harm himself repeatedly. The patient does not seem interested in answering questions and is getting progressively agitated by the conversation. Which of the following treatment modalities should be started immediately? Select all that apply. a. Cognitive behavior therapy *b. Hospitalization c. Patient counseling *d. Intensive psychiatric treatment with antipsychotics, antidepressants, and electroconvulsive therapy (ECT) Rationale: Suicidal thoughts and actions indicate severe depression, which requires immediate treatment with hospitalization. Intensive psychiatric treatment with antipsychotics, antidepressants, and/or electroconvulsive therapy (ECT) should be started immediately. Intensive psychological support needs to be given as part of therapy. However, since the patient is currently not in a situation to listen and comprehend and is getting agitated, counseling and cognitive behavior therapy cannot be started until the patient is stabilized by intensive psychiatric treatment.

Chapter 20: Delirium: Prevention, Early Recognition, and Treatment Multiple Choice Test Questions 1. Which of the following are common risk factors for delirium in acute hospital units? Select all that apply. *a. Dementia b. High cholesterol *c. Infection d. Recent fall Rationale: The most common risk factors for development of hospital delirium are older age, comorbid illness, dementia, infection, severity of medical illness, use of “high risk” medication, postoperative status, urinary catheterization, urea and electrolyte imbalance, immobility, diminished activities of daily living (ADL), sensory impairment, and malnutrition. High cholesterol and recent fall are not considered risk factors for delirium. If a fall requires surgery or hospital admission, that can be a risk factor for delirium. 2. A 78-year-old patient is admitted to the hospital for hip fracture surgery. The treating physician and nurse in charge should be vigilant about which of the following lab abnormalities? Select all that apply. *a. Elevated blood urea nitrogen (BUN)/creatinine ratio b. Low platelet count *c. Low hemoglobin (Anemia) *d. Metabolic acidosis Rationale: Certain laboratory abnormalities like elevated blood urea nitrogen (BUN)/creatinine ratio, metabolic acidosis, and anemia (low hemoglobin) can increase the risk of delirium and should be corrected immediately. Low platelet count is a risk factor for bleeding disorders, not delirium. 3. Which of the following are negative health consequences of delirium in older adults admitted to the ICU ? Select all that apply. *a. Higher mortality and complication rates *b. Longer time spent on mechanical ventilation *c. Higher likelihood of discharge to a long-term care facility d. Greater fatigue and loss of energy Rationale: Older adults with delirium suffer from various negative outcomes such as depression, decreased functional and cognitive status, increased mortality, increased hospital lengths of stay, increased geriatric syndrome complications, and increased chances of discharge to long-term care facilities. Those admitted to the ICU have higher mortality and complication rates, spend more time on mechanical ventilation, and are more likely to be discharged to a long-term care facility. Fatigue and loss of energy can be symptoms of depression, but are not negative health consequence specific to older adults admitted to the ICU.

4. An older adult is hospitalized. Which tool could be used to screen for delirium? Select all that apply. a. Diagnostic and Statistical Manual of Mental Disorders (DSM-5) *b. The Memorial Delirium Assessment Scale (MDAS) *c. The Confusion Assessment Method (CAM) *d. Delirium Rating Scale (DRS) *e. The NEECHAM Confusion Scale Rationale: Delirium has a rapid onset and typically fluctuating course, especially in the hospital setting. Therefore, nurses use a number of user-friendly and relatively rapid screening tools to screen older adults for delirium. These include the Memorial Delirium Assessment Scale (MDAS), Confusion Assessment Method (CAM), Delirium Rating Scale (DRS), NEECHAM Confusion Scale, and Nursing Delirium Screening Scale (Nu-DESC). The Diagnostic and Statistical Manual of Mental Disorders, 5th ed. (DSM-5) is a tool for individual assessment and diagnosing depression. It is not a screening tool. 5. An older adult is admitted for a major surgery. The medical history reveals that the patient is a known diabetic whose condition is often uncontrolled and who is prone to infection. After the procedure, the surgeon asks the nurse to keep a strict watch on the patient’s body temperature, blood counts, and blood glucose, and to note and report any chills, rigors, or change in behavior. What new postoperative negative sequeale related to the patient’s past medical history is the surgeon trying to avoid? a. Worsening of diabetes b. Infection *c. Delirium d. High blood pressure Rationale: Surgery in older adults is a stressful condition, and it increases the risk of worsening of diabetes post surgery. Uncontrolled diabetes is a risk for infection, especially with the patient’s past history of repeated infection. Infection is a risk factor for delirium in older adults. Fever, chill, rigor, and high white blood cell counts all indicate infection. Hence, the surgeon has asked the nurse to keep watch for these symptoms related to patient’s medical history to prevent delirium. The presence of these symptoms does not indicate a worsening of diabetes. Older patients are at risk of developing high blood pressure, but this is not related to infection or to diabetes.

6. A 70-year-old patient is admitted to the ICU following a fall. The patient has injured his jaw and is unable to talk. The nurse wants to assess whether the patient has delirium. Which screening scale can the nurse use? a. The Memorial Delirium Assessment Scale (MDAS) b. The Confusion Assessment Method (CAM) c. Delirium Rating Scale (DRS) *d. The Nursing Delirium Screening Scale (Nu-DESC) Rationale: The Nursing Delirium Screening Scale (Nu-DESC) is based on the Confusion Rating Scale (CRS). This is the only delirium screening scale that does not require patient participation as it evaluates the presence of confusional symptoms. The CRS assesses four symptoms of delirium: disorientation, inappropriate behavior, inappropriate communication, and illusions or hallucinations. The Memorial Delirium Assessment Scale (MDAS), Confusion Assessment Method (CAM), and Delirium Rating Scale (DRS) need patient participation for assessment. 7. A patient of Spanish origin is admitted to the critical care unit. Which delirium screening scale should the nurse prepare to use? a. The Nursing Delirium Screening Scale (Nu-DESC) b. The Memorial Delirium Assessment Scale (MDAS) *c. The Confusion Assessment Method (CAM) d. Delirium Rating Scale (DRS) Rationale: A version of the Confusion Assessment Method (CAM), known as CAM-ICU, is EA SM TBhAasNbKeS available for critically ill patientsT .C enEtL raL nE slaRte.dCiO ntM o 13 languages and is most likely to be available in Spanish. The Nu-DESC, MDAS, and DRAS are less likely to be useful for a Spanish-speaking patient. 8. An older hospitalized adult is lethargic, sedated, and responding slowly. The concerned nurse should use which screening scale to confirm the patient’s condition? a. Delirium Rating Scale (DRS) *b. The Nursing Delirium Screening Scale (Nu-DESC) c. brief CAM (bCAM) d. Ultra-Brief Delirium (UB-2) Rationale: The patient’s symptoms of becoming lethargic, sedated, and slow-to-respond indicates the patient is suffering from hypoactive delirium. The best screening scale for this patient is the Nursing Delirium Screening Scale (Nu-DESC), which assesses four symptoms and is based on the Confusion Rating Scale (CRS). The Nu-DESC also assesses a fifth symptom of psychomotor retardation, to account for the hypoactive variant of delirium. The Nu-DESC can be performed on a nonverbal patient. DRS, bCAM, and UB-2 need a verbal patient to complete the assessment.

9. An older adult has been in the ICU for two days after a major fracture surgery. The nurse notices that the patient is becoming agitated, is talking to himself, and appears to be disoriented. The medical officer on duty has started the patient on some medications. Which nonpharmacological intervention can the nurse use to to manage the patient’s new condition? Select all that apply. *a. Encouraging mobility *b. Sleep enhancement c. Detailed laboratory investigations d. Restricting mobility Rationale: The patient is exhibiting symptoms of delirium. There are many nonpharmacological interventions for delirium, such as encouraing mobility, enhancing sleep, taking care of nutrition and hydration, and ensuring proper vision and hearing. Detailed laboratory investigations are carried out to find the cause of delirium, not to manage the condition. A patient with delirium should not be restricted from movement. 10. An older adult is hospitalized with a week long history of vomiting and loose motion. The patient is screened and tests positive for delirium. What nursing care should be immediately started? Select all that apply. *a. Improve hydration *b. Correct metabolic disturbances, if any *c. Take care of nutrition *d. Intensively treat vomiting and diarrhea Rationale: Delirium in older adults can be precipitated by infection, poor nutrition, severe illness, and metabolic disturbances. Prolonged vomiting and diarrhea can cause dehydration, metabolic disturbances, and poor nutritional status due to decreased intake. All these need to be corrected on priority. It is also important to find the cause of and treat diarrhea, as it is often infective. Vomiting and diarrhea should be controlled as soon as possible so the patient’s hydration, nutrition, and metabolic status can be improved.

Chapter 21: Dementia: Assessment and Care Strategies Multiple Choice Test Questions 1. Which of these are common forms of progressive dementia in the United States? Select all that apply. *a. Alzheimer’s disease (AD) b. Creutzfeldt–Jacob disease *c. Frontotemporal dementia (FTD) d. Parkinson’s disease dementia (PDD) Rationale: In the United States, Alzheimer’s disease (AD) is the most common form of progressive dementia. Other common forms of progressive dementia include vascular dementia (VaD), dementia with Lewy bodies (DLB), and frontotemporal dementia (FTD). Progressive dementias that occur less commonly include Parkinson’s disease dementia (PDD), dementias associated with HIV, and Creutzfeldt–Jacob disease. 2. A patient comes into the clinic with mild cognitive impairment. Which of the following are risk factors for this condition that the patient should be assessed for? Select all that apply. a. High education *b. Hypertension *c. Depression *d. Coronary artery disease Rationale: Mild cognitive impairment (MCI) is characterized by cognitive impairment out of proportion to the age of the individual with the individual not meeting the criteria for dementia. MCI is seen more commonly in individuals with low education. Other risk factors include vascular risk factors, such as type 2 diabetes, hypertension, obesity, dyslipidemia, and smoking; cardiovascular disease outcomes, such as coronary artery disease, atrial fibrillation, congestive heart failure, and cerebrovascular disease; and neuropsychiatric conditions, such as depression, anxiety, and apathy. 3. A patient is suspected of having dementia. Which of the following tests could be used in detecting dementia? Select all that apply. *a. Clock Draw test (CDT) *b. St. Louis University Mental Status Exam (SLUMS) *c. Mini-Cog d. The Barthel Index Rationale: The various instruments that can be used to detect dementia include the Mini-Cog, Memory Impairment Screen, General Practitioner Assessment of Cognition, Clock Draw test (CDT), Montreal Cognitive Assessment (MoCA), and St. Louis University Mental Status Exam (SLUMS). The CDT is also useful in predicting future cognitive impairment. The Barthel Index assesses physical function.

4. Which of the following are components of mental status evaluation during cognitive assessment of a patient? Select all that apply. *a. Executive control functions *b. Orientation c. Activities of daily living (ADL) *d. Speech and language Rationale: During cognitive assessment, the mental status is evaluated under the following sections: state of consciousness, general appearance or behavior, orientation, attention and concentration, memory, judgment and insight, executive control functions, visual-spatial function, speech and language, thought content, mood and effect. Functional assessment of a patient involves assessing activities of daily living; this is not a core component of a cognitive assessment (though supplements the cognitive assessment to rule out mild cognitive impairment.) 5. A 76-year-old patient was brought by his son with complaints of progressive loss of memory, changes in behavior and personality, and judgmental errors made in situations for which his father earlier made the right decisions. The son also informed that his father needed more and more assistance with activities of daily living (ADL). After conducting a detailed history and other examinations, the medical officer asked for an MRI of the brain. What findings in the MRI can help clinch the diagnosis? Select all that apply. a. Intracellular accumulation of amyloid beta proteins *b. Extracellular accumulation of amyloid beta proteins *c. Neurofibrillary plaques anTdE“S taT ngBlA esN ”K inStE heLbLrE aiR n .COM d. Neurofibrillary plaques and “tangles” in the cerebrospinal fluid Rationale: The patient has presented with classic features of dementia, such as progressive loss of memory, language deterioration, deterioration of other cognitive functions, a declining ability to perform activities of daily living (ADL), changes in personality and behavior, and judgment dysfunction. An MRI clinches a diagnosis of Alzheimer’s disease (AD) if the MRI shows neurofibrillary plaques, “tangles” in the brain, and extracellular accumulation of amyloid beta proteins. These findings are not seen inside the cell (neurons) or the cerebrospinal fluid.

6. A 78-year-old patient is suffering from fluctuations in cognition. His wife stated that at times he is alert and at other times he is nonattentitve. She also noticed that her husband was progressively becoming slower, not sleeping properly, and not able to comprehend things. Most recently she noticed that his hands are trembling and his gait has become unsteady. What is the likely diagnosis for this patient? a. Parkinson diseae dementia (PPD) b. Vascular dementia (VaD) *c. Dementia of Lewy bodies (DLB) d. Frontotemporal dementia (FTD) Rationale: Clinical features of Dementia of Lewy bodies (DLB) and Parkinson disease dementia (PPD) include cognitive and behavioral changes in combination with features of Parkinsonism. Clinically, distinction can be made on the basis of the sequence of the appearance of symptoms. DLB begins with fluctuations in cognition and motor symptoms follow, as in this patient. However, motor symptoms precede cognitive impairment in PPD. Hence, based on the sequence of events, the likely diagnosis is DLB. Vascular dementia (VaD) occurs in older adults with a history of vascular disease, while clinical features of frontotemporal dementia (FTD) are mainly related to behavioral changes and/or language impairments. 7. A 60-year-old patient is admitted to the hospital for surgery. During history taking, the patient’s son informs that the patient often skips a shower and takes a long time to complete morning routines. Which test can the nurse use to check if the patient’s functional level is normal? a. The Functional Activities Questionnaire (FAQ) b. The AD8 c. The Alzheimer’s Disease Cooperative Study (ADCS)–ADL inventory *d. The Functional Assessment Staging Test (FAST) Rationale: The patient may be skipping a shower and spending long hours on morning routines due to laziness, constipation, or even as a habit, so the nurse needs a functional test that can differentiate between normal and abnormal functional level. The Functional Assessment Staging Test (FAST) is an effective test to discriminate between normal cognition, mild cognitive impairment (MCI), and dementia, and is useful in measuring functional performance. The Functional Activities Questionnaire (FAQ) is useful to discriminate early dementia. The AD8 is a useful screening test to identify an individual with the potential to have dementia. The Alzheimer’s Disease Cooperative Study (ADCS)–ADL inventory is a specialized functional test mainly used in clinical trials.

8. A firm wants to assess the cognitive function of all its older employees involved in tasks requiring high level of problem-solving skills. A nurse has been hired for this task. The human resource manager also requests that the nurse assess whether the employees driving to work would need pick-up/drop-off cab service because of their cognitive function. The nurse is looking for a tool that can be used to address all the company’s requirements. Which of the following tests can the nurse use? *a. Clock Draw test (CDT) b. St. Louis University Mental Status Exam (SLUMS) c. Montreal Cognitive Assessment (MoCA) d. The Functional Activities Questionnaire (FAQ) Rationale: The nurse needs a test that can assess executive functions, can recognize mild dementia, and is linked to driving capacity. The Clock Draw Test (CDT) is strongly linked with executive function (i.e., the ability to execute complex behaviors and to solve problems) and is useful in the detection of mild dementia. Scoring in CDT is based on the ability to free-hand draw the face of a clock, insert the hour numbers in the appropriate location, and then set the hands of the clock to the time designated by the examiner. The CDT is also moderately associated with driving performance. As the CDT score drops, the number of driving errors increase. The Montreal Cognitive Assessment (MoCA) can help address frontotemporal executive function (such as attention, planning, judgment, reasoning, problem solving, etc.) and has less educational and cultural bias. However, MoCA has no connection with driving capacity. The Functional Activities Questionnaire (FAQ) is useful to discriminate early dementia but cannot assess higher problem-solT viE ngST caB paAcN itK y.SSE t.LLL ouEiR s. UC niO veMrsity Mental Status Exam (SLUMS) has comparable sensitivity and specificity for detecting dementia as MoCA but cannot assess higher problem-solving capacity. 9. A 75-year old was brought to the clinic by relatives. The relatives informed that the previous nurse caring for the patient had tried to manage the condition without medication. However, the patient is progressively deteriorating, forgets easily, is losing track of words, and is not able to remember dates. The patient is not able to bathe independently, make coffee, or perform other similar activities, and the patient’s personality and behavior has become unpredictable. The patient also has chronic anorexia and nausea which is being investigated. The medical officer suggests that the patient needs some medication. What medication would be ideal in the patient’s situation? a. Donepezil hydrochloride *b. Memantine c. Tacrine hydrochloride d. Rivastigmine tartrate Rationale: The patient has classical features of Alzheimer Disease dementia. There is progressive loss of memory, language deterioration and deterioration of other cognitive functions, declining ability to perform activities of daily living (ADL), and changes in personality and behavior and judgment dysfunction. Memantine (Namenda) is approved for moderate–to-severe dementia and is known to improve cognition in AD dementia. This is the

best option as it also does not cause side effects of anorexia and nausea. Donepezil hydrochloride (Aricept) and rivastigmine tartrate (Exelon) are mainstays of treatment in AD dementia, but they may have gastrointestinal side effects, such as nausea, anorexia, and diarrhea. These medications should be avoided as the patient is being investigated for chronic nausea and vomiting. Tacrine hydrochloride (Cognex) was taken off the market in 2013 because of its adverse effect on the liver and multiple daily dosing. 10. A 75-year-old patient is brought by her daughter to the hospital as the patient is unable to look after herself, forgets to take her medicines, often gets lost in her neighborhood, is becoming more and more agitated, and is losing her personality. The daughter, who has just recently moved in with the patient to care for her, is visibly tense and agitated. What tools can the nurse use in managing this case? a. The Modified Caregiver Strain Index (CSI) *b. Progressively Lowered Stress Threshold (PLST) *c. The Preparedness for Caregiving *d. Describe, Investigate, Evaluate, and Create (DICE) Rationale: To manage this case, the nurse needs to focus on both the patient and the caregiver (daughter). The nurse needs to assess the environment in which the patient and caregiver live, help the daughter identify triggers for behavioral and psychological symptoms of dementia (BPSD), and then teach the caregiver how to manage those symptoms. Using the PLST model, the nurse can emphasize strategies in each of the PLST principles of care: maximize safe function, provide unconditional rT egEaS rdT , uBsA eN beKhS avEiL orL sE toRg.auCgOeMactivity and stimulation, “listen” to the behaviors, and modify the environment. The DICE tool will help the nurse assess key patient, caregiver, and environmental considerations and help the nurse design behavioral and environmental interventions to address these considerations.The nurse also needs to assess how well prepared the daughter is to care for her mother and then develop strategies to prepare her for the role of the caregiver. The Preparedness for Caregiving is an 8-item instrument that asks caregivers how well prepared they believe they are for multiple domains of caregiving. Items are rated 0 (not at all prepared) to 4 (very well prepared). This will help the nurse evaluate what aspects of caregiving for the daughter needs help preparing for, such as physical care, emotional support, setting up support services, or dealing with the stress of caregiving. The Modified Caregiver Strain Index (CSI) measures caregiver strain, but because the daughter has just moved in with her mother, the concept of caregiver strain does not apply yet.

Chapter 22: Pain Management in the Older Adult Multiple Choice Test Questions 1. An older patient in the postoperative surgical ward is suffering from severe, acute pain. Why is it important to diagnose the cause of the pain and treat it immediately? Select all that apply. *a. To avoid thromboembolism *b. To avoid persistent postsurgical pain c. To avoid constipation *d. To avoid functional decline Rationale: Inadequate management of severe, acute, postoperative pain is known to cause persistent postsurgical pain. Therefore, it is important to diagnose the cause of the pain and treat it immediately. Older adults suffering from acute pain in the hospital are also at increased risk of experiencing complications like thromboembolism, pneumonia, and functional decline. However, untreated acute pain in hospital setting is not known to increase risk of constipation. 2. An older adult comes to the outpatient clinic with ineffectively treated moderate-to-severe persistent pain. The nurse examining the patient should seek information regarding which complications? Select all that apply. *a. Social withdrawal and depression *b. Fall c. Thromboembolism *d. Sleep disturbances Rationale: An older adult with ineffectively treated moderate–to-severe persistent pain is at increased risk of depression, social withdrawal, sleep disturbances, impaired mobility, decreased activity engagement, and increased healthcare use. Also, moderate-to-severe persistent pain can increase the risk of falls, cognitive decline, deconditioning, gait disturbances, malnutrition, and slowed rehabilitation. Hospitalized patients suffering from acute severe pain are at increased risk of thromboembolism in a postsurgical setting.

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3. A 68-year-old patient is brought to the clinic with complaints of pain in the abdomen. Which of the following scales should be used to quickly assess only the intensity of pain in this patient? *a. Numerical Rating Scale (NRS) b. Faces Pain Scale c. McGill Pain Questionnaire d. Verbal Descriptor Scale (VDS) Rationale: The Numerical Rating Scale (NRS) is widely used in hospital settings. Patients are asked to rate the intensity of their pain on a 0 to 10 scale (0 being the least intense and 10 being the most intense). The Faces Pain Scale is more helpful in older adults with cognitive impairment or those above 80 years of age, as it uses cartoon-like faces exhibiting pain expressions, ranging from the least pain to the most pain possible. The McGill Pain Questionnaire is not just limited to intensity of pain but also assesses pain across several dimensions like location, effect, and intensity of pain. The Verbal Descriptor Scale (VDS) is typically used to measure pain intensity in a research setting rather than in a hospital setting. 4. A 70-year-old patient with cognitive impairment is brought to the clinic because the patient’s son feels that the patient is not acting like her normal self. After talking with the son, the nurse learns that the patient’s behavior has changed drastically over the last week. Which of the following behaviors can alert the nurse that the patient is in pain? Select all that apply. *a. Agitation *b. Crying loudly c. Sitting in a corner *d. Wandering aimlessly Rationale: Older adults with dementia often express pain through behavioral changes. These changes could be visible in interpersonal interactions (e.g., aggression, agitation, resisting care), activity patterns (e.g., wandering), or mental status (e.g., confusion, crying). Sitting in a corner or socially withdrawing is more of a behavior change seen in depressed patients.

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5. A 70-year-old patient is brought to the community clinic with complaints of right leg pain. The patient’s son asks the nurse to have patience, as the patient loses track of words and is not able to remember dates. The son informs the nurse that the patient had a routine monthly checkup at his doctor’s clinic 15 days back. After spending time with the patient, the nurse concludes that the patient has been in pain for at least a month. Why was the pain not diagnosed and managed at the doctor’s clinic 15 days back? Select all that apply. a. The patient did not report the pain, thinking it was a normal part of aging. *b. The patient reported the pain, but the doctor did not think it was important. *c. The patient forgot to mention the pain to his son and doctor. *d. The patient’s doctor did not have adequate knowledge regarding pain assessment in this patient. Rationale: The patient is an older adult suffering from dementia who may not report pain due to cognitive impairment. This is an important barrier to reporting pain because dementia reduces an older adult’s ability to remember and report pain. Similarly, healthcare providers find it difficult to detect pain in individuals who cannot verbally express it, lacking knowledge regarding adequate pain assessment and management in cognitively impaired older adults. Further, healthcare providers tend to underestimate reports of pain in older patients with cognitive impairment. Hence, older adults with dementia are undertreated for pain when compared with cognitively intact older adults. While older patients often do not report pain because they think it’s part of normal aging, in this patient, causes related to cognitive impairment are more relevant because of the patient’s condition.

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6. An 85-year-old patient is brought to the clinic by his daughter for a routine checkup. The daughter informs that the patient is mute and offers to answer any queries the nurse has. After examining the patient, the nurse notices that the patient grimaces when putting weight on his right leg while walking. When the nurse questions the patient regarding the grimace, the patient just dismisses it with wave. The patient’s daughter reports that the patient moans in his sleep, but there are no other complaints or findings. What should the nurse do in this case? a. Refer the patient to a specialist for further assessment. b. Ask the daughter to bring the patient back if the patient has any further complaints. *c. Assume that the patient is in pain and start analgesics and nonpharmacological treatment. *d. Ask the daughter to bring the patient back in two weeks for further assessment. Rationale: It is difficult to gather information regarding pain from nonverbal older adults. In this case, the nurse should use the four-step approach to gather information: attempt to find if the patient ever reported pain, look for pain behaviors (like grimacing while walking or moaning in sleep), look for signs of pain (like previous surgery or signs of arthritis), and question family members. Since pain behaviors were noticed while the nurse was gathering information, the nurse should assume that the patient is in pain and start analgesics and nonpharmacological treatment. The nurse should then schedule a follow-up to review the effect of treatment strategies. Since there were no complaints and findings in this case, there is no need to refer the patient to a specialist. Also, since the nurse found pain behaviors, the patient should not be sent home without proper management of the pain, as persistent leg pain in older adults can cause complications such as falls. 7. A 75-year-old patient is brought to the clinic in severe pain due to arthritis of the knee joints. The patient’s relatives inform the nurse that the patient needs assistance with bathing and other daily routines and forgets the date and to feed his pet cat. Which of the following treatments is likely to most benefit the patient? Select all that apply. *a. Ibuprofen b. Physiotherapy of the lower limbs *c. Celecoxib d. Exercise of knee joint Rationale: This patient is suffering from cognitive decline. In patients with dementia, pharmacological pain management should be tried on priority because altered cognitive functioning limits their ability to engage in nonpharmacological pain relief strategies. Hence, ibuprofen or celecoxib should be preferred over exercise and physiotherapy.

