Chapter 08: Laboratory Values and Diagnostics

Touhy: Ebersole & Hess' Toward Healthy Aging, 9th Edition

Multiple Choice

1. The nurse is reviewing the postsurgical laboratory values of an older adult client. The client’s erythrocyte sedimentation rate (ESR) is 20 mm/hr. The nurse initially responds to this data by: a. asking the client if he or she has been diagnosed with any chronic inflammatory diseases. b. recognizing that the value is normal for older adults. c. notifying the client’s health care provider immediately. d. requesting that the laboratory rerun the test.

ANS: B

The ESR can be slightly elevated (10-20 mm/hr) in healthy older adults, especially those with a chronic disease that results in inflammation. Asking the client if he or she has such a diagnosis is not the initial response. This slight elevation does not warrant immediate notification or rerunning of the test.

DIF: Cognitive Level: Applying REF: p. 91

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

2. An older client in a long-term care facility is receiving an annual physical examination and is ordered laboratory tests that include a complete blood count, serum electrolytes, and thyroid tests. When the client’s son questions why these tests are being ordered by saying, “Dad is 85 why are you bothering him?” the nurse’s response is based on an understanding that: a. the health care provider ordering the tests needs to explain the rationale to the son. b. when conducted annually, all of the tests are helpful in promoting maximum health for older adults in the long-term care setting. c. the tests are useful, but only if clinically indicated. d. the complete blood count and serum electrolytes are useful screening tests, but the usefulness of the thyroid test should be questioned.

ANS: B

Laboratory tests are a fast and accurate way of assessing key parts of an older person’s physical functioning. It is within the nurse’s scope of practice to answer the son’s question and it does not need to be referred to the health care provider. The laboratory tests are being used as annual screening and therefore do not need to be clinically indicated. Excessive sleepiness is not normal in an 85- year-old and may be a sign of a thyroid disorder.

DIF: Cognitive Level: Applying REF: p. 92

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

3. When asked by an older adult client, “What is the difference between my normal laboratory values and the ones for a 55-year-old?” The nurse responds based on the understanding that there are: a. age-adjusted ranges for older adults for all of the common laboratory findings, similar to those for infants and children. b. no age-adjusted ranges for older adults due to the large variations within the age group and the increasing number of factors that influence the results. c. age-adjusted ranges only for the over-85 age group; there are no expected changes in the 65- to 84-year-old age group. d. age-adjusted ranges only for the hematological tests, which are due mostly to changes in the bone marrow.

ANS: B

There are no age-adjusted ranges for laboratory values due to the variation within the group, as well as the many chronic illnesses of older adults. The older one is, the more likely variations are to be seen. Although several age-related hematological changes occur, mainly from changes in the bone marrow, few are clinically significant.

DIF: Cognitive Level: Remembering REF: p. 88

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Health Promotion and Maintenance

4. An older resident of a long-term care facility diagnosed with dementia has in the last 48 hours become more confused than usual and while usually requiring help with toileting has been incontinent of urine. The client’s health care provider orders a complete blood count and serum electrolytes. When the laboratory tests are all within normal limits, the nurse initially: a. attributes the changes in the resident’s functioning to advancing dementia. b. suggests that the resident be placed on broad-spectrum antibiotics to prevent infections. c. speaks with the health care provider regarding the changes in the client’s function and the possibility of obtaining a urine culture. d. changes the plan of care to include bladder training and implement a 24-hour calorie count.

ANS: C

Waiting for usual signs of infection or illness in older adults can be fatal. In older adults, signs of infection may be absent or not seen until the patient is septic or very ill. The nurse needs to be alert to the subtle changes in the patient. A change in mental status may be indicative of an infection. Laboratory values do not always change in older adults, often not until the patient is very ill. Placing a patient on broad-spectrum antibiotics does not prevent infections. This action may in fact cause bacteria to become drug resistant. All evidence points to the changes in functioning being attributable to acute illness. The nurse needs to respond to the acute illness first.

DIF: Cognitive Level: Applying REF: p. 90

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. Preventing falls b. Maintaining skin integrity c. Preventing infection d. Replacing fluids

5. An older woman with breast cancer has completed a course of external radiation and is receiving chemotherapy. After her recent chemotherapy treatment, she complains of severe weakness, dizziness, and lethargy and is admitted to the hospital. Her platelet count is 45,000. Based on this scenario, what nursing intervention is of the highest priority?