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8. A 65-year-old patient comes to the clinic with complaints of pain in all small joints of the hand and wrist. The patient informs the nurse that he has been taking acetaminophen once a day for the pain for several months. However, one week ago, the pain became more severe, limiting his ability to hold things. The nurse notes that the patient suffers from heart disease and is taking medication for the same. On examination, the nurse finds some deformities in the middle fingers of both hands. The doctor on duty runs some tests and X-rays and diagnoses the pain to be due to rheumatoid arthritis. What should the doctor prescribe for pain? a. Increased dose of acetaminophen but no more than 3000 mg daily b. Celecoxib c. Ibuprofen *d. Aspririn Rationale: The patient suffers from rheumatoid arthritis and heart disease. Acetaminophen is considered a reasonable choice for older patients at risk of cardiovascular disease. All other nonsteroidal anti-inflammatory drugs (NSAIDs), such as celecoxib and ibuprofen, and aspirin should be used with caution in older adults, especially in those with underlying cardiovascular diseases. 9. An older adult comes to the clinic complaining of pain for the past 7–8 months. The patient reports taking medications on time and diligently performing all exercises taught by her physiotherapist. Despite this, the pain is not improving and is affecting her quality of life. The patient has been treated with acetaminophen, ibuprofen, and most recently with Ra.nCagOeMpain? celecoxib. What should the doTcE toSr T noBwAN prK esScE rbL eL toEm *a. Oxycodone b. Naproxen c. Increased dose of celecoxib d. Desipramine Rationale: Opioid drugs like oxycodone are useful in managing persistent pain that is causing functional impairment, as in this patient. Naproxen is a nonsteroidal anti-inflammatory drug (NSAID) and is not helpful in this situation. Celecoxib is also an NSAID, and increasing its dose will also increase riks of cardiovascular disease and gastropathy. Desipramine is a tricyclic antidepressant that can be prescribed alongside an NSAID and opioid to manage pain, but is not recommended in older adults due to side effects like confusion, dry mouth, constipation, and orthostatic hypotension.

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10. A 75-year-old patient is brought to the clinic with complaints of severe pain in the chest. The patient has been taking ibuprofen to manage his pain. The patient’s son informs that the patient had herpes in the same area about two months back. What can be prescribed to manage the patient’s pain? Select all that apply. *a. Pregabalin *b. Gabapentin c. Nortriptyline *d. Lidocaine patch Rationale: Anticonvulsants (e.g., pregabalin and gabapentin) can be used as adjuvants for treating pain associated with postherpetic neuralgia. A lidocaine patch can also be used as an additional treatment, as this mode of delivery helps avoid systemic side effects of the drugs. Anticonvulsants have fewer adverse effects than tricyclic antidepressants (TCA) like nortriptyline. TCAs can cause confusion, dry mouth, constipation, and orthostatic hypotension and should be avoided.

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Chapter 23: Assessing, Managing, and Preventing Falls in Acute Care Multiple Choice Test Questions 1. An 82-year-old patient is brought to the emergency department after falling to the ground. Which of the following are common serious complications that can occur? Select all that apply. *a. Hip fracture *b. Traumatic brain injury (TBI) *c. Death d. Large skin wound on jaw Rationale: Serious injuries resulting from falls in older adults include hip fractures and traumatic brain injury (TBI). Further, adults who are 70 years and older are three times as likely to die from ground falls compared with adults younger than 70 years old. A large skin wound on the jaw is a relatively minor injury, is superficial, and will heal with stitches. 2. The nurse is taking history from an older adult brought to the clinic after a fall and finds that the patient is very apathetic toward the event. Why are older adults often apathetic toward falls? Select all that apply. a. They feel that healthcare providers do not take them seriously. *b. They blame themselves for falls. *c. They think falls happen wThE enStT heByApNerKfoSrE mLaLmEoRv. eC thO atMis risky for their age. *d. They do not want to burden their family, nurses, and others. Rationale: Older patients are often apathetic toward falls for reasons relating to self-blame behaviors, admitting to risk-taking behavior, or reluctance to impose on busy nurses. Older adults do not often feel that healthcare providers do not take them seriously, but instead feel that they don’t want to bother their providers. 3. What are the different reasons for falls in older adults identified through a comprehensive post-fall assessment (PFA) tool? Select all that apply. *a. Acute and chronic illness *b. Medications *c. Misjudgment d. Older age Rationale: A comprehensive post-fall assessment (PFA) tool identifies eight causes of fall in older adults: acute illness, chronic diseases, medications, behavior, unknown, environment, misjudgment, or poor patient safety awareness. While old age is a risk factor for falls, this is not a cause of fall identified by a PFA tool.

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4. What information regarding a fall in an older adult can be gathered using a comprehensive post-fall assessment (PFA) tool? Select all that apply. *a. Neurological and cardiovascular assessment *b. Assessment of physical and mental status *c. Mobility assessment d. Risk of future falls Rationale: A PFA tool is used after a fall to find its cause in older adults. It includes the following components apart from data on the patient’s physical status: fall history; fall circumstance; medical problems; medication review; mobility assessment; vision assessment; neurological examination, including mental status; and cardiovascular assessment. A PFA tool does not predict the risk of future falls. 5. A female, Caucasian older adult is brought to the emergency department after a fall from her chair. The patient is alert but in severe pain, and is unable to put weight on her right leg. On examination, there is swelling and bruising in the right hip and groin area. An x-ray of the area clinches the diagnosis. What could be the risk factors for this patient’s condition? Select all that apply. *a. Old age and immobility *b. Female sex and Caucasian ethnicity *c. Low calcium and vitamin D d. Traumatic brain injury

OlMder women, especially Caucasian Rationale: This patient has a hipTfrEacStuTrB eA caNuK seSdEbL yL thEeRfa.llC .O females, carry the greatest risk for hip fracture compared with men and women of African American or Asian descent. An underlying diagnosis of osteoporosis increases the risk for fallrelated hip fracture. Low calcium, low vitamin D, and immobility are risk factors for osteoporosis. The patient is alert and unlikely to have suffered a traumatic brain injury. 6. A 78-year-old patient fell down at home and was brought into the clinic for assessment. The patient’s son attempted to prevent the fall but could not reach the patient in time. The nurse questions how the patient fell, asks what the patient was doing just prior to the fall, and tries to recreate the scene of the fall. What are some common circumstances leading to falls that the nurse might consider? Select all that apply. *a. Patient fell while getting up from the toilet seat. *b. Patient rolled down the bed and fell. c. Patient was found lying on the floor. *d. Patient fell while walking. Rationale: The various circumstances which could lead an older adult to fall include a bed fall (patient rolls off the mattress or slips off the edge of the bed), a chair fall (patient slides from the chair or falls getting into or out of the chair), an ambulatory fall (patient falls while walking), a fall during transfer (patient falls getting on or off the toilet or falls when standing from a seated position), and an unwitnessed fall (patient found on the floor or lower level). However, since the patient’s son tried to reach the patient to prevent the fall, the nurse would not consider an unwitnessed fall.

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7. A 75-year-old patient, living alone, was found lying on the floor when neighbors entered the home during a daily wellness check. The neighbors bring the patient to the clinic. The patient informs the nurse that he suffers from dizziness and momentary blackouts on and off. Lately, he has been feeling very tired. He remembers falling down after one such episode. He has not been to a doctor for almost a year. What causes of dizziness and blackouts should be investigated in this patient? Select all that apply. *a. Cardiovascular b. Muscular *c. Neurological *d. Metabolic Rationale: Dizziness could be associated with cardiovascular causes (low blood pressure, low heart rate, orthostatic hypotension, etc). Black outs could be due to cardiovascular or neurological causes. Fatigue of recent onset could be due to metabolic causes (anemia, electrolyte disturbance, abnormal sugar levels, etc.). The patient does not have any muscular cause of fall as there is no complaint of any pain, slipping, etc. 8. An older adult was brought to the clinic after he fell down while standing up from his chair. The patient says that he has high blood pressure and was recently put on a new medication. The nurse examines his pulse and blood pressure. What would the nurse find in this patient? a. Slow heart rate (< 60 beats per minute) *b. Falling blood pressure when the patient stands c. Fast heart rate (> 100 beats per minute) d. Rising blood pressure whT enEtS heTpBaA tieNnKt S stE anLdL s ER.COM Rationale: Since the patient fell upon standing up from his chair, he is likely suffering from orthostatic hypotension. This could have been caused by the new medicine the patient is taking to control hypertension. The nurse will find that the patient’s blood pressure declines upon standing. The patient’s heart rate has no role to play in this condition. 9. An older adult was brought to the clinic after falling at home. On examination the nurse finds that the patient sways to one side when asked to walk in a steady line. What could be the cause of this sway? *a. Cerebellar issue *b. Gait ataxia c. Orthostatic hypotension d. Arthritis Rationale: This older adult had abnormal gait. If the 10-feet steady line walk test shows deviation or sway to one side, it means that the abnormal gait is due to a cerebellar issue or gait ataxia. This test is not positive in arthritis, which can also cause an abnormal gait. Orthostatic hypotension does not cause gait abnormality, but instead causes falls due to a decline in blood pressure upon standing.

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10. A 70-year old patient had a heart attack several years back but has been doing well since. She has been taking a blood thinner for several years. However, the patient recently suffered from a hemorrhagic stroke and had a fall because of that. She was hospitalized and treated and is now ready for discharge. The patient’s daughter wants to ensure that her mother will be safe at home. What interventions will ensure patient safety at home? Select all that apply. a. Ensuring early mobility after hemorrhagic stroke *b. Educating the patient about the condition and how to prevent falls *c. Equipping the house with proper flooring and safety equipment *d. Assessing the patient’s home environment and recreating the events prior to the patient’s fall Rationale: The patient’s home will need to be made safe from falls prior to her discharge. Also, it is important that the patient understands her condition, knows about the risks of falls, and is taught ways to prevent them. Assessing the patient’s home environment and recreating the events prior to fall with the patient will help build strategies to prevent future falls. Further, equipping the house with proper flooring and safety equipment will ensure that the patient’s environment is safe. Ensuring early mobility post stroke is an important measure to prevent future falls, but this measure is started in the hospital. At home, the patient can be asked to remain active.

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Chapter 24: Reducing Adverse Drug Events in the Older Adult Multiple Choice Test Questions 1. Adverse drug events (ADEs), or injuries resulting from medical interventions related to a drug, include which of the following situations? Select all that apply. *a. Medication errors *b. Adverse drug reactions *c. Overdoses *d. Missed doses *e. Allergic reactions Rationale: Adverse drug events (ADEs) include medication errors, adverse drug reactions, allergic reactions, and overdoses. A missed or skipped dose can contribute to an adverse drug reaction and is therefore also included as an ADE. 2. A patient with uncontrolled diabetes is taking several medications for diabetes and hypertension. What should the healthcare provider consider when prescribing a new medication for the patient’s diabetes? Select all that apply. *a. Ensure the new medication does not have an additive effect with any of the currently prescribed medications b. Stop all other medications for diabetes before starting the new medication *c. Educate patient about theTpE otS enTtiB alAsN idKeSefEfeLcL tsEoR f t.hC eO neMw medication *d. Ensure that the new medication is not the same as one already prescribed Rationale: Whenever a new medication is assigned to a patient, it has the potential to cause adverse drug reactions (ADRs) through duplication, additive effects, discontinuation of therapy, skipping medication, changing dose to cause, and physiologic antagonism. For such reasons, prescribers and medical staff should be vigilant of ADRs and their contributory factors. They should also educate the patient to recognize the side effects of the drugs they are taking. No medication for uncontrolled diabetes should be abruptly stopped, as this can cause a blood sugar spike and ADR. 3. An older adult experiences a medication-related event. What are the possible causes of medication-related events in older adults? Select all that apply. *a. Polypharmacy *b. Altered pharmacokinetics and pharmacodynamics c. Comorbid conditions *d. Medication adherence Rationale: Older adults experience medication-related events for five major reasons: alterations in pharmacokinetics and pharmacodynamics, polypharmacy (the use of five or more medications daily), therapeutic failures, iatrogenic causes, and medication adherence. Comorbid conditions can lead to polypharmacy, but comorbid conditions themselves are not one of the five major causes of medication-related events in older adults.

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4. A nurse is reviewing the medication list of a 72-year-old patient with multiple conditions. What tools can the nurse use to check if there are any medications with the potential to cause adverse drug events? Select all that apply. *a. Beers Criteria *b. STOPP Criteria c. Cockroft-Gault Formula *d. START Criteria *e. Brown Bag Method Rationale: The Beers Criteria is a medication list, comprised by the American Geriatrics Society of Medications, of drugs to be generally avoided or used with caution in adults 65 years of age and older due to potential harmful side effects and drug-to-drug interactions. The STOPP Criteria identifies potentially inappropriate prescriptions by physiological systems. The START criteria identify potential prescription omissions of medications. It is a vital tool in alerting doctors to the right treatment and recommends important medications for specific chronic conditions often omitted. It is intended to be used simultaneously with STOPP Criteria. The Brown Bag Method is used to assess all medications an older adult has at home, including prescriptions from all providers, over-the-counter (OTC) medications, and herbal remedies. The Cockroft-Gault Formula calculates creatinine clearance using patient age, body weight, and serum creatinine levels. A creatinine clearance of < 50 mL/min places older adult at risk for adverse drug events. It does not examine the medication list.

TiB 5. A 70-year-old frail patient waTs E adSm tteAdNtK oS thE eL hoLsE piRta.l C foO rM pneumonia. The patient has been coughing a lot and has had high fever on and off since admission. The patient has been receiving antibiotics and medicines for cough and fever. The nurse on duty suddenly notices that the patient is scratching a lot. Thinking the patient is itching due to dry skin, the nurse brings body lotion to the patient, but instead finds the whole body covered with rashes. What should the nurse do now? Select all that apply. a. Change all the medications, as any one could be causing the rash b. Start an anti-allergic medication to stop the itch *c. Immediately inform the doctor on duty to examine the rash and prescription list *d. Hold the next dose of medications until the patient has been examined by the doctor Rationale: Older frail patients are at increased risk of adverse drug reactions. A new symptom in a frail hospitalized patient taking multiple medications must always be considered an adverse drug effect first. The relationship between the new symptom and most recent medications should be evaluated before treating the symptom. Hence, the nurse should hold the next dose of all the medicines until the patient has been examined by the doctor. The nurse should immediately inform the doctor on duty to examine the new symptom and the prescription list to evaluate if any of the prescribed medications has rash as a side effect. Of all the medications prescribed, antibiotics are most likely to have caused rash as a side effect. Hence, only the medication most likely to have caused the rash would need to be changed. The rash and itch should not be treated until the cause of this new symptom is found.

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6. A 78-year-old with history of a cerebrovascular accident comes to the clinic with pain in the joints. The patient has been on warfarin since the episode. The nurse prescribes a painkiller. Which medications should the patient be instructed to avoid? Select all that apply. *a. Diclofenac b. Lidocaine patch *c. Acetaminophen *d. Ibuprofen Rationale: Nonsteroidal anti-inflammatory drugs (NSAIDs) like acetaminophen, diclofenac, and ibuprofen are known to cause adverse drug interactions when taken with warfarin and should be avoided. A lidocaine patch causes less systemic effects and therefore is a safe option to be prescribed with warfarin. 7. An older patient weighing 65 kg is hospitalized for managing various medical conditions, including a kidney condition. The patient is prescribed several medications to be taken post discharge. The nurse preparing the discharge wants to quickly check the risk of adverse drug events (ADEs) in the patient and calculates the creatinine clearance using a simple formula. Which creatinine clearance value should alert the nurse that the patient is at risk of ADEs? a. Creatinine clearance equal to 50 mL/min b. Creatinine clearance of > 50 mL/min *c. Creatinine clearance of < 50 mL/min d. Creatinine clearance cannot help assess the risk of ADEs Rationale: The nurse calculated rTeE naSl T clB eaAraNnKceSuEsL inLgEthRe.CCoO ckMroft-Gault Formula. A creatinine clearance of < 50 mL/min places the older adult at risk for ADEs. The nurse should be aware that in frail, low weight older adults, this formula may estimate far higher creatinine clearance levels than the actual glomerular filtration rates. A creatinine clearance greater than or equal to 50 mL/min does not indicate the older adult is at increased risk for ADEs. 8. An older adult comes to the pharmacy to fill his prescription for a diabetes medication. The pharmacist notes that the patient is also taking dietary supplements, over-the-counter (OTC) drugs, and herbal products for diabetes. This patient is at increased risk of adverse drug interactions from which of the following medications? Select all that apply. *a. Dietary supplements *b. Over-the-counter medications (OTCs) *c. Herbal products *d. Prescription medications Rationale: Older adults are the largest consumers of both prescription and over-the-counter (OTC) medications, which contribute to increased risk of adverse drug reactions. Older adults aged 62–85 also use dietary supplements more often than younger adults and have increased concurrent use of interaction medicines. When the patient is concurrently taking prescription and OTC medications for diabetes, along with dietary supplements and herbal products, all of these different medications can contribute to adverse drug reactions—not just the prescription medications.

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9. A 70-year-old patient is admitted to the hospital with uncontrolled hypertension and diabetes. The patient is currently taking medications for kidney disease. The doctor asks the nurse to compile the patient’s medication list and bring it to him for review. What should the nurse and doctor look for in the patient’s medication list? Select all that apply. *a. Medications to avoid or use with caution *b. Medications that need to be added to the list *c. Over-the-counter (OTC) medications *d. Inappropriate prescriptions Rationale: The patient who is suffering from several chronic conditions is susceptible to missing medications that should be prescribed. Alternatively, many medications get prescribed which should either be avoided or used with caution due to the potential to cause adverse drug reactions. The medication list should also be checked to ensure that the dose or strength of the drug is not missing and the prescription is complete. Finally, older adults often take OTC medications that have the potential to cause ADRs, and hence, these medications should be reviewed as well. 10. An older adult with severe osteoarthritis comes into the clinic for a follow-up visit. The nurse examines the patient and notices some functional decline. How can the nurse help the patient take the medications properly? *a. Ask the pharmacist to provide medications in a bottle/container with a non-childproof lid *b. Assess the patient’s health literacy *c. Ask the patient to bring all old prescription foils, packs, and bottles to the next visit *d. Ask the patient to repeat aTllEthSaTt B isAeN xpKlaSinEeL dL inEtR hi. sC viO siM t Rationale: Functional decline in this patient can be due to nonadherence to medication. Hence, the nurse should ensure the patient is adhering to the prescribed medications. Older patients with arthritis often find it difficult to remove tamperproof lids. A simple request to the pharmacist to provide a non-childproof lid may improve the safe and effective use of prescribed medication. The nurse should also assess if the patient understands what the drug is to be used for, how often it is to be taken, the circumstances of ingestion (e.g., with food), and other aspects of drug selfadministration that signal intelligent drug use. Pill count can be ascertained by asking the patient to bring all old prescription foils, packs, and bottles to the next visit. Teach back, or asking the patient to repeat all that is explained, helps the nurse recognize whether the patient has understood the instructions.

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Chapter 25: Urinary Incontinence in the Older Adult Multiple Choice Test Questions 1. A 76-year-old patient with hypertension and diabetes is brought to the clinic for a routine visit. The nurse notes that the patient also has urinary incontinence (UI). What could be the reason the patient has not sought professional help for the UI? Select all that apply. *a. The patient thinks that it is a natural process of aging. *b. The patient uses pads recommended by a friend to contain leakage. *c. The patient uses self-help strategies advertised on TV. *d. The patient is reluctant to discuss this personal problem. Rationale: Individuals with UI often believe that it is a normal consequence of aging and are likely to feel it is a personal problem that is difficult to discuss. Evidence suggests that individuals with UI prefer to combat it using self-help strategies, including containment, rather than seeking professional advice. These personal care strategies are often the result of information gained through lay media and personal contacts, and not necessarily from healthcare professionals. 2. An older adult comes to the clinic with complaints of passing urine involuntarily. What physical consequences can result if this symptom is not treated? Select all that apply. *a. Skin irritation or infection b. Skin tears *c. Limitation of functional status *d. Urinary tract infection (UTI) Rationale: The patient is suffering from urinary incontinence (UI). Physical consequences of UI include skin irritations or infections, urinary tract infections (UTIs), bloodstream infections, pressure ulcers, and limitation of functional status. Skin tears result from acute injury and not from chronic irritation as occurs in UI. 3. Which of the following parameters are required to maintain urinary continence in an older adult? Select all that apply. *a. Intact lower urinary tract *b. Cognitive ability to recognize voiding signals *c. Functional ability to use a commode or toilet d. Intact upper urinary tract Rationale: Continence requires intact lower urinary tract function, a cognitive and functional ability to recognize voiding signals and use a toilet or commode, the motivation to maintain continence, and an environment that facilitates the process. The upper urinary tract is not involved in urinary continence.

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4. Hospitalized older adults are at risk of developing which type of urinary incontinence (UI)? Select all that apply. *a. Chronic established *b. Transient *c. Nosocomial *d. New-onset Rationale: Hospitalized older adults are at risk of developing transient UI. In the literature, these cases have been referred to as new-onset, hospital nosocomial, and hospital acquired. Complicated by shorter hospital stays, older adults may also be at risk of being discharged without resolution of transient UI and, thus, urine leakage persists and may become established UI. 5. A 72-year-old patient who comes to the clinic says he is unable to hold his urine properly and often experiences urine leakage before reaching the bathroom. What other symptoms are likely to be present in this patient? Select all that apply. *a. Urinary frequency *b. Large amount UI *c. Nocturia d. Small amount UI Rationale: The patient has urge urinary incontinence (UI). Bladder changes common in aging make older adults particularly prone to this type of UI. In addition to urinary urgency, signs and TeBuAriNnK symptoms of urge UI most often T inE clS ud arS yE frL eqLuE enRc. y,CnOoM cturia, and enuresis. In urge UI, moderate to large amounts of UI are seen and not small leaks. 6. A 76-year-old patient comes to the clinic with severe chest congestion and coughing bouts. The patient complains that at times urine leaks with the cough. Prior to the cough, the patient struggled to control the urge to urinate before reaching the bathroom. Which of the following statements is correct regarding the patient’s condition? a. The patient has stress UI. b. The patient has urge UI. *c. The patient has mixed UI. d. The patient has overflow UI. Rationale: The patient has mixed UI (both stress and urge), as there is involuntary urine loss as a result of both increased intra-abdominal pressure (during cough) and detrusor instability (inability to control the urge to pass urine). The patient does not have overflow UI, as this type of UI is associated with a low urge to pass urine.

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7. A 78-year-old patient with hypertension and depression comes to the clinic with complaints of fever and a burning sensation upon urination. What tools can the nurse use to assess the patient’s risk of urinary incontinence (UI)? Select all that apply. *a. Patient history b. Bladder diary *c. Urinary Distress Inventory-6 (UDI-6) *d. Medication list Rationale: The patient’s symptoms indicate a urinary tract infection, which can be a cause or a physical consequence of UI. Taking the patient’s history helps the nurse establish symptoms and risk factors of UI and assess the severity of UI if it is present. UDI-6 is a tool that screens for UI. The patient may be taking diuretics for hypertension and sedative antipsychotics for depression. Since these medications increase the risk of UI, reviewing the medication list is also important. A bladder diary is a tool that helps assess a patient’s voiding pattern, incontinent episodes, and UI severity. However, this is used to objectively assess UI in patients, and not for assessing the risk of UI. 8. A 70-year-old patient comes to the clinic with complaints of passing urine while pushing heavy objects. After thorough history taking and examination, the nurse sends a request for a diagnostic test. Which of the following findings of the test are considered abnormal? a. Greater than 50 mL or 5% of the voided volume b. Greater than 100 mL or 10% of the voided volume c. Less than 100 mL or 20% of the voided volume ESofTtBheAvNoKidSeE Re.COM *d. Greater than 100 mL or 2T 0% dL voLluEm Rationale: The patient has stress incontinence. Initial diagnostic tests include urinalysis, urine culture and sensitivity, and postvoid residual (PVR) urine. A PVR of greater than 100 mL or 20% of the voided volume is considered abnormal and requires further evaluation by a urology specialist. 9. An older male patient who is obese has urinary incontinence and severe constipation, and is being cared for by a nurse. The patient is unable to control the urge to pass urine and thus experiences “accidents” frequently. Which of the following strategies can be used to prevent these occurrences? Select all that apply. *a. Voiding diary *b. Managing constipation *c. Weight loss d. Pelvic floor muscle exercises (PFMEs) Rationale: A multimodal approach to managing UI is ideal. Dietary and fluid management leading to weight loss will help manage the UI. The patient can also keep a voiding diary to track toileting habits along with implementation of timed voiding, prompted voiding, and habit training. Managing the patient’s constipation will relieve pressure on the bladder and help with the UI. PFMEs are useful in managing UI in older female patients.

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10. A nurse is counseling a 75-year-old patient with urinary incontinence. Which of the following should be a part of UI counseling? Select all that apply. *a. Weight loss *b. Healthy bladder behavior skills c. Restriction of fluid intake *d. Diet and exercise Rationale: Healthy bladder behavior skills help older adults become independent. These healthy bladder behaviors include eliminating bladder irritants like caffeine and acidic foods from the diet. Another important behavior skill is following a healthy diet and exercise. This will help the patient lose weight, which is important for managing UI. So working toward losing weight is a healthy bladder behavior skill. A patient with UI may believe fluid intake should be restricted, but too little fluid intake can result in concentrated urine, which, in turn, may cause increased bladder contractions and increased feelings of urinary urgency. Patients may be advised to limit fluid intake a few hours before bedtime to manage and limit nocturia, but otherwise fluid intake should not be restricted.

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Chapter 26: Prevention of Catheter-Associated Urinary Tract Infection Multiple Choice Test Questions 1. An older adult received a Foley’s catheter in the emergency department. The next day, the patient comes to the clinic with classic symptoms of catheter-associated urinary tract infection (CA-UTI). Which of the following are patient-related risk factors for CA-UTI? Select all that apply. a. Male sex *b. Older age (age > 50 years) *c. Serum creatinine > 2 mg/dL *d. Renal failure Rationale: Older age (age > 50 years), severe underlying illness, and serum creatinine > 2mg/dL are patient-related risk factors for CA-UTI. Renal failure is a severe underlying illness and can cause serum creatinine levels of greater than 2 mg/dL, making it a risk factors for CA-UTI. Female sex is a risk factor for CA-UTI and not male sex. 2. A 70-year-old patient receives a catheter in the emergency department. After how many hours can a catheter-associated urinary tract infection (CA-UTI) start? a. 12 hours b. 72 hours *c. 48 hours d. 24 hours Rationale: After microorganisms that cause a UTI enter the patient’s urinary tract, a biofilm made up of bacteria, host proteins, and slime forms on the outer surface of the catheter. Since the formation of biofilm and colonization with bacteria takes time, most CA-UTI occur after 48 hours of catheterization. 3. A patient is brought to the emergency department with suspected urinary retention. The nurse decides to insert an indwelling urinary catheter (IUC). What actions should the nurse take to prevent the patient from contracting a UTI in future? Select all that apply. *a. Use evidence-based care practices *b. Choose a product based on evidence *c. Monitor the patient’s progress d. Keep the IUC in until full treatment Rationale: Each IUC inserted is a potential source of infection. Hence, evidence-based care of IUCs is required. This can be done through strategies such as evidence-based product selection, evidence-based care practices (including insertion and maintenance), education of providers, surveillance of processes, and reporting practice outcomes and CAUTI rates. To help prevent the patient from contracting a UTI, the nurse should minimize the duration of IUC use through timely removal and should not keep the IUC in until full treatment.

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4. A 40-year old patient came to the emergency department for removal of an indwelling urinary catheter (IUC). Two days later, the patient presented with increased urinary frquency and urgency. What other signs and symptoms should guide the nurse in managing this patient? Select all that apply. *a. Suprapubic tenderness *b. Dysuria c. Fever > 36°C *d. Costovertebral angle pain or tenderness Rationale: The patient is suffering from catheter-associated urinary tract infection (CA-UTI). Signs and symptoms of CA-UTI include suprapubic tenderness, costovertebral angle pain or tenderness, urinary urgency and frequency, and dysuria when the catheter is not in place. In patients aged 65 years or older, a fever greater than 38°C is also a sign of UTI. 5. A 55-year-old patient received an indwelling urinary catheter (IUC) in the ICU. One day later, the nurse performing routine rounds finds the patient has a temperature of 39.5°C. On examination, the nurse also finds suprapubic tenderness. Which of the following statements regarding this patient is correct? a. The patient has asymptomatic bacteremic UTI (ABUTI). b. The patient has now developed urinary retention. *c. The patient has a non-catheter-associated urinary tract infection (Non-CA-UTI). d. The patient has a catheter-associated urinary tract infection (CA-UTI). Rationale: The patient’s fever anT dEsuSpTraBpA ubNiK c tSeE ndLeL rnE esRs.aC reOcM lassic symptoms of UTI. The patient has non-CA-UTI because the IUC has only been in place for one day; a patient whose catheter has been in place for two or more days may have a CA-UTI. The patient does not have ABUTI as the patient has a fever and other signs of UTI. The IUC may have been inserted for urinary retention, but with the IUC in place, the patient no longer is experiencing urinary retention.

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6. A 78-year-old female patient with a history of diabetes has been in the ICU and hospital ward for 10 days following a heart attack. The patient receives an indwelling urinary catheter (IUC) in the ward on the 11th day of hospitalization. The next day, the doctor on round asks the nurse on duty to monitor the patient for a catheter-associated urinary tract infection (CAUTI). Why does the nurse need to be alert regarding CA-UTI in this patient? Select all that apply. *a. Patient has diabetes. *b. IUC was inserted on 11th day of hospital stay. *c. IUC was inserted in hospital ward. *d. Old age and female sex. Rationale: The patient has several risk factors for CA-UTI. Patient-related risk factors for CAUTI include older age, female sex, underlying illness, diabetes mellitus, and renal disease. Of these, old age, female sex, diabetes, and underlying illness (heart disease) are present in this patient. Other hospital-related risk factors include insertion outside the operating room (here done in the ward) and after the 6th day of hospitalization (done on 11th day in this patient). Other hospital-related factors that can increase the risk of CA-UTI but are not present in this patient are duration of IUC, not maintaining a closed drainage system, and improper provider training regarding insertion. 7. A urologist inserts an indwelling urinary catheter (IUC) in the operating room after a procedure in a 75-year-old patient. The doctor adds the details of the procedure and IUC in the patient’s electronic health record (EHR). The urologist then adds a flag next to IUC on the EHR. What purpose does T thEeSflT agBsAeN rvKe?SELLER.COM a. It automatically reminds the nurse to empty the patient’s urinary bag. b. It automatically reminds the nurse to send urine for culture. c. It automatically calculates the urine volume entered in the EHR. *d. It automatically calculates the number of days the IUC has been in place. Rationale: Urinary catheter removal reminders and stop orders help reduce catheter-associated urinary tract infection (CA-UTI) rates. These reminders help reduce the duration of catheter usage by periodically checking if the catheter is still required, so it can be removed at the earliest time. EHR icons or flags that calculate the number of days the IUC has been placed are effective forms of electronic reminders. These flags do not automatically calculate urine volume, remind the nurse to empty the patient’s urinary bag, or remind the nurse to send urine for culture.

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8. A patient underwent a surgery under thoracic epidural analgesia. An indwelling urinary catheter (IUC) was inserted in the operating room just before the surgery. The patient was shifted to the ICU with the thoracic epidural analgesia catheter and IUC in place. The next day the intern on duty decides that the patient still needs epidural analgesia. What should be done with the two catheters? a. Both the epidural analgesia catheter and IUC should be retained. b. Both the epidural analgesia catheter and IUC should be changed. *c. The epidural analgesia catheter should be retained and the IUC should be removed. d. Both the epidural analgesia catheter and the IUC should be removed. Rationale: Keeping the IUC as long as thoracic epidural analgesia is maintained (higher than T9) may result in a higher incidence of catheter-associated urinary tract infection (CA-UTI) and increased hospital stay. IUC removal on the morning after surgery while the thoracic epidural catheter is still in place does not lead to increased incidence of urinary retention, infection, or higher rates of recatheterizations. Hence, the thoracic epidural catheter should be retained and IUC removed. Changing both catheters is not practiced due to increased risk of infection and other complications. 9. A male patient in the ICU has an indwelling urinary catheter (IUC). During the morning rituals, the nurse uses normal soap and water for sponging the patient and cleans the urinary meatus the same way. Which of the following statements is correct? a. The nurse has increased the risk of CA-UTI by not cleaning the urinary meatus with an antiseptic lotion. KaSl EsoLaLp EanRd.wCaOteMr during sponging/bathing and *b. Cleaning the urinary meatTuE sS wT ithBnAoNrm after bowel movement reduces the risk of CA-UTI. c. Touching the urinary meatus has increased the risk of CA-UTI. d. The urinary meatus should be covered to avoid contamination via the bathing sponge and water. Rationale: Urinary meatal care during sponging/bathing and after bowel movement is important to reduce the risk of catheter-associated urinary tract infection (CA-UTI). Cleaning the urinary meatus with normal soap and water reduces the risk of CA-UTI. Meatal cleansing with antiseptics, creams, lotions, or ointment has been found to irritate the meatus, possibly increasing the risk of infection. Touching the urinary meatus during cleaning does not increase the risk of CA-UTI. If the urinary meatus is covered, it is not being properly cleaned.

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10. The nurse reports that a 75-year-old male patient with severe arthritis is not able to walk quickly enough to the bathroom to pass urine in the toilet. The nurse also notices that at times the patient passes urine before he can get out of the bed. The nurse asks the doctor if an indwelling urinary catheter (IUC) will help the patient, but the doctor advises against an IUC. What is the most appropriate action the nurse can take to help this patient? a. Take the patient to the bathroom every three to four hours. *b. Arrange a bedside urinal and set up a urinary schedule. c. Arrange and keep a standby indwelling urinary catheter (IUC). d. Place a condom catheter instead of an IUC. Rationale: The patient’s decreased mobility is affecting the patient’s ability to hold the urine long enough to make it to the bathroom. Arranging a bedside urinal and setting up a urinary schedule will help the patient pass urine without mishaps. Taking the patient to the bathroom every three to four hours may possibly reduce the amount of bedwetting, but because of the patient’s severe arthritis, this is not the best option. An indwelling urinary catheter (IUC) is not indicated in this patient, hence keeping a standby will not help the patient. For less mobile male patients, the condom catheter is an effective alternative to an IUC, but it is not the most appropriate option in this case as there is still a small risk of infection with condom catheters.

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Chapter 27: Physical Restraints and Side Rails in Acute and Critical Care Settings Multiple Choice Test Questions 1. Which of the following are reasons for which nurses use restraints on a hospitalized patient? Select all that apply. *a. Patient care issues *b. Therapy disruption *c. Management of agitation or violent behavior *d. Staffing issues Rationale: Today’s hospital nurses cite prevention of patient therapy disruption as the primary reason for restraint use. Other less commonly voiced reasons for using restraints include patient care issues such as management of agitation or violent behavior, wandering, and positioning. A small proportion of nurses have cited insufficient staffing or legal concerns as reasons restraints were used. 2. An older adult admitted to the ICU repeatedly tries to pull out the intravenous line (IV). What could be the reason behind the patient’s behavior? Select all that apply. *a. Dementia *b. Delirium *c. Pain *d. Sedative Rationale: Self-termination of therapy in older adults is often due to delirium. Pain and sedatives contribute to delirium. Dementia may limit the patient’s ability to understand the situation and result in attempts to self-terminate therapy. 3. When are bed side rails considered to be a restraining device? Select all that apply. a. When used to protect a sedated patient from rolling out of the bed b. When transporting a patient from one location to another *c. When used for fall prevention for a conscious but cognitively impaired patient d. When used by a patient to assist with repositioning Rationale: Bed side rails are considered to be restraints when they are used to prevent falls for a conscious but cognitively impaired patient. When used to prevent a sedated patient from falling out of bed or during transportation from one unit to another, bed side rails are considered to be a protective device. Patients often use bed side rails as support to reposition themselves, and this is not considered to be restraint.

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4. How often does a physician’s order for physical restraint have to be renewed? Select all that apply. *a. Every 24 hours for nonviolent behavior b. Every 6 hours for violent or self-destructive behavior c. Every 4 hours for nonviolent behavior *d. As per hospital policy Rationale: Each restraint order must be renewed every 24 hours for nonviolent behavior and every 4 hours for violent or self-destructive behavior. Orders must also be renewed in accordance with hospital policy. 5. A 78-year-old patient who is very agitated is brought to the emergency department with severe acute abdominal pain. The patient’s attendant informs that the patient has been suffering from severe anxiety and arthritis for the past year. The nurse on duty decides to use restraints for this patient. Why is the use of restraints required in this patient? Select all that apply. *a. Sedative and analgesic drugs may be given *b. The patient’s history of anxiety and agitation c. Emergency department care *d. To prevent a fall Rationale: The patient has anxiety, is agitated, and is in severe pain, and thus may be treated with a sedative or analgesic medication. These treatment characteristics predict the use of restraints. Older age and severe aT rtE hrS itiTs B mAaN yK reS suEltLiL nE aR fa. ll,CeOspMecially since the patient is agitated and may be drowsy with analgesics/sedatives. Hence, the use of restraints may be required to prevent a fall. Physical restraints are not routinely required in emergency department care. 6. A 78-year-old patient is brought to the clinic by the patient’s son, who says the patient fell down at home and has been unable to put weight on the right leg since then. The patient is grimacing while limping. The son informs that the patient becomes hysterical on and off, is gradually losing memory, and has gradually lost the ability to carry out a daily routine. The physician suspects hip fracture and admits the patient for further management. Why would the physician also order the use of physical restraints (not necessarily appropriately)? Select all that apply. *a. Dementia diagnosis in the patient *b. Nurse not competent enough to manage this patient *c. To prevent patient from falling again *d. Patient history of hysterical behavior Rationale: Physicians order the use of restraints if they suspect that there are chances of harm to the patient, the patient has dementia, or the patient exhibits certain behaviors (such as on and off hysterical behavior). This patient is unstable and in pain, and is at risk of falling. The patient is exhibiting signs of dementia and has a history of hysterical behavior. Physicians may also order restraints if they do not trust that the nurse will be able to manage the patient, especially when a patient has multiple problems like this patient does.

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7. A 75-year-old frail patient in heart failure is admitted to the ICU. The physician asks the nurse to ensure that the patient is managed well without restraints. How can the nurse make the ICU setting around the patient conducive to monitoring the patient without restraints? Select all that apply. a. Raise the level of the bed high above the ground. *b. Ensure adequate lighting for monitoring the patient. *c. Ensure there is minimal noise in the ICU. *d. Allot a bed close to the toilet. Rationale: The patient is a frail, acutely ill older adult. Many hospitals provide care for these types of patients in settings that are not designed environmentally for the care of such older people. Hence, restraints may be required to manage these patients in traditional settings. Literature evidence shows that the use of environmental strategies in long-term care settings can enhance function among those suffering from dementia; similar strategies need to be considered in acute care settings. To facilitate monitoring, environmental changes can be made, such as implementing noise control and ensuring appropriate lighting. Assigning a bed close to the toilet can make it easier for the patient to walk the small distance unassisted. The patient will not be able to get down easily from a bed that is high above the ground. The height of bed will act as a restraint for the patient. 8. A hospital wants to build protocols around proper care of older adults and the use of restraints in their hospital care. What organizational factors should hospital management consider while building these protocols for providing appropriate, safe care to older adults? Select all that apply. a. Only older staff is employed to care for the patients. *b. Build the knowledge, skills, and sensitivity of healthcare providers. *c. Ensure proper communication of the plan of care among multiple disciplines and departments. *d. Include models of care delivery. Rationale: Several organizational factors ensure safe care of older adults and therefore result in less use of restraints. These factors include systems to determine staffing numbers and mix, models of care delivery, and transmission or communication of the plan of care among multiple disciplines and departments. Many healthcare providers (HCPs) lack the knowledge, skills, and sensitivity in providing appropriate care to older adults. Hence, protocols to sensitize and educate HCPs should be included in the organizational protocols. The age of the hospital employees is not important. The hospitals should ensure proper number and mix of hospital staff for each shift to ensure proper care.

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9. A 76-year-old patient with hypertension is admitted to the hospital for pneumonia. How should the nurse assess the patient to decide whether physical restraints are needed? Select all that apply. *a. Check the patient’s medication list. *b. Ask the patient to use the toilet before lying down on the bed. *c. Take the patient’s blood pressure when sitting and on standing. *d. Ask the patient about any previous falls, complaints of dizziness, blackouts, etc. Rationale: The nurse’s decision regarding restraints will depend on the risk of fall in this patient. For instance, the nurse can evaluate gait and balance by simply observing the patient’s ability to transfer in and out of bed and to walk to and from the bathroom. The nurse should watch for any difficulty with steadiness, an inability to stand up independently without using a rocking motion or the upper extremities, “plopping” onto the surface of a chair, and an inability to walk steadily to the bathroom without holding onto objects or the wall. Notation can be made of lightheadedness or dizziness, the presence of orthostatic hypotension (blood pressure that falls on standing), and the use of sedating medications (such as sleeping pills). 10. A 75-year-old patient is admitted to the hospital with complaints of uncontrolled diabetes mellitus. The patient’s attendant informs the nurse that the patient has recently had difficulty remembering her name and often walks aimlessly around the house. The nurse notices that the patient is unable to stand up from the chair unassisted, but walks confidently. What kind of physical restraint can the nurse use while managing this patient’s care? a. Bed call button *b. Low bed c. Chair alarm d. Chair with extended arm rests Rationale: The patient has a moderate risk of fall due to age. Because the patient is unable to get up from a chair unassisted, a low bed would be enough to restrain this patient. The patient is suffering from dementia, as identified by memory loss and walking aimlessly around the house. Thus, a call button or chair alarm would not be ideal, as the patient may forget to use them. A chair with extended arm rests would help the patient get up and therefore not act as a restraint.

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Chapter 28: Preventing Pressure Injuries and Skin Tears Multiple Choice Test Questions 1. A patient comes to the clinic with some skin tears and pressure injuries on the leg. The nurse records the injuries on the patient’s chart. Which of the following statements is correct? a. Skin tears occur on the skin and pressure injuries occur on mucous membranes. *b. Skin tears are acute injuries and pressure injuries are chronic injuries. c. Skin tears and pressure injuries are chronic injuries. d. Skin tears are chronic injuries and pressure injuries are friction injuries. Rationale: Skin tears are acute injuries and pressure injuries are chronic injuries that develop over a period of time. Pressure injuries are not friction injuries, as friction is a superficial force that cannot cause enough pressure on the skin to cause pressure injuries. Also, only devicerelated pressure injuries occur on mucosal surfaces. 2. A cancer patient is admitted to hospice. The nurse is checking for pressure ulcers. Where should the nurse check? Select all that apply. *a. Elbows *b. Heels *c. Sacrum *d. Knees Rationale: In addition to the usual sites on the sacrum and heels, elbows are a common site for pressure injuries in hospice patients. The knee is not a common site of pressure injury in hospice patients; however the nurse should conduct a full body check. 3. What is the reason for the lower incidence of Stage I pressure injuries found in dark-skinned individuals? a. Dark skin tolerates pressure better than light skin. b. Color changes are more difficult to detect in dark skin. c. Dark skin is less genetically predisposed to pressure injury. *d. Clinicians are not well versed to detect Stage I injuries in dark-skinned individuals. Rationale: Clinicians often erroneously believe that Stage I pressure ulcers are less common in dark-skinned individuals. However, this is not the case; in fact, clinicians are not able to detect Stage I pressure injuries in dark-skinned individuals due to misconceptions. Inadequate detection of Stage I pressure injuries in persons with darkly pigmented skin may be a result of clinicians mistakingly believing that dark skin tolerates pressure better than light skin or that color changes are more difficult to detect in dark skin. Further, pressure injury has no genetic predisposition.

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4. The nurse is caring for a patient in the hospital. Which of the following can be used to keep the patient’s skin moist in order to avoid pressure injuries? Select all that apply. *a. Silicone-based dermal nourishing cream *b. Lactic acid *c. Glycerin *d. Urea Rationale: After 8 months of use, silicone-based dermal nourishing cream reduced the proportion of hospital-acquired pressure ulcers (HAPUs) to zero. Another way to moisturize the skin is with humectants (such as urea, lactic acid, glycerin, and ceramides) that bind water to the stratum corneum. 5. A patient comes to the clinic complaining of a localized area of skin firmness with a weird sensation and changed color upon pressing. What is the diagnosis? a. Device related pressure injury b. Friction injury *c. Stage I pressure injury d. Stage II pressure injury Rationale: The patient has a Stage I pressure injury characterized by nonblanchable erythema. The patient had blanchable erythema which, along with changes in sensation, temperature, or firmness, may precede visual changes of nonblanchable erythema. In a Stage II pressure injury there is partial-thickness skin loss with exposed dermis. Device-related pressure injuries are found on mucous membranes. FrT icE tioSnTiB njA urNieKs S uE suL alL lyErR es.uC lt O inMthe formation of abrasions and blisters. 6. An 83-year-old terminally ill, bedridden cancer patient is being looked after by a nurse. The nurse notices a butterfly-shaped discoloration on the patient’s buttock. What could have caused this discoloration? Select all that apply. *a. Impaired cognition *b. Immobility c. Cancer *d. Malnourishment Rationale: The butterfly-shaped discoloration on the buttock is a pressure ulcer. Some of the important identified pressure injury risk factors include: 1) immobility (as seen in bedbound or chair-bound patients), 2) pressure damage, 3) undernourishment or malnutrition, 4) incontinence, 5) friable skin, 6) impaired cognitive ability, and 7) decreased ability to respond to one’s environment. Since the patient is bedridden, immobility is likely a factor with this patient. In addition, terminally ill cancer patients are malnourished. Older age along with terminal illness can impair cognition. Cancer by itself is not a cause or risk for pressure ulcer.

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7. A 75-year-old patient was admitted to the hospital for a hip fracture surgery. However, the surgery was postponed as the patient had uncontrolled diabetes mellitus. Which of the following statements regarding pressure injury are correct? Select all that apply. *a. A prevention program can reduce the risk of a pressure ulcer on the heels. b. Stage I pressure injuries are common after hip fractures. *c. Stage II pressure injuries are common after hip fractures. d. The risk of a pressure injury was reduced due to the delay in hip fracture surgery. Rationale: Implementation of a Heel Pressure Ulcer Prevention Program (HPUPP) for orthopedic patients can result in complete elimination of heel pressure injuries. Many patients with hip fracture develop Stage II or higher pressure injuries. The longer the delay in hip fracture surgery, the higher the risk of developing a pressure injury. 8. A 75-year-old patient is brought to the ICU after a hip fracture surgery. The patient is expected to be in the ICU for some time to manage several comorbid conditions. The nurse is asked to avoid pressure on patient’s bony points. Apart from repositioning the patient, what can the nurse use to remove pressure? Select all that apply. a. Polyurethane foam dressing on visible skin *b. Polyurethane foam dressing on bony points *c. Foam mattress on patient’s bed *d. Alternating air-pressure reducing mattress on patient’s bed Rationale: Pressure injuries occur on bony points. In ICU patients, pressure on the bony points can be reduced by using a foam oTr E alS teT rnBaA tinNgKaS irE -pLreLsE suR re.rC edOuM cing mattress on the patients bed, or by applying polyurethane foam dressing prophylactically on bony prominences, including the heels and sacrum. Pressure injuries only occur on bony points, so applying dressing on all exposed skin will not help. 9. A 78-year-old African American patient is admitted to the hospital for a major orthopedic surgery. The nurse uses the Braden Scale to measure the patient’s risk of developing pressure ulcers post surgery. Which of the following risk-onset scores would alert the nurse that the patient is at high risk of developing pressure ulcers? a. 23 or less *b. 18 or less c. 16 or less d. 20 or less Rationale: The Braden Scale is the most common scale used in the United States to assess the risk of pressure ulcers. A low Braden Scale score indicates that a patient is at risk for pressure injuries. Each of the six categories on the scale is ranked with a numerical score, with 1 representing the lowest possible subscore and indicating the greatest risk. The sum of the six subscores and the greatest risk is the final Braden Scale score, which can range from 6 to 23. In older adults and in persons with darkly pigmented skin (such as this patient), the risk-onset score on the Braden Scale is 18 or less. The original onset-of-risk score on the Braden Scale is 16 or less. The maximum score on this scale is 23, which indicates low risk. Similarly 20, also indicates low risk.