ANS: A

Fall prevention is the highest priority. The patient has at least two significant risk factors for falls (unsteady gait and complaints of dizziness). She has a platelet count of 45,000; a platelet count of less than 50,000 makes one at high risk for spontaneous bleeding. The nurse must observe for overt and covert bleeding. If the patient falls, she is very likely to have a significant injury because of the low platelet count. Maintaining skin integrity would be important in this patient because she has received external radiation, which can cause alterations in skin integrity, but this is not as high a priority. Although preventing infection is an important intervention in a patient with cancer who has received radiation and chemotherapy, there is no evidence that this patient has alterations in her laboratory values related to the treatments, so fall prevention is more critical. There are no specific indications that this patient is experiencing a fluid deficit.

DIF: Cognitive Level: Analyzing REF: p. 91

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

6. A 69- year-old patient in the geriatric clinic has an annual physical examination and a complete blood count and serum electrolytes are drawn. While the physical examination was uneventful, the laboratory results show an elevated blood urea nitrogen (BUN). The nurse will then: a. ask that the test be rerun since the client showed no physical signs of renal failure. b. review the client’s medication list since BUN can be affected by many specific medications. c. instruct the client on collecting a 24-hour urine specimen for a more detailed analysis. d. assure the client that an elevated BUN is normal in older adults.

ANS: B

BUN can be elevated as a result of certain medication therapies and so the nurse should assess for this possibility. An elevated BUN is not diagnostic of renal failure alone and will not necessarily be reflected in physical symptoms. A 24-hour urine sample will not generally be done to determine BUN levels. An elevated BUN is not expected as a normal part of aging. Renal functioning decreases substantially with aging, but in most cases the body is able to compensate adequately with only slight increases in laboratory findings.

DIF: Cognitive Level: Applying REF: p. 96

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

7. A 78- year-old female patient was recently diagnosed with atrial fibrillation and started on Coumadin (warfarin) for stroke prophylaxis. A nurse provides extensive education on warfarin including the need for routine blood testing. The woman states the following to a nurse: “I understand all that you have taught me, but I do not know what a good number for the INR test is.” The nurse bases her response on the knowledge that the recommended INR is: a. 1.0-2.0. b. 2.0-3.0. c. 3.0-4.0. d. 4.0-5.0.

ANS: B

Recommended INR for an individual with atrial fibrillation for stroke prevention in individuals over age 75 is 2.0-3.0.

DIF: Cognitive Level: Applying REF: p. 97

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

8. An older woman asks a nurse in the cardiology practice, “What is the ideal number that my cholesterol levels should be? I am confused by all of the different numbers.” The nurse formulates her response on the knowledge that: a. recent guidelines from the American Heart Association state that there is no “one size fits all” recommendation and that recommendations must be individualized to each patient. b. recent guidelines from the American Heart Association provide different recommendations for individuals age 65-74, 75-84, and over age 85. c. recent guidelines from the American Heart Association recommend a total serum cholesterol level below 100. d. recent guidelines from the American Heart Association recommend a total serum cholesterol level over 200.

ANS: A

Recent guidelines from the American Heart Association state that there is no “one size fits all” recommendation and that recommendations must be individualized to each patient. Multiple factors that must be considered include family history, other risk factors for heart disease, and long-term risk-benefit ratios.

DIF: Cognitive Level: Applying REF: p. 95

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation

Multiple Response

1. When a client asks, “What could be causing my triglycerides to be so low; I’m really careful about my diet?” the nurse responds by asking the client: (Select all that apply.)

a. “Is your type 2 diabetes well managed?” b. “Have you ever been diagnosed with renal failure?” c. “Do you have a history of pancreatitis?” d. “Are you on medication for hyperthyroidism?” e. “Could you tell me how you are careful about your diet?”

ANS: D, E

Abnormally low triglyceride levels are suggestive of malnutrition or hyperthyroidism. Reasons for elevated levels include chronic renal failure and poorly controlled diabetes. Severely elevated triglyceride levels (greater than 2000 mg/dL) are a strong risk factor for pancreatitis.

DIF: Cognitive Level: Applying REF: p. 95

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation a. Basic metabolic panel b. Vitamin D level c. Thyroid stimulating panel d. Vitamin B 12 e. Serum albumin level

2. An elderly man is brought to the geriatrics clinic by his wife because of his increasing confusion. As part of his medical workup, the nurse practitioner orders which of the following laboratory tests? (Select all that apply.)

ANS: A, B, C, D

The following laboratory tests are part of a workup for a change in mental status: Basic metabolic panel, vitamin D level, vitamin B 12 , thyroid stimulating panel. Serum albumin is not part of a dementia workup.

DIF: Cognitive Level: Remembering REF: p. 92

TOP: Integrated Process: Teaching/Learning

MSC: Client Needs: Physiological Adaptation