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10. A wheelchair-bound African American patient is sent to the skin clinic by the patient’s family physician with a suspected Stage I pressure ulcer. The nurse applies pressure to the affected area but finds no color change. How can the nurse examine the patient so as to not miss a Stage I pressure ulcer, if there is one? Select all that apply. a. Note any change in skin pigmentation as a pressure ulcer. *b. Check for color difference between bony prominences and adjoining skin. *c. Assess for a change in sensation in the suspected area. *d. Note the normal range of skin pigmentation on the patient’s body. Rationale: Patients with limited mobility are at increased risk of pressure ulcers. A Stage I pressure injury is characterized by nonblanchable erythema. However, blanchable erythema, along with changes in sensation, temperature, or firmness, may precede visual changes of nonblanchable erythema. Clinicians should pay careful attention to a variety of factors when assessing a patient with darkly pigmented skin for Stage 1 pressure injuries. Differences in skin color over bony prominences (e.g., the sacrum and the heels) as compared with surrounding skin may indicate the presence of a Stage 1 pressure injury. The skin should be assessed for alterations in pain or local sensation. In addition, clinicians need to be familiar with the range of skin pigmentation that is normal for a particular patient. Any change in skin pigmentation should not be taken as a pressure ulcer.

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Chapter 29: Optimizing Mealtimes for Persons Living With Dementia Multiple Choice Test Questions 1. An older adult with dementia clamps his mouth shut during meal times. Which of the following statements about this behavior are true? Select all that apply. *a. Caregivers sometimes interpret this as resistive or aversive behavior. b. Clamping the mouth shut is involuntary. *c. The patient could be trying to communicate something. d. This behavior is a symptom of dementia. Rationale: Feeding behaviors such as turning the head away and clamping the mouth shut were conceptualized as “aversive” behaviors in the mid-1990s. Caregivers typically interpreted these behaviors as “resistive” and stopped providing assistance. However, evidence shows this type of behavior is likely a form of communication, and the only form of control a person with dementia has during a meal interaction. For example, a person with dementia who doesn’t open their mouth may be trying to communicate the need for a sip of their drink. Once the drink is offered to the patient, the meal resumes, increasing meal intake. Since clamping the mouth shut is within the control of a patient with dementia, it is not an involuntary process. Clamping the mouth shut is not a symptom of dementia. 2. An older adult in a nursing care facility with cognitive decline is found to have poor nutrition status. Which of the followingTE mS etT hoBdAs N caKnSbE eL stL arEteRd.im ediately to improve the nutritional Cm OM status of this patient? Select all that apply. *a. Environment/routine modification *b. Nutritional supplements c. Tube feeding *d. Feeding assistance Rationale: Interventions to combat malnutrition fall into five major categories: nutritional supplements, training/education, environment/routine modification, feeding assistance, and mixed interventions. Tube feeding is only given for patients who cannot take oral feeds and to provide meals during end-of-life care; it is not a first step to improve nutritional status.

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3. The son of an older adult patient brings the patient to the community clinic with a complaint that the patient’s clothes are increasingly becoming loose. The patient happily participates in all family activities and is otherwise active. The patient’s son has not noticed any other abnormality except that the patient at times forgets to convey messages. What could be the cause of the patient’s loose clothing? Select all that apply. a. Aging *b. Cognitive decline *c. Malnutrition d. Depression Rationale: Clothes becoming loose can signal that the patient is losing weight. In the community setting, unintentional loss of body weight may be the first indicator of a cognitive issue for caregivers and providers. If an older adult is experiencing cognitive decline, the risk of malnutrition is greater. While patients with depression can stop eating and thus suffer from weight loss, the patient’s behavior does not indicate depression. Loss of weight is not an aging process. 4. An older adult has been diagnosed with dementia. Which visual field defect should the patient be assessed for that is typical of dementia? a. Poor adaption to dark and light *b. Loss of peripheral vision c. Inability to recognize patterns d. Impaired visual processing Rationale: As dementia progresses, peripheral vision is significantly reduced to binocular vision (top, bottom, and both sides of the visual field). Visual processing, the ability to adapt to darkness and light, and the ability to recognize patterns can be impaired due to normal aging, but are not affected by dementia.

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5. A 76-year-old patient who lives alone during the day is about to be discharged from the hospital. The patient often forgot recent events, and sometimes needed verbal cues with acts of daily living. In the hospital, the nurse noticed that the patient was not able to recognize the aroma of food or the smell of the floor cleaner. Because of this observation, the nurse is concerned regarding the patient’s safety at home. What advice should the nurse give to the caregiver to increase patient safety at home? Select all that apply. *a. Regularly check that the smoke and carbon monoxide detectors are working. b. Enhance the aroma of food. *c. Remove all old food from the home. d. Make food more visually appealing. Rationale: The patient’s symptoms indicate the patient has dementia that is causing smell deficits. Loss of smell poses a threat because the patient will be unable to smell spoiled food. Thus, caregivers should ensure food near expiration is removed from the home. Because the patient will not be able to smell smoke, the caregiver should also routinely check that smoke and carbon monoxide detectors are working. Enhancing the aroma of food and making food more visually appealing can help the patient appreciate the food better, but these steps do not increase patient safety. 6. A 79-year-old patient is brought to the clinic by the patient’s son with complaints of wandering aimlessly around the house, forgetting things, and changes in behavior. The patient’s son informs the nurse that it is becoming difficult to have visitors at home. The patient greets everyone with a hand shake as a habit. However, the patient does not let go of the visitor’s hand and squeezeTsEthSeThB anAdNvKeS ryEtiLgL htE lyR. . HC enOcM e, people have starting avoiding shaking hands with the patient, which makes the patient sad. What advice can the nurse give the son to improve the situation at home? Select all that apply. a. Ask visitors to come when the patient is sleeping. b. Implore the patient not to give much importance to handshakes. *c. Ask visitors to use the Under Hand Shake. *d. Ask visitors to use a “palm pump.” Rationale: The patient has a strong palmar reflex due to frontal neurodegeneration in dementia. Once the patient shakes someone’s hand, a grasp reflex is initiated that the patient has no control over. Until the reflex releases, the patient cannot let go of the hand and hence appears clingy. Also, since the muscle strength is strong, the handshake becomes a painful squeeze. Visitors can avoid a painful interaction by greeting the person with dementia using the Under Hand Shake. When using the Under Hand Shake, the person with dementia will not hurt the visitor no matter how hard he or she squeezes. The Under Hand Shake combined with a “palm pump” (gently squeezing and releasing the hand in a rhythm similar to a heartbeat) can also be very soothing to the person with dementia. This patient values the handshake as a way to communicate, so it should be maintained and the patient should not be discouraged from giving it importance. Patients with dementia should be allowed regular and frequent visitors; asking visitors to come when the patient is sleeping would deny the patient of socialization.

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7. A 77-year-old patient is brought to the clinic by his wife with complaints of forgetfulness, increased slowness in completing tasks, and not eating the food placed in front of him. The wife is exasperated that the patient reaches out to eat food on someone else’s plate while ignoring the food on his own plate. The nurse advises a simple strategy to deal with the meal difficulty faced by the patient’s wife. What strategy can help this patient eat? a. Placing food in the patient’s hand. b. Guiding the patient’s hand to his plate at the start of the meal. c. Handfeeding the patient. *d. Placing food at the point where the patient typically reaches out to eat. Rationale: Individuals with dementia have reduced peripheral vision or binocular vision; therefore, the patient may not be able to see his food when it is placed directly in front of him. However, the patient can see the food of his dining companions, explaining why the patient instead reaches across to another person’s plate. The patient’s food should be placed at the point where the patient usually reaches out to eat. The companion can move to another place and the patient’s tray can be placed where the companion used to eat. Redirecting the patient back to his own plate may prove futile if the patient cannot see the plate correctly. The patient with dementia who can eat unassisted should be encouraged to do so, rather than making the patient dependent by placing food in the patient’s hand or handfeeding. 8. An older adult patient who has been making poor decisions, forgetting the names of friends, and displaying behavioral changes is being discharged to home. The nurse is explaining the “SHAKE hands” approach to the patient’s caregiver. What does this mnemonic stand for? OnMows you, and Engage with a a. Be sure the person Sees yT ouEaSnT dBHAeaNrK sS yoEuL , iL sE AR le. rtC ,K handshake. *b. Be sure the person Sees you and Hears you, Approach slowly, Kneel down, and Engage with the Under Hand Shake. c. Be sure the person Shakes your hands with the Under Hand Shake. d. Approach steadily, be sure the person Sees you and Hears you, Kneel down, and Engage with a normal handshake. Rationale: Caregivers of a person with dementia need to call out to the person (verbal cue) and get into their field of vision from the front (visual cue, considering loss of peripheral vision) before touching the person (tactile cue). When cues are not delivered in this order, the person with dementia can experience a fight, flight, or fright response. Because the person with dementia has a strong grasp reflex, the caregiver should engage with an Under Hand Shake. A mnemonic to remember this approach is SHAKE Hands: Be sure the person Sees you and Hears you, Approach slowly, Kneel down and Engage with the Under Hand Shake. The “A” stands for Approach slowly, not Alert. The caregiver should ensure they are seen and heard before approaching the patient. A normal handshake is not preferred for patients with dementia.

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9. A 75-year-old patient is brought to the clinic for routine follow-up of the patient’s condition. The patient’s son informs that the patient continues to have problems remembering things, sometimes behaves aggressively, and forgets his way around neighborhood. The son also informs that the patient can eat independently, but loses interest in food very fast. What feeding assistance does this patient need? *a. Verbal and nonverbal cues b. Over Hand technique c. Under Hand technique d. Direct Hand technique Rationale: The patient’s dementia causes him to experience difficulty maintaining attention during meals. Hence, caregivers can use person-centered verbal cues (e.g., redirecting attention to meal, orienting to food items, expressing approval) and nonverbal cues (e.g., mimicking act of eating, positive gestures, and facial expressions) to promote self-feeding. The patient is otherwise able to eat independently and thus would not require the Over Hand technique (used when the person needs a little help initiating, maintaining or finishing a feeding cycle), Under Hand technique (used when the person no longer has skill finger ability), or Direct Hand technique (used as the last resort when caregivers need to do all of the work for the person with dementia). 10. A 79-year-old patient has meal time problems, and the patient’s caregiver is finding it increasingly difficult to feed this patient. Apart from the difficulties faced while eating, the patient also needs some assistance with acts of daily living, forgets things easily, and is SThaBtAfaNcK increasingly becoming irritabT leE .W toS rsEsL hoLuE ldRt. heCnOuM rse assess to solve the meal time problems? Select all that apply. a. Need for nutritional supplements *b. Patient’s difficulties *c. The dining area *d. Assistance given by the caregiver Rationale: The nurse should use the C3P Model, which is a problem-solving strategy that frames how licensed nurses can think through an identified meal time difficulty: Change the Person, Change the People, and/or Change the Place. Hence, the nurse can assess the person (patient), people (caregiver), and place (dining area). The need for nutritional supplements would only be assessed if the patient was suffering from weight loss.

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Chapter 30: Disorders of Sleep in the Older Adult Multiple Choice Test Questions 1. An older adult comes to the clinic with complaints related to sleep. Which of these sleep disorders are common in older adults? Select all that apply. *a. Insomnia b. Sleep walking *c. Restless leg syndrome *d. Obstructive sleep apnea Rationale: The most common primary sleep disorders in older adults are obstructive sleep apnea, restless leg syndrome, and insomnia. Sleep walking is a sleep disorder that is not common in older adults. 2. An older adult comes to the clinic with complaints of poor sleep. Which of the following should the nurse suspect may be the cause of poor sleep in this patient? Select all that apply. *a. Older age *b. Alterations in circadian activity rhythms *c. Insomnia *d. Changes in sleep architecture Rationale: Sleep-related problemTsEinSoTldBeAr N adKuS ltE s cLaL nE beRd.uCeOtoMnormal physiological changes that come with age, such as alterations in circadian activity rhythms or changes in sleep architecture. Poor sleep can also be due to a sleep disorder, such as insomnia, which is common in older adults. 3. A 69-year-old female patient complains of excessive day time sleepiness. Which of the following are negative health consequences of this condition? Select all that apply. *a. Mortality *b. Depression *c. Myocardial infarction d. Restless leg syndrome Rationale: Excessive daytime sleepiness is significantly associated with a higher likelihood of disability, increased risk of mortality, a substantially shorter disability-free life expectancy, and higher levels of depressive symptomatology. In one study, daytime sleepiness was the only sleep symptom associated with mortality, myocardial infarction, and congestive heart failure, particularly among women. Restless leg syndrome is a sleep disorder that can result in excessive daytime sleepiness, and is not a consequence of it.

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4. An older adult has just been diagnosed with a sleep disorder. The patient is at increased risk of which of the following? Select all that apply. *a. Falls b. Suicide *c. Depression *d. Excessive daytime sleepiness Rationale: An older adult with a sleep disorder is at increased risk of excessive daytime sleepiness, mood disorders, depression, and falls. Sleep disorders in older adults have not been linked to increased risk of suicide. 5. An older adult who has been diagnosed with obesity has daytime sleepiness and impaired daytime functioning. A sleep study shows cessation of respiratory airflow that lasts for at least 10 seconds. How many such episodes should occur to confirm the diagnosis? a. Greater than five episodes during two sleep tests *b. Greater than five episodes per hour of sleep c. Greater than five episodes per night of sleep d. Greater than three episodes per hour of sleep Rationale: Obstructive sleep apnea (OSA), which is common in older adults with obesity, is characterized by cessation of respiratory airflow (apneas) or reductions of airflow (hypopneas) that last for at least 10 seconds. This results in a microarousal that restores upper airway patency, permitting breathing and airflow to resume. OSA is diagnosed when these events occur at a rate CpOaMnied by daytime sleepiness and of greater than five episodes per hToEuS r oTfBslAeN epKaSnE dL arL eE acRc. om impaired daytime functioning. OSA is not diagnosed by greater than five episodes during two sleep tests, greater than five episodes per night of sleep, or greater than three episodes per hour of sleep. 6. A 78-year-old patient with obesity, dentures, excessive daytime sleepiness, and impaired daytime functioning has a positive sleep study. The study shows more than five reductions of airflow lasting for at least 10 seconds during 1 hour of sleep. Which of the following treatments can be used to help this patient? Select all that apply. a. Oral appliances *b. Surgical procedures *c. Weight reduction *d. Nasal continuous positive airway pressure (CPAP) Rationale: The patient has obstructive sleep apnea (OSA). Treatments for OSA include nocturnal positive airway pressure, surgical procedures designed to increase the posterior pharyngeal area, and weight reduction when obesity is a contributing factor. Nasal continuous positive airway pressure (CPAP) therapy, which is highly effective when individually titrated to eliminate apneas and hypopneas, is currently the gold standard for treating OSA. Although oral appliances offer a low-tech treatment option, they require a stable dentition that may be problematic for persons with extensive tooth loss or dentures.

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7. A 75-year-old patient with a known cardiovascular disease comes to the sleep clinic complaining of excessive daytime sleepiness. The patient shows reductions of airflow lasting for at least 10 seconds during a sleep study. For which of these cardiovascular conditions is the patient at increased risk? Select all that apply. a. Valvular heart disease *b. Atrial fibrillation *c. Coronary artery disease *d. Heart failure Rationale: The patient’s symptoms and sleep study results indicate the patient has obstructive sleep apnea (OSA). This sleep disorder is common in adults with cardiovascular disease and is associated with increased risk of heart failure, atrial fibrillation, and coronary artery disease. OSA does not increase the risk of valvular heart disease. 8. An older adult comes to the sleep clinic with complaints of poor sleep. The nurse completes a detailed questionnaire and finds that the patient is unlikely to be suffering from a sleep disorder. What could be the cause of poor sleep in this patient? Select all that apply. *a. Old age *b. An over-the-counter (OTC) medication *c. Arthritis *d. Nocturia Rationale: Sleep-related problems in older adults can be due to normal physiological changes that come with age, such as alteraTtiE onSsTinBA ciN rcK adSiaEnLaL ctE ivRit. yC rhOyM thms or changes in sleep architecture. Because older adults frequently have multiple medical conditions, they are also more likely to take OTC medications for symptom relief. However, many of these drugs (such as pseudoephedrine, alcohol, caffeine, and nicotine) interfere with sleep. Painful chronic conditions, such as arthritis, may be painful enough to cause nighttime awakenings. While voiding one time per night is commonly considered non-pathological in older adults, the increased frequency of nocturia, or two or more nighttime voids, may result in sleep fragmentation, difficulty in returning to sleep, and excessive daytime sleepiness or fatigue. 9. An older adult with painful arthritis comes to the sleep clinic with complaints of poor sleep for the past year. The patient’s attendant informs that the patient has difficulty falling asleep and wakes up often throughout the night. The patient has no other ailments or complaints. How should the patient’s condition be managed? Select all that apply. *a. Improve sleep hygiene. *b. Treat arthritis with more effective medications. c. Give short-term pharmacotherapy for sleep. *d. Recommend cognitive behavioral therapy. Rationale: The patient has chronic insomnia disorder, as the problem has been present for a year. Because it has now become a chronic learned behavior, improving sleep hygiene and introducing cognitive behavior therapy can help the patient. Also, since the patient’s arthritis could be disturbing sleep, treating the arthritis more effectively may help the patient sleep. Shortterm pharmacotherapy is only appropriate if the insomnia is situational and of recent onset.

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10. A 75-year-old patient with rheumatoid arthritis, cardiovascular disease, and poor diet complains of a strange sensation in his legs when he lies down to sleep. The sensation is strong enough to hamper his sleep. What could be the cause of this patient's condition? Select all that apply. a. Uremia *b. Rheumatoid arthritis c. Diabetes *d. Anemia Rationale: The patient’s symptoms indicate restless leg syndrome (RLS), which is a neurological condition characterized by the irresistible urge to move the legs. It is usually associated with disagreeable leg sensations that become worse during inactivity and often interferes with initiating and maintaining sleep. As a secondary condition, this movement disorder can be caused by the patient’s rheumatoid arthritis. Also, since the patient has poor diet, anemia could be a cause. Diabetes can cause RLS, but there is no indication that the patient has diabetes. Uremia can cause RLS in patients with diabetes, kidney disease, or hypertension, but this patient does not have any of these conditions.

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Chapter 31: The Frail Hospitalized Older Adult Multiple Choice Test Questions 1. A frail, 89-year-old patient is being examined by the nurse. What aspects of frailty should the nurse examine? Select all that apply. *a. Physical *b. Cognitive *c. Emotional *d. Memory Rationale: Frailty is generally understood as a multidimensional concept characterized by physical components (such as low physical activity, decreased muscle strength, and unintentional weight loss), as well as cognitive, emotional, social, and spiritual aspects. Frail individuals are significantly more likely to have cognitive decline, memory decline, and sarcopenia than nonfrail older adults. Hence, physical, emotional, cognitive, and memory aspects should be examined. 2. An older adult comes to the clinic for routine follow-up of diabetes care. What can be recommended to this patient to prevent frailty? Select all that apply. *a. Exercise *b. Vitamin D *c. Reduction of polypharmacy d. Weight reduction Rationale: Patients with diabetes are at risk of secondary frailty. In older adults, frailty can potentially be prevented or treated with specific modalities, such as exercise, protein-calorie supplementation, vitamin D, and the reduction of polypharmacy. Frail older adults have unintentional weight loss, therefore losing weight cannot be a strategy to prevent or treat frailty. 3. The nurse is examining a frail, older female in a community clinic. For which various frailty risk factors should the nurse should be alert? Select all that apply. *a. Hormonal abnormalities *b. Chronic kidney disease *c. Anemia d. Hypovitaminosis D Rationale: A number of risk factors have been identified for frailty, including: (a) chronic diseases (such as cardiovascular disease, diabetes, and chronic kidney disease), (b) physiological impairments, (c) anemia, (d) atherosclerosis, (e) autonomic dysfunction, (f) hormonal abnormalities, (g) obesity, and (h) environmental factors. Hypovitaminosis D is a risk factor for frailty in older men, not women.

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4. A frail, older adult patient is admitted for hip fracture surgery. How might frailty affect this patient’s post-surgery outcomes? Select all that apply. a. Decreased memory *b. Increased length of stay *c. Increased risk of discharge to an assisted-living facility *d. Increased risk of postoperative complications Rationale: In older surgical patients, frailty independently predicts postoperative complications, increased length of stay, discharge to a skilled or assisted-living facility, and mortality. Decreased memory can contribute to frailty, but it is not a post-surgery outcome. 5. The nurse is caring for a 70-year-old female patient. Which of the following test results should the nurse look for if frailty is suspected? Select all that apply. *a. Inability to walk 6 m with a walking stick in 30 seconds or less *b. Grip strength is less than 18 kg *c. Inability to walk 6 m without a walking stick in 30 seconds or less d. Grip strength is less than 30 kg Rationale: Grip strength and walking speed are commonly used measures of frailty. Slow walking speed is defined as an inability to walk 6 m in 30 seconds or less, with or without a walking stick. Grip strength is evaluated as the maximum of three attempts of the dominant hand using a handheld dynamometer: low grip strength is less than 18 kg in women. Grip strength of less than 30 kg is classified as low grip strength in men. 6. The nurse examines an older male adult who comes to the clinic with complaints of unintentional weight loss, slow speed, exhaustion, and poor grip. Which of the following are positive results that indicate frailty? Select all that apply. *a. Energy expenditure is 267 kcal/wk. b. Grip strength is 35 kg. *c. Exhaustion is experienced most of the time. *d. Recorded weight loss over the past year is 8% of total body weight. Rationale: The frailty phenotype index, with its five indicators (unintentional weight loss, exhaustion, muscle weakness, slowness while walking, and low levels of activity), is commonly used to identify frailty. A nurse can measure all five indicators using specific tests for each. Older adults with three or more of the five factors are considered to be frail. The various measures considered positive for frailty are: self-reported weight loss of 10 lbs, or recorded weight loss greater than or equal to 5% per year; self-reported exhaustion of 3 to 4 days per week, or most of the time, on the U.S. Center for Epidemiological Studies Depression Scale; slow gait speed, with standardized cutoff times to walk 15 feet stratified by sex and height; low grip strength, stratified by sex and body mass index (<30 kg in men); and low activity levels, characterized by energy expenditure that is less than 383 kcal/wk for men and less than 270 kcal/wk for women. The patient’s energy expenditure, exhaustion, and recorded weight loss results are all positive; having three of these factors indicates the patient is frail. The patient’s grip strength is above what would be considered low for males (30 kg).

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7. An older adult comes to the community clinic with complaints of exhaustion, weight loss, and low mobility. What tools can the nurse use to assess the patient’s condition? Select all that apply. *a. Frailty phenotype model b. FI-CGA *c. The SOF Index *d. The CHS Index Rationale: The patient’s symptoms indicate possible frailty. The frailty phenotype index, with its five indicators (unintentional weight loss, exhaustion, muscle weakness, slowness while walking, and low levels of activity), is commonly used to identify frailty. Older adults with three or more of the five factors are considered to be frail; those with one or two factors are prefrail, and those without any factors are robust or not frail. The SOF Index defines frailty as two or more of the following: weight loss, self-report of low energy, and low mobility. The CHS Index defines frailty as three or more of the following: shrinking, weakness, exhaustion, slowness, and low physical activity. The FI-CGA is used to assess illness and recovery in older hospitalized patients, not patients in community settings. 8. An older adult is brought to the emergency department after a fall. The patient’s son reports that the patient has been very fatigued, has lost weight, and is unable to walk even one block. Which of the following tools can the nurse use to quickly assess the patient based on the symptoms? a. Frailty phenotype model *b. Frail scale c. The SOF Index *d. Clinical Frailty Scale Rationale: The patient has classical symptoms of frailty. Two frailty tools are efficient for use in the busy acute care setting. The nine-point Clinical Frailty Scale and the five-item FRAIL scale (Fatigue, Resistance, Ambulation, Illnesses, & Loss of Weight). Three or more positive items on FRAIL scale indicate frailty. Aside from frailty, the FRAIL scale also screens for the risk for disability. The tool inquires about whether patients are fatigued, are unable to climb a flight of stairs or walk one block, have more than five illnesses, and lost more than 5% of body weight in the past year. The Frailty phenotype model and the SOF Index are used to assess frailty in the community setting.

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9. The medical record of a hospitalized older adult indicates that the patient has been diagnosed with multiple diseases, takes several medications, has lost a lot of weight in the past year, and remains fatigued. The patient will likely to be in the hospital for several days. What special precautions should the nurse take while caring for this patient? Select all that apply. *a. Functional status *b. Nutritional status *c. Hydration *d. Prophylaxis for deep vein thrombosis Rationale: This patient demonstrates characteristics of frailty. In addition to the increased predisposition to deep vein thrombosis and adverse medication effects, frail individuals are at increased risk for worsening functional status, delirium, falls, nosocomial infections, malnutrition, dehydration, immobilization, and decubitus ulcers while in the hospital. 10. A 77-year-old hospitalized patient has been losing a lot of weight, is unable to walk much, does not have a firm grip, and is often exhausted. The patient has a history of two falls in the past year. What interventions can be implemented in the hospital to help this patient? Select all that apply. *a. Encourage patient- and family-centric physical activities. *b. Provide nutritional supplements. *c. Give function-focused care. *d. Comprehensive geriatric assessment (CGA). Rationale: This patient demonstrT atE esScThB arA acNteKrS isE ticLsLoE f fRra.ilC tyOaMnd thus requires a multifaceted approach to address the potential for or actual presence of the hazards of hospitalization. Nutritional supplements, including fortified foods and essential vitamins and minerals, may be necessary. Increased exercise and physical activity during hospitalization have demonstrated significant positive benefits. Strategies to mitigate fall risk should be implemented without restricting physical activity. Patient- and family-centric physical activities are particularly useful for frail older adults. Function focused care and comprehensive geriatric assessment (CGA) are nursing interventions which can benefit frail older adults.

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Chapter 32: HIV Prevention and Care for the Older Multiple Choice Test Questions 1. How might an older adult contract an HIV infection? Select all that apply. *a. Using infected needles *b. Unprotected penetrative anal intercourse *c. Unprotected penetrative vaginal intercourse d. Vertical transmission during pregnancy Rationale: The modes of transmission of HIV in older adults include unprotected penetrative anal or vaginal intercourse and blood transmission (including infected injecting needles). Vertical transmission during pregnancy, delivery, and/or breastfeeding is not a mode of transmission in older adults. 2. How can HIV be prevented in older adults? Select all that apply. *a. Practicing fidelity *b. Properly using condoms *c. Identifying early non-symptomatic infections d. Decreasing the impact of the disease Rationale: HIV prevention programs in adults usually focus on primary and secondary preventions. Primary HIV prevenT tiE onSiT nBadAuNltK sS inE voLlL veEs R li. feC stO ylM e modifications that aim at avoiding infection with the virus, such as sexual abstinence, fidelity to sexual partner, or proper use of condoms. Secondary HIV prevention involves screening to identify early nonsymptomatic infections in order to begin early treatment. Decreasing the impact of the disease among those in whom the disease is already advanced is a tertiary HIV prevention strategy. 3. An older adult who is sexually active was never screened for HIV infection. Which of the following might explain why this older adult never opted for HIV screening during his routine checkups? Select all that apply. *a. He did not know he was at risk at his age. *b. He was not aware of the risk factors. c. He did not have enough money to receive HIV screening. *d. He was not aware he needed screening for HIV. Rationale: Older adults tend to have less knowledge of risk factors for HIV transmission compared to younger persons. Many older adults incorrectly assume that HIV and other sexually transmitted infections are a phenomenon for the younger generation. Because of this lack of awareness, older adults often do not consider the key secondary prevention method of screening for HIV as part of routine care even if they are sexually active. The cost of screening is not a known reason for sexually active older adults to opt out of HIV screening. Additionally, since the older adult was attending routine check-ups, money was not likely a factor.

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4. Why is treating AIDS difficult in older adults? Select all that apply. *a. Low CD4 counts *b. Quicker disease progression *c. Delayed diagnosis *d. Poor response to treatment Rationale: Persons over 50 years of age who acquire HIV usually have persistently low CD4 counts (little immunity strength) and thus respond poorly to treatment compared to younger persons. Even when older adults have initiated treatment for HIV, they maintain a lower CD4 count for a sustained period of time before any improvement is noticed, putting them at higher risk for disease progression and death. In older adults, there is a delay in diagnosis, and course of treatment due to several reasons. Often care and treatment is started when the immune system has been substantially damaged yielding a diagnosis of AIDs (CD4 counts so low that there is no defense for opportunistic infections). 5. An adolescent living with HIV in Africa is not adhering to medications. What could be the reasons? Select all that apply. *a. Did not disclose HIV status to relatives *b. Could not find a clinic to access medication *c. Found it difficult to take medicines in school *d. Faced guardianship issues Rationale: In Uganda, adolescents living with HIV reported a number of barriers to adherence of HIV medications. One barrier waT sE keSeT piB ngAN anKdStaEkL inLgEthRe.aC ntO i-M retroviral therapy (ART) pills while at school, because frequently taking pills among classmates and friends could create difficulties in preserving confidentiality. Adolescents whose HIV-positive parents had died struggled to deal with the loss and also had to face frequent change in guardianship, contributing to problems with adherence to ART. Also, individuals who failed to disclose their HIV status to their relatives had difficulties in adhering to ART as they attempted to conceal their HIV status. Despite the increasing availability of ART, accessibility and acceptability is still a major concern in some areas, and it is possible that the adolescent could not find a clinic to access the medication.

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6. A person living with HIV has progressed from acute HIV infection to clinical latency, but has not yet progressed to AIDS. What factors may have helped slow down this progression? Select all that apply. *a. Was diagnosed and started treatment early *b. Took HIV medications on time *c. Followed a healthy lifestyle *d. Genetic makeup of patient and virus Rationale: People living with HIV may progress through these stages (acute HIV infection to clinical latency to AIDS) at different rates depending on a variety of factors, including: their genetic makeup; how healthy they were before they were infected; how much virus they were exposed to and its genetic characteristics; how soon after infection they are diagnosed and linked to care and treatment; whether they see their healthcare provider regularly and take their HIV medications as directed; and different health-related choices they make, such as decisions to eat a healthy diet, exercise, and not smoke. 7. A 55-year-old living with HIV is engaging in risky behaviors such as being physically inactive, abusing substances, and not socializing. How can risky behavior impact the patient? Select all that apply. *a. Reduce length of life b. Delayed diagnosis c. Delay treatment d. Reduce response to treatment Rationale: Life expectancy has become similar between people living with HIV and those who are HIV negative. However, engaging in risky behaviors such as being physically inactive, abusing substances, and having a poor social network may cause reduced life expectancy. Delay in diagnosis and treatment and reduced response to treatment is not because of risky behavior. 8. An older adult living with HIV has two caregivers—one who handles the person’s cooking, laundry, and cleaning and another who takes care of the person’s bathing. What type of caregivers is looking after this person? a. Only formal *b. Formal and informal c. Only informal d. Family members Rationale: This person is being looked after by both formal and informal caregivers. Informal community-based care is usually offered by relatives and friends of the affected person mostly on a voluntary basis—that is, without a salary. Informal caregivers typically perform housekeeping tasks such as cooking, doing laundry, cleaning, and so on. Formal communitybased care is provided by professionals as a means to earn a living. Formal caregivers usually perform personal care tasks such as bathing and counseling. Such professionals may be nurses, psychologists, or social workers.

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9. An older adult patient living with HIV skips an appointment. At his next appointment, the nurse discovers that the patient has missed taking some of his pills. How will this patient be managed now? *a. He will be referred for outreach services. b. He will be referred for hospitalization. c. He will be assigned an informal caregiver. d. A family member will be trained to give him medicines. Rationale: Outreach referrals are done for patients who have defaulted on appointments, have missed laboratory tests, or need any form of medical support. Outreach workers assist patients with HIV in making and adhering to their medical appointments, understanding the importance to adhere to their medications as prescribed, and accessing other support services. Informal caregivers including family are not able to provide this type of support. Also, the patient is not sick enough to need hospitalization. 10. An older adult patient living with HIV is very anxious and feels he is unable to enjoy life since the diagnosis. The patient’s suffering can be mitigated through what type of service? a. Outreach care b. Family support *c. Counseling *d. Palliative care Rationale: Ideally, patients with HIV should be enrolled into palliative care as soon as they are diagnosed. Palliative care is care T aiE mSedTB atApN reK veSnEtiL ngLaEnR d.reCliO evMing the suffering of patients afflicted with chronic or life-threatening diseases in order to improve their quality of life. Palliation should be considered an important aspect of care, especially for older adults living with HIV. Formal counseling care will also help reduce the patient’s anxiety and fears. Outreach care is used for patients who have defaulted appointments, have missed laboratory tests, or need any form of medical support. Family support is important for patients living with HIV, but this is not directed at mitigating suffering and may not help alleviate the patient's particular concerns.

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Chapter 33: LGBTQ Perspectives for Older Adult Care Multiple Choice Test Questions 1. The nurse is caring for a patient in the LGBT community. What terms might be used to characterize the patient’s sexual, emotional, and physical attraction to others? Select all that apply. a. Men who have sex with women *b. Lesbian *c. Gay *d. Men who have sex with men Rationale: Sexual orientation refers to how a person characterizes their sexual, emotional, and physical attraction to others. Common terms that describe sexual orientation include heterosexual, gay, lesbian, and bisexual. However, some persons may describe their sexual orientation based on their sexual behavior, such as men who have sex with men (MSM) or women who have sex with women (WSW), when they fear a negative reaction to more commonly used terms. Men who have sex with women do not belong to the LGBT community. 2. The nurse cares for a variety of patients who identify in different ways with the sex that each person is born with. What are the types of identity that the nurse can come across? Select all that apply. *a. Cisgender *b. Genderqueer *c. Transgender *d. Gender fluid Rationale: An individual whose gender identity corresponds with the sex they were born with is known as cisgender. Transgender is the term used to describe an individual whose gender identity does not correspond to the sex they were assigned at birth. Other individuals have a gender identity that falls outside the sexes of male or female; some may identify as both male and female, or neither, or may experience an identity that evolves over time. Terms that describe such individuals include genderqueer, gender fluid, and gender nonbinary. 3. A person from the LGBTQ community explains to the nurse that he identifies as a man. Which of the following statements regarding this person is correct? Select all that apply. *a. This person is a transgender male. b. This person is a transgender female. *c. This person was assigned female sex organs at birth but identifies as a man. d. This person was assigned male sex organs at birth and identifies as a man. Rationale: A transgender male is someone who was assigned female sex organs at birth but who identifies as a man. Conversely, a transgender woman is someone born with male sex organs but identifies as a woman. A person who is assigned male sex organs at birth and identifies as a man is cisgender and would not be a member of the LGBTQ community.

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4. The nurse is taking history from a transgender female. During the conversation, how should the nurse address the patient? a. Assume the pronoun based on how the person is dressed. *b. Ask the person which pronoun they prefer. c. Use the pronoun “she.” d. Use the pronoun “he.” Rationale: It is important to ask the patient if their preferred pronoun is he, she, or they. The nurse should not assume which pronoun to use given the patient’s physical appearance and should not pick he or she without confirming first. 5. A transgender female patient recently underwent gender reassignment surgery. For which type of cancer should the patient be screened? a. Ovarian *b. Prostate c. Testicular d. Uterine Rationale: A transgender female is someone who was born with male sex organs but who identifies as a woman. During gender reassignment surgery, physical characteristics of the female identity are constructed. The prostate is retained in the transgender female’s body postsurgery while the penis, scrotum, and testicles are removed. Hence, the transgender female remains at risk of prostate cancer just like cisgender males. Because the testicles are removed in gender reassignment surgery, theTpE atS ieT ntBiA s nNoKt S atErL iskLE foR r. teC stO icM ular cancer. A transgender female does not have a uterus or ovaries, so there is no risk of uterine or ovarian cancer. 6. A transgender male patient recently underwent gender reassignment surgery. For which cancer should the patient be screened? a. Testicular b. Prostate *c. Breast d. Uterine Rationale: A transgender male is someone who was born with female sex organs but who identifies as a man. Transgender males who have had surgery should still be screened for breast cancer (as they still have a breast constructed into male shape from original breast tissue, nipples, and areolas) per guidelines, although they are not at increased risk of breast cancer. During gender reassignment surgery, external male genitalia are constructed. However, because the constructed testicles are prosthetic implants, there is no risk of testicular cancer. Transgender males don’t have a prostate gland, so there is no risk of prostate cancer. Because the uterus is removed in gender reassignment surgery, the patient is not at risk for uterine cancer.

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7. An MSM couple is found to be HPV positive. The healthcare provider decides to screen the couple for a particular cancer. What other risk factors for this cancer should be assessed? Select all that apply. a. Long-term use of oral contraceptives *b. Multiple sexual partners *c. Cigarette smoking *d. Presence of other sexually transmitted infection Rationale: Men who have sex with men are at increased risk of anal cancer due to HPV exposure. Other risks factors associated with an increased risk of anal cancer include multiple sexual partners, cigarette smoking, and presence of other sexually transmitted infection. Longterm use of oral contraceptives increases risk of cervical and breast cancer and not anal cancer. 8. A person from the LGBTQ community is taking medicines to reduce the male pattern of hair growth, alter the distribution of body fat, and increase breast size. When the patient is examined during a routine follow-up examination, the nurse should be vigilant about which of the following? Select all that apply. *a. Cardiovascular disease *b. Venous thromboembolism *c. Increase in triglycerides *d. Stroke Rationale: This patient is a transgender woman who is undergoing hormone therapy to help develop more feminine-appearing features, including reducing male pattern hair growth, altering the way body fat is distributed, increasing breast size, and reducing characteristically male muscle mass. This is typically accomplished by a combination of two hormonal therapies: an exogenous estrogen combined with an antiandrogen. The most significant risk associated with exogenous estrogen is a potential increase in venous thromboembolic events (VTE). Other risk factors associated with exogenous estrogen that the nurse should be vigilant about are an increase in triglycerides, stroke, and cardiovascular disease. 9. A person from the LGBTQ community is taking a medicine to decrease testosterone levels. The person is assured by the nurse that this is the most commonly prescribed medicine for decreasing testosterone levels. For which of the following side effects should the nurse monitor? a. Decreased libido *b. Hyperkalemia c. Ostopenia d. Liver toxicity Rationale: The patient is receiving antiandrogen therapy to decrease overall testosterone and achieve the desired change in secondary sex characteristics. Of the various antiandrogens used, the most commonly utilized option is a potassium-sparing diuretic called spironolactone. The patient is receiving spironolactone. The most common potential side effect of spironolactone is hyperkalemia. Other less commonly presribed antiandrogens carry risk of other side effects such as liver toxicity (finasteride), decreased bone mass/osteopenia, and decreased libido (gonadotropin-releasing hormone agonists like leuprolide).

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10. An older adult patient who is a transgender male is being admitted to a nursing facility. The patient has not undergone gender reassignment surgery and does not disclose the gender identity to the nurse who is looking after the admission. What could explain why the patient is hiding the gender identity? *a. Fear of mistreatment or bias from heterosexual peers. *b. Fear of neglect and care from the nursing staff. c. Fear of being assigned a room based on their gender identity. *d. Fear of being assigned a room based on their birth gender. Rationale: Older adults who belong to the LGBTQ community who enter into a nursing facility are often afraid that the nurses and healthcare staff will have their own personal biases against the LGBT identity, and thus fear that the staff may neglect, abuse, or persecute them. Patients may also fear mistreatment or bias from heterosexual peers who they cohabitate with in a longterm care facility, particularly if they are assigned a roommate. Transgender older adults hide their birth gender as they are afraid that they would be assigned a room based on the gender of their birth, rather than the gender they identify with, especially if they have not had a surgical transition.

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Chapter 34: Substance Misuse and Alcohol Use Disorder in the Older Adult Multiple Choice Test Questions 1. Which of the following changes in older adults result in a change in response to alcohol? Select all that apply. *a. Decreased total body water *b. Increased rates of alcohol metabolism in the gastrointestinal tract c. Increased comorbidities *d. Decreased body mass Rationale: The metabolic and organ changes of aging linked with drug or alcohol use contribute to high morbidity in advancing age. Decreased total body water and lower rates of alcohol metabolism in the gastrointestinal tract increase sensitivity to alcohol, resulting in decreasing tolerance with age. Decrease in body mass seen with age increases alcohol sensitivity. It is true that comorbidities are higher in older than in younger adults. However, while comorbidities worsen in the presence of alcohol or increase alcohol-related complications, comorbidities do not change an older adult’s response to alcohol. 2. A 70-year-old patient has been drinking alcohol for 20 years, yet does not meet the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) criteria for moderate to severe alcohol use disorder. When should this person be cautioned about potential consequences to health? Select all that apply. *a. Alcohol consumption at levels greater than 7 drinks weekly b. Alcohol consumption at levels greater than 3 drinks weekly *c. Alcohol consumption of more than 3 drinks on any single day d. Alcohol consumption of more than 2 drinks on any single day Rationale: The criteria for the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) may be less applicable to older adults, and hence this must be interpreted and applied in ageappropriate ways. Even when persons older than 65 years do not meet the DSM-5 criteria for a moderate or severe use disorder, alcohol consumption at levels greater than 7 drinks weekly or more than 3 drinks on any single day warrants teaching about potential consequences for health. 3. Long-term excess alcohol use is linked to which of the following medical problems? Select all that apply. *a. Gastrointestinal bleeding *b. Pancreatitis *c. Diabetes *d. Head and neck cancer Rationale: Long-term excess alcohol use is linked to common medical problems such as gastrointestinal bleeding, pancreatitis, sleep disorders, restlessness and agitation, abnormalities in liver function, pneumonia, and trauma, as well as chronic diseases such as neuropsychiatric disorders, digestive disorders, diabetes, cardiovascular disease, and pancreatic or head and neck cancer.

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4. A nurse is screening an older adult for substance misuse or abuse. Which screening tools can the nurse use? Select all that apply. *a. Alcohol Use Disorder Identification Test (AUDIT) *b. Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST) *c. Short Michigan Alcohol Screening Test-Geriatric version (SMAST-G) *d. Khavari Alcohol Test (KAT) Rationale: Screening, brief intervention, and referral to treatment (SBIRT) begins with screening an individual using a valid and age-appropriate screening tool to identify alcohol use behaviors that may place the individual at risk for health problems. Short, well-tested questionnaires that identify risk include the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), the Short Michigan Alcohol Screening Test-Geriatric version (SMAST-G), and the Alcohol Use Disorder Identification Test (AUDIT). Another screening tool is the A Q/F Index, such as the Khavari Alcohol Test (KAT). 5. A 68-year-old patient is being seen in a de-addiction clinic for a drinking problem. According to the patient’s daughter, the patient has been binge drinking for the last 15 years. Which of the following criteria are likely to be present in this patient? Select all that apply. *a. Patient is unable to give up drinking even though it spoils relationships with friends and relatives. *b. Patient is unable to cut down on alcohol use, having tried to give it up several times to no success. *c. Patient requires weeks to recover from the adverse effects of overdrinking. d. Patient's main reason for bTiE ngSeTdB riA nkNinKgSiE sL anLiE ntR en.sC eO crM aving for alcohol. Rationale: This patient has alcohol use disorder with binge drinking as a maladaptive behavior. A substance use disorder is diagnosed when a maladaptive pattern of use is evidenced by 11 criteria occurring over a 12-month period. Behaviors include impaired control over use of a substance (Criteria 1−4); an inability to cut down on use, with persistent failures to control use (Criterion 2); recovery from use occupying significant periods of time (Criterion 3); other role obligations are neglected (Criterion 5); use persists despite social, health and interpersonal problems worsened by use (Criterion 6); and a growing tendency to withdraw from work or recreational activities (Criterion 7). Craving or an intense desire to use a drug may occur (Criterion 4), but is not always present and is not the main reason for binge drinking. 6. A nurse is helping a 78-year-old patient recover from a drinking problem. Which of the following actions can the nurse take to support the patient’s recovery? Select all that apply. *a. Recommend the patient attends self-help groups. *b. Ensure the patient takes prescribed medications on time. *c. Recommend the patient attends group counseling. *d. Remind the family to be supportive and involved in the patient’s recovery. Rationale: Recovery can be achieved with medication, self-help, and psychotherapy. Nursing interventions include support of the patient’s attendance at self-help group meetings, continued involvement in treatment (such as methadone or buprenorphine maintenance), active community and family involvement, and/or group or individual psychotherapy.

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7. A 75-year-old patient has a substance abuse problem. The nurse finds that the patient has flushing, palmar erythema, and spider angiomas. The patient has tremors and positive Romberg sign. What medications can be prescribed to control the substance abuse? Select all that apply. *a. Naltrexone *b. Acamprosate *c. Disulfiram d. Buprenorphine Rationale: The patient abuses alcohol. Flushing, palmar erythema, and spider angiomas are seen in alcohol abuse. The patient can also have tremors, or a positive Romberg sign. There is strong evidence for both naltrexone and acamprosate to help individuals with risky or dangerous alcohol use patterns to decrease alcohol consumption. Naltrexone is an FDA-approved medication that comes in oral and once-monthly injectable formulations. Acamprosate calcium (Campral) has been shown to help chronic, heavy alcohol consumers achieve abstinence. Disulfiram (Antabuse) is used to deter alcohol consumption, thus it is intended for the person who wishes to achieve abstinence. The drug buprenorphine—both an opioid antagonist and partial agonist—is not used for alcohol abuse. This drug helps a person to stop using opioids and may be of particular benefit for persons who have a high risk of overdose or who have a cocaine and or heroin use disorder. 8. A nurse is examining an older adult for a substance abuse problem. The nurse finds that the patient has flushing, palmar erythema, and spider angiomas. The patient is unsteady, has positive Romberg sign, and hT asEtS reT mB orAsN . TKhSeEnL urL seEdRra.wCsObM lood for labs. Which of the following labs are likely to be abnormal in this patient? Select all that apply. *a. Carbohydrate-deficient transferrin (CDT) *b. Liver function tests (LFTs) c. Serum transferrin saturation *d. Gamma-glutamyl transferase (GGT) Rationale: Physical signs of heavy alcohol use include ecchymosis, spider angiomas, flushing, or palmar erythema. The patient who abuses alcohol may also have an altered level of consciousness, poor coordination, tremors, or a positive Romberg sign. When patients are using alcohol, there may be deviations in standard liver function tests (LFTs) and elevations in gammaglutamyl transferase (GGT) and carbohydrate-deficient transferrin (CDT) levels. Serum transferrin saturation is usually tested when iron deficiency anemia is suspected and is not likely to be abnormal in this patient.

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9. The nurse asks a patient to bring all the medications, vitamins, and supplements the patient is taking to the next appointment. Which assessment technique is the nurse applying? a. Medication bag *b. Brown bag c. Yellow bag d. Red bag Rationale: A helpful technique in assessing patient drug use is the “brown bag” technique. The patient is asked to bring in a brown bag containing all the prescribed medications, OTC medications, food supplements, and other legal or illicit drugs that the patient consumes weekly. The nurse then uses this information to develop the patient’s history and to open a discussion about the implications of drug use with the patient. 10. A nurse is screening an older adult for substance misuse or abuse. The nurse asks questions regarding first use early in the day, amount and frequency, inability to refrain, and using despite illness. Which score shows moderate substance abuse? a. 12 b. 3 c. 7 *d. 6 Rationale: The nurse is using the Fagerström Test for Nicotine Dependence-Revised. This sixquestion scale—which asks about first use early in the day, amount and frequency, inability to SpTrB refrain, and smoking despite illneTssE— ovAidNeK sS anEiL nL diE caRto.rC oO f tM he severity of nicotine use disorder: a score less than 4 signals low to moderate dependence on nicotine, 4 to 6 signals moderate dependence, and 7 to 10 signals high dependence.

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Chapter 35: Comprehensive Assessment and Management of the Critically Ill Older Adult Multiple Choice Test Questions 1. A 78-year-old patient is critically ill. Which of the following treatments might the physician decide to withhold due to the patient’s age? Select all that apply. *a. Mechanical ventilation *b. Surgery *c. Dialysis d. Medication Rationale: Older age is one of the factors that may lead to physician bias in refusing ICU admission, the decision to withhold mechanical ventilation, surgery, or dialysis, and an increased frequency of do-not-resuscitate orders. Physician bias is not seen in decisions to withhold medication. 2. An older adult with myocardial infarction (MI) and heart failure is admitted to the ICU. What factors can affect this patient’s ability to survive? Select all that apply. *a. Nature and extent of comorbidities *b. Mechanical ventilation use *c. Malnutrition *d. Severity of MI and heart fTaiEluSreTBANKSELLER.COM Rationale: This patient is suffering from a critical illness. Factors influencing an older adult’s ability to survive a critical illness are multifactorial and include severity of illness, nature and extent of comorbidities, medical diagnosis, mechanical ventilation use, complications, preexisting frailty, malnutrition, and patient preference. 3. An older adult is admitted in the ICU for worsening of COPD. The nurse should be careful to prevent the onset of which of the following geriatric syndromes? Select all that apply. *a. Delirium *b. Fall *c. Infection d. Dementia Rationale: New geriatric syndromes, the onset of which can be prevented with appropriate and timely ICU nursing interventions for an older hospitalized adult include delirium, urinary incontinence, infection, and falls. The nurse should ensure that the patient is cognitively stimulated, but dementia is not a new onset geriatric syndrome in hospitalized older patients.

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4. The ABCDEF bundle elements are intentionally interdependent and specifically designed to improve collaboration among ICU team members, standardize care processes, and break the cycle of oversedation, prolonged mechanical ventilation, and immobility. How can the ABCDEF bundle be implemented in patient care in the ICU? Select all that apply. a. Use of the assessment tools recommended in the hospital protocols *b. Standardized exercise/mobility activities *c. Spontaneous awakening trials (SATs)/spontaneous breathing trials (SBTs) *d. Engaging and empowering family members as active participants in ICU care Rationale: The elements of the ABCDEF bundle bring about changes in care through daily use of: (1) both SATs and SBTs, (2) select sedative medications, (3) standardized exercise/mobility activities, and (4) engaging and empowering family members as active participants in ICU care. The ABCDEF bundle of care can be implemented by using the assessment tools recommended in the PAD guidelines and not by using tools as per hospital protocol. 5. A 74-year-old patient is admitted to the ICU after hip fracture surgery. The patient has diabetes, hypertension, and arthritis. The patient’s attendant informs the nurse that the patient often forgets things and becomes confused. For which of the following syndromes that the patient might develop in the ICU should the nurse monitor in this patient? Select all that apply. a. Dementia *b. Delirium *c. Pain *d. Oversedation Rationale: When age-related changes such as cognitive decline are combined with the stress of acute pathology, multiple comorbidities, and polypharmacy (as seen in this patient), critically ill older adults are particularly vulnerable to a number of commonly encountered ICU syndromes such as pain, oversedation, and delirium. Newly acquired cognitive impairment and dementia following critical illness is common in older adults. However, the patient already had cognitive decline at ICU admission. Hence, though the nurse should care for dementia, this patient’s dementia is not newly acquired during the ICU stay.

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6. The nurse is examining a 77-year-old patient who has been admitted to the ICU for management of uncontrolled diabetes mellitus. What baseline information should the nurse collect regarding the patient’s functional ability? Select all that apply. *a. Ability to carry out activities of daily living (ADLs) *b. Use of glasses c. Use of a glucometer *d. Use of hearing aids Rationale: When an older adult is admitted to the ICU, nurses should assess the patient’s ability to perform ADLs and should also investigate whether the patient uses glasses, hearing aids, or assistive devices to perform their ADLs. Having these assistive devices available to the older adult while he or she is in the ICU is important to enhance communication, cognition, and rehabilitation efforts. A glucometer is used to check blood sugar levels, and while the patient may use it daily, it does not assist in ADLs; this information does not help the nurse assess the patient’s functional ability. 7. A 75-year-old patient is admitted to the ICU for management of multiple conditions. The patient is very agitated, so the physician on duty prescribes light sedation. Which of the following sedatives can be prescribed for this patient? Select all that apply. *a. Propofol b. Midazolam *c. Dexmedetomidine d. Lorazepam Rationale: For critically ill older adults, nonbenzodiazepine sedatives (i.e., propofol or dexmedetomidine) are recommended rather than benzodiazepines (i.e., midazolam or lorazepam). 8. A 73-year-old patient in the ICU initially had a good rapport with the nurse. However, the patient slowly started experiencing disturbed sleep, becoming restless and agitated and moaning throughout the night. Further, the patient repeatedly removes his hearing aids when the nurse walks into the room. What factors play a role in the nurse experiencing difficulty communicating with this patient? Select all that apply. a. Dementia *b. Preexisting hearing difficulty c. Speech and language difficulties *d. Delirium Rationale: This patient has classical signs of delirium, which makes communication difficult in the ICU setting. Communication was also hindered due to the patient’s preexisting hearing difficulty, which became pronounced when the patient started pulling out his hearing aids. While dementia and speech and language difficulties can hamper communication, these are not the cause of communication difficulties in this patient, as prior to the onset of delirium the patient communicated well with the nurse.

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9. A 70-year-old patient with a long-standing history of chronic obstructive lung disease and hypertension was brought to the ED gasping for breath. All measures to improve the patient’s condition were unsuccessful, and the patient went into respiratory failure. The patient was put on mechanical ventilation and shifted to the ICU. Aside from medical management of the patient, which of the following nursing interventions should be the focus of care in this patient? Select all that apply. *a. Conduct spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs) *b. Assess, prevent, and manage delirium *c. Encourage early mobility *d. Encourage family engagement Rationale: The ABCDEF bundle of care should be implemented for this patient as it is applicable to every ICU patient every day, regardless of mechanical ventilation status or admitting diagnosis. ABCDEF stands for: Assess, prevent, and manage pain; both spontaneous awakening trials (SATs) and spontaneous breathing trials (SBTs); choice of analgesia/sedation; assess, prevent, and manage delirium; early mobility (e.g., shifting sides to prevent skin break, sitting up, physiotherapy); and family engagement and empowerment. 10. A 68-year-old patient with heart failure is admitted to the ICU. The patient’s daughter gives the patient’s glasses, hearing aid, and walker to the nurse. The daughter voices a desire to help the patient as best as she can, and the patient seems happier when the daughter is around. What nursing interventions can integrate and empower the daughter to care better for the patient? *a. Keep the daughter updateT dE abSoT utBtA heNpKaS tieEnL t’L sE coRn. diC tiO onMand interventions being implemented. *b. Encourage the daughter to join daily bedside interdisciplinary rounds. *c. Encourage the daughter to help provide reorientation and calming measures. d. Ask the daughter to provide details about the patient’s medical condition. Rationale: Family engagement and empowerment helps critically ill older adults (above 65 years of age) recover faster. The daughter can help in patient care if she is kept updated about the patient’s condition and interventions being implemented, is encouraged to join daily bedside interdisciplinary rounds, and asked to help provide reorientation and calming measures. All these nursing interventions add to the knowledge of the daughter and empowers her to care better for the patient. Asking the daughter to provide details about the patient’s previous medical and surgical history helps the nurse and interdisciplinary team design appropriate interventions. The daughter’s contribution is important in designing the interventions, but it does not empower the daughter with any new knowledge to care better for the patient.

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Chapter 36: Fluid Overload: Identifying and Managing Heart Failure Patients at Risk for Hospital Readmission Multiple Choice Test Questions 1. An older adult is brought to the ED with shortness of breath, swelling of feet, and persistent cough and wheezing. What are the risk factors for this patient’s condition? Select all that apply. *a. Cardiovascular disease *b. Sedentary lifestyle c. Female sex *d. Overweight and obesity Rationale: The patient has symptoms of heart failure (HF). Risk factors for the development of HF include low levels of physical activity, cigarette smoking, overweight, obesity, diabetes mellitus, and cardiovascular diseases. Risk of HF is higher with male sex. 2. An older adult is brought to the ED with extreme breathlessness and fatigue. The patient’s son informs that the patient is not able to walk even a few steps without coughing. Also, the patient’s shoes have suddenly become very tight. The nurse identifies diabetes as a risk factor of the patient’s condition, but no other risk factors are present. The nurse then reviews the patient’s medication history. Which of the following medications can precipitate this patient’s condition? Select allTtE haSt T apBpA lyN . KSELLER.COM *a. Nonsteroidal anti-inflammatory drugs b. Amphetamines c. Cyclophosphamide *d. Pioglitazone Rationale: The patient has symptoms of heart failure (HF). Medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), thiazolidinediones (TZDs; pioglitazone), and alcohol can precipitate HF. Toxic substances, such as chemotherapeutic agents (anthracyclines, cyclophosphamide, 5-FU, trastuzumab) and illicit drugs (amphetamines, cocaine) can also precipitate HF but the patient is not taking these. 3. An older adult is being discharged to home after a week-long hospital stay following a diagnosis of myocardial infarction related to heart failure. Which of the following factors can increase the risk of readmission in this patient? Select all that apply. *a. Heart failure with acute infection *b. Anemia *c. Renal failure *d. Myocardial infarction related to heart failure Rationale: The initial diagnosis of HF is most often an acute index event requiring hospitalization. Patients are at risk of readmission after an initial diagnosis of HF if they have renal failure or electrolyte imbalance, rheumatoid arthritis, HF related to acute MI, HF with acute infection, or anemia with hemoglobin of less than 12. 160

4. According to the American College of Cardiology Foundation/American Heart Association Task Force (ACCF/AHA), what is stage C heart failure? a. Presence of structural heart disease but without signs or symptoms of HF b. “At-risk” stage without structural heart disease or symptoms of HF c. Refractory HF requiring the use of specialized interventions *d. Known structural heart disease and symptoms of HF Rationale: The American College of Cardiology Foundation/American Heart Association Task Force (ACCF/AHA) developed guidelines to classify HF in four stages based on the structural changes and damage to the heart: Stage A is considered a pre-HF stage or an “at-risk” stage without structural heart disease or symptoms of HF. Stage B includes individuals with structural heart disease but without signs or symptoms of HF. Stage C includes individuals with known structural heart disease and symptoms of HF or those who, after treatment, are now asymptomatic for their heart disease. Stage D includes individuals with refractory HF requiring the use of specialized interventions and those with marked symptoms at rest despite maximal medical therapy. 5. A 69-year-old patient is brought to the ED with shortness of breath, swelling of feet and ankles, and persistent cough and wheezing. The patient has a history of hypertension (HTN) and diabetes mellitus (DM). ECHO shows normal ejection fraction and high left ventricular (LV) filling pressure. What is the likely diagnosis? a. Chronic obstructive pulmonary disease (COPD) b. Systolic heart failure *c. Diastolic heart failure d. Iron deficiency anemia Rationale: Individuals with HTN and DM often develop heart failure (HF) with preserved LV systolic function (HF with a preserved ejection fraction [HFpEF]), or so-called diastolic HF. HFpEF is a clinical syndrome in which LV filling pressures are elevated and the LV ejection fraction is normal, yet the heart is unable to satisfy the systemic oxygen needs of an individual. Since the patient has normal ejection fraction and high LV filling pressure the patient has diastolic HF and not systolic HF as in systolic HF, the ejection fraction is low. Patients with COPD can present with shortness of breath and cough with wheezing, but they don’t have swelling of feet and ankles. Patients with iron deficiency anemia can present with shortness of breath and swelling of feet and ankles, but they don’t have cough with wheezing.

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6. A 78-year-old patient is brought to the ED with increasing breathlessness when walking, fatigue, and persistent cough with wheezing. The nurse examines the patient and notes pedal edema, blood pressure of 150/100 mmHg, and heart rate of 130 beats/min. An ECHO is arranged. What findings should the nurse expect? Select all that apply. *a. Preserved left ventricular ejection fraction (LVEF) *b. Aortic stenosis *c. Hypertrophic cardiomyopathy *d. Reduced left ventricular ejection fraction (LVEF) Rationale: The patient has heart failure, hypertension, and a high heart rate (HR). The severity of symptoms varies among patients and may not correlate with LVEF, as exercise capacity and quality of life are similarly reduced in heart failure with reduced ejection fraction (HFrEF) and heart failure with preserved ejection fraction (HFpEF). Thus, either of these findings could be expected. Hypertension, chronic heart disease (CHD), and hypertrophic cardiomyopathy are all abnormalities that are exacerbated by tachycardia. Aortic stenosis can cause diastolic abnormalities which may precipitate HF. 7. A 75-year-old patient comes to the clinic with complaints of breathlessness when walking. The nurse is trying to establish the functional level of the patient. Which of the following questions will help the nurse obtain a correct assessment? Select all that apply. *a. What is your maximal asymptomatic activity now, what was it 6 months ago, and what was it 1 year ago? b. Do you wake at night feeling short of breath? *c. How far can you walk witThE ouSt T feBelAinNgKsS hoErL t oLfEbR re. atC h?OM d. Do you experience shortness of breath when sitting? Rationale: Both patients and providers frequently attribute symptoms of fluid overload to aging. When symptoms occur during exertion, senior patients may simply decrease their activities. Because of inaccurate reporting of activity, HF in older adults is often difficult to recognize and, therefore, goes untreated. Thus, the nurse should routinely ask questions related to activitylimiting dyspnea. A key indicator in establishing a baseline for functional capacity is to ask the patient what his or her maximal asymptomatic activity is now, what it was 6 months ago, and what it was 1 year ago. Other important questions include “How far can you walk without feeling short of breath?” The nurse should avoid asking questions that can be answered “yes” or “no” (e.g., “Do you experience shortness of breath when sitting?” “Do you wake at night feeling short of breath?”). A better question would be “What do you do during a typical day?”

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8. A 75-year-old patient comes to the clinic with complaints of breathlessness when walking. The nurse is trying to establish the patient's level of functional limitation. After careful questioning, the nurse notes Class III. Which of the following patient characteristics denotes Class III level of functional capacity? a. Able to carry on any physical activity without discomfort. Symptoms not present at rest. With any physical activity, symptoms increase. *b. Marked limitation of physical activity. Comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. c. Marked limitation of physical activity. Comfortable at rest, but more than ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. d. Unable to carry on any physical activity without discomfort. Symptoms present at rest. With any physical activity, symptoms increase. Rationale: The New York Heart Association Functional Capacity Classification (NYHA) defines classes of functional limitation. Class I: No limitation of physical activity; ordinary physical activity does not cause undue fatigue, palpitation, dyspnea, or angina. Class II: Slight limitation of physical activity; ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. Class III: Marked limitation of physical activity; comfortable at rest, but less than ordinary physical activity results in fatigue, palpitation, dyspnea, or angina. Class IV: Unable to carry on any physical activity without discomfort; symptoms present at rest, increasing with any physical activity. 9. The nurse is examining a 74-year-old patient brought to the ED with sudden onset EhSicThBsAetNoKf S breathlessness upon exertion.TW finEdLinLgE sR w. illCcOoM nfirm the diagnosis using the Framingham criteria? Select all that apply. *a. Hepatojugular reflux, hepatomegaly, and tachycardia greater than or equal to 120 beats per minute *b. Hepatojugular reflux and rales c. Bilateral ankle edema, nocturnal cough, and hepatomegaly d. Nocturnal cough and dyspnea on ordinary exertion Rationale: The Framingham criteria are most often used to identify congestive heart failure (HF) or HF exacerbation. If two major criteria or one major with two minor criteria are present, the professional can have reasonable certainty that the patient has HF. Major criteria include paroxysmal nocturnal dyspnea, neck vein distension, rales, enlarged heart on chest x-ray, acute pulmonary edema, S3 gallop, increased central venous pressure, hepatojugular reflux, and weight loss greater than or equal to 4.5 kg (10 pounds) in response to treatment. Minor criteria include bilateral ankle edema, nocturnal cough, dyspnea on ordinary exertion, hepatomegaly, pleural effusion, and tachycardia greater than or equal to 120 beats per minute. Findings of hepatojugular reflux, hepatomegaly, and tachycardia greater than or equal to 120 beats per minute confirm HF because one major and two minor criteria are present. Findings of hepatojugular reflex and rales confirm HF because two major criteria are presenting. Findings of bilateral ankle edema, nocturnal cough, and hepatomegaly do not confirm HF because these are all minor criteria. Findings of nocturnal cough and dyspnea on ordinary exertion do not confirm HF because these are all minor criteria.

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10. A 75-year-old patient has just recovered from heart failure. The patient is being discharged home from the hospital with strict instructions to take weight daily “first thing in the morning on arising, before breakfast, and with no clothes or wearing light clothing to avoid false fluctuations.” The patient is asked to report immediately if the weight increases by a certain amount. What increase in weight should be reported immediately? a. A 1-lb weight gain in a week or a 3-lb weight gain in 2 weeks b. A 1-lb weight gain overnight or a 2-lb weight gain in a week c. A 2-lb weight gain in a week or a 3-lb weight gain in 2 weeks *d. A 2-lb weight gain overnight or a 3-lb weight gain in a week Rationale: The instructions given to the patient help ensure a baseline for consistency with regard to the patient's weight. A 2-lb weight gain overnight or a 3-lb weight gain in a week indicate that medical management must change, and should be reported immediately. Weight gains of 1-lb in a week, 1-lb overnight, or 2-lb in a week do not need to be reported immediately.

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Chapter 37: Cancer Assessment and Intervention Strategies in the Older Adult Multiple Choice Test Questions 1. A 70-year-old patient is diagnosed with cancer. Treatment decisions will depend on which of the following? Select all that apply. a. Patient’s age *b. Comorbidity *c. Health status *d. Life expectancy Rationale: Treatment decisions for older adult cancer patients depend on life expectancy, comorbidity, and health status but do not depend on chronological age. 2. An older adult patient diagnosed with cancer has many comorbid conditions. Which of the following statements regarding comorbidity in cancer are true? Select all that apply. a. For every chronic comorbid condition, life expectancy decreases 1.5 years. *b. For every chronic comorbid condition, life expectancy decreases 1.8 years. *c. The more severe the degree of comorbidity, the less probability of survival at 1 year and 5 years after a diagnosis of cancer. d. The more severe the degree of comorbidity, the less probability of survival at 5 and 10 years after a diagnosis of T caEnS ceTr.BANKSELLER.COM Rationale: Often, nonmalignant conditions can present more risk of mortality as compared with a cancer diagnosis. For every chronic comorbid condition, life expectancy decreases 1.8 years. The more severe the degree of comorbidity, the less probability of survival at 1 year and 5 years after a diagnosis of cancer. 3. An older adult patient is diagnosed with cancer. The nurse is performing a comprehensive geriatric assessment (CGA) before starting treatment. What are the benefits of a CGA in this patient? Select all that apply. *a. Assesses risk of toxicity to cancer chemotherapy *b. Helps identify if patient will benefit from cancer treatment *c. Helps assess risk of postoperative complications *d. Predicts postsurgical cognitive decline Rationale: The Society for International Oncology in Geriatrics (SIOG) recommends a CGA be administered to older adult patients who are receiving cancer care. The CGA has been used to identify people who may not benefit from cancer treatment, risk of postoperative complications, and risk of toxicity to cancer chemotherapy treatment. The CGA also provides information to avoid over and under treatment of cancer and is helpful in identifying older adult cancer patients who are most likely to benefit from more aggressive chemotherapy and from various surgical oncology procedures. Postsurgical cognitive changes can be predicted using CGA.

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4. An older adult patient is diagnosed with colorectal cancer. After performing a comprehensive geriatric assessment (CGA), the nurse sends a request for serum 25-hydroxyvitamin D (25OHD) assessment. What is the benefit of doing this lab in this patient? Select all that apply. a. Assess benefit of treatment *b. Assess survival c. Assess toxicity of treatment *d. Assess risk of fall Rationale: 25OHD will assess vitamin D levels to determine whether falls or muscle weakness can be a risk factor. People with lower concentrations of 25OHD have a high probably of falling. Also, in patients with colorectal cancer, higher levels of 25OHD are related to better survival. A CGA, not 25OHD, helps assess the benefit and risk of toxicity from cancer treatment. 5. A 69-year-old, otherwise healthy patient was diagnosed with breast cancer 3 days ago and is now admitted to the hospital for further management. The patient is very nervous and agitated because of the cancer diagnosis. A nurse is taking a detailed history from the patient. What information is important for managing cancer in this patient? Select all that apply. *a. Assess history of present cancer diagnosis *b. Assess family medical history of malignancy and ages on diagnosis *c. Assess regular cancer screening examinations *d. Assess smoking and alcohol use Rationale: The subjective informTaE tioSnToBbA taN inK edSfEroLmLE thR e. olC deOrMadult is a critical factor in the development of the plan of care. The following are issues that should be considered when conducting a health history of an older adult patient just diagnosed with cancer: assess history of present cancer diagnosis, assess family medical history of malignancy and ages on diagnosis, and assess whether patient had regular cancer screening examinations. Smoking and alcohol use have been identified as risk factors of many cancers, including breast cancer. 6. A 78-year-old patient is admitted to the hospital for management of cancer. Which of the following are part of a comprehensive geriatric assessment (CGA) for this patient? Select all that apply. *a. Assess the ability to perform self-care activities *b. Assess functional status and potential for falls c. Assess for cancer risk factors *d. Assess for depression and/or emotional distress Rationale: The Society for International Oncology in Geriatrics (SIOG) recommends a CGA be administered to older adult patients who are receiving cancer care. Functional, physical, emotional, and medication history and cognitive impairment in the acute care patient are generally included in a CGA. Hence, CGA in this patient will include assessment for ability to perform self-care activities, functional status and potential for falls, and depression and/or emotional distress. Assessment for cancer risk factors is important in cancer care but is not a part of CGA.

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7. A 73-year-old patient with lung cancer presents with anorexia, nausea, constipation, lethargy, confusion, polyuria, and polydipsia. The patients labs are as follows: calcium levels of 16.0 mg/dL; random blood glucose is 160 mg/dL and all other labs are within normal limits. What are the possible treatments for this patient’s condition? Select all that apply. *a. Hydration b. Thiazide diuretics *c. Calcitonin *d. Bisphosphonates Rationale: The patient has hypercalcemia, which is defined as calcium concentration greater than 10.2 mg/dL. Severe hypercalcemia should be considered a medical emergency. Signs and symptoms of hypercalcemia include lethargy, confusion, anorexia, nausea, constipation, polyuria, and polydipsia. The patient’s random blood glucose level is normal. Treatment of hypercalcemia depends on the severity. Hydration must be maintained to diminish the risk of exacerbation of hypercalcemia. Intravenous normal saline and loop diuretics should be implemented but will only last as long as the treatments are infusing. Bisphosphonates can help reduce bone reabsorption resulting in low serum calcium levels. Calcitonin can also be administered subcutaneously or intramuscularly and can also reduce calcium levels. Thiazide diuretics should be discontinued. 8. An older adult patient with blood cancer presents with flank pain, edema, lethargy, and restlessness. The patient has hematuria and hypertension. The patient’s uric acid is 14 mg/dL, calcium is 5.0 mg/dL, random blood glucose is 162 mg/dL, and potassium is 5.9 mEq/L. Which of the following lab abTnE orSmTaB litAieNs K arSeEseLeL nE inRt. hiC sO paMtient? Select all that apply. a. Hyperglycemia *b. Hyperuricemia *c. Hypocalcemia *d. Hyperkalemia Rationale: This patient with a hematological malignancy has tumor lysis syndrome and shows signs and symptoms of hyperuricemia. The patient has hyperuricemia, hypocalcemia, and hyperkalemia. In adults, hypocalcemia is defined as a total serum calcium concentration less than 8.8 mg/dL (<2.20 mmol/L); hyperuricemia is defined as uric acid greater than 10 mg/dL; hyperkalemia is defined as a serum potassium concentration greater than approximately 5.0 to 5.5 mEq/L. The patient does not have hyperglycemia since the random blood glucose level is normal.

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9. An older adult patient receiving chemotherapy for lung cancer suddenly starts feeling cold and is having chills. The patient’s oral temperature is 102°F. The nurse sends blood for lab tests. The patient’s absolute neutrophil count (ANC) is 1,100 cells/µL. Which of the following treatments could have prevented the patient’s condition? a. Prednisone *b. Granulocyte-colony stimulating factor (G-CSF) c. Doxorubicin d. Cyclophosphamide Rationale: The patient has neutropenic fever, which is an oncological medical emergency caused by the diminishment of neutrophils by chemotherapeutic agents. Neutropenia is defined by an oral temperature of 101°F and an ANC of less than 1,500 cells/µL. An ANC of less than 500 cells/µL is considered severe. Growth factors, such as G-CSF, work to elevate white blood cell counts necessary in fighting infection. G-CSFs should be proactively administered in patients who are considered at high risk of neutropenia and neutropenic fever. Prednisone, cyclophosphamide, and doxorubicin increase the risk of neutropenia and neutropenic fever. 10. An older adult patient with hematological malignancy is found to have high tumor burden and is very sensitive to chemotherapy. The patient is admitted to day care for a second round of chemotherapy. The intern asks the nurse to check blood calcium, potassium, uric acid, and phosphate levels before starting chemotherapy. What conditions is this patient at risk of developing? Select all that apply. *a. Renal failure b. Respiratory failure c. Chemotherapy failure *d. Tumor lysis syndrome Rationale: The patient is at increased risk of developing tumor lysis syndrome (TLS). TLS is caused when a tumor breaks down rapidly as a result of treatment or decompensation leading to massive cell death. TLS is often detected in hematological malignancies and can be associated with high proliferation rate, bulky tumor, high tumor burden, and sensitivity to chemotherapy. TLS causes hyperkalemia, hyperuricemia, and hyperphosphatemia, which can enhance the risk of renal failure, reduced cardiac function, and mortality. As chemotherapy agents become more effective, the risks increase for TLS, so chemotherapy failure is not expected. Lab abnormalities in TLS are not associated with an increased risk of respiratory failure.

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Chapter 38: Perioperative Care of the Older Adult Multiple Choice Test Questions 1. Preoperative assessment of older adult patients should consider which age of the patient? a. Psychological *b. Physiological c. Physical d. Chronological Rationale: As part of the comprehensive preoperative assessment of older adult patients, “it is useful to determine whether a patient is physiologically ‘young’ (i.e., exhibiting only changes associated with normal aging) or ‘old’ (i.e., exhibiting aging effects due to comorbidities in addition to normal aging)”. Chronological/physical age and psychological age are not considered in preoperative assessment. 2. What factors determine competence to consent to treatment in older adults? Select all that apply. *a. Ability to appreciate the nature of one’s situation and the consequences of one’s choices *b. Ability to reason about the risks and benefits of potential options *c. Ability to communicate a choice *d. Ability to understand the relevant information Rationale: From a legal and medical standpoint, competence to consent to treatment may require the following criteria: ability to appreciate the nature of one’s situation and the consequences of one’s choices, ability to understand the relevant information, ability to reason about the risks and benefits of potential options, and ability to communicate a choice. 3. Which of the following tools can be used to assess medical decision-making capacity of older adults? Select all that apply. *a. Mini-Cog *b. Aid to Capacity Evaluation *c. Hopkins Competency Assessment Test *d. Understanding Treatment Disclosure Rationale: Validated tools, such as the Standardized Mini-Mental State Examination (SMMSE) or the Mini-Cog must be used to evaluate the medical decision-making capacity of the patient. Other validated tools that can be used to assess capacity are the Aid to Capacity Evaluation (ACE) tool, the Hopkins Competency Assessment Test, and the Understanding Treatment Disclosure.

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4. What is the focus of interventions under the Perioperative Optimization of Senior Health (POSH) program? Select all that apply. *a. Manage comorbidities *b. Mitigate delirium risk c. Reduce anesthesia risk *d. Reduce polypharmacy Rationale: Interventions under the POSH initiative are focused on management of comorbidities, reduction of polypharmacy, enhancement of mobility and nutrition, and delirium risk mitigation. Reducing anesthesia risk is not the focus of interventions under the POSH program. 5. A 70-year-old patient is being admitted to the hospital for hip replacement surgery. The nurse determines that the patient has an American Society of Anesthesiologists (ASA) score of III. What does this imply for the patient? Select all that apply. *a. Greater blood loss b. Increased risk of infection *c. Need for blood transfusion d. Increased risk of surgical failure Rationale: An ASA score of III or higher is a predictor of greater blood loss and need for transfusion in total hip replacement patients. An ASA score of III is not a predictor of increased risk of infection or surgical failure. 6. A 68-year-old patient is brought to the ED with acute pain in the abdomen. The patient is diagnosed to have acute appendicitis and is being prepared for surgery. The patient has no comorbidities. A nurse is carrying out perioperative physical status classification of the patient. According to the American Society of Anesthesiologists (ASA), which category should be used to describe this patient? *a. I b. II c. III d. IV Rationale: To assess postoperative risks, the ASA Classification of Physical Health remains the most common tool used in appraising preoperative health of surgical patients. The patient’s preoperative health is categorized into five classes (I–V). This patient is in Class I as the patient has no comorbidities. According to the ASA classification, Class I is: patient is a completely healthy, fit patient. This patient would not be considered Class II (patient has mild systemic disease), Class III (patient has severe systemic disease that is not incapacitating), or Class IV (patient has incapacitating disease that is a constant threat to life).

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7. A 66-year-old patient is admitted for gall bladder surgery. A day before the surgery, the nurse prepares the medications for the patient. What precautions should the nurse take for safe use of these medications? Select all that apply. *a. Keeping medications in their original or labeled containers b. Training the patient to take the medication as advised *c. Obtaining verification from the pharmacy *d. Using electronic provider order entry with decision support Rationale: The patient is in the perioperative period. Perioperative medication prescribing and administration often bypasses standard safety checks, such as electronic provider order entry with decision support, pharmacy verification, and multiple nursing checks at the time of medication administration, which can lead to medication errors (MEs). Other potential factors for MEs include medications in unlabeled containers or removed from their original containers and placed into unlabeled containers. Since the patient is hospitalized, the nurse will administer the medication, so patient training is not required. 8. An older adult patient is being prepared for surgery. What precautions should be taken to prevent surgical site infection after the operation? Select all that apply. *a. Ensure glycemic control *b. Ensure proper skin and bowel preparation *c. Ensure normothermia d. Ensure hydration Rationale: Comprehensive surgicTaE l sSitTeBinAfeNcK tioSnEpLreLvEenRt. ioC nO stM rategies include well-established measures, such as surgical hand asepsis and other collaborative measures, such as antibiotic prophylaxis, glycemic control, maintaining normothermia, and skin and bowel preparation. Ensuring hydration is not a measure to prevent surgical site infection. 9. An older adult patient is asked to fast for 24 hours before a surgery to be performed under general anesthesia. How will this fasting impact the patient’s perioperative period? Select all that apply. *a. Increase risk of headache *b. Increase risk of vomiting *c. Increase risk of hypotension *d. Increase risk of hypoglycemia Rationale: This patient has been fasting for a long time (24 hours). Prolonged fasting has been associated with adverse physical and psychological perioperative complications such as irritability, headache, dehydration, emesis, hypotension, hypovolemia, and hypoglycemia. The traditional practice of not letting patients eat or drink after midnight (“NPO after midnight”) before general anesthesia aims to reduce the volume and acidity of stomach contents during surgery, thus reducing the risk of regurgitation or aspiration. Current guidelines recommend fasting of 2 hours for clear liquid and 6 hours for a light meal.

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10. A 66-year-old patient develops nausea and vomiting 6 hours after an abdominal surgery. The doctor on duty asks the nurse to be vigilant about complications. For which complications is this patient at risk? Select all that apply. *a. Pneumonia *b. Aspiration c. Surgical site infection *d. Wound dehiscence Rationale: Potential trajectories of postoperative nausea and vomiting (PONV) and postdischarge nausea and vomiting (PDNV) include aspiration, wound dehiscence, prolonged postoperative hospital stays, delayed return of a patient’s functional ability in the 24-hour period after surgery, and lost time from work for patients and care providers at home. Aspiration can increase risk of aspiration pneumonia. PONV does not increase risk of surgical site infection.

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Chapter 39: General Surgical Care of the Older Adult Multiple Choice Test Questions 1. Enhanced recovery after surgery (ERAS) is an evidence-based, multidisciplinary approach to the care of the surgical patient that has been shown to improve patient outcomes while decreasing length of stay and overall cost. Which part of the surgical duration do ERAS guidelines cover? a. Only surgical *b. Preoperative, perioperative, and postoperative c. Surgical and postoperative d. Preoperative and perioperative Rationale: ERAS programs cover care from pre-admission through the perioperative phase and into post-discharge (postoperative). 2. Which of the following patient safety indicators (PSIs) are directly related to postsurgical care in older adults discharged to home? Select all that apply. *a. Physiological and metabolic derangements *b. Wound dehiscence *c. Transfusion reaction d. Death Rationale: The PSIs directly related to postsurgical care include central venous catheter (CVC)related bloodstream infection, postoperative hemorrhage or hematoma rate, physiological and metabolic derangements, respiratory failure, pulmonary embolism or deep vein thrombosis (DVT), sepsis, wound dehiscence, and transfusion reaction. PSIs are directly related to death among surgical inpatients and not in patients discharged to home.

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3. An older adult patient with cognitive, visual, and renal impairment is undergoing comprehensive evaluation of cognitive and sensory (vision/hearing) function 8 weeks before surgery to assess risk of a particular postoperative complication. The nurse also informs the patient that he will be screened for at least 3 days postoperatively as well. What postoperative complication is the nurse expecting in this patient? *a. Delirium b. Aspiration c. Deep vein thrombosis d. Pneumonia Rationale: The ACOVE and NIA Expert Panel recommend that preoperative assessment for delirium be performed 8 weeks before surgery. ACOVE recommends screening to occur for at least the first 3 days after surgery as well. The AGS Expert Panel on Postoperative Delirium in Older Adults emphasizes the assessment of risk factors for postoperative delirium (such as cognitive, visual, and renal impairment), with the presence of two or more factors placing the patient at a greater risk of delirium after surgery. Moreover, patients should receive a comprehensive evaluation of cognitive and sensory (vision/hearing) function 8 weeks before surgery. This assessment is not done to assess the risk of other postoperative complications such as aspiration, deep vein thrombosis, or pneumonia. 4. The nurse is preparing to assess and manage pain in an older adult surgical patient. Inadequate pain management postsurgery can lead to which of the following complications? Select all that apply. *a. Delirium *b. Depression c. Dementia *d. Fatigue Rationale: Adequate assessment and management of pain are the nurse’s imperative for the older adult surgical patient, as a lack of pain control can lead to a host of complications, including delirium, depression, fluid imbalances, atelectasis, and fatigue. Inadequate pain management postsurgery does not lead to dementia in older adults.

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5. A nurse is caring for a 67-year-old patient postsurgery. The patient has poor hearing and vision. Since surgery, the patient has not been using glasses or hearing aids. On the second postoperative day, the nurse notices that the patient is moaning, restless, agitated, and trying to pull out the intravenous line. Which factors could have contributed to the patient’s condition? Select all that apply. *a. Hospital noise *b. Routine hospital procedures *c. Inattention to visual and hearing deficits d. Inadequate cognitive stimulation Rationale: The patient has developed delirium. Routine hospital care in older adult surgical patients may contribute to delirium resulting from effects on the patient’s sleep–wake cycle and sleep deprivation, often related to routine procedures and hospital noise and inattention to visual and hearing deficits, including lack of appropriate corrective lenses and hearing aids. Preoperative dementia can be a risk factor for delirium in older adults but is not applicable for this patient. Hence, the patient does not need cognitive stimulation. 6. A 78-year-old patient is brought to the ICU after a hip fracture surgery. Next day, the patient becomes confused, restless, and agitated. The doctor on duty looks at the vital signs and pulse oximetry and sends blood for laboratory evaluation. What lab abnormalities is the doctor expecting in this patient? Select all that apply. *a. Acidosis *b. Electrolyte imbalances *c. Hypoglycemia *d. Anemia Rationale: The patient has developed delirium postsurgery. This can occur due to metabolic derangements caused by hypoxia and acidosis, electrolyte imbalances, hypoglycemia, dehydration, and anemia. 7. A 65-year-old patient is being managed in the postsurgical unit after a hip surgery. Postsurgery, the patient complains of pain. The nurse assesses that the patient has moderate to severe pain and gives the patient the prescribed pain medication. Which of the following should be done after giving the pain medication to the patient? Select all that apply. *a. Document the pain medication given b. Reassess pain within 15 minutes of giving pain medication *c. Reassess pain within 4 hours of giving pain medication *d. Document reassessment in medical chart Rationale: ACOVE states that for complaints of moderate to severe pain, an intervention should be performed, reassessment of pain should occur within 4 hours, and documentation of the intervention and reassessment should be placed in the medical chart. The nurse should not reassess pain within 15 minutes of giving the pain medication.

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8. An older adult patient is unable to eat after surgery. There is excessive drooling and the patient keeps complaining of something stuck in the throat. Which nursing intervention is likely to help the patient eat? Select all that apply. *a. Altering food consistency *b. Speech therapy *c. Making the patient sit upright during and up to 1 hour after feeding *d. Aggressive oral care Rationale: Older adults may experience age-related decreases in swallowing function. Additionally, swallowing difficulties take longer to resolve following extubation for older adults, particularly after long surgeries, predisposing the older adult patient to postoperative dysphagia. As such, swallowing ability should be assessed early to address the need for fluid and caloric intake and to lower the risk of aspiration and debilitating aspiration pneumonia. If the swallowing assessment shows signs of aspiration, modification of the diet, including alterations in food consistency, upright positioning during and up to 1 hour after feeding, speech therapy, and aggressive oral care should be implemented to improve intake. 9. A 65-year-old patient becomes confused and agitated after an operation. The patient is in pain, and urine output is low. Blood creatinine is high. The patient has high fever and cough with wheezing. What complications could be responsible for the patient’s condition? Select all that apply. *a. Infection *b. Inadequate pain management *c. Renal and respiratory comTpE liS caTtiB onAsNKSELLER.COM *d. Side effects of medications Rationale: The patient has delirium. Older adult surgical patients are at a high risk of delirium for a number of causes, including immobility; infection; inadequate pain management; and cardiac, renal, and respiratory complications. Side effects of certain medications such as sedative hypnotics, analgesics especially narcotics, and medications with an anticholinergic effect can also cause delirium. Hence, patient’s medication list should be checked. 10. The nurse is caring for a 75-year-old postsurgical patient. The nurse notices that the patient shows changes in mental status and new-onset atrial fibrillation. The patient has low blood pressure but normal urine output. Which of the following conditions should be resolved immediately in this patient? a. Hypotension *b. Poor perfusion c. Atrial fibrillation d. Mental status Rationale: Since fluid volume shifts may take up to twice as long to resolve in an older adult surgical patient, urine output alone may not be enough to determine whether the patient has low blood volume leading to poor perfusion. The nurse should also be on the lookout for drops in blood pressure, changes in mental status, and new-onset atrial fibrillation, all of which could signify poor perfusion. Hence poor perfusion should be corrected immediately. Hypotension, atrial fibrillation, and changes in mental status will be corrected with adequate perfusion.

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Chapter 40: Care of the Older Adult With Fragility Hip Fracture Multiple Choice Test Questions 1. What is a fragility fracture? Select all that apply. *a. Fracture resulting from low-impact trauma *b. Fracture occurring in the absence of significant trauma c. Femoral neck fracture d. Fracture occurring in older adults Rationale: A fragility fracture is defined as a break in the bone resulting from low-impact trauma, such as falling from a standing height or less, or one that occurs in the absence of significant trauma. Femoral neck is the most common site of fragility fracture but all femoral neck fractures are not fragility fractures. Similarly, though fragility fracture is common in older adults, any fracture in an older adult is not a fragility fracture. 2. What is the most common location for a fragility hip fracture? Select all that apply. a. Intertrochanteric fracture b. Subtrochanteric fracture *c. Subcapital fracture *d. Femoral neck fracture Rationale: The most common locTaE tiS onTfBoA r aNfKraSgE iliLtyLhEipR. fraCcO tuMre is the femoral neck (45%– 53%) followed by intertrochanteric fractures (38%–49%) and, less often, subtrochanteric fractures (5%–15%). Subcapital fracture is also a femoral neck fracture. 3. Which of the following statements is true about bones at risk of fragility fracture? a. Osteoblasts work but osteoclasts do not b. Osteoclasts work but osteoblasts do not *c. Osteoclasts work more than osteoblasts d. Osteoblasts work more than osteoclasts Rationale: In adults, small amounts of bone mineral are lost as osteoclast cells clean up old bone, in a process known as resorption. These bone minerals are replaced by bone-building cells called osteoblasts in a process known as remodeling. With aging, the loss of bone occurs progressively and asymptomatically, accelerating in women after menopause. When the balance tips toward excessive resorption (osteoclast overactivity), bones weaken (osteopenia) and over time can become brittle and prone to fracture (osteoporosis).

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4. An older adult patient with sarcopenia and osteoporosis is at increased risk of fracture due to which of the following factors? Select all that apply. *a. Decreased bone mineral density *b. Limited mobility *c. Decreased muscle strength *d. Decreased muscle mass Rationale: The elevated fracture risk from sarcopenia and osteoporosis is a result of the decline of muscle mass and strength, the decrease in bone mineral density (BMD), and limited mobility. 5. A 70-year-old woman with poor vision and hearing and gait disturbances sustained a hip fracture without any trauma. The patient has loose fitting dentures, smokes and drinks to release stress, and is scared to walk due to gait disturbances and poor vision. What patientrelated factors could have caused the fracture? Select all that apply. *a. Poor nutrition *b. Decreased estrogen *c. Smoking and drinking *d. Sedentary lifestyle Rationale: This patient had risk factors for fall such as poor vision and hearing and gait disturbances, yet sustained a fracture without a fall. The patient had a fragility hip fracture. Patient-related conditions which could have caused this fracture are old age; gender because the drop in estrogen levels that occurs with menopause accelerates bone loss in women; nutrition because poor nutrition (due to looTsE eS fitTtiB ngAdNeK ntSuE reL s)LaE ndR. a dCiO etMlow in calcium and vitamin D contribute to increasing risk of hip fracture; and lifestyle because smoking and drinking more than two alcoholic beverages per day can interfere with normal processes of bone remodeling resulting in bone loss. Also, inactivity can weaken bones and cause fragility fractures in older adults. 6. A 78-year-old patient is brought to the clinic by the patient’s son because the patient is often unsteady on the feet. The nurse finds that the patient has poor handgrip strength and gait speed. Which interventions should the nurse consider to help treat the patient’s condition? Select all that apply. *a. Vitamin supplements *b. Protein supplements *c. Exercise *d. Ghrelin and ghrelin receptor agonists Rationale: The patient has sarcopenia. Interventions can mitigate some of the functional decline it causes. These include aerobic and resistance exercise; nutritional interventions (e.g., increased protein to counteract changes in protein metabolism as well as higher catabolic rates associated with chronic illness, and vitamin supplements); and pharmaceutical agents currently under investigation (testosterone, selective androgen receptor modulators, ghrelin and ghrelin receptor agonists, and angiotensin-converting inhibitors, among others).

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7. A 75-year-old patient is recovering from fragile hip fracture surgery at home. The patient is unable to do physiotherapy because of pain. How should the nurse reduce the pain experienced by the patient during exercises? *a. Time the pain medication b. Give pain medications intravenously c. Add a sedative to the pain killer d. Start opioids for better pain control Rationale: It is important to identify the time of the peak effect of the specific analgesic and route of administration and administer the analgesic when peak effect will coincide with physiotherapy or ambulation. Strategic timing of analgesics can help alleviate the increased pain of mobilization and reduce the need for additional opioid doses. Minimizing sedation while maximizing pain control is a goal to facilitate mobility. Pain medications that the patient is already on will be able to help reduce pain during physiotherapy if they are timed well, or a sedative or an opioid is added for better pain control. These are usually oral medications as the patient is at home. Giving intravenous pain medications is usually not a protocol followed for a patient discharged to home. 8. An older adult patient undergoes a DEXA scan to determine his bone health. Which of the following readings show poor bone health? Select all that apply. *a. Z-score measure of −2.0 *b. T-score between −1.0 and −2.5 c. Z-score above −2.0 d. T-score is 0.0 Rationale: The DEXA scan is the most widely used method to evaluate BMD. The WHO uses BMD measured by the DEXA to define osteoporosis. A DEXA scan measures the density of bone at two areas: the proximal femur and the lumbar spine. The results are reported as a T- and a Z-score. According to WHO criteria, a T-score higher than −0.1 is considered normal bone density, a T-score between −1.0 and −2.5 is considered osteopenia, and a T-score below −2.5 is considered osteoporosis. The Z-score is a comparative measure of persons of the same age and gender as the patient and can be used to evaluate men, children, and premenopausal women. A Z-score measure of −2.0 is considered low bone mass for chronological age and a Z-score of above −2.0 is considered within the expected range for age. The standard measure T-score is 0.0 representing bone density of a young healthy individual at peak bone health.

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9. An older adult patient recovering from fragile hip fracture surgery is being managed with opioids postsurgery. The nurse notes that the patient has not passed a bowel movement in the last 2 days. What other complications could this patient experience if the inability to pass a bowel movement continues? Select all that apply. *a. Delirium *b. Agitation *c. Abdominal pain *d. Bowel obstruction Rationale: The patient has developed constipation as a side effect of opioids. Although individual bowel habits vary, in general, the goal is that the patient has a moderate to large bowel movement (BM; e.g., at least 8 ounces) every 48 hours. Constipation is highly likely to increase the risk of abdominal and rectal pain, delirium, agitation, and bowel obstruction. 10. A 76-year-old patient is brought to the ED after suddenly complaining of severe pain in the hip region and inability to walk or bear any weight on the right leg. There is no history of fall. X-ray confirms a hip fracture. The patient has a previous history of myocardial infarction and has impaired kidney function. How should the nurse manage fluid balance in this patient? Select all that apply. *a. Monitoring vital signs *b. Administering diuretics as prescribed *c. Maintaining fluid input output chart *d. Monitoring symptoms Rationale: The patient is at increased risk of fluid overload. Preexisting heart failure or renal conditions that increase fluid load can worsen with the stress of injury and subsequent surgery. Recommended nursing interventions include ensuring that regular diuretics are administered as prescribed, monitoring vital signs, maintaining accurate documentation of fluid balance, and promptly reporting alterations in the patient’s clinical and cognitive status. Symptoms to monitor include urinary output less than 30 mL/hr, increasing blood pressure, shortness of breath, moist breath sounds, and dependent edema.

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Chapter 41: Acute Care Models Multiple Choice Test Questions 1. An older adult suffers from several comorbid conditions. Which of the following conditions are considered geriatric syndromes? Select all that apply. a. Pneumonia *b. Pressure ulcer *c. Urinary tract infection *d. Malnutrition Rationale: Geriatric syndromes are clinical conditions in older persons that do not fit into discrete disease categories. These conditions share four common risk factors: older age, baseline cognitive impairment, baseline functional impairment, and impaired mobility. Hence, geriatric syndromes include functional decline, pressure ulcers, fall-related injuries, undernutrition or malnutrition, urinary tract infections (can occur due to urinary incontinence, use of catheter, etc., which is common in older adults), and delirium. Pneumonia in older adults is not considered to be a geriatric syndrome as it is a discrete infectious disease which is not related to the four common risk factors. 2. An older adult is hospitalized in an acute care setting. Which patient care protocols regarding hospitalized patients need to be standardized to prevent adverse outcomes? Select all that apply. *a. Protocols related to restraints *b. Pain control protocols *c. Protocols to check medications *d. Protocols for detection of cognitive or affective changes Rationale: Geriatric protocols must be adopted in a standardized way to prevent adverse outcomes. Issues with inappropriate medication use (e.g., overuse of psychoactive drugs), unnecessary restraints, inadequate detection of cognitive or affective changes (e.g., delirium and depression), and poor pain control are examples of hospital factors that can lead to adverse outcomes. 3. Which of the following geriatric specialists are typically used as part of a geriatric consultation service? Select all that apply. *a. Healthcare provider who conducts comprehensive assessment *b. Advanced practice nurse *c. Psychiatrist d. Palliative care nurse Rationale: The consultants in a geriatric service may include a geriatrician, a geropsychiatrist, a geriatric advanced practice nurse (GAPN), or an interprofessional team of geriatric healthcare providers who conduct a CGA or evaluate a specific condition (such as older adult mistreatment), symptom (such as wandering), or situation (such as adequacy of spouse to care for patient at home). Palliative care nurses look after patients in palliative care and are not part of a geriatric consultation service. 181

4. A 76-year-old patient is hospitalized on an acute care for the elderly (ACE) unit. What benefits should the patient receive? Select all that apply. *a. Decreased chance of discharge to nursing home *b. Improved functional status at discharge *c. Decreased delirium *d. Fewer falls Rationale: Compared with other medical units, patients hospitalized on ACE units demonstrate prehospital or improved functional status at discharge without increases in hospital or postdischarge costs, and are less likely to be discharged to nursing homes. Other important positive outcomes associated with ACE units include improved drug prescribing, fewer falls, less delirium, and reduced mortality. 5. A nurse is caring for an anxious 70-year-old patient in a hospital setting. How can the nurse adjust the patient’s environmental setting to promote ambulation and cognition? Select all that apply. *a. Adjust lighting *b. Assign a bed with adjustable height *c. Ensure clocks and calendars are within patient’s view d. Assign a straight back chair Rationale: A hospital’s environment is meant to reduce physical obstacles for transferring and ambulating and promote cognitive orientation and socialization. Physical modifications in the EeRn.t C typical hospital setting that suppoTrtEaSfT rieBnA dN lyKeS nvEirLoL nm foO rM an older adult include using furniture (chairs and a bed) with adjustable height to facilitate mobility, carpeted flooring, clocks and calendars, and grab bars. The nurse can adjust the beds, chairs, clocks, calendars, and lighting in the hospital. The chair should be comfortable, and from which the patient can easily get up. Chairs of adjustable height and a hand bar are ideal.

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6. A 78-year-old patient was discharged from the hospital after treatment of a cardiovascular problem. The patient was then readmitted to the hospital a week later with complaints of breathlessness. The doctor on duty found that the patient was not taking all of his prescribed medications. The patient informed that the medication he was taking for high blood pressure before his last hospital admission was not mentioned in the discharge slip, so he thought that the medication had been stopped. Which aspects of discharge care were lacking for this patient? Select all that apply. a. Home care referrals *b. Reconciliation of medication *c. Preparation of patient and caregiver to follow discharge instructions d. Diagnostic follow-up instructions Rationale: Hospital readmission for older patients is most likely associated with medical errors in medication continuity, diagnostic workup, or test follow-up. Geriatric acute care models address the posthospital care environment and the care transition following hospital discharge by promoting coordination among healthcare providers, facilitating medication reconciliation, preparing patients and their caregivers to carry out discharge instructions, and making appropriate home care referrals. For this patient, one medication was missed on the discharge slip and the patient’s understanding of the discharge instructions was not clear. Hence, discharge care was lacking a reconciliation of the patient’s medications and confirmation that the patient and caregiver understood the discharge instructions. There is no indication the patient required home care referrals or a diagnostic follow-up.

KuSltEidLisLcE 7. Older adult patients have beenTE reS ceTivBinAgNm ipR lin.aCryOgMeriatric consultation services for the past 3 years. What potential benefits have these patients received? Select all that apply. *a. Reduction in the cost of stay b. Reduction in functional decline *c. Reduction in the use of physical restraints *d. Reduction in inappropriate medication use Rationale: Evidence shows that the use of geriatric consultation service brings about significant reductions in daily charges, ICU days, potentially inappropriate medication use, and the use of physical restraints. In addition, fewer consult patients die in the 6 to 8 months following discharge, end‐of‐life planning is increased, and costs are reduced. Geriatric consultation service does not provide statistically significant reduction in functional decline, readmissions, or length of stay.

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8. An older adult in an ACE unit is being looked after by a geriatrician, GAPN, and social worker. The patient has an unremarkable medical history and is in this unit recovering from multiple fractures of the leg. Which of the following specialists should be added in the acute care of this patient? Select all that apply. *a. Pharmacist *b. Physical therapist c. Audiologist *d. Nutritionist Rationale: ACE units provide CGA delivered by a multidisciplinary team with a focus on the rehabilitative needs of older patients. The patient’s core team includes a geriatrician, GAPN, and social worker. For rehabilitation post fracture, the patient will need to be seen by specialists from other disciplines, such as occupational and physical therapy, nutrition, pharmacy, and psychology. This patient does not have any history suggesting that an audiologist is required for the rehabilitative service. 9. An older adult is admitted to the hospital following a hip fracture. The nurse caring for the patient notes that the patient had difficulty remembering names and places prior to admission. How would the HELP program benefit this patient? Select all that apply. a. Prevent medication overuse *b. Prevent cognitive decline *c. Prevent functional decline d. Prevent delay in surgery

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Rationale: The Hospital Elder Life Program (HELP) is a multicomponent intervention that utilizes an interdisciplinary assessment, trained volunteers, and protocols to prevent cognitive and functional decline in hospitalized older adults. Preventing medication overuse and reducing time to surgery are important components of care of older patients but not the goal of the HELP program. 10. A 78-year-old patient is admitted to a rural hospital with multiple conditions. The hospital has no geriatric specialists and support staff. How can this hospital integrate geriatric consultation service into the hospital care model without considerably increasing the cost of care? a. Arrange for a GAPN to visit hospital weekly. b. Arrange for the patient to visit an urban hospital weekly. c. Arrange for a geriatric clinician to visit the hospital daily. *d. Arrange for an e-Geriatrician consult. Rationale: This rural hospital has no fellowship-trained geriatricians, geriatric psychiatrists, or geriatric nurse specialists. Because these specialists are not on site, the hospital should use webbased and other long-distance communication strategies. A geriatrician or a GAPN in another location can participate in “virtual” rounds with staff; the e-Geriatrician or e-APN has access to a system-wide electronic health record and a web-based assessment tool. Geriatric consultation service requires multiple rounds of communication, which is easier using a web-based or e-care model. Arranging for a GAPN or geriatric clinician to visit the hospital would increase the cost of care and may not be feasible given the need for multiple rounds of communication. Similarly, sending the patient weekly to an urban hospital is not a feasible option for continued care. 184

Chapter 42: Transitional Care Multiple Choice Test Questions 1. An older adult admitted to the hospital will need transitional care for which of the following situations? Select all that apply. *a. Shift from ICU to room *b. Shift from hospital to nursing care *c. Shift from room to specialty care office d. Shift from bed to chair in patient’s room Rationale: Transitional care is defined as a set of actions designed to ensure the coordination and continuity of healthcare as patients transfer between different locations or different levels of care within the same location. Shifting the patient from bed to chair does not involve a shift in location or levels of care. 2. Which of the following disease conditions are covered under the Hospital Readmissions Reduction Program (HRRP)? Select all that apply. *a. Elective hip replacement b. Hip fracture *c. Chronic obstructive pulmonary disease (COPD) *d. Heart attack Rationale: The HRRP is a value-based purchasing program that lowers payments to Inpatient Prospective Payment System (IPPS) hospitals with too many readmissions. It financially penalizes hospitals whose 30-day readmission rates for six targeted conditions—heart attack, heart failure, pneumonia, COPD, elective hip and knee replacement, and coronary artery bypass graft (CABG)—are high relative to other facilities. Hip fracture is not covered under the HRRP. 3. Inadequate access to transition care resources in older adults is likely to be seen in which of the following situations? Select all that apply. *a. Patients living alone *b. Patients with a mental condition c. Patients with a chronic disease *d. Patients with multiple comorbidities Rationale: Healthcare disparities and lack of or inadequate access to transition care resources will be more pronounced in the disenfranchised segment of older adults: those who are living alone, have multiple comorbidities, or are suffering from mental illness. Others who may not receive proper transition care include the undomiciled, victims of elder abuse and neglect, the uninsured, and those lacking in legal status. Patients with a chronic disease would not face inadequate access to transition care resources.

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4. Evidence-based transition care models (TCMs) target which medical conditions in hospitalized older adults? Select all that apply. *a. Heart failure *b. Septicemia *c. Implant or graft complications *d. Spondylosis Rationale: Evidence-based TCMs target these 10 high-volume, high-risk most common diagnoses for inpatient stays among patients between 65 and 74 years of age: septicemia, heart failure, complication of device (implant or graft), acute cerebrovascular disease, spondylosis (intervertebral disc disorders and other back problems), dysrhythmias, chronic obstructive pulmonary disease, bronchiectasis, pneumonia, and acute myocardial infarction. 5. How should the nurse prepare a 70-year-old patient for discharge to home? Select all that apply. *a. Ensure that the patient and caregiver understand when the next follow-up visit occurs. *b. Ensure that the caregiver understands how to care for the patient at home. *c. Ensure that the patient and the caregiver understand all medication-related instructions. d. Ensure that the patient refills the prescription at home if any medication gets over before the next visit. Rationale: Patients and their caregivers are often unprepared for transitions and are overwhelmed by discharge information. Poor preparation of the patient and his or her informal caregivers for the next level-of-caTrE eS inT teB rfA acNeK , bSeEitLthLeEhRo. mC eO orManother facility, compromises overall patient safety. The nurse should ensure that the patient and caregiver are prepared for care at home, understand how and when to take medications, and know when to come for the next follow-up visit. Ensuring that the patient has all the prescribed medicines until the next visit is important, and should be communicated to the patient and caregiver. However, it is not the nurse’s duty to ensure that the patient fills the prescription when at home. 6. An older adult patient is being shifted from a hospital to nursing care. What factors should be considered before moving the patient? Select all that apply. *a. All patient-related information should be communicated to nursing care. *b. A single point person care should be used to ensure continuity of care. *c. The patient and the caregiver should be educated. d. A multidisciplinary team should be utilized. Rationale: The patient needs transition care during a shift from the hospital to nursing care. Many factors contribute to gaps in care during critical transitions, such as poor communication, incomplete transfer of information, inadequate education of older adults and their family caregivers, limited access to essential services, and the absence of a single point person to ensure continuity of care. The use of a multidisciplinary team during transition will cause communication gaps; it is better to have a single point person to ensure continuity of care.

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7. A 75-year-old Alaska Native is being discharged to home after being treated for heart failure. What disparities is this patient likely to face in the discharge care? Select all that apply. a. Patient discharged without discharge instructions *b. Incomplete written discharge summary *c. Poorly understood discharge information *d. Patient's preference of discharge care not considered Rationale: Alaska Native patients are less likely to be given complete written discharge instructions, don’t feel they understand how to manage their health after discharge, and have reported that staff did not take their preferences into account when deciding what the patient’s discharge healthcare would be. Although minor communities are often discharged with incomplete or poorly understood discharge instructions, they do still receive discharge instructions. 8. An older hospitalized adult is being discharged to home. The patient is assigned a coach under the hospital’s care model. The coach will advise support tools around which four pillars of intervention in this setting? a. Diagnostic tests, medication, health record keeping, and follow-up with the primary physician b. Medication, health record keeping, follow-up with the primary physician, and physiotherapy *c. Medication, health record keeping, follow-up with the primary physician, and recognizing and responding to red flags of worsening condition d. Diagnostic tests, medicatiT onE,SreTcB ogAnN izK inSgEaL ndLrEesRp. onCdOinMg to red flags of worsening condition, and physiotherapy Rationale: The care transitions intervention (CTI) involves a nurse, social worker, occupational therapist functioning as a “transition coach.” This coach teaches patients self-management skills, ensures their needs are met during a transition between healthcare settings, and helps them achieve positive outcomes as outlined in the four pillars of CTI: medication self-management, dynamic patient-centered health record keeping, follow-up care with the primary physician, and learning how to recognize and respond to red flags that indicate their condition is worsening. 9. A hospital superintendent asks the nurse to redesign the hospital discharge process. Which of the following interventions should the nurse consider? Select all that apply. *a. Adding a separate medication form *b. Sharing the discharge form with the primary care physician *c. Arranging primary care visits for the patient *d. Having a clinical pharmacist call patients after discharge Rationale: Redesigned hospital discharge process interventions include sending discharge forms or individualized information to primary care providers, using specific forms for medications, having a clinical pharmacist call patients after discharge, arranging patients’ primary care visits, and facilitating communication with outpatient offices (i.e., sharing discharge forms).

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10. A nurse is being trained to provide transition care to older adults. The nurse learns about two very common transition care models. The instructor asks the nurse to read about other, less common, care models for the next class. Which additional transition care models should the nurse read about next? Select all that apply. *a. Geriatric Resources for Assessment and Care of Elders (GRACE) b. Advanced Practice Nurses TCM *c. Better Outcomes for Older Adults through Safe Transitions (BOOST) d. Care Transitions Intervention Model Rationale: The two common transition care models are The Advanced Practice Nurses TCM and the Care Transitions Intervention Model. Other less common models that the nurse should be aware of include GRACE and BOOST.

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Chapter 43: Palliative Care Models Multiple Choice Test Questions 1. Which of the following are characteristics that underpin palliative care? Select all that apply. a. Care provision and coordination is limited to one discipline. *b. Patient and family hopes for peace and dignity are supported throughout the course of illness. *c. The circle of care includes patients, families, and palliative and nonpalliative health providers. d. Care must always be provided concurrently with life-prolonging therapies. Rationale: There are specific characteristics that underpin palliative care: (a) services are appropriate at any stage of illness for a person with a serious illness based on needs and not prognosis; (b) the circle of care includes patients, families, and palliative and nonpalliative health providers who collaborate and communicate about care needs; (c) goals of care for patients and families are supported and congruency is assured throughout the course of illness, during the dying process, and after death. Care provision is holistic and provided by an interdisciplinary team, thus is not restricted to one discipline; Also, services are available in conjunction with or independent of curative or life-prolonging therapies. 2. A patient who is suffering from a serious illness wants to move to hospice care. The nurse looking after the patient explains to the patient why palliative care would be more suitable. Why would the nurse suggestTpE alSliT atB ivA eN caKrS e iEnL stL eaEdRo. f hCoOspMice care? *a. The disease is expected to reduce the patient’s life expectancy. b. The patient has a life expectancy of 6 months or less. c. Hospice will not be covered by insurance, but palliative care would be. d. The physician has certified that the patient needs palliative care. Rationale: The patient with a serious illness that is expected to reduce the patient’s life expectancy qualifies for palliative care. If the patient had a terminal illness that would reduce life expectancy to 6 months or less, hospice care would be recommended. Both hospice and palliative care are covered by insurance. Physicians often certify when patients need hospice care. 3. Which of the following aspects of palliative care focus on healthcare improvement and moving care upstream? Select all that apply. *a. Public education and engagement in palliative care *b. Person-centered and family-focused palliative care *c. Clinician−patient communication and advance care planning *d. Professional education, policies, and payment for palliative care Rationale: The five areas for quality palliative care in achieving healthcare improvement and moving care upstream to patients with serious illness, rather than focusing on end of life, are: (a) delivery of person-centered and family-focused palliative care; (b) clinician−patient communication and advance care planning; (c) professional education in palliative care; (d) policies and payment for palliative care; and (e) public education and engagement in palliative care. 189

4. When should palliative care be given to a cancer patient, according to the National Comprehensive Cancer Network? Select all that apply. *a. Uncontrolled symptoms *b. Serious comorbid physical and psychosocial conditions *c. Life expectancy less than 6 months *d. Family has concerns about disease course and/or treatment options Rationale: The National Comprehensive Cancer Network suggests the following criteria for palliative care: (a) uncontrolled symptoms, (b) moderate to severe distress related to diagnosis and treatment, (c) serious comorbid physical and psychosocial conditions, (d) life expectancy less than 6 months, and (e) patient and family concerns about the course of disease and/or treatment options. 5. The cancer care team looking after a patient with advanced cancer has provided the patient and caregivers with information regarding cancer prognosis, treatment benefits and harms, and estimates of the total and out-of-pocket costs of cancer care. End-of-life care should be provided that is consistent with which of the following? a. Patient and caregiver’s affordability and insurance coverage *b. The needs, values, and preferences of patient and caregiver c. The hospital’s policy for care of advanced cancer d. The recommendation of the primary care physician Rationale: There are two palliative care–specific recommendations. The first is that the cancer care team should provide patientsTaEnS dT thB eiA rN faK mSilE ieL sL wE ithR. unCdO erM standable information on cancer prognosis, treatment benefits and harms, palliative care, psychosocial support, and estimates of the total and out-of-pocket costs of cancer care. The second is that in the setting of advanced cancer, the cancer care team should provide patients with end-of-life care consistent with their needs, values, and preferences. End-of-life care is not provided based on affordability, hospital policy, or the recommendation of the primary care physician. 6. Which of the following are included in the 10 quality and practice standards for hospice care? Select all that apply. *a. Patient- and family-centered care *b. Ethical and legal aspects c. Comprehensive psychological, physical, and psychiatric care *d. Organizational and workforce excellence Rationale: The NHPCO created 10 quality and practice standards for hospice care: (1) patientand family-centered care, (2) ethical behavior and consumer rights, (3) clinical excellence and safety, (4) inclusion and access, (5) organizational excellence, (6) workforce excellence, (7) standards, (8) compliance with laws and regulations, (9) stewardship and accountability, and (10) performance measurement. Both palliative and hospice care are governed by ethical and legal aspects and are patient and family centered. However, comprehensive psychological, physical, and psychiatric care is a domain of palliative care only and is not included in the 10 quality and practice standards of hospice care.

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7. A 45-year-old patient has several comorbid conditions that are expected to reduce daily functioning and also predictably reduce life expectancy. The patient is currently employed and lives with his family. Where can this patient receive situation-specific care? Select all that apply. *a. Hospital practices *b. Community clinics *c. Disease-specific clinics d. An assisted-living facility Rationale: The patient needs palliative care that encompasses populations of patients at all ages within the broad range of diagnostic categories who are living with a persistent or recurring medical condition that adversely affects their daily functioning or will predictably reduce life expectancy. The patient can receive palliative care from hospital, office, or outpatient-based palliative care practices, disease-specific clinics, and community clinics. The patient does not need to go into an assisted-living facility for palliative care as the patient is currently employed, can live at home with his family, and can be given palliative care from outpatient settings. 8. A 78-year-old patient is recovering at home after hip fracture surgery. The patient needs comprehensive physical, psychological, and pharmacy support. The patient is looked after by her daughters. The nurse assessing the patient’s needs is likely to refer the patient for which type of care? a. Nursing facility–based palliative care *b. Home-based palliative care c. Home-based hospice care d. Nursing facility–based hospice care Rationale: Home-based palliative care programs work well for geriatric patients who are too sick to travel to appointments. The patient is home-bound because of the hip fracture surgery and has a caregiver at home. Hence, the home-based palliative care model will work better for this patient than nursing facility–based palliate care. Hip fracture surgery will not reduce life expectancy to 6 months or less, nor is it a terminal illness, hence the patient does not need hospice care.

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9. A patient with uncontrolled diabetes and kidney failure is admitted to a nursing care facility, as the patient’s family lives far away and cannot help care for the patient at home. The nursing care facility faces challenges in providing continued care for the patient’s physical, psychological, and emotional needs. What challenges are likely faced by the nursing home in providing the type of care this patient requires? Select all that apply. *a. High staff turnover *b. Shortage of qualified staff *c. Reimbursement issues *d. Inability to arrange external consultation Rationale: The patient needs palliative care. However, palliative care initiatives in nursing homes are beset with the challenges of high staff turnover, staff shortages of qualified individuals, regulatory requirements, reimbursement issues, and various health policies. Palliative care in the long-term care setting works on two models—external consultative teams and internal consultative teams. Hence, an inability to arrange for either of these consulting services can also be a challenge in providing continued palliative care. 10. A 70-year-old patient with severe hypertension has many comorbid conditions and is worried about the consequences these conditions will have on his life. The nurse examines the patient, goes through the medical records, and notes that the patient is very anxious and illinformed about his medical conditions. The nurse also notes that the patient needs diseasespecific counseling and psychological support. The patient is covered under Medicare. What challenges will this patient face in getting the type of care he needs? Select all that apply. a. Medicare will not cover mTeE diSciTnB eA exNpK enSsE esL . LER.COM *b. Medicare will not cover interdisciplinary care. c. Medicare will not cover nursing care. *d. Medicare will limit the number of consultations the patient can receive. Rationale: This patient needs palliative care. Because the patient has many comorbid conditions, the patient will need an interdisciplinary team to look after him, which requires several visits to different care teams. However, palliative care models have limitations because of Medicare regulations. Under the Medicare Hospice or Home Health Benefit, palliative care lacks interdisciplinary care, as nurses provide the care alone. Further, palliative care under the Medicare Hospice Benefit is time limited to only a few consultation visits. Medicare will cover the expenses of nursing care and medicines.

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Chapter 44: Care of the Older Adult in the Emergency Department Multiple Choice Test Questions 1. Older adults who are discharged from the ED are at increased risk of which of the following? Select all that apply. *a. Death *b. Functional loss *c. Readmission d. Pneumonia Rationale: Older adults who are discharged from the ED are more likely to be readmitted; they also risk functional loss and higher rates of mortality. However, they are not at increased risk of pneumonia and other infections if they are discharged from ED. 2. Older adults being treated at the ED are at increased risk of which of the following? Select all that apply. *a. Increased risk of hospital admissions *b. Incorrect diagnosis *c. Less information *d. Inadequate pain management Rationale: As compared to younT geEr S peTrB soAnN s, KoS ldE erLaL duElR ts.inCtO heMED are more likely to experience missed or incorrect diagnoses, inadequate pain management, and less information. Older adults being treated in the ED are at increased risk of getting admitted to a hospital. 3. The nurse is examining a 76-year-old patient in an ED. Which triage should the nurse use to most correctly assess the urgency of treatment for this patient? a. Manchester Triage System (MTS) *b. Canadian Triage and Acuity Scale (CTAS) c. Emergency Severity Index (ESI) d. Triage Risk Screening Tool (TRST) Rationale: The three most widely-used emergency patient triage are the CTAS, the ESI, and the MTS. The CTAS has demonstrated high validity for older adults and is an especially useful tool for categorizing severity in older adults and for recognizing older adults who require immediate lifesaving intervention. The performance of the MTS appears inferior in older patients than younger patients, illustrated by a worse predictive ability of the MTS for in-hospital mortality in older patients. Under-triage has been reported in older adults when the ESI guidelines are not precisely followed. The TRST is used in the ED to assess the risk of adverse events, not urgency of treatment.

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4. A nurse is discharging an older adult from the ED to be managed at home. The discharge plan is to be made based on the patient’s risk of adverse outcomes. Which of the following tools can the nurse use to assess the risk of adverse outcomes after discharge from ED? Select all that apply. a. Manchester Triage System (MTS) *b. Identification of Seniors at Risk (ISAR) c. Emergency Severity Index (ESI) *d. Triage Risk Screening Tool (TRST) Rationale: Two commonly used tools, the ISAR and the TRST, evaluate the presence/absence of risk factors for adverse outcomes. These tools are useful in guiding a plan to prevent avoidable complications during the ED stay, during hospitalization (if admitted), and after an ED visit (when transitioning to home or another setting). The ESI and MTS are tools to assess urgency of treatment, not the risk of adverse outcomes. 5. A 70-year-old patient is brought to the ED by his son following a fall at home. The patient has a history of hypertension, diabetes, and arthritis, and has been taking medications for these conditions for years. The son informs the nurse that of late the patient has been losing track of important events, forgetting to take his medicines, and misplacing his things. What are the challenges faced by the nurse in managing this patient? Select all that apply. *a. Polypharmacy *b. Cognitive decline *c. Functional impairment *d. Communication Rationale: The complex presentation of disease and illness in older adults, along with complicated polypharmacy, functional impairment, communication problems, and cognitive impairment, presents a challenge to the ED nurse. 6. A 78-year-old patient is brought to the ED after a fall at home that caused the patient to hit his head against the staircase. There is a bleeding laceration running across the patient’s forehead. The patient appears to be confused but is otherwise talking and responding to questions. The nurse uses a popular ED triage tool to assess how soon the patient needs to be seen by the physician. What assessment should the nurse make? a. Patient should be immediately seen by the physician. *b. Patient should be seen within 15 minutes by the physician. c. Patient should be seen within 30 minutes by the physician. d. Patient should be seen within 45 minutes by the physician. Rationale: The nurse used the Canadian Triage and Acuity Scale (CTAS) to assess the urgency of treatment. According to the CTAS, this patient had an emergent threat of progressing to worse condition. Patients with altered mental states, head injury, and severe trauma should be seen within 15 minutes of ED admission. Patients in need of resuscitation should be seen immediately. Patients requiring urgent treatment should be seen within 30 minutes, and patients with less urgent needs should be seen within an hour of being brought to the ED.

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7. A 75-year-old patient is brought to the ED after falling at the store. The patient does not remember the reason she was shopping. The patient’s daughter informs the nurse that the patient has been increasingly needing assistance with activities of daily living, often forgets routine acts, is on four medications for diabetes and hypertension, and was admitted to the hospital about 3 months back to manage poorly controlled diabetes. The nurse uses a risk assessment tool to score the patient’s risk of functional decline, readmission to hospital, and repeat ED visit. What score is considered positive on this tool? a. Score of less than or equal to 2 b. Score of at least 5 *c. Score of greater than or equal to 2 d. Score of greater than or equal to 1 Rationale: The nurse is using the Identification of Seniors At Risk Tool (ISAR). The tool asks for answers for the following questions: Before the injury or illness, did you need someone to help you on a regular basis? Since the injury or illness, have you needed more help than usual? Have you been hospitalized for one or more nights in the past 6 months? In general, do you see well? In general, do you have serious problems with your memory? Do you take more than three medications daily? The ISAR tool is positive when the score is greater than or equal to 2 and is a predictor of increased risk of death, institutionalization, functional decline, repeat ED visit, and hospital readmission in the 6 months following an ED visit. 8. A nurse in the ED uses a tool to assess a 75-year-old patient. Which of the following findings in the patient would show that the patient needs comprehensive geriatric evaluation and more detailed follow-up? Select allTthEaS tT apBpA lyN . KSELLER.COM *a. Poor recall memory *b. History of two recent falls *c. Was admitted to hospital for COPD about 2 months back d. Is taking five or more medications Rationale: The nurse is using the Triage Risk Screening Tool (TRST). The risk assessment using TRST is positive when there is history or evidence of cognitive impairment (poor recall or orientation), difficulty walking/transferring or recent fall(s), ED use in the previous 30 days, or hospitalization in the previous 90 days. This tool considers the patient to be at risk of adverse outcomes if taking five or more medications.

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9. An older adult is brought to the ED with high fever and stomach upset. The patient’s attendant tells the nurse that the patient drinks regularly and also smokes. What questions can the nurse quickly ask the patient to assess substance abuse? Select all that apply. *a. Do you think you should cut down on alcohol? *b. Do you feel guilty about smoking? *c. Are you criticized for drinking and annoyed by it? d. Have you ever smoked late in the evening to steady your nerves? Rationale: The nurse can quickly administer the CAGE questionnaire. CAGE consists of four basic questions: 1. Have you felt you ought to cut down on your drinking or drug use? 2. Have people annoyed you by criticizing your drinking or drug use? 3. Have you felt bad or guilty about your drinking or drug use? 4. Have you ever had a drink or used drugs first thing in the morning to steady your nerves, get rid of a hangover, or get the day started? 10. A 72-year-old patient who lives alone is being discharged to home from the ED. The nurse prepares the discharge summary in simple language and sits down with the patient to go over the discharge instructions for the medications. What should the nurse quickly assess regarding this patient’s ability to take medications at home? Select all that apply. *a. Can identify the medicine *b. Can open medicine container c. Knows where to keep medicines at home *d. Knows the correct dose of the medicine and when to take it Rationale: The patient lives alonT e,EsS oT wB illAnNeK edStE oL seLlfE -aRd. mC inOisM ter the medications. The nurse is using a standardized tool that assesses older adults’ ability to self-administer their medication, such as the Drug Regimen Unassisted Grading Scale (DRUGS), which takes approximately 5 minutes to complete. This tool requires subjects to perform the following four tasks with each of their medications: (a) identify the appropriate medication, (b) open the container, (c) select the correct dose, and (d) report the appropriate timing of doses. Knowing where to keep medicines at home does not demonstrate the patient’s ability to self-administer a medication.

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